Providing hospice care in rural areas: challenges and strategies

Hospices in rural settings face challenges in the provision of hospice care as a result of their location and the size of their service area population. To ascertain the challenges that hospices face in serving rural communities, researchers conducted in-depth case studies of four different models of hospice care in rural areas. The authors describe strategies used by the case study hospices and recommend policies that could increase access to hospice care for rural Medicare beneficiaries and other rural residents. National initiatives to improve end-of-life care need to consider the special challenges faced by rural hospices.     

A 30-day toxicity study of inhaled fenitrothion in the albino rat

The significance of inhalation as a route of exposure to organophosphorus insecticides was assessed by exposing male and female Sprague-Dawley rats via a nose-only technique to respirable (2.0-μm diameter), aqueous aerosols of a fenitrothion-emulsifier mixture (11% technical fenitrothion, 1.5% Atlox 3409F, 1.5% Dowanol TPM, 86% water) at chamber concentrations of 6.7, 20.0, and 60.0 μg insecticide/liter of air for 2 hr/day for 30 consecutive days. Rats of each treatment group were bled at Days 8 and 15, and at necropsy after 30 days of treatment. Subgroups (six rats/sex/treatment) were necropsied 30 days post-treatment to study the regression of treatment effects. Measured parameters included body weight, food consumption, plasma, and erythrocyte cholinesterase as well as brain cholinesterase and hepatic and renal carboxylesterases of necropsied animals. Body weight and food intake were depressed in all groups including air-exposed control rats. Muscle fasciculations (♀, high dose) and a clear secretion (♂ and ♀, high dose) were correlated with a dose-dependent plasma, erythrocyte, and brain cholinesterase inhibition which was greater after 15 and 30 days of treatment than after 7 days. Brain, plasma, and erythrocyte enzyme levels had returned to normal values by 30 days post-treatment, as had the hepatic and renal carboxylesterases. Detailed hematological, urinary, blood biochemical, and histopathological studies revealed no other deleterious effects of treatment.     

The occurrence of carcinoma of the rectum following ileoproctostomy for familial polyposis.

Ileoproctostomy was performed in 32 patients (13 Female and 19 male), with polyposis coli ranging in age from 10 to 54 years. Seven patients (22%) developed cancer of the retained rectum with a median follow-up of 14 years. Two (20%) of ten patients, followed for 10 to 15 years, and three (50%) of six patients, followed for 15 to 20 years, developed rectal cancer. Rectal cancer developed in two of 14 patients who had their ileoproctostomy at 14 cm and in five of 18 patients who had their ileoproctostomy at a higher level, with a median followup of 7 and 11 years, respectively. Rectal cancer developed in two of 15 teenage patients undergoing ileoproctostomy and in nine of 17 patients aged 20 to 54 years. The present average ages of the two groups were 25 and 41 years, and the average age at which rectal cancer appeared was 40 years. Three of the patients who developed rectal cancer had numerous polypectomies over the years, and there was a tendency to develop tubulovillous and villous adenomas with a variable degree of atypia leading to carcinoma. One patient also showed a return to high levels of coprostanol and secondary fecal bile acids. Proctocolectomy, if acceptable, may be the treatment of choice; ileoproctostomy may mean that the patient eventually will undergo a proctectomy. The ileoanal endorectal pull-through procedure has a great deal to offer to these patients, and further study is necessary to evaluate this procedure.     

Functional endoscopic sinus surgery: 5 year follow up and results of a prospective, randomised, stratified, double-blind, placebo controlled study of postoperative fluticasone propionate aqueous nasal spray

One hundred nine patients with chronic rhinosinusitis underwent functional endoscopic sinus surgery. Seventy seven patients had polyposis. The population was studied prospectively for 5 years postoperatively. Seventy two patients attended the 5 year follow-up visit. At 1, 2, 3, 4 and 5 years of follow-up all outcome measures except olfactory detection thresholds (visual analogue scores, endoscopic findings, nasal mucociliary clearance times, total nasal volumes) were significantly improved compared to preoperative baseline values. Olfactory detection thresholds were significantly improved at 1 and 2 years postoperation. Patient symptom scores were improved in a greater percentage of patients than more objective outcome measures. Thirty eight patients required a total of 88 postoperative rescue medication courses with prednisolone and antibiotic. Twelve patients failed the study as they required at least 1 rescue medication course a month for 2 consecutive months. We demonstrated an 89% 5 year "survival" rate with regards to the risk of failure. The patients were also entered into a randomised, stratified, prospective, double-blind, placebo controlled study of fluticasone propionate aqueous nasal spray 200 mcg twice daily, commencing 6 weeks after FESS, with a 5 year follow-up. The change in overall visual analogue score was significantly better in the FPANS group at 5 years. The changes in endoscopic oedema and polyp scores and in total nasal volumes were significantly better in the FPANS group at 4 years but not 5 years. Last value carried forward analysis demonstrated that changes in endoscopic polyp score and in total nasal volume was significantly better in the FPANS group at 5 years. Significantly more prednisolone rescue medication courses were prescribed in the placebo group. Of the 12 patients who failed the study, 10 were in the placebo group. This difference nearly achieved significance.