Patient related factors in frequent readmissions: the influence of condition,access to services and patient choice

Background  

People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors.     

Is Survival from Infiltrating Lobular Carcinoma of the Breast Different from That of Infiltrating Ductal Carcinoma?

Previous studies of patients with breast cancer have compared survival of invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) with contradictory results. This study examines the effect of the diagnosis of IDC or ILC in conjunction with age at diagnosis, pathologic tumor size, pathologic stage, histologic grade, and lymph node status of 307 women with IDC or ILC in 1992 in the Greater Western region of Sydney in Australia. Survival analysis was conducted using the Kaplan-Meier method. Relative risks associated with IDC or ILC and other important prognostic factors and adjusted for each other were computed using Cox proportional hazard regression. The proportion of grade I tumors was significantly higher in ILC (41%) than in IDC (16%). Conversely, the proportion of grade III tumors was only 18% in ILC as against 41% in IDC (p = 0.020). The 10-year survival of women with IDC was 69%, compared to 84% for ILC (p = 0.073). However, the 15 percentile point difference between overall survival of IDC and ILC was markedly reduced after adjustment for nodal status. The difference was eight percentile points for node-negative patients (p = 0.361) and five percentile points for node-positive patients (p = 0.464). Age at diagnosis, tumor size, pathologic stage, and lymph node status were independent prognostic indicators for 10-year survival. There was no prognostic difference between IDC and ILC. The result shows the importance of adjusting for other important clinicopathologic characteristics before comparing the overall survival of IDC and ILC.     

Oesophageal ulcers secondary to doxycycline and herpes simplex infection in an immunocompetent patient

Oesophageal ulcerations are generally rare occurrences that are most commonly associated with gastro-oesophageal reflux disorder. Other causes include medications and infections in immunocompromised patients. Among the medications used in daily practice, doxycycline is most commonly implicated. Multiple aetiologies are generally uncommon. We report a case of mid-oesophageal ulcerations secondary to doxycycline and herpes simplex virus infection in an immunocompetent patient.     

Angiodysplasia of the gallbladder

Introduction

Angiodysplasia is a term used to describe distinct mucosal vascular ectasias found mainly in the gastrointestinal tract. Angiodysplasia of the gallbladder is exceedingly rare.

Presentation of case

We encountered a patient who presented with biliary colic and subsequently underwent an elective laparoscopic cholecystectomy. The angiodysplasia of the gallbladder was found incidentally on histopathological examination of the excised gallbladder.

Discussion

Review of the literature showed only one other reported case of angiodysplasia of the gallbladder. The condition may be found incidentally after histopathological examination of the gallbladder removed for gallstone; or it may present with haemobilia.

Conclusion

We presented an extremely rare case of angiodysplasia of the gallbladder, which was found incidentally after histopathological examination of the gallbladder removed for gallstone. Angiodysplasia of the gallbladder has the potential to bleed. Laparoscopic cholecystectomy is effective in providing a definitive cure.     

Cytomegalovirus colitis in immunocompetent patients

Cytomegalovirus (CMV) infection can present with severe manifestations that are associated with significant morbidity and mortality, especially in immunocompromised patients. CMV infections in immunocompetent patients are usually transient and do not exhibit many symptoms. However, in some patients, the manifestations can be severe. We report CMV colitis in two immunocompetent patients; one in a young man who was critically ill with septicaemia and significant non-bloody diarrhoea that responded to specific CMV treatment, and another in an elderly woman who presented with nonspecific abdominal pain and fever that resolved without specific CMV treatment.     

Primary biliary cirrhosis in Brunei Darussalam

BACKGROUND:Primary biliary cirrhosis(PBC)is an uncommon autoimmune cholestatic disease that predominantly affects women.Certain human leukocyte antigens(HLAs) have been reported to be associated with susceptibility for PBC.We describe the profiles of PBC in Brunei Darussalam. METHODS:All patients with PBC(n=10)were identified from our prospective databases.The HLA profiles(n=9,PBC)were compared to controls(n=65)and patients with autoimmune hepatitis(n=13,AIH). RESULTS:All patients were women with a median age of 51 years(27-83)at diagnosis.The prevalence rate of the disease was 25.6/million-population and the estimated incidence rate varied from 0 to 10.3/million-population per year.Chinese (41.15/million)and the indigenous(42.74/million)groups had higher prevalence rates compared to Malays(22.62/ million).The prevalence among female population was 54.6/ million-population.All patients were referred for abnormal liver profiles.Five patients had symptoms at presentations: jaundice(20%),fatigue(20%),arthralgia(30%)and pruritus (20%).Serum anti-mitochondrial antibody was positive in 80%of the patients.Overlap with AIH was seen in 30%.Liver biopsies(n=8)showed stage I(n=2),II(n=4)and III(n=2) fibrosis.There were no significant differences in the HLA profiles between PBC and AIH.Compared to the controls,PBC patients had significantly more HLA class I alleles specifically B7(P=0.003),Cw7(P=0.002)and Cw12(P=0.007)but not the class II alleles.At a median follow-up of 23.5 months(2 to 108), all patients were alive without evidence of disease progression. CONCLUSIONS:PBC is also a predominant female disorder in our local setting and most had mild disease.The HLA profiles of our patients were different to what have been reported.     

A better model of diabetes self-management? Interactions between GP communication and patient self-efficacy in self-monitoring of blood glucose

Objective

The aim of this exploratory study was to investigate the interaction between patient self-efficacy and GP communication in explaining diabetes self-management in a disadvantaged region of Sydney, Australia.

Methods

This study was undertaken in South West Sydney with the Fairfield Division of General Practice. We used a cross-sectional survey design to assess patients’ self-reported beliefs and behaviours about diabetes self-management. We used hierarchical multiple linear regression to test for interaction effects in diabetes self-management, following tests for clustering using multilevel modeling.

Results

Of those eligible for survey, 105 patients completed the telephone survey (72%). There was a significant interaction between diabetes self-efficacy and GP communication in blood glucose testing; high-ratings of GP communication enhanced self-monitoring of blood glucose when patient self-efficacy was high but impeded self-monitoring of blood glucose when self-efficacy was low. There were no significant interaction effects for the general diet or exercise scales.

Conclusion

This exploratory study suggests a complex relationship between patient self-efficacy and GP communication in self-monitoring of blood glucose. It is likely optimal diabetes self-management behaviours are produced by a fit between high patient self-efficacy and high quality GP communication.

Practice implications

There is a risk that GPs who are sensitive to their patients’ low self-efficacy in self-monitoring of blood glucose may step in and take over the monitoring role and inadvertently reduce self-management.     

Tumour location is not an independent prognostic factor for survival following a diagnosis of breast cancer

Previous studies of patients with breast cancer have examined tumour location as a prognostic factor for survival with contradictory results. The current population-based study with 356 women examines the effect of tumour location and other important prognostic factors on survival. Univariate analyses indicated that central location (P < 0.001), a larger pathological tumour size (P = 0.003), number of positive lymph nodes (P < 0.001), younger age at diagnosis (P = 0.003), a more advanced TNM stage (P < 0.001), a higher grade (P = 0.016) and histologic type (P = 0.011) were associated with a higher risk of breast cancer death. The 10-year survival of women with central location was 33%, compared to 73% for medial and 71% for lateral (P < 0.001). However, the differences among tumour locations were markedly reduced after adjustment separately for early (P = 0.39) and advanced (P = 0.56) TNM stages, which also confirmed the results of multivariate analysis that the location does not influence survival after adjustment for other important clinicopathological characteristics.     

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

Background  

Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors.