Spontaneous rupture of the spleen in initial presentation of Hodgkin's disease

A 46-year-old man presented with a four-week history of fevers, occasional chills, and a two-week history of sweats and poor appetite. He also complained of progressive weakness and lethargy. After initial evaluation, while awaiting further consultation, the patient developed rapidly progressing abdominal pain and light-headedness. He was moved immediately into the emergency treatment area. He was noted to have an acute abdomen and was taken to surgery. An enlarged Hodgkin's-infiltrated spleen with an actively bleeding hematoma was removed. The patient denied any history of trauma.     

Evaluation of a rapid theophylline test strip assay in the emergency department setting

Test strips recently have become available to measure theophylline levels. One such test strip (AccuLevel) had not been tested in an actual clinical situation with nontechnician personnel. We prospectively evaluated the test strip on consecutive emergency department patients, comparing it with the agglutination inhibition method used by our hospital laboratory. Nurses and medics who ran the test were given only a brief demonstration and explanation of the manufacturer's instructions. The 61 test strip levels correlated highly with the laboratory results (r = 0.92, slope = 0.89, y-intercept = 0.99). The test strip results were available in less time (mean of 0.51 hours vs 1.89 hours for the laboratory, P less than .0001). The most accurate readings were obtained by those who ran the test most frequently. Caffeine intake did not influence the test. Cost was significantly lower than charges at local hospitals.     

Equity of access to adult hospice inpatient care within north-west England

There is a growing debate about the question of equity of access to hospice and palliative care services. Even countries with relatively well developed palliative care systems are considered to have problems of access and inequity of provision. Despite these concerns, we still lack a relevant evidence base to serve as a guide to action. We present an analysis of access to adult hospice inpatient provision in the north-west region of England that employs Geographical Information Systems (GIS). Measures of the possible demand for, and supply of, hospice inpatient services are used to determine the potential accessibility of cancer patients, assessed at the level of small areas (electoral wards). Further, the use of deprivation scores permits an analysis of the equity of access to adult inpatient hospice care, leading to the identification of areas where additional service provision may be warranted. Our research is subject to a number of caveats--it is limited to inpatient hospice provision and does not include other kinds of inpatient and community-based palliative care services. Likewise, we recognise that not everyone with cancer will require palliative care and also that palliative care needs exist among those with nonmalignant conditions. Nevertheless, our methodology is one that can also be applied more generally.     

Geographical epidemiology of residence of patients with motor neuron disease in Lancashire and south Cumbria

OBJECTIVES—To seek objective evidence forgeographical clustering of places of residence of patients with motorneuron disease (MND).
METHODS—A complete residential history frombirth to onset of disease was obtained from a cohort of 130 patients with MND from Lancashire and south Cumbria presenting to theDepartment of Neurology in Preston between 1 January 1989 and 31 December 1993. These data were compared with population basedreference data from the 1991UK Census.
RESULTS—Some areal units showed a greater, othersa lesser, number of MND patient residences than expected. The resultssuggest that the background population incidence of MND is relativelylow and that the overall incidence figures previously quoted have been skewed upwards by areas in which the incidence of MND is relatively increased. These findings were further tested by Poisson modelling. ThePoisson model provided a poor fit for the data at postcode district andsector levels confirming that patients with MND were significantly morelikely to have lived in some areas than others after allowing forvariation in population of the different areal units and for variationin duration of residence.
CONCLUSIONS—These findings reinforce the resultsof previous work, much of which has been qualitative rather thanquantitative. The results presented here suggest a low backgroundincidence of MND in the context of generally quoted overall incidencefigures. This low background incidence is, however, skewed upwards bysome areal units with a relatively high incidence, thus achievingoverall incidence rates comparable with generally quoted figures. Weconclude that there is prima facie evidence of spatial patterns in the distribution of places of residence of patients with MND. Further examination of occupational and environmental factors in the lives ofthe patients with MND is required to obtain a better understanding ofthe importance of these findings.

     

Modelling exposure opportunities: estimating relative risk for motor neurone disease in Finland

This paper addresses the issues surrounding an individual's exposure to potential environmental risk factors, which can be implicated in the aetiology of a disease. We hope to further elucidate the 'lag' or latency period between the initial exposure to potential pathogens and the physical emergence of the disease, with specific reference to the rare neurological condition, motor neurone disease (MND), using a dataset obtained from the Finnish Death Certificate registry, for MND deaths between the period 1985-1995. A space-time approach is adopted, whereby patterns in both time and space are considered. No prior assumptions about the aetiology of MND are adopted. By using methods for the analysis of point processes, which preserve the continuous nature of the data, we resolve some of the problems of analysis that are often based on arbitrary areal units, such as postcode boundaries, or political boundaries. We use kernel estimation to model space-time patterns. Raised relative risk is assessed by adopting appropriate adjustments for the underlying population at risk, with the use of controls. Significance of the results is assessed using Monte Carlo simulation, and comparisons are made with results obtained from Openshaw's geographical analysis machine (GAM). Our results demonstrate the utility of kernel estimation as a visualisation tool. Small areas of elevated risk are identified, which need to be more closely examined before any firm conclusions can be drawn. We highlight a number of issues concerning the inadequacies of the data, and possibly of the techniques themselves.     

Impact of community neonatal services: a multicentre survey

OBJECTIVES: To explore the impact of a community neonatal service on high risk infant survivors in the first year of life. DESIGN: Retrospective multicentre survey. Postal questionnaires were sent to selected parents. SETTING: Thirty two neonatal units in England and Wales. PATIENTS: Inclusion criteria: infants over 12 months of age with birth weight < or =1500 g, or who received level I intensive care for at least 48 hours. Exclusion criteria: multiple births, infants who had died or had severe congenital abnormalities. A total of 3367 eligible infants were selected, and their parents were sent a questionnaire; 65% responded. MAIN OUTCOME MEASURES: Length of stay on the neonatal unit from birth to initial discharge. Readmission to hospital during the first year of life. RESULTS: The median length of stay in units with a community neonatal service was 35 days compared with 37 days in units without. When adjusted for infant and parent characteristics, the median length of stay was reduced by 12.6% where a community neonatal service was provided (95% confidence interval 5.3% to 19.3%). The readmission rates were 44.6% in units with a community neonatal service and 43.5% in units without. There was no significant reduction in the adjusted odds of readmission. CONCLUSIONS: The retrospective nature of this study means that these findings cannot be definitely attributed to the presence of a community neonatal service. However, the results suggest that community neonatal services may reduce the length of stay without any subsequent increase in readmission.