Stochastic models for geriatric in-patient behaviour

Departments of geriatric medicine engage in two distinct formsof clinical activity: acute/rehabilitative and long-stay care.These are organizationally distinct and have very differentresource needs. Current hospital planning models, however, assumethat patients all move through the system at the same rate,thereby ignoring this effect of inherent heterogeneity in patientbehaviour. The present paper describes the movement of patientsthrough geriatric hospitals by a two-stage continuous-time Markovmodel, where the stages represent acute/rehabilitative and long-staypatients respectively. Patients are initially admitted to thefirst stage, from which they may depart from the system, bydeath or discharge, or move into the second stage, from whichthey eventually depart by death or discharge (unlikely). Admissionsare modelled in two ways: either as replacements for departuresor as a Poisson stream. Expressions for the distribution andmovement of numbers of patients are derived and evaluated fordata from a number of hospitals. Such an approach has the advantage,over previous crude models, of taking into account differenttypes of patients and introducing variability, thus making itpossible to extract variances as well as means of numbers ofgeriatric patients requiring hospital care.     

Rectal aminosalicylate therapy for distal ulcerative colitis: a meta-analysis

Background: To summarize and quantify the evidence supporting rectal 5- or 4-aminosalicylate (ASA) therapies for disease exacerbation or remission maintenance in distal ulcerative colitis, we performed a meta-analysis. Methods: All randomized, double-blind controlled trials involving aminosalicylate therapy were retrieved from a MEDLINE search, review articles on ulcerative colitis therapy or their bibliographies. Of 55 studies retrieved, 19 met the inclusion criteria. Appraisal and data extraction were performed by two observers and scoring disagreements were resolved by consensus. Results: Eleven trials tested 5-ASA and three tested 4-ASA in active ulcerative colitis. 5-ASA was superior to placebo for inducing remission or symptomatic improvement in active ulcerative colitis with a pooled odds ratio of 7.36 (95% Confidence interval (CI): 4.72–11.47). In four trials the pooled odds ratio for endoscopic improvement was 10.04 (95 % CI: 5.72–17.61) and for histological improvement 10.31 (95% CI: 5.85–18.18). Studies evaluating 4–ASA suggest a benefit similar to prednisolone in treating active disease. Five trials assessed remission maintenance with 5-ASA, and when compared to placebo gave a pooled odds ratio of 16.22 (95% CI: 4.71–55.92). No dose-response relationship was observed. ASA compounds were not therapeutically superior to other treatments. Conclusions: We conclude that rectal 5-ASA is effective therapy for active distal ulcerative colitis. More trials are needed to assess 4-ASA, dose-response effects and the ideal regimen for remission maintenance.     

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

OBJECTIVE:To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy. METHODS: Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis. RESULTS: A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy. CONCLUSIONS: Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.     

Psychiatric disorder in Queensland primary schoolchildren

ABSTRACT. Nine hundred and eighty-six 10 and 11-year-old children were screened for psychiatric disorder using a method developed by Rutter for a same-age English population. The prevalence rate was 14%, with rural children showing a lower rate (10%) than urban (15%), and metropolitan (18%). Comparisons between Australian and English children suggest a higher rate of disorder among the former; significantly so in the case of girls (p<.02), with a significant increase in emotional disorder among boys (p<.02), and an increase in conduct disorder among girls but not at a level of statistical significance. The results on teacher questionnaires alone showed a prevalence rate and distribution very comparable to the English study. These findings are discussed in the light of cultural differences and changing social attitudes.