Optic nerve breast metastasis mimicking meningioma

Purpose: We report on an optic nerve breast metastasis masquerading initially as a central retinal vein occlusion and later as an optic nerve meningioma. Methods: A 60-year-old female presented with a left central retinal vein occlusion (CRVO). She represented 7 months later with left upper ptosis, proptosis and painful rubeotic glaucoma. Computed tomography (CT) and magnetic resonance imaging suggested an optic nerve meningioma. On referral to the regional orbital unit, a mild left external ophthalmoplegia was noted and, in view of previous right mastectomy and chemotherapy 3 years earlier, the left optic nerve was biopsied simultaneously with left enucleation of her painful eye. Results: Histopathology showed infiltration of the optic nerve and meningeal sheath spreading into the subretinal space and vitreous by malignant epithelial cells, consistent with breast origin. Further CT imaging and bone scans revealed no other metastases. Single field left orbit radiotherapy of 20 Gy was given in five fractions and Arimidex (Zeneca Pharmaceuticals, Cheshire, England) was commenced with the cessation of tamoxifen. The patient was also given an ocular prosthesis. Sadly, she lost vision in her other eye due to retrograde malignant invasion of her optic chiasm and died 6 weeks later. Conclusions: Orbital and choroidal metastases are relatively common but isolated optic nerve metastases are extremely rare. Progressive infiltration of the nerve is likely to enhance CRVO ischaemia and resultant rubeotic glaucoma. In the diagnosis of CRVO, proptosis or external ophthalmoplegia, the presence of pre-existing malignant disease should raise concerns, as delay in diagnosis may affect outcome, particularly if the metastases are sensitive to pharmacological therapy.     

RESEARCH LETTER: Uptake of research findings into clinical practice: a controlled study of the impact of a brief external intervention on the use of corticosteroids in preterm delivery

To the Editor: There are a large number of studies addressing the impact of continuing medical education (Davis et al. 1995) and clinical guidelines (Grimshaw & Russell 1993) on changing clinical practice, but comparatively little on the impact of purchasers of health care. There is some evidence that financial incentives and penalties can influence practice (Greco & Eisenberg 1993). It has been suggested that purchasers can play an important role in implementing research findings (Haines & Jones 1994). Indeed, the separation of purchasers and providers has been viewed as an opportunity to use knowledge about effectiveness to improve health services (Dunning et al. 1994). We report a study the aim of which was to explore the impact that a specific brief external intervention might have on a detailed aspect of clinical practice: the use of corticosteroids in preterm labour. The intervention was initiated by public health physicians on behalf of a Health Authority. It formed a part of the Getting Research Into Practice (GRIP) initiative in the old Oxford Health Region, UK.  The administration of corticosteroids to mothers expected to deliver prematurely reduces neonatal mortality and morbidity (Crowley et al. 1990). The first trial which suggested that corticosteroids were effective in this role was published in 1972, and evidence from 12 trials was assembled in a systematic review published in January 1990 (Crowley et al. 1990). Despite the accumulating evidence, in 1991 many women delivering prematurely in the UK and elsewhere were not receiving corticosteroids (Anon 1992;Donaldson 1992). The apparent failure of obstetricians to make full use of this treatment has been cited as an example of the delayed implementation of research findings that can occur in clinical practice (Haines & Jones 1994; Enkin 1996).     

Description and predictors of hospital costs of oesophageal cancer during the first year following diagnosis in Northern Ireland

The cost‐effectiveness of novel interventions in the treatment of cancer is well researched; however, relatively little attention is paid to the cost of many aspects of routine care. Oesophageal cancer is the ninth most common cancer in the UK and sixth most common cause of cancer death. It usually presents late and has a poor prognosis. The hospital costs incurred by oesophageal cancer patients diagnosed in Northern Ireland in 2005 (n = 198) were determined by review of medical records. The average cost of hospital care per patient in the 12 months from presentation was £7847. Variations in total hospital costs by age at diagnosis, gender, cancer stage, histological type, mortality at 1 year, co‐morbidity count and socio‐economic status were analysed using multiple regression analyses. Higher costs were associated with earlier stages of cancer and cancer stage remained a significant predictor of costs after controlling for cancer type, patient age and mortality at 1 year. Thus, although early detection of cancer usually improves survival, this would mean increased costs in the first year. Deprivation achieved borderline significance with those from more deprived areas having lower resource consumption relative to the more affluent.     

Improving communication between health professionals and women in maternity care: a structured review

Objective  To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.
Search strategy  The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.
Inclusion criteria  Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.
Data extraction and synthesis  95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.
Results  The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.
Conclusions  The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.     

Whose responsibility is it anyway? Hospital admission and discharge of older people in an inner-London District Health Authority

The division of responsibilities that exists between primary and secondary health care services and health and social care services may create problems in the provision of care to patients whose needs mean that a number of different agencies are involved in their care The objective of all the agencies involved is the smooth transfer of clients between different sectors of care provision One client group thought to be particularly vulnerable to dislocations in the continuous pattern of care provision is older people Problems over the division of responsibility between professional groups are particularly evident on admission to and discharge from hospital It is the latter rather than the former aspect that has been the focus of research An extensive multi-methods study of the admission and discharge of older people from hospital in an inter-city District Health Authority was undertaken This paper examines the transfer of older people between different elements of the health and social care systems Our study illustrates that on neither admission nor on discharge was there a clearly defined mechanism for affecting liaison between hospital and community Clearly, the responsibility for this task must be delegated to a specific group However, such responsibility must be given within a properly resourced and managed system, otherwise the current position of blurred responsibilities will remain It is unclear as to how the reform of the National Health Service and the introduction of the internal market and the purchaser/provider division will aid the improved co-ordination which this study has identified as being required     

AUDIT OF THE RELATIONSHIP BETWEEN EPISIOTOMY AND RISK OF MAJOR PERINEAL LACERATION DURING CHILDBIRTH

SUMMARY The beneficial effect of mediolateral episiotomy in reducing major perineal lacerations during childbirth has been questioned. In a test of the hypothesis of no association between episiotomy and the incidence of major perineal lacerations, the incidence of major perineal laceration was determined in three cohort groups in one maternity unit between 1984 and 1991. Among those undergoing non-instrumental delivery, no reduction in the incidence of major lacerations could be demonstrated following episiotomy. Among those undergoing episiotomy, the incidence of major lacerations was significantly higher following instrumental delivery.     

Audit in palliative care: does practice change?

This study aimed to document current palliative care initiatives, identify any reported changes in working practice as a result of audit, and determine the opinions of palliative care staff towards audit. All 31 established palliative care services within the former North West Thames Regional Health Authority were sent a brief postal questionnaire on previous and current audit activities. Of the 28 units who responded, most (78%, n =21) were currently involved in audit with a further 7% ( n =2) planning to implement audit in the near future. Changes as a result of audit included implementation of standards, for example response to referrals; improvements in documentation, for example revision of case notes; and changes to unit practice, such as converting to multidisciplinary care plans. The respondents viewed the main advantage of carrying out any audit project as the improvement or maintenance of the quality of patient care. The principal disadvantage expressed was the time-consuming nature of audit. An audit with a clear aim and thorough design can provide valuable evidence upon which new policies or strategies in palliative care can be based. By educating and training staff in audit and illustrating the benefits, any concerns about carrying out audit could be addressed.     

From local concern to randomized trial: the Watcombe Housing Project

Background  A randomized study of the effect on people's health of improving their housing is underway in Torbay. The link between poor health, particularly respiratory health, and poor housing conditions has been recognized for a long time, but there have been few intervention studies to demonstrate that improving housing can improve health. In 1994, South and West Devon Health Authority set up a community development project in a deprived area of Torbay, in response to the concerns of local primary health-care workers. A community development worker helped local residents survey their homes for dampness and record their respiratory symptoms. The survey reported high levels of condensation/dampness and respiratory illness and the Council agreed to direct the majority of their housing improvement funds to the estate over the next 3 years. The Health Authority, University of Plymouth and Torbay Council were successful in obtaining funding to evaluate the housing improvements from the NHS R & D programme.
Participants and methods  Of 119 houses eligible for the study, 50 were chosen at random and improved in the first year. The rest were improved the following year. Questionnaires screening for health problems were sent to all 580 residents and baseline surveys of the indoor environment were also carried out. More detailed health surveys were completed by community nurses visiting residents in their homes. All adults were asked to complete SF-36 and GHQ 12 questionnaires, as well as disease-specific questionnaires if appropriate.
Progress  All houses in the study have now been improved, including insulation, double-glazing, re-roofing, heating, ventilation and electrical rewiring. Follow-up surveys are underway.     

The epidemiology of tuberculosis by ethnic group in Birmingham and its implications for future Trends in tuberculosis in the UK

Objectives. To describe the epidemiology of tuberculosis (TB) in Birmingham, UK, by ethnic group and to assess the implications of the findings for future trends in TB in the UK.

Methods. Retrospective review of records of all patients notified with TB in Birmingham during 1989–1994.

Results. The decline in TB notifications in Birmingham halted and then reversed in 1987–1992. Trends in overall notifications were mainly influenced by trends in cases of Asian origin. Crude notification rates in 1989–1994 are 17 times higher in Asian than Caucasian residents (p < 0.01). Rates in African Caribbean residents are also statistically significantly higher than in Caucasians (p < 0.01) but significantly lower than in Asians. Crude rates for Asian people born abroad are 4.1 times higher than for Asians born in the UK (p < 0.01) but only 3.8% of Asian patients had been resident in the UK for less than 1 year. The group accounting for the highest number of cases were female Asians aged 20–29, followed by male Asians of the same age. Age‐specific rates show that incidence increases with age in both Asian and white groups, with a small peak in 20–29‐year‐old Asians. TB is uncommon in all Caucasian age‐groups under 50 years of age (less than 1 per 10 000) but is relatively common in all Asian age‐groups over 15 years of age (over 10 per 10 000).

Conclusions. The different epidemiology of TB in the Caucasian and Asian populations in the UK suggests that from about the second decade of the next century, TB in the UK will almost be entirely a problem of ethnic minorities and that even if new infection was eliminated now in Asian people, cases due to reactivation would continue to occur until the third quarter of the next century.