Factors associated with timeliness of post-primary care referral, diagnosis and treatment for lung cancer: population-based, data-linkage study

Background:

The NHS Cancer Plan for England set waiting time targets for cancer referral (14 days from GP referral to first hospital appointment) and treatment (31 days from diagnosis, 62 days from urgent GP referral). Interim diagnostic intervals can also be calculated. The factors that influence timely post-primary care referral, diagnosis and treatment for lung cancer are not known.

Methods:

Northern and Yorkshire Cancer Registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to investigate the factors (socioeconomic position, age, sex, histology, co-morbidity, year of diagnosis, stage and performance status (PS)) that may influence the likelihood of referral, diagnosis and treatment within target, for 28 733 lung cancer patients diagnosed in 2006–2010.

Results:

Late-stage, poor PS and small-cell histology were associated with a higher likelihood of post-primary care referral, diagnosis and treatment within target. Older patients were significantly less likely to receive treatment within the 31-day (odds ratio (OR)=0.79, 95% confidence interval (CI) 0.69–0.91) and 62-day target (OR=0.80, 95% CI 0.67–0.95) compared with younger patients.

Conclusions:

Older patients waited longer for treatment and this may be unjustified. Patients who appeared ill were referred, diagnosed and treated more quickly and this ‘sicker quicker' effect may cancel out system socioeconomic inequalities that might result in longer time intervals for more deprived patients.

A prospective longitudinal study of retinal structure and function in achromatopsia

PURPOSE

To longitudinally characterize retinal structure and function in achromatopsia (ACHM) in preparation for clinical gene therapy trials.

METHODS

Thirty-eight molecularly confirmed ACHM subjects underwent serial assessments, including spectral domain optical coherence tomography (SD-OCT), microperimetry, and fundus autofluorescence (FAF). Foveal structure on SD-OCT was graded and compared for evidence of progression, along with serial measurements of foveal total retinal thickness (FTRT) and outer nuclear layer (ONL) thickness. Fundus autofluorescence patterns were characterized and compared over time.

RESULTS

Mean follow-up was 19.5 months (age range at baseline, 6-52 years). Only 2 (5%) of 37 subjects demonstrated change in serial foveal SD-OCT scans. There was no statistically significant change over time in FTRT (P = 0.83), ONL thickness (P = 0.27), hyporeflective zone diameter (P = 0.42), visual acuity (P = 0.89), contrast sensitivity (P = 0.22), mean retinal sensitivity (P = 0.84), and fixation stability (P = 0.58). Three distinct FAF patterns were observed (n = 30): central increased FAF (n = 4), normal FAF (n = 11), and well-demarcated reduced FAF (n = 15); with the latter group displaying a slow increase in the area of reduced FAF of 0.03 mm(2) over 19.3 months (P = 0.002).

CONCLUSIONS

Previously published cross-sectional studies have described conflicting findings with respect to the age-dependency of progression. This study, which constitutes the largest and longest prospective longitudinal study of ACHM to date, suggests that although ACHM may be progressive, any such progression is slow and subtle in most patients, and does not correlate with age or genotype. We also describe the first serial assessment of FAF, which is highly variable between individuals, even of similar age and genotype.

The role of patient, tumour and system factors in socioeconomic inequalities in lung cancer treatment: population-based study

Background:

Reducing socioeconomic inequalities in lung cancer treatment may reduce survival inequalities. However, the reasons for treatment variation are unclear.

Methods:

Northern and Yorkshire cancer registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to explore the role of stage, histology, performance status and comorbidity in socioeconomic inequalities in lung cancer treatment, for 28 733 lung cancer patients diagnosed in 2006–2010, and in a subgroup with stage recorded (n=7769, 27%).

Results:

Likelihood of receiving surgery was significantly lower in the most deprived group (odds ratio (OR)=0.75, 95% confidence interval (CI) 0.65–0.86); however, the OR was attenuated when including histological subtype (OR=0.82, 95% CI 0.71–0.96). Patients in the most deprived group were significantly less likely to receive chemotherapy in the fully adjusted full cohort model including performance status (OR=0.64, 95% CI 0.58–0.72) but not in the staged subgroup model when performance status was included (OR=0.88, 95% CI 0.72–1.08). Socioeconomic inequalities in radiotherapy were not found.

Interpretation:

Socioeconomic inequalities in performance status statistically explained socioeconomic inequalities in receipt of chemotherapy in the selective staged subgroup, but not in the full cohort. Socioeconomic variation in histological subtype may account for some of the socioeconomic inequalities in surgery.

Retinal structure and function in achromatopsia: implications for gene therapy

PURPOSE

To characterize retinal structure and function in achromatopsia (ACHM) in preparation for clinical trials of gene therapy.

DESIGN

Cross-sectional study.

PARTICIPANTS

Forty subjects with ACHM.

METHODS

All subjects underwent spectral domain optical coherence tomography (SD-OCT), microperimetry, and molecular genetic testing. Foveal structure on SD-OCT was graded into 5 distinct categories: (1) continuous inner segment ellipsoid (ISe), (2) ISe disruption, (3) ISe absence, (4) presence of a hyporeflective zone (HRZ), and (5) outer retinal atrophy including retinal pigment epithelial loss. Foveal and outer nuclear layer (ONL) thickness was measured and presence of hypoplasia determined.

MAIN OUTCOME MEASURES

Photoreceptor appearance on SD-OCT imaging, foveal and ONL thickness, presence of foveal hypoplasia, retinal sensitivity and fixation stability, and association of these parameters with age and genotype.

RESULTS

Forty subjects with a mean age of 24.9 years (range, 6-52 years) were included. Disease-causing variants were found in CNGA3 (n = 18), CNGB3 (n = 15), GNAT2 (n = 4), and PDE6C (n = 1). No variants were found in 2 individuals. In all, 22.5% of subjects had a continuous ISe layer at the fovea, 27.5% had ISe disruption, 20% had an absent ISe layer, 22.5% had an HRZ, and 7.5% had outer retinal atrophy. No significant differences in age (P = 0.77), mean retinal sensitivity (P = 0.21), or fixation stability (P = 0.34) across the 5 SD-OCT categories were evident. No correlation was found between age and foveal thickness (P = 0.84) or between age and foveal ONL thickness (P = 0.12).

CONCLUSIONS

The lack of a clear association of disruption of retinal structure or function in ACHM with age suggests that the window of opportunity for intervention by gene therapy is wider in some individuals than previously indicated. Therefore, the potential benefit for a given subject is likely to be better predicted by specific measurement of photoreceptor structure rather than simply by age. The ability to directly assess cone photoreceptor preservation with SD-OCT and/or adaptive optics imaging is likely to prove invaluable in selecting subjects for future trials and measuring the trials' impact.

Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice -- an evidence-based international guide

BACKGROUND

Evidence suggests that the gut microbiota play an important role in gastrointestinal problems.

AIM

To give clinicians a practical reference guide on the role of specified probiotics in managing particular lower gastrointestinal symptoms/problems by means of a systematic review-based consensus.

METHODS

Systematic literature searching identified randomised, placebo-controlled trials in adults; evidence for each symptom/problem was graded and statements developed (consensus process; 10-member panel). As results cannot be generalised between different probiotics, individual probiotics were identified for each statement.

RESULTS

Thirty seven studies were included; mostly on irritable bowel syndrome [IBS; 19 studies; treatment responder rates: 18-80% (specific probiotics), 5-50% (placebo)] or antibiotic-associated diarrhoea (AAD; 10 studies). Statements with 100% agreement and 'high' evidence levels indicated that: (i) specific probiotics help reduce overall symptom burden and abdominal pain in some IBS patients; (ii) in patients receiving antibiotics/Helicobacter pylori eradication therapy, specified probiotics are helpful as adjuvants to prevent/reduce the duration/intensity of AAD; (iii) probiotics have favourable safety in patients in primary care. Items with 70-100% agreement and 'moderate' evidence were: (i) specific probiotics help relieve overall symptom burden in some patients with diarrhoea-predominant IBS, and reduce bloating/distension and improve bowel movement frequency/consistency in some IBS patients and (ii) with some probiotics, improved symptoms have led to improvement in quality of life.

CONCLUSIONS

Specified probiotics can provide benefit in IBS and antibiotic-associated diarrhoea; relatively few studies in other indications suggested benefits warranting further research. This study provides practical guidance on which probiotic to select for a specific problem.

Xenon-enhanced computed tomography cerebral blood flow measurements in acute cerebral ischemia: Review of 56 cases

OBJECTIVE

Ischemic stroke must be diagnosed promptly if patients are to be treated with thrombolytic therapy. The diagnosis of acute cerebral ischemia, however, is usually based on clinical and computed tomography (CT) scan findings. CT scans are often normal in the first few hours after stroke. The purpose of this study was to determine whether Xenon-enhanced CT (XeCT) cerebral blood flow (CBF) studies could increase the sensitivity of stroke detection in the acute stage.

METHODS

CBF studies performed within 8 hours of symptom onset were evaluated in 56 patients who presented with hemispheric stroke symptoms. Mean CBF in the symptomatic vascular territory was calculated and compared with the corresponding contralateral area. CBF values below 18 mL/100g/min on 2 adjacent regions of interest were considered ischemic lesions. CT scans and angiograms were compared with the XeCt findings. Neurological condition on admission and discharge was evaluated by using National Institutes of Health Stroke Scale (NIHSS) scores.

RESULTS

The mean NIHSS score on admission was 12+/-5. Early CT scans were abnormal in 28 (50%) patients. There were 9 (16%) patients who had normal XeCT scans because of spontaneous reperfusion of the ischemic area. XeCT studies showed an ischemic lesion in 47 (84%) patients. In these patients, the mean CBF in the affected vascular territory was 16+/-8 mL/100g/min compared with 35+/-13 mL/100g/min in the contralateral specular territory (P<0.001). There were no false positive or negative XeCT studies, and the location of the perfusion defect corresponded with the CT and/or angiographic findings in all cases. Eight patients died (14%), and the 48 survivors (86%) had a mean NIHSS score of 9+/-6 on discharge.

CONCLUSIONS

CBF measurements were correlated with the CT and angiographic results and greatly assisted in the diagnosis of acute ischemic stroke. XeCT studies used for estimating the location and extent of cerebral ischemia may be important in the triage of patients for acute stroke therapy.

The Aarhus statement: improving design and reporting of studies on early cancer diagnosis

Early diagnosis is a key factor in improving the outcomes of cancer patients. A greater understanding of the pre-diagnostic patient pathways is vital yet, at present, research in this field lacks consistent definitions and methods. As a consequence much early diagnosis research is difficult to interpret. A consensus group was formed with the aim of producing guidance and a checklist for early cancer-diagnosis researchers. A consensus conference approach combined with nominal group techniques was used. The work was supported by a systematic review of early diagnosis literature, focussing on existing instruments used to measure time points and intervals in early cancer-diagnosis research. A series of recommendations for definitions and methodological approaches is presented. This is complemented by a checklist that early diagnosis researchers can use when designing and conducting studies in this field. The Aarhus checklist is a resource for early cancer-diagnosis research that should promote greater precision and transparency in both definitions and methods. Further work will examine whether the checklist can be readily adopted by researchers, and feedback on the guidance will be used in future updates.

Psychological Distress and Social Support in Informal Caregivers of Stroke Survivors

Background: A high degree of burden is often experienced by informal caregivers of stroke survivors. However, little is known about the long-term impact of the caregiving role. This study sought to examine the relationship between social support and the psychological effects experienced by long-term caregivers of stroke survivors. Methods: The design was a prospective, multicentre, hospital-based stroke cohort study with 3 years of follow-up. Caregivers of participating stroke survivors completed questionnaires either through face-to-face interview or over the telephone. Primary outcome measures were the Medical Outcome Study (MOS) Social Support Survey and the Irritability, Depression, and Anxiety (IDA) Scale, and the association between them was investigated using multivariate logistic regression. Results: 174/217 (80%) stroke survivors participated at 3 years, involving 116 informal caregivers (mean age 66.9 years, 71% female). Increasing social support was correlated with lower levels of depression, anxiety and inward irritability in caregivers. Social support was independently associated with anxiety (OR 0.55, 95% CI 0.35–0.85; p = .007) and inward irritability (OR 0.47, 95% CI 0.29–0.77; p = .002). Furthermore, social support was significantly associated with carer strain, as assessed by the Caregiver Strain Index. Conclusions: The amount of social support available to long-term caregivers of stroke survivors may be an important factor in lowering psychological burden in these caregivers.