Barriers to uptake of services for coronary heart disease: qualitative study

OBJECTIVES

To identify factors within the South Yorkshire coalfields that influence use of health services by people with angina.

DESIGN

Qualitative study using semistructured individual and group interviews.

SETTING

General practice and community settings in Barnsley and Rotherham health authorities.

PARTICIPANTS

14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners.

MAIN OUTCOME MEASURES

Barriers to accessing health services.

RESULTS

A complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness.

CONCLUSIONS

Many of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral.

Sensitivity of the cervical transformation zone to estrogen-induced squamous carcinogenesis

Regions where one type of epithelium replaces another (metaplasia) have a predilection for cancer formation. Environmental factors are closely linked to metaplastic carcinogenesis. In particular, cervical cancers associated with human papillomavirus (HPV) infection develop primarily at the transformation zone, a region where metaplastic squamous cells are detected in otherwise columnar epithelial-lined endocervical glands. Previously, we reported estrogen-induced multistage vaginal and cervical carcinogenesis in transgenic mice expressing HPV16 oncogenes in basal squamous epithelial cells. In the present study to investigate the threshold neoplastic response to exogenous estrogen, we treated groups of transgenic mice with lower hormone doses. A 5-fold reduction in estrogen dose induced squamous carcinogenesis solely at the cervical transformation zone compared with other reproductive tract sites. Further study delineated stages of transformation zone carcinogenesis, including formation of hyperplastic lower uterine glands and emergence of multiple foci of squamous metaplasia from individual stem-like glandular reserve cells, followed by neoplastic progression of metaplasia to dysplasia and squamous cancer. We propose that a combination of low-dose estrogen and low-level HPV oncogene expression biases transformation zone glandular reserve cells toward squamous rather than columnar epithelial fate decisions. Synergistic activation of proliferation by viral oncoprotein cell cycle dysregulation and estrogen receptor signaling, together with altered paracrine stromal-epithelial interactions, may conspire to support and promote neoplastic progression and cancer formation.

Post-partum rubella immunisation: a controlled trial of two vaccines

The effectiveness of two rubella vaccines (RA 27/3 and Cendehill) in women vaccinated post partum was compared. Significantly more women who received RA 27/3 gave satisfactory seroconversion responses than women who received Cendehill (97.6% vs 82.2%). This difference was reflected in the geometric mean titres (43.6 vs 17.0). More women who received RA 27/3 had minor side-effects, but the difference was not significant. The serological response to both vaccines was not affected by the concurrent administration of anti-D immunoglobulin. In view of these findings, the replacement of Cendehill vaccine with RA 27/3 vaccine for women vaccinated post partum should be considered.