The journey of cancer patients and the quest to equity: findings from Morocco

OBJECTIVES

Rapid diagnostic and assessment pathways for cancer patients provide timely and effective care. This study took place in Morocco, where the majority of patients treated in the public sector are diagnosed at an advanced stage. The aim of this study was to determine the duration of different time intervals along the cancer patient pathway and to highlight problem areas so that strategies can be implemented to make the process more equitable and effective.

STUDY DESIGN

Cross-sectional study.

METHODS

Recently diagnosed cancer patients were recruited from four major oncology centres in Morocco; namely, Marrakech, Casablanca, Rabat, and Fez. A questionnaire survey was administered, including sociodemographic and medical information and questions on access to the oncology centre, beliefs, and opinions on the medical staff. The dates of symptom recognition, assessment, diagnosis referral, biopsy, and treatment initiation were collected. Different time intervals (patient, diagnosis, biopsy, and treatment) were estimated and their determinants were investigated.

RESULTS

A total of 812 patients were interviewed. The majority of participants were breast cancer patients. In total, 60% of participants were at stage III-IV. The main facilitators of cancer diagnosis confirmation and treatment initiation were easy access to diagnosis and treatment facilities, financial resources, personal history of cancer, time availability, late stage at diagnosis, advanced age, and private health insurance. The patient interval (i.e., time from symptom recognition to initial healthcare assessment) had a median duration of 30 days. The biopsy and treatment intervals were within the current international recommendations (7 and 28 days, respectively). However, the diagnosis interval (52 days) was twice as long as the recommended timeframes from the UK, Australia, and the World Health Organization (<28 days).

CONCLUSIONS

Interval targets should be defined to encourage health systems to be more equitable and effective and to ensure that cancer patients are treated within a defined timeframe.

Meta-analysis of the efficacy of cold coagulation as a treatment method for cervical intraepithelial neoplasia: a systematic review

BACKGROUND

Cold coagulation is an ablative method for treatment of cervical intraepithelial neoplasia (CIN). Despite reports of efficacy against all grades of CIN (CIN1-3), cold coagulation has been infrequently used since the 1980s, and was absent from the recent Cochrane review on CIN treatment.

OBJECTIVES

To provide a systematic review of cold coagulation efficacy and acceptability for CIN treatment through meta-analysis of clinical reports and a randomised control trial.

SEARCH STRATEGY

A literature search in PubMed, Web of Science, EMBASE, and regional databases yielded 388 papers. Title, abstract and/or reference list review identified 22 papers describing cold coagulation treatment of CIN, with 13 providing adequate data for inclusion in the meta-analysis.

SELECTION CRITERIA

Publications or conference abstracts describing original data (number of women treated, followed up and cured, provider type, cure definition) were retained. No language or publication date limitations were imposed.

DATA COLLECTION AND ANALYSIS

Data extracted from 13 studies were pooled, and statistical analyses of proportion cured were conducted with data stratified by lesion grade and study region.

MAIN RESULTS

Among 4569 CIN patients treated with cold coagulation, summary proportion cured of 96% [95% confidence interval (CI) 92-99%] and 95% (92-98%) were obtained for CIN1 and CIN2-3 disease, respectively. Side-effects and adverse effects were infrequent, and fertility was not impaired.

CONCLUSIONS

Cold coagulation CIN cure rates were comparable to those of other excisional and ablative methods. Cold coagulation is indicated for all grades of CIN, is safe, quick and acceptable, and may be of particular relevance for use in resource-limited settings.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Completed suicide in adults of rural Kerala: rates and determinants

BACKGROUND

India has witnessed a dramatic increase in suicide rates during the past few decades. The southern state of Kerala has been reporting the highest rates of suicide. Since suicide rates are estimated from death registries, they are likely to be under-reported because the civil registration system is incomplete and suicide deaths are poorly reported.

METHODS

A cohort of 132 000 participants (age 35 years and above) in Thiruvananthapuram (erstwhile Trivandrum) district, Kerala was followed up for mortality from 1996 to 2005, after having filled-in a lifestyle questionnaire at baseline. The cause of death was based on verbal autopsy. Suicide methods were recorded and rates were estimated, and suicide risks were calculated according to several socioeconomic factors.

RESULTS

During the follow up period, a total of 11 608 deaths, of which 385 were suicides (3.3% of total deaths), were registered. The overall suicide rate was 39.3/100 000 person-years among adults 35-90 years of age (men: 78/ 100000; women: 16.5/100000). The predominant methods of suicide were hanging, followed by poisoning and drowning. The suicide determinants were male gender, middle-age (40-60 years), Hindu, alcohol drinkers and secondary education level (< or = 7 years). Neither low socioeconomic level, living alone, nor being a married woman was associated with suicide risk.

CONCLUSION

Suicide rates were consistent with the official rates of Thiruvananthapuram district (37/100 000). However, our study population did not include the 14-34-year-old age-group which represents more than 37% of all suicides and hence it is more likely that the official rates are under-reported. Determinants of suicide were in line with previous studies.

Vegetable and Fruit Intake and Stroke Mortality in the Hiroshima/Nagasaki Life Span Study

BACKGROUND AND PURPOSE

Fruits and vegetables are known for their beneficial effects on chronic diseases. The purpose of the present study was to investigate the protective effect of a diet rich in fruits and vegetables on total stroke mortality and its 2 main subtypes in men and women separately.

METHODS

A prospective cohort study of 40 349 Japanese men and women was initiated in 1980-1981 and followed until 1998. Fruit and vegetable intake was assessed at baseline on the basis of the response to a food frequency questionnaire. During the 18-year follow-up period, deaths from stroke were registered.

RESULTS

A total of 1926 stroke deaths were identified during the follow-up period. An increasing frequency of intake of green-yellow vegetables and fruit was associated with a reduced risk of death from intracerebral hemorrhage and cerebral infarction. Daily intake of green-yellow vegetables was associated with a significant 26% reduction in the risk of death from total stroke in men and women compared with an intake of once or less per week. The protective effect associated with daily fruit and vegetable intake was observed for both cerebral infarction and intracerebral hemorrhage mortality but was slightly stronger and clearer for infarction than for hemorrhage, with a 32% reduction in men and a 30% reduction in women. Daily fruit intake was associated with a significant 35% reduction in risk of total stroke in men and a 25% reduction in women and was equally strong for both intracerebral hemorrhage and cerebral infarction.

CONCLUSIONS

Daily consumption of green-yellow vegetables and fruits is associated with a lower risk of total stroke, intracerebral hemorrhage, and cerebral infarction mortality. The protective effects are similar in both men and women.

Vegetables and fruit intake and cancer mortality in the Hiroshima/Nagasaki Life Span Study

The association between green-yellow vegetables and fruit consumption and risk of cancer death was investigated in a prospective study of 38 540 men and women who were atomic-bomb survivors in Hiroshima and Nagasaki, Japan. Study participants completed a dietary questionnaire in 1980-1981 and were followed-up for cancer deaths until March 1998, during which time 3136 cancer deaths were identified. Daily or almost daily fruit consumption was associated with a significant 12% reduction in total cancer mortality (RR=0.88; 95% CI, 0.80-0.96 for daily intake compared with intake once per week or less). Daily or almost daily green-yellow vegetables consumption was associated with a marginally significant 8% reduction in total cancer mortality (0.92; 0.94-1.01). Green-yellow vegetables consumption was associated with a significant reduction in liver cancer mortality (0.75; 0.60-0.95). Fruit consumption was associated with a significantly reduced risk of stomach cancer and lung cancer mortality (0.80; 0.65-0.98). Green-yellow vegetables and fruit consumption was associated with a reduction in oesophageal cancer, but these associations were not statistically significant. Neither green-yellow vegetables nor fruit consumption was associated with colorectal cancer or breast cancer mortality. These results support the evidence that daily consumption of fruit and vegetables reduces the risk of total cancer, and specifically cancers of the stomach, liver, and lung.

Dementia as a predictor of functional disability: a four-year follow-up study

BACKGROUND

Prospective studies have shown that cognitive impairment is a strong and consistent risk factor of physical disability. However, cognitive impairment has been based on the result of a single screening tool.

OBJECTIVE

To investigate the role of cognition in the subsequent incidence and decline of functional disability in basic activities of daily living (ADL) and instrumental activities of daily living (IADL) after a full assessment of dementia.

METHODS

A group of 1,358 Japanese atomic bomb survivors aged 61 years or older who lived in the community or in institutions in Hiroshima City were followed for 4 years. During the baseline survey (1993-1995), subjects were administered a screening test for cognitive impairment. Those suspected of dementia underwent a series of cognitive tests (Hasegawa's dementia scale, Clinical Dementia Rating) and a neurological examination. The diagnosis of dementia was made according to DSM-III-R criteria. Study subjects were questioned about their reported ADL and their IADL. During the follow-up period, deaths were recorded and a follow-up survey (1997-1999) used to assess ADL and IADL performance.

RESULTS

Dementia, even after adjustment for age, sex and history of stroke, was a strong predictor of functional disability, as indicated by ADL (odds ratio, OR = 14.0; confidence interval, CI = 5.4-36.3), IADL (OR = 10.1, CI = 2.2-46.4), and also by assessment of decline in ADL (OR = 9.8, CI = 4.2-22.8) or IADL status (OR = 3.9, CI = 1.8-8.3).

CONCLUSION

Dementia is an important determinant of functional status. Deterioration in ADL is more significant than deterioration in IADL, suggesting that factors other than cognition, such as motivation or perceptual, sensory and motor abilities, may be important in IADL performance. This study confirms previous findings on risk factors that affect functional ability and extends our knowledge by examining several criteria of function that are important in the daily lives of elderly people.

Active and cognitive impairment-free life expectancies: results from the Melton Mowbray 75+ health checks

OBJECTIVES

To estimate active and cognitive impairment-free life expectancy at older ages from longitudinal data collected during two consecutive rounds of health checks for patients aged > or =75 years.

SETTING

A single, large general practice serving Melton Mowbray, Leicestershire, UK, and its surrounding area.

OUTCOME MEASURES

active life expectancy was defined by independence in seven activities of daily living (mobility, transfer from bed, transfer from chair, bathing, feeding, dressing, using the toilet). Cognitive impairment was defined by a score of < or =7 on the information/orientation subtest of the Clifton Assessment Procedures of the Elderly.

RESULTS

We assessed 1557 people aged > or =75 years at baseline. Active life expectancy at age 75 was 4.6 years for men and 3.1 years for women (50.5 and 29.2% of remaining life). Cognitive impairment-free life expectancy at age 75 was 8.4 years for men and 9.9 years for women (92.3 and 93.4% of remaining life). The proportion of active life decreased dramatically with age in both sexes: after the age of 87, almost all of remaining life was spent with some activity restriction. The proportion of life free from cognitive impairment, in comparison, decreased slowly in men and remained relatively constant in women at around 90%.

CONCLUSIONS

The extra years lived by women over men appear to be spent with some form of activity restriction, although not all with cognitive impairment. Monitoring these trends over time will be important to ascertain whether we are exchanging longer life for poorer health.

Effects of exercise training on home blood pressure values in older adults: a randomized controlled trial

OBJECTIVE

To determine the effects of exercise training on the blood pressure (BP) values of older adults, using home blood pressure measurement.

DESIGN

Randomized controlled trial.

PARTICIPANTS

A total of thirty-nine free-living older adults (including 19 men) aged from 60-81 years with home systolic blood pressure > 120 mmHg and without significant cardiopulmonary-musculoskeletal disease, were randomly allocated to either 25 weeks of exercise training (exercise group) or to a control program (control group).

MAIN OUTCOME MEASUREMENTS

Change in the 2-week averages of home systolic and diastolic blood pressure values measured with a validated automatic device before, during and after the intervention period.

RESULTS

Compared with the control group, the exercise group showed a significant decrease in values for home systolic blood pressure (maximum between-group difference = 7.7 mmHg, P = 0.003) and home diastolic blood pressure (4.2 mmHg, P = 0.001). These changes were observed for both genders.

CONCLUSIONS

Exercise training was effective for older adults in lowering home blood pressure values. This is the first trial to demonstrate the usefulness of home blood pressure measurement in examining the effect of exercise training on blood pressure values.

[Active life expectancy: factors influencing regional and gender differences]

Active life expectancy (ALE) is defined as an expected duration to be spent with a certain level of physical/mental function. The objectives of this article are to indicate ALE values based on our prospective observation, and to discuss factors influencing regional and gender differences in ALE values. We estimated ALE without disability in basic activities of daily living (ADL) on a 5% random sample (n = 3,459) of the residents aged 65 years and over in Sendai City between 1988 and 1991. At the age 65, ALE was 14.7 years for men and 17.7 years for women. ALE occupied 91% of the total life expectancy for men and 87% for women. As compared with the reports for the American elderly, ALE was longer in Sendai than in the United States. The duration to be spent with disability was shorter among the subjects in Sendai. We estimated ALEs in three functional areas: basic ADL, instrumental ADL, and mobility, on all the residents aged 65 years and over (n = 3,590) at Wakuya Town between 1994 and 1996. For both sexes, ALE in IADL was shorter than those in basic ADL and mobility. The development and progression of disability were different between sexes: men experienced disability at a younger age and progressed at a faster rate than women.

Randomized controlled trial of exercise training for older people (Sendai Silver Center Trial; SSCT): study design and primary outcome

Physical exercise is expected to improve and maintain physical function in older people, thus promoting health and preventing or postponing the onset of disability in later life. The Sendai Silver Center Trial (SSCT) was a randomized controlled trial designed to evaluate the efficacy of exercise training among healthy free-living older people. Sixty-five eligible participants, aged from 60 to 81 years, were randomly allocated to an exercise group or a control group. The subjects in the exercise group were asked to attend training classes at the Sendai Silver Center, a municipal health and welfare facility in the center of Sendai City, at least twice a week for 25 weeks. Each training class, lasting two hours, started with a warm-up session, followed by an endurance session with a bicycle ergometer, and a resistance exercise training session using rubber films, and ended with a cool-down session. The subjects in the control group were asked to attend recreational classes at the Center twice a month. There were no drop-outs or accidents during the intervention. Comparison of maximum oxygen consumption (VO2max) before and after the 25-week intervention revealed a significant increase in the exercise group (2.1 ml/kg/min) but no significant change in the control group. Our result is equivalent to the participants becoming younger in aerobic capacity by five years after six months of exercise training.

Trends in dementia-free life expectancy among elderly members of a large health maintenance organization

BACKGROUND

This study examined the secular trends of life expectancy without dementia among elderly American members of a health maintenance organization, and observed if an increased life expectancy is accompanied by an increase in the duration of life with dementia.

METHODS

The data derived from two chronological 9-year prospective cohort studies of members of the Kaiser Permanente Medical Care Program of Northern California. The first and second cohorts included 2,702 and 2,926 people aged > or =65 years free from dementia at baseline. Life expectancy without dementia or dementia-free life expectancy (DemFLE) is defined as the average number of years a person is expected to live without dementia. Total life expectancy is equal to the sum of DemFLE and life expectancy with dementia. Estimations of DemFLE were based on mortality data and incidence of dementia, using double-decrement life tables.

RESULTS

Between the first and second cohorts, all-cause mortality rates declined, while the incidence of dementia remained constant in both men and women. Among the males, total life expectancy increased at a higher rate than DemFLE. Consequently, the duration of life with dementia was extended in the second cohort. Conversely, among the females DemFLE increased at a higher rate than total life expectancy, thus the duration of life with dementia decreased in the second cohort. The median age of dementia onset was postponed by 2-3 years in the second cohort for females, and did not show any specific difference between the two cohorts in males.

CONCLUSION

The trends of health expectancies suggest an extension of the duration of life with dementia for males and a compression of dementia for females. A decreased incidence of risk factors for dementia among females in the second cohort such as stroke may explain these trends.

Health-life expectancy according to various functional levels

OBJECTIVES

To estimate disability-free life expectancy according to three functional levels.

DESIGN

A 2-year prospective study of older residents in a rural Japanese community. The functional ability of each individual was determined with self-completed questionnaires at baseline (1994) and at follow-up (1996).

SETTING AND PARTICIPANTS

All residents of Wakuya Town, Japan, who were aged 65 years or older at the start of the study in 1994 (n = 3590).

MEASUREMENTS

Single-year increment-decrement life tables were constructed from mortality rates and incidence of disability rates. Independent life expectancies in three functional areas: basic activities of daily living (ADL), instrumental activities of daily living (IADL), and mobility, were estimated for each sex and each year of age.

RESULTS

The incidence and prevalence of disability were similar in men and women. For both sexes, independent life in IADL was shorter than independent life in ADL and mobility. The development and progression of disability were different between sexes: men experienced disability at a younger age and at a faster rate than women.

CONCLUSIONS

The slow progress of disability, with a longer duration in a disabled state among women, induces a heavy burden on health and welfare resources. Interventions to delay the onset of disability in women should reduce the economic burden to society as well as improve the quality of life. Prospective studies to look at the process of disablement, based on direct observation, are needed to confirm the gender differences.

[The health and welfare system for elderly in France]

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.

Factors related to the desire to enter a nursing home among elderly Japanese

A cross-sectional survey on 1462 residents aged 55 years and over was conducted in an urban Japanese community to describe the factors influencing the people's desire to be institutionalized in later life. Multiple logistic regression analyses were performed to identify the variables associated with the desire for a nursing home placement. Men unsatisfied with their family bonds were more likely to desire placement in a nursing home. Younger women living alone or dissatisfied with their health status demonstrated a greater desire to be institutionalized. Among the elderly aged 70 years old and over, those who were dissatisfied with their family bonds or disabled in going outdoors were more likely to desire to live in a welfare facility. Gender, housing and financial characteristics were not significant factors for the desire to be institutionalized. Numerous factors were similar with actual predictors of nursing home placement; however, the elderly advancing in age were more concerned to remain at home. The present findings suggest that, aside from physical and mental disability, the family-related issue is the most important factor prompting the desire for institutionalization.

Dementia-free life expectancy among elderly Japanese

A 3-year prospective cohort study was conducted to estimate the life expectancy free of dementia (dementia-free life expectancy) in a representative sample of older persons living in an urban Japanese community. For the persons aged 65 years and older, who were not demented at the baseline survey in 1988, mortality and incidence rates of dementia were calculated. At the age of 65 years, males showed a total life expectancy of 18 years, including 16 years free of dementia, and females showed a total life expectancy of 23 years, including 18 years without dementia. At 65 years, the dementia-free life expectancy represented 89% of the total life expectancy for males and 79% for females. Total life expectancy and dementia-free life expectancy were longer among females than among males. However, the life-years with dementia were longer among females. This result would be attributable to a higher incidence of dementia and a lower mortality among females.

Factors affecting death at home in Japan

Despite the wish of the Japanese people to spend their final moments at home, the percentage of deaths at home among elderly is decreasing. Moreover, large variations in this rate were observed over the country. The present ecological study analyzed the relationship between the percentage of deaths at home for decedents aged 70 and over, and demographic, medical and socioeconomic characteristics. The data published in 1990 by the Japanese National Government were analyzed by correlation, principal-component, and multiple linear regression analyses. The results showed that the percentage of deaths at home for decedents aged 70 and over was positively associated with the number of persons per household, and the area of floor space per house. The divorce rate, the national tax per capita, and the mean length of hospitalization for stroke showed a negative association with the percentage of deaths at home. In the prefectures where the crude death rates of stroke and senility were high, elderly were more likely to die at home. These results suggested the importance of the number of family caregivers, and the housing conditions for terminal care at home. This research may lead to improve home medical assistance which is still underdeveloped in Japan.