The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

Beyond A to E: addressing the unfamiliar issues arising in the acute and immediate phase post-catastrophe

During a time in which there is increased focus on level 5 and 6 prehospital emergency care provision and utilisation in the deployed military space, it is important to consider the range of care that more junior medical practitioners may be exposed to. The initial response to a catastrophe at a level pertaining to General Duties Medical Officers or similar forward-deployed tri-service personnel comprises acute care and triage skills, which are widely taught through prehospital courses and Foundation training. However, beyond that, the necessary workload becomes less clear. To provide comprehensive care in-theatre, there is the need to consider more nuanced and unfamiliar issues such as components in the immediate postcatastrophe landscape. These include aspects such as care of human remains, mental health, chronic conditions in the acute phase and the scope of military medical assistance within the wider relief effort. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Assessing how routes to diagnosis vary by the age of patients with cancer: a nationwide register-based cohort study in Denmark

BACKGROUND

Older patients with cancer have poorer prognosis compared to younger patients. Moreover, prognosis is related to how cancer is identified, and where in the healthcare system patients present, i.e. routes to diagnosis (RtD). We investigated whether RtD varied by patients' age.

METHODS

This population-based national cohort study used Danish registry data. Patients were categorized into age groups and eight mutually exclusive RtD. We employed multinomial logistic regressions adjusted for sex, region, diagnosis year, cohabitation, education, income, immigration status and comorbidities. Screened and non-screened patients were analysed separately.

RESULTS

The study included 137,876 patients. Both younger and older patients with cancer were less likely to get diagnosed after a cancer patient pathways referral from primary care physician compared to middle-aged patients. Older patients were more likely to get diagnosed via unplanned admission, death certificate only, and outpatient admission compared to younger patients. The patterns were similar across comorbidity levels.

CONCLUSIONS

RtD varied by age groups, and middle-aged patients were the most likely to get diagnosed after cancer patient pathways with referral from primary care. Emphasis should be put on raising clinicians' awareness of cancer being the underlying cause of symptoms in both younger patients and in older patients.

Population trends in emergency cancer diagnoses: The role of changing patient case-mix

BACKGROUND

Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown.

METHODS

We analysed 'Routes to Diagnosis' data on cancer patients (2006-2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations.

RESULTS

Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%-19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction.

CONCLUSION

Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed.

Geographic variation in the use of lymphadenectomy and external-beam radiotherapy for endometrial cancer: a cross-sectional analysis of population-based data

OBJECTIVE

To quantify geographic variation in the use of lymphadenectomy and/or external-beam radiotherapy (EBRT) for endometrial cancer in England.

DESIGN

Cross-sectional analysis of population-based data.

SETTING

English cancer registry data, linked to chemotherapy, radiotherapy and hospital episodes statistics data.

POPULATION

Twenty-two thousand four hundred and eighty-three women with endometrial cancer presenting without clinical or radiological evidence of distant metastatic spread, diagnosed in England from 2013 to 2016.

METHODS

Proportions of patients receiving lymphadenectomy and/or EBRT were compared across 19 Cancer Alliances, to identify variations in clinical practice. Two separate logistic regression models assessed the impact on variation of adjustment for tumour and patient characteristics.

MAIN OUTCOME MEASURES

Receipt of lymphadenectomy, receipt of EBRT.

RESULTS

There was substantial variation by Cancer Alliance in the adjusted proportion of women with endometrial cancer receiving lymphadenectomy (range 5% [95% CI 4-6%] to 48% [95% CI 45-52%]) and EBRT (range 10% [95% CI 7-12%] to 31% [95% CI 28-33%]), after adjusting for variation in pathological grade, age, comorbidities, deprivation, ethnic group and (EBRT only) FIGO stage. Different approaches to clinical practice were identified; (i) one Cancer Alliance had significantly higher than average lymphadenectomy and significantly lower than average EBRT use, (ii) three had high use of both lymphadenectomy and EBRT, (iii) one had low lymphadenectomy use and high EBRT use, and (iv) three had low use of both lymphadenectomy and EBRT.

CONCLUSIONS

Lymphadenectomy is probably used to triage for EBRT when lymphadenectomy use is high and EBRT use is low. This is probably a result of variation in local endometrial cancer management guidelines, suggesting that UK recommendations should be clarified.

TWEETABLE ABSTRACT

There is geographic variation in England in the use of lymphadenectomy and radiotherapy to treat endometrial cancer.

The longitudinal validity, reproducibility and responsiveness of the Brisbane Burn Scar Impact Profile (caregiver report for young children version) for measuring health-related quality of life in children with burn scars

BACKGROUND

The measurement of health-related quality of life (HRQoL) provides information about the perceived burden of the health condition and treatments from a lived experience. The Brisbane Burn Scar Impact Profile (caregiver report for young children, BBSIP^0-8), developed in 2013, is a proxy-report measure of burn scar-specific HRQoL. The aim of this study was to report its psychometric properties in line with an evaluative purpose.

METHODS

Caregivers of children up to 8 years of age at risk of burn scarring were recruited into a prospective, longitudinal cohort study. Caregivers completed the BBSIP^0-8, Pediatric Quality of Life Inventory and Patient Observer Scar Assessment Scale at baseline (approximately ≥85% of the total body surface area re-epithelialised), 1-2 weeks after baseline and 1-month after baseline. Psychometric properties measured included internal consistency, test-retest reliability, validity and responsiveness.

RESULTS

Eighty-six caregivers of mostly male children (55%), of a median age (IQR) of 1 year, 10 months (2 years, 1 month) and total body surface area burn of 1.5% (3.0%) were recruited. Over one third of participants were grafted and 15% had contractures or skin tightness at baseline. Internal consistency of ten item groups ranged from 0.73 to 0.96. Hypothesised correlations of changes in the BBSIP^0-8 items with changes in criterion measures supported longitudinal validity (ρ ranging from -0.73 to 0.68). The majority of item groups had acceptable reproducibility (ICC = 0.65-0.83). The responsiveness of five item groups was supported (AUC = 0.71-0.90).

CONCLUSION

The psychometric properties tested support the use of the BBSIP^0-8 as an evaluative measure of burn scar-related health-related quality of life for children aged below eight years in the early post-acute period of rehabilitation. Further investigation at longer time period after burn injury is indicated.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Variation in 'Fast-Track' Referrals for Suspected Cancer by Patient Characteristic and Cancer Diagnosis: Evidence From 670,000 Patients With Cancers of 35 Different Sites

Background: In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. Methods:  We examined data from 669,220 patients with 35 cancers diagnosed 2006-2010 following either fast-track or nonfast track primary-to-secondary care referrals using a bespoke English dataset, the 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristics and cancer diagnosis and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. Results:  There were large variations in the odds of fast-track referral by cancer ( P < 0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35 respectively, using rectal cancer as reference); while patients with brain cancer and leukemias least likely (adjusted odds ratios 0.05 and 0.09 respectively for brain cancer and acute myeloid leukemia). There were sex, age and deprivation differences in the odds of fast-track referral ( P < 0.013), which varied in their size and direction for patients with different cancers ( P < 0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. Conclusion: Fast-track referrals are less likely for cancers characterized by nonspecific presenting symptoms and patients belonging to low incidence demographic strata. Interventions beyond clinical guidelines for “alarm” symptoms are needed to improve diagnostic timeliness.

Timeliness of Presentation and Referral Among Cancer Patients Who Presented With Abdominal Symptoms: Evidence to Inform Symptom Awareness Campaigns

Background: Abdominal symptoms at presentation are common among patients subsequently diagnosed with cancer. While public health education campaigns in England and other countries have traditionally focused on 'red flag' symptoms associated with a single common cancer (e.g., 'blood in poo' and colorectal cancer), there is increasing interest in raising awareness of symptoms grouped by body area or system (eg 'abdominal symptoms'). Evidence regarding the frequency and nature of abdominal symptoms at presentation among a representative cancer patient cohort could inform the design and evaluation of community based cancer symptom awareness campaigns. Aim: To describe the frequency of abdominal symptoms at presentation among an incident cohort of cancer patients, examine variation in diagnostic timeliness and subsequently diagnosed cancer sites by abdominal symptom. Methods: The presenting symptom(s) of 15,956 cancer patients from a national audit of primary care records in England was coded into symptom categories. Eight abdominal symptoms with a range of predictive values and specificity for cancer were studied: abdominal pain, change in bowel habit, bloating/distension, dyspepsia, rectal bleeding, dysphagia, reflux, and nausea/vomiting. We investigated the prevalence of abdominal symptoms among the cancer patient population, examined variation in the length of the patient interval (time from symptom onset to presentation to primary care) and primary care interval (time from presentation to specialist referral) by symptom, and described the associated spectrum of diagnosed cancer sites for each individual symptom. Results: Almost a quarter (23%) of the incident cancer patient population had abdominal symptom(s) at presentation (n=3,661/15,956). The relative lengths of the patient and primary care intervals varied greatly by abdominal symptom. One in two cancer patients who had dysphagia before diagnosis presented 30 days after symptom onset (median (IQR) patient interval: 30 (10-61) days), but were referred immediately (median (IQR) primary care interval: 0 (0-14) days). In comparison, cancer patients who presented with abdominal pain had longer intervals postpresentation (median (IQR) patient interval: 7 (0-28) days, median (IQR) primary care interval: 16 (2-43) days). The majority (88.6%) of cancer patients who presented with an abdominal symptom were diagnosed with an abdominal or adjacent cancer, including colorectal, esophageal, ovarian, and pancreatic cancers. However, the remainder of patients were diagnosed with solid tumors of nonabdominal organ origin (7.6%) or a hematologic cancer (3.8%). Conclusion: Cancer symptom awareness campaigns focusing on abdominal symptoms could contribute to the earlier diagnosis of numerous common and rarer cancers. Evidence regarding the relative lengths of the patient and primary care intervals could be used as a measure of relative need for raising awareness.

Variation in 'fast-track' referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites

BACKGROUND

In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups.

METHODS

We examined data from 669 220 patients with 35 cancers diagnosed in 2006-2010 following either fast-track or 'routine' primary-to-secondary care referrals using 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer.

RESULTS

There were large variations in the odds of fast-track referral by cancer (P<0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35, respectively, using rectal cancer as reference); whereas patients with brain cancer and leukaemias least likely (adjusted odds ratios 0.05 and 0.09, respectively, for brain cancer and acute myeloid leukaemia). There were sex, age and deprivation differences in the odds of fast-track referral (P<0.013) that varied in their size and direction for patients with different cancers (P<0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer.

CONCLUSIONS

Fast-track referrals are less likely for cancers characterised by nonspecific presenting symptoms and patients belonging to low cancer incidence demographic groups. Interventions beyond clinical guidelines for 'alarm' symptoms are needed to improve diagnostic timeliness.

Stage at diagnosis and early mortality from cancer in England

Background:

Stage at diagnosis is a key predictor of overall cancer outcome. For the first time, stage completeness is high enough for robust analysis for the whole of England.

Methods:

We analysed data from the National Cancer Registration Service's (NCRS) Cancer Analysis System on persons diagnosed with breast, colorectal, lung, prostate or ovarian cancers in England in 2012. One-year relative survival (followed-up to the end of 2013) was calculated along with adjusted excess rate ratios, for mortality within 1 year.

Results:

One-year relative survival decreased with increasing stage at diagnosis. For breast, prostate and colorectal cancers survival showed a major reduction for stage 4 cancers, whereas for lung and ovarian cancers there were substantial decreases in relative survival for each level of increase in stage. Excess rate ratios for mortality within 1 year of diagnosis showed that stage and age were the most important cofactors, but they also identified the statistically significant effects of sex, income deprivation and geographic area of residence.

Conclusions:

Further reductions in mortality may be most effectively achieved by diagnosing all cancers before they progress to stage 4, but for lung and ovarian cancers there is also a need for a stage shift to earlier stages together with efforts to improve stage-specific survival at all stages.

The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers

BACKGROUND

Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus.

METHODS

We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10 953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site.

RESULTS

Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid).

CONCLUSIONS

The findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.

Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data

Background:

For patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown.

Methods:

We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category.

Results:

Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5–45) for patients undergoing investigation and 0 days (IQR 0–10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation.

Interpretation:

For six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.

Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers

BACKGROUND

Evidence is needed about the promptness of cancer diagnosis and associations between its measures.

METHODS

We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009-10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or 'interval' hereafter) and the number of pre-referral consultations.

RESULTS

Among 13,035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman's r=0.70). The association was at least moderate for any cancer (Spearman's r range: 0.55 (prostate)-0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g., multiple myeloma) and vice versa (e.g., breast cancer).

CONCLUSION

The number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.

Routes to diagnosis for cancer - determining the patient journey using multiple routine data sets

BACKGROUND

Cancer survival in England is lower than the European average, which has been at least partly attributed to later stage at diagnosis in English patients. There are substantial regional and demographic variations in cancer survival across England. The majority of patients are diagnosed following symptomatic or incidental presentation. This study defines a methodology by which the route the patient follows to the point of diagnosis can be categorised to examine demographic, organisational, service and personal reasons for delayed diagnosis.

METHODS

Administrative Hospital Episode Statistics data are linked with Cancer Waiting Times data, data from the cancer screening programmes and cancer registration data. Using these data sets, every case of cancer registered in England, which was diagnosed in 2006-2008, is categorised into one of eight 'Routes to Diagnosis'.

RESULTS

Different cancer types show substantial differences between the proportion of cases that present by each route, in reasonable agreement with previous clinical studies. Patients presenting via Emergency routes have substantially lower 1-year relative survival.

CONCLUSION

Linked cancer registration and administrative data can be used to robustly categorise the route to a cancer diagnosis for all patients. These categories can be used to enhance understanding of and explore possible reasons for delayed diagnosis.

Flexible therapeutic landscapes of labour and the place of pain relief

Flexibility in the design and enactment of spaces of healthcare is important in how providers respond to variations in patient expectations and experience. Health geographers have contributed to a wide body of literature concerning the therapeutic qualities of landscapes and the material, social and symbolic orderings of place and their uniqueness for individuals. In this paper, we draw upon these findings and a 'culture of place' approach to consider the complexities of maternity care and issues of pain relief. Given that pain is widely held to be a subjective experience and one that, in an era of patient decision making, increasingly demands discretionary approaches to its relief, we consider how medical professionals help to construct flexibility in healthcare and how this affects therapeutic landscapes. Drawing on analysis of four focus groups involving parent educators, midwives, health visitors, anaesthetists and obstetricians in the NE of England, we explore the material and discursive construction of flexible therapeutic landscapes and pain relief. Our findings suggest that flexibility is constrained and fashioned in association with health care professional's sense of place as already constituted. We propose that providing maternity care professionals with an explicit awareness of how places are relationally constructed, may help in expanding the therapeutic qualities of particular settings, and support a (more) flexible approach.

Spatially complex distribution of dissolved manganese in a fjord as revealed by high-resolution in situ sensing using the autonomous underwater vehicle Autosub

Loch Etive is a fjordic system on the west coast of Scotland. The deep waters of the upper basin are periodically isolated, and during these periods oxygen is lost through benthic respiration and concentrations of dissolved manganese increase. In April 2000 the autonomous underwater vehicle (AUV) Autosub was fitted with an in situ dissolved manganese analyzer and was used to study the spatial variability of this element together with oxygen, salinity, and temperature throughout the basin. Six along-loch transects were completed at either constant height above the seafloor or at constant depth below the surface. The ca. 4000 in situ 10-s-average dissolved Mn (Mnd) data points obtained provide a new quasi-synoptic and highly detailed view of the distribution of manganese in this fjordic environment not possible using conventional (water bottle) sampling. There is substantial variability in concentrations (<25 to >600 nM) and distributions of Mnd. Surface waters are characteristically low in Mnd reflecting mixing of riverine and marine end-member waters, both of which are low in Mnd. The deeper waters are enriched in Mnd, and as the water column always contains some oxygen, this must reflect primarily benthic inputs of reduced dissolved Mn. However, this enrichment of Mnd is spatially very variable, presumably as a result of variability in release of Mn coupled with mixing of water in the loch and removal processes. This work demonstrates how AUVs coupled with chemical sensors can reveal substantial small-scale variability of distributions of chemical species in coastal environments that would not be resolved by conventional sampling approaches. Such information is essential if we are to improve our understanding of the nature and significance of the underlying processes leading to this variability.

Prediction of impaired metabolic adaptation by antenatal Doppler studies in small for gestational age fetuses

The increased risk of hypoglycaemia for infants who are small for gestational age (SGA) is well known, and further information regarding metabolic adaptation can be gained by examining the profiles of glucose and other metabolic fuels in such infants. Not all SGA infants experience hypoglycaemia, however, and the ability to identify, antenatally, those at most risk would be helpful for obstetric and neonatal management. This study investigated metabolic differences between two groups of SGA infants who had antenatal umbilical artery Doppler studies. Fourteen had end diastolic velocities (EDV) present and 11 had absent EDV. The absent EDV group had significantly lower non-esterified fatty acid (NEFA) concentrations at birth, and lower blood glucose and NEFA concentrations in the first six hours after birth. After the first day, few metabolic differences were found between the two groups. Antenatal Doppler studies may identify those SGA infants who fail to achieve neonatal metabolic adaptation and are most at risk of early neonatal hypoglycaemia.

Recurrent anaphylactoid reaction during caesarean section

A 28-year-old woman presented for emergency Caesarean section at 31 weeks' gestation with deranged liver function and a history of recurrent anaphylactoid reactions during previous pregnancy-related anaesthetics. The anaesthetic management and outcome of this case is presented.

Single dose antibiotic prophylaxis in high risk patients undergoing transurethral prostatectomy

In a randomized controlled clinical trial single dose antibiotic prophylaxis (gentamicin 80 mg IV) was evaluated in 36 patients with indwelling urethral catheters undergoing transurethral prostatic resection. Prophylaxis resulted in a significant reduction in postoperative bacteriuria (P less than 0.01), pyrexia (P less than 0.001), bacteraemia (P less than 0.01) and septicaemia (P less than 0.05). During the same period there was one case of postoperative bacteriuria but no systemic infection in 25 consecutive patients undergoing elective prostatectomy with no local risk factors and in the absence of prophylaxis. A policy of selective antibiotic prophylaxis is justified and in high risk patients with in-dwelling catheters single dose prophylaxis is highly effective.

Role and functions of the academic coordinator of clinical education in physical therapy education: a survey

The Academic Coordinator of Clinical Education occupies a unique position in physical therapy education, often serving as the link between the didactic and the clinical domains of the program. A wealth of anecdotal information suggests the need for a more systematic study of the role and functions of the ACCE. A survey based on a self-administered questionnaire was sent to the ACCEs at 101 physical therapy education programs in the United States. A usable response rate of 79% was sufficient for the analysis. This study identifies some of the functions of the ACCEs, profiles their demographic characteristics, and describes the educational programs in which they work. The time ACCEs devote to participation in teaching, administrative, scholarly, and service activities is reported. In general, the ACCEs reported that the didactic and clinical curricula of their programs were well integrated.

Immune function in blood donors following short-term lymphocytapheresis

Lymphocyte losses occur during repeat plateletpheresis and/or leukapheresis procedures and are potentially harmful to normal host immune function. This concern prompted us to study the effect of repeat lymphocytapheresis (lymphapheresis) on the immune system of healthy blood donors. Following a total of six lymphapheresis procedures over a 12-day period with removal of a mean of 41.6 X 10(9) lymphocytes, there were no significant changes in donor (n = 5) absolute lymphocyte counts, quantitative immunoglobulin levels or immune response capability as assessed by the following in vitro assays: percent of E, EA, and EAC rosette-forming cells, the percent of surface membrane immunoglobulin bearing cells, and the blastogenic responses to stimulation with phytohemagglutinin, pokeweed mitogen and concanavalin A. The procedures were well-tolerated without complications. During a follow-up period of 18 months, significant increases in total white cell counts (but not absolute lymphocyte counts), and in quantitative immunoglobulin levels (IgG, IgM, and IgA) were observed. The median increases in immunoglobulin levels ranged from 27.5% for IgG to 44% for IgA. We conclude that lymphapheresis as described is relatively safe and our results are reassuring in relation to lymphocyte losses that may occur during repeat cytapheresis procedures of normal blood donors.

The antibody-dependent cell-mediated cytotoxic reaction. II. The effect of the concentration of anti-target cell antibodies on the identity of the human effector cells

The circulating leucocytes of normal adults (lymphocytes, monocyte-lymphocyte mixtures and neutrophils) were investigated for their capacity to induce antibody-dependent cell-mediated cytotoxicity (ADCC). The target cell was the rabbit antibody-sensitized chicken erythrocyte. Under conditions of optimal target cell sensitization by anti-target cell antibodies, ADCC cytotoxic activity was exhibited by the neutrophils and lyphocytes to the apparent exclusion of the monocytes. The lymphocytes exhibit activity more rapidly than do the neutrophils and they are more active on an equal cell basis. However, when the effector cells were investigated using target cells sensitized with the anti-target cell antiserum in a threshold concentration, the monocyte and not the lymphocyte or neutrophil displayed ADCC cytotoxic activity. It was concluded that the effector cells in the circulation are heterogeneous and include subclasses of lymphocytes, monocytes and neutrophils and that the identity of the cytotoxic effector cells appears to vary with the concentration of anti-target cell antibodies.

The antibody-dependent cell-mediated cytotoxic reaction. I. The morphological and functional heterogeneity of the rabbit cytotoxic cells

The circulating WBC and cells of the various rabbit lymphoid organs (thymus, bone marrow, lymph nodes, appendix, sacculus rotundus and Peyer's patches) were systematically investigated for their capacity to mediate antibody-dependent cell-mediated cytotoxicity (ADCC). The target cells used were antibody-sensitized ⁵¹Cr-labelled chicken erythrocytes. Phagocytic cells and lymphocytes were capable of inducing lysis of these sensitized target cells and they might act rapidly or show a delay in the onset of activity depending upon the organ sources of these cells. Among the circulating cells, both mononuclear cells and heterophils showed ADCC activity. The cytotoxic cells in the different lymphoid organs could be distinguished from each other on the basis of the following criteria. (i) Rabbit WBC, spleen and bone marrow cells consistently exhibited cytotoxic activity early in culture with the target cells (6–8 h), with activity levelling off by 24–48 h. In contradistinction, the cells of the gut-associated lymphoid tissues (appendix, sacculus rotundus and Peyer's patches), thymus and lymph nodes did not display significant cytotoxic activity until 48–72 h of culture. (ii) Removal of phagocytic cells from the WBC, spleen and lymph node cells resulted in almost total loss of ADCC activity. On the other hand, the ADCC cytotoxic activity of the thymus and bone marrow cells was not significantly affected following removal of phagocytic cells. (iii) The cytotoxic activity of the WBC, spleen and lymph node cells was inhibited by soluble aggregates of rabbit gammaglobulin whereas that of the bone marrow and thymus cells was not.

Rabbit ADCC cytotoxic cells could therefore be classified into a number of categories on the basis of their capacity to demonstrate immediate or delayed cytotoxic activity, their phagocytic or non-phagocytic properties and the susceptibility or lack of susceptibility of their ADCC cytotoxic activity to be inhibited by aggregates of gammaglobulin. It was therefore concluded that the ADCC effector cells in the rabbit parenchymal organs were heterogeneous. The circulating effector cells (the heterophils and monocytes), however, appeared to constitute functionally homogeneous populations of cells.

Some additional results on the maintenance of kappa particles in Paramecium aurelia (stock 51) after loss of the gene K

Additional data are presented on the maintenance of kappa particles in cells ofP. aurelia(stock 51) after removal of the geneK. It is shown that kappa particles may be maintained for as long as twenty-seven fissions in the absence ofK, or may disappear before eight fissions. Slight retardation in fission rate of paramecia quickly eliminates kappa particles. The bearing of these results on the metagon theory is discussed.