General practice performance in referral for suspected cancer: influence of number of cases and case-mix on publicly reported data

Background:

Publicly available data show variation in GPs' use of urgent suspected cancer (USC) referral pathways. We investigated whether this could be due to small numbers of cancer cases and random case-mix, rather than due to true variation in performance.

Methods:

We analysed individual GP practice USC referral detection rates (proportion of the practice's cancer cases that are detected via USC) and conversion rates (proportion of the practice's USC referrals that prove to be cancer) in routinely collected data from GP practices in all of England (over 4 years) and northeast Scotland (over 7 years). We explored the effect of pooling data. We then modelled the effects of adding random case-mix to practice variation.

Results:

Correlations between practice detection rate and conversion rate became less positive when data were aggregated over several years. Adding random case-mix to between-practice variation indicated that the median proportion of poorly performing practices correctly identified after 25 cancer cases were examined was 20% (IQR 17 to 24) and after 100 cases was 44% (IQR 40 to 47).

Conclusions:

Much apparent variation in GPs' use of suspected cancer referral pathways can be attributed to random case-mix. The methods currently used to assess the quality of GP-suspected cancer referral performance, and to compare individual practices, are misleading. These should no longer be used, and more appropriate and robust methods should be developed.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:

British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.

Methods:

Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.

Results:

On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.

Conclusions:

Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.

Modifiable and fixed factors predicting quality of life in people with colorectal cancer

Background:

People with colorectal cancer have impaired quality of life (QoL). We investigated what factors were most highly associated with it.

Methods:

Four hundred and ninety-six people with colorectal cancer completed questionnaires about QoL, functioning, symptoms, co-morbidity, cognitions and personal and social factors. Disease, treatment and co-morbidity data were abstracted from case notes. Multiple linear regression identified modifiable and unmodifiable factors independently predictive of global quality of life (EORTC-QLQ-C30).

Results:

Of unmodifiable factors, female sex (P<0.001), more self-reported co-morbidities (P=0.006) and metastases at diagnosis (P=0.036) significantly predicted poorer QoL, but explained little of the variability in the model (R²=0.064). Adding modifiable factors, poorer role (P<0.001) and social functioning (P=0.003), fatigue (P=0.001), dyspnoea (P=0.001), anorexia (P<0.001), depression (P<0.001) and worse perceived consequences (P=0.013) improved the model fit considerably (R²=0.574). Omitting functioning subscales resulted in recent diagnosis (P=0.002), lower perceived personal control (P=0.020) and travel difficulties (P<0.001) becoming significant predictors.

Conclusion:

Most factors affecting QoL are modifiable, especially symptoms (fatigue, anorexia, dyspnoea) and depression. Beliefs about illness are also important. Unmodifiable factors, including metastatic (or unstaged) disease at diagnosis, have less impact. There appears to be potential for interventions to improve QoL in patients with colorectal cancer.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study

OBJECTIVES

To determine what factors are associated with the time people take to consult with symptoms of lung cancer, with a focus on those from rural and socially deprived areas.

METHODS

A cross-sectional quantitative interview survey was performed of 360 patients with newly diagnosed primary lung cancer in three Scottish hospitals (two in Glasgow, one in NE Scotland). Supplementary data were obtained from medical case notes. The main outcome measures were the number of days from (1) the date participant defined first symptom until date of presentation to a medical practitioner; and (2) the date of earliest symptom from a symptom checklist (derived from clinical guidelines) until date of presentation to a medical practitioner.

RESULTS

179 participants (50%) had symptoms for more than 14 weeks before presenting to a medical practitioner (median 99 days; interquartile range 31-381). 270 participants (75%) had unrecognised symptoms of lung cancer. There were no significant differences in time taken to consult with symptoms of lung cancer between rural and/or deprived participants compared with urban and/or affluent participants. Factors independently associated with increased time before consulting about symptoms were living alone, a history of chronic obstructive pulmonary disease (COPD) and longer pack years of smoking. Haemoptysis, new onset of shortness of breath, cough and loss of appetite were significantly associated with earlier consulting, as were a history of chest infection and renal failure.

CONCLUSION

For many people with lung cancer, regardless of location and socioeconomic status, the time between symptom onset and consultation was long enough to plausibly affect prognosis. Long-term smokers, those with COPD and/or those living alone are at particular risk of taking longer to consult with symptoms of lung cancer and practitioners should be alert to this.

Influences on pre-hospital delay in the diagnosis of colorectal cancer: a systematic review

Colorectal cancer is a major global health problem, with survival varying according to stage at diagnosis. Delayed diagnosis can result from patient, practitioner or hospital delay. This paper reports the results of a review of the factors influencing pre-hospital delay - the time between a patient first noticing a cancer symptom and presenting to primary care or between first presentation and referral to secondary care. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Fifty-four studies were included. Patients' non-recognition of symptom seriousness increased delay, as did symptom denial. Patient delay was greater for rectal than colon cancers and the presence of more serious symptoms, such as pain, reduced delay. There appears to be no relationship between delay and patients' age, sex or socioeconomic status. Initial misdiagnosis, inadequate examination and inaccurate investigations increased practitioner delay. Use of referral guidelines may reduce delay, although evidence is currently limited. No intervention studies were identified. If delayed diagnosis is to be reduced, there must be increased recognition of the significance of symptoms among patients, and development and evaluation of interventions that are designed to ensure appropriate diagnosis and examination by practitioners.

Secondary prevention clinics for coronary heart disease: a 10-year follow-up of a randomised controlled trial in primary care

OBJECTIVES

To evaluate the effects of nurse-led secondary prevention clinics for coronary heart disease (CHD) in primary care on total mortality and coronary event rates after 10 years.

DESIGN

Follow-up of a randomised controlled trial by review of national datasets.

SETTING

Stratified random sample of 19 general practices in northeast Scotland.

PARTICIPANTS

Original study cohort of 1343 patients, aged <80 years, with a working diagnosis of CHD, but without dementia or terminal illness and not housebound.

INTERVENTION

Nurse-led secondary prevention clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow-up for 1 year,

MAIN OUTCOME MEASURES

Total mortality and coronary events (non-fatal myocardial infarctions (MIs) and coronary deaths).

RESULTS

Mean (SD) follow-up was at 10.2 (0.19) years. No significant differences in total mortality or coronary events were found at 10 years. 254 patients in the intervention group and 277 patients in the control group had died: cumulative death rates were 38% and 41%, respectively (p = 0.177). 196 coronary events occurred in the intervention group and 195 in the control group: cumulative event rates were 29.1% and 29.1%, respectively (p = 0.994). When Kaplan-Meier survival analysis, adjusted for age, sex and general practice, was used, proportional hazard ratios were 0.88 (0.74 to 1.04) for total mortality and 0.96 (0.79 to 1.18) for coronary death or non-fatal MI. No significant differences in the distribution of cause of death classifications was found at either 4 or 10 years.

CONCLUSIONS

After 10 years, differences between groups were no longer significant. Total mortality survival curves for the intervention and control groups had not converged, but the coronary event survival curves had. Possibly, therefore, the earlier that secondary prevention is optimised, the less likely a subsequent coronary event is to prove fatal.

Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer

As knowledge on the causation of cancers advances and new treatments are developed, early recognition and accurate diagnosis becomes increasingly important. This review focused on identifying factors influencing patient and primary care practitioner delay for upper gastrointestinal cancer. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Included studies were those evaluating factors associated with the time interval between a patient first noticing a cancer symptom and presenting to primary care, between a patient first presenting to primary care and being referred to secondary care, or describing an intervention designed to reduce those intervals. Twenty-five studies were included in the review. Studies reporting delay intervals demonstrated that the patient phase of delay was greater than the practitioner phase, whilst patient-related research suggests that recognition of symptom seriousness is more important than recognition of the presence of the symptom. The main factors related to practitioner delay were misdiagnosis, application and interpretation of tests, and the confounding effect of existing disease. Greater understanding of patient factors is required, along with evaluation of interventions to ensure appropriate diagnosis, examination and investigation.

Patient motivations surrounding participation in phase I and phase II clinical trials of cancer chemotherapy

Successful advances in the treatment of advanced malignant diseases rely on recruitment of patients into clinical trials of novel agents. However, there is a genuine concern for the welfare of individual patients. The aim of this study was to examine motives of patients entering early clinical trials of novel cancer therapies. Questionnaire survey with both open- and close-ended questions. The patients were surveyed after they had given informed consent and before or during the first cycle of treatment. In all, 38 phase I/II trial patients participated and completed the survey. Obtaining possible health benefit was listed by 89% as being a ‘very important’ factor in their decision to participate, with only 17% giving reasons of helping future cancer patients and treatment. Other items cited as a ‘very important’ motivating factor were ‘trust in the doctor’ (66%), ‘being treated by the latest treatment available’ (66%), ‘better standard of care and closer follow-up’ (61%), and ‘closer monitoring of patients in trials’ (58%). Only 47% patients indicated that someone had explained to them about any ‘reasonable’ alternatives to the trial. In total, 71% strongly agreed that ‘surviving for as long time as possible was the most important thing (for them)’. Nearly all (97%) indicated that they knew the purpose of the trial and had enough time to consider participation in the trial (100%). In this survey, most patients entering phase I and II clinical trials felt they understood the purpose of the research and had given truly informed consent. Despite this, most patients participated in the hope of therapeutic benefit, although this is known to be a rare outcome in this patient subset. Trialists should be aware, and take account of the expectations that participants place in trial drugs.

Secondary prevention clinics: improving quality of life and outcome

General practitioners have been encouraged to target patients with coronary heart disease for secondary prevention, but putting this into practice has proven challenging. However, there is now evidence of the benefits from nurse led clinics in primary care. Randomised trials have shown that such clinics can lead to improvement in both medical and lifestyle components of secondary prevention. This has in turn been associated with improved quality of life and a reduction in mortality. Benefits are conditional on several factors: in particular, risk factors are only reduced if clinic attendance is accompanied by appropriate prescribing, and improvements in risk factors are only sustained if the clinics are continued.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Provision of oncology services in remote rural areas: a Scottish perspective

There is a paucity of research into rural health care services. In particular little is known about the provision of specialist cancer services for patients who live in remote rural areas of the UK. This study set out to investigate current models of medical and clinical oncology care in Scotland. A national survey with key health professionals was conducted to identify rural oncology schemes currently in operation. Detailed quantitative data about the schemes together with qualitative data on how health professionals view current models of care were collected by a computer-assisted telephone survey. Schemes that currently provide outpatient and chemotherapy oncology services for remote rural patients fell into three categories: central clinics (5); shared care outreach clinics with chemotherapy provision (11); and shared care outreach clinics without chemotherapy provision (7). All radiotherapy was conducted at central clinics (5). Widely varying practices in delivery of cancer care were found across the country. The main issues for professionals about current models of care involved expertise, travelling and accessibility (for patients), communication and expansion of the rural service. Nation-wide consistency in cancer care has still to be achieved. Travelling for treatment was seen to take its toll on all patients but particularly for the very remote, elderly and poor. Most professionals believe that an expansion of rural services would be of benefit to these patients. It is clear, however, that the proper infrastructure needs to be in place in terms of local expertise, ensured quality of care, and good communication links with cancer centres before this could happen.

Providing cancer services to remote and rural areas: consensus study

There is controversy about how cancer care should be provided to patients in remote and rural areas. The aim of this project was to measure consensus among health professionals who treat rural patients with cancer about priorities for cancer care. A modified Delphi process was used. Of 78 health professionals in Grampian, 62 responded (79%). Of 49 items suggested, there was agreement on 26 (53%), encompassing fast access to diagnosis, high-quality specialist treatment, and well-coordinated delivery of care with good and fast communication and effective team working between all health professionals involved. Specialist oncology nurses in local hospitals were considered a priority along with good facilities, accommodation, and transport for patients. There was no agreement on the best location for chemotherapy (local or central). The only large difference of opinion between participants based in primary and secondary care concerned chemotherapy provision at local community hospitals (primary care was in favour, hospital practitioners against, P&<0.001). In making their decisions, participants took problems of access into account, but were also concerned with quality of care and feasibility in the current health service. Our findings show that more evidence is needed regarding the balance of risks and benefits of local chemotherapy provision. Overall, however, there is agreement on many principles for cancer care that could be translated into practice.

Impact of deprivation and rural residence on treatment of colorectal and lung cancer

For common cancers, survival is poorer for deprived and outlying, rural patients. This study investigated whether there were differences in treatment of colorectal and lung cancer in these groups. Case notes of 1314 patients in north and northeast Scotland who were diagnosed with lung or colorectal cancer in 1995 or 1996 were reviewed. On univariate analysis, the proportions of patients receiving surgery, chemotherapy and radiotherapy appeared similar in all socio-economic and rural categories. Adjusting for disease stage, age and other factors, there was less chemotherapy among deprived patients with lung cancer (odds ratio 0.39; 95% confidence intervals 0.16 to 0.96) and less radiotherapy among outlying patients with colorectal cancer (0.39; 0.19 to 0.82). The time between first referral and treatment also appeared similar in all socio-economic and rural groups. Adjusting for disease stage and other variables, times to lung cancer treatment remained similar, but colorectal cancer treatment was quicker for outlying patients (adjusted hazard ratio 1.30; 95% confidence intervals 1.03 to 1.64). These findings suggest that socio-economic status and rurality may have a minor impact on modalities of treatment for colorectal and lung cancer, but do not lead to delays between referral and treatment.

Rural and urban differences in stage at diagnosis of colorectal and lung cancers

There is evidence that patients living in outlying areas have poorer survival from cancer. This study set out to investigate whether they have more advanced disease at diagnosis. Case notes of 1323 patients in north and northeast Scotland who were diagnosed with lung or colorectal cancer in 1995 or 1996 were reviewed. Of patients with lung cancer, 42% (69/164) living 58 km or more from a cancer centre had disseminated disease at diagnosis compared to 33% (71/215) living within 5 km. For colorectal cancer the respective figures were 24% (38/161) and 16% (31/193). For both cancers combined, the adjusted odds ratio for disseminated disease at diagnosis in furthest group compared to the closest group was 1.59 (P = 0.037). Of 198 patients with non-small-cell lung cancer in the closest group, 56 (28%) had limited disease (stage I or II) at diagnosis compared to 23 of 165 (14%) of the furthest group (P = 0.002). The respective figures for Dukes A and B colorectal cancer were 101 of 196 (52%) and 67 of 172 (39%) (P = 0.025). These findings suggest that patients who live remote from cities and the associated cancer centres have poorer chances of survival from lung or colorectal cancer because of more advanced disease at diagnosis. This needs to be taken into account when planning investigation and treatment services.

Treating patients with colorectal cancer in rural and urban areas: a qualitative study of the patients' perspective

OBJECTIVES

The aim of the present study was to explore the perspectives of patients receiving treatment for colorectal cancer and compare priorities and attitudes in rural and urban areas.

METHOD

A qualitative study was carried out involving four focus groups in the Aberdeen and Northern Centre for Haematology, Oncology and Radiotherapy. The sample comprised 22 patients at various stages of treatment for colorectal cancer and 10 of their relatives from different locations of Northeast Scotland and Shetland. The main themes generated by participants were identified, and similarities and differences between urban and rural patients were noted within these themes.

RESULTS

Components of care that were important to rural and urban patients were speed of referral to specialists for treatment and issues of communication including test results and delivery of bad news. Tensions were perceived at the interface of primary and secondary care and these were blamed for delays in referral and communication breakdowns. For some, the referral process comprised a series of barriers to be overcome, and there were additional hurdles for remote patients referred initially to local (non-specialist) hospitals. Rural patients appeared to be less demanding than their urban counterparts when evaluating their care, and this was extended to the acceptance of some clear transport problems.

CONCLUSIONS

For patients, the most important components of cancer care were similar, whether rural or urban residents. The main differences for rural patients were lower expectations of care and more hurdles before reaching specialist care. These differences might explain the trend to more advanced disease at diagnosis in rural patients if they lead to significant delays. GPs have major influences on this and all the patients' priorities.

Rural factors and survival from cancer: analysis of Scottish cancer registrations

In this survival study 63,976 patients diagnosed with one of six common cancers in Scotland were followed up. Increasing distance from a cancer centre was associated with less chance of diagnosis before death for stomach, breast and colorectal cancers and poorer survival after diagnosis for prostate and lung cancers.

Systematic review of cancer treatment programmes in remote and rural areas

In an attempt to ensure high quality cancer treatment for all patients in the UK, care is being centralized in specialist centres and units. For patients in outlying areas, however, access problems may adversely affect treatment. In an attempt to assess alternative methods of delivering cancer care, this paper reviews published evidence about programmes that have set out to provide oncology services in remote and rural areas in order to identify evidence of effectiveness and problems. Keyword and textword searches of on-line databases (MEDLINE, EMBASE, HEALTHSTAR and CINAHL) from 1978 to 1997 and manual searches of references were conducted. Fifteen papers reported evaluations of oncology outreach programmes, tele-oncology programmes and rural hospital initiatives. All studies were small and only two were controlled, so evidence was suggestive rather than conclusive. There were some indications that shared outreach care was safe and could make specialist care more accessible to outlying patients. Tele-oncology, by which some consultations are conducted using televideo, may be an acceptable adjunct. Larger and more methodologically robust studies are justified and should be conducted.

Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care

OBJECTIVE

To evaluate whether nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease.

DESIGN

Randomised controlled trial.

SETTING

A random sample of 19 general practices in northeast Scotland.

PATIENTS

1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease, but without terminal illness or dementia and not housebound.

INTERVENTION

Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up.

MAIN OUTCOME MEASURES

Components of secondary prevention assessed at baseline and one year were: aspirin use; blood pressure management; lipid management; physical activity; dietary fat; and smoking status. A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient.

RESULTS

There were significant improvements in aspirin management (odds ratio 3.22, 95% confidence interval 2.15 to 4.80), blood pressure management (5.32, 3.01 to 9.41), lipid management (3.19, 2.39 to 4.26), physical activity (1.67, 1.23 to 2.26) and diet (1.47, 1.10 to 1.96). There was no effect on smoking cessation (0.78, 0.47 to 1.28). Of six possible components of secondary prevention, the baseline mean was 3.27. The adjusted mean improvement attributable to intervention was 0.55 of a component (0.44 to 0.67). Improvement was found regardless of practice baseline performance.

CONCLUSIONS

Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease. Most patients gained at least one effective component of secondary prevention and, for them, future cardiovascular events and mortality could be reduced by up to a third.

Secondary prevention in coronary heart disease: baseline survey of provision in general practice

OBJECTIVE

To determine secondary preventive treatment and habits among patients with coronary heart disease in general practice.

DESIGN

Process of care data on a random sample of patients were collected from medical records. Health and lifestyle data were collected by postal questionnaire (response rate 71%).

SETTING

Stratified, random sample of general practices in Grampian.

SUBJECTS

1921 patients aged under 80 years with coronary heart disease identified from pre-existing registers of coronary heart disease and nitrate prescriptions.

MAIN OUTCOME MEASURES

Treatment with aspirin, beta blockers, and angiotensin converting enzyme inhibitors. Management of lipid concentrations and hypertension according to local guidelines. Dietary habits (dietary instrument for nutritional evaluation score), physical activity (health practice indices), smoking, and body mass index.

RESULTS

825/1319 (63%) patients took aspirin. Of 414 patients with recent myocardial infarction, 131 (32%) took beta blockers, and of 257 with heart failure, 102 (40%) took angiotensin converting enzyme inhibitors. Blood pressure was managed according to current guidelines for 1566 (82%) patients but lipid concentrations for only 133 (17%). 673 of 1327 patients (51%) took little or no exercise, 245 of 1333 (18%) were current smokers, 808 of 1264 (64%) were overweight, and 627 of 1213 (52%) ate more fat than recommended.

CONCLUSION

In terms of secondary prevention, half of patients had at least two aspects of their medical management that were suboptimal and nearly two thirds had at least two aspects of their health behaviour that would benefit from change. There seems to be considerable potential to increase secondary prevention of coronary heart disease in general practice.

Secondary prevention clinics for coronary heart disease: randomised trial of effect on health

OBJECTIVE

To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease.

DESIGN

Randomised controlled trial of clinics over one year with assessment by self completed postal questionnaires and audit of medical records at the start and end of the trial.

SETTING

Random sample of 19 general practices in northeast Scotland.

SUBJECTS

1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound.

INTERVENTION

Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up.

MAIN OUTCOME MEASURES

Health status measured by the SF-36 questionnaire, chest pain by the angina type specification, and anxiety and depression by the hospital anxiety and depression scale. Use of health services before and during the study.

RESULTS

There were significant improvements in six of eight health status domains (all functioning scales, pain, and general health) among patients attending the clinic. Role limitations attributed to physical problems improved most (adjusted difference 8.52, 95% confidence interval 4.16 to 12. 9). Fewer patients reported worsening chest pain (odds ratio 0.59, 95% confidence interval 0.37 to 0.94). There were no significant effects on anxiety or depression. Fewer intervention group patients required hospital admissions (0.64, 0.48 to 0.86), but general practitioner consultation rates did not alter.

CONCLUSIONS

Within their first year secondary prevention clinics improved patients' health and reduced hospital admissions.

Review of 1198 cases of penetrating cardiac trauma

BACKGROUND

This study was a clinicoforensic analysis of the prevalence and outcome of traumatic cardiac injuries in Durban.

METHODS

Between 1990 and 1992, 1198 patients sustained cardiac trauma. Seventy (6 per cent) reached hospital alive and 1128 (94 per cent) were taken directly to the mortuary. Seven hundred victims had suffered stab wounds, 494 gunshot wounds and four blast injuries. Gunshot injuries increased from 34 per cent in 1990 to 50 per cent in 1992. The mean (s.d.) age was 30.5 (5.4) years and the majority (91 per cent) were men.

RESULTS

Thirty-five (50 per cent) of those who reached hospital alive died, including all four gunshot victims. Significant factors associated with survival were isolated injury, the presence of cardiac tamponade (univariate and multivariate analysis), right ventricular injury, single cardiac chamber injury and absence of pleural breach (univariate analysis alone). Delay in operative intervention was associated with a higher mortality rate. When analysing the patients who did not reach hospital alive, 202 (18 per cent) with tamponade due to an isolated stab wound were identified as a subset who might have been saved with prompt treatment.

CONCLUSION

An increasing number of gunshot injuries in combination with delays in reaching hospital and in receiving treatment accounted for the high mortality rate in this unselected series.

Cardiac rehabilitation in Scotland: is current provision satisfactory?

BACKGROUND

Cardiac rehabilitation is an effective intervention, lowering mortality following myocardial infarction and reducing morbidity in patients with coronary heart disease. However, its level of provision was unclear. This study aimed to provide a comprehensive description in Scotland.

METHODS

A national survey of hospital, general practice and community sources was conducted in 1994 to identify cardiac rehabilitation programmes in Scotland. Detailed information about each programme was collected by computer-assisted telephone interviews.

RESULTS

Sixty-nine programmes were identified, providing out-patient cardiac rehabilitation to 4980 patients and in-patient cardiac rehabilitation to 8920 patients. This represented 17 per cent and 30 per cent of patients admitted to hospital with coronary heart disease (excluding heart failure), respectively. There was considerable geographical variation in provision and dependence on sources outside the health service for much funding.

CONCLUSIONS

Despite evidence of benefits from randomized trials, the overall provision of cardiac rehabilitation in Scotland was low. Considerable inequity was demonstrated between different health board areas. There is opportunity for better provision, which would improve care for many patients with coronary heart disease.

Outpatient cardiac rehabilitation: are the potential benefits being realised?

OBJECTIVE

to give a comprehensive description of the practice of outpatient cardiac rehabilitation in Scotland.

DESIGN

an identifying survey of 1,270 individuals in hospital, general practice and community sources nationally, followed by computer-assisted telephone interviews about programme characteristics with key personnel from identified cardiac rehabilitation schemes.

OUTCOME MEASURES

patient provision, referral criteria and programme features.

RESULTS

65 programmes provided outpatient cardiac rehabilitation for 4,980 patients in one year, representing 17% of the 29,180 patients who survived admission to hospital with coronary heart disease. Cardiac rehabilitation practice varied widely: 53 (82%) programmes included exercise, although only 19 (29%) at the most beneficial level; 40 (62%) included relaxation training, although only three (5%) at a level shown to give benefit; 47 (72%) included education, although only 16 (25%) in a manner with reported benefits in randomised trials.

CONCLUSIONS

outpatient cardiac rehabilitation was provided to a minority of patients with coronary heart disease. Programmes varied widely, and were often more limited than those reporting mortality and morbidity benefits in randomised trials. There is a substantial gap between current provision and practice of cardiac rehabilitation and that advocated in published guidelines.

The secondary spikes of climbing fibre responses recorded from Purkinje cell axons in cat cerebellum

Responses evoked in Purkinje cells by climbing fibre activity were investigated by recording from Purkinje cell axons in the cerebellum of anaesthetized cats. Purkinje cell axons were identified by firing pattern and by latency of responses to stimulation of peripheral nerve and of the inferior olive. Axonal climbing fibre responses usually consisted of one to two spikes, suggesting that normally only the initial spike or, at most, this and one of the secondary spikes are propagated down the Purkinje cell axon. When two successive climbing fibre responses were evoked, the number of spikes in the second response was increased, usually up to three to five. This effect could be obtained at stimulation intervals of up to 100 ms. In a few cases it was possible for a climbing fibre response to be preceded by a parallel fibre volley evoked by stimulation of the cerebellar surface. This increased the number of spikes in the axonal climbing fibre response. The results suggest that the number of propagated spikes in the climbing fibre response can be modified by a preceding input to the Purkinje cell.

The secondary spikes of climbing fibre responses recorded from Purkinje cell somata in cat cerebellum

Extracellularly recorded climbing fibre responses in Purkinje cell somata in the cerebellar cortex were investigated in cats deeply anaesthetized with barbiturate. The effects on the amplitude of initial and secondary spikes of preceding climbing fibre activation, on-beam parallel fibre activation and off-beam parallel fibre activation were studied. When a climbing fibre response was preceded by climbing fibre activation there was a decrease in the amplitude of the initial spike of the second response at intervals up to 25 ms and little effect at longer intervals. Secondary spike amplitude was greatly increased at intervals up to 100 ms. When a complex spike was preceded by on-beam parallel fibre activation there was a decrease in the initial spike amplitude at short intervals and an increase in the amplitude at long intervals. Secondary spike amplitude was increased up to 150 ms after an on-beam parallel fibre volley. When a complex spike was preceded by off-beam parallel fibre stimulation there was an increase in initial spike amplitude at intervals up to about 200 ms and a decrease in secondary spike amplitude at intervals up to about 150 ms. The results show that the amplitude of the secondary spikes can be modified by a preceding input to the Purkinje cell. The results also suggest that the secondary spikes are generated in the Purkinje cell dendrites and the initial spike in the soma.

Origin in the medial accessory olive of climbing fibres to the x and lateral c1 zones of the cat cerebellum: a combined electrophysiological/WGA-HRP investigation

The climbing fibres to the x and lateral c1 zones of the anterior lobe of the cerebellum arise as branches of common stem olivary axons. Anatomical studies have shown that the c1 zone receives its climbing fibres from the dorsal accessory olive (DAO). It has, therefore, been assumed that the x-zone also receives its climbing fibres from this olivary subnucleus. The present study demonstrates that both the x-zone and the lateral part of the c1 zone in fact receive their climbing fibre input from the middle portion of the medial accessory olive (MAO) (approximate antero-postero-levels P10-13). Electrophysiological techniques were used to define the extent of these cerebellar zones and small volumes (15-50 nl) of wheat germ agglutinin-horseradish peroxidase (WGA-HRP) were pressure injected into the defined zone. These small pressure injections resulted in injection sites with minimal spread to adjacent zones. The sensitive tetramethylbenzidine (TMB) reaction was used to visualize both the injection site and retrogradely labelled cells in the inferior olive. This combination of electrophysiological and neuroanatomical techniques gave extremely reproducible results. The results suggest that the zone previously named lateral c1 would be better designated cx.

Plateau potentials evoked by climbing-fibre stimulation are restricted to the Purkinje cell dendrites of the cat

The present study investigated the duration of afterdepolarizations in Purkinje cell somata following climbing-fibre activation. Intracellular recordings revealed that, in cells with membrane potentials more negative than -50 mV and with normal spike-generating capabilities, climbing-fibre activation resulted in somatic responses with short afterdepolarizations. As the cell deteriorated and the resting membrane potential became more positive, the duration and form of the climbing-fibre response resembled the plateau potentials recorded from proximal dendrites. The absence of plateau potentials in undamaged Purkinje cell somata was confirmed by extracellular recording of test spike amplitudes following evoked climbing-fibre responses.

The olivocerebellar projection in the rat: an autoradiographic study

The extent of the olivocerebellar projection was examined in the rat using autoradiographic techniques. In animals in which injections of [3H]leucine encompassed the whole olive unilaterally (4 cases), the vast majority of olive cells was densely labelled and climbing fibres were heavily labelled throughout the contralateral hemicerebellum, except for some small gaps which were not consistently located between cases. The multiple injections required to cover the oliver inevitably labelled cells in the reticular formation surrounding the olive, and it is possible that these neurones might also provide climbing fibres to the cerebellum. To control for this possibility, the inferior olive was pharmacologically destroyed (4 cases) prior to [3H]leucine injections similar in size and placement to those given to normal animals. Examination of the cerebellar cortex of these pretreated animals revealed no molecular layer labelling despite identification of labelled reticular neurones. It was thus demonstrated that all regions of the cerebellar cortex receive afferents from the inferior olive which terminate as climbing fibres. The distribution of these terminations over the entire cortex permits the conclusion that the inferior olive is the major source of climbing fibres in the rat. The same conclusions are reached using [3H]methionine as the tracer (4 cases).

Topographical localization in the olivocerebellar projection in the rat: an autoradiographic study

The topographical organization of the olivocerebellar projection in the rat was examined by making small localized injections of tritiated leucine into the inferior olive (12 cases). The overall projection pattern is displayed in the form of a topographical map, revealing that the olivocerebellar projection is organized in sagittally orientated strips of cerebellar cortex, each of which receives its terminations from a discrete portion of the olive. The projection pattern is compared to that in the cat. In addition, the laterality of the projection is discussed.

Dendritic plateau potentials evoked in Purkinje cells by parallel fibre volleys in the cat

Responses evoked in Purkinje cell dendrites by parallel fibre volleys and climbing fibre impulses were investigated by intra- and extracellular recording from cat cerebellar cortex. The depth distribution of recording sites suggested that the intracellular recordings were predominantly from proximal dendrites whereas the extracellular recordings were predominantly from distal dendrites. Parallel fibre stimulation evoked monosynaptic excitation and disynaptic inhibition in the dendrites and, at higher strength, prolonged plateau-like responses in distal dendrites but only rarely in proximal dendrites. However, when the inhibitory synapses were blocked with topically applied picrotoxin, parallel fibre volleys evoked plateau potentials also in proximal dendrites. The duration of the parallel-fibre-evoked plateau potentials in distal dendrites was prolonged by increasing the intensity of the eliciting stimulus or by increasing the number of stimuli. A similar prolongation in the duration of climbing-fibre-evoked plateau potentials was observed when brief repetitive stimulation was applied to the inferior olive. The investigation provided evidence that under physiological conditions plateau potentials in Purkinje cell dendrites are exclusively evoked by climbing fibre impulses.

Interaction between responses in Purkinje cells evoked by climbing fibre impulses and parallel fibre volleys in the cat

The plateau-like depolarizing potentials evoked in Purkinje cell dendrites by impulses in climbing fibres (Ekerot & Oscarsson, 1981) were conditioned by single parallel fibre volleys and investigated by intra- and extracellular recording from cat cerebellar cortex. The conditioning parallel fibre volleys evoked predominantly inhibitory potentials of long duration in the Purkinje cell dendrites. Massive parallel fibre volleys, which may evoke plateau-like depolarizing potentials (Campbell, Ekerot, Hesslow & Oscarsson, 1983) were avoided. In proximal dendrites parallel fibre volleys preceding climbing fibre responses reduced or abolished the plateau potential, whereas the initial spike-like component of the climbing fibre responses was largely unaffected. Parallel fibre stimulation during already established plateau potentials immediately terminated the plateaus. In distal dendrites parallel fibre stimulation preceding climbing fibre responses reduced or abolished both the plateau potential and the initial component of the climbing fibre responses. Parallel fibre stimulation during established plateau potentials did not immediately terminate the plateau potentials but reduced their duration. The results of the present investigation suggest that single dendritic branches of Purkinje cells serve as independent integrators of mossy fibre and climbing fibre inputs.