Understanding GPs' referral decisions for younger patients with symptoms of cancer: a qualitative interview study.

BACKGROUND: Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients. AIM: To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral. DESIGN AND SETTING: Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England. METHOD: Participants (n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes. RESULTS: GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria. CONCLUSION: While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation.

Patients' views on the decision to investigate cancer symptoms in older adults: a qualitative interview study in primary care.

BACKGROUND: Cancer is predominantly a disease of older adults. To date there has been little research on the experiences of older adults or their views on the diagnostic pathway. AIM: To gain an improved understanding of the views and experiences of older adults on all aspects of cancer investigation. DESIGN AND SETTING: This was a qualitative study using semi-structured interviews with patients aged ≥70 years. Patients were recruited from primary care in West Yorkshire, UK. METHOD: Data were analysed using a thematic framework analysis. RESULTS: The themes identified in participants' accounts included the patients' process of decision making, the value of having a diagnosis, the patients' experience of cancer investigations, and the impact of the COVID-19 pandemic on the diagnostic pathway. Older adults in this study indicated a clear preference for having clarity on the cause of symptoms and the diagnosis, even in the face of unpleasant investigations. Patients suggested they wanted to be involved in the decision process. CONCLUSION: Older adults who present to primary care with symptoms suggestive of cancer may accept diagnostic testing solely for the benefit of knowing the diagnosis. There was a clear patient preference that referrals and investigations for cancer symptoms should not be deferred or delayed based on age or subjective assessments of frailty. Shared decision making and being involved in the decision-making process are important to patients, regardless of age.

Microalbuminuria in young Sudanese patients with type 1 diabetes.

Overnight urinary albumin excretion (UAE) was measured in 51 patients, nine to 18 years old, with type 1 (insulin-dependent) diabetes mellitus and in 22 healthy subjects using radioimmunoassay. Thirteen diabetic patients (25.5%) had microalbuminuria defined as UAE rate between 20 and 200 microg/min. Eleven of these patients were over 13 years of age. This gives a frequency of microalbuminuria of 42% (11/26) in the diabetic children and adolescents in the age group 14-18 years. UAE rate was positively correlated with both age at diagnosis and duration of diabetes. Arterial blood pressure, systolic and diastolic, glycosylated hemoglobin (HbA1c) and insulin dosage U.kg- 1.day-1 were significantly higher (P<0.001) in the diabetic patients with microalbuminuria compared to the diabetic patients with normal UAE rate. Retinal changes were also more common in the microalbuminuric diabetic patients than in the diabetic patients without microalbuminuria (P<0.01). This study has revealed a high prevalence of microalbuminuria in young Sudanese patients with type 1 (insulin-dependent) diabetes mellitus and emphasized the importance of routine screening of diabetic children after the age of 12 years.

Trimethoprim-sulphamethoxazole in the treatment of enteric fever.

Twenty-three patients with typhoid fever diagnosed by blood culture were treated with co-trimoxazole (trimethoprim/sulphamethoxazole, 1 :5) at a dosage of 10 mg trimethoprim/kg/day in two divided daily doses for 10 days. Twenty-two patients responded, the mean period to defervescence being three days and to relief of toxaemia being 1-7 days. Another nineteen patients with similarly proven typhoid were treated with chloramphenicol (100 mg/kg/day) in four divided daily doses for 10 days. Eighteen patients responded, defervescence occurring in an average of 4-1 days and relief of toxaemia in a mean of 2-6 days. None of the patients included in the study developed complications, relapses or became a convalescent carrier during the period of observation.