Cancer symptom awareness and barriers to symptomatic presentation in England--are we clear on cancer?

BACKGROUND: Low cancer awareness may contribute to delayed diagnosis and poor cancer survival. We aimed to quantify socio-demographic differences in cancer symptom awareness and barriers to symptomatic presentation in the English population. METHODS: Using a uniquely large data set (n=49 270), we examined the association of cancer symptom awareness and barriers to presentation with age, gender, marital status and socio-economic position (SEP), using logistic regression models to control for confounders. RESULTS: The youngest and oldest, the single and participants with the lowest SEP recognised the fewest cancer symptoms, and reported most barriers to presentation. Recognition of nine common cancer symptoms was significantly lower, and embarrassment, fear and difficulties in arranging transport to the doctor's surgery were significantly more common in participants living in the most deprived areas than in the most affluent areas. Women were significantly more likely than men to both recognise common cancer symptoms and to report barriers. Women were much more likely compared with men to report that fear would put them off from going to the doctor. CONCLUSIONS: Large and robust socio-demographic differences in recognition of some cancer symptoms, and perception of some barriers to presentation, highlight the need for targeted campaigns to encourage early presentation and improve cancer outcomes.

Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome?

OBJECTIVES: To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke. DESIGN: Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index. SETTING: South east London. SUBJECTS: People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures. RESULTS: One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826. CONCLUSIONS: The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains.

A long-term follow-up of stroke patients.

BACKGROUND AND PURPOSE: Two hundred ninety-one residents of southeast London, younger than 75 years, suffered their first stroke in 1989/1990. The objectives of this study were to determine the long-term outcome of this cohort of stroke patients in terms of impairment, disability, handicap, and quality of life and their use of services and prevention measures subsequent to their stroke. METHODS: The survivors and their identified caregivers were traced and completed a structured interview questionnaire that included the Barthel Index, modified Rankin Scale, Hospital Anxiety and Depression Scale (HAD), Mini-Mental State Examination, Frenchay Activities Index, and Caregiver Strain Index. RESULTS: One hundred twenty-three people (42%) were alive, of whom 106 were interviewed. The mean interval between the stroke and the long-term follow-up was 4.9 years. Thirty-one of the survivors (29%) were severely or moderately disabled, 39 (37%) were mildly disabled, and 36 (34%) were functionally independent. Of the 96 people who completed the HAD, 35 (36%) had scores suggesting that they were depressed or had borderline depression. The most likely nontherapy services to have been provided were chiropody and district nursing. Five people had received respite care. Of the 104 subjects for whom information about their home was available, 53 (51%) had had an adaptation. Seventy-five people (71%) had an aid or appliance. Sixty-five people (61%) were on aspirin, and an additional 14 (13%) were on warfarin. Fifty subjects (47%) identified a main caregiver. No one with a moderate or more severe disability was living at home without an identified caregiver. CONCLUSIONS: The levels of both health and social service provision are likely to be inadequate for this population. The use of prevention measures is encouraging. There is a clear need for a coordinated policy to guide assessment and management across sectors.

Biologic and environmental risk factors for regression after photorefractive keratectomy.

BACKGROUND/PURPOSE: After photorefractive keratectomy (PRK), the final refraction in the majority of patients is near the intended refraction. However, a significant proportion of patients show regression, which is commonly associated with corneal haze. This study aims to determine whether biologic and environmental factors influence the outcome of PRK. METHODS: One hundred patients prospectively underwent -3.00- or -6.00-diopter corrections. Three months after surgery, 100% of patients answered a questionnaire that recorded their biologic characteristics, medical and ocular history, and postoperative exposure to physical and chemical insults. Multivariable analysis identified those factors associated with regression. RESULTS: Multivariable analysis showed that the risk of regression was increased significantly in patients who underwent higher dioptric or smaller diameter treatments (P = 0.045) and in those who had had regression after treatment of the first eye (P = 0.019). There was no difference between the sexes, but regression was 13.5 times more likely in females who were taking oral contraceptives. Regression was increased in those exposed to solar radiation (odds ratio, 7.6; 95% confidence interval, 1.82-32.22) and sun beds (odds ratio, 2.4; 95% confidence interval, 0.64-9.39), and was significantly greater in patients with ocular-surface disorders (on univariable analysis only; P = 0.034). Regression was not associated with previous contact lens wear, swimming, cigarette smoking, or minor ocular trauma. CONCLUSION: The questionnaire identified biologic and environmental risk factors for regression. The biologic risk factors may be used preoperatively to counsel patients and, where necessary, advise them against surgery. The environmental risk factors are largely avoidable by modification of patient behavior.

Lipoprotein(a) as a determinant of the severity of angiographically defined carotid atherosclerosis.

We measured fasting serum lipids, lipoproteins, apolipoproteins and lipoprotein(a) [Lp(a)] in 49 Caucasian patients with transient ischaemic attacks undergoing carotid angiography. The severity of extracranial cerebrovascular disease was assessed visually by a highly reproducible grading system that focused on the internal carotid artery and carotid bifurcation. Compared with a healthy reference group, patients had significantly higher serum concentrations of: total cholesterol (mean +/- SD), 6.2 +/- 1.6 vs. 5.6 +/- 1.0 mmol/l, p = 0.02; apolipoprotein B, 1.4 +/- 0.5 vs. 1.2 +/- 0.3 g/l, p = 0.03; triglyceride [geometric mean(95% CI)], 2.02(1.75-2.32) vs. 1.66(0.67-4.06) mmol/l, p = 0.03; and Lp(a), 0.33(0.26-0.42) vs. 0.17(0.40-0.76) g/l, p < 0.001. Regression analysis showed that of the lipoprotein-related variables, only Lp(a) was significantly related to the severity of carotid artery disease (p = 0.04) in the patients; this association remained significant after adjusting for age, sex, blood pressure, and a history of stroke. Serum Lp(a) concentration was significantly higher in patients with carotid artery disease severity score above the median value of the sample population compared with those below the median: 0.45 vs. 0.24 g/l (95% CI for difference 0.35-0.88), p = 0.01. Elevated serum Lp(a) is a significant determinant of the extent of carotid atherosclerosis and may be useful in identifying patients most at risk of stroke.

Serum lipids, lipoproteins and apolipoproteins in pregnant non-diabetic patients.

AIMS: To investigate the effect of pregnancy on serum concentrations of lipids, lipoproteins, and apolipoproteins. METHODS: Fasting serum concentrations of total cholesterol, triglyceride, low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), apolipoproteins AI, AII, and B, and lipoprotein (a) were measured in 178 women with normal glucose tolerance in the second and third trimesters of pregnancy and in a control group of 58 non-pregnant women of similar age. Data were analysed using the unpaired t test and by one-way analysis of variance. RESULTS: The pregnant women had significantly higher concentrations of total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol, and apolipoproteins AI and B (p < 0.001) and apolipoprotein AII (p = 0.003) than the control women. The ratio of apolipoprotein B:apolipoprotein AI was significantly higher in the pregnant women than in the controls (p < 0.001), but the total cholesterol:HDL cholesterol ratio was not significantly different. No significant difference was found in the concentration of lipoprotein (a). CONCLUSIONS: Hyperlipidaemia is common in the second half of pregnancy. This may be a purely physiological response to pregnancy or it may be indicative of pathology in some women. These results warrant a follow up study to investigate whether the hyperlipidaemic response to pregnancy is variable and if so, whether it can predict future hyperlipidaemia in a manner analogous to that of impaired glucose tolerance during pregnancy, predicting non-insulin dependent diabetes in later life.

Patterns of acute stroke care in three districts of southern England.

OBJECTIVE: To quantify the use of health care services by acutely ill stroke patients in three district health authorities. DESIGN: A follow up study of all patients recorded in population based registers who had a first ever stroke in three district health authorities, with assessment following the onset and three months after the stroke. SETTING: West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. SUBJECTS: All first time stroke patients under the age of 75 years who presented between 15 August 1989 and 14 August 1990. MEASUREMENTS AND MAIN RESULTS: Hospital admission rates, rates of use of rehabilitation services, and contact with medical practitioners together with assessment of disability and handicap were determined. A total of 386 strokes were registered. Seventy eight per cent were treated in hospital and younger and incontinent patients were significantly more likely to be admitted. The median stay was 21 days. Patients in West Lambeth, those paralysed, and those who stayed longer in hospital were more likely to receive physiotherapy. Altogether 265 patients were followed up, 117 having died within three months of the stroke. During the three months, 150 (57%) had seen a hospital physician and 181 (69%) their general practitioner, but 18 (7%) had seen neither. Sixty seven (26%) patients were moderately or severely disabled. Twenty seven per cent of inpatients had received no inpatient physiotherapy and 67% of all patients no outpatient physiotherapy during the three months. CONCLUSIONS: The hospital admission rates were high, with long lengths of stay. There were significant differences in the amount of rehabilitation received in each district. This was low overall, especially for those not admitted to hospital. As expected, patients admitted for long periods were the most likely to receive therapy. Before district policies for admission and management of stroke patients can be drawn up, increased knowledge of which aspects of stroke management are effective is needed. Policies should aim to provide planned, coordinated care between hospital and the community. It is striking that many patients received no form of rehabilitation therapy.

Does the incidence, severity, or case fatality of stroke vary in southern England?

STUDY OBJECTIVES: To determine differences in incidence and case fatality of stroke in district health authorities with differing standardised mortality ratios (SMR) for stroke in residents aged under 65 years in whom death from stroke is considered 'avoidable'. DESIGN: Registration of first ever strokes in three district health authorities. Patients were assessed and followed up over one year by one of three observers. SETTING: West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. PARTICIPANTS: Patients under the age of 75 years having a first ever in a lifetime stroke between 15 August 1989 and 14 August 1990. MEASUREMENTS AND MAIN RESULTS: Age specific incidence rates and survival time from stroke to death. Severity was assessed in terms of the level of consciousness and the presence of speech, urinary, and motor impairment within the first 24 hours of the stroke. Altogether 386 strokes were registered. There was a significant difference in the incidence rate between district health authorities in those aged under 65 (p < 0.01). The overall case fatality was 26% at three weeks with no significant difference between the districts. Poor survival was associated jointly with increased age and with coma, incontinence, and swallowing impairment in the first 24 hours after a stroke. CONCLUSIONS: The SMRs for stroke in those aged under 65 in these three health districts reflect the incidence of stroke. Case fatality at three weeks does not vary between these districts and consequently would not be a sensitive indicator of the quality of care. This also suggests that differences in services between the districts did not lead to changes in prognosis. In districts with high SMRs for stroke there is a need for further study and reduction of risk factors, thereby reducing the incidence and burden of stroke locally. This study provides a framework for assessing the needs for stroke prevention and treatment in both rural and urban areas without an elaborate protocol and detailed neurological assessment.

Acute renal failure treated by haemofiltration: factors affecting outcome.

Two hundred and fifty consecutive patients with acute renal failure treated by continuous haemofiltration on one intensive care unit (ICU) were studied prospectively to investigate the possibility of predicting outcome at the time of referral. Logistic regression analysis was used to identify important prognostic factors and the regression coefficients were used to weight a scoring system for the severity of illness of patients with acute renal failure. Overall survival was 53% with improvement over the course of the study. Multivariate analysis showed that outcome was related to age, need for artificial ventilation, use of inotropes, urine volume, serum bilirubin, arterial base deficit and serum creatinine. The scoring system based on the first five of these variables had a specificity of predicting death of 67% and a sensitivity of 76%.

Barbiturate blood levels found at necropsy in proven cases of acute barbiturate poisoning.

In order to determine whether blood barbiturate levels could be used to ascertain that death had been caused by barbiturate overdose, samples of blood from 128 subjects of coroners' necropsies were examined for barbiturate content. Sixty of these were well authenticated cases of barbiturate overdosage, and barbiturates were implicated, together with other factors such as alcohol and carbon monoxide, in a further 16 cases. The remaining 52 cases were of an eliminatory nature, 10 of which had low barbiturate blood levels considered to be within the therapeutic range.The results indicate that when the accepted levels producing loss of consciousness are exceeded, and maintained, death will ensue if treatment is not given. These results may be of value in assessing findings in necropsies requested by the coroner, and are in no way applicable to the living patient in whom it is well established that recovery from higher blood levels may take place if adequate treatment is available.