Cancers of unknown primary diagnosed during hospitalization: a population-based study.

BACKGROUND: Cancers of Unknown Primary (CUP) are the 3-4th most common causes of cancer death and recent clinical guidelines recommend that patients should be directed to a team dedicated to their care. Our aim was to inform the care of patients diagnosed with CUP during hospital admission. METHODS: Descriptive study using hospital admissions (Scottish Morbidity Record 01) linked to cancer registrations (ICD-10 C77-80) and death records from 1998 to 2011 in West of Scotland, UK (population 2.4 m). Cox proportional hazards models were used to assess effects of baseline variables on survival. RESULTS: Seven thousand five hundred ninety nine patients were diagnosed with CUP over the study period, 54.4% female, 67.4% aged ≥ 70 years, 36.7% from the most deprived socio-economic quintile. 71% of all diagnoses were made during a hospital admission, among which 88.6% were emergency presentations and the majority (56.3%) were admitted to general medicine. Median length of stay was 15 days and median survival after admission 33 days. Non-specific morphology, emergency admission, age over 60 years, male sex and admission to geriatric medicine were all associated with poorer survival in adjusted analysis. CONCLUSIONS: Patients with a diagnosis of CUP are usually diagnosed during unplanned hospital admissions and have very poor survival. To ensure that patients with CUP are quickly identified and directed to optimal care, increased surveillance and rapid referral pathways will be required.

Predicting sleep disordered breathing in outpatients with suspected OSA.

OBJECTIVE: To validate the utilities of Berlin, STOP and STOP-BANG Questionnaires, other patient characteristics, comorbidities, Epworth Sleepiness Scale (ESS), fractional exhaled nitric oxide (FENO) and blood markers for the prediction of sleep disordered breathing (SDB) on limited polygraphy. SETTING: North Glasgow Sleep Service (a tertiary referral centre). PARTICIPANTS: 129 consecutive patients, aged ≥16 years, referred to the sleep clinic for assessment of possible obstructive sleep apnoea. INTERVENTIONS: We selected cut-points of apnoea hypopnoea index (AHI) of ≥5 and ≥15/h from their home polygraphy and determined associations of these with individual symptoms, questionnaire scores and other results. Receiver operating characteristic analysis and univariate and multivariate logistic regression were used to explore these. PRIMARY AND SECONDARY OUTCOMES MEASURES: Primary: The utility of STOP, STOP-BANG and Berlin Questionnaires for prediction of SDB. Secondary: The utility of other measures for prediction of SDB. RESULTS: AHI was ≥5 in 97 patients and ≥15 in 56 patients. STOP and STOP-BANG scores were associated with both AHI cut-points but results with ESS and Berlin Questionnaire scores were negative. STOP-BANG had a negative predictive value 1.00 (0.77-1.00) for an AHI ≥15 with a score ≥3 predicting AHI ≥5 with sensitivity 0.93 (95% CI 0.84 to 0.98) and accuracy 79%, while a score ≥6 predicted AHI ≥15 with specificity 0.78 (0.65 to 0.88) and accuracy 72%. Neck circumference ≥17 inch and presence of witnessed apnoeas were independent predictors of SDB. CONCLUSIONS: STOP and STOP-BANG Questionnaires have utility for the prediction of SDB in the sleep clinic population. Modification of the STOP-BANG Questionnaire merits further study in this and other patient groups.

Outcomes of a specialist weight management programme in the UK National Health Service: prospective study of 1838 patients.

OBJECTIVES: There is limited evidence on the effectiveness of weight management programmes provided within routine healthcare and inconsistent use of outcome measures. Our aim was to evaluate a large National Health Service (NHS) weight management service and report absolute and proportional weight losses over 12 months. DESIGN: Prospective observational study. SETTING: Glasgow and Clyde Weight Management Service (GCWMS), which provides care for residents of NHS Greater Glasgow and Clyde area (population 1.2 million). PARTICIPANTS: All patients who began GCWMS between 1 October 2008 and 30 September 2009. INTERVENTIONS: Structured educational lifestyle programme employing cognitive behavioural therapy, 600 kcal deficit diet, physical activity advice, lower calorie diet and pharmacotherapy. PRIMARY AND SECONDARY OUTCOMES MEASURES: Baseline observation carried forward (BOCF), last observation carried forward (LOCF) and changes in programme completers reported using outcomes of absolute 5 kg and 5% weight losses and mean weight changes at a variety of time points. RESULTS: 6505 referrals were made to GCWMS, 5637 were eligible, 3460 opted in and 1916 (34%) attended a first session. 78 patients were excluded from our analysis on 1838 patients. 72.9% of patients were women, mean age of all patients at baseline was 49.1 years, 43.3% lived in highly socioeconomically deprived areas and mean weights and body mass indices at baseline were 118.1 kg and 43.3 kg/m(2), respectively. 26% lost ≥5 kg by the end of phase 1, 30% by the end of phase 2 and 28% by the end of phase 3 (all LOCF). Weight loss was more successful among men, particularly those ≤29 years old. CONCLUSIONS: Routine NHS weight management services may achieve moderate weight losses through a comprehensive evidence-based dietary, activity and behavioural approach including psychological care. Weight losses should be reported using a range of outcome measures so that the effectiveness of different services can be compared.

Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women.

OBJECTIVES: To describe the effect of multidisciplinary care on survival in women treated for breast cancer. DESIGN: Retrospective, comparative, non-randomised, interventional cohort study. SETTING: NHS hospitals, health boards in the west of Scotland, UK. PARTICIPANTS: 14,358 patients diagnosed with symptomatic invasive breast cancer between 1990 and 2000, residing in health board areas in the west of Scotland. 13,722 (95.6%) patients were eligible (excluding 16 diagnoses of inflammatory cancers and 620 diagnoses of breast cancer at death). INTERVENTION: In 1995, multidisciplinary team working was introduced in hospitals throughout one health board area (Greater Glasgow; intervention area), but not in other health board areas in the west of Scotland (non-intervention area). MAIN OUTCOME MEASURES: Breast cancer specific mortality and all cause mortality. RESULTS: Before the introduction of multidisciplinary care (analysed time period January 1990 to September 1995), breast cancer mortality was 11% higher in the intervention area than in the non-intervention area (hazard ratio adjusted for year of incidence, age at diagnosis, and deprivation, 1.11; 95% confidence interval 1.00 to 1.20). After multidisciplinary care was introduced (time period October 1995 to December 2000), breast cancer mortality was 18% lower in the intervention area than in the non-intervention area (0.82, 0.74 to 0.91). All cause mortality did not differ significantly between populations in the earlier period, but was 11% lower in the intervention area than in the non-interventional area in the later period (0.89, 0.82 to 0.97). Interrupted time series analyses showed a significant improvement in breast cancer survival in the intervention area in 1996, compared with the expected survival in the same year had the pre-intervention trend continued (P=0.004). This improvement was maintained after the intervention was introduced. CONCLUSION: Introduction of multidisciplinary care was associated with improved survival and reduced variation in survival among hospitals. Further analysis of clinical audit data for multidisciplinary care could identify which aspects of care are most associated with survival benefits.

Evaluation of the first phase of a specialist weight management programme in the UK National Health Service: prospective cohort study.

OBJECTIVE: To evaluate the first phase of a specialist weight management programme provided entirely within the UK National Health Service. DESIGN: Prospective cohort study using multiple logistic regression analysis to report odds of ≥5 kg weight loss in all referrals and completers, and odds of completion, with 95 % confidence intervals. Anxiety and depression 'caseness' were measured by the Hospital Anxiety and Depression Scale. SETTING: Glasgow and Clyde Weight Management Service (GCWMS) is a specialist multidisciplinary service, with clinical psychology support, for patients with BMI ≥35 kg/m2 or BMI ≥30 kg/m2 with co-morbidities. SUBJECTS: All patients referred to GCWMS between 2004 and 2006. RESULTS: Of 2976 patients referred to GCWMS, 2156 (72·4 %) opted into the service and 809 completed phase 1. Among 809 completers, 35·5 % (n 287) lost ≥5 kg. Age ≥40 years, male sex (OR = 1·39, 95 % CI 1·05, 1·82), BMI ≥ 50 kg/m2 (OR = 1·70, 95 % CI 1·14, 2·54) and depression (OR = 1·81, 95 % CI 1·35, 2·44) increased the likelihood of losing ≥5 kg. Diabetes mellitus (OR = 0·55, 95 % CI 0·38, 0·81) and socio-economic deprivation were associated with poorer outcomes. Success in patients aged ≥40 years and with BMI ≥50 kg/m2 was associated with higher completion rates of the programme. Patients from the most deprived areas were less likely to lose ≥5 kg because of non-completion of the programme. CONCLUSIONS: Further improvements in overall effectiveness might be achieved through targeting improvements in appropriateness of referrals, retention and effective interventions at specific populations of patients.

Evidence-based infection control planning based on national healthcare-associated infection prevalence data.

This study identifies factors associated with a high prevalence of healthcare-associated infection (HAI) in the Scottish inpatient population, on the basis of the Scotland National HAI Prevalence Survey data set. The multivariate models developed can be used to predict HAI prevalence in specific patient groups to help with planning and policy in infection control.

Patterns of ocular morbidity and blindness in leprosy--a three centre study in Eastern India.

BACKGROUND: Eye disease and visual impairment due to leprosy are not uncommon, but their prevalence and the risk factors for such pathology have yet to be fully characterized. METHODS: An observational study of leprosy-affected individuals in the community, in three districts in Eastern India was performed to determine the prevalence of ocular morbidity and blindness. The subjects were chosen by stratified random sampling, according to stage of treatment, or stage of post-treatment surveillance. Each subject underwent ophthalmic examination according to a standard pro-forma. RESULTS: Thirty-three out of 1137 (2.9%) subjects were blind according to the WHO classification, and 232/1137 (20.7%) had moderate visual impairment. The prevalence of blindness and visual impairment was greatest in one centre, Jhalda. Multivariate Logistic Regression analysis showed that longer duration of disease, more advanced treatment stage and older age were independently associated with blindness. One hundred and forty-one cases (28%) in Muzaffarpur, 95 cases (63%) in Saldoha and 378 cases (78%) in Jhalda had active or treated multibacillary leprosy. DISCUSSION: The prevalence of blindness in leprosy varies in different population groups, with differing patterns of leprosy-related ocular morbidity, blindness and disease type evident even in different areas of the same region. Leprosy screening and surveillance programmes should include ocular examination as part of routine screening, particularly in individuals with a history of multi-bacillary disease. Individuals with known sight- threatening pathology should undergo continued active follow up. Local epidemiological studies would enable appropriate programme planning and efficient allocation of resources.

An evaluation of economics and acceptability of screening for Chlamydia trachomatis infection, in women attending antenatal, abortion, colposcopy and family planning clinics in Scotland, UK.

OBJECTIVE: The aims of this study were to determine cost effectiveness of screening for Chlamydia trachomatis in hospital-based antenatal and gynaecology clinics, and community-based family planning clinics. Additionally, women's views of screening were determined in the hospital-based clinics. DESIGN: Cost effectiveness based on decision model. Model probabilities were generated for a hypothetical sample of 250 women in each age group in each setting, based on prevalence studies, published data and expert opinion. A prospective observational study was used to generate data on prevalence and acceptability. SETTING: Antenatal, gynaecology and family planning clinics in Aberdeen, Edinburgh and Glasgow. SAMPLE: Prevalence was estimated in 2817 women. Acceptability was determined in 484 women. METHODS: An economic evaluation was performed using prevalence data from this and a previous study, and using outcome data from the literature and observational work. Incremental cost effectiveness ratios were estimated for each age group and clinical setting. Sensitivity analyses were performed to determine the robustness of incremental cost effectiveness ratios to changes in the incidence of long term sequelae and costs. The prevalence of infection was determined by nucleic acid amplification of urine samples or endocervical swabs. Knowledge of C. trachomatis and women's views of screening were determined using structured questionnaires. MAIN OUTCOME MEASURES: Direct health service costs of screening, incidence and costs associated with adverse sequelae, women's views of screening and prevalence of infection. RESULTS: The estimated cost of screening 250 women in each age group in each the four sample populations (total population of 3750) is 49,367 UK pounds, while preventing 64 major sequelae. This represents a net cost of 771.36 UK pounds in preventing one major sequela. Selective screening of all women under 20 years and all patients attending abortion clinics were shown to be the most cost effective strategies. These results were relatively insensitive to changes in estimated parameters, such as uptake rate, probabilities and unit costs of all major sequelae averted. Prevalence (95% CI) of infection in the highest risk groups (those aged under 20 in both antenatal and abortion clinics) was 12.1% (8.6-16.7) and 12.7% (7.3-21.2), respectively. The majority (>95%) of women agreed with a policy of regular screening for C. trachomatis, and screening in the settings employed in this study was largely acceptable. CONCLUSIONS: A single episode of screening for C. trachomatis does not result in net cost savings. Currently recommended strategies of screening for C. trachomatis in women under 25 years of age in abortion clinics are supported by our data on prevalence and acceptability. These data also suggest that hospital-based screening strategies should be further extended to include younger women attending antenatal clinics and all women of reproductive age attending colposcopy clinics.

Opportunistic screening for genital Chlamydia trachomatis infection and partner follow-up in family planning clinics in three Scottish cities.

Three large urban family planning clinics (FPCs) in Scotland participated in a study to examine the implications of opportunistically offering urine testing for genital Chlamydia trachomatis infection and FPC follow-up of positive women and of their male partners. Ninety-eight percent (3029) of women accepted the test. The prevalence of infection was 5.2% and this decreased significantly with age. There was no significant difference in prevalence between centres. Ninety-one percent of positive women intended to inform at least one partner about their infection status. Pretest counselling took about 10 minutes per woman while management (excluding full screening for sexually transmitted infections) of positive women took an additional 10 minutes. Screening in the FPC is acceptable to many women and to some of their male partners. Training and resources for administration and staffing are required if opportunistic screening is to be implemented.