Influence of a regional centralised upper gastrointestinal cancer service model on patient safety, quality of care and survival.

AIMS: The aim of this study was to determine outcomes of a reconfigured centralised upper gastrointestinal (UGI) cancer service model, allied to an enhanced recovery programme, when compared with historical controls in a UK cancer network. MATERIALS AND METHODS: Details of 606 consecutive patients diagnosed with UGI cancer were collected prospectively and outcomes before (n = 251) and after (n = 355) centralisation compared. Primary outcome measures were rates of curative treatment intent, operative morbidity, length of hospital stay and survival. RESULTS: The rate of curative treatment intent increased from 21 to 36% after centralisation (P < 0.0001). Operative morbidity (mortality) and length of hospital stay before and after centralisation were 40% (2.5%) and 16 days, compared with 45% (2.4%) and 13 days, respectively (P = 0.024). The median and 1 year survival (all patients) improved from 8.7 months and 39.0% to 10.8 months and 46.8%, respectively, after centralisation (P = 0.032). On multivariate analysis, age (hazard ratio 1.894, 95% confidence interval 0.743-4.781, P < 0.0001), centralisation (hazard ratio 0.809, 95% confidence interval 0.668-0.979, P = 0.03) and overall radiological TNM stage (hazard ratio 3.905, 95% confidence interval 1.413-11.270, P < 0.0001) were independently associated with survival. CONCLUSION: These outcomes confirm the patient safety, quality of care and survival improvements achievable by compliance with National Health Service Improving Outcomes Guidance.

Comparison of patients' needs and doctors' perceptions of information requirements related to a diagnosis of oesophageal or gastric cancer.

The aim of this study was to assess the information needs of patients diagnosed with oesophageal and gastric cancer and to compare these with their perceived information needs in the opinion of junior doctors. One hundred patients and 100 doctors responded to a questionnaire regarding the information needs of cancer patients. Seventy-nine per cent of patients wanted as much information as possible about their diagnosis, but only 35% of doctors were willing to give all the available information (P < 0.0001). Seventy-seven per cent of patients wanted to receive their diagnosis from a consultant whereas only 5% of doctors believed that patients should receive their diagnoses from a consultant (P < 0.0001). Eighty-four per cent of doctors were willing to communicate a serious illness with a good prognosis, yet only 43% would communicate a diagnosis with a poor prognosis (P < 0.0001). All 100 doctors had received formal training in breaking bad news, but 20 considered this inadequate. Socio-economic deprivation was associated with poor access to supplementary Internet derived information (P < 0.001). The majority of patients with a diagnosis of oesophagogastric cancer want a great deal of information regarding their illness, which contrasts with doctors' perceptions. Adequate training in information disclosure may help address this issue.

Prognostic significance of age in the radical treatment of oesophageal cancer with surgery or chemoradiotherapy: a prospective observational cohort study.

AIMS: To compare the outcomes of stage-directed surgical therapy and chemoradiotherapy (CRT) for oesophageal cancer and to determine if a significant age-treatment interaction exists to guide therapy. MATERIALS AND METHODS: Five hundred and eight consecutive patients with oesophageal cancer suitable for radical treatment based on radiological stage and performance status were studied (275 surgery; 93 surgery alone, 131 neoadjuvant chemotherapy, 51 neoadjuvant CRT and 233 definitive CRT). The primary measure of outcome was survival. RESULTS: Thirty-day mortality rates and 2-year survival after surgery and CRT in patients<70 years were 2.4 and 57.5%, respectively, compared with 0 (P=0.207) and 47.3% (P=0.011), respectively. Thirty-day mortality rates and 2-year survival after surgery and CRT in patients>or=70 years were 7.0 and 45.1%, respectively, compared with 0 (P=0.029) and 46.3% (P=0.992), respectively. Multivariate analysis including only surgical patients in the model revealed three factors to be independently and significantly associated with survival; endoscopic ultrasound (EUS) T stage (P=0.033), EUS lymph node metastasis count (>or=2 versus 0: hazard ratio 1.67, 95% confidence interval 1.06-2.92, P=0.026), and age>or=70 years (hazard ratio 1.51, 95% confidence interval 1.05-2.16, P=0.025). CONCLUSION: Overall survival for patients treated with surgery was strongly age dependent around the age of 70 years, and patients>or=70 years with oesophageal cancer should be aware that outcomes after CRT are similar to those after surgery.

Prospective comparison of endosonography, computed tomography, and histopathological stage of junctional oesophagogastric cancer.

AIMS: To assess the strength of agreement between the perceived preoperative stage of Siewert II (oesophagogastric junction) and Siewert III (proximal gastric tumours) as determined by computed tomography (CT) and endoscopic ultrasound (EUS), both alone and in combination, with histopathological stage. METHODS: Forty-four patients with Siewert II (n=18) and III (n=26) adenocarcinomas of the oesophagogastric junction underwent preoperative CT at their local hospitals followed by specialist EUS, and the strengths of the agreement between the radiological stages and the histopathological stages were determined by the weighted Kappa statistic (Kw). RESULTS: Kw for Siewert II T and N stages was 0.491 (p=0.016) and 0.4 (p=0.087) for CT compared with 0.852 (p=0.0001) and 1 (p=0.0001) for EUS. Kw for Siewert III T and N stages was 0.181 (p=0.206) and 0.121 (p=0.376) for CT compared with 0.173 (p=0.195) and 0.263 (p=0.031) for EUS. CONCLUSION: Siewert II tumour T and N stages were more accurately predicted by EUS than CT, but Siewert III tumour T and N stages were more difficult to assess, arguably because of anatomical constraints at the oesophagogastric junction. CT and EUS are complimentary techniques, and these results highlight the importance of multidisciplinary discussion in planning treatment.

Prospective randomised clinical trial of providing patients with audiotape recordings of their oesophagogastric cancer consultations.

OBJECTIVE: To evaluate audiotape-recorded consultations at which a new diagnosis of oesophageal or gastric cancer was given to patients with reference to information retention, psychological outcome and socio-economic deprivation. METHODS: Fifty-eight patients were randomised to receive audiotaped consultations or not. Thirty-one patients received tapes (12 oesophageal and 19 gastric cancers) and were compared with 27 control patients (12 oesophageal and 15 gastric cancers). All patients were re-interviewed and completed a hospital anxiety and depression (HAD) questionnaire. Socio-economic deprivation scores were calculated using National Indices of Multiple Deprivation. RESULTS: Patients randomised to receive tapes were more likely to retain information (31 patients) than control patients (18 patients, p=0.001). Median (range) HAD scores were similar in both groups of patients [HAD A tape 6 (0-21) vs. no tape 5 (2-14), HAD D tape 3 (0-23) vs. 4 (0-10), respectively]. Deprivation correlated significantly with higher HAD A scores in control patients (p=0.039) but was not associated with information retention (p=0.667). CONCLUSION: Taped consultations were associated with significantly better information retention without adverse psychological outcomes. Providing an audiotape may reduce the effect of socio-economic deprivation on patient anxiety. PRACTICE IMPLICATIONS: Audiotaping, or its equivalent, would be a valuable tool in the multidisciplinary approach to cancers of the upper gastrointestinal tract.

Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer.

We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

Prognostic significance of alarm symptoms in patients with gastric cancer.

BACKGROUND: The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome. METHODS: Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years). RESULTS: It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival. CONCLUSION: Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.

Prospective comparison of D1 vs modified D2 gastrectomy for carcinoma.

To compare the outcomes after D1 gastrectomy with those after modified D2 gastrectomy (preserving pancreas and spleen) performed by specialist surgeons for gastric cancer in a large UK NHS Trust. In all, 118 consecutive patients with gastric adenocarcinoma were referred by postcode, to undergo either a D1 gastrectomy (North Gwent (RJ), n=36, median age 76 years, 21 m) or a modified D2 gastrectomy (South Gwent (WL), n=82, 70 years, 57 m). Operative mortality in the two groups of patients was similar (D1 8.3% vs D2 7.3%, chi2 0.286, DF 1, P=0.593). Overall cumulative survival at 5 years was 32% after D1 gastrectomy compared to 59% after D2 gastrectomy (chi2 4.25, DF 1, P=0.0392). In patients with stage III cancers, survival was 8% after D1, compared with 33% after D2 gastrectomy (chi2 6.43, DF 1, P=0.0112). In a multivariate analysis, T stage (hazard ratio 2.339, 95% CI 1.683-2.995, P=0.01), N stage (hazard ratio 4.026, 95% CI 3.536-4.516, P=0.0001) and the extent of lymphadenectomy (hazard ratio 0.258, 95% CI -0.426-0.942, P=0.0001) were independently associated with durations of survival. In conclusion, modified D2 gastrectomy can improve survival four-fold for patients with stage III gastric cancer, without significantly increasing morbidity and mortality when compared with a D1 gastrectomy.

Comparison of special interest computed tomography, endosonography and histopathological stage of oesophageal cancer.

AIMS: To assess the strength of agreement between the perceived pre-operative stage of oesophageal tumours as determined by spiral computed tomography (CT) and endoscopic ultrasound (EUS), both alone and in combination, with the histopathological stage. METHODS: Sixty patients with oesophageal cancer underwent both pre-operative CT and EUS performed by two consultant radiologists with a special interest in upper gastrointestinal radiology. The strength of the agreement between the radiological stage and the histopathological stage was determined by means of the weighted Kappa statistic (Kw). RESULTS: Sensitivity for T and N stages was 58% and 79% for CT, and 72% and 91% for EUS. Specificity for T and N stages was 80% and 84% for CT, and 85% and 68% for EUS. Kw for T and N stages was 0.455 (p=0.0001) and 0.603 (p=0.0001) for CT compared with 0.604 (p=0.0001) and 0.610 (p=0.0001) for EUS. In patients when CT and EUS agreed regarding the T and N stages, the strength of agreement between the radiological and the histopathological stage was greater (Kw T 0.613 (p=0.0001), Kw N 0.781 (p=0.0001)). CONCLUSION: CT and EUS are complimentary techniques for the staging of oesophageal tumours, and these results reinforce the importance of specialist radiology in stage directed management.

Developing a departmental culture for reporting adverse incidents.

A simple, reproducible model for reporting adverse events was developed in order to promote cultural awareness and acceptance of risk management within the authors' department. A departmental proforma was created and prospective reporting of adverse events was encouraged. In the six months prior to commencing this study only four adverse incidents were reported. Following the introduction of the proforma 64 critical incidents and near-misses were reported in the one-year period. In conclusion a simple model for reporting critical incidents and near-misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer patients continuous improvement in care.

Illumination of x-rays: the usual lights exposed.

AIMS: Faced with pressure of work and limited resource, doctors frequently use the nearest available light to examine x-ray films. The aim of this study was to examine the relative intensities of hospital light sources, and to compare these with the light intensity guidelines (1500 to 3000 candelas) of the British Institute of Radiology. METHODS: The relative intensities of seven hospital light sources were examined using a standard light meter at a constant 30 cm from the source. A control group of 10 individual consultant's x-ray viewing boxes were compared with six other ward based light sources. RESULTS: Only two light sources approached the British Institute of Radiology light intensity x-ray viewing criteria: the x-ray viewing boxes of consultant radiologists with a median light intensity of 3503 candelas (chi(2)=13.3, df 1; p=0.0001), and daylight from north facing windows with a median of 1464 candelas when overcast (chi(2)=8.571, df 1; p=0.003) and 4669 candelas in sunshine (chi(2)= 6.364, df 1; p=0.0001). CONCLUSION: Few hospital light sources met the British Institute of Radiology guidelines. The long held high regard of artists for northern light appears justified even in the environment of a British district general hospital.

Comparative study of "staples versus sutures" in skin closure following Dupuytren's surgery.

This prospective, randomized controlled trial assessed the use of staples for closure of the palmar skin following Dupuytren's surgery. Although staples were significantly quicker to insert than sutures, patients experienced significantly more pain on removal of staples. There was no difference in the cosmetic appearance of the wound in the two groups. We recommend use of staples for palmar wound closure following long procedures.

Clinical information in psychiatric practice: what do doctors know, what do they think is known and what do they record?

Deficiencies in recording clinical information are a widespread problem in both psychiatry and medicine. Previous studies have not established whether information not recorded in the notes is nonetheless known to clinicians. This study compared both the information known to individual clinicians and that recorded in the notes with previously established criteria. Overall, individual clinicians recalled more information than was recorded in the notes (median values: clinicians 47-63% of criteria; notes 42%) and when all this individual knowledge was pooled, 88% of the preset criteria were satisfied. Consultants, but not more junior staff, recalled significantly more about subsections of the history which they considered to be especially relevant to the management plan for a given patient. Only a third of data not known to clinicians, but thought by them to be recorded in the notes, was actually present. The implications of these findings for clinical audit and medical education are discussed.

Pott's puffy tumour reviewed.

The aim of this paper is to highlight Potts puffy tumour as a pathological entity distinct from other causes of peri- and supraorbital swelling. This uncommon condition is usually not recognised initially and is easily confused with neoplasms or local eye pathology. A case is reported and investigations and management reviewed.