Management of lymphoma patients in a cancer unit: an audit of 15 years' experience in a district general hospital.

The objectives were to analyse data obtained in a district general hospital medical oncology unit over a 15-year period, and to provide a comparator for standards of care for lymphoma patients in new cancer units. Prospectively collected data were analysed on 208 consecutive patients presenting with lymphoma, on an 'all-comers' basis, between 1981 and 1996. Treatment was with radiotherapy and/or chemotherapy, according to local protocols. The outcome measure was survival from the date of diagnosis. The 5-year actuarial survival was 72.7% for Hodgkin's disease and 55.7% for non-Hodgkin's lymphoma. Age and stage of disease were the only predictors of survival in a multivariate analysis. Histological classification was not a useful predictor of survival in this analysis. Survival figures comparable with those obtained nationally and across Europe are attainable in a cancer unit. Multiple pathways of referral of lymphoma patients operate in our region.

The effects on prescribing patterns and costs of having a special interest in asthma.

To define the characteristics of general practices with a special clinical interest in asthma and to estimate the resulting extra prescribing costs, we sent a postal questionnaire to all English practices containing members of the General Practitioners in Asthma Group. Item and cost comparisons for 24 PACT (prescribing analysis and cost) aggregates were made between practices who had operated an agreed, written management plan for asthma before 1 April 1990 and all other practices in their respective Family Health Services Authorities. One hundred and sixty-three practices with GPIAG members responded (70%), of which 26 filled the management plan requirement. These 26 practices showed evidence of significantly better asthma care provision than the remainder of the sample. Their prescribing costs were significantly higher for respiratory drugs (median 37% higher) but lower in other drug categories. For respiratory drugs, costs were significantly higher for inhaled adrenoceptor stimulants, steroid inhalers, large spacers, and peak flow meters, but lower for cough medicines and systemic nasal decongestants: the number of items prescribed showed similar patterns. The prescribing costs of practices claiming a special interest in asthma are likely to show higher respiratory drug costs, but overall prescribing costs showed no increase in the practices studied.

Serum albumin and CA125 are powerful predictors of survival in epithelial ovarian cancer.

OBJECTIVE: To assess the prognostic significance of presentation serum albumin, clinical stage and CA125 levels in ovarian cancer. DESIGN: Retrospective analysis of data using a Cox proportional hazards model. SETTING: A district general hospital oncology unit. SUBJECTS: One hundred and fourteen consecutive patients with epithelial ovarian cancer. INTERVENTIONS: Cytotoxic chemotherapy and surgery. MAIN OUTCOME MEASURE: Survival. RESULTS: A linear increase in risk was observed with high log CA125 (P < 0.0001) and with low albumin (P < 0.0001). In late stage patients (III and IV) albumin is the best predictor of survival (P = 0.0006). The presence of ascites, blood transfusion, type of surgery or chemotherapy did not improve the predictive model. CONCLUSIONS: CA125 and albumin can be used to identify prognostic subgroups independently of stage. Albumin alone can also be used as a predictor of survival. A simple classification of patients into three groups based on serum albumin of 41 g/l or more, 35 to 40 g/l and 34 g/l or less provides a clear separation of survival curves in the present group of patients.

Measuring prescribing: the shortcomings of the item.

OBJECTIVES: To assess the validity of the item as a measure of the volume of a drug prescribed; and to investigate the possibility that higher quantities per item are prescribed for patients who are not exempt from the prescription charge. DESIGN: Five substudies. For the first, a frequency distribution was derived of the different quantities per item of 10 commonly used drugs prescribed by 20 randomly selected practices in each of five family health service authority areas. For the second, the variation in average quantity per item for the same drugs in the same practices was calculated. For the third and fourth, variation in average quantity per item for 90 commonly used drugs was calculated for all 90 family health service authorities and for all 14 regional health authorities in England. For the fifth, the average quantity per item for each of the 90 drugs was regressed on the percentage of items exempt from the prescription charge, at family health service authority level, and the percentage of variation explained by the regression found. MAIN OUTCOME MEASURE: Distribution of quantity per item; variation in average quantity per item between the practices, between family health service authorities, and between regions; and percentage of variation between family health service authorities accounted for by exemption from the prescription charge. RESULTS: Wide variation was found in the quantities per item prescribed by the practices, and in the average quantity per item between practices and between family health service authorities. No family health service authority was consistently high or low in quantity per item across the 90 drugs. Variation in average quantity per item was less at regional than at family health service authority level, though still high for many of the drugs. The proportion of variation accounted for by exemption from prescription charges ranged from 0% to 49% across the 90 drugs. CONCLUSIONS: The item is unsuitable as a measure of prescribing volume, even at regional level: a new measure, based on standard daily dosages, is needed. The percentage of the variation in quantity per item accounted for by exemption is inconsistent, and in over half the 90 drugs it was below 20%--therefore it is not a useful predictor.

The Acute Infarction Ramipril Efficacy (AIRE) Study: rationale, design, organization, and outcome definitions.

The rationale, design, organization, and outcome definitions of the Acute Infarction Ramipril Efficacy (AIRE) Study are described prospectively. A total of 2,000 patients (1,000 per treatment group) will be recruited to this multicenter, multinational, double-blind, randomized, placebo-controlled study investigating the effect of oral treatment with ramipril (2.5 or 5 mg twice daily) on the total mortality of survivors of an acute myocardial infarction (AMI) with early clinical evidence of heart failure. Secondary outcomes of the study include progression to severe/resistant heart failure (at which time the patient will be withdrawn from the study treatment), reinfarction, and stroke. Treatment will be initiated in hospital between day 3 and day 10 following AMI, and follow-up continued for an average of 15 months and a minimum of 6 months. The study data will be analyzed on an intention-to-treat basis: a single formal interim analysis will be conducted after 175 deaths. An Independent Adjudicating Panel will act as the overall ethical supervisory body for the study and will retain the randomization code. An International Steering Committee will be responsible for the clinical definitions of the secondary study outcomes, and will regularly review progress of the study. We believe that early treatment with ramipril may reduce the total mortality of patients surviving an AMI with clinical evidence of heart failure.