Socioeconomic variation in uptake of colonoscopy following a positive faecal occult blood test result: a retrospective analysis of the NHS Bowel Cancer Screening Programme.

BACKGROUND: Bowel cancer is a serious health burden and its early diagnosis improves survival. The Bowel Cancer Screening Programme (BCSP) in England screens with the Faecal Occult Blood test (FOBt), followed by colonoscopy for individuals with a positive test result. Socioeconomic inequalities have been demonstrated for FOBt uptake, but it is not known whether they persist at the next stage of the screening pathway. The aim of this study was to assess the association between colonoscopy uptake and area socioeconomic deprivation, controlling for individual age and sex, and area ethnic diversity, population density, poor self-assessed health, and region. METHODS: Logistic regression analysis of colonoscopy uptake using BCSP data for England between 2006 and 2009 for 24 180 adults aged between 60 and 69 years. RESULTS: Overall colonoscopy uptake was 88.4%. Statistically significant variation in uptake is found between quintiles of area deprivation (ranging from 86.4 to 89.5%), as well as age and sex groups (87.9-89.1%), quintiles of poor self-assessed health (87.5-89.5%), non-white ethnicity (84.6-90.6%) and population density (87.9-89.3%), and geographical regions (86.4-90%). CONCLUSION: Colonoscopy uptake is high. The variation in uptake by socioeconomic deprivation is small, as is variation by subgroups of age and sex, poor self-assessed health, ethnic diversity, population density, and region.

Bowel cancer screening is safe, detects earlier stage cancer and adenomas in 50% of cases: experience of the prevalent round of screening from two first wave centres in the North East of England.

OBJECTIVE: The NHS Bowel Cancer Screening Programme (BCSP) began roll-out in 2006 aiming to reduce cancer mortality through detection at an earlier stage. We report results from the prevalent round of screening at two first wave centres and compare with the UK pilot study. DESIGN: This is a service evaluation study. Data were collected prospectively for all individuals undergoing faecal occult blood testing (FOBt) and colonoscopy including: uptake and outcomes of FOBt, colonoscopic performance, findings, histological data and complications. Continuous data were compared using a two-tailed test of two proportions. SETTING: The South of Tyne and Tees Bowel Cancer Screening centres. PATIENTS: Participants of the BCSP. MAIN OUTCOME MEASURES: 1) Colonoscopy Quality Assurance and 2) Cancer stage shift. RESULTS: 195,772 individuals were invited to participate. Uptake was 54% and FOBt positivity 1.7%. 1524 underwent colonoscopy with caecal intubation in 1485 (97%). 180 (12%) cancers were detected. Dukes stages were: 76 (42%) A; 47 (26%) B; 47 (26%) C; 8 (4%) D and 2 (1%) unknown. This demonstrates a significantly earlier stage at diagnosis compared with data from 2867 non-screening detected cancers (p<0.001). Adenomas were detected in 758 (50%). One perforation occurred (0.07%) and two intermediate bleeds requiring transfusion only (0.12%). Both caecal intubation and adenoma detection were significantly higher than in the UK pilot study (p<0.001). CONCLUSIONS: The prevalent round of screening demonstrates a high adenoma and cancer detection rate and significantly earlier stage at diagnosis. Complications were few providing reassurance regarding safety. Efforts are required to improve uptake.

The use of N-terminal pro-B type natriuretic peptide in a pre-operative setting to predict left ventricular systolic dysfunction on echocardiogram.

Heart failure is a major risk factor for adverse postoperative events following non-cardiac surgery. The use of transthoracic echocardiogram as a pre-operative investigation to assess cardiac dysfunction has limitations in this setting. The N-Terminal fragment of B-Type natriuretic peptide (NT proBNP) has been used in screening for heart failure. We have investigated the use of NT proBNP as a screening tool for left ventricular systolic dysfunction to reduce the requirement for pre-operative echocardiograms. Ninety-eight pre-operative non-cardiac surgical patients scheduled to undergo echocardiography were assessed clinically and with an NT proBNP measurement. Echocardiogram was used to define two groups of patients depending on the presence or absence of abnormal left ventricular function and the NT proBNP level was compared between the groups using non-parametric and receiver-operator-characteristic (ROC) curve analysis. In terms of pre-operative screening, a NT proBNP of <38.2 pmol x l(-1) had a 100% negative predictive value in predicting patients with normal left ventricular systolic function and would have prevented the requirement for echocardiogram in 43% of pre-operative patients. NT proBNP was superior to electrocardiological and clinical criteria for detection of a normal echocardiogram. This may have significant impact in the pre-operative assessment of patients undergoing non-cardiac surgery.

Applicability of estimated glomerular filtration rate in stratifying chronic kidney disease.

OBJECTIVE: The aim of this audit was to evaluate the degree of glomerular filtration rate (GFR) among inpatients and outpatients in a District General Hospital, with special attention given to laboratory testing and impact on health delivery. BACKGROUND: UK Chronic Kidney Disease guidelines recommend that investigation of renal function should be accompanied by an estimation of GFR (eGFR) in order to identify and manage patients with chronic kidney disease (CKD). The estimated GFR forms the basis for classification of CKD and appropriate action plans for patient management and follow-up. METHOD: A retrospective audit of 8160 results from a predominantly British Caucasian population was carried out; extracting creatinine results from two isolated months in years 2001 and 2004. The estimated GFR (eGFR) was calculated using the MDRD formula. The data were classified according to demography, serum creatinine and eGFR. Patients from the 2001 database were classified according to eGFR and those with a value of <60 mL/min/1.73 m(2) were followed up in 2004. RESULTS: The difference in eGFR between the men and women was significantly different with medians (confidence intervals) of 80.1 (41-109) and 64.4 (30-84.6) (p<0.0001), respectively. There was an inverse association between age and eGFR in both genders (p<0.0001), with a decrease in eGFR of around 7 % for each decade increase in age. 1926 patients (24 %) of results studied had eGFR <60 mL/min, of whom 64 % were females and 36 % males. Follow-up of patients with eGFR<60 mL/min from 2001 showed that 4 % progressed to stages 4 and 5 CKD. CONCLUSION: eGFR is inversely associated with increasing age and female gender. MDRD derived eGFR fails to completely compensate for age and gender variations and thus different action limits may be required. Small but significant numbers of patients progressed to stages 4 and 5 CKD. Additional clarity in describing "progressive fall in eGFR" in the guidelines would improve identification of the population most at risk.

Best practice in primary care pathology: review 6.

This sixth best practice review examines four series of common primary care questions in laboratory medicine: (1) laboratory monitoring in hypertension and heart failure abnormalities; (2) markers of inflammatory joint disease; (3) laboratory investigation of chronic diarrhoea; and (4) mumps and chickenpox. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Comparison of pre-treatment CYFRA 21 - 1 and SCC-Antigen assay in primary cervical carcinoma - a preliminary report.

CYFRA21 - 1, a fragment of cytokeratin19, has been widely assessed as a serum marker of squamous malignancies. Previous studies using CYFRA21 - 1 and SCC-Antigen have shown mixed results but have indicated a better predictive prognostic value for SCC-Ag as compared to CYFRA21-1. The aim of our prospective, observational, pilot study was to evaluate the role of CYFRA21-1 and SCC-Ag in primary cervical carcinoma. Pre-operative serum CYFRA21-1 and SCC-Ag were measured (n = 14) in women with cervical carcinoma and correlated with staging, clinico-pathological parameters and prognostic data. Logistic regression analysis with CYFRA 21 - 1 test status (positive or negative) as a dependent variable showed that nodal metastases (p = 0.001) and lymphovascular space invasion (LVSI) (p = 0.005) were significant predictors, whereas stage and SCC-Ag levels were not significant. There was also no statistically significant correlation between SCC-Ag and CYFRA21-1 levels. If larger studies confirm these preliminary results, the option of laparoscopic surgical staging in patients with raised CYFRA21-1 levels could be considered.

Severe hyponatraemia: investigation and management in a district general hospital.

AIMS: To study the incidence, investigation, and management of severe hyponatraemia (serum sodium < 120 mmol/litre) over a period of six months in a district general hospital. METHODS: The laboratory computer was used to identify all inpatients who had a serum sodium concentration of less than 120 mmol/litre over a six month period. The records of these patients were reviewed for the relevant demographic, clinical, and laboratory data, in addition to diagnosis, treatment, and outcome of hospitalisation. RESULTS: Forty two patients were studied, with a female to male ratio of 2 : 1. Nine patients had central nervous system symptoms, and four of these patients died in hospital. Only 14 patients had their urinary electrolytes and/or osmolality checked. A diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was mentioned in eight patients, sometimes without checking their urinary electrolytes or osmolality. Twenty one patients died in hospital. The patients who died did not have lower serum sodium values or a higher rate of correction of hyponatraemia, but they all suffered from advanced medical conditions. CONCLUSIONS: The possible cause of hyponatraemia should always be sought and that will require an accurate drug history, clinical examination, and assessment of fluid volume, plus the measurement of urinary electrolytes and osmolality in a spot urine sample. The diagnosis of SIADH should not be confirmed without the essential criteria being satisfied. The current or recent use of diuretics is a possible pitfall in the diagnosis of SIADH. The rate of serum sodium correction of less than 10 mmol/day is probably the safest option in most cases.

Comparison of two direct methods for HDL cholesterol measurement with an indirect precipitation method in diabetic patients.

The conventional precipitation method for measuring HDL cholesterol involves a centrifugation step which prevents automation of the method. Several methods have been introduced for measuring HDL cholesterol without the need for a centrifugation step. These new methods are therefore automatable and can process a large number of samples in a short period of time. Measuring HDL cholesterol is an important aspect of management of diabetes mellitus. In this study, we compared 2 direct methods for measuring HDL cholesterol with a conventional precipitation technique in 63 patients with either Type 1 or Type 2 diabetes mellitus. Both direct methods showed acceptable precision but they both showed positive bias compared to the conventional precipitation method. The greatest degree of bias occurs at low HDL cholesterol levels, which are more important for Type 2 patients. Such differences may affect cardiovascular risk calculation in patients with diabetes. Further studies are required to investigate if a correction factor needs to be introduced when these direct assays are used to measure HDL cholesterol in patients with Type 2 diabetes mellitus.

Serum fructosamine as a marker of 5-year risk of developing diabetes mellitus in patients exhibiting stress hyperglycaemia.

AIMS: We examined whether the level of random serum glucose (RSG) in subjects exhibiting stress hyperglycaemia is a useful marker of the future risk of developing diabetes mellitus (DM), and whether serum fructosamine is of any additional value. METHODS: All non-diabetic adults attending Accident and Emergency in 1994-1995, who had venesection, were studied. Serum fructosamine and RSG were routinely measured in all such patients. Using the laboratory biochemistry database the number of subjects with stress hyperglycaemia (RSG > 11.1 mmol/l) was determined, and their corresponding fructosamine values were recorded. The number of subjects who developed DM over the following 5 years was determined. RESULTS: Three hundred and seventeen patients had stress hyperglycaemia, and follow-up data were available on 224 patients. Of these patients, 63 (28%) had developed DM over the 5 years follow-up period. RSG and fructosamine levels at baseline of patients subsequently developing DM were (mean +/- sd (range)) 16.7 +/- 7.0 (11.2-55.0) mmol/l and 3.3 +/- 0.6 (1.3-4.5) mmol/l, respectively. The patients who did not develop DM had a similar baseline RSG, 15.9 +/- 3.3 (11.2-30.6) mmol/l; P = 0.170, but lower baseline fructosamine, 2.4 +/- 0.4 (1.6-3.8) mmol/l; P < 0.001. Receiver-operating characteristics showed that a serum fructosamine > or = 2.8 mmol/l was a useful marker of the future risk of DM (75% sensitivity, 74% specificity, 53% positive and 88% negative predictive power). CONCLUSIONS: The level of RSG in stress hyperglycaemia does not predict the future development of DM. Raised serum fructosamine is a more useful marker of future DM risk than RSG alone. Further prospective studies are needed.

Hypnotic devices may be more than placebo.

The study attempted to assess the effectiveness of two devices in facilitating the induction of hypnosis in subjects preselected as low in hypnotizability. Undergraduates were exposed to no treatment (control) or one of four combinations of devices during the induction phase of being administered the Stanford Hypnotic Susceptibility Scale, Form B of Weitzenhoffer and Hilgard (1959). Analyses revealed only one of the conditions resulted in a significant difference in subjects' realness ratings of hypnotic items and an increase in hypnotizability score. If the effect is more than a chance significance of placebo, the underlying mechanisms remain unknown.

Incidence of phrenic nerve block and hypercapnia in patients undergoing carotid endarterectomy under cervical plexus block.

Deep cervical plexus blockade blocks the second, third and fourth cervical nerve roots. The phrenic nerve arises from C3, C4, C5 and should therefore be commonly blocked with cervical plexus blockade. The aim of this study was to report the incidence of phrenic nerve block and to assess the effect of this on arterial carbon dioxide tension (PaCO2) in premedicated and sedated patients. Forty patients were studied, blood gases being taken on the day before surgery, immediately before performing the block and then every 20 minutes until the operation was completed. Fluoroscopy was used to determine ipsilateral hemidiaphragmatic dysfunction due to phrenic nerve block. The patients were then divided into two groups of analysis. Group A patients had evidence of phrenic nerve block, Group B patients had no evidence of phrenic nerve block. Fluoroscopy showed that 22 patients (55%) had evidence of phrenic nerve block (Group A), 18 patients showed no change (Group B). PaCO2 levels increased in both groups following premedication, from 41 +/- 5 mmHg (mean +/- SD) to 46 +/- 5 mmHg in Group A, and 41 +/- 4 mmHg in Group B; twenty minutes after cervical plexus block the PaCO2 rose to 49 +/- 6 mmHg in Group A, and 48 +/- 6 mmHg in Group B. These changes were not statistically significantly different when the two groups were compared.

Combined general and epidural anesthesia versus general anesthesia for major abdominal surgery: postanesthesia recovery characteristics.

BACKGROUND AND OBJECTIVES: Outcome studies comparing general anesthesia combined with epidural anesthesia (GEN-EPI) to general anesthesia (GEN) for major abdominal surgery have been equivocal. However, many believe that patients anesthetized with GEN-EPI fair better than GEN. This study tests the hypothesis that there are favorable recovery characteristics associated with GEN-EPI as compared with GEN following abdominal surgery. METHODS: A prospective randomized double-blind trial, consisting of 30 patients ages 18-74 undergoing abdominal surgery was undertaken. Patients received either GEN-EPI or GEN by standardized protocol. At the end of surgery the epidural catheter was removed and psychological testing was performed over 24 hours to determine recovery characteristics. These included the modified Slater test, the Self-Assessment Manikin, the Kendrick Digital Copying Test, the Hospital Anxiety and Depression Scale, as well as visual analog scales for pain and appearance. RESULTS: Patients receiving GEN-EPI emerged from anesthesia faster (P < .03) with less pain on awakening (P < .04 at rest; P < .01 on coughing), had better psychomotor function at 2 hours (P < .04), and were less drowsy at 4 hours (P < .04), than patients with GEN. There was no difference in pain intensity after the initial assessment, morphine usage, mood, anxiety, and depression at any other measurement period. CONCLUSION: Transient quantifiable differences in recovery characteristics exist between patients receiving GEN-EPI and GEN.

In search of predictors of hypnotic sequelae.

The present one-group correlational study was an attempt to examine questionnaire data that included medical and psychosocial histories and an inventory of fears, social problems, and previous stressful situations in an effort to determine if any predictors of negative sequelae to hypnosis would emerge. After completing questionnaires, undergraduates (n = 432) were administered a group hypnotic susceptibility scale, then were given sequelae questionnaires to complete within two hours, and another two days later. Significant correlations were obtained between occurrence of aftereffects and susceptibility score, number of somatic complaints, and number of previous stressful situations. Results are discussed in the context of the overall ability of these data to predict hypnotic sequelae.

Equipment for the large-scale electromanipulation of plant protoplasts.

Electric fields are now used extensively for the genetic manipulation of plant cells through protoplast fusion and direct gene uptake. The cost of commercially available electrofusion and electroporation equipment remains prohibitive for many laboratories. This paper describes an electronic apparatus, suitable for the large-scale electrofusion and electroporation of plant protoplasts that is compatible in both function and cost with commercially available equipment.

The use of hypnosis in cocaine addiction.

An unusual case is presented in which hypnosis was successfully used to overcome a $500 (five grams) per day cocaine addiction. The subject was a female in her twenties. Six months into her addiction, she acquired a commercial weight-control tape that she used successfully to stop smoking cigarettes (mentally substituting the word "smoking"), as well as to bring her down from her cocaine high and allow her to fall asleep. After approximately 8 months of addiction, she decided to use the tape in an attempt to overcome the addiction itself. Over the next 4 months, she listened to the tape three times a day, mentally substituting the word "coke." At the end of this period, her addiction was broken, and she has been drug free for the past 9 years. Her withdrawal and recovery were extraordinary because hypnosis was the only intervention, and no support network of any kind was available.

The effect of preventive measures in reducing aftereffects to hypnosis.

In the present study we assessed the efficacy of several procedures in minimizing the occurrence of aftereffects of a hypnotic induction. We gave experimental subjects (n = 347) a brief lecture dispelling some myths about hypnosis, told them no psychological treatment would be undertaken, and then administered the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A) in which all references to aftereffects had been removed. We gave the standard version of the HGSHS:A to control subjects (n = 340). Although the treatment condition did not reduce the overall incidence of effects, long-term effects were significantly reduced. Medical and psychosocial histories were obtained from subjects prior to the induction, but they proved to be of limited value in predicting sequelae. Contrary to the results of Coe & Ryken (1979), hypnosis produced more frequent sequelae than a nonhypnotic classroom experience (watching a film followed by an introductory psychology lecture) for subjects in an ad hoc control group.

Transnasal endoscopic closure of anterior fossa cerebrospinal fluid fistula.

The anterior skull base can be approached intranasally, and the development of endoscopes and accompanying endoscopic instruments in recent years makes possible extremely precise and defined work along the ethmoid and sphenoid sinus roof. Since these areas are the most frequent locations of anterior skull base CSF rhinorrhea, it follows that the localization and subsequent closure of these defects theoretically can be accomplished in this manner. Our report and others show that closure of CSF leaks can be accomplished successfully using this procedure, with minimal morbidity and at a fraction of the cost of frontal craniotomy. In our opinion, this should become the initial procedure of choice for closure of anterior fossa CSF leaks in amenable cases.

The effect of prior knowledge of hypnotic items on hypnotic performance and depth.

First we exposed experimental subjects to either the hypnotic items they were about to experience or to those items embedded in a longer list of hypnotic items. We then asked them to give item-difficulty ratings prior to administration of a standard group susceptibility scale. Controls received no prior exposure to any hypnotic items. We obtained four dependent measures: hypnotic susceptibility score, an in-hypnosis depth report, Field (1965) Depth Inventory score, and retrospective depth reports. The three groups did not differ significantly on any of the dependent measures. Although this result differs from that of Shor, Pistole, Easton, and Kihlstrom (1984), who found that prior knowledge of items depressed susceptibility scores, this may be due to procedural differences between the two studies. Subjects' self-predictions of item difficulty were poor to modest, and accuracy of predictions was not related to any of the four dependent measures.