Meeting report: 2nd international conference: antibody incompatible transplantation and transplant infectious disease

The 2nd International Conference on Antibody Incompatible Transplantation and Transplant Infectious Disease took place at the University of Warwick on 23rd and 24th November 2012. The aims of the meeting were to discuss the pertinent clinical and laboratory issues surrounding antibody incompatible transplantation and to provide a contemporary analysis of transplant infectious disease. This report summarises the key points discussed at the meeting.

The Patient Concerns Inventory: A Tool to Uncover Unmet Needs in a Cancer Outpatient Clinic

The Patient Concerns Inventory (PCI) is a holistic, patient reported tool that aids in identifying concerns and issues. it is a 55-item checklist of issues that may be grouped into categories of general function, specific head and neck function, emotional-psychological and others, which include finances, treatment related matters and social care. The PCI also gives patients an opportunity to identify from a list of 15 multidisciplinary team (MDT) members whom they would like to see or be referred on to.

Serum placental-type alkaline-phosphatase levels in patients with epithelial ovarian-carcinoma

Serum placental alkaline phosphatase (PLAP)-type immunoreactivity was measured in 190 women with epithelial ovarian malignancy, 27 women with borderline ovarian cancer and 334 control subjects with non-neoplastic or benign gynaecological disease. Smoking, ABO blood group and menopausal status affect serum concentrations of PLAP and results were corrected for these. Circulating levels were elevated in patients with cancer and increased with stage. Levels were unaltered in borderline ovarian disease. Two-year stage corrected survival analysis demonstrated a significant worsening of prognosis in patients with serum PLAP-type levels greater than the 100th centile for controls.

Platelet transfusions in haematology patients: are we using them appropriately?

BACKGROUND AND OBJECTIVES

A large proportion of all platelet components are given to haematology patients. As there are risks associated with their transfusion, costs associated with production, and shortages may occur, it is important that their use is appropriate.

STUDY DESIGN AND METHODS

The study was split into two parts, a survey to assess local practice guidelines and an assessment of platelet usage. A total of 123 hospitals completed the survey and 168 hospitals submitted data of 40 haematology patients over a 3-month period.

RESULTS

The organizational survey found that 36% of hospitals routinely give prophylactic platelet transfusions to patients with long-term bone-marrow failure. Also, a significant minority of hospitals administer platelet transfusions if the platelet count is below a certain threshold prior to performing a bone-marrow aspirate (11%) or a bone-marrow aspirate and trephine (23%); both of these are contrary to UK platelet transfusion guidelines. Data were collected on a total of 3402 patients, of which 3296 cases were eligible for analysis. They received approximately 46% of all platelet components issued to participating hospitals in England during the study period. The majority (69%) of platelet transfusions were prophylactic; of these only 33% were given when the platelet count was ≤10×10(9)/l. Using an algorithm, based on current UK guidelines, 60% of prophylactic transfusions were appropriate, 6% could not be assessed and 34% were inappropriate. A total of 10% of all prophylactic transfusions were double the standard adult dose.

CONCLUSIONS

There is considerable potential for decreased use of platelet transfusions with a consequent improvement in their appropriate use and cost reduction.

Issues patients would like to discuss at their review consultation: variation by early and late stage oral, oropharyngeal and laryngeal subsites

PURPOSE

The patient concerns inventory (PCI) was developed to help patients raise issues/concerns during routine follow-up and to indicate team members they want to see. This paper reports the use of the PCI across various H&N Cancer sub-sites (oral, oropharyngeal and laryngeal) and stages of disease (early and late) and describes the main concerns that patients want to discuss using a cross-sectional survey comprising the PCI with the University of Washington Quality of Life questionnaire. Patients treated for primary H&N squamous cell carcinoma, 1998-2009, were identified from the University Hospital Aintree H&N Cancer database. 447/775 (58 %) patients responded. Fear of recurrence concerns was common to all clinical groups (range 32-67 %). Speech issues were more common with laryngeal tumours, and saliva issues with oropharyngeal tumours (32 % early, 48 % late). Apart from early-stage laryngeal tumours, patients consistently reported issues concerning dental health/teeth and chewing. The median (IQR) number of concerns overall was 4 (2-7), with significant variation (p < 0.001) between clinical groups ranging from 2 (1-6) for early-stage oral to 6 (2-10) for late-stage oropharyngeal and 7 (5-9) late-stage laryngeal. The results indicated that PCI can be readily incorporated into managing HNC patients and supports a holistic multidisciplinary approach to clinic consultations. It accommodates difficult issues such as fear of recurrence and intimacy. Completion of the PCI by patients before consultation can highlight problems and concerns that doctors can target for discussion, thereby streamlining consultations, and ensuring that patient needs are better met, thus creating a more effective service.

Evaluation of the limitations of using the University of Washington Quality of Life swallowing domain alone to screen patients in the routine clinical setting

A broad patient-completed screening tool in routine clinical practice in head and neck oncology has merit, but clinicians should be aware that its simplicity could lead to some patients and the detail of their problems being missed. The purpose of this study was to compare the University of Washington Quality of Life (UWQoL) swallowing domain with the MD Anderson Dysphagia Inventory (MDADI) in relation to the need for interventions for swallowing around one year after treatment. The group comprised 112 consecutively referred patients to speech and language therapy between January 2007 and August 2009 after primary operation for previously untreated oral and oropharyngeal squamous cell carcinoma (SCC). A total of 78 patients completed questionnaires (median time of assessment 11.7 months, IQR 6.1-12.2). There were significant (p<0.001) and moderately strong correlations (rs=0.51-0.62) between the UWQoL swallowing domain score and MDADI subscales and total scores, and also with individual MDADI questions: taking a great deal of effort (rs=0.71); being upset (rs=0.61); and not going out (rs=0.62) were the strongest in regard to swallowing. Use of a gastrostomy tube was associated with worse UWQoL and MDADI scores. In conclusion, patients who score 100 on the UWQoL do not require swallowing to be evaluated further. Those who score 70 could benefit from the detailed MDADI to help to clarify the specific problem and the impact it has before being referred to speech and language therapy. Those who score less than 70 should be brought to the attention of speech and language therapists to confirm that appropriate support and intervention are in place.

Quality of life in older people with oral cancer

There is a growing elderly population presenting with, and surviving, oral cancer. Making decisions about treatment is complex, and is influenced in part by prognosis and expected outcomes for health-related quality of life (HRQoL). We used the University of Washington Head and Neck Quality of Life scale (UWQoL) to compare HRQoL in patients by age group at a time closest to one year after primary surgery. Survival was analysed using data from the Office for National Statistics. A consecutive series of 1091 patients treated curatively for oral squamous cell carcinoma (SCC) at the regional maxillofacial unit at Aintree University Hospital between 1992 and 2009 were included in the main analysis. UWQoL data for 638 patients were available from about one year after treatment. Older patients (65 years or over) reported better physical and emotional function notably in regard to appearance, speech, saliva (75 years and over), pain, shoulder, mood, and anxiety than younger patients with head and neck cancer treated by operation. In conclusion, older patients seem to cope and adjust well to treatment and this is reflected in their HRQoL scores, which are higher in many domains than those of younger patients with head and neck cancer.

The identification of mood and anxiety concerns using the patients concerns inventory following head and neck cancer

The aim of this study was to investigate the concurrent use of the Patient Concerns Inventory (PCI) and the University of Washington Quality of life instruments (UW-QOL), as a means of identifying mood and anxiety concerns in patients following head and neck cancer treatment. From August 2007 to July 2009, 204 patients (454 clinic appointments) attending one consultant's oncology review clinic completed the UW-QOLv4 and PCI prior to their consultation. Before entering consultations, 17% (79/454) of patients reported problems with mood and 20% (89/454) reported problems with anxiety on the UW-QOL. Regarding the items raised by patients using the PCI prior to consultation, 'mood' was raised in 10% (46/454), 'anxiety' in 13% (58/454) and 'depression' in 10% (44/454) of cases. In 32% (145/454) of consultations, 44% (89/204) patients had reported significant anxiety or mood problems on the UW-QOL, or highlighted issues of anxiety, mood and/or depression on the PCI for discussion. Patients completing the PCI were more often referred to the clinical psychologist and to the emotional support worker. The results showed that the combination of the UW-QOL questionnaire and the PCI provide a practical means of screening for psychological distress in clinics.

Patients' perspective of financial benefits following head and neck cancer in Merseyside and Cheshire

The aim of this interview study was to ask patients with head and neck cancer in the Mersey region about their need for financial benefits, the advice they were given about benefits and financial matters, and the financial burden of the disease. Stratified quota sampling was by employment status, whether work had been affected by the cancer, and by sex. Of 51 interviewees (mean (SD) age 61(8) years) 20 were retired, 11 were unemployed, 13 worked full-time, and 7 worked part-time. Cancer had affected the work status of 24. Since diagnosis 57% had suffered financially; this was particularly high in those who had retired (65%), and in those whose work had been affected by cancer (79%). Quality of life had decreased in 53% as a result of the financial impact of the disease. This was most common in the unemployed (64%), and in those whose work was affected by cancer (83%). Only a quarter had been given adequate help and information about finance; this was lowest in the unemployed (18%) and highest in those who were fully employed (39%). One third (17/51) had never claimed benefits. The most common benefits were Disability Living Allowance and Incapacity Benefit. Two-thirds (21/31) had applied for benefits after diagnosis, 18 of these were directly as a result of the disease. The median (IQR) weekly income from benefits was £88 (£60-170). Patients and carers need better access to financial advice. We suggest that each multidisciplinary team should have a designated benefits or financial advisor who is readily available to patients in the clinic and on the ward.

A double blind randomised trial of IIb or not IIb neck dissections on electromyography, clinical examination, and questionnaire-based outcomes: a feasibility study

The aim of this double-blind randomised controlled trial was to evaluate the feasibility of a study to compare differences using electromyographic (EMG) or nerve conduction studies (NCS), questionnaires completed by patients, and range of movement, after selective supraomohyoid neck dissection in patients with and without level IIb for node-negative oral cancer. Between January 2006 and July 2008 we recruited 57 previously untreated consecutive patients with node-negative T1 or T2 squamous cell carcinomas (SCC) of the anterior two-thirds of the tongue and floor of the mouth. Thirty-eight patients were randomised (32 unilateral and 6 bilateral dissections) into two groups. Preoperatively and at 6 weeks postoperatively we collected EMG or NCS data on trapezius muscle activity (primary outcome), the University of Washington quality of life scale (UWQoLv4), the neck dissection impairment index (NDII), and range of movement. At 6 months data on range of movement and data from the questionnaires were obtained. There was a greater mean fall in trapezius M-response amplitude for those who had IIb dissected, which suggested that inclusion of this level caused additional morbidity. However, it was not significant for patients who had unilateral dissections or for all necks combined. Changes in M-amplitude from baseline to 6 weeks, and from baseline to 6 months were strongly associated with changes in the shoulder domain of the UWQoL and the NDII, but were less strong for change in range of movement. This feasibility study has shown that a randomised controlled trial (RCT) is achievable. The combination of EMG or NCS with questionnaire data preoperatively and to 6 weeks would suffice and would simplify a new study design.

Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008

BACKGROUND

The 2003 UK Chronic Obstructive Pulmonary Disease (COPD) audit revealed wide variability between hospital units in care delivered.

AIMS

To assess whether processes of care, patient outcomes and organization of care have improved since 2003.

DESIGN

A UK national audit was performed in 2008 to survey the organization and delivery of clinical care provided to patients admitted to hospital with COPD.

METHODS

All UK acute hospital Trusts (units) were invited to participate. Each unit completed cross-sectional resource and organization questionnaires and a prospective clinical audit comprising up to 60 consecutively admitted cases of COPD exacerbation. Comparison between 2003 and 2008 includes aggregated statistics for units participating in both audit rounds.

RESULTS

A total of 192 units participated in both audit rounds (6197 admissions in 2003 and 8170 in 2008). In 2008, patients were older and of a poorer functional class. Overall mortality was unchanged but adjusting for age and performance status, inpatient mortality (P = 0.05) and 90-day mortality (P = 0.001) were both reduced in 2008. More patients were discharged under a respiratory specialist (P < 0.01), treated with non-invasive ventilation if acidotic (P < 0.001) and accepted onto early discharge schemes (P < 0.01) while median length of stay fell from 6 to 5 days (P < 0.001). Within these mean data, however, there remains considerable inter-unit variation in organization, resources and outcomes.

CONCLUSION

Overall improvements in resources and organization are accompanied by reduced mortality, shorter admissions and greater access to specialist services. There remains, however, considerable variation in the quality of secondary care provided between units.

Pulmonary rehabilitation in the United Kingdom

We audited the UK provision of pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) and the quality of the programmes provided against national standards. All eligible UK Acute Trusts were invited to participate in a national audit of COPD in 2008. Eleven quality indicators for PR were derived from the National Institute for Health and Clinical Excellence (NICE) and the British Thoracic Society guidelines. Participants provided details of staff involved in their programme to self-assess whether they met each quality indicator in full, partially or not at all. Data were collected using a bespoke Web tool. Data were received from 239 acute units, a trust participation rate of 98%. Of the 239 units, 138 (58%) had provision of PR for all eligible patients and 76 (32%) for some but not all patients. Of these 214 PR, 13 (6%) programmes met all 11 quality indicators in full, median 8 with an interquartile range (IQR) of 7-9 for all PR programmes. One third of the programmes fully met the standards that continuation PR phases be provided, staff be trained in resuscitation and services be fully audited. Despite widespread provision of PR in the UK, the quality of programmes is variable and often less than satisfactory. Lack of funding is cited as a primary barrier to all eligible COPD patients not receiving PR. Those responsible for PR must act to improve the quality of services and audit their effectiveness before service expansion to meet future demand that can be justified.