Identifying appearance-related concerns in routine follow-up clinics following treatment for oral and oropharyngeal cancer

Facial disfigurement can be a consequence of treatment for oral or oropharyngeal cancer. Patients' concerns about appearance and the impact this has on quality of life are very important, but are often not recognised in a busy outpatient clinic. We aimed to assess concerns about appearance using the University of Washington Quality of Life questionnaire version 4 (UW-QoL) and the Patient Concerns Inventory (PCI), a self-administered questionnaire that allows patients to choose what they would like to discuss in their consultation. Prospective data were collected from 204 patients who attended routine follow-up clinics from August 2007 to mid-July 2009. Fifty-seven percent were male, 68% had cancer of the oral cavity, 78% had clinical T1-T2 tumours, 19% had node positive tumours, 44% had had radiotherapy since diagnosis, and 48% had had free-flap reconstructive surgery. They all completed the questionnaires using touch-screen computer technology at 454 clinic appointments. Appearance was raised on the inventory at 9% (42/454) of clinics, and at 10% (47/454) it was indicated as a serious problem on the UW-QoL questionnaire. Concerns about appearance were raised on the inventory or were shown to be a serious problem on the UW-QoL in 14% (64/454) of patients. The main factors associated with those who reported concerns about appearance were age (younger patients), sex (female), T stage (III and IV), and site (oropharynx). Patients who choose concerns about appearance for discussion on the UW-QoL questionnaire and not on the PCI risk being missed if only the PCI is completed. Both tools compliment the screening of patients who have problems with facial disfigurement; failure to identify them can have serious clinical and psychosocial implications.

Stroke thrombolysis in England, Wales and Northern Ireland: how much do we do and how much do we need?

BACKGROUND

Data are limited on the proportion of stroke patients nationally appropriate for thrombolysis either within the 3 h time window or the recently tested 4.5 h. This information is important for the redesign of services.

METHODS

Data on case mix, eligibility for thrombolysis, treatment and outcomes were extracted from the National Sentinel Stroke 2008 Audit dataset. This contains retrospective data on up to 60 consecutive stroke admissions from each acute hospital in England, Wales and Northern Ireland between 1 April and 30 June 2008.

FINDINGS

All relevant hospitals participated, submitting data on 11,262 acute stroke patients. 2118 patients arrived within 2 h and 2596 within 3 h of the onset of symptoms and 587 people were already in hospital. Therefore, 28% (3183) were potentially eligible for thrombolysis based on a 3 h time criterion. Of these, 1914 were under 80 years and 2632 had infarction with 14% (1605) meeting all three National Institute of Neurological Disorders and Stroke study criteria and so being potentially eligible for thrombolysis. If the time window is increased to 4.5 h then only another 2% became eligible. If the age limit was removed for treatment, the percentage potentially appropriate for tissue plasminogen activator increased to 23% within 3 h and 26% within 4.5 h. Overall, 1.4% (160) of patients were thrombolysed.

INTERPRETATION

Thrombolysis rates are currently low in the UK. 14% of patients in this sample were potentially suitable for thrombolysis using the 3 h time window. This would only increase marginally if thrombolysis was extended to include those up to 4.5 h. The greatest impact on increasing the proportion of patients suitable for thrombolysis would be to increase the number of patients presenting early and by demonstrating that the treatment is safe and effective in patients over 80 years of age.

Surgery for oesophageal cancer at Galway University Hospital 1993-2008

BACKGROUND

Surgical volume and outcome remain controversial in the management of oesophageal cancer.

AIMS

To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH).

METHODS

Between 1994 and 2008, patients who underwent oesophagectomy were analysed.

RESULTS

During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively.

CONCLUSIONS

Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.

Fear of recurrence following head and neck cancer in the outpatient clinic

Fear of recurrence (FOR) following head and neck cancer is one of the most frequent concerns of patients and is associated with psychological distress. The aims of this study were, first, to report the clinical characteristics of patients selected for FOR concerns on a patient concerns inventory (PCI) and, second, to compare the degree of FOR using a FOR questionnaire of those patients expressing FOR concerns on the PCI with those who did not. Two cohorts were used. The first comprised consecutive oncology patients attending clinics from August 2007 for 9 months (N = 123). These patients completed the PCI only. The second comprised patients attending the same clinic for over 4 months from October 2008 (N = 68), and this group completed both the PCI and the FOR questionnaire. FOR was the most frequently selected issue on the PCI (42%). There were no obvious differences in selecting FOR by patient characteristics. Those who scored 'a lot' or 'all the time' for questions 1-6 in the FOR questionnaire and responses (on a 10-point scale) of 7-10 for question 7 were deemed as having 'significant' FOR. In those raising the issue of FOR on the PCI, 79% (15/19) had significant problems compared to 24% (12/49) if they did not. FOR is a common concern and because it is not possible to identify patients based on clinical parameters, it is important to screen for FOR to direct patients to appropriate support and intervention.

A randomised trial of peer review: the UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project

Peer review has been widely employed within the NHS to facilitate health quality improvement but has not been rigorously evaluated. This article reports the largest randomised trial of peer review ever conducted in the UK. The peer review intervention was a reciprocal supportive exercise that included clinicians, hospital management, commissioners and patients which focused on the quality of the provision of four specific evidence-based aspects of chronic obstructive pulmonary disease care. Follow up at 12 months demonstrated few quantitative differences in the number or quality of services offered in the two groups. Qualitative data in contrast suggested many benefits of peer review in most but not all intervention units and some control teams. Findings suggest peer review in this format is a positive experience for most participants but is ineffective in some situations. Its longer term benefits and cost effectiveness require further study. The generic findings of this study have potential implications for the application of peer review throughout the NHS.

Longitudinal evaluation of restricted mouth opening (trismus) in patients following primary surgery for oral and oropharyngeal squamous cell carcinoma

Trismus is a serious problem for some patients after oral and oropharyngeal cancer, and it has a detrimental impact on quality of life and function. We know of few published papers that include preoperative assessment in reports on the longitudinal outcomes of mouth opening after oral and oropharyngeal surgery. We prospectively measured mouth opening in patients who had primary surgery for oral and oropharyngeal cancer from baseline to six months to find out the characteristics at baseline and at discharge of those who develop trismus at six months. Ninety-eight patients were eligible between February 2007 and March 2008, and 64 (65%) were recruited into the study. The range of mouth opening was measured on three occasions: before operation, on the ward before discharge from hospital, and at follow-up six months after operation. Using a criterion of 35 mm or less as an indication of trismus, 30% (19/63) had trismus before operation, 65% (37/57) at hospital discharge, and 54% (26/48) at six month follow-up. Patients at high risk of trismus were those with T stage 3 or 4 cancers who required free flap reconstruction and adjuvant radiotherapy; radiotherapy was the most significant factor at six months. Trismus at discharge was a prediction of trismus at six months. Interventions such as spatulas or a passive jaw mobiliser should be targeted at patients at high risk early in the postoperative phase. The efficacy of such interventions needs further research.

What is the quality of the evidence base for pre-implant surgery of the atrophic jaw?

This review aimed to evaluate the level of evidence for bone augmentation preimplant surgery for atrophic jaws in studies which measure outcome. Medline, Embase, Cochrane library and online journal searches were performed with a defined search strategy and the abstracts screened against selection criteria. The resultant papers were sorted by study design using the Cochrane study design algorithm, analysed for clinical/statistical homogeneity and graded with the Oxford Centre of Evidence-based Medicine levels of evidence. The initial online Medline search yielded 1194 results and the Embase search yielded 490 results. Using the selection criteria, 10 studies were identified. Additionally, 5 articles were identified from bibliography and online searches, giving a total of 15 studies for grading. All 15 studies were graded as level 4 evidence. No meta-analysis of outcomes was possible with the low level of evidence and degree of heterogeneity found. The best grade of recommendation that can be made for a particular preimplant surgical bone augmentation procedure, from these level 4 studies, is Grade C. Benchmarking studies by assessing quality of evidence can be helpful to inform future study designs with respect to reporting study outcomes with a higher level of evidence.

The NERC DataGrid services

This short paper outlines the key components of the NERC DataGrid: a discovery service, a vocabulary service and a software stack deployed both centrally to provide a data discovery portal, and at data providers to provide local portals and data and metadata services.