Understanding ethnic and other socio-demographic differences in patient experience of primary care: evidence from the English General Practice Patient Survey

BACKGROUND

Ethnic minorities and some other patient groups consistently report lower scores on patient surveys, but the reasons for this are unclear. This study examined whether low scores of ethnic minority and other socio-demographic groups reflect their concentration in poorly performing primary care practices, and whether any remaining differences are consistent across practices.

METHODS

Using data from the 2009 English General Practice Patient Survey (2 163 456 respondents from 8267 general practices) this study examined associations between patient socio-demographic characteristics and 11 measures of patient-reported experience.

FINDINGS

South Asian and Chinese patients, younger patients, and those in poor health reported a less positive primary care experience than White patients, older patients and those in better health. For doctor communication, about half of the overall difference associated with South Asian patients (ranging from -6 to -9 percentage points) could be explained by their concentration in practices with low scores, but the other half arose because they reported less positive experiences than White patients in the same practices. Practices varied considerably in the direction and extent of ethnic differences. In some practices ethnic minority patients reported better experience than White patients. Differences associated with gender, Black ethnicity and deprivation were small and inconsistent.

CONCLUSION

Substantial ethnic differences in patient experience exist in a national healthcare system providing universal coverage. Improving the experience of patients in low-scoring practices would not only improve the quality of care provided to their White patients but it would also substantially reduce ethnic group differences in patient experience. There were large variations in the experiences reported by ethnic minority patients in different practices: practices with high patient experience scores from ethnic minority patients could be studied as models for quality improvement.

Phase II trial of sorafenib in esophageal (E) and gastroesophageal junction (GEJ) cancer: Response observed in adenocarcinoma

41

Background: Sorafenib is a tyrosine kinase inhibitor targeting VEGFr, PDGFr, Raf and other pathways. Encouraging response and survival were observed in a phase II trial combining sorafenib with chemotherapy in GE cancer (J Clin Oncol 27:2947;2010). We are studying single agent sorafenib in a phase II trial with the primary endpoint to assess progression free survival (PFS). Secondary endpoints include response and therapy tolerance.

Methods: Patients (pts) with measurable metastatic E and GEJ cancer with no more than 3 prior chemotherapy regimens were treated with sorafenib 400 mg BID. CT scans were performed monthly for the first 2 months, then every 2 months.

Results: Sixteen of 35 pts have been accrued and 14 are currently evaluable. 13 male, 3 female, median KPS 80%, age 58, GEJ 7, E 9, squamous 2, adenocarcinoma (AC)14. An ongoing complete response (11+ months) was observed in a pt with biopsy proven metastatic neck lymphadenopathy (E primary AC, recurrence after prior chemoradiotherapy and surgery). A second pt (GEJ AC) had protracted stable disease in bulky celiac node disease (15+ months). Grade 3 toxicity was limited to skin rash (1 pt), hand foot reaction (1 pt), and fatigue (1 pt). Only 3 of 14 pts (21%) had early disease progression at 2 months or less. Median PFS 4 mos, 4 patients (29%) continue on therapy for more than 7 months. The majority of tumors tested positive for phospho-erk by immunohistochemistry (11/14, 79%).

Conclusions: The observation of a durable complete response and protracted stable disease to sorafenib in E cancer is remarkable. Further accrual continues to define PFS. Supported by a grant from Bayer.

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Fractured migrated oesophageal stent fragment presenting as small bowel obstruction three years after insertion

Oesophageal stent migration is a recognised complication; however, few present distal to the stomach causing obstruction. To date, this has never been reported as occurring later than 2 years after insertion. An 84-year-old woman presented with small bowel obstruction secondary to a fractured migrated metallic oesophageal stent fragment; this occurred 3 years after placement for a benign oesophageal stricture, which had failed conservative management. Intra-operatively, the fractured segment of oesophageal stent was found at the ileocaecal junction.

What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records

The aim was to describe the consulting behaviour and clinical outcomes of children presenting with headache in primary care. This was a historical cohort study using data from the UK General Practitioner Research Database. Cases were children aged 5-17 years who presented to primary care with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor). Controls were age, sex and practice matched. Their records were examined for consultations, referrals, relevant treatments and specific diseases in the subsequent year. Children with headache (n = 48 575) were identified and matched to controls. At presentation, 9321 (19.2%) of headaches were labelled primary, 549 (1.1%) secondary and 38 705 (79.7%) received no formal diagnosis. Of the latter group, 2084 (5.4%) received a primary headache diagnosis in the subsequent year. Following a diagnosis of migraine, 258 (3.5%) had received a triptan and 1598 (21%) were using propranolol or pizotifen. Total consultations were higher in cases than in controls in the year before the headache: cases ages 5-8 years, mean (s.d.) 5.0 (4.0) consultations; controls 4.0 (3.5) consultations. In 1 year controls had 43 430 consultations, of which 256 (0.6%) were for headache, of whom 64 (25%) were referred to secondary care. Headache was a risk factor for benign and malignant tumours, cerebrovascular disease, primary disorders of raised intracranial pressure and depression. This risk was reduced if a diagnosis of a primary headache disorder could be made. Although there is an increased likelihood of a serious pathology with headache presentations, the risk is small particularly if a diagnosis of a primary headache is made. General practitioners are likely to be underdiagnosing migraine. This study can inform management guidelines for new presentations of headache in primary care, particularly when a secondary pathology is suspected.

Regional anaesthesia for caesarean section: a choice of three techniques

Over the last 20 years, there has been a large increase in the proportion of caesarean sections (Brown and Russell, 1995) which are performed under regional rather than general anaesthesia. A bilateral sensory block from the T4 dermatome (nipple level) to the sacral nerve roots (perineum) is necessary.

Ethnicity and persistent symptom burden in breast cancer survivors

INTRODUCTION

Relatively few studies of breast cancer survivors have included nonwhite women or women who do not speak English.

METHODS

We administered a survey to patients who were >or=3 months post-completion of their adjuvant treatment for stage 0-III breast cancer at Columbia University Medical Center in order to assess the prevalence of 16 physical and emotional symptoms and identify sociodemographic factors associated with these symptoms. Univariate analysis, factor analysis, ANOVA, and multiple linear regression analysis were performed.

RESULTS

Of 139 patients surveyed, 58 were white, 63 Hispanic, and 18 black. The symptom most commonly reported was fatigue(76%), and the most common severe symptom was muscle aches(40%). Most patients(70%) complained of >or=6 symptoms. Hispanic women were more likely to report >10 symptoms (p < 0.05). Factor analysis reduced the 16 symptoms to 4 underlying symptom clusters that we categorized as 'depression', 'chemotherapy', 'hormone', and 'pain'-related. In the multiple linear regression models, Hispanic women were more likely to report chemotherapy-related symptoms (p < 0.05) and pain-related symptoms (p < 0.05). Unemployed women were more likely to report chemotherapy-related symptoms (p < 0.05). Women <45 years old were less likely to report chemotherapy (p < 0.05) and pain-related symptoms (p < 0.05).

CONCLUSIONS

The majority of women in this study, particularly those who were Hispanic, elderly, or unemployed, experienced persistent symptoms, most commonly fatigue and muscle aches.

IMPLICATIONS FOR CANCER SURVIVORS

Because Hispanic, elderly, or unemployed women experience greater symptom burden, efforts should made to address their unique needs.

Reduced helminth burden increases allergen skin sensitization but not clinical allergy: a randomized, double-blind, placebo-controlled trial in Vietnam

BACKGROUND

Observational evidence suggests that infection with helminths protects against allergic disease and allergen skin sensitization. It is postulated that such effects are mediated by helminth-induced cytokine responses, in particular IL-10.

OBJECTIVE

We tested this hypothesis in a rural area of central Vietnam where hookworm infection is endemic.

METHODS

One thousand five hundred and sixty-six schoolchildren aged 6-17 were randomly allocated to receive either anti-helminthic therapy or a placebo at 0, 3, 6, and 9 months. We compared changes in the prevalence of exercise-induced bronchoconstriction, allergen skin sensitization, flexural eczema on skin examination, questionnaire-reported allergic disease (wheeze and rhinitis symptoms), and immunological parameters (hookworm-induced IFN-gamma, IL-5, IL-10) between 0 and 12 months.

RESULTS

One thousand four hundred and eighty-seven children (95% of these randomized) completed the study. The most common helminth infections were hookworm (65%) and Ascaris lumbricoides (7%). There was no effect of the therapy on the primary outcome, exercise-induced bronchoconstriction (within-participant mean percent fall in peak flow from baseline after anti-helminthic treatment 2.25 (SD 7.3) vs. placebo 2.19 (SD 7.8, P=0.9), or on the prevalence of questionnaire-reported wheeze [adjusted odds ratio (OR)=1.16, 95% confidence interval (CI) 0.35-3.82, P=0.8] and rhinitis (adjusted OR=1.39, 0.89-2.15, P=0.1), or flexural dermatitis on skin examination (adjusted OR=1.15, 0.39-3.45, P=0.8). However, anti-helminthic therapy was associated with a significantly higher allergen skin sensitization risk (adjusted OR=1.31, 1.02-1.67, P=0.03). This effect was particularly strong for children infected with A. lumbricoides at baseline (adjusted OR=4.90, 1.48-16.19, P=0.009). Allergen skin sensitization was inversely related to hookworm-specific IL-10 at baseline (adjusted OR=0.76, 0.59-0.99, P=0.04). No cytokine tested, including IL-10, changed significantly after the anti-helminthic therapy compared with the placebo.

CONCLUSION

A significant reduction in worm burden over a 12-month period in helminth-infected children increases the risk of allergen skin sensitization but not of clinical allergic disease. The effect on skin sensitization could not be fully explained by any of the immunological parameters tested.

Association between migraine, anxiety and depression

Logistic regression was used to evaluate the relationship between self-reported medical diagnosis of migraine, self-reported depressive symptomology (RDS) and self-reported anxious symptomology (RAS) in the National Health Interview Survey ( n = 30 852). Semipartial squared correlations evaluated the population-level variability between RDS, RAS and migraine impairment. Migraine prevalence was 15.2% (overall), 20.5% (women) and 9.4% (men). Migraine risk was higher in participants with RAS [odds ratio (OR) 2.30, 95% confidence interval (CI) 2.09, 2.52), with RDS (OR 2.23, 95% CI 1.93, 2.58), who smoked (OR 1.19, 95% CI 1.09, 1.30), or who consulted a mental health provider (OR 1.45, 95% CI 1.27, 1.65). Although migraine risk was increased in both women (OR 1.93) and men (OR 2.42) with RAS ( P < 0.001), men with RAS had a higher migraine risk than did women with RAS ( P < 0.001). Only 7% of the variability in migraine impairment (population level) was predicted by variability in RDS and/or RAS.

Interventionist causal models in psychiatry: repositioning the mind-body problem

The diversity of research methods applied to psychiatric disorders results in a confusing plethora of causal claims. To help make sense of these claims, the interventionist model (IM) of causality has several attractive features. First, it connects causation with the practical interests of psychiatry, defining causation in terms of 'what would happen under interventions', a question of key interest to those of us whose interest is ultimately in intervening to prevent and treat illness. Second, it distinguishes between predictive-correlative and true causal relationships, an essential issue cutting across many areas in psychiatric research. Third, the IM is non-reductive and agnostic to issues of mind-body problem. Fourth, the IM model cleanly separates issues of causation from questions about the underlying mechanism. Clarifying causal influences can usefully structure the search for underlying mechanisms. Fifth, it provides a sorely needed conceptual rigor to multi-level modeling, thereby avoiding a return to uncritical holistic approaches that 'everything is relevant' to psychiatric illness. Sixth, the IM provides a clear way to judge both the generality and depth of explanations. In conclusion, the IM can provide a single, clear empirical framework for the evaluation of all causal claims of relevance to psychiatry and presents psychiatry with a method of avoiding the sterile metaphysical arguments about mind and brain which have preoccupied our field but yielded little of practical benefit.

J/psi production at HERA

We consider the J/psi photoproduction data collected at the DESY ep collider HERA in the light of next-to-leading order predictions for the color-singlet yield and polarization. We find that, while the shapes of inclusive distributions in the transverse momentum and inelasticity are well reproduced, the experimental rates are larger than those given by the color-singlet contribution alone. Furthermore, the next-to-leading order calculation predicts the J/psi's to be mostly longitudinally polarized at high transverse momentum in contrast with the trend of the preliminary data from the ZEUS Collaboration.

Activated c-Src (Y215) kinase expression predicts for early relapse on tamoxifen in human breast cancer

Abstract #3025

Recent studies have demonstrated activation of the non-receptor tyrosine kinase c-Src in tamoxifen resistant breast cancer cell lines, which when treated with Src inhibitors demonstrate a reduction in motility and invasiveness. However, there are little published translational studies confirming a role for c-Src in tamoxifen resistance in vivo. We aim to determine if activated c-Src expression correlates clinically with increased recurrence on tamoxifen.&#x2028; Methods&#x2028; Tissue microarrays were constructed from a patient cohort of 402 Tamoxifen treated ER positive patients. Immunohistochemistry was performed using commercially available antibodies to Total Src as well as to activated (phosphorylated) c-Src at 2 sites (Y416 and Y215) (pSrc416 and pSrc215 respectively). Expression was assessed by 2 independent scorers (weighted histoscore method). HER1-3 status and expression of membranous phosphorylated ER (sites serine 118 and 167) had previously been determined. All statistical calculations were performed using SPSS 15, including Kaplan-Meier life table analysis with log rank testing of differences in breast cancer related relapse whilst on tamoxifen.&#x2028; Results&#x2028; Membranous pSrc215 was observed in 20.3% of the cases but was more frequently observed in the cytoplasm (85.9%) and nucleus (90.5%). Overexpression of cytoplasmic pSrc215 was associated with an earlier time to recurrence (p = 0.037).&#x2028; &#x2028; Cox regression analysis confirmed this to be independent of grade, nodal and HER1-3 status (p=0.028, HR 3.17 (1.14–8.85)). Cytoplasmic pSrc215 was also strongly correlated with membranous phospho-ER, EGFR and HER3 status (Mann Whitney; p&lt;0.001, p=0.026, p&lt;0.001 respectively). Membranous and nuclear pSrc215 staining were not associated with time to relapse.&#x2028; Over expression of Total Src and pSrc416 did not predict for relapse.&#x2028; Discussion&#x2028; Our findings provide support to in vitro studies linking c-Src with tamoxifen resistance. The phosphorylation site pSrc215 is a putative site of activation by HER2 and PGFR resulting in up to 50 fold activation of Src in vitro. The correlations demonstrated with HER status and membranous ER lead us to speculate that this interplay between non genomic ER and Src activation may provide a mechanism for the lack of response to tamoxifen in these patients.&#x2028; Further studies are required to determine if activated pSrc215 represents activated c-Src alone or may also represent activation of other Src family members as the Y416 and Y215 sequences are highly conserved amongst the Src kinases with homologous activation sites. If confirmed, future use of novel combination therapies with Src inhibitors may have an important role in combating tamoxifen resistance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3025.

Lack of transmission of porcine circovirus type 2 to weanling pigs by feeding them spray-dried porcine plasma

An experiment was conducted to determine whether spray-dried porcine plasma containing 2.47 x 10(5) dna copies of porcine circovirus type 2 (pcv-2) could infect weanling pigs when fed to them. Five specific pathogen-free (spf) weanling pigs were fed ad libitum for 45 days a control diet and six pigs were fed a test diet containing 8 kg sdpp per 100 kg feed. The two groups were housed in separate biosecurity level-3 rooms. None of the pigs in either group developed any clinical signs or became pcv-2 viraemic or seroconverted.