The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

Time of Day Preferences and Daily Temporal Consistency for Predicting the Sustained Use of a Commercial Meditation App: Longitudinal Observational Study

BACKGROUND

The intensive data typically collected by mobile health (mHealth) apps allows factors associated with persistent use to be investigated, which is an important objective given users' well-known struggles with sustaining healthy behavior.

OBJECTIVE

Data from a commercial meditation app (n=14,879; 899,071 total app uses) were analyzed to assess the validity of commonly given habit formation advice to meditate at the same time every day, preferably in the morning.

METHODS

First, the change in probability of meditating in 4 nonoverlapping time windows (morning, midday, evening, and late night) on a given day over the first 180 days after creating a meditation app account was calculated via generalized additive mixed models. Second, users' time of day preferences were calculated as the percentage of all meditation sessions that occurred within each of the 4 time windows. Additionally, the temporal consistency of daily meditation behavior was calculated as the entropy of the timing of app usage sessions. Linear regression was used to examine the effect of time of day preference and temporal consistency on two outcomes: (1) short-term engagement, defined as the number of meditation sessions completed within the sixth and seventh month of a user's account, and (2) long-term use, defined as the days until a user's last observed meditation session.

RESULTS

Large reductions in the probability of meditation at any time of day were seen over the first 180 days after creating an account, but this effect was smallest for morning meditation sessions (63.4% reduction vs reductions ranging from 67.8% to 74.5% for other times). A greater proportion of meditation in the morning was also significantly associated with better short-term engagement (regression coefficient B=2.76, P<.001) and long-term use (B=50.6, P<.001). The opposite was true for late-night meditation sessions (short-term: B=-2.06, P<.001; long-term: B=-51.7, P=.001). Significant relationships were not found for midday sessions (any outcome) or for evening sessions when examining long-term use. Additionally, temporal consistency in the performance of morning meditation sessions was associated with better short-term engagement (B=-1.64, P<.001) but worse long-term use (B=55.8, P<.001). Similar-sized temporal consistency effects were found for all other time windows.

CONCLUSIONS

Meditating in the morning was associated with higher rates of maintaining a meditation practice with the app. This is consistent with findings from other studies that have hypothesized that the strength of existing morning routines and circadian rhythms may make the morning an ideal time to build new habits. In the long term, less temporal consistency in meditation sessions was associated with more persistent app use, suggesting there are benefits from maintaining flexibility in behavior performance. These findings improve our understanding of how to promote enduring healthy lifestyles and can inform the design of mHealth strategies for maintaining behavior changes.

An audit of clinically triaged women at low risk for breast cancer presenting to the Helen Joseph Mammography Unit

BACKGROUND

The Helen Joseph Hospital (HJH) breast clinic utilises a clinical triage system to stratify patients based on their risk of breast cancer into high-, medium-, or low-risk profiles. This allows for timeous imaging and subsequent management of those patients at increased risk for breast cancer. The primary objective was to determine the cancer detection rate (CDR). The secondary objective was to correlate biopsy results with the Breast Imaging-Reporting and Data System (BI-RADS) risk assessment.

METHODS

A retrospective audit of the patients at low risk for breast cancer who were referred to the breast imaging unit (BIU) in 2019 at HJH. Patients were clinically assessed as low risk based on a triage form and were identified using the imaging files stored in the BIU. Results were recorded on Microsoft Excel and calculated as per the American College of Radiology guidelines.

RESULTS

The total population sample consisted of 398 patients. Two patients were characterised as BI-RADS 4 and underwent breast biopsies. One patient was diagnosed with histologically proven breast cancer. The CDR was 2.51%. The most representative groups were the age group of 60-69 years, BI-RADS breast density B and BI-RADS risk assessment 2.

CONCLUSION

Amongst the low-risk population, both the CDR and spectrum of disease was comparable to that of a screening population. This may be due to the use of a triage system prior to imaging, as well as an increase in clinical awareness of breast cancer within a tertiary institution.

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

BACKGROUND

The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis.

METHODS

A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2.

RESULTS

Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8%).

CONCLUSION

BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies.

An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit

BACKGROUND

Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH.

METHOD

A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented.

RESULTS

Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58%).

CONCLUSION

There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease.

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

ABSTRACT BACKGROUND: The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis METHODS: A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2 RESULTS: Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8% CONCLUSION: BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies Keywords: malignant breast pathology, high risk patient, Helen Joseph Hospital Breast Clinic

An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit

ABSTRACT BACKGROUND: Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH METHOD: A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented RESULTS: Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58% CONCLUSION: There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease Keywords: clinically benign breast disease, breast imaging unit, Helen Joseph Hospital

Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures

Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.

Molten metal high pressure injection injury of the hand

The second case of high temperature molten metal, high-pressure injection injury of the hand is reported here. Like in the previous case, there was an innocent-looking entry point with deep thermal injury to the flexor tendons and the digital nerves that appeared a few days after the injury and lead to finger amputation. LEVEL OF EVIDENCE: 5.

Imaging and clinical features of breast tuberculosis: a review series of 62 cases

AIM

To outline the disease burden of breast tuberculosis (TB) as a quantitative analysis amongst three tertiary hospitals in South Africa, with correlation to their clinical, demographic, and imaging features.

MATERIALS AND METHODS

A retrospective analysis was undertaken over an 18-month period (01/01/2017-30/06/2018) of all patients undergoing laboratory investigations for breast disease at the mammography departments of these three tertiary centres.

RESULTS

The prevalence of breast TB was 2.5% (n=62) of 2,516 patients. The median age of presentation was 38.5 years (interquartile range [IQR] 33-45). HIV status was known in 45 patients, of whom 36 were HIV infected (80%, 95% CI: 0.65-0.90, p<0.0001). Based on the ultrasound and/or mammogram findings, the patients were classified into five categories: TB breast abscess (40.3%), inflammatory/disseminated (24.2%), isolated TB lymphadenitis (22.6%), nodular (11.3%), and sclerosing form (1.6%). Histology demonstrated necrotising granulomatous inflammation in 57 cases (92%). Acid-fast bacilli (AFB) were positive in 8.1% (n=5) of the cytology and 16.1% (n=10) of the histology specimens. Culture for Mycobacterium tuberculosis was positive in 27% (17 cases), and in 12.9% (n=8). AFB were detected histologically using polymerase chain reaction (PCR) testing.

CONCLUSION

Knowledge of the varied clinical and radiological features is necessary to maintain a high degree of suspicion to prevent misdiagnoses, inappropriate management, and complications. Ultrasound-guided core biopsy rather than fine-needle aspiration (FNA) is advocated as the first-line intervention in diagnosing or excluding this disease, as it yields a better tissue sample and more often a positive diagnosis.

High-pressure injection injuries of the fingers: Long-term follow-up in patients after extensive debridement

High-pressure injection injuries to the fingers resulting from the introduction of a foreign substance, such as oil or paint, through a minor puncture wound are rare but can have serious clinical consequences. The objective of this article was to examine the long-term outcomes after surgical debridement of these injuries. We present a retrospective case series of 8 adults who had a high-pressure injection injury to their hand and underwent surgical debridement in our facility. Data were extracted from our outpatient registry. Assessment included a full physical examination, grip strength, range of motion, two-point discrimination and Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We followed 8 male patients for an average of 12.7 years. Their average age was 37 at time of injury and all had injured their right dominant hand. Seventy-five percent of the injuries were to the index finger. Seven out of the 8 patients returned to their pre-injury occupation, 4 out of 8 patients had reduced range of motion of the affected digit. Injury sequelae adversely affected activities of daily living (ADL) with an average QuickDASH score of 26. Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand. Sensation was also reduced in the affected digit in 7 out of 8 patients. All patients suffered from some level of neuropathic pain and/or cold intolerance. High pressure injection injury to the fingers is a serious event found amongst industrial laborers. In most patients, this injury will lead to long-term disability along with a negative impact on ADL. However, most patients eventually return to their pre-injury occupation. Extensive, single or repeat debridement of high-pressure injection injuries remains a valid treatment option with good long-term results.

The role of social context in symptom appraisal and help-seeking among people with lung or colorectal symptoms: A qualitative interview study

Prolonged diagnostic intervals are associated with poorer outcomes, and the patient interval appears to be a substantial contributor to the overall length of the diagnostic interval. This study sought to understand how the broader context of people's lives influenced symptom appraisal and help-seeking, comparing experiences by length of the patient interval. Patients referred with a suspicion of lung or colorectal cancer were invited to complete a questionnaire about their symptoms, with 26 respondents purposively sampled to take part in a semi-structured interview about their patient intervals. Embodied experience, appraisal, help-seeking decision-making and consultation were identified as component stages of the patient interval, with the factors affecting movement between these stages located in one of four contextual domains: individual experience, interpersonal relationships, healthcare system interactions and social and temporal context. The length of the patient interval was related to the type of symptom(s) experienced, discussion of symptoms with others and the social responsibilities people held during symptomatic periods. A contextual model of the patient interval illustrates the stages and domains of this interval, as grounded in the data from this study. The model has potential application to future studies examining the patient interval for a range of symptoms.

Bromelain-based enzymatic debridement and minimal invasive modality (mim) care of deeply burned hands

The objective was to critically review the data and assess the implications of NexoBrid [NexoBrid-NXB formerly Debrase Gel Dressing-DGD]^a in the special field of deep hand burns. Detailed analysis of endpoints in the treatment of hand burn patients was conducted as part of a multi-center, open label, randomized, controlled two-arm study to evaluate the safety and efficacy of NXB enzymatic debridement, comparing it to the current standard of care (SOC). These results were compared to a large cohort of patients treated with NXB in a previous, single arm study. Thirty-one burned hands were treated with NXB and 41 hand burns were in the SOC group. In the NXB group, 4 out of 31 hand burns (12.9%) required some excisional debridement compared to 29 out of the 41 (70.7%) in the SOC group (p<0.0001). Mean percentage of burn wound area excised in the NXB group was 4.4 ± 13.1% compared to 52.0 ± 41.4% in the SOC group (p<0.0001). None of the NXB-treated hands required escharotomy compared to 4 out of the 41 (9.7%) in the SOC group. NXB enzymatic debridement demonstrated a statistically significant reduction in burn wound excision and auto-grafting compared to SOC, and seems to prevent the need for emergency escharotomy. ^a DGD is produced by MediWound and distributed under the name NexoBrid®.

Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries

Background:

The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval.

Methods:

We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997–2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set.

Results:

The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001).

Conclusions:

This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific ‘safe’ waiting time as the length of the primary care interval appears to have negative impact from day one.

Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer

OBJECTIVE

Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening.

DESIGN

Qualitative analysis of semistructured in-depth interviews and written accounts.

PARTICIPANTS AND SETTING

People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location.

RESULTS

20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life.

CONCLUSIONS

Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release

Objectives

Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords.

Materials and Methods

Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system.

Results

We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases.

Conclusions

These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture.

Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072.

Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®)

Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Irritable bowel syndrome: an integrated explanatory model for clinical practice

BACKGROUND

Although irritable bowel syndrome (IBS) is a symptom-based diagnosis, clinicians' management of and communication about the disorder is often hampered by an unclear conceptual understanding of the nature of the problem. We aimed to elucidate an integrated explanatory model (EM) for IBS from the existing literature for pragmatic use in the clinical setting.

METHODS

Systematic and exploratory literature searches were performed in PubMed to identify publications on IBS and EMs.

KEY RESULTS

The searches did not identify a single, integrated EM for IBS. However, three main hypotheses were elucidated that could provide components with which to develop an IBS EM: (i) altered peripheral regulation of gut function (including sensory and secretory mechanisms); (ii) altered brain-gut signaling (including visceral hypersensitivity); and (iii) psychological distress. Genetic polymorphisms and epigenetic changes may, to some degree, underlie the etiology and pathophysiology of IBS and could increase the susceptibility to developing the disorder. The three model components also fit into one integrated explanation for abdominal symptoms and changes in stool habit. Additionally, IBS may share a common pathophysiological mechanism with other associated functional syndromes.

CONCLUSIONS & INFERENCES

It was possible to elucidate an integrated, three-component EM as a basis for clinicians to conceptualize the nature of IBS, with the potential to contribute to better diagnosis and management, and dialog with sufferers.

The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports

BACKGROUND

Patients diagnosed with cancer in the context of an emergency presentation (EP) have poorer outcomes. It is often assumed that such patients present to the emergency department without consulting their general practitioner (GP). Little work has been done to identify primary care involvement before hospital attendance.

METHODS

Participating primary care practices completed a significant event audit (SEA) report for the last patient diagnosed with cancer as a result of an EP. Accounts were synthesised and a qualitative approach to analysis undertaken.

RESULTS

SEAs for 222 patients were analysed. A range of cancers were included, the most common being lung (32.4%) and upper gastrointestinal (19.8%). In most cases, patients had contact with their practice before diagnosis, primarily in the period immediately before admission. In only eight cases had there been no input from primary care. Accounts of protracted primary care contact generally demonstrated complexity, often related to comorbidity, patient-mediated factors or reassurance provided by negative investigations. Learning points identified by practices centred on the themes of presentation and diagnosis, consultation and safety-netting, communication and system issues, patient factors and referral guidelines.

CONCLUSIONS

There is extensive primary care input into patients whose diagnosis results from EP, and for the most part potential 'delay' in referral can be reasonably explained by the complexity of the presentation or by coexisting patient factors.

Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study

BACKGROUND

This prospective cohort study aimed to identify symptom and patient factors that influence time to lung cancer diagnosis and stage at diagnosis.

METHODS

Data relating to symptoms were collected from patients upon referral with symptoms suspicious of lung cancer in two English regions; we also examined primary care and hospital records for diagnostic routes and diagnoses. Descriptive and regression analyses were used to investigate associations between symptoms and patient factors with diagnostic intervals and stage.

RESULTS

Among 963 participants, 15.9% were diagnosed with primary lung cancer, 5.9% with other thoracic malignancies and 78.2% with non-malignant conditions. Only half the cohort had an isolated first symptom (475, 49.3%); synchronous first symptoms were common. Haemoptysis, reported by 21.6% of cases, was the only initial symptom associated with cancer. Diagnostic intervals were shorter for cancer than non-cancer diagnoses (91 vs 124 days, P=0.037) and for late-stage than early-stage cancer (106 vs 168 days, P=0.02). Chest/shoulder pain was the only first symptom with a shorter diagnostic interval for cancer compared with non-cancer diagnoses (P=0.003).

CONCLUSIONS

Haemoptysis is the strongest symptom predictor of lung cancer but occurs in only a fifth of patients. Programmes for expediting earlier diagnosis need to focus on multiple symptoms and their evolution.

Assessing the impact of an English national initiative for early cancer diagnosis in primary care

BACKGROUND

The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer.

METHODS

A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not.

RESULTS

Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme's effectiveness.

CONCLUSIONS

Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads.

Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care--a Rome Foundation working team report

OBJECTIVE

To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care.

METHODS

Systematic searches of PubMed and Embase.

RESULTS

Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)].

CONCLUSIONS

There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.

Factors associated with timeliness of post-primary care referral, diagnosis and treatment for lung cancer: population-based, data-linkage study

Background:

The NHS Cancer Plan for England set waiting time targets for cancer referral (14 days from GP referral to first hospital appointment) and treatment (31 days from diagnosis, 62 days from urgent GP referral). Interim diagnostic intervals can also be calculated. The factors that influence timely post-primary care referral, diagnosis and treatment for lung cancer are not known.

Methods:

Northern and Yorkshire Cancer Registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to investigate the factors (socioeconomic position, age, sex, histology, co-morbidity, year of diagnosis, stage and performance status (PS)) that may influence the likelihood of referral, diagnosis and treatment within target, for 28 733 lung cancer patients diagnosed in 2006–2010.

Results:

Late-stage, poor PS and small-cell histology were associated with a higher likelihood of post-primary care referral, diagnosis and treatment within target. Older patients were significantly less likely to receive treatment within the 31-day (odds ratio (OR)=0.79, 95% confidence interval (CI) 0.69–0.91) and 62-day target (OR=0.80, 95% CI 0.67–0.95) compared with younger patients.

Conclusions:

Older patients waited longer for treatment and this may be unjustified. Patients who appeared ill were referred, diagnosed and treated more quickly and this ‘sicker quicker' effect may cancel out system socioeconomic inequalities that might result in longer time intervals for more deprived patients.

The role of patient, tumour and system factors in socioeconomic inequalities in lung cancer treatment: population-based study

Background:

Reducing socioeconomic inequalities in lung cancer treatment may reduce survival inequalities. However, the reasons for treatment variation are unclear.

Methods:

Northern and Yorkshire cancer registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to explore the role of stage, histology, performance status and comorbidity in socioeconomic inequalities in lung cancer treatment, for 28 733 lung cancer patients diagnosed in 2006–2010, and in a subgroup with stage recorded (n=7769, 27%).

Results:

Likelihood of receiving surgery was significantly lower in the most deprived group (odds ratio (OR)=0.75, 95% confidence interval (CI) 0.65–0.86); however, the OR was attenuated when including histological subtype (OR=0.82, 95% CI 0.71–0.96). Patients in the most deprived group were significantly less likely to receive chemotherapy in the fully adjusted full cohort model including performance status (OR=0.64, 95% CI 0.58–0.72) but not in the staged subgroup model when performance status was included (OR=0.88, 95% CI 0.72–1.08). Socioeconomic inequalities in radiotherapy were not found.

Interpretation:

Socioeconomic inequalities in performance status statistically explained socioeconomic inequalities in receipt of chemotherapy in the selective staged subgroup, but not in the full cohort. Socioeconomic variation in histological subtype may account for some of the socioeconomic inequalities in surgery.

Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice -- an evidence-based international guide

BACKGROUND

Evidence suggests that the gut microbiota play an important role in gastrointestinal problems.

AIM

To give clinicians a practical reference guide on the role of specified probiotics in managing particular lower gastrointestinal symptoms/problems by means of a systematic review-based consensus.

METHODS

Systematic literature searching identified randomised, placebo-controlled trials in adults; evidence for each symptom/problem was graded and statements developed (consensus process; 10-member panel). As results cannot be generalised between different probiotics, individual probiotics were identified for each statement.

RESULTS

Thirty seven studies were included; mostly on irritable bowel syndrome [IBS; 19 studies; treatment responder rates: 18-80% (specific probiotics), 5-50% (placebo)] or antibiotic-associated diarrhoea (AAD; 10 studies). Statements with 100% agreement and 'high' evidence levels indicated that: (i) specific probiotics help reduce overall symptom burden and abdominal pain in some IBS patients; (ii) in patients receiving antibiotics/Helicobacter pylori eradication therapy, specified probiotics are helpful as adjuvants to prevent/reduce the duration/intensity of AAD; (iii) probiotics have favourable safety in patients in primary care. Items with 70-100% agreement and 'moderate' evidence were: (i) specific probiotics help relieve overall symptom burden in some patients with diarrhoea-predominant IBS, and reduce bloating/distension and improve bowel movement frequency/consistency in some IBS patients and (ii) with some probiotics, improved symptoms have led to improvement in quality of life.

CONCLUSIONS

Specified probiotics can provide benefit in IBS and antibiotic-associated diarrhoea; relatively few studies in other indications suggested benefits warranting further research. This study provides practical guidance on which probiotic to select for a specific problem.

Xenon-enhanced computed tomography cerebral blood flow measurements in acute cerebral ischemia: Review of 56 cases

OBJECTIVE

Ischemic stroke must be diagnosed promptly if patients are to be treated with thrombolytic therapy. The diagnosis of acute cerebral ischemia, however, is usually based on clinical and computed tomography (CT) scan findings. CT scans are often normal in the first few hours after stroke. The purpose of this study was to determine whether Xenon-enhanced CT (XeCT) cerebral blood flow (CBF) studies could increase the sensitivity of stroke detection in the acute stage.

METHODS

CBF studies performed within 8 hours of symptom onset were evaluated in 56 patients who presented with hemispheric stroke symptoms. Mean CBF in the symptomatic vascular territory was calculated and compared with the corresponding contralateral area. CBF values below 18 mL/100g/min on 2 adjacent regions of interest were considered ischemic lesions. CT scans and angiograms were compared with the XeCt findings. Neurological condition on admission and discharge was evaluated by using National Institutes of Health Stroke Scale (NIHSS) scores.

RESULTS

The mean NIHSS score on admission was 12+/-5. Early CT scans were abnormal in 28 (50%) patients. There were 9 (16%) patients who had normal XeCT scans because of spontaneous reperfusion of the ischemic area. XeCT studies showed an ischemic lesion in 47 (84%) patients. In these patients, the mean CBF in the affected vascular territory was 16+/-8 mL/100g/min compared with 35+/-13 mL/100g/min in the contralateral specular territory (P<0.001). There were no false positive or negative XeCT studies, and the location of the perfusion defect corresponded with the CT and/or angiographic findings in all cases. Eight patients died (14%), and the 48 survivors (86%) had a mean NIHSS score of 9+/-6 on discharge.

CONCLUSIONS

CBF measurements were correlated with the CT and angiographic results and greatly assisted in the diagnosis of acute ischemic stroke. XeCT studies used for estimating the location and extent of cerebral ischemia may be important in the triage of patients for acute stroke therapy.

The Aarhus statement: improving design and reporting of studies on early cancer diagnosis

Early diagnosis is a key factor in improving the outcomes of cancer patients. A greater understanding of the pre-diagnostic patient pathways is vital yet, at present, research in this field lacks consistent definitions and methods. As a consequence much early diagnosis research is difficult to interpret. A consensus group was formed with the aim of producing guidance and a checklist for early cancer-diagnosis researchers. A consensus conference approach combined with nominal group techniques was used. The work was supported by a systematic review of early diagnosis literature, focussing on existing instruments used to measure time points and intervals in early cancer-diagnosis research. A series of recommendations for definitions and methodological approaches is presented. This is complemented by a checklist that early diagnosis researchers can use when designing and conducting studies in this field. The Aarhus checklist is a resource for early cancer-diagnosis research that should promote greater precision and transparency in both definitions and methods. Further work will examine whether the checklist can be readily adopted by researchers, and feedback on the guidance will be used in future updates.

Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease

BACKGROUND

Coeliac disease is increasingly diagnosed in adult patients who present with atypical symptoms or who are asymptomatic and detected by case screening. Its treatment, a gluten-free diet, can have a considerable impact on daily living. Understanding the factors associated with non-adherence is important in terms of supporting patients with their condition.

AIM

To investigate factors associated with adherence to a gluten-free diet in adults with coeliac disease.

METHODS

A literature search of multiple electronic databases using a pre-determined search string for literature between 1980 and November 2007 identified a possible 611 hits. After checking for relevance, 38 studies were included in this review.

RESULTS

Rates for strict adherence range from 42% to 91% depending on definition and method of assessment and are the lowest among ethnic minorities and those diagnosed in childhood. Adherence is most strongly associated with cognitive, emotional and socio-cultural influences, membership of an advocacy group and regular dietetic follow-up. Screen and symptom-detected coeliac patients do not differ in their adherence to a gluten-free diet.

CONCLUSIONS

The existing evidence for factors associated with non-adherence to a gluten-free diet is of variable quality. Further and more rigorous research is needed to characterize those individuals most likely to be non-adherent to assist them better with their treatment.