Patient-reported outcome measures show FIT as an acceptable investigation to rule out colorectal cancer in the two-week wait cohort

INTRODUCTION

Use of faecal immunochemical testing (FIT) for symptomatic patients is increasing. FIT is recommended as a triage tool from primary care to the two-week wait (TWW) suspected cancer pathway, but there is still little known about patient attitudes.

AIM

The aim of this study was to explore patient opinions of FIT and how it might be applied in the TWW pathway.

METHODS

A telephone survey was conducted for patients from the TWW pathway who had undergone both conventional colonic investigation and FIT. Five questions explored expectations, attitudes towards results and experience of the investigations using a Likert scale 1-5. Differences in opinion were compared using median and mode scores and visualised using bar charts.

RESULTS

One hundred and nine TWW patients agreed to answer the five questions. All had taken a stool sample for FIT, 50 underwent colonoscopy, 51 had a CT colonography and 8 underwent flexible sigmoidoscopy. Most patients (85%) scored 5 (completely satisfied) with these conventional colonic investigation methods they underwent for ruling out colorectal cancer (median 5). However, 30% of patients scored 5 (completely satisfied) if using a negative FIT to not require additional colonic investigation. The median score to perform FIT was 5 (very easy) compared with a median of 4 (easy) to undergo the other colonic investigations.

CONCLUSIONS

Symptomatic patients can perform FIT with little difficulty, and often would have been happy to avoid conventional colonic investigations with a negative result. However, shared decision-making should be employed to identify those who would be dissatisfied with relying on FIT for further investigation decisions.

Metrics are required for diagnostic accuracy in acute medicine

The article by Subbe et al raise important considerations as to what is deemed quality care in medicine. Throughput in acute medicine is highly prized. Prompt decision making, and action, is certainly required for several groups of unwell patients, but there is system-wide pressure to maintain this fast pace for all patients. It does not automatically follow that quicker medicine benefits all patients to some degree. 'Productivity' may come at the cost of too much medicine - characterised by overdiagnosis, overtreatment, and substantial resource utilisation.

Rhythmicity of patient flow in an acute medical unit: relationship to hospital occupancy, 7-day working and the effect of COVID-19

BACKGROUND

The Acute Medical Unit (AMU) provides care for unscheduled hospital admissions. Seven-day consultant presence and morning AMU discharges have been advocated to improve hospital bed management.

AIMS

To determine whether a later time of daily peak AMU occupancy correlates with measures of hospital stress; whether 7-day consultant presence, for COVID-19, abolished weekly periodicity of discharges.

DESIGN

Retrospective cohort analysis.

METHODS

: Anonymised AMU admission and discharge times were retrieved from the Profile Information Management System (PIMS), at a large, urban hospital from 14 April 2014 to 31 December 2018 and 20 March to 2 May 2020 (COVID-19 peak). Minute-by-minute admission and discharge times were combined to construct a running total of AMU bed occupancy. Fourier transforms were used to determine periodicity. We tested association between (i) average AMU occupancy and (ii) time of peak AMU occupancy, with measures of hospital stress (total medical bed occupancy and 'medical outliers' on non-medical wards).

RESULTS

: Daily, weekly and seasonal patterns of AMU bed occupancy were evident. Timing of AMU peak occupancy was unrelated to each measure of hospital stress: total medical inpatients (Spearman's rho, rs = 0.04, P = 0.24); number of medical outliers (rs = -0.06, P = 0.05). During COVID-19, daily bed occupancy was similar, with continuation of greater Friday and Monday discharges than the weekend.

CONCLUSIONS

: Timing of peak AMU occupancy did not alter with hospital stress. Efforts to increase morning AMU discharges are likely to have little effect on hospital performance. Seven-day consultant presence did not abolish weekly periodicity of discharges-other factors influence weekend discharges.

Impact of COVID-19 on angioplasty service and outcome of patients treated for critical limb ischaemia

Background

Peripheral artery disease (PAD) is a major challenge worldwide and endovascular revascularization is an important component of treatment that is affected by COVID-19 restrictions.

Purpose

Here, we evaluated the impact of COVID-19 restriction on angioplasty service and outcome of patients undergoing lower limb angioplasty.

Methods

Consecutive patients undergoing endovascular revascularisation between August 2018-March 2021 in a UK district general hospital were analysed retrospectively. Indications for angioplasty of all patients were discussed and agreed upon in multi-disciplinary teams. We compared time from referral to angioplasty, patient and procedural characteristics, technical success, peri-procedural complications, and outcome (wound healing, major amputation, target lesion revascularization, death) in patients treated 'before' and after February 2020 (“during COVID-19”).

Results

One hundred nineteen patients were treated 'before' (92% critical limb ischaemia [CLI]; 60% diabetes mellitus) and 72 were treated 'during COVID-19' (96% CLI; 61% diabetes mellitus). While the total monthly number of patients treated did not change, the number of outpatients treated as day cases increased (40% to 72%) and overnight stays for social reasons decreased (16% to 10%). Treatment of hospitalized patients decreased from 44% to 18%. The percentage of outpatients treated at <14 days after referral increased from 39% to 63% and hospitalized patients treated <5 days from 47% to 54%. Neither COVID-19 nor time to procedure affected wound healing (p(log Rank) = 0.451; median time to healing 168±25 days) and amputation free survival (p(log Rank) = 0.924; median survival 368±30 days) in all CLI patients significantly. However, amputation-free survival was significantly worse in hospitalized as compared to outpatients (p(log Rank) <0.001; median survival 155±20 vs 368±30 days) with similar wound healing in those that survived (p(log Rank) = 0.340; median time to wound healing 168±25 days). Of note, the known causes of death were sepsis (32%), pneumonia (18%), COVID pneumonia (18%), cardiac (16%) and stroke (8%).

Conclusions

Adapting to COVID-19 restriction we maintained a safe and effective angioplasty service while shortening waiting times. Very high mortality rates in patients after hospitalization indicated that CLI need to be treated much earlier and more aggressively to avoid disease progression requiring hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Importance of cannulated prolactin test in the definition of hyperprolactinaemia

PURPOSE

Recent guidelines suggest that a single prolactin measurement is adequate to confirm hyperprolactinaemia. This may lead to unnecessary investigation of artefactual hyperprolactinaemia. Prolactin measurement drawn from an indwelling cannula after rest removes stress as a confounding variable. The objective was to determine the frequency of true hyperprolactinaemia amongst patients referred following a single prolactin measurement.

METHODS

A cannulated study was considered if prolactin on referral ('Referral Prolactin') was <5,500 mU/L (260 ng/mL) but >410 mU/L (19 ng/mL) in males or >510 mU/L (24 ng/mL) in females, irrespective of clinical context. Case-notes of 267 patients undergoing cannulated prolactin measurement over a 10-year period (2000-2010) were reviewed. Pre-existing pituitary disease, dopamine antagonist use, and macroprolactinaemia were excluded. Morning ante-cubital vein cannulation was followed immediately by withdrawal of 'Repeat Prolactin' sample. After 120-min bed-rest, 'Resting Prolactin' was withdrawn through the cannula.

RESULTS

235 patients were included for analysis. 64 (27%) were within normal range; following Repeat Prolactin in 41 (17%) and Resting Prolactin in 23 (9%) cases. Referral Prolactin was higher in patients with true hyperprolactinaemia, 1,637 ± 100 mU/L (77.2 ± 4.7 ng/mL) than with artefactual hyperprolactinaemia, 1,122 ± 68 mU/L (52.9 ± 3.2 ng/mL; P < 0.001) but there was substantial overlap. 21 out of 171 cases (12%) with true hyperprolactinaemia had a macroadenoma. Presenting symptoms did not predict true hyperprolactinaemia. Referral Prolactin of 2,000 mU/L (94 ng/mL) had 97% specificity to identify true hyperprolactinaemia.

CONCLUSIONS

Reliance on a single, non-rested prolactin value may lead to over-diagnosis of hyperprolactinaemia. A resting sample should be considered with random values <2,000 mU/L (94 ng/mL).

Metabolic effects of intensive insulin therapy in critically ill patients

Our aim was to investigate the effects of glycemic control and insulin concentration on lipolysis, glucose, and protein metabolism in critically ill medical patients. For our methods, the patients were studied twice. In study 1, blood glucose (BG) concentrations were maintained between 7 and 9 mmol/l with intravenous insulin. After study 1, patients entered one of four protocols for 48 h until study 2: low-insulin high-glucose (LIHG; variable insulin, BG of 7-9 mmol/l), low-insulin low-glucose (LILG; variable insulin of BG 4-6 mmol/l), high-insulin high-glucose [HIHG; insulin (2.0 mU . kg(-1).min(-1) plus insulin requirement from study 1), BG of 7-9 mmol/l], or high-insulin low-glucose [HILG; insulin (2.0 mU.kg(-1).min(-1) plus insulin requirement from study 1), BG of 4-6 mmol/l]. Age-matched healthy control subjects received two-step euglycemic hyperinsulinemic clamps achieving insulin levels similar to the LI and HI groups. In our results, whole body proteolysis was higher in patients in study 1 (P < 0.006) compared with control subjects at comparable insulin concentrations and was reduced with LI (P < 0.01) and HI (P = 0.001) in control subjects but not in patients. Endogenous glucose production rate (R(a)), glucose disposal, and lipolysis were not different in all patients in study 1 compared with control subjects at comparable insulin concentrations. Glucose R(a) and lipolysis did not change in any of the study 2 patient groups. HI increased glucose disposal in the patients (HIHG, P = 0.001; HILG, P = 0.07 vs. study 1), but this was less than in controls receiving HI (P < 0.03). In conclusion, low-dose intravenous insulin administered to maintain BG between 7-9 mmol/l is sufficient to limit lipolysis and endogenous glucose R(a) and increase glucose R(d). Neither hyperinsulinemia nor normoglycemia had any protein-sparing effect.