An investigation of routes to cancer diagnosis in 10 international jurisdictions, as part of the International Cancer Benchmarking Partnership: survey development and implementation

OBJECTIVES

This paper describes the methods used in the International Cancer Benchmarking Partnership Module 4 Survey (ICBPM4) which examines time intervals and routes to cancer diagnosis in 10 jurisdictions. We present the study design with defining and measuring time intervals, identifying patients with cancer, questionnaire development, data management and analyses.

DESIGN AND SETTING

Recruitment of participants to the ICBPM4 survey is based on cancer registries in each jurisdiction. Questionnaires draw on previous instruments and have been through a process of cognitive testing and piloting in three jurisdictions followed by standardised translation and adaptation. Data analysis focuses on comparing differences in time intervals and routes to diagnosis in the jurisdictions.

PARTICIPANTS

Our target is 200 patients with symptomatic breast, lung, colorectal and ovarian cancer in each jurisdiction. Patients are approached directly or via their primary care physician (PCP). Patients' PCPs and cancer treatment specialists (CTSs) are surveyed, and 'data rules' are applied to combine and reconcile conflicting information. Where CTS information is unavailable, audit information is sought from treatment records and databases.

MAIN OUTCOMES

Reliability testing of the patient questionnaire showed that agreement was complete (κ=1) in four items and substantial (κ=0.8, 95% CI 0.333 to 1) in one item. The identification of eligible patients is sufficient to meet the targets for breast, lung and colorectal cancer. Initial patient and PCP survey response rates from the UK and Sweden are comparable with similar published surveys. Data collection was completed in early 2016 for all cancer types.

CONCLUSION

An international questionnaire-based survey of patients with cancer, PCPs and CTSs has been developed and launched in 10 jurisdictions. ICBPM4 will help to further understand international differences in cancer survival by comparing time intervals and routes to cancer diagnosis.

Invasive mucormycosis and aspergillosis in a healthy 22-year-old battle casualty: case report

BACKGROUND

Invasive mucormycosis or aspergillosis is a life-threatening infection. The disease typically occurs in immunocompromised patients (e.g., those with diabetes mellitus or burns) but is rarely serious in otherwise-healthy young trauma patients.

METHODS

Case report and literature review.

RESULTS

A previously-healthy 22-year-old United States Marine who sustained large soft tissue injuries in support of Operation Enduring Freedom underwent multiple operations in theater to stabilize his wounds. He was evacuated first to Landstuhl Regional Medical Center in Germany and thence to the National Naval Medical Center in Maryland, where appropriate antifungal therapies were initiated and wide débridements were undertaken without success. His clinical status deteriorated, and he died. Tissue examination revealed systemic invasive mucormycosis and aspergillosis.

CONCLUSION

The suspicion of invasive fungal infections must be tested early if intervention is to be curative.

Assessment of patient management skills and clinical skills of practising doctors using computer-based case simulations and standardised patients

CONTEXT

Standardised assessments of practising doctors are receiving growing support, but theoretical and logistical issues pose serious obstacles.

OBJECTIVES

To obtain reference performance levels from experienced doctors on computer-based case simulation (CCS) and standardised patient-based (SP) methods, and to evaluate the utility of these methods in diagnostic assessment.

SETTING AND PARTICIPANTS

The study was carried out at a military tertiary care facility and involved 54 residents and credentialed staff from the emergency medicine, general surgery and internal medicine departments.

MAIN OUTCOME MEASURES

Doctors completed 8 CCS and 8 SP cases targeted at doctors entering the profession. Standardised patient performances were compared to archived Year 4 medical student data.

RESULTS

While staff doctors and residents performed well on both CCS and SP cases, a wide range of scores was exhibited on all cases. There were no significant differences between the scores of participants from differing specialties or of varying experience. Among participants who completed both CCS and SP testing (n = 44), a moderate positive correlation between CCS and SP checklist scores was observed. There was a negative correlation between doctor experience and SP checklist scores. Whereas the time students spent with SPs varied little with clinical task, doctors appeared to spend more time on communication/counselling cases than on cases involving acute/chronic medical problems.

CONCLUSION

Computer-based case simulations and standardised patient-based assessments may be useful as part of a multimodal programme to evaluate practising doctors. Additional study is needed on SP standard setting and scoring methods. Establishing empirical likelihoods for a range of performances on assessments of this character should receive priority.

Surgery aboard ship: is it safe?

A retrospective review was performed on 684 surgical procedures done aboard U.S. Atlantic Fleet ships during a 3-year period from 1994 to 1996. These procedures were compared with similar procedures performed at the Naval Medical Center in Portsmouth, Virginia. Morbidity and mortality rates were calculated and compared. A very low morbidity rate (0.43%) was reported for surgical procedures performed while deployed compared with 1.69% for procedures at the Naval Medical Center. One mortality was reported. These extremely low rates are felt to be attributable to multiple causes, including a highly selected, healthy patient population, performance of only low-risk procedures, early presentation of surgical problems, and early medical evacuation of patients with complex medical and surgical problems. We feel that elective surgical procedures such as vasectomy, circumcision, inguinal hernia repair, and hemorrhoidectomy can be performed safely aboard ship. This would increase the training opportunity for all members of the medical department and at the same time decrease the costs and risks associated with medical evacuation.

Pericardio peritoneal window: laparoscopic approach

Transdiaphragmatic approach to the pericarium through the use of the laparoscope is a safe and rapid way to obtain biopsy of the pericardium and create a window. No drainage tubes are needed: pericardial fluid is absorbed by the peritoneum; there is no need for double lumen tubes for one lung ventilation; and the laparoscopy incisions are small and almost painless.