Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies

Background

Most patients with respiratory tract infections (RTIs) are prescribed antibiotics in general practice. However, there is little evidence that antibiotics bring any value to the treatment of most RTIs. Point-of-care C-reactive protein testing may reduce antibiotic prescribing.

Aim

To systematically review studies that have examined the association between point-of-care (POC) C-reactive protein testing and antibiotic prescribing for RTIs in general practice.

Design and setting

Systematic review and meta-analysis of randomised controlled trials and observational studies.

Method

MEDLINE^® and Embase were systematically searched to identify relevant publications. All studies that examined the association between POC C-reactive protein testing and antibiotic prescribing for patients with RTIs were included. Two authors independently screened the search results and extracted data from eligible studies. Dichotomous measures of outcomes were combined using risk ratios (RRs) with 95% confidence intervals (CIs) either by fixed or random-effect models.

Results

Thirteen studies containing 10 005 patients met the inclusion criteria. POC C-reactive protein testing was associated with a significant reduction in antibiotic prescribing at the index consultation (RR 0.75, 95% CI = 0.67 to 0.83), but was not associated with antibiotic prescribing at any time during the 28-day follow-up period (RR 0.85, 95% CI = 0.70 to 1.01) or with patient satisfaction (RR 1.07, 95% CI = 0.98 to 1.17).

Conclusion

POC C-reactive protein testing significantly reduced antibiotic prescribing at the index consultation for patients with RTIs. Further studies are needed to analyse the confounders that lead to the heterogeneity.     

Chest pain without established ischaemic heart disease in primary care patients: associated comorbidities and mortality

Background

Ischaemic heart disease (IHD) can be excluded in the majority of patients with unspecific chest pain. The remainder have what is generally referred to as non-cardiac chest pain, which has been associated with gastrointestinal, neuromusculoskeletal, pulmonary, and psychiatric causes.

Aim

To assess morbidity and mortality following a new diagnosis of non-specific chest pain in patients without established IHD.

Design of study

Population-based cohort study with nested case-control analysis.

Setting

UK primary care practices contributing to the General Practice Research Database.

Method

Patients aged 20–79 years with chest pain who had had no chest pain consultation before 2000 and no IHD diagnosis before 2000 or within 2 weeks after the index date were selected from the General Practice Research Database. The selected 3028 patients and matched controls were followed-up for 1 year.

Results

The incidence of chest pain in patients without established IHD was 12.7 per 1000 person-years. In the year following the index date, patients who had chest pain but did not have established IHD were more likely than controls to receive a first IHD diagnosis (hazard ratio [HR] = 18.2, 95% confidence interval [CI] = 11.6 to 28.6) or to die (HR = 2.3, 95% CI = 1.3 to 4.1). Patients with chest pain commonly had a history of gastro-oesophageal reflux disease (GORD; odds ratio [OR] = 2.0, 95% CI = 1.5 to 2.7) or went on to be diagnosed with GORD (risk ratio 4.5, 95% CI = 3.1 to 6.4).

Conclusion

Patients with chest pain but without established IHD were found to have an increased risk of being diagnosed with IHD. Chest pain in patients without established IHD was also commonly associated with GORD.     

Clinical features of kidney cancer in primary care: a case-control study using primary care records

Background

Kidney cancer accounts for over 4000 UK deaths annually, and is one of the cancer sites with a poor mortality record compared with Europe.

Aim

To identify and quantify all clinical features of kidney cancer in primary care.

Design

Case-control study, using General Practice Research Database records.

Method

A total of 3149 patients aged ≥40 years, diagnosed with kidney cancer between 2000 and 2009, and 14 091 age, sex and practice-matched controls, were selected. Clinical features associated with kidney cancer were identified, and analysed using conditional logistic regression. Positive predictive values for features of kidney cancer were estimated.

Results

Cases consulted more frequently than controls in the year before diagnosis: median 16 consultations (interquartile range 10–25) versus 8 (4–15): P<0.001. Fifteen features were independently associated with kidney cancer: visible haematuria, odds ratio 37 (95% confidence interval [CI] = 28 to 49), abdominal pain 2.8 (95% CI = 2.4 to 3.4), microcytosis 2.6 (95% CI = 1.9 to 3.4), raised inflammatory markers 2.4 (95% CI = 2.1 to 2.8), thrombocytosis 2.2 (95% CI = 1.7 to 2.7), low haemoglobin 1.9 (95% CI = 1.6 to 2.2), urinary tract infection 1.8 (95% CI = 1.5 to 2.1), nausea 1.8 (95% CI = 1.4 to 2.3), raised creatinine 1.7 (95% CI = 1.5 to 2.0), leukocytosis 1.5 (95% CI = 1.2 to 1.9), fatigue 1.5 (95% CI = 1.2 to 1.9), constipation 1.4 (95% CI = 1.1 to 1.7), back pain 1.4 (95% CI = 1.2 to 1.7), abnormal liver function 1.3 (95% CI = 1.2 to 1.5), and raised blood sugar 1.2 (95% CI = 1.1 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was 1.0% (95% CI = 0.8 to 1.3).

Conclusion

Visible haematuria is the commonest and most powerful single predictor of kidney cancer, and the risk rises when additional symptoms are present. When considered alongside the risk of bladder cancer, the overall risk of urinary tract cancer from haematuria warrants referral.     

Predictors of incident atrial fibrillation and influence of medications: a retrospective case�Ccontrol study

Background

Atrial fibrillation (AF) is a common condition, associated with raisedmortality and risk of majormorbidity, and is predicted to increase due to an aging population.

Aim

To update earlier research of AF predictors using UK data.

Design and setting

Case–control analysis of adults aged 18 years and older with a diagnosis of AF in practices registered with the General Practice Research Database (GPRD) in the UK.

Method

Using the GPRD, a case.control analysis was performed using logistic regression to compare 55 412 incident AF cases to 216 400 controls, for medical history and prior use of drugs. The association between time since start of diagnosis or drug use and AF risk was summarised using Spline regression.

Results

The following were confirmed as risk factors for AF: heart failure (risk ratio [RR] 2.91 [95% CI = 2.59 to 3.27]); ischaemic heart disease (IHD) (RR 2.00 [95% CI = 1.78 to 2.24]); hypertension (RR 2.60 [95% CI = 2.32 to 2.92]); hyperthyroidism (RR 1.56 [95% CI = 1.39 to 1.75]); being a heavy drinker (RR 1.43 [95% CI = 1.27 to 1.60]); cerebrovascular accident (RR 1.48 [95% CI = 1.32 to 1.66]); and obesity (bodymass index ≥30 kg/m² RR 1.29 [95% CI = 1.15 to 1.45]). Current use of oral glucocorticoids (RR 1.62 [95% CI = 1.44 to 1.82]) and of beta-2 agonists (RR 1.30 [95% CI = 1.16 to 1.46]) were identified as significant risk factors, and statins (RR 0.82 [95% CI = 0.73 to 0.92]) as a significant protective factor. No effect was found for current use of bisphosphonates (RR 0.95 [95% CI = 0.85 to 1.07]), renin.angiotensin.aldosterone system (RAAS) agents (RR 1.04 [95% CI = 0.93 to 1.17]), or xanthine derivatives (RR 1.09 [95% CI = 0.97 to 1.22]). Spline regression analysis found the effect of heart failure, IHD, use of oral glucocorticoids, and use of statins on the likelihood of developing AF was sustained over a number of years.

Conclusion

These findings update the risk factors that are associated with AF, and confirmthe protective properties of statins and the risks of beta-2 agonists in developing AF, but not the supposed protective qualities of glucocorticoids and RAAS agents.     

Mortality and cancer in patients with new musculoskeletal episodes: a cohort study

Background

The risk of serious outcome in persons presenting to primary care with common regional musculoskeletal problems is unknown.

Aim

To determine the risk of mortality and cancer in older patients presenting with new musculoskeletal problems.

Design of study

Cohort study.

Setting

One hundred and seventy-nine general practices contributing to the General Practice Research Database.

Method

Cases were 48 206 people aged ≥50 years, with a recorded musculoskeletal problem in 1996 but none during the previous 2 years. Cases were allocated to groups based on problem location (for example, the back). A total of 40 254 controls had no musculoskeletal consultation during 1996 or during the previous 2 years. Outcome measures were mortality and recorded malignant and pre-malignant neoplasms 1 and 10 years after baseline consultation.

Results

Mortality rates in the first year of follow-up were higher for cases (373 per 10 000 person-years) than controls (244). The hip (standardised mortality ratio 2.36; 95% confidence interval [CI] = 1.99 to 2.77 compared to controls) and back (2.07; 95% CI = 1.87 to 2.28) groups had the highest 1-year rates. Ten-year mortality rates were closer between groups. Higher cancer rates were found for the back, hip, and neck groups. The first-year excess mortality in cases was only partly explained by cancer and other comorbidity (hip hazard ratio 1.72; 95% CI = 1.43 to 2.07; back 1.68; 95% CI = 1.49 to 1.90).

Conclusion

New consulting episodes of musculoskeletal problems in the back or hip are associated with higher subsequent cancer rates and increased mortality risk in older people. Unexpected cancer and death in these patients remains rare but the ability of clinical signs and symptoms to identify persons at risk needs to be confirmed.     

Adverse events recorded in English primary care: observational study using the General Practice Research Database

Background

More accurate and recent estimates of adverse events in primary care are necessary to assign resources for improvement of patient safety, while predictors must be identified to ameliorate patient risk.

Aim

To determine the incidence of recorded iatrogenic harm in general practice and identify risk factors for these adverse events.

Design and setting

Cross-sectional sample of 74 763 patients at 457 English general practices between 1 January 1999 and 31 December 2008, obtained from the General Practice Research Database.

Method

Patient age at study entry, sex, ethnicity, deprivation, practice region, duration registered at practice, continuity of care, comorbidities, and health service use were extracted from the data. Adverse events were defined by Read Codes for complications of care (Chapters S, T, and U). Crude and adjusted analyses were performed by Poisson regression, using generalised estimating equations.

Results

The incidence was 6.0 adverse events per 1000 person-years (95% confidence interval [CI] = 5.74 to 6.27), equivalent to eight adverse events per 10 000 consultations (n = 2 540 877). After adjustment, patients aged 65–84 years (risk ratio [RR] = 5.62, 95% CI = 4.58 to 6.91; P<0.001), with the most consultations (RR = 2.14, 95% CI = 1.60 to 2.86; P<0.001), five or more emergency admissions (RR = 2.08, 95% CI = 1.66 to 2.60; P<0.001), or the most diseases according to expanded diagnosis clusters (RR = 8.46, 95% CI = 5.68 to 12.6; P<0.001) were at greater risk of adverse events. Patients registered at their practice for the longest periods of time were less at risk of an adverse event (RR = 0.40, 95% CI = 0.35 to 0.47; P<0.001).

Conclusion

The low incidence of recorded adverse events is comparable with other studies. Temporal sequencing of risk factors and case ascertainment would benefit from data triangulation. Future studies may explore whether first adverse events predict future incidents.     

Ecalmpsia: maternal and fetal outcome

Objective

To determine the incidence of eclampsia and examine the maternal and fetal outcome.

Methods

A hundred and twenty consecutive admissions with eclampsia managed in Aminu Kano Teaching Hospital, Kano, Nigeria, were prospectively collated and analysed. Maternal and fetal morbidity and mortality were recorded.

Results

The incidence of eclampsia was 1.2% of deliveries. Most (69.2%) of the patients had no antenatal care. In 93 (77.5%), the convulsions were controlled with diazepam, and 22.5% magnesium sulphate. Maternal complications rate was 39.2%, and use of Diazepam for control of convulsions increases complications (RR 3.12, 95% CI = 1.23–7.92, p= 0.02). Case fatality rate was 11.7%, diazepam use failed to achieve significant association with maternal death (RR 8.64, 95% CI = 0.53–140.29, p= 0.13). Stillbirth rate was 22.5% with significant association with diazepam use (RR 7.55, 95% CI= 1.07–3.09, p=0.04). Birth asphyxia was recorded in 39.1% and low birth weight in 25.8%.

Conclusion

The incidence of eclampsia in our hospital was very high, with corresponding high maternal and perinatal morbidity and mortality. Increased antenatal screening and use of magnesium sulphate to control convulsions will reduce the incidence and associated morbidity and mortality for both mother and fetus.     

Quantifying the risk of multiple myeloma from symptoms reported in primary care patients: a large case–control study using electronic records

Background

Patients with myeloma experience the longest diagnostic delays compared with patients with other cancers in the UK; 37% are diagnosed through emergency presentations.

Aim

To identify and quantify the risk of myeloma from specific clinical features reported by primary care patients.

Design and setting

Matched case–control study using General Practice Research Database primary care electronic records.

Method

Putative clinical features of myeloma were identified and analysed using conditional logistic regression. Positive predictive values (PPVs) were calculated for the consulting population.

Results

A total of 2703 patients aged ≥40 years, diagnosed with myeloma between 2000 and 2009, and 12 157 age, sex, and general practice-matched controls were identified. Sixteen features were independently associated with myeloma: hypercalcaemia, odds ratio 11.4 (95% confidence interval [CI] = 7.1 to 18), cytopenia 5.4 (95% CI = 4.6 to 6.4), raised inflammatory markers 4.9 (95% CI = 4.2 to 5.8), fracture 3.1 (95% CI = 2.3 to 4.2), raised mean corpuscular volume 3.1 (95% CI = 2.4 to 4.1), weight loss 3.0 (95% CI = 2.0 to 4.5), nosebleeds 3.0 (95% CI = 1.9 to 4.7), rib pain 2.5 (95% CI = 1.5 to 4.4), back pain 2.2 (95% CI = 2.0 to 2.4), other bone pain 2.1 (95% CI = 1.4 to 3.1), raised creatinine 1.8 (95% CI = 1.5 to 2.2), chest pain 1.6 (95% CI = 1.4 to 1.8), joint pain 1.6 (95% CI = 1.2 to 2.2), nausea 1.5 (95% CI = 1.1 to 2.1), chest infection 1.4 (95% CI = 1.2 to 1.6), and shortness of breath 1.3 (95% CI = 1.1 to 1.5). Individual symptom PPVs were generally <1%, although were >10% for some symptoms when combined with leucopenia or hypercalcaemia.

Conclusion

Individual symptoms of myeloma in primary care are generally low risk, probably explaining diagnostic delays. Once simple primary care blood tests are taken, risk estimates change. Hypercalcaemia and leucopenia are particularly important abnormalities, and coupled with symptoms, strongly suggest myeloma.     

Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis

Background

The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality.

Aim

The study sought to validate CRB-65 and assess its clinical value in community and hospital settings.

Design of study

Systematic review and meta-analysis of validation studies of CRB-65.

Method

Medline (1966 to June 2009), Embase (1988 to November 2008), British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality.

Results

Fourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19).

Conclusion

CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice.     

Quality of prescribing in care homes and the community in England and Wales

Background

Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK.

Aim

To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes.

Design and setting

Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008–2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years.

Method

Comparison of age- and sex-standardised use of ‘concern’ and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria).

Results

Compared to the community, care home residents were more likely to receive ‘concern’ drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales.

Conclusion

Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.     

Sleep disturbances as a predictor of cause-specific work disability and delayed return to work

Study Objective:

To examine sleep disturbances as a predictor of cause-specific work disability and delayed return to work.

Design:

Prospective observational cohort study linking survey data on sleep disturbances with records of work disability (≥ 90 days sickness absence, disability pension, or death) obtained from national registers.

Setting:

Public sector employees in Finland.

Participants:

56,732 participants (mean age 44.4 years, 80% female), who were at work and free of work disability at the study inception.

Measurements and Results:

During a mean follow-up of 3.3 years, incident diagnosis-specific work disability was observed in 4,028 (7%) employees. Of those, 2,347 (60%) returned to work. Sleep disturbances 5-7 nights per week predicted work disability due to mental disorders (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3-1.9) and diseases of the circulatory system (HR = 1.6, 95% CI 1.2-2.1), musculoskeletal system (HR = 1.6, 95% CI 1.4-1.8) and nervous system (HR = 1.5, 95% CI 1.0-2.2), and injuries and poisonings (HR = 1.6, 95% CI 1.2-2.1) after controlling for baseline age, sex, socioeconomic status, night/shift work, health behaviors (e.g., smoking, exercise), diagnosed somatic diseases, use of pain killers, depression, and anxiety. In addition, sleep disturbances prior to disability were associated with higher likelihood of not returning to work after work disability from musculoskeletal diseases (HR = 1.2, 95% CI 1.1-1.7) and, in men, after work disability due to mental disorders (HR = 4.4, 95% CI 1.7-11.1).

Conclusions:

Sleep disturbances are associated with increased risk for subsequent disabling mental disorders and various physical illnesses. They also predict the outcome of work disability due to musculoskeletal disorders.

Citation:

Salo P; Oksanen T; Sivertsen B; Hall M; Pentti J; Virtanen M; Vahtera J; Kivimäki M. Sleep disturbances as a predictor of cause-specific work disability and delayed return to work. SLEEP 2010;33(10):1323-1331.     

Predictive values of GPs’ suspicion of serious disease: a population-based follow-up study

Background

Knowledge is sparse on the prevalence of suspicion of cancer and other serious diseases in general practice. Likewise, little is known about the possible implications of this suspicion on future healthcare use and diagnoses.

Aim

To study the prevalence of GPs’ suspicions of cancer or other serious diseases and analyse how this suspicion predicted the patients’ healthcare use and diagnoses of serious disease.

Design and setting

Prospective population-based cohort study of 4518 patients consulting 404 GPs in a mix of urban, semi-urban and rural practices in Central Denmark Region during 2008–2009.

Method

The GPs registered consultations in 1 work day, including information on their suspicion of the presence of cancer or another serious disease. The patients were followed up for use of healthcare services and new diagnoses through the use of national registers.

Results

Prevalence of suspicion was 5.7%. Suspicion was associated with an increase in referrals (prevalence ratio [PR] = 2.56, 95% confidence interval [CI] = 2.22 to 2.96), especially for diagnostic imaging (PR = 3.95, 95% CI = 2.80 to 5.57), increased risk of a new diagnosis of cancer or another serious disease within 2 months (hazard ratio [HR] = 2.98, 95% CI = 1.93 to 4.62) — especially for cancer (HR = 7.55, 95% CI = 2.66 to 21.39) — and increased use of general practice (relative risk [RR] = 1.14, 95% CI = 1.06 to 1.24) and hospital visits (RR = 1.90, 95% CI = 1.62 to 2.23). The positive predictive value of a GP suspicion was 9.8% (95% CI = 6.4 to 14.1) for cancer or another serious disease within 2 months.

Conclusion

A GP suspicion of serious disease warrants further investigation, and the organisation of the healthcare system should ensure direct access from the primary sector to specialised tests.     

Verbal and non-verbal behaviour and patient perception of communication in primary care: an observational study

Background

Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours.

Aim

To explore the relationship of observer ratings of behaviours of videotaped consultations with patients’ perceptions.

Design and setting

Observational study in general practices close to Southampton, Southern England.

Method

Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains.

Results

In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), ‘back-channelling’ (for example, saying ‘mmm’) (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness (‘aloof’) was helpful and optimism unhelpful. Finishing with non-verbal ‘cut-offs’ (for example, looking away), being professionally cool (‘aloof’), or patronising, (‘infantilising’) resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication.

Conclusion

These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional ‘coolness’ at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end.     

Incidence and risk factors associated with meniscal injuries among active-duty US military service members

Context:

Few population-based studies have examined the incidence of meniscal injuries, and limited information is available on the influence of patient''s demographic and occupational factors.

Objective:

To examine the incidence of meniscal injuries and the influence of demographic and occupational factors among active-duty US service members between 1998 and 2006.

Design:

Cohort study.

Setting:

Using the International Classification of Diseases (9th revision) codes 836.0 (medial meniscus), 836.1 (lateral meniscus), and 836.2 (meniscus unspecified), we extracted injury data from the Defense Medical Surveillance System to identify all acute meniscal injuries among active-duty military personnel.

Patients or Other Participants:

Active-duty military personnel serving in all branches of military service during the study period.

Main Outcome Measure(s):

Incidence rate (IR) per 1000 person-years at risk and crude and adjusted rates by strata for age, sex, race, rank, and service.

Results:

During the study period, 100201 acute meniscal injuries and 12115606 person-years at risk for injury were documented. The overall IR was 8.27 (95% confidence interval [CI] = 8.22, 8.32) per 1000 person-years. Main effects were noted for all demographic and occupational variables (P< .001), indicating that age, sex, race, rank, and service were associated with the incidence of meniscal injuries. Men were almost 20% more likely to experience an acute meniscal injury than were women (incidence rate ratio = 1.18, 95% CI = 1.15, 1.20). The rate of meniscal injury increased with age; those older than 40 years of age experienced injuries more than 4 times as often as those under 20 years of age (incidence rate ratio = 4.25,95% CI = 4.08, 4.42).

Conclusions:

The incidence of meniscal injury was sub-stantially higher in this study than in previously reported studies. Male sex, increasing age, and service in the Army or Marine Corps were factors associated with meniscal injuries.     

Risk of hepatitis B and C infections in Tehranian wrestlers

Context:

Although bloodborne infections are among the most important global health issues, limited data are available on bloodborne infections in athletes.

Objective:

To determine and compare the prevalence of markers of hepatitis B (HBV) and hepatitis C (HCV) viruses and the risk factors for these infections among wrestlers in Tehran and among a control group of athletes in the same geographic area who took part in low- to moderate-contact sports (ie, volleyball and soccer).

Design:

Case-control study.

Setting:

Laboratory.

Patients or Other Participants:

A total of 420 male wrestlers were randomly selected from 28 wrestling clubs in Tehran using a cluster-sample–setting method. The control group (205 volleyball players from 21 clubs and 205 soccer players from 16 clubs) was selected from the same geographic area.

Main Outcome Measure(s):

The risk factors for HBV and HCV and serum levels of anti-HBcAg (antibodies to the HBV core antigen), HBsAg (HBV surface antigen), and anti-HCV (antibodies to HCV) in both groups.

Results:

The prevalence of anti-HBcAg was 13.4% (95% confidence interval [CI] = 10.2%, 16.7%) in wrestlers and 10.9% (95% CI = 7.9%, 14.0%) in the control group. The prevalence of HBsAg was 1.2% (95% CI = 0.2%, 2.2%) in wrestlers and 0.5% (95% CI = −0.2%, 1.2%) in the control group. The prevalence of anti-HCV was 0.5% (95% CI = −0.2%, 1.1%) in wrestlers and 0 in the control group. Some risk factors for bloodborne infections were more common in the wrestlers than in the control group.

Conclusions:

Within the limits of our study, we found no evidence that participation in Tehranian wrestling increased HBV or HCV transmission when compared with transmission in athletes participating in low- to moderate-contact sports. Prevention of bloodborne infections in Tehranian wrestlers should be focused not only on appropriate care for bleeding injuries but also on general risk factors for these conditions.     

Are alarm symptoms predictive of cancer survival?: Population-based cohort study

Background

Alarm symptom presentations are predictive of cancer diagnosis but may also be associated with cancer survival.

Aim

To evaluate diagnostic time intervals, and consultation patterns after presentation with alarm symptoms, and their association with cancer diagnosis and survival.

Design and setting

Cohort study using the Clinical Practice Research Database, with linked Cancer Registry data, in 158 general practices.

Method

Participants included those with haematuria, haemoptysis, dysphagia, and rectal bleeding or urinary tract cancer, lung cancer, gastro-oesophageal cancer, and colorectal cancer.

Results

The median (interquartile range) interval in days from first symptom presentation to the corresponding cancer diagnosis was: haematuria and urinary tract cancer, 59 (28–109); haemoptysis and lung cancer, 35 (18–89); dysphagia and gastro-oesophageal cancer, 25 (12–48); rectal bleeding and colorectal cancer, 49 (20–157). Three or more alarm symptom consultations were associated with increased odds of diagnosis of urinary tract cancer (odds ratio [OR] 1.84, 95% CI = 1.50 to 2.27), lung cancer (OR = 1.76, 95% CI = 1.07 to 2.90) and gastro-oesophageal cancer (OR = 2.17, 95% CI = 1.48 to 3.19). Longer diagnostic intervals were associated with increased mortality only for urinary tract cancer (hazard ratio 2.23, 95% CI = 1.35 to 3.69). Patients with no preceding alarm symptom had shorter survival from diagnosis of urinary tract, lung or colorectal cancer than those presenting with a relevant alarm symptom.

Conclusion

After alarm symptom presentation, repeat consultations are associated with cancer diagnoses. Longer diagnostic intervals appeared to be associated with a worse prognosis for urinary tract cancer only. Mortality is higher when cancer is diagnosed in the absence of alarm symptoms.