Usefulness of Carcinoembryonic Antigen for Monitoring Tumor Progression during Palliative Chemotherapy in Metastatic Colorectal Cancer

Purpose

To evaluate the efficacy of carcinoembryonic antigen (CEA) measurement for monitoring tumor progression during palliative chemotherapy in metastatic colorectal cancer.

Materials and Methods

Forty-eight patients with initially unresectable metastatic colorectal cancer (n=26, 54.2%) or recurrent unresectable metastatic colorectal cancer (n=22, 45.8%) received FOLFOX-4 chemotherapy for palliation. Serum CEA levels and carbohydrate antigen 19-9 levels were measured and computed tomography (CT) studies were performed prior to chemotherapy and after 3 cycles of chemotherapy. From the CT images, tumor responses were evaluated according to the Response Evaluation Criteria in Solid Tumors criteria and categorized as complete response, partial response, stable disease, and progressive disease. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of tumor marker assessments for determining tumor response were calculated.

Results

The sensitivity, specificity and diagnostic accuracy of CEA assessment for prediction of disease progression were 50%, 77% and 69%, respectively. When the patients were dichotomized according to baseline CEA level, the initially elevated CEA group showed higher sensitivity and higher diagnostic accuracy compared to the initially normal CEA group (sensitivity=67% vs. 20%; diagnostic accuracy=71% vs. 62%).

Conclusion

CEA assessment could be useful for monitoring tumor progression during palliative chemotherapy in only patients with initially elevated CEA level.     

Clinical features of bladder cancer in primary care

Background

Bladder cancer accounts for over 150 000 deaths worldwide. No screening is available, so diagnosis depends on investigations of symptoms. Of these, only visible haematuria has been studied in primary care.

Aim

To identify and quantify the features of bladder cancer in primary care.

Design and setting

Case-control study, using electronic medical records from UK primary care.

Method

Participants were 4915 patients aged ≥40 years, diagnosed with bladder cancer January 2000 to December 2009, and 21 718 age, sex, and practice-matched controls, were selected from the General Practice Research Database, UK. All clinical features independently associated with bladder cancer using conditional logistic regression were identified, and their positive predictive values for bladder cancer, singly and in combination, were estimated.

Results

Cases consulted their GP more frequently than controls before diagnosis: median 15 consultations (interquartile range 9–22) versus 8 (4–15): P<0.001. Seven features were independently associated with bladder cancer: visible haematuria, odds ratio 34 (95% confidence interval [CI] = 29 to 41), dysuria 4.1 (95% CI = 3.4 to 5.0), urinary tract infection 2.2 (95% CI = 2.0 to 2.5), raised white blood cell count 2.1 (95% CI = 1.6 to 2.8), abdominal pain 2.0 (95% CI = 1.6 to 2.4), constipation 1.5 (95% CI = 1.2 to 1.9), raised inflammatory markers 1.5 (95% CI = 1.2 to 1.9), and raised creatinine 1.3 (95% CI = 1.2 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was PPV of 3.9% (95% CI = 2.2 to 3.2).

Conclusion

Visible haematuria is the commonest and most powerful predictor of bladder cancer in primary care, and warrants investigation. Most other previously reported features of bladder cancer were associated with the disease, but with low predictive values. There is a need for improved diagnostic methods, for those patients whose bladder cancer presents without visible haematuria.     

Proteinuria as a Risk Factor for Mortality in Patients with Colorectal Cancer

Purpose

We investigated the effects of proteinuria and renal insufficiency on all-cause mortality in patients with colorectal cancer, with special emphasis on cancer staging and cancer-related deaths.

Materials and Methods

We retrospectively studied a cohort of patients with colorectal cancer. In protocol 1, patients were classified into four groups based on the operability of cancer and proteinuria: group 1, early-stage cancer patients (colorectal cancer stage ≤3) without proteinuria; group 2, early-stage cancer patients with proteinuria; group 3, advanced-stage cancer patients without proteinuria (colorectal cancer stage=4); and group 4, advanced-stage cancer patients with proteinuria. In protocol 2, patients were classified into four similar groups based on cancer staging and renal insufficiency (eGFR <60 mL/min/1.73 m²). Between January 1, 1998 and December 31, 2009, 3379 patients were enrolled in this cohort and followed until May 1, 2012 or until death.

Results

The number of patients with proteinuria was 495 (14.6%). The prevalence of proteinuria was higher in advanced-stage cancer (n=151, 22.3%) than in early-stage cancer patients (n=344, 12.7%). After adjusting for age, gender and other clinical variables, the proteinuric, early-stage cancer group was shown to be associated with an adjusted hazard ratio of 1.67 and a 95% confidence interval of 1.38-2.01, compared with non-proteinuric early-stage cancer patients. However, renal insufficiency was not associated with colorectal cancer mortality.

Conclusion

Proteinuria is an important risk factor for cancer mortality, especially in relatively early colorectal cancer.     

Colorectal cancer mortality in Poland – analysis of regional variation

Introduction

In 1999 in Poland 7,139 people died of colon cancer, while in 2008 this number rose to 9,915. Among malignant tumours, colorectal cancer is the second most commonly occurring one, frequently leading to death. The main reason for this is the fact that in 50% of patients with this cancer the illness is diagnosed at an advanced stage already. The risk increases significantly after 60 years of age. The aim of study was analysing the mortality of patients with colorectal cancer over 10 years in Poland (1999-2008), in both men and women from all provinces in the country.

Material and methods

The basis for the study was the number of deaths caused by colorectal cancer taking into account sex. Statistical data were drawn from the National Cancer Registry.

Results

In 1999 in Poland 3,706 men and 3,433 women died of colorectal cancer, while in 2008 the number of deaths stood at 5,385 and 4,530 respectively. In the years 1999-2008, colorectal cancer mortality rates among men were approximately 1.5 times higher than among women, and the majority of provinces demonstrate an upward trend. Among women the differences in the values of the coefficients are less clear.

Conclusions

Early detection of cancer could significantly reduce mortality among patients with colon cancer. Screening for colorectal cancer and colonoscopy are tests that should permanently become a part of preventive measures aimed at detecting disease and teaching risk factors, particularly in males and people over 60 years of age.     

Clinical features of metastatic cancer in primary care: a case–control study using medical records

Background

How metastatic cancer initially presents is largely unknown.

Aim

To identify clinical features of metastatic cancer in primary care.

Design and setting

Case–control study in 11 general practices in Devon, UK.

Method

Cases of patients who had died with metastatic breast, colorectal, or prostate cancer were selected. In addition, two control groups were formed of patients with the same primary cancer but without metastases (‘cancer controls’) and patients without cancer (‘healthy controls’), matched for age, sex, and practice. All symptoms, signs, and laboratory test abnormalities in the year before metastasis were identified. The primary analysis used conditional logistic regression.

Results

In total, 162 cases, 152 cancer controls, and 145 healthy controls were studied. Common symptoms associated with cancer were: vomiting, 40 (25%) cases and 13 (9%) cancer controls (multivariable odds ratio [OR] 3.5, 95% confidence interval [CI] = 1.3 to 9.4, P = 0.011); low back pain, 38 (24%) cases and 17 (11%) cancer controls (OR 2.5, 95% CI = 1.1 to 5.6, P = 0.032); loss of appetite, 32 (20%) cases and nine (6%) cancer controls (OR 4.0, 95% CI = 1.2 to 13.2, P = 0.021); and shoulder pain, 27 (17%) cases and eight (5%) cancer controls (OR 5.3, 95% CI = 1.6 to 18, P = 0.007). Groin pain was uncommon, but strongly associated (16 [10%] cases and one [1%] cancer control [OR 10, 95% CI = 1.2 to 82, P = 0.032]), as was pleural disease (nine [6%] cases and one [1%] cancer control [OR 10, 95% CI = 1.1 to 92, P = 0.038]).

Conclusion

These features of disseminated cancer have been reported before in studies from secondary care, but the scarcity of specific symptoms (such as local pain) and the fairly common occurrence of non-specific symptoms (vomiting and loss of appetite) is important and may explain delays in the diagnosis of metastases.     

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.     

Predicting lymph node status in patients with early gastric carcinoma using double contrast-enhanced ultrasonography

Introduction

Double contrast-enhanced ultrasonography (DCUS) is a new method we used in predicting lymph node metastasis (LNM) in patients with early gastric cancer.

Material and methods

Seventy-six patients with early gastric cancer diagnosed by gastroscope and confirmed by pathology after operation were examined using DCUS preoperatively. Group N1 included 15 patients with LNM and group N0 61 patients without LNM.

Results

In group N1, 13 patients (87%) had marked hyperenhancement during early arterial phase using DCUS, and 2 patients (13%) were unmarked as hyperenhancement. In group N0, 24 patients (39%) had marked hyperenhancement during early arterial phase using DCUS, and 37 patients (61%) had unmarked hyperenhancement. The sensitivity and specificity of marked hyperenhancement in predicting LNM in patients with early gastric cancer was 86.7% and 60.7% respectively, and the Youden’s index was 0.474. The κ value of this method was 0.89.

Conclusions

Double contrast-enhanced ultrasonography is a new valuable method to evaluate LNM at an early stage of gastric cancer and prognosis of early gastric cancer preoperatively.     

Pandemic influenza A(H1N1)pdm09: risk of infection in primary healthcare workers

Background

Healthcare workers in primary care are at risk of infection during an influenza pandemic. The 2009 influenza pandemic provided an opportunity to assess this risk.

Aim

To measure the prevalence of seropositivity to influenza A(H1N1)pdm09 among primary healthcare workers in Canterbury, New Zealand, following the 2009 influenza pandemic, and to examine associations between seropositivity and participants’ sociodemographic characteristics, professional roles, work patterns, and seasonal influenza vaccination status.

Design and setting

An observational study involving a questionnaire and testing for influenza A(H1N1)pdm09 seropositivity in all primary healthcare workers in Canterbury, New Zealand between December 2009 and February 2010.

Method

Participants completed a questionnaire that recorded sociodemographic and professional data, symptoms of influenza-like illness, history of seasonal influenza vaccination, and work patterns. Serum samples were collected and haemagglutination inhibition antibody titres to influenza A(H1N1)pdm09 measured.

Results

Questionnaires and serum samples were received from 1027 participants, from a workforce of 1476 (response rate 70%). Seropositivity was detected in 224 participants (22%). Receipt of seasonal influenza vaccine (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.2 to 3.3), recall of influenza (OR = 1.9, 95% CI = 1.3 to 2.8), and age ≤45 years (OR = 1.4, 95% CI = 1.0 to 1.9) were associated with seropositivity.

Conclusion

A total of 22% of primary care healthcare workers were seropositive. Younger participants, those who recalled having influenza, and those who had been vaccinated against seasonal influenza were more likely to be seropositive. Working in a dedicated influenza centre was not associated with an increased risk of seropositivity.     

Risk of colorectal cancer in relation to frequency and total amount of red meat consumption. Systematic review and meta-analysis

Introduction

The colon and rectum are common sites of food-related cancer in developed countries. Recent studies strongly suggest that red meat intake is associated with colon cancer, whereas for rectal cancer such an association still needs to be proved. The aim of the study was to assess the role of total amount and frequency of red meat intake in colorectal carcinogenesis based on published data using meta-analysis methods.

Material and methods

The literature published until 2009 was selected from: MEDLINE, PubMed, Scopus, Embase, CancerLit, Google Scholar and Cochrane Library databases. The used search terms were: colorectal cancer, colon cancer, rectal cancer, meat intake, red meat intake, red meat consumption, meat consumption, colorectal cancer risk, colon cancer risk, rectal cancer risk and lifestyle. Articles investigating red meat intake of more often than once a day or 50 g per day were reviewed and selected for further analysis.

Results

Twenty-two studies fulfilled the established criteria. A meta-analysis confirmed the carcinogenic effect of the consumption of over 50 g of red meat per day for the colon (relative risk 1.21, 1.07–1.37) but not for the rectum (relative risk 1.30, 0.90–1.89). Red meat intake more frequently than once a day can induce both colonic (relative risk 1.37, 1.09–1.71) and rectal cancer (relative risk 1.43, 1.24–1.64).

Conclusions

Red meat intake is associated with elevated risk of developing colorectal cancer. The frequency of red meat consumption rather than total amount of consumed meat is associated with a higher risk of colorectal carcinogenesis.     

Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm

Background

Early diagnosis of cancer could improve survival so better tools are needed.

Aim

To derive an algorithm to estimate absolute risks of different types of cancer in men incorporating multiple symptoms and risk factors.

Design and setting

Cohort study using data from 452 UK QResearch® general practices for development and 224 for validation.

Method

Included patients were males aged 25–89 years. The primary outcome was incident diagnosis of cancer over the next 2 years (lung, colorectal, gastro-oesophageal, pancreatic, renal, blood, prostate, testicular, other cancer). Factors examined were: ‘red flag’ symptoms such as weight loss, abdominal distension, abdominal pain, indigestion, dysphagia, abnormal bleeding, lumps; general symptoms such as tiredness, constipation; and risk factors including age, family history, smoking, alcohol intake, deprivation score and medical conditions. Multinomial logistic regression was used to develop a risk equation to predict cancer type. Performance was tested on a separate validation cohort.

Results

There were 22 521 cancers from 1 263 071 males in the derivation cohort. The final model included risk factors (age, BMI, chronic pancreatitis, COPD, diabetes, family history, alcohol, smoking, deprivation); 22 symptoms, anaemia and venous thrombo-embolism. The model was well calibrated with good discrimination. The receiver operator curve statistics values were: lung (0.92), colorectal (0.92), gastro-oesophageal (0.93), pancreas (0.89), renal (0.94), prostate (0.90) blood (0.83, testis (0.82); other cancers (0.86). The 10% of males with the highest risks contained 59% of all cancers diagnosed over 2 years.

Conclusion

The algorithm has good discrimination and could be used to identify those at highest risk of cancer to facilitate more timely referral and investigation.     

Dipeptidyl Peptidase 10, a Novel Prognostic Marker in Colorectal Cancer

Purpose

The dipeptidyl peptidase IV (DPPIV) gene family exhibits multiple functions and is involved in the pathogenesis of various diseases. It has attracted pharmaceutical interest in the areas of metabolic disorders as well as cancer. However, clinicopathologic significance of DPPIV family in colorectal cancer is not fully understood.

Materials and Methods

The clinical relevance of DPPIV and DPP10 expression was determined by immunohistochemical staining, and by assessing its clinicopathologic correlation in 383 colorectal cancer patients with known clinical outcomes.

Results

DPPIV was not expressed in normal colon mucosa, but it showed luminal expression in 52 of the 383 colorectal cancers (13.5%). DPPIV expression in tumors was associated with right-sided location of the colon (p=0.010) and more advanced tumor stage (p=0.045). DPP10 was expressed in normal colonic mucosa, but its expression varied in primary colorectal cancer tissues. Loss of DPP10 expression was found in 11 colorectal cancers (CRCs) (2.9%), and multivariate analysis showed that loss of DPP10 expression was an independent factor for poor patient prognosis (p=0.008).

Conclusion

DPP10 may play a role in disease progression of colorectal cancer and loss of DPP10 expression in primary CRC is significantly associated with poor survival outcomes.     

Risk of breast cancer in symptomatic women in primary care: a case–control study using electronic records

Background

Breast cancer is the most common cancer in the UK. GPs are encouraged to refer all women whose symptoms may represent cancer, rather than selecting those at highest risk.

Aim

To identify and quantify features of breast cancer in primary care.

Design and setting

A UK case–control study using the Clinical Practice Research Database (CPRD).

Method

Possible features of breast cancer were identified in the year before diagnosis, and odds ratios calculated using conditional logistic regression. Positive predictive values (PPVs) were estimated for consulting women.

Results

A total of 3994 women aged ≥40 years with breast cancer between 2000 and 2009, and 16 873 age-, sex-, and practice-matched controls were studied. Median age at diagnosis was 63 years (interquartile range 55–74 years). Four features were significantly associated with breast cancer: breast lump (odds ratio [OR] 110; 95% confidence interval [CI] = I88 to150), breast pain (OR = 4.2; 95% CI = 3.0 to 6.0), nipple retraction (OR = 26; 95% CI = 10 to 64), nipple discharge (OR = 19; 95% CI = 8.6 to 41): all P-values <0.01. In the year before diagnosis, 1762 (44%) of cases had a breast lump compared with 132 (0.8%) controls. The PPV of breast cancer with a breast lump was 4.8% in women aged 40–49 years, rising to 48% in women aged >70 years. PPVs were lower in women who also reported breast pain.

Conclusion

Generally, the figures support current referral practice. However, the low likelihood of cancer for all the non-lump symptoms means that the current guidance recommends investigation for possible cancer at a more liberal risk threshold than for other cancers. Although supported by patients, this may not meet current NHS criteria for cost–benefit.     

Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm

Background

Early diagnosis of cancer could improve survival so better tools are needed.

Aim

To derive an algorithm to estimate absolute risks of different types of cancer in women incorporating multiple symptoms and risk factors.

Design and setting

Cohort study using data from 452 UK QResearch® general practices for development and 224 for validation.

Method

Included patients were females aged 25–89 years. The primary outcome was incident diagnosis of cancer over the next 2 years (lung, colorectal, gastro-oesophageal, pancreatic, ovarian, renal tract, breast, blood, uterine, cervix, other). Factors examined were: ‘red flag’ symptoms including weight loss, abdominal pain, indigestion, dysphagia, abnormal bleeding, lumps; general symptoms including tiredness, constipation; and risk factors including age, family history, smoking, alcohol intake, deprivation, body mass index (BMI), and medical conditions. Multinomial logistic regression was used to develop a risk equation to predict cancer type. Performance was tested on a separate validation cohort.

Results

There were 23 216 cancers from 1 240 864 females in the derivation cohort. The final model included risk factors (age, BMI, chronic pancreatitis, chronic obstructive pulmonary disease, diabetes, family history, alcohol, smoking, deprivation); 23 symptoms, anaemia and venous thrombo-embolism. The model was well calibrated with good discrimination. The receiver operating curve statistics were lung (0.91), colorectal (0.89), gastro-oesophageal (0.90), pancreas (0.87), ovary (0.84), renal (0.90), breast (0.88), blood (0.79), uterus (0.91), cervix (0.73), other cancer (0.82). The 10% of females with the highest risks contained 54% of all cancers diagnosed over 2 years.

Conclusion

The algorithm has good discrimination and could be used to identify those at highest risk of cancer to facilitate more timely referral and investigation.     

Temporal resolution in individuals with neurological disorders

OBJECTIVE:

Temporal processing refers to the ability of the central auditory nervous system to encode and detect subtle changes in acoustic signals. This study aims to investigate the temporal resolution ability of individuals with mesial temporal sclerosis and to determine the sensitivity and specificity of the gaps-in-noise test in identifying this type of lesion.

METHOD:

This prospective study investigated differences in temporal resolution between 30 individuals with normal hearing and without neurological lesions (G1) and 16 individuals with both normal hearing and mesial temporal sclerosis (G2). Test performances were compared, and the sensitivity and specificity were calculated.

RESULTS:

There was no difference in gap detection thresholds between the two groups, although G1 revealed better average thresholds than G2 did. The sensitivity and specificity of the gaps-in-noise test for neurological lesions were 68% and 98%, respectively.

CONCLUSIONS:

Temporal resolution ability is compromised in individuals with neurological lesions caused by mesial temporal sclerosis. The gaps-in-noise test was shown to be a sensitive and specific measure of central auditory dysfunction in these patients.     

Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice

Background

Continuity of care may affect the diagnostic process in cancer but there is little research.

Aim

To estimate associations between patient–doctor continuity and time to diagnosis and referral of three common cancers.

Design and setting

Retrospective cohort study in general practices in England.

Method

This study used data from the General Practice Research Database for patients aged ≥40 years with a diagnosis of breast, colorectal, or lung cancer. Relevant cancer symptoms or signs were identified up to 12 months before diagnosis. Patient–doctor continuity (fraction-of-care index adjusted for number of consultations) was calculated up to 24 months before diagnosis. Time ratios (TRs) were estimated using accelerated failure time regression models.

Results

Patient–doctor continuity in the 24 months before diagnosis was associated with a slightly later diagnosis of colorectal (time ratio [TR] 1.01, 95% confidence interval [CI] =1.01 to 1.02) but not breast (TR = 1.00, 0.99 to 1.01) or lung cancer (TR = 1.00, 0.99 to 1.00). Secondary analyses suggested that for colorectal and lung cancer, continuity of doctor before the index consultation was associated with a later diagnosis but continuity after the index consultation was associated with an earlier diagnosis, with no such effects for breast cancer. For all three cancers, most of the delay to diagnosis occurred after referral.

Conclusion

Any effect for patient–doctor continuity appears to be small. Future studies should compare investigations, referrals, and diagnoses in patients with and without cancer who present with possible cancer symptoms or signs; and focus on ‘difficult to diagnose’ types of cancer.     

Digital rectal examination in primary care is important for early detection of prostate cancer: a retrospective cohort analysis study

Background

Currently, there is no standardised screening for prostate cancer in Europe. Assessment of risk is opportunistically undertaken in consultation with the GP or urologist. Evaluation of the prostate gland consists of a prostate-specific antigen (PSA) serum level and a digital rectal examination (DRE) of the gland. DRE is an essential part of the assessment that can independently predict prostate cancer in the setting of a normal PSA level.

Aim

To evaluate the clinical usefulness of the DRE in general practice and urology clinics, and to ascertain its positive predictive value and sensitivity.

Design and setting

A retrospective analysis study of a cohort of Irish men who underwent TRUS guided biopsy of the prostate in a single Irish tertiary referral centre, despite a normal PSA level. Patients were identified from a Rapid Access Prostate Clinic patient database. Pathological biopsy results were correlated with clinical DRE findings.

Method

Patient demographics, PSA levels, and DRE findings from a prospectively established database and hospital data systems from May 2009 to October 2013 were analysed.

Results

Of 103 men referred over a 53-month period with a normal age-adjusted PSA level, 67% were referred on the basis of an abnormal DRE alone. Thirty-five per cent of males with a normal PSA had prostate cancer. DRE alone had a sensitivity and specificity of 81% and 40% respectively in diagnosing prostate cancer, with a positive predictive value of 42%. Seventy-six per cent of these men had high-grade disease.

Conclusion

DRE is a key part of the assessment for prostate cancer. It can independently identify patients at risk of prostate cancer, with a substantial proportion of these having clinically significant disease requiring treatment. This study reinforces the importance of DRE in the primary care setting in the assessment for prostate cancer. An abnormal DRE, even in the setting of a normal PSA level, necessitates referral.     

Carotid stenosis: what is the high-risk population?

OBJECTIVE:

Prevention is the best treatment for cerebrovascular disease, which is why early diagnosis and the immediate treatment of carotid stenosis contribute significantly to reducing the incidence of stroke. Given its silent nature, 80% of stroke cases occur in asymptomatic individuals, emphasizing the importance of screening individuals with carotid stenosis and identifying high-risk groups for the disease. The aim of this study was to determine the prevalence and the most frequent risk factors for carotid stenosis.

METHODS:

A transversal study was conducted in the form of a stroke prevention campaign held on three non-consecutive Saturdays. During the sessions, carotid stenosis diagnostic procedures were performed for 500 individuals aged 60 years or older who had systemic arterial hypertension and/or diabetes mellitus and/or coronary heart disease and/or a family history of stroke.

RESULTS:

The prevalence of carotid stenosis in the population studied was 7.4%, and the most frequent risk factors identified were mean age of 70 years, carotid bruit, peripheral obstructive arterial disease, coronary insufficiency and smoking. Independent predictive factors of carotid stenosis include the presence of carotid bruit or peripheral obstructive arterial disease and/or coronary insufficiency.

CONCLUSIONS:

The population with peripheral obstructive arterial disease and/or coronary insufficiency and carotid bruit should undergo routine screening for carotid stenosis.     

Diagnostic value of microRNA for pancreatic cancer: a meta-analysis

Introduction

MicroRNAs have been reported to be aberrantly expressed in patients with pancreatic cancer. The aim of the present meta-analysis is to establish the overall diagnostic accuracy of the measurement of microRNA for diagnosing pancreatic cancer.

Material and methods

After a systematic review of English language studies from Medline, Embase, and Cochrane Library, the sensitivity, specificity, and other measures of accuracy of microRNA in the diagnosis of pancreatic cancer were pooled using random-effects models. The methodological quality of each study was assessed by QUADAS (quality assessment for studies of diagnostic accuracy). Statistical analysis was performed by employing Meta-Disc 1.4 software and STATA. Summary receiver operating characteristic curves were used to summarize overall test performance. Deeks’ test was used to test the potential publication bias.

Results

Nine studies from seven publications met our inclusion criteria. The summary estimates for microRNAs in the diagnosis of pancreatic cancer in these studies were pooled sensitivity 0.89 (95% CI: 0.86-0.91), specificity 0.93 (95% CI: 0.90-0.95), positive likelihood ratio 11.62 (95% CI: 5.75-23.50), negative likelihood ratio 0.14 (95% CI: 0.08-0.24), diagnostic odds ratio 115.13 (95% CI: 33.73-351.28), and the area under the curve was 0.97.

Conclusions

MicroRNA assay plays an important role in the diagnosis of pancreatic cancer. The results of microRNA assays should be interpreted in parallel with clinical findings and the results of conventional tests.     

Identifying patients with suspected colorectal cancer in primary care: derivation and validation of an algorithm

Background

Earlier diagnosis of colorectal cancer could help improve survival so better tools are needed to help this.

Aim

To derive and validate an algorithm to quantify the absolute risk of colorectal cancer in patients in primary care with and without symptoms.

Design and setting

Cohort study using data from 375 UK QResearch® general practices for development and 189 for validation.

Method

Included patients were aged 30–84 years, free at baseline from a diagnosis of colorectal cancer and without rectal bleeding, abdominal pain, appetite loss, or weight loss in the previous 12 months. The primary outcome was incident diagnosis of colorectal cancer recorded in the next 2 years. Risk factors examined were age, body mass index, smoking status, alcohol status, deprivation, diabetes, inflammatory bowel disease, family history of gastrointestinal cancer, gastrointestinal polyp, history of another cancer, rectal bleeding, abdominal pain, abdominal distension, appetite loss, weight loss, diarrhoea, constipation, change of bowel habit, tiredness, and anaemia. Cox proportional hazards models were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 4798 incident cases of colorectal cancer from 4.1 million person-years in the derivation cohort. Independent predictors in males and females included family history of gastrointestinal cancer, anaemia, rectal bleeding, abdominal pain, appetite loss, and weight loss. Alcohol consumption and recent change in bowel habit were also predictors in males. On validation, the algorithms explained 65% of the variation in females and 67% in males. The receiver operating curve statistics were 0.89 (females) and 0.91 (males). The D statistic was 2.8 (females) and 2.9 (males). The 10% of patients with the highest predicted risks contained 71% of all colorectal cancers diagnosed over the next 2 years

Conclusion

The algorithm has good discrimination and calibration and could potentially be used to help identify those at highest risk of current colorectal cancer, to facilitate early referral and investigation.     

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

Background

The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.

Aim

To investigate whether using the rule adds to the GP’s clinical judgement.

Design and setting

A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.

Method

Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP’s clinical judgement aided by the MHS. Their accuracy was compared with the GPs’ unaided clinical judgement.

Results

Sensitivity and specificity of the GPs’ unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = −2.4 to 19.6) and the specificity was similar (difference −0.4%, 95% CI = −5.3 to 4.5); the sensitivity of the triage was similar (difference −1.5%, 95% CI = −9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = −6.9 to 23.0 and 5.8%, 95% CI = −1.6 to 13.2, respectively).

Conclusion

Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.