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

Background

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

Aim

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

Design

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 of a diagnosis of renal tract cancer (bladder, kidney, ureter, or urethra) and without haematuria, abdominal pain, appetite loss, or weight loss in previous 12 months. The primary outcome was incident diagnosis of renal tract cancer recorded in the next 2 years. Risk factors examined were age, body mass index, smoking, alcohol, deprivation, treated hypertension, renal stones, structural kidney problems, diabetes, previous diagnosis of cancer apart from renal tract cancer, haematuria, abdominal pain, appetite loss, weight loss, diarrhoea, constipation, 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 2878 incident cases of renal tract cancer from 4.1 million person-years in the derivation cohort. Independent predictors in both males and females were age, smoking status, haematuria, abdominal pain, weight loss, and anaemia. A history of prior cancer other than renal tract cancer, and appetite loss were predictors for females only. On validation, the algorithms explained 75% of the variation in females and 76% in males. The receiver operating curve statistics were 0.91 (females) and 0.95 (males). The D statistic was 3.53 (females) and 3.60 (males). The 10% of patients with the highest predicted risks contained 87% of all renal tract cancers diagnosed over the next 2 years.

Conclusion

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

Microbial aetiology and sensitivity of asymptomatic bacteriuria among ante-natal mothers in Mulago hospital, Uganda

Background

Asymptomatic bacteriuria in pregnancy is associated with potential urinary and obstetric complications. However the prevalence aetiology and antimicrobial sensitivity patterns of asymptomatic bacteriurea among women attending ante-natal care in our Hospital is not known.

Objective

To determine the prevalence and identify the aetiological agents associated with assymptomatic bacteriurea in antenatal mothers in Mulago Hospital. We also intented to determine the anti-microbial sensitivity patterns of the common uropathogen in this population

Methods

We performed culture and anti-microbial sensitivity tests on urine samples from 218 consecutive ante-natal mothers in Mulago Hospital. All participants did not have any clinical symptoms attributable to urinary tract infection.

Results

Twenty nine (13.3%) of the samples had significant bacterial growth and E.coli was the commonest isolate (51.2%). There was a high level (20–62%) of anti-bacterial resistance to the commonly used antibiotics.

Conclusion

Asymptomatic bacteriuria is common among ante-natal mothers in Mulago. E. Coli that is resistant to the most commonly used antibiotics is the commonest isolate.”     

The association between symptoms and bladder or renal tract cancer in primary care: a systematic review

Background

Appropriate selection for further investigation of patients presenting in primary care with symptoms that may indicate cancer is key to early diagnosis.

Aim

To quantify the risk of urinary tract cancer in patients presenting in primary care with symptoms that may indicate bladder or renal cancer.

Design and setting

Systematic review of studies relating to bladder or renal cancer in primary care.

Method

Databases searched were MEDLINE, PreMEDLINE, Embase, the Cochrane Library, Web of Science (SCI and SSCI), and ISI Proceedings from 1980 to August 2014, and PsycINFO (1980–2012) and BioMed Central (inception to 2012) for retrospective, prospective, or case-control diagnostic accuracy studies of symptomatic patients presenting to primary care with one or more symptoms for whom follow-up data were available. The target conditions were bladder or renal cancer. The studies were appraised using the QUADAS-2 tool.

Results

Eleven studies with 3 451 675 patients were included. The positive predictive value (PPV) from meta-analysis of visible haematuria was 5.1% in adult patients. It increased with age and was higher in males. The PPVs of other single symptoms were very low, with the highest non-haematuria PPV being 1.4% for anaemia in males. Fewer data were available on the PPVs of symptom combinations. Generally, these data showed that, with the exception of symptom combinations including haematuria, these were very low.

Conclusion

The only high-risk feature of bladder/renal cancer in primary care was visible haematuria, and this clearly warrants investigation. However, not all patients with one of these cancers experience haematuria, so a policy restricting investigation to patients with haematuria will inevitably delay the diagnosis in some patients.     

A comparative study to assess the effect of amikacin sulfate bladder wash on catheter-associated urinary tract infection in neurosurgical patients

Background:

The indwelling urinary catheter is an essential part of modern medical care. Unfortunately, when poorly managed, the indwelling catheter may present a hazard to the very patients it is designed to protect. Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes.

Aims and Objectives:

The primary objective was to study the effect of amikacin sulfate bladder wash on CAUTI in neurosurgical patients. The other objectives were to study the various organisms causing CAUTI and their antibiotic sensitivity and resistance pattern.

Materials and Methods:

This was a prospective randomized controlled study performed on 60 patients who met the inclusion criteria at the neurosurgical intensive care of the All India Institute of Medical Sciences between June and December 2006. The patients were randomized into two groups – one was the trial group which received amikacin bladder wash, while the other was the control group that did not receive any bladder wash.

Results:

Forty percent of the subjects in the control group developed CAUTI, while none of the subjects in study group developed CAUTI. (Fisher''s exact test, P value < 0.001) Pseudomonas aeruginosa (51%) was the commonest pathogen.

Conclusions:

Amikacin sulfate bladder wash was effective in preventing CAUTI. It can thus decrease the antibiotic usage thereby preventing the emergence of antibiotic resistance.     

Serum adenosine deaminase,catalase and carbonic anhydrase activities in patients with bladder cancer

OBJECTIVES:

The relationship between adenosine deaminase and various cancers has been investigated in several studies. However, serum adenosine deaminase activity and carbonic anhydrase and catalase activities in patients with bladder cancer have not previously been reported. Therefore, the aim of this study was to measure serum adenosine deaminase, carbonic anhydrase and catalase activities in patients with bladder cancer.

MATERIALS AND METHODS:

Forty patients with bladder cancer and 30 healthy controls were enrolled in the study. Serum adenosine deaminase, carbonic anhydrase and catalase activities were measured spectrophotometrically.

RESULTS:

Serum adenosine deaminase, carbonic anhydrase and catalase activities were significantly higher in patients with bladder cancer than controls (all significant, p<0.001).

CONCLUSIONS:

These markers might be a potentially important finding as an additional diagnostic biochemical tool for bladder cancer.     

Antibiogram of nosocomial urinary tract infections in Felege Hiwot referral hospital, Ethiopia

Background

Nosocomial infections increase the cost of medical care, extend hospital stay and reflect on the morbidity and mortality of the admitted patients. Urinary tract infections (UTIs) are one of the most common nosocomial infections in humans.

Objectives

To determine the prevalence and antibiogram of nosocomial UITs from a referral hospital.

Methods

A cross-sectional study was conducted on 1 254 patients from April to August 2010. Antimicrobial susceptibility tests were done using disc diffusion technique as per the standard of Kirby-Bauer method.

Results

Of the 1 254 patients, 118 (9.4%) developed nosocomial UTIs. Seventy three (61.9%) and 44 (37.1%) of the bacterial isolates were gram negative and gram positive, respectively. One patient had a mixed infection. E. coli, S.aureus and K. pneumonia were the most predominant isolates. Gender, catheterization and pre-operative antimicrobial prophylaxis and underlying diseases were significantly associated with the occurrence of nosocomial UTIs (p=0.001). Most bacterial isolates showed high resistance rates (>80%) to ampicillin, amoxicillin/clavulanic acid, chloramphenicol and cloxacillin.

Conclusion

Catheterization and preoperative antibiotic prophylaxis were found to be the risk factors for nosocomial infection. Effective infection prevention measures should be in place to reduce the prevalence of nosocomial UTIs.     

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.     

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.     

The sensitivities to first-line antibiotic therapy of the common urinary tract bacterial infections detected in urine samples at a hospital in metropolitan Kampala (Uganda)

Background

Urinary tract infections (UTIs) are among the most common human infections. Many urinary tract bacteria are capable of expressing drug resistance. Resistant bacteria may be present from the commencement of the infection or may develop during treatment. This study focused on the problem of antibiotic resistance to the first-line drugs that were used to treat patients presenting with urinary tract infections at Rubaga hospital in Kampala, Uganda.

Objectives

The objective of this study was to isolate and identify the major bacterial pathogens of symptomatic and asymptomatic UTIs among patients at Rubaga hospital. Furthermore, the study sought to determine the antimicrobial susceptibility patterns of the major bacterial isolates to the first-line drugs used to treat UTIs at Rubaga hospital.

Methods

Urine samples were aseptically collected and examined microscopically and were microbiologically cultured on blood agar, nutrient agar and on MacConkey agar. The isolates obtained were then identified using standard tests and tested for antimicrobial sensitivity by the Kirby-Bauer technique.

Results

The isolated pathogens included Escherichia coli (10.9%), Staphylococcus (31.9%), Streptococcus (9.2%), Klebsiella species (21.0%) and Proteus species (10.1%). 20 (16.8%) of the isolates were lactose fermenting gram-negative rods that were also indole-negative. These isolates were termed ‘unclassified coliforms’ in this study but were probably Enterobacter species. On antimicrobial susceptibility testing, all the gram-negative isolates were significantly resistant to amoxycillin, cotrimoxazole, erythromycin, and to nalidixic acid; but were susceptible to nitrofurantoin. Among the gram-negative isolates, only Klebsiella species were significantly resistant (p<0.05) to ciprofloxacin. The gram-positive cocci were susceptible to amoxycillin, ciprofloxacin, and to erythromycin but resistant to cotrimoxazole and nalidixic acid. Unlike the Staphylococcus species that were significantly resistant to nitrofurantoin, Streptococcus species were moderately susceptible to the drug.

Conclusion

The common urinary tract bacteria detected in Rubaga hospital in Uganda were most sensitive to Ciprofloxacin and Nitrofurantoin.     

Diagnostic classification in patients with suspected deep venous thrombosis: physicians' judgement or a decision rule?

Background

Clinical decision rules can aid in referral decisions for ultrasonography in patients suspected of having deep venous thrombosis (DVT), but physicians are not always convinced of their usefulness and rely on their own judgement.

Aim

To compare the performance of a clinical decision rule with the probability of DVT presence as estimated by GPs.

Design of study

Cross-sectional survey.

Setting

Primary care practices in The Netherlands.

Method

GPs (n = 300) estimated the probability of the presence of DVT (range 0–100%) and calculated the score for the clinical decision rule in 1028 consecutive patients with suspected DVT. The clinical decision rule uses a threshold of three points and so, for the GP estimates, thresholds were introduced at 10% and 20%. If scores were below these estimates, it was not considered necessary to refer patients for further examination. Differences between the clinical decision rule and the GP estimates were calculated; this is discrimination (c-statistic) and classification of patients.

Results

Data of 1002 patients were eligible for analysis. DVT was observed in 136 (14%) patients. Both the clinical decision rule and GP estimates had good discriminative power (c-statistic of 0.80 and 0.82 respectively). Fewer patients were referred when using the clinical decision rule compared with a referral decision based on GP estimates: 51% versus 79% and 65% (thresholds at 10% and 20% respectively). Both strategies missed a similar and low proportion of patients who did have DVT (range 1.4–2.0%).

Conclusion

In patients suspected of DVT both GP estimates and a clinical decision rule can safely discriminate in patients with and without DVT. However, fewer patients are referred for ultrasonography when GPs rely on a clinical decision rule to guide their decision making.     

Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women

Background

Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed.

Aim

To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI).

Design of study

Validation study.

Setting

Primary care.

Method

A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines.

Results

Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule — based on presence of nitrite, or both leucocytes and blood — was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features.

Conclusion

A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.     

Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease

Background

GPs in England are required to keep a register of patients with chronic kidney disease (CKD). National Institute for Health and Clinical Excellence (NICE) guidelines recommend regular follow-up, but patients are perceived to be low risk and not requiring active management.

Aim

To assess treatment needs of CKD stage 3 patients in primary care, as well as their awareness of CKD.

Design and setting

A cross-sectional analysis from a longitudinal prospective study in 32 general practices.

Method

A total of 1741 participants underwent clinical assessment including urine and blood tests. Participants were asked about awareness of their CKD. Results were reviewed and a letter recommending treatment in line with NICE guidelines was sent to their GP.

Results

The mean age of participants was 73 ± 9 years; 60% (n = 1052) were female and diabetes was present in 17%; 67% of participants required further intervention. Most required improved control of hypertension (n = 1576; 33.1% of cohort). Other recommendations included advice to investigate anaemia (n = 1142; 8.2%) or stop nephrotoxic drugs (n = 1120; 7.5%). Less than 6% of participants met NICE criteria for referral to nephrology services and 41% were unaware of their CKD diagnosis. Multivariable analysis identified subjects with formal educational qualifications, age <75 years, estimated glomerular filtration rate (eGFR) 30–44 ml/min/1.73 m², and significant albuminuria as more likely to be aware of their diagnosis.

Conclusion

The study data show that the majority of patients required at least one intervention to improve the management of their CKD. Most interventions could be delivered in primary care and only a minority required nephrology referral. Many patients were unaware of their CKD diagnosis, and efforts should be made to improve this to facilitate involvement in their care.     

Standard surgical treatment for benign prostatic hyperplasia is safe for patients over 75 years: Analysis of 100 cases from a high-volume urologic center

OBJECTIVES:

In this study, we aimed to determine the complications of standard surgical treatments among patients over 75 years in a high-volume urologic center.

METHODS:

We analyzed 100 consecutive patients older than 75 years who had undergone transurethral prostatic resection of the prostate or open prostatectomy for treatment of benign prostatic hyperplasia from January 2008 to March 2010. We analyzed patient age, prostate volume, prostate-specific antigen level, international prostatic symptom score, quality of life score, urinary retention, co-morbidities, surgical technique and satisfaction with treatment.

RESULTS:

Median age was 79 years. Forty-eight patients had undergone transurethral prostatic resection of the prostate, and 52 had undergone open prostatectomy. The median International Prostatic Symptom Score was 20, the median prostate volume was 83 g, 51% were using an indwelling bladder catheter, and the median prostate-specific antigen level was 5.0 ng/ml. The most common comorbidities were hypertension, diabetes and coronary disease. After a median follow-up period of 17 months, most patients were satisfied. Complications were present in 20% of cases. The most common urological complication was urethral stenosis, followed by bladder neck sclerosis, urinary fistula, late macroscopic hematuria and persistent urinary incontinence. The most common clinical complication was myocardial infarction, followed by acute renal failure requiring dialysis. Incidental carcinoma of the prostate was present in 6% of cases. One case had urothelial bladder cancer.

CONCLUSIONS:

Standard surgical treatments for benign prostatic hyperplasia are safe and satisfactory among the elderly. Complications are infrequent, and urethral stenosis is the most common. No clinical variable is associated with the occurrence of complications.     

Barriers engaging families and GPs in childhood weight management strategies

Background

The rapid increase in the prevalence of childhood obesity in recent years has led to inconclusive debate about the most effective way to manage the condition and the most appropriate care setting. Primary care has been suggested as a key site to identify and treat obesity in children.

Aim

To identify children from general practice databases with a body mass index (BMI) categorised as ‘obese’, and invite them for a primary care consultation and possible referral to a specialist secondary care clinic.

Design and setting

Targeted screening of GP practice databases for obese children in 12 general practices in Bristol, UK.

Method

Participating GP practices searched databases for children''s BMIs which were then screened by the study team to identify obese children (≥98th centile). Practices invited families of obese children to consult their GP with the potential for referral to a specialist clinic. Follow-up data was recorded with respect to: consultations; consultations about child''s weight; and referrals to specialist clinic; and other referrals.

Results

A total of 285 letters inviting families to consult their GP were sent; 134 patients consulted their GP in the follow-up period (minimum 3 months), and 42 of these consultations discussed the child''s weight. Nineteen patients received a secondary care referral and six received an alternative weight-management referral.

Conclusion

The low take-up following the mail-out of an invitation to consult highlights the inherent difficulties of engaging families and their obese children in care pathways that facilitate long-term weight management.     

Anti-proteinuric effect of sulodexide in immunoglobulin a nephropathy

Purpose

We conducted a multi-center randomized double-blind study to determine the effects of 6-month therapy with sulodexide on urinary protein excretion in patients with idiopathic Immunoglobulin A (IgA) nephropathy.

Materials and Methods

A total of seventy-seven patients participated in the study. They were randomly allocated to one of three groups: sulodexide 75 mg or 150 mg daily or the placebo for 6 months. The primary end point was the achievement, at 6 months, of at least 50% reduction in urine protein/creatinine ratio (UPCR) from the baseline value.

Results

At 6 months, the primary end point was achieved by 12.5% of the patients assigned to the placebo, 4.0% of the patients assigned to sulodexide 75 mg daily and 21.4% of those assigned to 150 mg (p=0.308). Treatment with sulodexide 150 mg daily for 6 months significantly reduced log UPCR from 6.38±0.77 at baseline to 5.98±0.94 at 6 months (p=0.045), while treatment with sulodexide 75 mg daily and placebo did not.

Conclusion

A 6-month treatment with sulodexide did not achieve 50% reduction of urinary protein excretion in IgA nephropathy patients, but showed a tendency to increase the time-dependent anti-proteinuric effect. Therefore, long-term clinical trials on a larger scale are warranted to elucidate the hypothesis that sulodexide affords renal protection in IgA nephropathy patients.     

Resistant plasmid profile analysis of multidrug resistant Escherichia coli isolated from urinary tract infections in Abeokuta,Nigeria

Background

Multi-drug resistant Escherichia coli has become a major threat and cause of many urinary tract infections (UTIs) in Abeokuta, Nigeria.

Objectives

This study was carried out to determine the resistant plasmids of multidrug resistant Escherichia coli isolated from (Urinary tract infections)UTIs in Abeokuta.

Methods

A total of 120 Escherichia coli isolates were obtained from urine samples collected from patients attending inpatient and outpatient clinics presenting UTI; with their biodata. Antibiotics susceptibility was performed and multi-drug resistant isolates were selected for plasmid profiling. Plasmids were extracted by the alkaline lysis method, electrophoresed on 0.8% agarose gel and profiled using a gel-photo documentation system gel.

Results

Escherichia coli isolates obtained shows high resistance to cloxacillin (92.5%), amoxicillin (90.8%), ampicillin (90.8%), erythromycin (75.8%), cotrimoxazole (70.0%), streptomycin (70.0%) and tetracycline (68.3%) while 85.8% and 84.2% were susceptible to gentamycin and ceftazidime respectively. Sixteen Escherichia coli strains were observed to be resistant to more than two classes of antibiotics. The resistant plasmid DNA was detectable in 6(37.5%) of the 16 multidrug resistant Escherichia coli having single sized plasmids of the same weight 854bp and were all resistant to erythromycin, cefuroxime, cloxacillin, amoxicillin, ampicillin and cotrimoxazole.

Conclusion

This study has highlighted the emergence of multidrug resistant R-plasmids among Escherichia coli causing urinary tract infections in Abeokuta, Nigeria. There is a high level of resistance to many antimicrobials that are frequently used in Abeokuta, Nigeria.     

Comparison between two shock wave regimens using frequencies of 60 and 90 impulses per minute for urinary stones

PURPOSE:

Two different regimens of SWL delivery for treating urinary stones were compared.

METHODS:

Patients with urinary stones were randomly divided into two groups, one of which received 3000 shocks at a rate of 60 impulses per minute and the other of which received 4000 shocks at 90 impulses per minute. Success was defined as stone‐free status or the detection of residual fragments of less than or equal to 3 mm three months after treatment. Partial fragmentation was considered to have occurred if a significant reduction in the stone burden was observed but residual fragments of 3mm or greater remained.

RESULTS:

A total of 143 procedures were performed with 3000 impulses at a rate of 60 impulses per minute, and 156 procedures were performed with 4000 impulses at 90 impulses per minute. The stone‐free rate was 53.1% for patients treated with the first regimen and 54.8% for those treated with the second one (p =  0.603). The stone‐free rate for stones smaller than 10 mm was 60% for patients treated with 60 impulses per minute and 58.6% for those treated with 90 impulses per minute. For stones bigger than 10 mm, stone‐free rates were 34.2% and 45.7%, respectively (p = 0.483). Complications occurred in 2.3% of patients treated with 60 impulses per minute and 3.3% of patients treated with 90 impulses per minute.

CONCLUSION:

No significant differences in the stone‐free and complication rates were observed by reducing the total number of impulses from 4000 to 3000 and the frequency from 90 to 60 impulses per minute.     

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.     

Do general practices provide equitable access to physical activity interventions?

Background

Exercise referral schemes are widespread across England. National guidance emphasises the need to engage groups that are disadvantaged.

Aim

To examine the influence of socioeconomic deprivation on referral to, and use of, exercise referral schemes.

Design of study

Cross-sectional analysis of patients referred by general practices to exercise referral schemes between 2004 and 2006.

Setting

Six primary care trusts (PCTs) in Greater London.

Method

Routine data about patients who had been referred to exercise referral schemes were used to estimate risk ratios for referral by general practice deprivation quintile, odds ratios (ORs) for uptake, and ORs for completion of exercise referral schemes by patients'' deprivation status quintile.

Results

All 317 general practices in the six PCTs were included in the referral analysis. Referrals were less likely from general practices serving advantaged socioeconomic areas (adjusted risk ratio for trend across deprivation quintiles 0.84; 95% confidence interval [CI] = 0.76 to 0.93). This study found no association between patients'' deprivation status and their likelihood of taking up (adjusted OR, least versus most deprived quintile 1.05; 95% CI = 0.83 to 1.33) or completing the scheme (adjusted OR 1.23; 95% CI = 0.84 to 1.79).

Conclusion

General practices within areas of deprivation were more likely to refer patients to exercise referral schemes than practices in more advantaged areas. Once referred, it was found that patients living in areas of deprivation were as likely to take up and to complete the scheme as those living in more advantaged locations. Research is needed to identify the organisational and contextual factors that allow this pattern of service delivery, which appears to facilitate access to care among patients who live in areas of deprivation.