Referral Letters for 2-Week Wait Suspected Colorectal Cancer do not Allow a ‘Straight-to-Test’ Pathway

INTRODUCTION

Some clinicians have argued that 2-week wait suspected colorectal cancer patients can go ‘straight-to-test’ to facilitate time to diagnosis and treatment. The aim of this study was to evaluate whether the currently used referral letters are reliable enough to allow that pathway.

PATIENTS AND METHODS

General practitioner (GP) letters referring patients under the Two Week-Wait Rule for suspected colorectal cancer were prospectively reviewed over a 6-month period. Three examining consultants were asked to outline the tests they would perform having only read the letter, and then again after a clinical consultation with the patient. The outcome of these tests was tracked.

RESULTS

A total of 217 referral letters of patients referred under Two Week Wait Rule for suspected colorectal cancer were studied. Having just read the referral letter, the most frequently requested test was colonoscopy (148), then CT scan (48), barium enema (44), followed by gastroscopy (23) and flexible sigmoidoscopy in 15 patients (some patients would have had more than one test requested). After consultation with the patients, tests requested as guided by the GP letter were changed in 67 patients (31%), where 142 colonoscopies, 61 CT scans, 37 barium enemas, 23 flexible sigmoidoscopies and 19 gastroscopies were organised. The referral indication which had tests changed most often was definite palpable rectal mass (67%), while patients referred with definite palpable right-sided abdominal mass had their tests least often changed (9%). A total of 22 patients were found to have colorectal cancers (10%) and 30 patients were diagnosed with polyps (14%). Out of 142 colonoscopies performed, 19 (13%) showed some pathology beyond the sigmoid colon and of the 23 patients who had flexible sigmoidoscopy initially, only three went on to have colonoscopy subsequently. During the 6-month period of the study, only five breaches of the waiting time targets were recorded (1 to the 31-day target and 4 to the 62-day target).

CONCLUSIONS

A significant number of patients would have had tests changed after a clinical consultation. However, only a small number required further investigations having had a consultation prior to their initial investigations. We conclude that 2-week wait suspected colorectal cancer patients should be seen in the clinic first and should not proceed ‘straight-to-test’.     

Organized breast screening programs in Canada: effect of radiologist reading volumes on outcomes

PURPOSE: To examine retrospectively the relationship between radiologist screening program reading volumes and interpretation results. MATERIALS AND METHODS: This research project was reviewed by the University of British Columbia Research Ethics Board. Informed patient consent was not required. Data were requested from Canadian provincial screening programs for the period 1988-2000. Cancer detection rates, abnormal interpretation rates, and positive predictive values (PPVs) were calculated for individual radiologists in those programs. Multivariate Poisson mixed regression models were used to examine the effect of patient age, screening examination sequence (first or subsequent screening examination), province, radiologist reading volume, and interradiologist differences on cancer detection rate, abnormal interpretation rate, and PPV. RESULTS: The results of the interpretation of 1406678 screening mammograms by 304 radiologists from seven provincial programs were analyzed. Cancer detection rate, abnormal interpretation rate, and PPV all varied according to age of woman screened and screening sequence and across the sample of radiologists. None of the rates varied by province. Neither the cancer detection rate nor the abnormal interpretation rate varied by reading volume, but the average PPV was increased by 34% for volumes over 2000 mammograms versus volumes of 480-699 mammograms per year. There was no evidence that the magnitude of variability around the average, for radiologists reading the same volume of mammograms, varied across different volume groups for any of the outcome measures. CONCLUSION: Cancer detection did not vary with reading volume. The average PPV for individual radiologists increased as reading volume rose up to 2000 mammograms per year; it stabilized at higher volumes.     

Prognostic and aetiological factors in chronic thromboembolic pulmonary hypertension

Several prognostic variables have previously been identified in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Specific medical conditions have also been associated with the development and prognosis of CTEPH. Using a national registry, the current authors have assessed the prognostic value of a larger number of variables and have also attempted to validate the clinical importance of previously identified aetiological factors. Baseline information for all 469 CTEPH patients diagnosed in the UK pulmonary hypertension service between January 2001 and June 2006 was collected from hospital records. Although univariate analysis confirmed the prognostic importance of pulmonary resistance, in multivariate analysis gas transfer and exercise capacity predicted pulmonary endarterectomy perioperative mortality. Cardiac index and exercise capacity independently predicted outcome in patients with nonoperable disease. Previous splenectomy was noted in 6.7% of patients, being significantly more common in patients with nonoperable than operable disease (13.7 versus 3.6%). Medical risk factors were not found to predict mortality. In a large national cohort, predictors of outcome in patients with both operable and nonoperable chronic thromboembolic pulmonary hypertension have been identified. These may be useful in planning treatment. The aetiological importance of previously identified medical risk factors has been confirmed, although the current authors were unable to validate their prognostic strength.     

Cue-conditioned alcohol seeking in rats following abstinence: involvement of metabotropic glutamate 5 receptors

Background and purpose:

The current study was designed to: (i) examine whether functional interactions occur between receptors known to regulate alcohol self-administration; and (ii) characterize relapse to alcohol seeking following abstinence.

Experimental approach:

The selective cannabinoid CB₁ receptor antagonist SR141716A (0.03–1.0 mg·kg⁻¹ i.p.) resulted in a dose-dependent reduction in ethanol self-administration in ethanol-preferring Indiana-preferring rats. SR141716A was then co-administered with either the selective glutamate metabotropic glutamate 5 (mGlu₅) receptor antagonist 3-[(2-methyl-1,3-thiazol-4-yl)ethynyl]pyridine (MTEP) or the selective adenosine A_2A receptor antagonist {"type":"entrez-protein","attrs":{"text":"SCH58261","term_id":"1052882304","term_text":"SCH58261"}}SCH58261.

Key results:

When administered at individually sub-threshold doses, a combination of SR141716A (0.1 mg·kg⁻¹) and {"type":"entrez-protein","attrs":{"text":"SCH58261","term_id":"1052882304","term_text":"SCH58261"}}SCH58261 (0.5 mg·kg⁻¹ i.p.) produced a reduction (28%) in ethanol self-administration. Combinations of threshold doses of SR141716A (0.3 mg·kg⁻¹) and {"type":"entrez-protein","attrs":{"text":"SCH58261","term_id":"1052882304","term_text":"SCH58261"}}SCH58261 (2.0 mg·kg⁻¹, i.p.) caused an essentially additive reduction (68%) in alcohol self-administration. A combination of individually sub-threshold doses of CB₁ and mGlu₅ receptor antagonists did not affect alcohol self-administration; however, combined threshold doses of SR141716A (0.3 mg·kg⁻¹) and MTEP (1.0 mg·kg⁻¹ i.p.) did reduce ethanol self-administration markedly (80%). Cue-conditioned alcohol seeking was attenuated by pretreatment with MTEP (1.0 mg·kg⁻¹) co-administered with SR141716A (0.3 mg·kg⁻¹ i.p.). In contrast, {"type":"entrez-protein","attrs":{"text":"SCH58261","term_id":"1052882304","term_text":"SCH58261"}}SCH58261 (2.0 mg·kg⁻¹) co-administered with SR141716A (0.3 mg·kg⁻¹ i.p.) did not reduce cue-conditioned alcohol seeking.

Conclusions and implications:

Adenosine A_2A and cannabinoid CB₁ receptors regulated alcohol self-administration additively, but combined low-dose antagonism of these receptors did not prevent cue-conditioned alcohol seeking after abstinence. In contrast, combined low-dose antagonism of mGlu₅ and CB₁ receptors did prevent relapse-like alcohol seeking after abstinence, suggesting a prominent role for mGlu₅ receptors in this paradigm.     

Two dimensional SDS PAGE analysis of epididymal tissue proteins of normal and castrated bulls (Bos taurus) and identification of an androgen dependant protein

A study was undertaken with an objective of two dimensional SDS-PAGE analysis of protein profile in tissues of all caput, corpus and cauda of epididymis in both castrated and normal bulls and identification of androgen dependent protein/s in the epididymal tissues of bull (Bos taurus). Two dimensional SDS-PAGE analysis for protein spots of different molecular weight (MW) with pI 3.5 to 7.35 and pI > 7.35 to 9.3 between the three regions in the normal and castrated bull as well as between normal and castrated bull of a particular region revealed significant differences. Similarly, comparison between the three regions of the normal and castrated bull epididymis for the number of protein spots irrespective of the MW in pI range of 3.5 to 7.35 and pI range > 7.35 to 9.3 revealed significant differences. The number of protein spots found to be significantly higher in caput, corpus and cauda epididymis of the normal bull when compared to similar region of the castrated bull epididymis. Most of the proteins, which are secreted, are having MW between 20 and 85 kDa. Six proteins, which are known to be highly dependent on androgens, are also of acidic in nature except for one protein having basic pH. A protein spot (pI: 6.55–6.85, and MW: <20 kDa) which appeared at the same site in all the three regions of the epididymis in the normal bull but was absent at the same site in all the three regions of the castrated bull was subjected for identification of the protein by MALDI-MS. The results revealed that this protein is an interferon-stimulated protein and it could be ISG15/UCRP.     

Response Rates for Patient-Reported Outcomes Using Web-Based Versus Paper Questionnaires: Comparison of Two Invitational Methods in Older Colorectal Cancer Patients

Background

Improving questionnaire response rates is an everlasting issue for research. Today, the Internet can easily be used to collect data quickly. However, collecting data on the Internet can lead to biased samples because not everyone is able to access or use the Internet. The older population, for example, is much less likely to use the Internet. The Patient-Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship (PROFILES) registry offers a platform to collect Web-based and paper questionnaires and to try different measures to improve response rates.

Objective

In this study, our aim was to study the influence of two methods of invitation on the response rate. Our second aim was to examine the preference of questionnaire mode of administration (paper or Web-based) for the older patient in particular.

Methods

To test these two invitational methods, 3406 colorectal cancer patients between ages 18 and 85 years received an invitation containing an access code for the Web-based questionnaire. They could also request a paper questionnaire with an included reply card (paper-optional group). In contrast, 179 randomly selected colorectal cancer patients received a paper questionnaire with the invitation (paper-included group). They could also choose to fill out the Web-based questionnaire with the included access code.

Results

Response rates did not differ between the paper-optional and the paper-included groups (73.14%, 2491/3406 and 74.9%, 134/179, P=.57). In the paper-optional group, online response was significantly higher when compared to the paper-included group (41.23%, 1027/2491 vs 12.7%, 17/134, P<.001). The majority of online respondents responded after the first invitation (95.33%, 979/1027), which was significantly higher than the paper respondents (52.19%, 764/1464, P<.001). Respondents aged 70 years and older chose to fill out a paper questionnaire more often (71.0%, 677/954). In the oldest age group (≥80 years), 18.2% (61/336) of the respondents filled out a Web-based questionnaire.

Conclusions

The lack of difference in response rates between invitation modes implies that researchers can leave out a paper questionnaire at invitation without lowering response rates. It may be preferable not to include a paper questionnaire because more respondents then will fill out a Web-based questionnaire, which will lead to faster available data. However, due to respondent preference, it is not likely that paper questionnaires can be left out completely in the near future.