An Audit of Urology Two-Week Wait Referrals in a Large Teaching Hospital in England

INTRODUCTION

Two week wait referral guidelines have been published by the UK Department of Health for suspected urological cancers. Concordance to these guidelines is variable. Our objectives were to assess the incidence of urological malignancy and the proportion of inappropriate referrals in the two-week wait pathway.

PATIENTS AND METHODS

Retrospective audit of all two-week wait referrals to the urology department over 6 months. Inappropriate referrals were those not satisfying the referral criteria, but referred under the two-week wait system. Detection rates were calculated for each referral criterion based on diagnosis obtained from histology, imaging reports and clinic letters.

RESULTS

Incidence of cancer was 90 of 400 two-week wait referrals (23%). The cancer-detection rate based on reasons for referral ranged from 50 of 122 (41%) for elevated prostate-specific antigen levels to 2 of 56 (4%) for scrotal lumps; 42 (11%) referrals were inappropriate.

CONCLUSIONS

The overall cancer-detection rate is acceptable. Most inappropriate referrals were for long-standing symptoms and non-specific testicular/scrotal symptoms. The testicular cancer detection rate raises questions about the two-week wait guidelines. Providing general practitioners with fast-track scrotal ultrasound and revising the guideline may reduce the disproportionately high number of patients referred with suspected testicular cancer. Other inappropriate referrals are a cause for concern as they add to the workload of the ‘urgent-referral’ pathway.Urological cancers (those involving the prostate, testis, penis, urethra, bladder, ureters and kidneys) accounted for 15.4% of all new cancers in England,¹ and 12.1% of deaths from cancer,² in England and Wales, in 2004.The two-week wait referral guidelines published by the UK Department of Health for suspected urological cancers³ are summarised in 4 There is wide variation among various centres and regions in the concordance of general practitioner (GP) referrals based on these guidelines, and also the rate of cancers detected based on the two-week wait system.

Table 1

Two-week wait referral guidelines for suspected urological cancers

Genetic variation in taste perception: does it have a role in healthy eating?

Taste is often cited as the factor of greatest significance in food choice, and has been described as the body's 'nutritional gatekeeper'. Variation in taste receptor genes can give rise to differential perception of sweet, umami and bitter tastes, whereas less is known about the genetics of sour and salty taste. Over twenty-five bitter taste receptor genes exist, of which TAS2R38 is one of the most studied. This gene is broadly tuned to the perception of the bitter-tasting thiourea compounds, which are found in brassica vegetables and other foods with purported health benefits, such as green tea and soya. Variations in this gene contribute to three thiourea taster groups of people: supertasters, medium tasters and nontasters. Differences in taster status have been linked to body weight, alcoholism, preferences for sugar and fat levels in food and fruit and vegetable preferences. However, genetic predispositions to food preferences may be outweighed by environmental influences, and few studies have examined both. The Tastebuddies study aimed at taking a holistic approach, examining both genetic and environmental factors in children and adults. Taster status, age and gender were the most significant influences in food preferences, whereas genotype was less important. Taster perception was associated with BMI in women; nontasters had a higher mean BMI than medium tasters or supertasters. Nutrient intakes were influenced by both phenotype and genotype for the whole group, and in women, the AVI variation of the TAS2R38 gene was associated with a nutrient intake pattern indicative of healthy eating.     

Effect of intensive versus standard blood pressure control on depression and health-related quality of life in type 2 diabetes: the ACCORD trial

OBJECTIVE

We tested the hypothesis that intensive (systolic blood pressure [SBP] <120 mmHg) rather than standard (SBP 130–139 mmHg) blood pressure (BP) control improves health-related quality of life (HRQL) in those with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Subjects were 1,028 ACCORD (Action to Control Cardiovascular Risk in Diabetes) BP trial HRQL substudy participants who completed baseline and one or more 12-, 36-, or 48-month HRQL evaluations. Multivariable linear regression assessed impact of BP treatment assignment on change in HRQL.

RESULTS

Over 4.0 years of follow-up, no significant differences occurred in five of six HRQL measures. Those assigned to intensive (vs. standard) BP control had statistically significant worsening of the Medical Outcomes Study 36-item short-form health survey (SF36) physical component scores (−0.8 vs. −0.2; P = 0.02), but magnitude of change was not clinically significant. Findings persisted across all prespecified subgroups.

CONCLUSIONS

Intensive BP control in the ACCORD trial did not have a clinically significant impact, either positive or negative, on depression or patient-reported HRQL.In those with type 2 diabetes (T2DM), adequate blood pressure (BP) control may enhance control of hypertension (HT)-related symptoms and reduce the risk of major vascular events that impair health-related quality of life (HRQL) (1,2). However, the net impact of BP treatment on HRQL in patients with T2DM is determined by the balance of treatment burden, hypotension-related adverse events, and BP medication side effects on the one hand and potential reductions of cardiovascular disease (CVD) and microvascular events on the other (3).In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, intensive BP control did not reduce the main prespecified, composite macrovascular outcome, or reduce mortality or myocardial infarctions, although intensive BP treatment did reduce the rate of strokes (4,5). In light of mixed clinical results, the impact of BP interventions on HRQL may inform the selection of optimal BP targets by clinicians and patients.