CANCER REFERRALS: DO FAST TRACK REFERRALS WORK???

BMJ 2007;335:267-268 (11 August)
Editorials
Fast track referral for cancer
Has not improved patient outcomes in the UK
BY: Moyez Jiwa, professor of primary care, Christobel Saunders, professor of surgical oncology

The current cancer referral policy in the UK—whereby patients with a given set of symptoms are seen within two weeks—results in more patients who have cancer being seen on routine waiting lists than on the fast track list. This means diagnosis is delayed even further.

Introduction of the two week standard clinics has not improved the outcomes for patients in some of the commonest cancers.

Many factors affect the decision to refer for an expert opinion, including a patient’s help seeking behaviour, doctor-patient communication, eliciting and interpreting signs and symptoms, applying evidence to decision making, negotiation with the patient about the need for and most appropriate route of referral, and conveying the information in sufficient detail to allow the patient to be fully informed about the need for urgency or otherwise.

It has been calculated that if the practitioner successfully negotiates each of the above stages on 80% of occasions then only a small percentage of decisions will be evidence based.

A substantial proportion of patients with common cancers present as emergencies with advanced disease; in the case of colorectal cancer this has been estimated to be as high as 20%.

Furthermore, given that cancer is an uncommon diagnosis in general practice, practitioners are unlikely in most cases to opt to investigate symptomatic patients.

In practice, however, doctors will act on the basis of personal experience, respected local opinion, and anecdotal evidence rather than on high quality published research .

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ANAESTHETISTS GUIDELINES FOR MANAGING VERY OBESE PATIENTS

BMJ 2007;335:275 (11 August).

Anaesthetists get new guidelines for morbidly obese patients
BY: Toby Reynolds

The rising number of morbidly obese people in the UK population has prompted anaesthetists to write new guidelines for managing these higher risk patients, emphasising the need for training and suitable equipment.

In England nearly 3% of women and 1% of men are morbidly obese (with a body mass index (BMI) of >40), and well over a fifth of the population are obese (BMI >30).
We do know that these patients suffer a higher incidence of anaesthetic complications, but we don’t have hard data to quantify this.

Every major hospital is likely to encounter patients weighing more than 150 kg.

Morbidly obese patients have a greater risk of developing deep vein thrombosis, wound infection, and respiratory complications. They are also more likely to need intensive care after an operation.

In such patients intubation is often more difficult, low oxygen saturation during general anaesthesia is more common, and regional anaesthesia is harder where landmarks are obscured.

Staff were also at risk, highlighting back pain as a potential consequence of unsafe lifting.

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GETTING IT WRONG

One of the quotes of the week in August 2007 was:
“Getting it wrong, very wrong, is part of the process.”

This could be about anything medical basically, so if you want to find out what this author was on about, you have to go and look for yourself, as I couldn’t find it that quickly. BMJ 11.08.07, volume 335, in Letters.

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EU POSTPONES RESTRICTION TO USE MRI SCANS

EU postponed threathened restriction of using MRI scanners

Rory Watson, BMJ 2007;335:844-845

Medical specialists, patients’ groups, and European parliamentarians launched a campaign last week to ensure that new EU health and safety legislation will not restrict the use of magnetic resonance imaging (MRI).

The Alliance for MRI fears that new Europe-wide measures, which are
designed to protect employees , from short term exposure to electromagnetic fields, will inadvertently make it harder to use equipment to diagnose and treat illnesses from cancer and heart attacks to strokes and brain tumours.

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PREDICTING MENTAL ILLNESS IN SOLDIERS PART THREE

BMJ 2006;333:1123 (25 November).
Letters
Predicting mental illness in soldiers
Pre-deployment screening for vulnerability to post- traumatic stress disorder
By: Ferhal Utku, Ken Checinski, senior lecturer in addictive behaviour

That post-traumatic stress disorder (and other mental disorders) are difficult to predict, with the implication that ex-service personnel are likely to present to civilian mental health services with such conditions.

Post-trauma debriefing is possibly harmful, so service personnel need vigilant monitoring for mental disorder after the fact.

This is particularly important when they leave the protective group environment provided by military life.

PS: I Know these are American soldiers but it illustrates very well how dangerous and stressfull life in a war zone can be.

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ENDOMETRIOSIS AND ITS DELAY IN DIAGNOSIS (IN GENERAL PRACTICE)

Management of endometriosis in general practice: the pathway to diagnosis By: Pugsley, Zoë

BJGP, Volume 57, Number 539, June 2007 , pp. 470-476(7).

Background: The prevalence of endometriosis is estimated to be around 10%. Diagnosis is through visualisation of the lesions, mostly via laparoscopy.

Ultrasound was frequently requested by GPs, but was helpful in diagnosing endometriosis in only 10.6% of women who underwent a scan.

Thirty-nine per cent of women were referred to gynaecologists two or more times BEFORE a positive diagnosis was made.

The median time from first presentation with symptoms to diagnosis was 9.0 years. NINE years

Read more about the MANAGEMENT of ENDOMETRIOSIS here.

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DOPING IN SPORT

BMJ 2007;335:618 (22 September).

Doping in sport—a warning from history.

East German athletes who were doped to win gold medals in 1976 Olympics now struggle with chronic health problems.

Sport is tough, mean, and uncompromising.

The German Democratic Republic looked coldly at what was required and did it. Potential medal winners were selected at an early age for sports school, trained, and prepared systematically.

Athletes were given oral anabolic steroids until the time of competition but were injected with testosterone during competition as it was then undetectable.

It is the involuntary and systematic abuse of underage athletes that hits hardest. These athletes, recruited from as young as 10 years old, did not know what medication they were taking and were discouraged from asking.

The sports doctors had signed a confidentiality agreement, monitored by the East German secret police, the Stasi. They made no protest, and 70 of them were later convicted of illegal doping.

We were left wondering where those doctors are now and how they feel about their role.

Perhaps it is a little unfair to judge history by current standards. But doping remains a part of sport.

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ANTIDEPRESSANTS IN CHILDREN AND ADOLESCENTS

BMJ 2007;335:607 (22 September).

BMJ updates

Second generation antidepressants should remain an option for children and adolescents with depression or anxiety.

Are second generation antidepressants associated with suicidal ideation or suicide attempts in children and adolescents with depression or anxiety?

Answer Yes, but the risk is small and statistically non-significant. In general, the benefits of these agents outweigh the risks.

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POLLUTION CAUSES HEART PROBLEMS

BMJ 2007;335:587 (22 September).

Diesel pollution promotes myocardial ischaemia.

It is already clear that air pollution is associated with an increased risk of cardiovascular events such as heart attack, arrythmias, and even death. To investigate why, researchers from Europe did a controlled experiment on 20 men with stable coronary heart disease.

The men exercised on a bicycle ergometer in clean air and in air containing diesel fumes at a concentration found in heavy traffic. As expected, the men had asymptomatic myocardial ischaemia during the exercise periods. But it was significantly worse when they were exposed to diesel.

Advise: don’t exercise in heavy traffic, surprise surprise.

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FERTILITY

THE MOST IMPORTANT DETERMINANT OF A COUPLE’S FERTILITY IS THE WOMAN’S AGE.

BMJ 22.9.07 quote of the week.

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