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Early detection of colorectal cancer using symptoms and the ColonFlag: case-control and cohort studies
Background: Early detection of colorectal cancer confers substantial prognostic benefit. Most symptoms are non-specific and easily missed. The ColonFlag algorithm identifies risk of undiagnosed colorectal cancer using age, sex and changes in full blood count (FBC) indices. The aim of this study was to investigate whether the ColonFlag detects undiagnosed colorectal cancer prior to the recording of symptoms in general practice. Methods: : We conducted case-control and cohort studies by linking primary care data from the Clinical Practice Research Datalink with colorectal cancer diagnoses from the National Cancer Registry. A ColonFlag score was derived for each FBC. We assessed the prevalence of symptoms at six-monthly intervals prior to index date (diagnosis date for cases, randomly selected date for controls). We then derived odds ratios (ORs) and area under the receiver operating characteristic (AUROC) curve for the ColonFlag, and for symptoms using logistic regression at each interval (primary outcome 18-24 months). Results: : We included 1,893,641 patients, 10,875,556 FBCs and 8,918,037 ColonFlag scores. ColonFlag scores began to increase in cases compared with controls around 3-4 years before diagnosis. The AUROC for a diagnosis 18-24 months following the ColonFlag score was 0.736 (95% CI 0.715-0.759), falling to 0.536 (95% CI 0.523-0.548) with adjustment for age. ORs for individual symptoms became non-significant prior to 12 months before index date, except for abdominal pain (females OR=1.29, p<0.0001 at 12-18 months) and rectal bleeding (females OR=2.09, males OR=1.92, p<0.0001 at 18-24 months). Conclusions: : Symptoms appear relatively late in the colorectal cancer process and are limited for supporting early stage detection. The ColonFlag can discriminate usefully at 18-24 months before diagnosis, suggesting a role for this algorithm in primary care, although some of its discriminatory ability comes from the age variable.
Incidence of rheumatoid arthritis is not related to indicators of socioeconomic deprivation.
ObjectiveTo evaluate the role of socioeconomic factors in susceptibility to rheumatoid arthritis (RA).MethodsA prospective population based register of inflammatory joint disease (NOAR) recruited 687 adults between 1990 and 1992, of whom 50% satisfied ARA criteria for RA at presentation. Using census data, social class specific incidence rates were calculated for both sexes. A correlation analysis was undertaken examining the association between incidence rates and 5 indicators of socioeconomic status.ResultsThere was no trend of increasing incidence with declining social class. None of the 5 indicators examined showed any evidence of association with incidence (rs range 0.0-0.3).ConclusionIn contrast to the data on factors influencing outcome in established RA, the socioeconomic status variables examined did not explain susceptibility patterns in the population studied.
Ethnicity and paediatric healthcare utilisation: Improving the quality of quantitative research : Claire Zhang
Abstract Background The COVID-19 pandemic highlighted the stark health inequities affecting minority ethnic populations in Europe. However, research on ethnic inequities and healthcare utilisation in children has seldom entered the policy discourse. A scoping review was conducted in the UK, summarising and appraising the quantitative evidence on ethnic differences (unequal) and inequities (unequal and unfair or disproportionate to healthcare needs) in paediatric healthcare utilisation. Methods Embase, Medline and grey literature sources were searched for studies published 2001-2021. Studies that found differences and inequities were mapped by ethnic group and healthcare utilisation outcome. They were appraised using the National Institute for Health and Care Excellence appraisal checklists. The distribution of studies was described across various methodological parameters. Results Of the 61 included studies, most found evidence of ethnic variations in healthcare utilisation (n = 54, 89%). Less than half attempted to distinguish between ethnic differences and inequities (n = 27, 44%). Studies were concentrated on primary and preventive care and hospitalisation, with minimal evidence on emergency and outpatient care. The quality of studies was often limited by a lack of theory underpinning analytical decisions, resulting in conflation of difference and inequity, and heterogeneity in ethnic classification. The majority of studies examined children's ethnicity but overlooked parent/caregiver ethnicity, and also didn't investigate patterns across age, year or location. Conclusions To improve the validity, generalisability and comparability of research on ethnicity and paediatric healthcare utilisation, findings from this scoping review were used to develop recommendations for future research. These lessons could be applied more broadly across the European context to improve evidence generation and evidence-based policy-making to reduce inequities in healthcare. Key messages • Quantitative studies of ethnicity and paediatric healthcare utilisation in the UK lack the use of sound theoretical frameworks, and often do not distinguish between ethnic differences and inequities. • The quality of future studies can be improved with greater attention to how ethnicity is classified and analysed, alongside specific considerations for examining healthcare utilisation in children.
Low prevalence of rheumatoid arthritis in the urbanized Chinese of Hong Kong.
ObjectiveTo establish the prevalence of rheumatoid arthritis (RA) in the urbanized Chinese of Hong Kong.Methods2000 adults in 2 housing blocks were screened using a structured interview. Those who screened positive had an examination, rheumatoid factor analysis and radiographs taken. Subjects were classified using the Rome, New York and 1987 ACR criteria (modified and unmodified) for RA.ResultsThe prevalence of RA, using the modified 1987 ACR criteria, was 0.35%. This is significantly lower than published data for European Caucasians (standardized morbidity ratio = 0.27; 95% CI 0.09-0.63).ConclusionRA is rare in urbanized Chinese.
Do new cases of rheumatoid arthritis cluster in time or in space?
ObjectivesTo examine for evidence of clustering in time, in space and in space/time in the occurrence of rheumatoid arthritis (RA).SettingA population-based incidence register of RA in the East Anglian region of the UK: population size 413,000.SubjectsIn all 687 new cases of inflammatory joint disease registered between 1 January 1990 and 31 December 1994 were studied. Population data were obtained from postcode areas by age and sex.AnalysisTime trend analysis was conducted over the first 36 months and observed and expected distributions compared. Spatial clustering was based on comparison of observed distribution using map grid references to random expectation based on simulation. A similar procedure was undertaken for time/space clustering.ResultsThere was no evidence of a time trend. There was only modest evidence of spatial clustering with non-random distribution observed in one area but there was no evidence of time/space clustering.ConclusionAlthough a viral aetiology is the strongest candidate for RA, no evidence of a localized event in time was associated with disease development in this population.
Oral contraceptives and rheumatoid arthritis: results from a primary care-based incident case-control study.
ObjectiveThe possibility that oral contraceptives offer a protective effect against the development of rheumatoid arthritis is still contentious. Of the 17 studies investigating this association, 11 have found a protective effect, and 6 have not. These differences are probably attributable to either selection or information biases in a subset of studies, although the exact reason is unknown. To overcome the methodological problems inherent in the design of previous studies, we have conducted a population-based case-control study.MethodsWomen who were incident cases of inflammatory polyarthritis, defined as swelling of at least two joint areas lasting at least 4 weeks, were recruited directly from primary care and compared with age-matched women from the same population.ResultsCases and controls reported a similar level of "ever use" of oral contraceptives, adjusted odds ratio = 0.88 (95% confidence interval, 0.47, 1.64). The cases were, however, less likely to report using oral contraceptives at the time of onset, adjusted odds ratio = 0.22 (95% confidence interval, 0.06, 0.85). Similar results were observed for cases who satisfied the criteria for rheumatoid arthritis and cases who did not.ConclusionThese results indicate that only current oral contraceptive use protects against the development of inflammatory polyarthritis.
Changing patterns of rheumatology manpower and practice in the UK in the 1990s.
This paper reports the results of two surveys of all UK rheumatologists conducted in 1993 and 1995. Results are presented by regional health authority and by country. During the 2 yr, there has been a rise in the number of consultants, but a fall in the proportion doing rheumatology combined with rehabilitation. Consultants are working harder-doing more clinics and seeing more patients. Regional disparities in service provision persist, but are slowly diminishing. On the whole, the south of the country is better provided with consultants, but has fewer in-patient facilities, while the reverse is true in the north.
Negotiating un/sanitary citizenship: the reception of UK government COVID-19 public health messaging by racialised people highly exposed to infection
Governments across the world differently invoked citizen responsibility for responding to the risk of COVID-19 infection. Approaches which focused on changing social practices served to reinforce distinctions between ‘sanitary’ and ‘unsanitary’ citizenship. This paper examines citizens’ responses to public health policy messaging, exploring as a case study the reception of UK Government messaging about responsible behaviour during the first two years of the COVID-19 pandemic. We examine the public responses to such messaging from narrative interviews with 43 people who became ill with COVID-19. These interviews were with people who identified as members of the minoritised religious and racialised groups, who were most heavily burdened by the impact of COVID-19. Interviewees challenged assumptions that they were ‘irresponsible’ for having caught COVID-19, and instead directed attention towards the ways in which pandemic guidance was unworkable. Some actively critiqued government messaging, questioning the problematic racialisation of pandemic messaging and challenging individual responsibilisation for the management of the pandemic. Through this analysis we demonstrate the active role of citizens in enacting, and at times resisting, health policy.
How women living with HIV in the UK manage infant-feeding decisions and vertical transmission risk – a qualitative study
Background: The World Health Organization (WHO) recommends that women with HIV breastfeed for a minimum of one year. In contrast, across high-income countries, HIV and infant-feeding guidelines recommend exclusive formula feeding if parents want to avoid all risk of postpartum transmission. However, recently these guidelines (including in the United Kingdom (UK)) increasingly state that individuals with HIV should be supported to breast/chest feed if they meet certain criteria; such as an undetectable maternal HIV viral load and consent to additional clinical monitoring. Between 600 and 800 pregnancies are reported annually in women with HIV in the UK, with low rates of vertical transmission (0.22%). Informed infant-feeding decision-making requires clinical support. Currently, little research addresses how individuals with HIV in high-income countries navigate infant-feeding decisions with their clinical teams and familial and social networks, and the resources needed to reach an informed decision. Methods: Semi-structured remote interviews were conducted between April 2021 – January 2022 with UK-based individuals with a confirmed HIV diagnosis who were pregnant or one-year postpartum. Using purposive sampling, pregnant and postpartum participants were recruited through NHS HIV clinics, community-based organisations and snowballing. Data were analysed thematically and organised using NVivo 12. Results: Of the 36 cisgender women interviewed, 28 were postpartum. The majority were of Black African descent (n = 22) and born outside the UK. The majority of postpartum women had chosen to formula feed. Women’s decision-making regarding infant-feeding was determined by (1) information and support; (2) practicalities of implementing medical guidance; (3) social implications of infant-feeding decisions. Conclusion: The evolution of UK HIV and infant-feeding guidelines are not reflected in the experiences of women living with HIV. Clinicians’ emphasis on reducing the risk of vertical transmission, without adequately considering personal, social and financial concerns, prevents women from making fully informed infant-feeding decisions. For some, seeking advice beyond their immediate clinical team was key to feeling empowered in their decision. The significant informational and support need among women with HIV around their infant-feeding options must be addressed. Furthermore, training for and communication by healthcare professionals supporting women with HIV is essential if women are to make fully informed decisions.
A manifesto for improving cancer detection: four key considerations when implementing innovations across the interface of primary and secondary care
Improving cancer outcomes through innovative cancer detection initiatives in primary care is an international policy priority. There are unique implementation challenges to the roll-out and scale-up of different innovations, requiring synchronisation between national policy levers and local implementation strategies. We draw on implementation science to highlight key considerations when seeking to sustainably embed cancer detection initiatives within health systems and clinical practice. Points of action include considering the implications of change on the current configuration of responsibility for detecting cancer; investing in understanding how to adapt systems to support innovations; developing strategies to address inequity when planning innovation implementation; and anticipating and making efforts to mitigate the unintended consequences of innovation. We draw on examples of contemporary cancer detection issues to illustrate how to apply these recommendations to practice.
Global Blood Pressure Screening During and After Pregnancy: May Measurement Month 2019.
BACKGROUND: Hypertensive disorders of pregnancy are associated with high maternal and fetal morbidity and mortality. There are limited global data on the characteristics of women during and after pregnancy hypertension. METHODS: May Measurement Month is a global campaign to raise awareness of the importance of blood pressure. Adults (≥18 years) recruited through opportunistic sampling during May 2019 had blood pressure measured and comorbidities and lifestyle data collected. This secondary analysis included 16 519 pregnant women and 529 172 nonpregnant women (16 457 with previous raised blood pressure in pregnancy) from 64 countries. RESULTS: Almost half of the pregnant women (56.7%) reported not having had their blood pressure measured in the past year, and 14.3% (95% CI, 12.1-16.6) had hypertension (blood pressure ≥140/90 mm Hg or taking antihypertensive medication). Diabetes was self-reported in 7.6% (5.9-9.3) of pregnant women with hypertension and 2.8% (1.9-3.6) of pregnant women without hypertension. In nonpregnant women with and without a history of pregnancy hypertension, age-standardized proportions with current hypertension were 53.2% (50.8-55.7) versus 33.3% (29.3-37.3); with diabetes were 14.4% (11.8-17.0) versus 8.5% (6.3-10.9); and with body mass index ≥30 kg/m2 were 28.4% (23.5-33.3) versus 16.6% (13.0-20.2). CONCLUSIONS: Hypertension in pregnancy was common in this global sample but many cases had not previously been identified. There was a clustering of cardiovascular risk factors in both pregnant women with current hypertension and previously raised blood pressure in pregnancy. This work highlights the importance of screening pregnant women for hypertension, which remains a challenge in large parts of the world.
Errors associated with co-names of medicines: The nomenclature of combination medicinal products.
In comparison to the efforts required to bring a new drug or formulation to the clinic, bestowing a name on a medicine is relatively simple. However, if the name we choose causes confusion-by making its contents ambiguous or if it is too alike another drug-it can precipitate clinical errors. This prompted the World Health Organization to set up the International Nonproprietary Naming Committee in the 1970s to select unambiguous names for drugs. Unfortunately, multidrug products-which are becoming increasingly popular-do not fall under the remit of conventional International Non-proprietary Nomenclature. We have identified 26 combination formulations that have been historically named with the co-drug format in the United Kingdom. Most of them have also been prescribed in the United Kingdom in the past year, and although several of them are not prescribed very often, 11 were prescribed more than 2000 times. In this paper, we have explored the literature to identify prescribing errors with co-drug products and found several idiosyncrasies that have caused drug errors in the past. We advocate for a standard nomenclature (state the international nonproprietary name [INN] of each component followed by dose information in the x + y format) for these products on the box and in prescribing resources. We hope that this will enhance clarity and safety during prescribing and administration, particularly for high-volume drugs like paracetamol + codeine (co-codamol), amoxicillin + clavulanic acid (co-amoxiclav) and trimethoprim + sulfamethoxazole (co-trimoxazole).
