Douglas G. Tincello

Effect of delays in primary care referral on survival of women with epithelial ovarian cancer: retrospective audit

Abstract Objective: To examine referral pathways from primary care for patients with epithelial ovarian cancer and to identify factors related to survival at 18 months. Design: Retrospective review of patient notes. Setting: General practices and receiving hospitals within Mersey region. Subjects: 135 patients with epithelial ovarian cancer identified from an audit in the Mersey area between 1992 and 1994. Main outcome measures: Delays between onset of symptoms and treatment attributable to patient, general practitioner, and hospital. Results: 105 (78%) women first presented to their general practitioner within four weeks of the onset of symptoms. 99 (73%) women were referred to hospital by their general practitioners within four weeks of presentation, and 95 (70%) were seen in hospital within two weeks of referral. Multivariate analysis with survival as the dependent variable identified age (odds ratio 0.96, 95% confidence interval 0.93 to 0.99) cancer stage III or more (0.15, 0.05 to 0.43), and non-specific symptoms (0.36, 0.14 to 0.89) as significant variables. Conclusion: Most patients attended their general practitioner within four weeks and were referred within two weeks. No evidence was found that delays in referral or diagnosis adversely affected survival at 18 months. Stage of disease at surgery was the most important adverse factor. An effective screening programme is the most likely method to improve survival. What is already known on this topic Epithelial ovarian cancer is the most common gynaecological cancer in the United Kingdom 75% of patients present with advanced incurable disease, and five year survival is 30% The Department of Health recommends that everyone suspected of having ovarian cancer should be seen within two weeks of referral by their general practitioner What this study adds 78% of patients have had symptoms for less than 4 weeks when they present to general practice and are referred to hospital within four weeks of presentation 70% of patients are seen in hospital within two weeks of the referral Delay by patients and general practitioners does not affect survival beyond 18 months

Computerised analysis of fetal heart rate recordings in maternal type I diabetes mellitus

Objective 1. To study computerised cardiotocograph parameters from women with type I diabetes; 2. to examine the significance of observed differences from the expected normal values.

Antenatal screening for postpartum urinary incontinence in nulliparous women: a pilot study

UNLABELLED Antenatal screening for postpartum urinary incontinence in nulliparous women: a pilot study. OBJECTIVE To examine the utility of joint mobility scoring (JMS) as a screening test for postpartum urinary incontinence. STUDY DESIGN A prospective cohort study in a teaching hospital involving 150 nulliparous women. JMS was calculated. The incidence of incontinence and pad use was recorded. Univariate and multiple logistic regression analyses were used to identify factors independently associated with incontinence. RESULTS Hundred and three women completed the study. 43.7% of subjects were incontinent antenatally and 4.9% remained incontinent at the study end. JMS was normally distributed and similar in continent and incontinent women. Elbow hyperextension (>180 degrees ) was associated with postnatal incontinence (odds ratio 10.6; 95% CI 1.24, 90.8). Elbow hyperextension had a sensitivity of 80%, specificity of 75%, positive predictive value of 14%, and negative predictive value of 99% for postnatal incontinence. CONCLUSION Joint hypermobility score is not a useful screening test. Elbow hyperextension is associated with an increased likelihood of postnatal urinary incontinence. It is unclear whether this test has clinical utility outside a research setting.

How doctors record breaking bad news in ovarian cancer

Revealing the diagnosis of cancer to patients is a key event in their cancer journey. At present, there are no minimal legal recommendations for documenting such consultations. We reviewed the Hospital records of 359 patients with epithelial ovarian cancer in the Mersey Area between 1992 and 1994. We identified the following factors: age, hospital, postcode, surgeon, stage of disease and survival. These were compared to information recorded at the time of the interview such as person present, descriptive words used, prognosis, further treatment and emotional response. In 11.6%, there was no information recorded in the notes. The diagnosis was recorded in 304 (94.7%), prognosis in 66 (20.6%) and collusion with relatives in 33 (10.3%). A total of 42 separate words/phrases were identified relating to diagnosis; cancer was recorded in 60 (19.6%). Collusion was three times as common in the patients over 65 years (17.9 vs 5.7%, P=0.001). There was a reduction in the number of diagnostic words recorded in the patients over 65 years (90.3 vs 98.3%, P=0.002) and by type of surgeon (P=0.001). Information was often poorly recorded in the notes. We have shown that the quality of information varies according to patient age, surgeon and specialty.

Computerised antenatal fetal heart rate recordings between 24 and 28 weeks of gestation

Objective To assess computerised fetal heart rate recordings between 24 and 28 weeks of gestation for gestation related differences.

A urinary control device for management of female stress incontinence.

Objective To examine the performance of a silicon urinary control device for nonsurgical management of women with genuine stress incontinence. Methods A 3-month prospective study involved 41 women with genuine stress incontinence. They completed urinary diaries of voiding, incontinence, and severity of incontinence on a 4-point scale over a week. Subjects were taught how to apply the device and used it as required from the second week. Visual analogue scales were used to record aspects of use (such as acceptability, comfort, and ease of application), and 2-hour perineal pad tests were completed at recruitment, after 2 weeks, and after 3 months. Data were compared by Mann-Whitney U test, or Wilcoxon test. Results Ten women (24.4%) declined to participate and six (14.6%) withdrew before 2 weeks. Ten (24.4%) failed to attend for 2-week follow-up and 11 (26.8%) did not continue for 3 months. Two (4.9%) did not attend 3-month follow-up. Only two women (4.9%) completed the study. There was no difference in pad test results or in results from voiding diaries. Conclusion The urinary incontinence device had low acceptability and was ineffective, and we cannot recommend it for nonsurgical management of genuine stress incontinence.

Leukocyte populations in interstitial cystitis and idiopathic reduced bladder storage

OBJECTIVES Mast cells and leukocyte populations in bladder biopsies from women with interstitial cystitis (IC) or idiopathic reduced bladder storage (sensory urgency [SU]) were compared to determine whether any evidence of a common etiology between these conditions could be found. METHODS Biopsies from 40 patients (9 meeting the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases criteria [IC] and 31 who did not [SU]) and 20 controls (having colposuspension for stress incontinence) were stained with monoclonal antibodies against leukocyte antigens and mast cell tryptase. The median cell counts from 10 high power fields were calculated and compared between cases and controls. The clinical and urodynamic data were also compared. RESULTS Nocturia (odds ratio 26.7; 95% confidence interval 3.3 to 245.5) and bladder pain (odds ratio 18.5; 95% confidence interval 1.8 to 193.1) were associated with significant odds ratios for disease (IC or SU compared with controls) in logistic regression analysis. Patients with IC were significantly older than those with SU (P = 0.05). Leukocyte populations showed only increased CD20+ cells in patients with IC compared with the others (P = 0.03). CONCLUSIONS The analysis of the clinical, urodynamic, and cystoscopic data showed no differences between patients with IC and those with SU, except for age. Nocturia or bladder pain discriminated between patients and controls. The lymphocytic infiltrate in SU is similar to that seen in IC but with fewer CD20+ cells. These data support the work of others and may indicate that SU has a common etiology with IC.

Oxybutynin for detrusor instability with adjuvant salivary stimulant pastilles to improve compliance : results of a multicentre, randomized controlled trial

Objective To test the hypothesis that compliance with oxybutynin would be improved if the severity of dry mouth could be reduced, thus leading to improved urinary symptom response and improved outcome, in a randomized, controlled trial of oxybutynin with or without salivary stimulant pastilles in patients with detrusor instability.

Oxybutynin for detrusor instability with adjuvant salivary stimulant pastilles to improve compliance: results of a multicentre, randomized controlled trial

Objective To test the hypothesis that compliance with oxybutynin would be improved if the severity of dry mouth could be reduced, thus leading to improved urinary symptom response and improved outcome, in a randomized, controlled trial of oxybutynin with or without salivary stimulant pastilles in patients with detrusor instability.

Reduced schedule of antenatal visits. Effect of fewer visits on postnatal depression is important.

EDITOR,—Jim Sikorski and colleagues have conducted a large and detailed trial of the benefits and problems associated with different patterns of antenatal care.1 Such studies, examining outcomes such as satisfaction with care, anxieties about the health of the fetus, and the ability of new parents to cope with their baby, are essential to allow proper evaluation of the recommendations in Changing Childbirth, the report of an expert maternity group.2 The authors found that women in …