Tp Griffin

The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review

BACKGROUND Over 37,000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care. AIM To conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer. DESIGN Systematic review. METHOD MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool. RESULTS Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥ 50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding. CONCLUSION The findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.

End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection — case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was £3173 per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

Reducing hospital admissions

Guidance should be evidence based and take a holistic view of patient care

Association between maternal education and objectively measured physical activity and sedentary time in adolescents

Background Investigating socioeconomic variation in physical activity (PA) and sedentary time is important as it may represent a pathway by which socioeconomic position (SEP) leads to ill health. Findings on the association between childrens SEP and objectively assessed PA and/or sedentary time are mixed, and few studies have included international samples. Objective Examine the associations between maternal education and adolescents objectively assessed PA and sedentary time. Methods This is an observational study of 12 770 adolescents (10–18 years) pooled from 10 studies from Europe, Australia, Brazil and the USA. Original PA data were collected between 1997 and 2009. The associations between maternal education and accelerometer variables were examined using robust multivariable regression, adjusted for a priori confounders (ie, body mass index, monitor wear time, season, age and sex) and regression coefficients combined across studies using random effects meta-analyses. Analyses were conducted in March 2014. Results Adolescents of university educated mothers spent more time sedentary (9.5 min/day, p=0.005) and less time in light activity (10 min/day, p<0.001) compared with adolescents of high school educated mothers. Pooled analysis across two studies from Brazil and Portugal (analysed separately because of the different coding of maternal education) showed that children of higher educated mothers (tertiary vs primary/secondary) spent less time in moderate to vigorous PA (MVPA) (6.6 min/day, p=0.001) and in light PA (39.2 min/day: p<0.001), and more time sedentary (45.9 min/day, p<0.001). Conclusions Across a number of international samples, adolescents of mothers with lower education may not be at a disadvantage in terms of overall objectively measured PA.

Dynamics of Discontinuous Systems with Imperfections and Noise

Many physical systems of engineering importance are discontinuous (examples include systems with impacts, freeplay, backlash, gears). The study of deterministic versions of these systems is now well established but these models tend to ignore any imperfections in the system or the effects of noise. In this paper we show how the introduction of imperfections and noise can have a dramatic effect on the systems behaviour. We focus our attention on a much studied simple generic model of discontinuous systems, namely that of the piecewise linear map and its associated ordinary differential equation.

Secondary care data may mislead

Two methodological concerns make it tricky to interpret the findings of Jellema and colleagues’ systematic review of diagnosing colorectal cancer in primary care.1 Firstly, studies from settings other than primary care were included. Any population that has …