Biomedical subjects
Publications and source records attributed to A M Pollock.
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This study describes the management of colorectal cancer, diagnosed in 1988, of residents in three South Thames Districts. Of the 328 cases identified as having being diagnosed in 1988, case notes were retrieved on 263 (80%) including 62 registered by death certificate only. There were 159 cases (61%) of colon cancer and 104 cases (39%) of rectal cancer. Of these, 172 cases (68%) were admitted electively and 90 (32%) as emergencies. Patients subsequently diagnosed with colon cancer had a relative risk of being admitted through emergency (relative to rectal cancer patients) of 1.39 (95% C.I.: 1.16, 1.67). Elective admissions varied significantly by district of residence (P < 0.0001) ranging from 36-65% for colon cancers and from 63-92% for rectal cancers across the three districts. Dukes' stage was recorded in only 143 (54%) sets of case notes, with significant variation by district of residence in the proportion of elective patients for whom a Dukes' stage was indicated (P < 0.01). Two-hundred and thirty-six (90%) cases received treatment. Of the treated cases, 233 patients received surgery with 29 cases of colon cancer (18%) and 32 cases of rectal cancer (31%) receiving adjuvant therapy. The proportions of anterior resection, AP resection and colostomies given, varied by district. Patients presenting for elective surgery were more likely to be treated by a consultant than patients presenting on emergency: the relative risks were 2.58 (95% C.I.: 1.74, 3.82) for colon cancer patients and 4.93 (95% C.I.: 2.20, 11.06) for rectal cancer patients. In 44 (26%) colon cancer cases and 21 (22%) rectal cancer cases it was explicitly stated that the tumour had not been fully resected. For colon tumours the five year relative survival rates were 35% (95% C.I.: 21%, 50%), 52% (95% C.I.: 34%, 70%), and 14% (95% C.I.: -2%, 30%) in districts A, B and C respectively. The corresponding figures for rectal tumours were 45% (95% C.I.: 27%, 64%), 62% (95% C.I.: 41%, 83%) and 24% (95% C.I.: -1%, 50%). There were wide variations in the representation, management of and survival from colorectal cancers across the three districts. Differences were significant at the level of district of residence, mode of presentation and surgical grade. More assiduous recording of Dukes' stage is imperative if consensus is to be achieved on effective management. Further work is also warranted on district differences in diagnostic and referral protocols.
The objective of this study was to review the processes by which individuals' needs are being assessed and related to local eligibility criteria under the new arrangements for community care. An audit of the assessment process, definitions and measurement of need against Department of Health guidance was undertaken across the eight social services departments in South Thames (West) region. The results showed there is no standard approach to assessing needs: all social services have developed different assessment processes and different criteria for identifying needs. None use standardised measures of dependency such as the Barthel Index. Scales for measuring dependency have been developed locally so are not comparable between local authorities. Whilst local authorities have published eligibility criteria, in the main, these are purely descriptive accounts with considerable variation in practice in how local authorities are determining eligibility for services. In many authorities there remains ambiguity as to whether published eligibility criteria relate to eligibility for assessment or eligibility for services. Only one authority had attempted to quantify population needs and service provision in advance of setting its eligibility criteria. In conclusion, information collected on individuals cannot be aggregated for use in population-based planning, nor for monitoring purposes in any of the eight local authorities. National guidance is required on definitions of need and eligibility criteria. There is a need for a standardised core community data set, which embraces both health and social care.
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The Association of Metropolitan Authorities has recently proposed that responsibility for the NHS should pass from health authorities to local authorities. One of the fiercest debates at the outset of the NHS was whether the hospitals should be run by local authorities. In the end the minister for health, Aneurin Bevan, decided against local democracy and in favour of a national health service. His arguments included the fact that equality of treatment could not be guaranteed if facilities varied with local finances and that even the largest authorities were not big enough to pool risks and expertise. All these arguments still apply today, and the recent changes in community care provide an insight into how a market model of local authority control might work. The changes have been accompanied by a shift from public to private sector provision and the introduction of charges for services that the NHS once provided free. As important, the willingness and ability of local authorities to raise extra revenue from local taxes and charges affect the service they can provide, so leading to inequalities of provision. Local authorities have yet to make the case that they can preserve the fundamental principles and benefits of the NHS, including its reliance on central taxation and unified funding formulas.
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This paper describes the results of a study set up to investigate factors associated with the high proportions of 'death certificate only' registrations (DCOs) for all cancers registered in south-east England between 1987 and 1989 and to identify those which might be subject to registry intervention. DCOs as a proportion of all registrations (n = 162,131) were analysed by age, sex, district of residence, place of death and survival. DCO registration ratios (standardised for age and sex) were then derived for each of the 56 districts in the Thames Regions. A multiple logistic regression model was generated to estimate the effect of age at diagnosis, tumour survival and patient sex on final source of registration. To minimise the number of dummy variables needed, each of the 56 districts was ranked into quartiles: quartile 1 contained the 14 districts with the lowest age- and sex-standardised ratios for DCO registrations and quartile 4 comprised the 14 districts with the highest DCO ratios. Final source of registration was treated as a binomial trial (case notes or death certificates). The significance of associations was measured using the deviance difference as an approximate chi-square statistic. The effect of each variable on source of registration was estimated as an odds ratio. Interaction terms were also fitted. To estimate the effect of place of death on DCO registrations, a second model was generated for deceased patients only (n = 98,455, adding 'place of death' to the list of explanatory variables already used. A further interaction term was fitted to account for interaction between place of death and district quartile of residence. Around 24% of all patient deaths were registered as DCOs by the Thames Cancer Registry between 1987 and 1989. Of these, 40.9% died in an acute NHS hospital setting, 37.1% died at home, 10.4% died in hospices and 3.4% died in non-NHS hospitals. Increasing age, decreasing survival, district of residence and place of death were positively associated with death certificate registrations. The district effect was sustained in the regression model with significant positive associations shown for DHA quartile of residence. In the deceased group of patients, both district of residence and place of death were independent predictors of DCOs. Death occurring outside the acute NHS hospital setting increased the odds of being a DCO within and across district quartiles. DCOs could be reduced by better case ascertainment in some districts.(ABSTRACT TRUNCATED AT 400 WORDS)
Acute neurotoxicity following the administration of the recommended oral dose of acyclovir (800 mg twice daily) to dialysis-dependent patients is increasingly recognised. This suggests that the recommended dose is too high. Little is known of the pharmacokinetics of oral acyclovir in dialysis patients. We studied 7 patients with oliguric end stage renal failure receiving haemodialysis. Following haemodialysis, each patient received a single 800-mg tablet of acyclovir. Plasma acyclovir levels were monitored over the next 48 h as well as before and after the next routine dialysis. Peak plasma levels were achieved at 3 h (12.54 +/- 1.76 microM, range 8.5-17.5 microM) with the half-life calculated to be 20.2 +/- 4.6 h. Mean plasma level of 6.29 +/- 0.94 microM were within the quoted range to inhibit herpes zoster virus (4-8 microM) at 18 h. Haemodialysis (4-5 h) eliminated 51 +/- 11.5% of the acyclovir which remained at 48 h. Computer modelling of various dose modifications suggests that a loading dose of 400 mg and a maintenance dose of 200 mg twice daily is sufficient to maintain a mean plasma acyclovir level of 6.4 +/- 0.8 microM. A further loading dose (400 mg) after dialysis would raise the residual acyclovir concentration by 6.1 +/- 1.0 microM. Such a dose modification should prevent neurotoxicity, whilst the rapid elimination of acyclovir by a single haemodialysis treatment provides both a diagnostic and therapeutic tool when toxicity is suspected.
BACKGROUND: We had two aims in undertaking this study, as follows: (1) to describe regional and district trends in incidence and treatment for colorectal cancer in South East England from 1982 to 1988; (2) to examine the effect of registration practice and case ascertainment on district variations in incidence and treatment using data on death certificate only (DCO) registrations, mortality and stage. METHODS: We included all cases registered by the Thames cancer registry diagnosed with colon or rectal cancer between 1982 and 1988 and resident in 28 districts in the two South Thames regions. Indirect standardized incidence ratios were calculated for the districts and a alpha 2 test for trend was carried out. RESULTS: In the SE England regional analysis, between 1982 and 1988 there was a significant increase in the incidence of cases of colon and rectal cancer in the over-75s, but treatment rates remained unchanged. Treatment rates fell significantly in the under-65s although incidence rates remained unchanged. Age is a strong predictor of nontreatment. Between 1982 and 1988 the relative risk of not receiving treatment increased for all ages over 65 years. DCO registrations accounted for 22 percent and 15 percent of all colon and rectal cancer cases, respectively, between 1982 and 1988. The proportions rose (between 1982 and 1988) from 10 and 8 percent to 25 and 19 percent in colon and rectal cancer, respectively. DCO registration rates increased over time and in all age groups in South East England for both colon and rectal cancer between 1982 and 1988, but the largest increase was in the over-75s. Thirty-two per cent of colon and 25 per cent of rectal cases were unstaged. Although the proportion of unstaged cases remained constant over time, they were increasingly the result of DCO registrations. Errors in the registry staging data rendered those cases which were staged unusable. In the district analysis, there were significant variations in age-standardized incidence, treatment and DCO registration ratios across the 28 districts for men and women with colon and rectal cancer between 1982 and 1988. DCO registrations show a negative correlation with treatment for both colon and rectal cancer (p < 0.05) and with incidence for only rectal cancer. CONCLUSIONS: We report significant differences in age-standardized incidence and treatment ratios across 28 districts in South East England, some of which, can be accounted for by differences in registration practice. There is a complex relationship between DCO registrations and incidence and treatment for both colon and rectal cancer. DCO registrations are a good proxy for under-ascertainment of incidence in rectal cancer but not colon cancer, and are a good proxy for under-ascertainment of treatment in both colon and rectal cancers. Information from the cancer registry can be used to examine registration and treatment rates across districts. However, if variations are to be adequately explained, meticulous data collection on stage and quality control are essential.
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Conventional solution-phase polymerase chain reaction (PCR) and in situ PCR/PCR in situ hybridization are powerful tools for retrospective analysis of fixed paraffin wax-embedded material. Amplification failure using these techniques is now encountered in some centres using archival fixed tissues. Such 'failures' may not only be due to absent target DNA sequences in the tissues, but may be a direct effect of the type of fixative, fixation time and/or fixation temperature used. The type of nucleic acid extraction procedure applied will also influence amplification results. This is particularly true with in situ PCR/PCR in situ hybridization. To examine these effects in solution-phase PCR, beta-globin gene was amplified in 100 mg pieces of tonsillar tissue fixed in Formal saline, 10% formalin, neutral buffered formaldehyde, Carnoy's Bouin's, buffered formaldehyde sublimate, Zenker's, Helly's and glutaraldehyde at 0 to 4 degrees C, room temperature and 37 degrees C fixation temperatures and for fixation periods of 6, 24, 48 and 72 hours and 1 week. DNA extraction procedures used were simple boiling and 5 days' proteinase K digestion at 37 degrees C. Amplified product was visible primarily yet variably from tissue fixed in neutral buffered formaldehyde and Carnoy's, whereas fixation in mercuric chloride-based fixatives produced consistently negative results. Room temperature and 37 degrees C fixation temperature appeared most conducive to yielding amplifiable DNA template. Fixation times of 24 and 48 hours in neutral buffered formaldehyde and Carnoy's again favoured amplification.(ABSTRACT TRUNCATED AT 250 WORDS)
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This paper describes the effect of including death certificate only (DCO) registrations on 5 year relative survival rates for colorectal cancer in four district health authorities (DHAs) in south-east England. A retrospective case note study was set up to examine all cases of colorectal cancer listed in the Thames Cancer Registry (TCR) as having been diagnosed in 1983 and 1988 and resident in one of four districts, A, B, C and D. A total of 673 sets of cases notes were requested from all hospitals within the four districts, including 150 sets on DCO cases. Of 465 (69%) sets of case notes retrieved, 378 (72.3%) were non-DCO cases. Of these, 14 were excluded from survival analysis because of missing dates of diagnosis or death in the notes. Eighty-seven (58.0%) sets of case notes were retrieved on DCO registrations, of which seven were excluded because no date of diagnosis was available in the notes. Retrieval rates on case note registrations varied by DHA of residence: 73.3% in DHA A, 96.6% in DHA B, 34.5% in DHA C and 79.2% in DHA D. The corresponding figures for DCO registrations were 63.5%, 69.0%, 7.4% and 76.2%. Cumulative relative 5 year survival rates by DHA of residence were calculated first for cases registered from case notes and then for all cases including those registered solely from a death certificate. The total number of cases used in the survival analysis was 444 (18% DCOs). In all four DHAs, 5 year survival decreased with the inclusion of DCO registrations: by 9.1% in district A (from 52.8 to 43.7), by 4.5% in district B (from 59.6 to 55.1), by 4.8% in district C (from 80.0 to 75.2) and by 7.6% in district D (from 31.4 to 23.8). The overall reduction in survival was 8.6%. The exclusion of death certificate only registrations from survival data is an important source of bias. Using TCR data, we compared DCO proportions for colorectal cancer with other sites. DCO proportions were shown to vary by tumour site and survival time. The DCO registration is an important quality measure of ascertainment and follow-up. OPCS should publish DCO proportions by registry area and cancer site. Registries should implement DCO monitoring as part of quality improvement programmes.
AIMS: To investigate the feasibility of using fixed cells with the polymerase chain reaction (PCR) in situ hybridisation and to investigate possible reasons for reaction failure. METHODS: Fixed SiHa and CaSki cells were used in an experimental model of PCR in situ hybridisation for the detection of low and intermediate copy number viral infection in fixed cells. RESULTS: PCR in situ hybridisation was able to detect one to two copies of human papillomavirus (HPV) 16 in SiHa cells, using small fragment amplicons (120 base pairs), confirming the high detection sensitivity and flexibility of the technique. Problems were encountered with localisation of PCR amplified product in CaSki cells (200-300 copies of HPV 16 per cell) owing to diffusion of product post amplification. Overall, 40% of reactions were successful, which confirms the current unreliability of the technique. Within cell preparations, about 50% of cells contained amplified product. CONCLUSION: PCR in situ hybridisation represents the marriage of two revolutionary molecular pathological techniques. However, it is currently unreliable, with reaction failure common. Standardised, dedicated equipment is urgently required if the technique is to achieve universal acceptance. In the future, the technique may be used to detect chromosomal translocations in human tumours and to study cellular gene expression.
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