Privacy and dignity in a hospice environment-the development of a clinical audit.

A clinical audit was developed and conducted at St Gemma's Hospice, Leeds, to provide evidence of the standard of privacy and dignity afforded to patients in the wards and Day Hospice. It involved setting standards from key documents and including patients, carers, and staff in developing questionnaires. The questionnaires were administered to 30 patients and 130 members of the multidisciplinary team. The response rates were 91% (patients) and 78% (staff). Evaluation of the questionnaires showed that 70% of patients rated their satisfaction with privacy and dignity as 'excellent', with the remaining 30% rating it 'very good'. For the most part, the ratings of staff and patients were in agreement and indicated achievement of the expected standard. However, some areas of concern were identified, including providing opportunity for hand washing prior to meals, closer monitoring of visitor numbers, avoiding interruption to staff, and maintaining privacy during conversations with staff. Disseminating the results of the audit resulted in some important discussions in the clinical teams and the formulation of an action plan to address the concerns.

A prospective study of the incidence, prevalence and mortality of multiple sclerosis in Leeds.

OBJECTIVE: To establish the prospective incidence of multiple sclerosis and mortality rates of people with multiple sclerosis in Leeds Health Authority and an updated prevalence of multiple sclerosis on 31 October 1999. METHODS: A population based prevalence register established on 30 April 1996 was maintained by prospectively registering all new cases of multiple sclerosis, flagging all cases with the National Health Service Central Register for notification of deaths and by registering all new clinical events. General practitioners notified patients with multiple sclerosis moving into or out of the area. RESULTS: 136 incident cases were prospectively registered from 30 April 1996 living in Leeds Health Authority (with an estimated resident population of 728,840). 57 deaths were notified. 792 people with multiple sclerosis were identified living in Leeds on 31 October 1999. The mean annual incidence rate for the three-year period 1996-1998 was 6.1/10(5) (95% CI: 5.1-7.2). The sex ratio of incident cases was 2.3 to 1 women to men. On 31 October 1999 the prevalence of multiple sclerosis in the Leeds Health Authority was 108.7/10(5) (95% CI: 101.2-116.5). This compares with a prevalence of 97.3/10(5) (95% CI: 90.3-104.7) on 30 April 1996. The prevalence of definite and probable multiple sclerosis was 93.3/10(5) (95% CI: 86.4-100.6) and of suspected multiple sclerosis was 15.4/10(5) (95% CI 12.7-18.5). Crude annual mortality rates of people with multiple sclerosis for 1997 and 1998 were 1.9/10(5) (95% CI: 1.1 to 3.2) and 3.2/10(5) (95% CI: 2.0 to 4.7). Multiple sclerosis was noted as the underlying cause of death in 8 (14%) cases. CONCLUSION: The incidence of multiple sclerosis in the Leeds Health Authority is similar to that in the south of the United Kingdom. The difference in successive prevalence figures is less than that published in other serial studies. Multiple sclerosis was notified as the underlying cause of death in a minority of deaths in people with multiple sclerosis.

Serum 25-hydroxyvitamin D3 levels are associated with breslow thickness at presentation and survival from melanoma.

PURPOSE: A cohort study was carried out to test the hypothesis that higher vitamin D levels reduce the risk of relapse from melanoma. METHODS: A pilot retrospective study of 271 patients with melanoma suggested that vitamin D may protect against recurrence of melanoma. We tested these findings in a survival analysis in a cohort of 872 patients recruited to the Leeds Melanoma Cohort (median follow-up, 4.7 years). RESULTS: In the retrospective study, self-reports of taking vitamin D supplements were nonsignificantly correlated with a reduced risk of melanoma relapse (odds ratio = 0.6; 95% CI, 0.4 to 1.1; P = .09). Nonrelapsers had higher mean 25-hydroxyvitamin D(3) levels than relapsers (49 v 46 nmol/L; P = .3; not statistically significant). In the cohort (prospective) study, higher 25-hydroxyvitamin D(3) levels were associated with lower Breslow thickness at diagnosis (P = .002) and were independently protective of relapse and death: the hazard ratio for relapse-free survival (RFS) was 0.79 (95% CI, 0.64 to 0.96; P = .01) for a 20 nmol/L increase in serum level. There was evidence of interaction between the vitamin D receptor (VDR) BsmI genotype and serum 25-hydroxyvitamin D(3) levels on RFS. CONCLUSION: Results from the retrospective study were consistent with a role for vitamin D in melanoma outcome. The cohort study tests this hypothesis, providing evidence that higher 25-hydroxyvitamin D(3) levels, at diagnosis, are associated with both thinner tumors and better survival from melanoma, independent of Breslow thickness. Patients with melanoma, and those at high risk of melanoma, should seek to ensure vitamin D sufficiency. Additional studies are needed to establish optimal serum levels for patients with melanoma.

Vitamin D receptor gene polymorphisms, serum 25-hydroxyvitamin D levels, and melanoma: UK case-control comparisons and a meta-analysis of published VDR data.

We have carried out melanoma case-control comparisons for six vitamin D receptor (VDR) gene single nucleotide polymorphisms (SNPs) and serum 25-hydroxyvitamin D(3) levels in order to investigate the role of vitamin D in melanoma susceptibility. There was no significant evidence of an association between any VDR SNP and risk in 1028 population-ascertained cases and 402 controls from Leeds, UK. In a second Leeds case-control study (299 cases and 560 controls) the FokI T allele was associated with increased melanoma risk (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.06-1.91, p=0.02). In a meta-analysis in conjunction with published data from other smaller data sets (total 3769 cases and 3636 controls), the FokI T allele was associated with increased melanoma risk (OR 1.19, 95% CI 1.05-1.35), and the BsmI A allele was associated with a reduced risk (OR 0.81, 95% CI 0.72-0.92), in each instance under a parsimonious dominant model. In the first Leeds case-control comparison cases were more likely to have a higher body mass index (BMI) than controls (p=0.007 for linear trend). There was no evidence of a case-control difference in serum 25-hydroxyvitamin D(3) levels. In 1043 incident cases from the first Leeds case-control study, a single estimation of serum 25-hydroxyvitamin D(3) level taken at recruitment was inversely correlated with Breslow thickness (p=0.03 for linear trend). These data provide evidence to support the view that vitamin D and VDR may have a small but potentially important role in melanoma susceptibility, and putatively a greater role in disease progression.

Environmental risk factors for relapse of melanoma.

AIM: To identify lifestyle factors affecting risk of relapse. METHODS: A comparison of 131 relapsed melanoma patients with 147 non-relapsers. RESULTS: Relapsers were more likely to report financial hardship using a number of different measures including access to holidays and feeling financially insecure (odds ratio (OR) 5.7, 95% confidence interval (CI) (1.5, 21.4)). Relapsers worked longer hours (mean 37h per week compared with 31, p=0.02). There was no reported difference in stress associated with recent life events. There was no effect of housing quality, employment factors or body mass index (BMI) on risk of relapse. There was a protective effect of antibiotics in the peri-operative period. CONCLUSION: The study provides preliminary evidence for adverse effects of chronic financial hardship, but not recent stressful events on cancer relapse. As these data were collected in a retrospective case-control study subject to recall bias, the data must now be explored in a prospective study.