Ovarian cancer symptom awareness and anticipated delayed presentation in a population sample.

BACKGROUND: While ovarian cancer is recognised as having identifiable early symptoms, understanding of the key determinants of symptom awareness and early presentation is limited. A population-based survey of ovarian cancer awareness and anticipated delayed presentation with symptoms was conducted as part of the International Cancer Benchmarking Partnership (ICBP). METHODS: Women aged over 50 years were recruited using random probability sampling (n = 1043). Computer-assisted telephone interviews were used to administer measures including ovarian cancer symptom recognition, anticipated time to presentation with ovarian symptoms, health beliefs (perceived risk, perceived benefits/barriers to early presentation, confidence in symptom detection, ovarian cancer worry), and demographic variables. Logistic regression analysis was used to identify the contribution of independent variables to anticipated presentation (categorised as < 3 weeks or ≥ 3 weeks). RESULTS: The most well-recognised symptoms of ovarian cancer were post-menopausal bleeding (87.4%), and persistent pelvic (79.0%) and abdominal (85.0%) pain. Symptoms associated with eating difficulties and changes in bladder/bowel habits were recognised by less than half the sample. Lower symptom awareness was significantly associated with older age (p ≤ 0.001), being single (p ≤ 0.001), lower education (p ≤ 0.01), and lack of personal experience of ovarian cancer (p ≤ 0.01). The odds of anticipating a delay in time to presentation of ≥ 3 weeks were significantly increased in women educated to degree level (OR = 2.64, 95% CI 1.61 - 4.33, p ≤ 0.001), women who reported more practical barriers (OR = 1.60, 95% CI 1.34 - 1.91, p ≤ 0.001) and more emotional barriers (OR = 1.21, 95% CI 1.06 - 1.40, p ≤ 0.01), and those less confident in symptom detection (OR = 0.56, 95% CI 0.42 - 0.73, p ≤ 0.001), but not in those who reported lower symptom awareness (OR = 0.99, 95% CI 0.91 - 1.07, p = 0.74). CONCLUSIONS: Many symptoms of ovarian cancer are not well-recognised by women in the general population. Evidence-based interventions are needed not only to improve public awareness but also to overcome the barriers to recognising and acting on ovarian symptoms, if delays in presentation are to be minimised.

Incorporating community-based participatory research principles into environmental health research: challenges and lessons learned from a housing pilot study.

In environmental health research, a community-based participatory research (CBPR) approach can effectively involve community members, researchers, and representatives from nonprofit, academic, and governmental agencies as equal partners throughout the research process. The authors sought to use CBPR principles in a pilot study; its purpose was to investigate how green construction practices might affect indoor exposures to chemicals and biological agents. Information from this pilot informed the development of a methodology for a nationwide study of low-income urban multifamily housing. The authors describe here 1) the incorporation of CBPR principles into a pilot study comparing green vs. conventionally built urban housing, 2) the resulting implementation and reporting challenges, and 3) lessons learned and implications for increased community participation in environmental health research.

Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007.

BACKGROUND: The authors consider whether differences in stage at diagnosis could explain the variation in lung cancer survival between six developed countries in 2004-2007. METHODS: Routinely collected population-based data were obtained on all adults (15-99 years) diagnosed with lung cancer in 2004-2007 and registered in regional and national cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Stage data for 57 352 patients were consolidated from various classification systems. Flexible parametric hazard models on the log cumulative scale were used to estimate net survival at 1 year and the excess hazard up to 18 months after diagnosis. RESULTS: Age-standardised 1-year net survival from non-small cell lung cancer ranged from 30% (UK) to 46% (Sweden). Patients in the UK and Denmark had lower survival than elsewhere, partly because of a more adverse stage distribution. However, there were also wide international differences in stage-specific survival. Net survival from TNM stage I non-small cell lung cancer was 16% lower in the UK than in Sweden, and for TNM stage IV disease survival was 10% lower. Similar patterns were found for small cell lung cancer. CONCLUSIONS: There are comparability issues when using population-based data but, even given these constraints, this study shows that, while differences in stage at diagnosis explain some of the international variation in overall lung cancer survival, wide disparities in stage-specific survival exist, suggesting that other factors are also important such as differences in treatment. Stage should be included in international cancer survival studies and the comparability of population-based data should be improved.

Dyspnoea and mortality in older people in the community: a 10-year follow-up.

BACKGROUND: examine baseline dyspnoea and subsequent 10-year mortality adjusting for age and gender and determine whether dyspnoea is related to early or late mortality or both. Examine the relationship between dyspnoea and mortality adjusting for confounding effects of underlying diseases. METHODS: we sent modified Medical Research Council (MRC) dyspnoea questionnaire to identify breathlessness in 1,404 randomly selected subjects from general practitioner lists of 5,002 subjects aged 70 years and over living in the community. A further random sample of 500 subjects underwent clinical assessment including pulmonary function tests, electrocardiography and echocardiography. Subjects were followed up for 10 years and all deaths were recorded, using general practitioner records and the local death registry. RESULTS: prevalence of dyspnoea was 32.3%. Breathlessness was associated with early mortality and late mortality. At 2 years 10.1% breathless subjects died compared with 3.4% non-breathless (P=0.02). At 10 years 63.3% breathless had died compared with 40.5% non-breathless (P=0.0001). Increasing grade of MRC dyspnoea was associated with 10 mortality. Advancing age (OR: 2.27), male gender (OR: 1.95), breathlessness (OR: 2.53), left ventricular dysfunction (OR: 5.01) and chronic airways disease (OR: 3.04) were all significantly associated with 10-year mortality. After adjustment of age, gender and underlying diseases breathlessness was associated with 10-year mortality (P=0.02). CONCLUSION: dyspnoea is a predictor of early and late mortality and increasing grade of dyspnoea is associated with a higher rate of mortality. Dyspnoea is an independent risk factor for mortality after adjustment for age, gender and underlying diseases.

Survival from twenty adult cancers in the UK and Republic of Ireland in the late twentieth century.

BACKGROUND: International studies have shown that cancer survival was generally low in the UK and the Republic of Ireland compared to western and northern European countries, but no systematic comparative analysis has been performed between the UK countries and the Republic of Ireland. METHODS: Population-based survival for 20 adult malignancies was estimated for the UK and the Republic of Ireland. Data on adults (15-99 years) diagnosed between 1991 and 1999 in England, Scotland, Wales, Northern Ireland (1993-99) and the Republic of Ireland (1994-99) were analysed. All cases were followed up until the end of 2001. Relative survival was estimated by sex, period of diagnosis and country, and for the nine regions of England. Predicted survival was estimated using the hybrid approach. RESULTS: Overall, cancer survival in UK and Republic of Ireland improved during the 1990s, but there was geographic variation in survival across the UK and Republic of Ireland. Survival was generally highest in Ireland and Northern Ireland and lowest in England and Wales. Survival tended to be higher in Scotland for cancers for which early detection methods were in place. In England, survival tended to be lower in the north and higher in the south. CONCLUSIONS: The geographic variations in survival seen across the UK and Republic of Ireland are narrower than between these countries and comparable European countries. Artefact is likely to explain some, but not all of the differences across the UK and Republic of Ireland. Geographic differences in stage at diagnosis, co-morbidity and other clinical factors may also be relevant.

Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England.

BACKGROUND: The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. METHODS: We analysed population-based survival in 2.2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996-2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996-2000 (before the cancer plan), 2001-03 (initialisation), and 2004-06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. FINDINGS: 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996-2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996-2000 and 2001-03, but higher in England than in Wales during 2004-06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North-South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001-03 and 2004-06. INTERPRETATION: The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004-06, whereas the opposite was true during 2001-03. This reversal of survival trends in 2001-03 and 2004-06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan.

Atlanta Streets Alive: A Movement Building a Culture of Health in an Urban Environment.

BACKGROUND: Open Streets are community-based programs that promote the use of public space for physical activity (PA), recreation and socialization by closing streets temporarily to motorized vehicles, allowing access to pedestrians. The city of Atlanta hosted its first Open Streets event, Atlanta Streets Alive (ASA), in May 2010. An evaluation of the first 5 ASA events from May 2010 to May 2012 was conducted. The purpose was to learn about the characteristics of ASA participants, the influence of the event on their PA, and perceptions of safety and neighborhood social capital. METHODS: ASA's evaluation had 2 components: participant counts and a participant survey. Characteristics of participation were compared among the 3 different events in which surveys were conducted using the Pearson χ2 test and F test as appropriate. RESULTS: The estimated participation at ASA increased from nearly 3,500 (ASA 1 to 4) to 12,520 (ASA 5). The number of events increased to 3 per year for a total of 10 events until 2014. Overall, 19.4% of participants met the weekly PA recommendation during 1 event. CONCLUSIONS: The expanding diversity of routes, participants, and sponsorships highlights the potential promise such programming offers in terms of establishing an urban culture of health.

Pedigree construction and disease confirmation: a pilot study in Wales exploring the role of nonclinical personnel.

Pedigree construction and disease confirmation are the means by which reported family histories are translated into a verified clinical tool informing risk assessment and management decisions by clinical genetics staff. In this study, we hypothesised that pedigree generation data processes do not generally require the clinical expertise of genetic counsellors and that they could be successfully transferred to nonclinical data administrators. We made a pragmatic comparison of two processes of pedigree generation by different personnel from 14 consecutive family history questionnaires containing 88 living and decease affected individuals. The pedigrees generated by the genetic counsellor and the data administrator were compared; discrepancies were quantified and their source determined. The information gathered by the data administrator mirrored that of the genetic counsellors in 89% of cases. Time was saved by permitting direct access to cancer registry and local oncology centre databases. Constructing a pedigree is not always a case of transferring clear-cut data. Decisions need to be made about which cancers to confirm. Notable differences emerged in the number of pieces of information not transferred. Ambiguous information was often interpreted differently, suggesting the need for clinical staff to review pedigrees after their initial plotting by the data administrator. This study demonstrates a good degree of concordance between pedigrees constructed by a nonclinical data administrator and those of experienced genetic counsellors. However, the redirection of all pedigree activity to nonclinical personnel up to the point of risk review is not possible at present.

Genetic variation in eleven phase I drug metabolism genes in an ethnically diverse population.

The extent of genetic variation found in drug metabolism genes and its contribution to interindividual variation in response to medication remains incompletely understood. To better determine the identity and frequency of variation in 11 phase I drug metabolism genes, the exons and flanking intronic regions of the cytochrome P450 (CYP) isoenzyme genes CYP1A1, CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP3A4 and CYP3A5 were amplified from genomic DNA and sequenced. A total of 60 kb of bi-directional sequence was generated from each of 93 human DNAs, which included Caucasian, African-American and Asian samples. There were 388 different polymorphisms identified. These included 269 non-coding, 45 synonymous and 74 non-synonymous polymorphisms. Of these, 54% were novel and included 176 non-coding, 14 synonymous and 21 non-synonymous polymorphisms. Of the novel variants observed, 85 were represented by single occurrences of the minor allele in the sample set. Much of the variation observed was from low-frequency alleles. Comparatively, these genes are variation-rich. Calculations measuring genetic diversity revealed that while the values for the individual genes are widely variable, the overall nucleotide diversity of 7.7 x 10(-4) and polymorphism parameter of 11.5 x 10(-4) are higher than those previously reported for other gene sets. Several independent measurements indicate that these genes are under selective pressure, particularly for polymorphisms corresponding to non-synonymous amino acid changes. There is relatively little difference in measurements of diversity among the ethnic groups, but there are large differences among the genes and gene subfamilies themselves. Of the three CYP subfamilies involved in phase I drug metabolism (1, 2, and 3), subfamily 2 displays the highest levels of genetic diversity.

European reference values for Doppler indices of left ventricular diastolic filling.

The European Study Group on diastolic heart failure requires objective evidence of abnormal left ventricular diastolic function to establish the diagnosis of diastolic heart failure, which is common in older people. Reference values for Doppler indices of transmitral flow, used to assess left ventricular diastolic function, have not been reported for people 70 years and over in Europe. The aim of this study was to establish reference values for these Doppler indices of transmitral flow in older people. A random sample of 355 subjects aged 70 and over, living in the community underwent clinical assessment and echocardiography. Asymptomatic subjects with no cardiovascular disease and cardiovascular risk factors were identified. Measurements of five commonly used Doppler indices of transmitral flow from these subjects were obtained and reference range expressed as mean+/-2 standard deviations and as percentiles. We have therefore generated reference Doppler values of transmitral flow for people aged over 70 in a British population.

The impact of built environment on pedestrian crashes and the identification of crash clusters on an urban university campus.

OBJECTIVES: Motor vehicle-pedestrian crash is a significant public health concern. The urban campus of Georgia State University poses unique challenges due to a large number of students and university employees. The objectives of this study are twofold: 1) to examine the correlation between specific features of the built environment on and around the University campus and pedestrian crashes; and 2) to identify crash clusters in the study area using network-based geospatial techniques. METHODS: We obtained pedestrian crash data (n=119) from 2003 to 2007 from Georgia Department of Transportation and evaluated environmental features pertaining to the road infrastructure, pedestrian infrastructure and streetscape for each road segment and intersection. Prevalence rate of each feature with pedestrian crashes present was calculated. We used network-based Kernel Density Estimation to identify the high density road segments and intersections, then used network-based K-function to examine the clustering of pedestrian crashes. RESULTS: Over 50% of the crosswalk signs, pedestrian signals, public transit, and location branding signs (more than three) at intersections involved pedestrian crashes. More than half of wider streets (greater than 29 feet), two-way streets, and streets in good condition had pedestrian crashes present. Crashes occurred more frequently in road segments with strong street compactness and mixed land use present and were significantly (p<0.05) clustered in these high-density zones. CONCLUSION: Findings can be used to understand the correlation between built environment and pedestrian safety, to prioritize the high-density zones for intervention efforts, and to formulate research hypotheses for investigating pedestrian crashes.

Leukaemia incidence in Welsh children linked with low level radiation--making sense of some erroneous results published in the media.

A series of self-published epidemiological reports purporting to show a major excess risk of leukaemia in pre-school children living near the Irish Sea coast of Wales have been presented in the media as evidence of the harmful effects of low level radiation arising from Sellafield. The Welsh Cancer Intelligence and Surveillance Unit (WCISU), the body responsible for population-based cancer information in Wales, can provide insights into the validity of these reports, which appear to be a consequence of various mistakes. This raises important questions about the research governance of such reports and the communication of scientific findings via the mass media. Without suitable safeguards the media are in danger of promulgating misinformation.

Cement, cancers and clusters: an investigation of a claim of a local excess cancer risk related to a cement works.

BACKGROUND: We investigated claims by a campaigning group of a cancer cluster associated with a local cement works. METHODS: To investigate cancer rates in the town we defined the study area as the Census wards matching the geographical area code supplied to the campaigning group. Standard methods were applied to registered cases of cancer for the area for the years 1974-1989 to derive observed and expected numbers. The significance of the relative risk was assessed using the Poisson distribution. By selecting a different denominator population we attempted to reproduce the results of the campaign group. Cancer rates around the cement works were investigated for four cancer types plausibly associated with emissions, using cancer registrations for the years 1985-1994. Cases were mapped to 1981 Census ward boundaries, and the same statistical methods were used, but expected counts were also adjusted for deprivation. Rates were calculated for an inner 2 km zone and outer zone 2-5 km from the works. Relative risk was calculated and the ratio of risks was examined for evidence of increased risk closer to the works. RESULTS: Relative risks were not significantly elevated either in the town or around the cement works itself. We were able to reproduce the likely errors that resulted in the elevated relative risks for five cancer groups claimed by the campaigning group. CONCLUSIONS: We found no evidence of increased incidence of cancer around the cement works. Incorrect handling of cancer registration data can result in spurious cancer clusters and unnecessary public alarm.

Inhaler technique in older people in the community.

BACKGROUND: Good inhaler technique and medication concordance is important for symptom and disease control in chronic airways disease. OBJECTIVES: Establish the prevalence of inhaler use; the main inhaler devices used by older people at home; their ability to use the inhalers they have been prescribed; and the relationship between perceived ease of use and actual performance. DESIGN: Cross-sectional population based study. SUBJECTS: Subjects aged 70 years and over living at home. METHODS: 500 subjects were randomly selected from 5002 subjects aged 70 years and over living at home. Inhalers used over the previous 24 hours were identified by a nurse on home visit. Those with cognitive impairment were excluded. Inhaler system was assessed and graded by a doctor as acceptable (perfect or minor errors) or unacceptable (major errors), using previously published criteria. Perceived ease of use of the device was rated as easy, moderate or difficult. RESULTS: 423 subjects participated in the study. The population prevalence of inhaler use was 15.8% (12.0, 19.7). Of the 91 inhaler devices used, 39 (42.8%) were metered dose inhalers, 34 (37.4%) were metered dose inhalers with large volume spacers, and 18 (19.8%) were breath-actuated devices. Thirty-two subjects (82.1%) using metered dose inhalers had an acceptable technique compared with 33 (97.1%) of those using metered dose inhalers with large volume spacers and 13 (72.2%) of those using breath-actuated devices (P < 0.05). Up to three quarters of inhalers were considered easy to use but 12% of subjects who rated their inhaler device as being easy to use made major errors. CONCLUSION: Metered dose inhaler was the most frequently prescribed inhaler and was used correctly by most subjects especially in combination with large volume spacers. Major errors were more common with breath-actuated devices. Inhaler technique should be checked as patients' perception of their inhaler skills correlates poorly with actual performance.

Left ventricular systolic dysfunction and atrial fibrillation in older people in the community--a need for screening?

BACKGROUND: Heart failure and stroke are major causes of morbidity and mortality in older people. Angiotensin converting enzyme inhibitors improve symptoms and survival in left ventricular systolic dysfunction. Anticoagulants are effective in stroke prevention in atrial fibrillation with aspirin being a less effective alternative. OBJECTIVES: To determine the prevalence of left ventricular systolic dysfunction, health services utilisation and prescribing of diuretics and angiotensin converting enzyme inhibitors in left ventricular systolic dysfunction, and the prevalence of atrial fibrillation and anti-platelet/thrombotic therapy in atrial fibrillation in older people in the community. METHODS: 500 subjects were drawn by two-stage random sampling from 5,002 subjects aged 70 years and over living at home. Subjects were screened for atrial fibrillation and left ventricular systolic dysfunction using electrocardiography and echocardiography. RESULTS: The population prevalence amongst older people of left ventricular systolic dysfunction was 9.8% and of atrial fibrillation 7.8%. More than two-thirds of those with left ventricular systolic dysfunction were not on angiotensin converting enzyme inhibitors. Of those in atrial fibrillation, 35% were taking aspirin, 24% were taking warfarin and 41% were on neither aspirin nor warfarin. Nearly 90% of older people in the community have had contact with their general practitioner over the past year, and over half of those with left ventricular systolic dysfunction have had contact with hospital-based services over the past 2 years. CONCLUSIONS: Left ventricular systolic dysfunction is under-treated in older people in the community. Despite the high level of contact with hospital and community-based services, the majority of those with systolic left ventricular dysfunction are not on angiotensin converting enzyme inhibitors and a significant proportion of those in atrial fibrillation are not on any treatment for stroke prevention.

Diastolic heart failure in older people.

OBJECTIVES: To determine the prevalence of diastolic heart failure in older people in the community, identify associated risk factors and measure its impact on function and quality of life. DESIGN: Cross-sectional population-based study. METHODS: A two-stage random sample of 500 subjects was drawn from 5,002 subjects aged 70 years and over living at home. Diastolic heart failure was diagnosed by a panel of three physicians, based on clinical assessment and echocardiographic indicators of diastolic dysfunction. MAIN OUTCOME MEASURES: Prevalence of diastolic heart failure and its effect on function and quality of life as measured by Nottingham Extended Activities of Daily Living, Hospital Anxiety and Depression and SF-36 questionnaires. RESULTS: The prevalence of diastolic heart failure was 5.54% (95% CI = 3.71, 7.87) and was higher in women (8.32%) than in men (1.25%), P = 0.008. On multivariate analysis of variance, diastolic heart failure was associated with female gender and history of ischaemic heart disease. Subjects with diastolic heart failure had significantly poorer functional status and physical health than those without heart failure. CONCLUSIONS: Diastolic heart failure is relatively common in older people and is associated with adverse affects in older people's lives.