Tracheal tube obstruction as a complication of transoesophageal echocardiography.

Complications of transoesophageal echocardiography are numerous and may have serious consequences. We present the case of a 31-year-old woman with postoperative airway obstruction secondary to a transesophageal echocardiography probe. The patient had been admitted with acute myocarditis and required temporary mechanical support with a biventricular assist device. She deteriorated on the intensive care unit several hours later with hypoxaemia, high airway pressures and reduced tidal volumes. Sedation was adequate and no external obstruction in the breathing circuit was observed. The tracheal tube was noted to be permanently deformed in the oropharynx, causing airway obstruction. Tracheal tube exchange was required, and the patient recovered from the event. We suspect that the position of the transoesophageal echocardiography probe in the operating theatre had contributed to the deformity, and the presence of airway obstruction was masked by the reduced ventilatory parameters instituted while on mechanical circulatory support. The biventricular assistance devices were explanted subsequently, and the patient was discharged home on day 31. This is the first reported case of a kinked tracheal tube where transoesophageal echocardiography probe placement was suspected to have contributed. A high index of suspicion is required for this complication on the intensive care unit.

Trends in the epidemiology of head and neck cancer in London.

BACKGROUND: Head and neck cancers [HNCs] are biologically heterogeneous tumours. The objectives of this study were to describe trends in incidence of HNCs amongst London residents by sex, age, anatomical site, deprivation and ethnicity. METHODS: Annual age-standardised incidence rates [ASRs] were calculated on HNC registration data, overall and for specific cancer sites, by sex and morphology (1985-2010) and area-based socio-economic deprivation score (2006-2010). Age-standardised incidence rate ratios [IRRs] for the main ethnic groups were calculated by cancer site, using White males and females as the reference groups (1998-2009). RESULTS: The ASR of HNC in males increased by 40% from 17.3 [95% CI: 15.8-18.6] to 24.2 [95% CI: 22.5-25.8] per 100 000 and in females by 87% from 7.0 [95% CI: 6.2-7.8] to 13.1 [95% CI: 11.9-14.2] per 100 000. Seventy-three per cent of cases spanned four cancer sites: larynx, thyroid, oral and oropharynx. Larynx was most common (23%), and had the highest male: female ratio (6 : 1); ASRs decreased significantly over time, most notably in males [P < 0.001]. Oral cavity was the second most common (21%), with a male: female ratio of 2 : 1, and increasing ASRs in both sexes [P < 0.001]. The majority of cases were male (64%) and from deprived areas (59%). Deprivation was associated with a significantly higher incidence for larynx (males), oropharynx (males and females) and oral cavity (females) [P < 0.05]. The age-specific rate for middle-aged adults (45-64 years) was high for oropharyngeal cancer. The incidence of thyroid cancers increased significantly in both sexes [P < 0.001], and this was the only site more common in females. One in five cases with known ethnicity was from a non-White group (20%). Compared with their White counterparts, Bangladeshi females had a higher incidence of oral, laryngeal and thyroid cancers; Chinese males and females had a higher incidence of nasopharyngeal cancer; and Pakistani and Indian females and Indian males also had higher incidence of oral cancer. CONCLUSIONS: HNCs are increasing in London males and females with significant variation by cancer site over time; oral and oropharyngeal cancers show the most significant rise, with implications for public health action and service provision.

The association of mood disorders with breast cancer survival: an investigation of linked cancer registration and hospital admission data for South East England.

BACKGROUND: Data linkage studies find that depression before or after a breast cancer diagnosis predicts reduced survival. This study aimed to determine whether depression or bipolar recorded in routine hospital admission data independently predicts survival in English breast cancer patients and whether onset in relation to cancer diagnosis is significant. METHODS: Data on 77,173 women diagnosed with breast cancer (ICD-10 C50) in South East England, 2000-2009, were included. Of these, 131 women had a diagnosis of bipolar affective disorder (ICD-10 F31) and 955 of depression (either depressive episodes (ICD-10 F32) or depressive disorder (ICD-10 F33)) recorded in Hospital Episode Statistics between 3 years before and a year following cancer diagnosis. Kaplan-Meier plots were used to examine overall survival. Cox regression analyses were carried out overall and separately for mood disorder diagnoses before and after the cancer diagnosis and adjusted for confounding variables. RESULTS: A record of depression was a predictor of worse overall survival in breast cancer patients (adjusted HR = 1.33, 95% CI: 1.20-1.48, p < 0.001), while the effect of bipolar was not statistically significant (adjusted HR = 1.33, 95% CI: 0.97-1.82, p = 0.079). New recordings of depression and bipolar diagnoses following a cancer diagnosis appeared better predictors of overall survival than a prior history of either. CONCLUSIONS: There is evidence that English breast cancer patients with depression and bipolar recorded in routine hospital data have worse overall survival than those without these mood disorders. Further work exploring the concordance of records within administrative health data with clinical diagnosis and cause-specific death within these patient groups is needed.

Adverse drug reactions in special populations - the elderly.

The International Conference on Harmonization considers older people a 'special population', as they differ from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics and greater vulnerability to adverse drug reactions (ADRs). Medical practice is often based on single disease guidelines derived from clinical trials that have not included frail older people or those with multiple morbidities. This presents a challenge caring for older people, as drug doses in trials may not be achievable in real world patients and risks of ADRs are underestimated in clinical trial populations. The majority of ADRs in older people are Type A, potentially avoidable and associated with commonly prescribed medications. Several ADRs are particularly associated with major adverse consequences in the elderly and their reduction is therefore a clinical priority. Falls are strongly associated with benzodiazepines, neuroleptics, antidepressants and antihypertensives. There is good evidence for medication review as part of a multifactorial intervention to reduce falls risk in community dwelling elderly. Multiple medications also contribute to delirium, another multifactorial syndrome resulting in excess mortality particularly in frail older people. Clostridium difficile associated with use of broad spectrum antibiotics mainly affects frail older people and results in prolonged hospital stay with substantial morbidity and mortality. Antipsychotics increase the risk of stroke by more than three-fold in patients with dementia. Inappropriate prescribing can be reduced by adherence to prescribing guidelines, suitable monitoring and regular medication review. Given the heterogeneity within the older population, providing individualized care is pivotal to preventing ADRs.

The survival of patients with high grade glioma from different ethnic groups in South East England.

Studies in the United States (US) have reported varying treatment and survival for patients with high grade glioma from different ethnic groups. This study investigates for the first time whether differences also exist in the United Kingdom (UK). This population-based cohort study used cancer registration data for 4,845 patients diagnosed in South East England between 2000 and 2009. Linked self-assigned ethnicity data within Hospital Episode Statistics were used to define White, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African, Other and Not known groups. Logistic regression was used to generate odds ratios for a record of receipt of treatment (surgery, radiotherapy and chemotherapy), adjusting for sex, age, morphology, socioeconomic deprivation and comorbidity in each ethnic group. Hazard ratios were generated using Cox regression, adjusting for sex, age, morphology, socioeconomic deprivation, comorbidity and treatment. The overall one-year survival was 28.4 %. Ethnicity data was available for 3,793 (78 %) patients. Receipt of treatment was generally similar between different ethnic groups after adjustment for sex, age, morphology, socioeconomic deprivation and comorbidity. After adjustment for potential confounders, the Indian (HR 0.72, p = 0.037) and Other groups (HR 0.76, p = 0.003) had better survival, while the Not known group (HR 1.34, p < 0.0001) had worse survival than the White group. Patients from UK Indian groups have better survival than White patients while those from Black ethnic groups appear to have similar survival to White patients. These findings suggest the need to investigate possible contributing factors including the completeness of follow-up, clinical performance status and tumour biology.

Variation, precision and validity of 1-year survival estimates for lung, breast, colon and prostate cancer in South East England primary care trusts.

BACKGROUND: English cancer policy has encouraged primary care trusts (PCTs) to consider their 1-year cancer survival estimates. This study quantifies variation in these estimates across 39 PCTs in the London and South East Coast strategic health authorities, and explores their precision, possible confounding by age and bias due to death certificate only (DCO) registrations. STUDY DESIGN: Retrospective observational study. METHODS: One-year relative survival estimates and data on DCO registrations for patients diagnosed with lung, colorectal, breast and prostate cancers between 2002 and 2006 were extracted from the UK Cancer Information Service. Direct age standardization was performed with weightings derived from the standard cancer patient population for Europe. Pearson correlation coefficients between survival estimates and DCO proportions were calculated. RESULTS: Mean 1-year PCT survival estimates ranged from 6.9 to 19.4 percentage points, and the precision of individual estimates ranged from ±0.9 to ±6.5 percentage points (at 95% confidence level). Age standardization significantly changed the estimates of nine PCTs for breast cancer, five PCTs for lung cancer and three PCTs for colorectal cancer. None of the prostate cancer estimates were affected significantly. DCO proportions were positively associated with lung cancer survival and negatively associated with colorectal and breast cancer survival. CONCLUSIONS: PCT 1-year cancer survival estimates may be informative, but caveats relating to data quality and hence the validity of the estimates means that they require careful investigation before naïve use, as random variation, confounding due to age and bias due to DCO registrations may be significant.

Lung cancer incidence and survival in different ethnic groups in South East England.

BACKGROUND: This study aimed to examine the incidence and survival of lung cancer patients from several different ethnic groups in a large ethnically diverse population in the United Kingdom. METHODS: Data on residents of South East England diagnosed with lung cancer between 1998 and 2003 were extracted from the Thames Cancer Registry database. Age- and socioeconomic deprivation-standardised incidence rate ratios were calculated for males and females in each ethnic group. Overall survival was examined using Cox regression, adjusted for age, socioeconomic deprivation, stage of disease and treatment. Results are presented for White, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African and Chinese patients, apart from female survival results where only the White, South Asian and Black ethnic groups were analysed. RESULTS: Compared with other ethnic groups of the same sex, Bangladeshi men, White men and White women had the highest incidence rates. Bangladeshi men had consistently higher survival estimates compared with White men (fully adjusted hazard ratio 0.46; P<0.001). Indian (0.84; P=0.048), Black Caribbean (0.87; P=0.47) and Black African (0.68; P=0.007) men also had higher survival estimates. South Asian (0.73; P=0.006) and Black (0.74; P=0.004) women had higher survival than White women. CONCLUSION: Smoking prevention messages need to be targeted for different ethnic groups to ensure no groups are excluded. The apparent better survival of South Asian and Black patients is surprising, and more detailed follow-up studies are needed to verify these results.

Investigation of low 5-year relative survival for breast cancer in a London cancer network.

BACKGROUND: Breast cancer 5-year relative survival is low in the North East London Cancer Network (NELCN). METHODS: We compared breast cancer that was diagnosed during 2001-2005 with that in the rest of London. RESULTS: North East London Cancer Network women more often lived in socioeconomic quintile 5 (42 vs 21%) and presented with advanced disease (11 vs 7%). Cox regression analysis showed the survival difference (hazard ratio: 1.27, 95% confidence interval (CI): 1.15-1.41) reduced to 1.00 (95% CI: 0.89-1.11) after adjustment for age, stage, socioeconomic deprivation, ethnicity and treatment. Major drivers were stage and deprivation. Excess mortality was in the first year. CONCLUSION: Late diagnosis occurs in NELCN.

Is it possible to determine use of hospice palliative care services by matching hospice and cancer registry data?

Population-based studies investigating access to palliative care often use death in a hospice as a proxy for service use. We linked data from a large South London hospice to Thames Cancer Registry (TCR) data to determine whether patients who received hospice services differed from those who did not. We matched hospice data for 2474 cancer patients dying between 2000 and 2006, while resident within a restricted catchment area, to TCR data for residents in this area. During matching 14.2% (n = 352) of hospice patients were excluded due to differing key dates or addresses. In addition, 5.6% (n= 175) of residents initially defined as not receiving hospice services were recorded as dying in a hospice in the TCR dataset. The problems of overlapping catchment areas and of defining patients receiving services meant we could not adequately determine use of hospice services. This method might be applied more successfully to non-urban hospices, primary care trusts or larger regions.

Suicide in cancer patients in South East England from 1996 to 2005: a population-based study.

BACKGROUND: Studies from around the world have shown that suicide risk is increased in cancer patients, but no previous detailed analysis has been carried out in England. METHODS: We calculated standardised mortality ratios (SMRs) for suicide in 206,129 men and 211,443 women diagnosed with cancer in South East England between 1996 and 2005, relative to suicide rates in the general population. RESULTS: We found a significantly increased risk of suicide in men (SMR 1.45, 95% confidence interval (CI) 1.20-1.73) and a moderately increased risk in women (SMR 1.19, 95% CI 0.88-1.57). In both sexes, relative risk of suicide was greatest in the first year after cancer diagnosis (SMR for men 2.42, 95% CI 1.84-3.13; SMR for women 1.44, 95% CI 0.82-2.33), and was also greater in individuals diagnosed with types of cancer with high fatality (SMR for men 2.67, 95% CI 1.71-3.97; SMR for women 2.17, 95% CI 0.80-4.73). CONCLUSION: There is a critical period immediately after the diagnosis of cancer during which the excess risk of suicide is particularly high. Carers need to be aware of the importance of attending to both the physical and emotional needs of cancer patients and cancer survivors.

Trends in the incidence and survival of cancer in teenagers and young adults: regional analysis for South East England 1960-2002.

AIMS: This study aimed to describe trends in the incidence and survival of cancer in teenagers and young adults in South East England between 1960 and 2002, and the influence of socioeconomic status upon survival. MATERIALS AND METHODS: Data on 1788 patients aged 15-24 years were extracted from the Thames Cancer Registry, assigning each to a diagnostic group using the Birch and Marsden classification. Age-specific incidence rates in 5-year periods for the age groups 15-19 and 20-24 years were calculated for each diagnosis. Five-year relative survival estimates by diagnostic group were calculated for both age groups using 5-year periods of follow-up and non-overlapping years of diagnosis. To calculate overall survival estimates by socioeconomic group, the 10-year follow-up period 1993-2002 was used. RESULTS: Overall incidence rates were 162 per million person-years in 15-19 year olds and 261 in 20-24 year olds. We found a higher overall incidence in males, in 20-24 year olds and an increasing incidence over the last four decades, particularly in this age group. In both the 15-19 and 20-24 years age groups lymphomas were most common. The 5-year relative survival improved for all diagnostic groups, except bone tumours in the older age group, particularly for leukaemia and slightly more for the 20-24 than 15-19 years age group. Teenagers aged 15-19 years and living in more deprived areas had a significantly lower survival than those in more affluent areas. CONCLUSIONS: These findings confirm the increased incidence and improved outcome of cancer in teenagers and young adults. Future analyses should investigate trends in bone tumour survival across regions, survival by socioeconomic status and the influence of specialised care on further improvements in survival.

Breast cancer incidence, stage, treatment and survival in ethnic groups in South East England.

Studies from the US have shown variations in breast cancer incidence, stage distribution, treatment and survival between ethnic groups. Data on 35 631 women diagnosed with breast cancer in South East England between 1998 and 2003 with self-assigned ethnicity information available were analysed. Results are reported for White, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African and Chinese women. Age-standardised breast cancer incidence rate ratios, patterns of stage of disease at diagnosis, treatment, overall and breast cancer-specific survival were examined. All ethnic groups studied had lower age-standardised breast cancer incidence rates than White women, with Bangladeshi women having the lowest rate ratio (0.23, 95% CI: 0.20-0.26). White women were the most likely to have a stage recorded at diagnosis (adjusted proportion 75%), and least likely to be diagnosed with metastatic disease (7%). Black African women were the least likely to have a record of cancer surgery (63%) or hormone therapy (32%), and most likely to receive chemotherapy (38%). After fully adjusting for age, socioeconomic deprivation, stage of disease and treatment received, there was no significant variation in breast cancer-specific survival. However, Black African women had significantly worse overall survival (hazard ratio 1.24, P=0.025). These findings suggest that a strategy of earlier detection should be pursued in Black and South Asian women.

Trends in the epidemiology of larynx and lung cancer in south-east England, 1985-2004.

We analysed data on 8987 larynx and 174060 lung cancer patients diagnosed between 1985 and 2004, of which 17.3% of larynx and 35.5% of lung cancers were in females. The age-standardised rates for each cancer declined in both sexes, but since the 1990s, the rates in females over 70 years of age have been diverging.

Testis and prostate cancer incidence in ethnic groups in South East England.

International variations in the incidence of testis and prostate cancer are well established. Data from the USA have also shown differences between White and Black men; however, there has been little work on ethnicity and cancer incidence in the UK, due to incomplete ethnicity information in cancer registries. The Hospital Episode Statistics (HES) dataset has more complete information on self-assigned ethnicity for inpatients of English NHS hospitals. Data on 194 590 male patients resident in South East England diagnosed with cancer between 1998 and 2003 were extracted from the Thames Cancer Registry (TCR). Of these, ethnicity information from HES was obtained for 123 507 (63%), ethnicity information from TCR was available for a further 5909 (3%), and no ethnicity was available for 65 174 (33%). Compared with 'All White' men, testis cancer incidence was significantly lower in Indian, Pakistani, Bangladeshi, Other Asian, Black Caribbean, Black African, Other Black and Chinese men. Prostate cancer incidence was significantly increased in Black Caribbean, Black African, Other Black, Indian, Pakistani, Mixed White and Black Caribbean and Mixed White and Black African groups compared with 'All White' men. Bangladeshi and Chinese men had a significantly decreased incidence of prostate cancer. The incidence of prostate cancer in Indian and Pakistani men showed convergence towards the rates in the white population, suggesting the existence of modifiable risk factors in these men. Most other variations in these data are consistent with international comparisons, and indicate that genetic variations in susceptibility are very influential.

A randomized prospective trial of OKT3 induction in the current immunosuppression era.

Recent improvements in immunosuppression and subsequent decreases in the incidence of acute rejection have brought into question the benefit of the use peri-transplant antibody therapy (i.e. induction therapy). In the current era of immunosuppression that includes mycophenolate mofetil (MMF) and cyclosporine emulsion (Neoral, Novartis, Basle, Switzerland), we designed and have completed a prospective, randomized trial to address this question. Cadaveric and living donor renal allograft recipients were randomized to receive either OKT3/MMF/delayed Neoral/prednisone or MMF/immediate Neoral/prednisone without OKT3. The incidence of rejection episodes was the primary end point. Patients with delayed graft function were excluded. All rejection episodes were biopsy proven and all patients have been followed for a minimum of 2 yr. Fifty-four patients received OKT3 induction, of which 6 patients suffered a rejection episode (11%), while 13 patients (27%) not receiving OKT3 (p=0.04) had a rejection episode. Four patients in the no OKT3 group suffered multiple rejections, while there were only 2 with more than one episode in the OKT3 group. There was no increased incidence of infectious complications in the group receiving OKT3. Hospital costs tended to be higher in the OKT3-treated group, but were not significantly different. The low incidence of rejection in the OKT3-treated group was intriguing and validates the use of antibody therapy in the early post-operative periods even in the era of improved baseline immunosuppression.

Non-linear dielectric spectroscopy: antifouling and stabilisation of electrodes by a polymer coating.

Non-linear dielectric spectroscopy (NLDS) has previously been shown to produce quantitative information that is indicative of the metabolic state of various organisms, by modeling the non-linear effects of their membranous enzymes on an applied oscillating electromagnetic field using supervised multivariate analysis methods. However, the instability of the characteristics of the measuring apparatus rendered the process temperamental at best in the laboratory and impractical for field use. The main practical problem, of the non-stationarity of the electrode-solution interface and the ease with which the electrode surfaces are subject to protein fouling. It is addressed by applying a thin, electrically transparent antifouling coat to the electrodes. This reduces the interminable cleaning procedures previously required to prepare the electrodes for use, increases their usable lifetime before recleaning, and also improves the precision and linearity of multivariate models on NLDS data.

Pulmonary Rhizopus infection in a diabetic renal transplant recipient.

Infectious complications after renal transplantation remain a major cause of morbidity and mortality. Mucormycosis is a rare infection in renal transplant recipients; however, mortality is exceedingly high. Risk factors predisposing to this disease include prolonged neutropenia, diabetes, and patients who are immunosuppressed (Singh N, Gayowski T, Singh J, Yu LV. Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report and review of zygomycosis in solid-organ transplant recipients, Clin Infect Dis 1995: 20: 617). Life-threatening infections can occur, as this fungus has the propensity to invade blood vessel endothelium, resulting in hematological dissemination. We report a case of cavitary Rhizopus lung infection, 2 months after renal transplantation, where the patient was treated successfully with Amphotericin B and surgical resection of the lesions with preservation of his allograft function. In this era of intensified immunosuppression, we may see an increased incidence of mucormycosis in transplant population. Invasive diagnostic work-up is mandatory in case of suspicion; Amphotericin B and, in selected cases, surgical resection are the mainstays of therapy.