Case reports suggest that there may be an increased risk of some cancers associated with sickle cell disease. However, population-based studies are scarce and there is no comprehensive enumeration of the risks across the whole range of site-specific cancers. Our aim was to provide this.
We used an English national dataset of linked statistical records of hospital admissions and deaths from 1999 to 2011 to undertake a retrospective cohort study.
England.
Records of all hospital admissions in England with SCD or with conditions included in the control cohort.
Rate ratios were calculated comparing rates of cancer in a sickle cell disease cohort and a control cohort, confining the analyses to people whose ethnicity was recorded as Black.
Comparing the sickle cell disease cohort with the cohort without sickle cell disease, the rate ratio for all cancers combined was 2.1 (95% confidence interval 1.7–2.5). There were significantly high rate ratios for haematological malignancies, including Hodgkin’s lymphoma (rate ratio 3.7, 1.5–8.4), non-Hodgkin’s lymphoma (2.6, 1.3–4.8), multiple myeloma (5.5, 2.8–10.1), lymphoid leukaemia (3.3, 1.3–8.0) and myeloid leukaemia (10.0, 4.6–21.5). Four solid tumours showed elevated rate ratios: colon cancer (2.8, 1.2–5.5), non-melanoma skin cancer (4.4, 1.3–12.2), kidney cancer (5.4, 2.3–11.5) and thyroid cancer (5.1, 1.3–15.4).
The risk of some malignancies may be raised in patients with sickle cell disease. However, this study was based on administrative data without the scope to validate these against patients’ full clinical records. Our findings need confirmation or refutation. If confirmed, work to elucidate, at the genetic and molecular level, why people with sickle cell disease have elevated risks of individual cancers might make contributions to the fundamental understanding of carcinogenesis.
To investigate whether invitations for publicly funded cervical screening provide sufficient information to enable an informed choice about participation.
Cross-sectional study using a checklist of 23 information items on benefits and harms from cervical screening and the risks related to cervical cancer.
Invitations to publicly funded cervical screening in 10 Scandinavian and English-speaking countries.
Ten Scandinavian and English speaking countries.
Sixteen screening units representing 10 Scandinavian and English speaking countries.
Number of information items presented in invitations for cervical screening.
We contacted 21 coordinating units from 11 countries and 20 (95%) responded. Of these, four units did not issue invitations, but the remaining 16 coordinating units in 10 different countries supplied a sample. The invitations for cervical screening were generally information poor and contained a median of only four out of 23 information items possible (17%), ranging from 0 to 12 (0–52%). The most important harms of cancer screening, overdiagnosis and overtreatment, were typically downplayed or unmentioned. The same applied to other important harms, such as false-positive results and the psychological consequences from an abnormal test result. The majority of invitations took a paternalistic approach. While only two invitations (17%) included a pre-assigned appointment date, eight (70%) of the invitations contained strong appeals for participation.
Invitations to cervical cancer screening were information poor and biased in favour of participation. This means that informed choice is not possible, which is in conflict with modern requirements for personal involvement in medical decisions.
Current advice for patients being discharged from hospital suggests a body mass index of 18.5 to 24 kgm–2, although this aspirational target may often not be achieved. We examined the relationship between body mass index on discharge from hospital and subsequent mortality over a maximum follow-up of 3.8 years.
We conducted a survival analysis using linked hospital records data with national hospital episode statistics and national death certification data. Participants & Setting: The analysis included adult patients who were admitted to University Hospitals Birmingham NHS Foundation Trust for a period of over 24 h during 2011, excluding day cases and regular day case attenders.
The relationship between body mass index and mortality at medium term was estimated separately in both men and women, after accounting for case-mix.
For both males and females, the relationship between body mass index at discharge and the loge hazard of death was strongly non-linear (p = 0.0002 for females and p < 0.0001 for males) and predictive (both p < 0.0001). In all models, the optimal body mass index range associated with best survival was 25 to 35 kgm–2, with a sharp increase in risk for lower body mass index.
There was little evidence to support current aspirational body mass index targets in the discharge population. Hospitals should ensure adequate nutrition especially among those with a reduced body mass index.
To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm.
Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009.
52 preventable hospital deaths.
England.
The nature of problems in care and contributory factors underlying avoidable deaths in hospital.
The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability.
Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.
The views of practitioners at the ‘sharp end’ of care provision are increasingly recognised as important indicators of quality of care. The National Health Service (NHS) Staff Survey in England has quantified employees' views on how far they would be happy with the standard of care provided by their organisation if a friend or family member needed treatment. We aimed to characterise the concerns that might affect the willingness of staff to recommend their own organisations.
Qualitative study involving semi-structured interviews. Data analysis based on the constant comparative method.
Members of clinical and managerial staff in four NHS organisations (n = 70), and senior stakeholders across the NHS including clinicians, managers and others with a strategic or senior-level perspective (n = 98).
One hundred and sixty-eight interviews were conducted: 70 in four case study organisations and 98 across the wider English NHS.
Not applicable.
Asking study participants the ‘if a friend...’ question offered insider views on the quality of care. Some staff had no concerns, but others, identified significant problems with consistency, reliability and behaviour of staff. Participants identified reasons for poor care that included inadequate organisational systems; structural problems of understaffing and under-resourcing; weaknesses in professional cultures and professional competence and failure to deal with problems such as unacceptable conduct. Participants emphasised that staff were not always able to deliver high-quality care because they worked in difficult conditions.
Asking staff to give accounts of their willingness to recommend their organisation to family and friends elicits important insights into quality and safety of care. Such accounts might be able to provide warning signs that could signal organisational decline and avert healthcare scandals, but use outside a research context requires further evaluation.
To describe a successful mentoring scheme designed for mid-career clinician scientists and to examine factors associated with mentee report of positive career impact.
Mixed methods study including in-depth interviews and cross-sectional data collection via an online survey.
Academy of Medical Sciences mentoring scheme set up in 2002 and evaluated in 2010.
One hundred and forty-seven of 227 mentees took part in the study (response rate of 65%). Ten mentees, three mentors and eight stakeholders/scheme staff were selected to participate in in-depth interviews.
Qualitative data: Interviews were transcribed, and free text was analysed to identify themes and subthemes in the narrative. Quantitative data: We examined the associations of reported positive career impact of mentoring by performing simple and multiple logistic regression analysis.
Mentoring success was determined by a variety of factors including reasons for selection (e.g. presence of a personal recommendation), mentee characteristics (e.g. younger age), experience and skills of the mentor (e.g. ‘mentor helped me to find my own solutions’) and the quality of the relationship (e.g. ‘my mentor and I set out clear expectations early on’).
Our evaluation demonstrates that both mentor and mentee value mentoring and that careful planning of a scheme including preparation, training and ongoing support of both mentor and mentee addressing expectations, building rapport and logistics are likely to be helpful in ensuring success and benefit from the intervention.
To describe the status of health information systems in 14 sub-Saharan African countries of the World Health Organization African Region.
Country workshops to assess the system, using a tool for rating/scoring the performance of health information systems.
Fourteen sub-Saharan African countries of the African Region.
Country stakeholders in the ministries of health, national statistics offices, health programmes, donors and technical agencies.
State of resources, indicators, data sources, data management, information products, dissemination and use of health information.
The highest score was in the identification and harmonisation of indicators (73%), reflecting successful efforts to identify priority indicators and reach international consensus on indicators for several diseases. The lowest score (41%) was in data management, the ability to collect, store, analyse and distribute data, followed by resources – policy and planning, human and financial resources, and infrastructure (53%). Inadequate policy and planning (44%) was identified as the most important barrier to strengthening health information systems, followed by human and financial resources (48%) and infrastructure (66%). The average score for dissemination and use of health information was 57% – ‘present, but not adequate’ – with the highest score being for analysis and use, which was rated ‘adequate’. The use of data for policy and advocacy, planning and priority-setting, resource allocation, and implementation and action were all considered ‘present, but not adequate’, with resource allocation scoring the lowest (50%).
National health information systems are weak in the surveyed countries and much more needs to be done to improve the quality and relevance of data, and their management, sharing and use for policy-making and decision-making.
Healthcare professionals find breaking bad news difficult and upsetting. Increasing cultural diversity has led to a greater number of patients whose first language differs to that of the healthcare provider, with more patients requiring a translator to facilitate communication. Hospitals often ask non-clinical translators to facilitate breaking bad news. We sought to explore the experiences of translators within a specialist oncology centre.
Following ethical and governance approvals, semi-structured interviews were undertaken with five translators recruited from the specialist oncology centre. Interviews were audiotaped and transcribed verbatim. The data were analysed thematically, with major themes and subthemes identified.
Outpatient setting of a regional cancer centre.
Translators serving a regional cancer centre.
Qualitative data identified through thematic analysis.
Major themes included the significant emotional impact of translating distressing information, the challenges of accurately conveying information in a culturally congruent format and the need for formal briefing, debriefing and support. Subthemes included feeling guilty for divulging distressing news, being the focus of patients’ distress or anger, and feeling in conflict with the patient or family and issues surrounding confidentiality. Translators also felt a strong sense of advocacy for the patients and found encounters with death and dying emotionally challenging.
The increasing use of translators in the care of patients with advanced cancer is increasingly resulting in lay people being subject to similar emotional pressures faced by clinical staff, yet without the necessary formal training or support mechanisms that are recommended for clinicians. This exploratory study highlights the training and support needs of non-clinical staff as identifying a unique set of communication challenges faced by translators.
To describe the mechanisms and systems of knowledge acquisition, creation, diffusion, application and improvement of knowledge in two layers of the health system: health policy formulation and the provision of clinical services.
A questionnaire-based survey.
Health research institutions in 46 countries of the World Health Organization (WHO) African Region.
Key informants in 847 health research institutions in most of the 46 countries of the Region.
Existence of knowledge management infrastructure or components of infrastructure in the countries of the Region.
Central national bodies are always cited as having a major role in policy-setting. Non-national bodies most frequently provide advice and act in monitoring and evaluation, while decentralised entities are strongly involved in dissemination, implementation, and monitoring and evaluation. In general, ministries tend not to have an explicit knowledge management framework and do not map knowledge sources and flows for policy-making. The main sources of evidence are guidelines or recommendations from international or national agencies, although systematic reviews are rarely used. Routine monitoring and evaluation of quality and effectiveness of the process of policy development and its implementation was reported in 19 of the 39 respondent countries. In most respondent countries, electronic medical records were rarely used.
As systematic reviews are rarely utilised as a source of evidence in policy development and few mechanisms exist to assess the performance of the policies, there are significant opportunities for improving policy development.
To describe the state of research ethics policies and practices in health research institutions in sub-Saharan African countries.
A structured questionnaire was used to solicit information on research ethics from 847 health research institutions.
Forty-two sub-Saharan African countries.
Key informants from the 847 health research institutions.
Existence of institutional ethics review policies and mechanisms.
About half (51%) of respondent institutions reported having policies on research ethics and 58% had written policies requiring that researchers obtain informed consent of research participants. About one-third of respondent institutions (34%) had established ethics review committees, 42% required that studies went through ethics review committees and 46% had linkages with national or regional ethics organisations. Regarding operating procedures for ethics review committees, 53% had adopted standard operating procedures. Less than one-quarter of respondent institutions reported having policies in place to monitor ongoing research. Of the institutions that monitored ongoing research, 34% did an annual ethical review and 74% required a periodic written report. Only 36% provided any type of ethics training for staff, including those conducting health research and those who were not members of the ethics review committee.
There are substantial gaps in the capacity of health research institutions in the WHO African Region to undertake ethical review of studies before, during and after studies conducted. There is a need to strengthen such capacity in order to ensure the wellbeing of individuals enrolled in studies and that of communities that host these studies.
To describe and analyse research output from surveyed national health research institutions in Africa.
The survey used a structured questionnaire to solicit information from 847 health research institutions in 42 countries of the World Health Organization African Region.
Eight hundred and forty-seven health research institutions in 42 sub-Saharan African countries.
Key informants from the health research institutions.
Volume, type and medium of publications, and distribution of research outputs.
Books or chapters for books accounted for the highest number of information products published (on average 16.7 per respondent institution), followed by patents registered in country (8.2), discussion or working papers (6.5) and conference proceedings (6.4). Publication in a peer-reviewed journal constituted only a minor part of research output (on average about 1 paper per institution). Radio and TV broadcasts on health research accounted for the highest number of products issued by institution staff (on average 5.5 per institution), followed by peer-reviewed journals indexed internationally (3.8) or nationally (3.1). There were, on average, 1.5 press releases, 1.5 newspaper or magazine articles, and 1.4 policy briefs per institution. Over half of respondent institutions (52%) developed briefs and summaries of articles to share with their target audiences, 43% developed briefs for possible actions and 37% provided articles and reports upon request. Only a small proportion of information products produced were available in institutional databases.
The research output of health research institutions in the Region is significant, but more effort is needed to strengthen research capacity, including human and financial resources.
To describe the current status of institutional facilities and the supporting research infrastructure of surveyed health research institutions in Africa, including information on communication technologies and connectivity, library resources, and laboratory operations and resources.
The survey used a structured questionnaire, Tool 6 from the World Health Organization (WHO) Health Research System Analysis Initiative: Methods for Collecting Benchmarks and Systems Analysis Toolkit, to solicit information from 847 health research institutions in 42 countries of the WHO African Region.
Eight hundred and forty-seven health research institutions in 42 sub-Saharan African countries.
Key informants from the health research institutions.
The availability of laboratory, information and communication, and library facilities in health research institutions.
Less than half of the respondent health research institutions had computer laboratories (49%), network computers (50%) and information technology support (38%). More than two-thirds (67%) had a library. Electronic subscriptions to international journals were observed to be very low, with an average of three subscriptions per institution. Almost two-thirds of the surveyed institutions (69%) reported having laboratories, about half of which (55%) were accredited nationally. Linkages and research collaborations were generally weak, particularly those with other laboratories in the Region. Challenges included financial and human resource constraints and the inability to communicate effectively with partners.
Health research institutions in the Region have insufficient access to essential facilities such as laboratories, libraries, computers and the Internet to generate, access and share information.
Following the election of the Labour government in 1997, policies were developed in England to reduce waiting times for NHS treatment with commitments to reduce health inequalities. Similar policies were adopted in Scotland but with less emphasis on the use of the private sector to deliver NHS treatments than in England. This study uses routinely collected NHS Scotland data to analyse geographical and socioeconomic inequalities in elective hip arthroplasty treatment before and after the introduction of the waiting time initiatives in Scotland in 2003.
Ecological study design.
Scotland.
NHS-funded patients receiving elective hip arthroplasty delivered by the NHS and private hospitals between 1 April 1998 and 31 March 2008.
Directly standardised treatment rates and incidence rate ratios calculated using Poisson regression.
There was a 42% increase in NHS-funded hip arthroplasties carried out in Scotland from 4095 in 2002–2003 (1 April 2002–31 March 2003) to 5829 in 2007–2008. There is evidence of a statistically significant reduction in geographical inequality (likelihood ratio test p < 0.001) but no evidence of any statistically significant change in socioeconomic inequality (p = 0.108), comparing the 5 years after 1 April 2003 with the 5 years before 1 April 2003. The number of NHS-funded hip arthroplasties undertaken privately rose from 1.1% in 2002–2003 to 2.9% in 2007–2008, whereas the NHS Golden Jubilee National Hospital increased its share from 3.3% to 10.6% over the same period.
The reduction in geographical inequality, or ‘postcode lottery’, in hip arthroplasty treatment in Scotland may be due to increased NHS capacity, in particular the development of the NHS Golden Jubilee National Hospital in Clydebank, Greater Glasgow as a dedicated centre to reduce surgery waiting times.
Rest and Recuperation (R & R) is a period of home leave taken during an operational deployment; we sought to examine the relationship between taking R & R and mental health.
A survey-based post-intervention evaluation.
UK
232 members of the UK Armed Forces; 42 of which completed pre and post R & R surveys.
Alcohol use, Post Traumatic Stress Disorder, Common Mental Disorder Symptoms and R & R experiences.
12.1% of respondents (n=27) reported symptoms of common mental disorder and 3.7% (n=8) reported probable PTSD. 50% (n=110) reported hazardous use of alcohol during R & R. In the pre- and post-assessed sample, mental health status and alcohol use levels were similar at both survey points. Using principal component analysis, five components of R & R were identified; mentally switching off from deployment, travel experience, physical recovery, relaxation, rest and social support. R & R was extremely popular and although it did not improve mental health overall, the ability to engage with or derive satisfaction from aspects of the five components was significantly associated with better mental health and less alcohol use at the end of R & R.
Operational commanders should advise personnel about the best way to actively engage with R & R before they leave theatre and be aware of the significant detrimental impact of disrupted travel arrangements upon the ability to benefit from R & R.
We aimed to quantify the relationship between national income and infant and under-five mortality in developing countries.
We conducted a systematic literature search of studies that examined the relationship between income and child mortality (infant and/or under-five mortality) and meta-analysed their results.
Developing countries.
Child mortality (infant and /or under-five mortality).
The systematic literature search identified 24 studies, which produced 38 estimates that examined the impact of income on the mortality rates. Using meta-analysis, we produced pooled estimates of the relationship between income and mortality. The pooled estimate of the relationship between income and infant mortality before adjusting for covariates is –0.95 (95% CI –1.34 to –0.57) and that for under-five mortality is –0.45 (95% CI –0.79 to –0.11). After adjusting for covariates, pooled estimate of the relationship between income and infant mortality is –0.33 (–0.39 to –0.26) while the estimate for under-five mortality is –0.28 (–0.37 to –0.19). If a country has an infant mortality of 50 per 1000 live births and the gross domestic product per capita purchasing power parity increases by 10%, the infant mortality will decrease to 45 per 1000 live births.
Income is an important determinant of child survival and this work provides a pooled estimate for the relationship.
To examine the effect of the 24-h doctors’ strike on 21 June 2012 on hospital activity in English NHS hospitals.
Retrospective descriptive study of inpatient, outpatient and Accident and Emergency (A &E) activity in NHS hospitals over the strike period.
All English NHS hospitals.
Patients admitted to hospital, patients with outpatient appointments and A &E attendances over a three-week period (from 11 to 29 June 2012), excluding weekends and spanning the strike day.
Numbers and percentage change of inpatient admissions (elective and emergency), day surgery cases, outpatient appointments cancellations, A &E attendances and in-hospital deaths on the day of the strike compared with patient activity on the Thursday before and the Thursday after the strike week.
There were a total of 795,267 admissions, 5,602,971 outpatient appointments, 356,645 outpatient cancellations (by NHS provider), 4,470,208 outpatients seen by medical staff, 986,322 A &E attendances and 13,857 in-hospital deaths over the three-week period. Compared with the non-strike period, on the day of the strike, emergency admissions fell by 2.4% while the elective admissions decreased by 12.8%. There was a 7.8% drop in the number of outpatients seen by medical staff on the day of the strike and a 45.5% increase in the number of cancelled appointments by NHS hospitals, while A &E attendances dropped by 4.7%. The impact of the strike across regional Health Authorities in England was varied. The North West Health Authority was affected the most while the least affected Health Authorities were the South West, East of England and South Central.
The 24-h doctors’ strike in England on 21 June 2012 significantly affected the provision of healthcare by NHS hospitals. We observed regional variations on NHS service levels on the day of the strike.
Most existing health-related quality-of-life research concerns the impact of disease on patients. However, in several medical specialties including dermatology, oncology, and physical and mental disability, studies have been carried out investigating the impact of disease on the lives of families of patients. The aim of this paper is to review the literature which relates to the impact of disease on family members of patients. The OVIDSP Medline was selected as the primary database. Searches were limited to sources published in English. One hundred and fifty-eight papers were identified for review. The definition of family varied across the literature, and a broad definition was accepted in this review. This review shows that a wide variety of aspects of family members' lives can be affected, including emotional, financial, family relationships, education and work, leisure time, and social activities. Many of these themes are linked to one another, with themes including financial impact and social impact being linked to emotional impact. Some positive aspects were also identified from the literature, including family relationships growing stronger. Several instruments exist to measure the impact of illness on the family, and most are disease or specialty specific. The impact of disease on families of patients is often unrecognized and underestimated. Taking into account the quality of life of families as well as patients can offer the clinician a unique insight into issues such as family relationships and the effect of treatment decisions on the patient's close social group of partner and family.