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To explore how pre-existing conditions affect the diagnostic process for potential cancer in primary care patients.
Qualitative interview study using thematic analysis underpinned by a critical realist approach.
Primary care practices recruited through four Clinical Research Networks and UK health charities across England.
Interviews were conducted with 75 patients with one or more pre-existing conditions (anxiety/depression, diabetes, obesity, chronic obstructive pulmonary disease, Parkinson’s disease or multiple long-term conditions (four or more)) and 28 primary care professionals (general practitioners and nurses).
The study identified legitimacy as a central theme influencing patient trajectories in the health system while trying to receive a diagnosis for symptoms with which they presented to primary care. Patients engaged in self-triage to determine whether symptoms were ‘legitimate’ enough to seek care. Subsequent triaging steps (by receptionists, nurses and online systems) acted as gatekeepers, with decisions influenced by effectiveness of describing the symptom and subjective impressions. During consultations, clinicians relied on a mix of symptom narrative clarity, medical history and objective ‘metrics’ (eg, blood results, family history) to determine legitimacy for further investigations. Pre-existing conditions could either lower the threshold for referrals or obscure potential cancer symptoms. The stigma associated with mental health diagnoses often undermined perceived legitimacy and contributed to delays.
Legitimacy is continuously negotiated throughout the diagnostic pathway. It is shaped by social, moral and biomedical judgements. To promote early cancer diagnosis for patients with pre-existing conditions, clinicians must make legitimacy assessments explicit, reduce stigma especially around mental health and standardise triage processes.
Numerous published case reports have described retained drug needle fragments in soft tissue as causes of localised pain and infections in persons who inject drugs (PWIDs). Furthermore, there are case reports of PWIDs with lung and heart embolisations caused by needle emboli. Subcutaneously retained needles also pose a risk of needlestick injury to medical staff. There are no previous epidemiological attempts to evaluate how common X-ray-confirmed retained drug needle fragments are among community-dwelling PWIDs. Due to the unclear clinical relevance of needle fragment retentions, there is a need to systematically evaluate the prevalence of retained needles, related complications and risk factors predisposing needle fragmentations.
We have planned a prospective cross-sectional study covering multiple ambulatory clinics that manage PWIDs in Tampere, Finland. PWIDs will be asked to give their written informed consent prior to any study procedures. Initially, we aim to recruit a sample for a pilot study of 20 adults (≥18 years) who will be asked to fill out a questionnaire related to their drug use history and their suspicions of having retained needle fragments. Subsequently, participants will undergo X-ray imaging of the injection sites as part of the study. Female participants of childbearing age (
We submitted the study protocol for ethics review to the Tampere University Hospital Ethics Committee and received their favourable opinion (study code: R22037). We subsequently sought organisational permission from the clinics to conduct the study. To be enrolled, PWIDs must provide written informed consent. The study results will be published in international peer-reviewed journals and conference proceedings.
The ‘Developing and evaluating an adapted behavioural activation intervention for depression and diabetes in South Asia (DiaDeM)’ trial investigates a psychological intervention, behavioural activation (BA), on people with both diabetes and depression in Bangladesh and Pakistan. This study aimed to aid the intervention and trial design.
This was a modelling study using microsimulation to assess the intervention’s cost-effectiveness. Diabetes was modelled using the UK Prospective Diabetes Study model based on Pakistani patients and depression was modelled using Patient Health Questionnaire-9 (PHQ-9) trajectories allowing for multiple depressive episodes. It was assumed that diabetes-related adverse events increased depression recurrence, while depression impacted haemoglobin A1c, increasing diabetes-related events. The model estimated (1) maximum cost of BA which would be cost-effective (headroom analysis) to inform intervention design, and (2) value of reducing uncertainty around different measures (value of information analysis) to prioritise data collection in the DiaDeM study.
Analysis was conducted from a Pakistani healthcare perspective over a lifetime with costs and outcomes discounted at 3%.
BA plus usual care was compared against usual care. BA involved six sessions by a trained (non-mental health) facilitator. The usual care comparator was the prevailing mix of pharmacological and non-pharmacological treatments used in Pakistan.
The primary outcome was disability-adjusted life-years (DALYs). Secondary outcomes included life years, healthcare costs and the rate of depression and diabetes-related events.
Over their lifetime, individuals receiving BA plus usual care avoid 3.2 (95% credible interval: 2.7 to 3.8) years of mild depression and experience fewer diabetes-related events. BA plus usual care resulted in an additional 0.27 (0.03 to 0.52) life years, 0.98 (0.45 to 1.86) DALYs averted and had incremental healthcare costs of –US$97 (–US$517 to US$142), excluding BA costs. The maximum cost per BA course at which was cost-effective is US$83 (US$9 to US$214). Value of information analysis found the most important measures to include in the trial are the impact of depression on diabetes and PHQ-9 over time.
This is the first model to jointly model depression and diabetes for South Asia and uses novel methods to reflect the diseases and inform intervention and trial design. This evidence has helped to inform the design of the DiaDeM intervention and the trial to evaluate it.
DiaDeM trial: ISRCTN40885204, DOI: ; pre-results, DOI:
The PREgnancy Care Integrating translational Science, Everywhere Network was established to investigate specific placental disorders (pregnancy hypertension, preterm birth, fetal growth restriction and stillbirth) in sub-Saharan Africa. We created a repository of clinical and social data with associated biological samples from pregnant and non-pregnant women. Alongside this, local infrastructure and expertise in the field of maternal and child health research were enhanced.
Pregnant women were recruited in participating health facilities in The Gambia, Kenya and Mozambique at their first antenatal visit or at the time a placental disorder was diagnosed (Kenya and The Gambia only). Follow-up study visits were conducted in the third trimester, delivery and 6 weeks to 6 months postpartum. To elucidate the difference between pregnancy and non-pregnancy biology in these settings, non-pregnant nulliparous and parous women, aged 16–49 years, were recruited opportunistically primarily from family planning clinics in Kenya and Mozambique, and randomly through the Health and Demographic Surveillance System in The Gambia. Non-pregnant participants only had one study visit. Biological samples were processed rapidly and locally, stored initially in liquid nitrogen and then at –80°C, and details entered into an OpenSpecimen database linked to their social determinants and clinical research data.
A total of 6932 pregnant and 1825 non-pregnant women were recruited to the study, providing a repository of clinical and social data and a biorepository of 482 448 samples. To date, baseline descriptive analysis of the cohort has been undertaken, as well as a substudy on the prevalence of COVID-19 in the cohort.
Analysis of data and samples will include an analysis of biomarker and social and physical determinants of health and how these interact in a systemic approach to understanding the origins of common placental disorders. The data from non-pregnant women will provide control data for comparison with the data from normal and complicated pregnancies. Findings will be disseminated to local stakeholders and communities through meetings and ongoing community engagement and globally by publication and presentations at scientific meetings.
FreshRSS 