Influences on pre-hospital delay in the diagnosis of colorectal cancer: a systematic review

Colorectal cancer is a major global health problem, with survival varying according to stage at diagnosis. Delayed diagnosis can result from patient, practitioner or hospital delay. This paper reports the results of a review of the factors influencing pre-hospital delay – the time between a patient first noticing a cancer symptom and presenting to primary care or between first presentation and referral to secondary care. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Fifty-four studies were included. Patients' non-recognition of symptom seriousness increased delay, as did symptom denial. Patient delay was greater for rectal than colon cancers and the presence of more serious symptoms, such as pain, reduced delay. There appears to be no relationship between delay and patients' age, sex or socioeconomic status. Initial misdiagnosis, inadequate examination and inaccurate investigations increased practitioner delay. Use of referral guidelines may reduce delay, although evidence is currently limited. No intervention studies were identified. If delayed diagnosis is to be reduced, there must be increased recognition of the significance of symptoms among patients, and development and evaluation of interventions that are designed to ensure appropriate diagnosis and examination by practitioners

Pasture chemoscapes and their ecological services

Ruminant livestock-production systems are between a rock and a hard place; they are experiencing increasing societal pressure to reduce environmental impacts in a world that demands increased food supply. Recent improvements in the understanding of the nutritional ecology of livestock by scientists may help livestock producers respond to these seemingly contradictory demands. Forages are nutrition and pharmacy centers with primary (nutrients) and plant secondary compounds (PSC; pharmaceuticals, nutraceuticals), which can provide multiple services for the proper functioning of agroecosystems. Legumes with lower contents of fiber and higher contents of nonstructural carbohydrates, coupled with different types and concentrations of PSC (e.g., condensed tannins, terpenes), create a diverse array of chemicals in the landscape (i.e., the “chemoscape”) with the potential to enhance livestock nutrition, health and welfare relative to foodscapes dominated by grasses and other conventional feeds. These PSC-containing plants may reduce methane emissions and nitrogen (N) excretion from animals while increasing animal growth rate compared with swards dominated by grasses, and provide meat quality that appeals to consumers. Condensed tannins from sainfoin and saponins from alfalfa and manure of cattle consuming these forages also reduce N mobilization in soils, reduce nutrient leaching, and increase plant-available N stores for future use. The challenge for future pastoral production systems is to design multifunctional spatiotemporal arrangements of forages with “ideal” chemical diversity for specific ecoregions, aiming to achieve sustainability while increasing production goals and improving ecosystem services. Thus, the objective of this review is to stimulate the quest for chemically and taxonomically diverse pastoral feeding systems that optimize overall productivity; reduce environmental impacts; and enhance livestock, soil, and human health