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PubMed2002

Mammographic tissue, breast cancer risk, serial image analysis, and digital mammography. Part 2. Serial breast tissue change and related temporal influences.

The work presented herein is the second part of a review of breast tissue-related cancer-risk research. Briefly, in part 1, the tissue-risk research is discussed. In this part, factors that influence temporal breast tissue change are reviewed. Since breast composition is correlated with some of the known risk factors, understanding these influences may provide a mechanism for measuring the dynamics of breast cancer risk. The purpose of this work is to provide support for an automated serial mammography study under way at the authors' institution, where the digital mammographic images are acquired with a full-field digital mammography imaging system. At the initiation of the serial study, it was clear that the authors did not fully understand the nature of the problem: automatically comparing similar mammographic scenes acquired at different times. The evidence indicates that there are many factors that influence breast tissue at any given time and thus have the ability to alter the associated radiographic appearance over time. In general, the topics considered herein include aging; involution; breast development; exogenous and endogenous hormonal interactions such as hormone replacement therapy, oral contraceptive use, and menstrual timing; screening sensitivity issues and interval cancers; tumor growth rates; sojourn times; and lifestyle factors such as diet and exercise. Throughout this work, commentaries and suggestive strategies for automated serial image analysis are provided.

Aging↗

PubMed2005

Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy.

BACKGROUND: The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined. METHODS: We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling. RESULTS: Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of 194 dollars per screened patient, for a cost-effectiveness ratio of 15,078 dollars per quality-adjusted life-year. Screening cost less than 50,000 dollars per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was 41,736 dollars per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost 57,138 dollars per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection. CONCLUSIONS: The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.

Adult↗

PubMedDate not supplied

Development and assessment of a screening test for detecting childhood disabilities.

The paper outlines the development and assessment of a screening test for broad-based identification of major disabilities in children under 6 years of age. The Disability Screening Schedule (DSS) has been developed which should act as a one time screen for all major disabilities viz. physical, motor, sensory and mental retardation. The DSS was developed after reviewing a number of existing screening instruments. It was pilot tested in 3 phases and suitably modified. Nineteen AWW received a short training and used the DSS to screen children with disabilities in their respective areas. It was field tested by administering it on 3560 children (0-6 years) drawn from nine urban slums of South Delhi. The workers used the DSS and identified 245 children as having an impairment/at risk conditions and 3315 children were reported as normal. The investigator cross checked 219 'impaired' and 536 'normal' children. On the basis of the review exercise, the DSS was validated and was found to have a sensitivity of 0.89 and a specificity of 0.98. The DSS is a short questionnaire, and the administration time is about 5 minutes.

Child↗

PubMed1994

Fetal anomalies in a controlled one-stage ultrasound screening trial. A report from the Helsinki Ultrasound Trial.

The aim of the study was to compare whether systematic strictly timed screening of all pregnancies would improve the detection of major fetal anomalies. All pregnant women (95%) from a certain area were randomly allocated for one ultrasound screening examination between the 16th and 20th weeks of gestation. Otherwise the screening (N = 4691) and control groups (N = 4619) received the same antenatal care. Screening included a systematic search for fetal anomalies. In the screening group, 40% of major fetal anomalies were detected in the screening, and 11 abortions were induced because the malformation was either lethal or severely handicapping. In the control group, 77.0% of participants had ultrasound examination any time during pregnancy. By ultrasound 13 (27%) major fetal anomalies were detected, only two of these before the 21st week of gestation. Screening detected most of the anomalies of the central nervous system and genitourinary system and cases with multiple anomalies, but was less satisfactory in detecting the anomalies of the heart and gastrointestinal tract. The perinatal mortality rate was 4.2 per 1000 in the screening group and 8.4 per 1000 in the control group (p = 0.013). The detection of major fetal anomalies in ultrasound screening can reduce perinatal mortality. A systematic search for fetal anomalies should be included in the ultrasound screening of all pregnancies.

Abortion, Induced↗

PubMed1999

Transhepatic approach for cardiac catheterisation in children: initial experience.

AIM: To assess initial experience of cardiac catheterisation in children by the transhepatic approach where conventional venous access is impossible. PATIENTS AND METHODS: Percutaneous transhepatic cardiac catheterisation was performed on six occasions in five children (three male) aged 4 to 36 months (mean 17 months). All children had documented femoral venous occlusion and all but one had occlusion of the superior vena cava. Ultrasound was used in five of the six procedures to help identify a large hepatic vein. A 4 F or 5 F sheath was introduced into the vein using the Seldinger technique. In the fourth patient, hepatic venous access was obtained immediately without the assistance of ultrasound. RESULTS: Percutaneous transhepatic catheterisation was successfully performed at all six attempts. Total procedure time ranged from 120 to 200 minutes (mean 138 minutes) and screening time from 14 to 22 minutes (mean 16.8 minutes). A serious complication was encountered in only one patient who had a retroperitoneal bleed after administration of thrombolysis for loss of femoral arterial pulse. CONCLUSIONS: The percutaneous transhepatic technique can provide a safe alternative approach for cardiac catheterisation in children with multiple venous occlusion. The procedure can be performed very simply using the Seldinger technique and equipment normally used for conventional venous cannulation for cardiac catheterisation.

Cardiac Catheterization↗

PubMed2002

Real-time antifungal susceptibility screening aids management of invasive yeast infections in immunocompromised patients.

We examined the utility of a semi-solid agar antifungal susceptibility screening (SAAS) test in real-time management of eight immunocompromised patients with invasive yeast infections. Tests of amphotericin B and fluconazole concentrations of 0.5 and 2 mg/L and 1, 8 and 40 mg/L, respectively, were performed on Candida albicans (two), Candida tropicalis (two), Candida krusei (one), Candida glabrata (one) and Trichosporon species (spp.) (two). All but the Trichosporon spp. and C. glabrata isolates were resistant to fluconazole at > or = 40 mg/L, and patients were successfully managed accordingly. Real-time antifungal susceptibility screening can assist in clinical management of invasive yeast infections.

Adult↗

PubMed1994

Urgent therapy for acute stroke. Effects of a stroke trial on untreated patients.

BACKGROUND AND PURPOSE: As part of the recruitment efforts for the National Institutes of Health Tissue Plasminogen Activator Pilot Study, public education and awareness campaigns were conducted to encourage early hospital arrival. We evaluated the change in arrival times during the course of the study for all stroke patients, including those who were not entered into study. METHODS: Data were gathered on all patients presenting within 24 hours of stroke onset to all of the study hospitals. Coincident with the start of the study, educational and promotional programs, which stressed signs and symptoms of stroke and the need to call 911, were presented to physicians, paramedical personnel, and the public. The study was divided into four quartiles to analyze differences in time to hospital arrival and use of 911. RESULTS: Of 2099 patients screened, time data were available on 1116. During the course of the study, the mean time from symptom onset to hospital arrival declined significantly (3.2 hours versus 1.5 hours). Patients arrived for treatment sooner at community hospitals than at university/teaching hospitals. The use of 911 increased from 39% in the first quartile of the study to 60% in the fourth quartile. This was a consistent finding in all study sites. Increased use of 911 was seen almost exclusively in patients with nonhemorrhagic stroke. CONCLUSIONS: Times from stroke onset to hospital arrival decreased significantly during the course of the National Institutes of Health Tissue Plasminogen Activator Pilot Study. Significantly increased use of 911 was the likely major explanation for the shortened arrival times. The decrease in arrival times may be a consequence of the public and professional education programs conducted at all study sites.

Acute Disease↗

PubMed2000

A randomized controlled trial comparing cholecystocholangiography with cystic duct cholangiography during laparoscopic cholecystectomy.

BACKGROUND: The rate of intraoperative cholangiography fell after the advent of laparoscopic cholecystectomy due to the perceived difficulty of cystic duct cannulation. It is suggested that cholecystocholangiography (CCC) is a valid and easier alternative. The present study compares cystic duct cholangiography (CDC) to CCC with evaluation of procedural time, success rate, image quality, cost and radiation exposure. METHODS: Patients undergoing laparoscopic cholecystectomy were randomized to CCC (n = 40) or CDC (n = 36). Details of operative times, radiation exposure, and use of disposable equipment were recorded prospectively. Cholangiograms were performed using image intensification and were scored from 0 to 6 according to adequacy of images. Data were analysed on an intention-to-treat basis with the chi-squared test, t-test or Fisher's exact test. RESULTS: The success rate for CDC was 100% and for CCC it was 72% (P = 0.0005). Patients with a failed CCC went on to have CDC for a success rate in the CCC arm of 92.5%. Comparing CDC to CCC, there was no significant difference in cost ($30.16 vs $33.36: P = 0.11), operative time (1 h 13 min vs 1 h 3 min; P = 0.19) or cholangiogram time (8 vs 9 min: P = 0.39). There was a significant difference in screening time (0:41 vs 1:33 min; P < 0.0001), adequate image quality (100 vs 72.5%, P = 0.0005) and procedure-related complications (0 vs 5; P = 0.03). CONCLUSIONS: A significant number of CCC fail. Successful CCC provides inferior image quality and greater radiation exposure. It provides no benefit in time or cost and cannot be recommended for operative cholangiography.

Adult↗

PubMed2003

Cost-effectiveness of pancreatic cancer screening in familial pancreatic cancer kindreds.

BACKGROUND: Endoscopic screening of families predisposed to pancreatic cancer is increasingly used, but the cost-effectiveness of screening is unknown. METHODS: A decision analysis was used to compare one-time screening for pancreatic dysplasia with EUS to no screening in a hypothetical cohort of 100 members of familial pancreatic cancer kindreds. Abnormal EUS findings are confirmed with ERCP and patients with abnormal findings are candidates for total pancreatectomy. Lifetime medical care costs and life expectancy were modeled, and the main analysis was conducted from the third-party payer perspective. The base-case analysis assumed a 20% prevalence of pancreatic dysplasia and 90% sensitivity of EUS and ERCP. RESULTS: Endoscopic screening was cost-effective, with an incremental cost-effectiveness ratio of $16,885/life-year saved. Screening was more cost-effective as the probability of dysplasia increased and as the sensitivity of EUS and ERCP increased. Screening remained cost-effective if the prevalence of dysplasia was greater than 16% or if the sensitivity of EUS was greater than 84%. Procedure costs had a limited impact on cost-effectiveness. CONCLUSIONS: Endoscopic screening of carefully selected members of familial pancreatic cancer kindreds appears to increase patient life expectancy in a cost-effective manner. Screening should be performed in centers that have experience with endoscopic screening for pancreatic dysplasia. The cost-effectiveness of repeated screening remains to be determined.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2006

Impact of a national beta-thalassemia carrier screening program on the birth rate of thalassemia major.

BACKGROUND: In Taiwan, the prevalence of beta-thalassemia trait is at least 1.1%. The Taiwan government initiated a National Screening Program in 1993. Herein we examine the differences before and after the initiation of this program. PROCEDURE: Data consisting of the total number of patients and the birth prevalence beta-thalassemia major were collected. Ninety-one patients with transfusion-dependent thalassemia treated in our hospitals were included for analysis. DNA analysis was performed for 86 patients. RESULTS: In Taiwan 361 patients exist. The birth prevalence of per 100,000 births was 5.6% in 1994 and declined to 1.21 in 2002. Fourteen patients were born after the program's initiation. DNA analysis of them revealed a new mutation (IVS-1-5 (G-C)), which was introduced through an inter-racial marriage. Otherwise, the remainder was the common beta-thalassemia mutations found in Taiwan. CONCLUSIONS: Despite how successful the National Screening Program is, a few doctors still failed to detect parents at risk. In addition, we are concerned about the emerging problem of the increase of interracial marriages where parents may not have appropriate screening. Hence, postgraduate education programs for physicians, health education for the general population, and timely screening of inter-racial marriage should become a priority.

Child↗

PubMed2006

Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy.

INTRODUCTION: The increased use of fluoroscopy during percutaneous nephrolithotomy (PCNL) places the urologist and operating room personnel at an occupational risk for measurable radiation exposure. We evaluated the degree of radiation exposure received by the patient and operating room personnel at our endourology facility during PCNL. PATIENTS AND METHOD: The incident radiation dose to the patient and the urologist during 50 consecutive PCNL procedures was monitored using lithium fluoride thermo-luminescent dosimeter chips (TLD chips). A hand held radiation survey meter was used to measure the radiation in air at different positions occupied by various operating room personnel. The approximate distances of the various personnel from the X-ray tube were also measured. RESULTS: PCNL was performed upon 35 males and 15 females. The average time for the procedure was 75 minutes (range: 30-150 min). The mean fluoroscopy screening time during the procedure was 6.04 min (range 1.8-12.16 min) with a mean fluoroscopy tube potential of 68 kVp and a mean tube current of 2.76 mA. The mean radiation exposure dose to the patient was 0.56 mSv (SD +/- 0.35), while the mean incident radiation exposure to the finger of the urologist was 0.28 mSv (SD +/- 0.13). CONCLUSION: The various operating room personnel are within safe radiation dose limits during PCNL. Efficient fluoroscopy further reduces the radiation scatter. All occupational personnel should 'achieve as low as reasonably achievable' dose by adhering to good practices.

Adolescent↗

PubMed2006

Spectrum of epithelial cell abnormalities of uterine cervix in a cervical cancer screening programme: implications for resource limited settings.

OBJECTIVE: (1) To compute the frequencies and peak age incidences of epithelial cell abnormalities (ECA) of uterine cervix in a cytology-based screening programme and (2) to analyze the comparative frequencies of squamous intraepithelial lesions (SIL) and malignancies in age groups <40 and > or =40 years, in order to assess the implications for screening protocol in resource limited settings. STUDY DESIGN: Pap smears form 29,475 women were cytologically screened over a 4-year period as a part of hospital-based screening programme. The frequencies, peak age incidences and mean age of various ECA detected were computed. The data was further stratified in to age groups <40 (Gp 1) and > or =40 (Gp 2) and comparative profile of the lesions was analyzed. RESULTS: On cytologic screening of the smears 5.6% ECA were detected. Atypical squamous cells-undetermined significance (ASC-US) and low grade SILs (LSIL) were diagnosed more frequently in Gp 1 (p<0.001) while atypical glandular cells (AGC) and malignancies were more significantly more frequent in Gp 2 (p<0.001). The frequency of HSIL was similar in the two groups. The SILs predominated in the fourth decade while the malignant lesions were most frequent in age >50 years. The mean age for LSIL and HSIL was 34.7 and 37.7 years, respectively, while for malignancy it was 51.8 years thus corroborating the hypothesis that a prolonged latent phase exists between the precursor lesions and the onset of invasive cancer. CONCLUSIONS: Since the goal of any screening programme should be to pick up majority of the precursor lesions and not frank cancers, it is desirable to initiate screening before 40 years of age. The WHO recommendation of once in a life time screening between 35 and 40 years of age seems appropriate for resource limited settings like ours.

Adult↗

PubMedDate not supplied

The use of electrical impedance spectroscopy in the detection of cervical intraepithelial neoplasia.

The objective of this study was to assess the performance of cervical impedance spectroscopy in the detection of cervical intraepithelial neoplasia (CIN) using the new MKIII impedance probe. A prospective observational study recruited women referred to colposcopy with an abnormal Papanicolaou smear. A pencil probe incorporating four gold electrodes was used to measure electrical impedance spectra from cervical epithelium. Colposcopy examinations, including probe positioning, were video recorded to allow for correlation between results obtained from colposcopic impression, histopathologic examination of colposcopic punch biopsies, and impedance measurements. Cervical impedance-derived parameters R, S, R/S, C, and Fc were assessed to see if significant difference in values obtained in CIN and normal epithelium existed. The performance of the probe in identifying women with CIN was also assessed. One hundred seventy-six women were recruited and 1168 points analyzed. Parameters R, S, and Fc showed significant separation of CIN or squamous intraepithelial lesion (SIL) from squamous, mature metaplastic, and columnar epithelium. Sensitivities of 74% and specificity of 53% can be achieved in identifying CIN 2/3 (High-grade SIL) in screened women. We conclude that cervical impedance spectrometry provides a potentially promising real-time screening tool for CIN with similar sensitivity and specificity to currently used screening tests. Further research is ongoing to develop the probe for potential clinical use.

Cervix Uteri↗

PubMed2000

Factors associated with repeat mammography screening.

BACKGROUND: Even organizations with differing mammography recommendations agree that regular repeat screening is required for mortality reduction. However, most studies have focused on one-time screening rather than repeat adherence. We compare trends in beliefs and health-related behaviors among women screened and adherent to the National Cancer Institute's screening mammography recommendations (on schedule), those screened at least once and nonadherent (off schedule), and those never screened. METHODS: Our data are from a baseline telephone interview conducted among 1,287 female members of Blue Cross Blue Shield of North Carolina who were aged either 40 to 44 years or 50 to 54 years. RESULTS: The 3 groups differed significantly on beliefs and health-related behaviors, with the off-schedule group almost consistently falling between the on-schedule and never screened groups. Off-schedule women were more likely than on-schedule women, but less likely than those never screened, to not have a clinical breast examination within 12 months, to be ambivalent about screening mammography, to be confused about screening guidelines, and to not be advised by a physician to get a mammogram in the past 2 years. Off-schedule women perceived their breast cancer risk as lower and were less likely to be up to date with other cancer screening tests. CONCLUSIONS: Our findings suggest that women who are off schedule are in need of mammography-promoting interventions, including recommendations from and discussion with their health care providers. Because they are more positive and knowledgeable about mammography than women who have never been screened, they may benefit from brief interventions from health care providers that highlight the importance of repeat screening.

Adult↗

PubMed1994

HIV screening of surgeons and dentists: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists. DESIGN: We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years. RESULTS: Using "best-case" scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively. CONCLUSIONS: HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.

AIDS Serodiagnosis↗

PubMed1998

Simple, sensible preventive measures for managed care settings.

The best preventive care consists of a combination of office-based services: patient education, life style counseling, clinical vigilance through routine check ups, and the administration of timely screening. In a healthcare environment of tightened resources, tighter schedules, and increased patient demand for your time, it is nevertheless possible to offer substantive preventive care for older patients in an efficient and cost effective manner. Interventions for cardiovascular disease include weight loss, a low-fat diet, vitamin E, and folic acid. Screening is recommended for breast, cervical, and colon cancer, but prostate cancer screening is controversial. The value of mammograms in women over age 50 is well-established. Preventive measures for osteoporosis include calcium and vitamin D, estrogen replacement, and weight-bearing exercise.

Aged↗

PubMedDate not supplied

Role of depth in eye distance measurements: comparison of single and stereo-photogrammetry.

Photogrammetry has been used as an alternative to direct measurements to obtain facial distances for a variety of anthropometric applications. Taking measurements from photographs is less intrusive to subjects and reduces screening time, but measurements from single frontal photographs neglect depth information and may be inadequate for screening purposes. This study examined the role of depth in measurements of palpebral fissure length, interpupillary distance, inner canthal distance, and outer canthal distance using single- and stereo-photogrammetry; an operator selected landmarks on single and stereo digital photographs displayed on a computer monitor. Depth was not found to make a significant contribution to eye distances in an idealized system where the real-world coordinates of points on the eye were known from three-dimensional calibration of stereo photographs. However, the differences found between measurements taken from single frontal photographs and those from stereo-photogrammetry indicated that measurements from single photographs are prone to errors due to misalignment of the camera, the face, and the calibration instrument during image acquisition; if single photographs are to be used, the placement of these components should be carefully monitored.

Anthropometry↗

PubMed1997

A rapid and nonisotopic method for the screening and sequencing of p53 gene mutations in formalin-fixed, paraffin-embedded tumors.

Evaluation of the clinical significance of p53 gene mutations requires molecular analysis of primary tumors from large series of patients with long follow-up periods. In this study, we describe a sensitive, rapid, nonisotopic and inexpensive procedure for the polymerase chain reaction (PCR)-single-stranded conformational polymorphism (SSCP) detection and subsequent sequencing of p53 mutations in formalin-fixed and paraffin-embedded tumor (PET) samples. To optimize this method, we used a panel of 34 mutations previously identified in this gene by isotopic PCR-SSCP analysis of frozen colorectal carcinomas. Identical SSCP band shifts were observed in PET sections from each of these frozen tumors, except for one case in which the tumor cell content was probably too low. All of the 34 mutations were detected by use of an optimized minigel SSCP/silver staining procedure. The total PCR-SSCP screening time with use of this protocol was less than 8 hours. An additional improvement was the use of multiplex SSCP to screen two p53 exons (5/7 and 6/8) simultaneously, thus effectively halving the amount of reagents and time required for mutation analysis. To identify the exact nucleotide alterations, mutant single-stranded DNA was excised from silver-stained SSCP gels, reamplified, and used as template in sequencing reactions. The PCR-SSCP procedure we describe can be performed in routine histopathology laboratories, requiring only a thermal cycler and minigel electrophoresis apparatus. Our results demonstrated the feasibility of conducting large retrospective analyses of p53 gene mutation status in archival tumor material. Studies of this kind should allow elucidation of the clinical role of p53 mutation in various human cancer types.

Carcinoma↗