Vision screening in a primary care setting. A missed opportunity?

To determine the effectiveness of vision screening in a primary care setting, we administered a questionnaire and a vision test to 458 patients from a general medical clinic. Subjects were referred for complete ophthalmologic evaluation if they failed the vision test or met other "high-risk" criteria based on information contained in the questionnaire. Patient-initiated requests for eye examinations were also honored. A total of 169 patients were scheduled for eye examinations, and 148 actually underwent ophthalmologic evaluation. One hundred one of those examined were referred on the basis of the study criteria. "Serious eye disease" (cataract, glaucoma, diabetic retinopathy, or age-related macular degeneration) was diagnosed in 96 (95%) of these patients. Prompt surgical intervention was recommended in 27 (27%), and medical treatment was begun in 21 (21%). Of those with serious eye disease, 59% met the criteria by failing the vision test, while 69% met the high-risk criteria determined by the questionnaire. Of the 148 subjects who received ophthalmologic evaluations, 47 requested them. Serious eye disease was diagnosed in 23 (50%) of the 47 patients. None of these individuals required immediate surgery, and medical treatment for glaucoma was begun in eight (17%). These data suggest that screening for serious eye disease in a primary care setting is an efficient mechanism to use for the identification of patients with undetected ocular disorders that require follow-up or treatment.     

Is screening for pancreatic cancer in high-risk groups cost-effective? – Experience from a Danish national screening program

ObjectivePancreatic cancer (PC) is the fourth leading cause of cancer death worldwide, symptoms are few and diffuse, and when the diagnosis has been made only 10–15% would benefit from resection. Surgery is the only potentially curable treatment for pancreatic cancer, and the prognosis seems to improve with early detection. A hereditary component has been identified in 1–10% of the PC cases. To comply with this, screening for PC in high-risk groups with a genetic disposition for PC has been recommended in research settings.DesignBetween January 2006 and February 2014 31 patients with Hereditary pancreatitis or with a disposition of HP and 40 first-degree relatives of patients with Familial Pancreatic Cancer (FPC) were screened for development of Pancreatic Ductal Adenocarcinoma (PDAC) with yearly endoscopic ultrasound. The cost-effectiveness of screening in comparison with no-screening was assessed by the incremental cost-utility ratio (ICER).ResultsBy screening the FPC group we identified 2 patients with PDAC who were treated by total pancreatectomy. One patient is still alive, while the other died after 7 months due to cardiac surgery complications. Stratified analysis of patients with HP and FPC provided ICERs of 47,156 US$ vs. 35,493 US$ per life-year and 58,647 US$ vs. 47,867 US$ per QALY. Including only PDAC related death changed the ICER to 31,722 US$ per life-year and 42,128 US$ per QALY. The ICER for patients with FPC was estimated at 28,834 US$ per life-year and 38,785 US$ per QALY.ConclusionsWith a threshold value of 50,000 US$ per QALY this screening program appears to constitute a cost-effective intervention although screening of HP patients appears to be less cost-effective than FPC patients.     

Is there a benefit to adding rituximab to CHOP in the overall survival of patients with B-cell non-Hodgkin's lymphoma in a developing country?

Rituximab (R) has changed the prognosis of patients with non-Hodgkin's lymphoma (NHL) in developed countries, but its role has not been analyzed in underprivileged circumstances. One hundred and two patients with NHL treated in a developing country were analyzed: 28 patients with follicular lymphoma (FL) and 74 with diffuse large B-cell lymphoma (DLCL). Patients were treated upfront with either cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or R-CHOP; the decision to employ R depending solely on the ability of patients to defray it. In DLCL, 42 were given CHOP and 32 R-CHOP, whereas in FL, 19 were given CHOP and 9 R-CHOP. The impact of the addition of R was found to be clearer in FL than in DLCL. In patients with DLCL, the overall survival (OS) was 87% at 80 months for those treated with R-CHOP and 84% at 145 months for those treated with CHOP (not significant). In patients with FL, the OS was 89% at 88 months for those treated with R-CHOP and 71% at 92 months for those treated with CHOP (P = 0··05). In a multivariate analysis, other variables which were identified to be associated with the OS were IPI and number of cycles in DLCL. It is concluded that R produced a mild positive impact in the OS of patients with FL, but not in those with DLCL. Since the addition of R results in a 36-fold increase in treatment costs, these observations may be important to decide therapeutic approaches in NHL patients living in underprivileged circumstances.     

Lung cancer in rheumatoid arthritis. Is there a need for better risk assessment and screening?

Clinical Rheumatology - Extra-articular manifestations are common in rheumatoid arthritis (RA), with lung involvement being one of the commonest. Apart from interstitial lung disease which is a...     

Women hospitalized with atrial fibrillation: Gender differences,trends and outcome from a 20-year registry in a middle eastern country (1991–2010)

Background

Most of the published research on atrial fibrillation (AF) is limited to studies in the developed world and included mainly Caucasian patients. Data about women with AF among other ethnicities is very limited.

Objectives

The aim of this study was to compare the clinical characteristics, treatment and outcome of women to men hospitalized with AF in a middle-eastern country.

Methods

Retrospective analysis of prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Clinical characteristics, management, and outcomes of AF patients were compared according to gender.

Results

During the 20-years period; 1417 women and 2432 men were hospitalized for AF. Women were 5 years older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment and were also less likely to be current smokers and to have ischemic heart disease and impaired left ventricular function when compared to men. There was no gender preference in the use of anticoagulation. The prevalence of concomitant ischemic heart disease and hypertension increased, while the prevalence of valvular heart disease and heart failure decreased among patients hospitalized with AF over the study period. In-hospital mortality and stroke rates were comparable between the two groups.

Conclusions

Women hospitalized with atrial fibrillation were older in age and had higher prevalence of co-morbid cardiovascular risk factors compared to men whereas, mortality and stroke rates were comparable.     

Variation in mitochondrial DNA levels in muscle from normal controls. Is depletion of mtDNA in patients with mitochondrial myopathy a distinct clinical syndrome?

Summary Recent studies have identified a group of patients with cytochrome oxidase (COX) deficiency presenting in infancy associated with a deficiency of mtDNA in muscle or other affected tissue (Moraes et al 1991). We used a novel approach to compare the level of mitochondrial (mtDNA) compared to nuclear DNA in skeletal muscle from a group of patients and controls, based on dot blots that were hybridized with a mtDNA probe labelled with³⁵S[dCTP] and a reference nuclear DNA probe labelled with [³²P]dCTP.The ratio of mtDNA to nuclear DNA varied in samples from different muscles of the same individual. Secondly, fetal muscle had very low levels of mtDNA compared to nuclear DNA, and data from older controls (cross-sectional rather than sequential) suggest that this increases rapidly over the first 3 months after birth and thereafter more slowly. Four patients with COX deficiency had levels of mtDNA that were below the age-specific range defined by normal quadriceps muscle. The clinical features of two of these patients were similar to earlier case reports of mtDNA depletion. In three patients the clinical course was relatively benign compared to cases that have previously been described.Levels of mtDNA in skeletal muscle from some patients with other forms of muscle disease were also found to be low, suggesting that mtDNA depletion, possibly related to depletion of mitochondria, may be a relatively non-specific response of muscle to various pathological processes. However, there does appear to be a distinctive group of young patients with reduced cytochrome oxidase activity in muscle, in whom marked mtDNA depletion reflects the primary defect.     

Pertussis surveillance in Switzerland, 1992 to 1997 - a large epidemic in 1994. What next?

Cases of whooping cough have been recorded by the Swiss Sentinel Surveillance Network Sentinella (SSSN) since June 1991 to monitor pertussis trends in Switzerland and to assess the current vaccination strategy. The Sentinella network consists of a sampl     

Trends in hospitalization for heart failure in Scotland, 1990-1996. An epidemic that has reached its peak?

AIMS: Studies in the 1980s and early 1990s showed striking increases in hospitalization rates for heart failure. This report describes contemporary trends in hospitalization for heart failure. METHODS: Scotland (population of 5.1 million) has a well described system for recording details of all hospitalizations. All hospital discharges (and deaths) can be linked to each patient. We examined the period 1990-1996 (158 989 hospitalizations with a principal or secondary diagnosis of heart failure). RESULTS: Compared to 1990, the number of hospitalizations with a principal diagnosis of heart failure increased in men (by 16%) and women (by 12%), although the highest numbers were recorded in 1993 in women (21%) and in 1994 in men (24%). Similar trends were seen for the number of patients hospitalized overall and those having a 'first ever' hospitalization. Hospitalizations with a secondary diagnosis of heart failure increased much more strikingly (by 110% and 60% in men and women, respectively). Re-hospitalization became more common, increasing by 53% and representing 23% of all hospitalizations in 1996. Median length of stay fell (from 9 to 8 days in men and 13 to 10 days in women with a principal diagnosis of heart failure), resulting in 100 877 fewer inpatient days. Heart failure (principal diagnosis) still, however, accounted for 4.2% of all inpatient medicine/geriatric bed-days in 1996. Although inpatient case fatality fell slightly, the total number of deaths due to heart failure (principal diagnosis) increased slightly. CONCLUSIONS: Heart failure continues to be a common cause of hospitalization. The previously reported 'epidemic' of increasing rates of hospitalization for heart failure in Scotland and elsewhere between 1980 and 1990, however, seems to have peaked (in about 1993/4).     

Clinical screening for HIV in a health centre setting in urban Kenya: an entry point for voluntary counselling, HIV testing and early diagnosis of HIV infection?

A study was conducted among patients attending a public health centre in Nairobi, Kenya in order to (a) verify the prevalence of HIV, (b) identify clinical risk factors associated with HIV and (c) determine clinical markers for clinical screening of HIV infection at the health centre level. Of 304 individuals involved in the study,107(35%) were HIV positive. A clinical screening algorithm based on four clinical markers, namely oral thrush, past or present TB, past or present herpes zoster and prurigo would pick out 61 (57%) of the 107 HIV-positive individuals. In a resource-poor setting, introducing a clinical screening algorithm for HIV at the health centre level could provide an opportunity for targeting voluntary counselling and HIV testing, and early access to a range of prevention and care interventions.     

Primary resistance to antituberculosis drugs: a national survey conducted in C?te d'Ivoire in 1995-1996. Ivoirian Study Group on Tuberculosis Resistance.

SETTING: A national survey of resistance to the antituberculosis drugs used in C?te d'Ivoire was conducted in 1995-1996. OBJECTIVE: To determine the rate of primary resistance to antituberculosis drugs. METHODS: Consecutive new tuberculous patients with positive smear were recruited from tuberculosis centres and rural health centres. Drug susceptibility testing was performed according to the proportion method. Positive cultures were tested against streptomycin, isoniazid, rifampicin, and ethambutol. All resistant strains and 10% of all randomly sampled cultures were sent to an external laboratory for quality control. Human immunodeficiency virus (HIV) tests were performed for consenting patients at the tuberculosis centres. RESULTS: Among the 430 samples, 320 were available for analysis. Primary resistance to antituberculosis drugs was observed for 13.4% of the patients (43/320); multidrug resistance (to at least isoniazid and rifampicin) was observed for 5.3% of the patients; 14.2% of HIV-negative and 16.2% of HIV-positive patients were resistant to at least one antituberculosis drug (P = 0.70). CONCLUSION: This study is representative of antituberculosis drug resistance in C?te d'Ivoire. The rate of primary resistance is high and emphasises the need for a sentinel survey of tuberculous resistance. The National Tuberculosis Control Programme needs to make improvements in its management of tuberculosis cases.     

Is B-type natriuretic peptide a useful screening test for systolic or diastolic dysfunction in patients with coronary disease? Data from the Heart and Soul Study

BACKGROUND: Whether B-type natriuretic peptide (BNP) levels can be used to screen for ventricular dysfunction in patients at risk of heart failure but without overt symptoms is not known. We examined the characteristics of a BNP test for identifying systolic and diastolic dysfunction in outpatients with stable coronary disease. METHODS: In a cross-sectional study of 293 outpatients who had stable coronary disease and no history of heart failure, we compared elevations in plasma BNP levels with echocardiography for the diagnosis of systolic dysfunction (ejection fraction <55%) and diastolic dysfunction (diastolic dominant pulmonary vein flow with ejection fraction > or =55%). RESULTS: A total of 48 patients (16%) had systolic dysfunction, and among the remaining 245 with preserved systolic function, 31 (13%) had diastolic dysfunction. At the standard cutpoint of >100 pg/mL, an elevated BNP level was 38% sensitive (80% specific) for systolic dysfunction and 55% sensitive (85% specific) for diastolic dysfunction. Negative likelihood ratios were 0.8 (95% confidence interval [CI]: 0.6 to 1.0) for systolic dysfunction and 0.5 (95% CI: 0.4 to 0.8) for diastolic dysfunction. Positive likelihood ratios were 1.9 (95% CI: 1.2 to 2.9) for systolic dysfunction and 3.8 (95% CI: 2.4 to 5.9) for diastolic dysfunction. Areas under the receiver operating characteristic curves were 0.59 (95% CI: 0.49 to 0.69) for systolic dysfunction and 0.79 (95% CI: 0.71 to 0.87) for diastolic dysfunction. CONCLUSION: These data suggest that BNP is not a useful screening test for asymptomatic ventricular dysfunction in patients with stable coronary disease.     

Is routine viral screening useful in patients with recent‐onset polyarthritis of a duration of at least 6 weeks? Results from a nationwide longitudinal prospective cohort study

Objective

To study the contribution of routine viral screening tests in patients with early rheumatoid arthritis (RA) or a potential for progressing to RA.

Methods

Eight hundred thirteen patients with swelling of at least 2 joints for at least 6 weeks and a symptom duration of less than 6 months in the ESPOIR cohort were screened for parvovirus B19 (IgG and IgM anti–parvovirus B19 antibodies), hepatitis B virus (HBV; hepatitis B surface antigen), hepatitis C virus (HCV; anti‐HCV antibodies), and human immunodeficiency virus (HIV; anti–HIV‐1 and ‐2 antibodies).

Results

Parvovirus B19 testing was performed in 806 patients and showed longstanding immunity in 574 (71.2%) and no antibodies in 223 (27.7%). Among the 9 remaining patients (7 IgG positive/IgM positive, 1 IgG negative/IgM positive, and 1 IgG indeterminate/IgM positive), only 2 (0.25%; 95% confidence interval [95% CI] 0–0.99%) had a positive polymerase chain reaction test for parvovirus B19; these patients (women ages 34 and 40 years) had no extraarticular signs. HIV seroprevalence was 0.12% (n = 1 of 813; 95% CI 0.01–0.8%) and HCV seroprevalence was 0.86% (n = 7 of 808, 95% CI 0.38–1.86%). HCV‐related arthritis was diagnosed in 4 patients (0.5%). HCV‐seropositive patients had significantly higher transaminase levels than the other patients (P = 0.001), with no significant differences for the other laboratory data. HBV seroprevalence was 0.12% (n = 1 of 808; 95% CI 0.01–0.8%); the positive HBV status was known before study inclusion, and the patient had no diagnosis of HBV‐related arthritis. Finally, routine viral testing identified 2 patients with parvovirus B19 infection and 3 with HBV infection (0.6%; 95% CI 0.2–1.5%). Cost was €85.05 per patient (total €68,720).

Conclusion

Routine serologic testing did not contribute substantially to the diagnosis in this context.     

Which mild head injured patients should have follow-up after discharge from an accident and emergency ward? A study in a university hospital setting in Kelantan, Malaysia

Mild head injury (MHI) is a common presentation to many hospitals in both rural and urban settings in Southeast Asia, but it is not well studied. We studied 330 patients that presented to Hospital Universiti Sains Malaysia Emergency Department with possible MHI, with the intentions to identify prognostic factors that may improve the diagnosis of MHI in the emergency setting as well as to determine which patients would need follow-up. Patients' one-year outcomes were classified as discharged well (DW) for patients without post-traumatic signs and symptoms and discharged with long term follow-up (DFU) for patients with such signs and symptoms. Four patients died and 82 were DFU. An abnormal skull X ray was associated with mode of accident and type of transportation, older age, presence of vomiting, confusion, bleeding from ear, nose or throat, abnormal pupil size on the right side associated with orbital trauma, unequal pupillary reflexes, absence of loss of consciousness (LOC), a lower Glasgow Coma Scale (GCS) score, multiple clinical presentations, and DFU. An abnormal CT scan was associated with older age, multiple clinical presentation, skull X-ray findings, and DFU. A similar analysis on outcomes revealed that mode of accident, older age, vomiting, confusion, headache, bleeding from ear, nose and throat, neurological deficits, absence of LOC, pupil size, multiple presentation, abnormal skull X ray, CT scan of the brain, and a GCS of 13 was associated with DFU. In conclusion, all patients involved in motor vehicle accidents (MVAs), especially motorcycles, aged over 30 years of age, with multiple clinical presentations, including a lower GCS, and with abnormal radiological findings should have a longer follow-up due to persistent post-traumatic symptomatology.