Intestinal parasites in refugee claimants: a case study for selective screening?

The medical profiles of 1,967 refugee claimants to Montreal, Quebec, Canada from January 1987 to July 1987 were reviewed to evaluate the importance of imported intestinal parasite infection in this group and to re-examine the screening policy governing these infections. An overall infection rate of 29.3% was obtained for pathogenic parasites, where helminths were four times more frequently found than the protozoa Entamoeba histolytica and Giardia lamblia. Age, sex, years of schooling, country of origin and level of eosinophilia were found to be associated with infection, with country of origin being the strongest predictor of infection. These results document the parasite infection in a select group of immigrants which would not have been identified and treated if a special program of screening were not in operation. We suggest that the present immigration policy of no screening for intestinal parasite infection be at least modified to include a recommendation that new arrivals, who are considered to be at high risk for parasite infection, be informed that an examination for parasites would be beneficial to their personal health.     

A comparison of methods of adjusting stillbirth and neonatal mortality rates for birthweight in hospital and geographical populations

Birthweight-specific rates can be useful for summarising stillbirth and neonatal mortality in populations but, sometimes, a single summary measure is required to compare several relatively small subpopulations. However, any particular summary has its shortcomings, and various methods have been proposed. We wished to compare mortality between local authorities and between hospitals in the Thames regions and thus required a single summary measure for each subpopulation. It was not obvious in advance which summary to use or whether a single method would work well for both local authorities (a geographical unit) and hospitals. This study compared six methods of calculating a single summary, three using indirect standardisation to adjust (500 g bands, 10-percentile bands, 10 z-score bands) and three using regression to adjust (mean birthweight, proportion < 2500 g, proportion < 1500 g). The data used were 570 016 births in the Thames Regions, broken down into its 96 local authorities and 65 hospitals. To investigate how well each adjustment had performed, we calculated the rank correlation between the crude and various adjusted mortality rates and mean birthweight, proportion < 2500 g and proportion < 1500 g. This was done separately in the local authorities and hospitals. If a method of adjustment had worked very well, these correlations should be negligible. For the local authorities, adjustment for proportion < 1500 g gave the lowest correlations. Adjustment for mean birthweight and 500 g-band standardisation did not appear to work so well but gave moderately low correlations. For hospitals, 500 g standardisation gave the lowest correlations. Adjustment for mean birthweight and proportion < 2500 g worked only moderately well. Percentile and z-score adjustment did not work well for local authorities or hospitals. We conclude that several methods appear to work reasonably well for local authorities, whereas for hospitals, 500 g indirect standardisation worked best. Percentile and z-score standardisation did not work well in these subpopulations.     

Recruitment methods for screening programmes: The price of high compliance

High population compliance is seen as a prerequisite for an equitable screening service. To achieve high compliance fixed appointments are usually advocated. However, the costs of achieving high compliance have not previously been described. To assess the costs of achieving high compliance we have used a randomised trial of two common appointment methods: 800 women aged 45-49 living within 20 miles of Aberdeen were selected at random from the Community Health Index. They were randomly assigned to receive one of two letters—one offering a fixed appointment, the other inviting them to telephone to make an appointment. For a defined population fixed appointments achieved high compliance but only by reducing the opportunities for screening; for every 100 women screened, 110 additional women were denied the opportunity of a screening test. In contrast the open letters of invitation achieved efficiency by increasing the number of women screened with given resources within a larger population. Thus for screening services with fixed budgets, high compliance is achieved only by screening fewer people.     

The implications of high bed occupancy rates on readmission rates in England: A longitudinal study

Hospital bed occupancy rates in the English National Health Service have risen to levels considered clinically unsafe. This study assesses the association of increased bed occupancy with changes in the percentage of overnight patients discharged from hospital on a given day, and their subsequent 30-day readmission rate. Longitudinal panel data methods are used to analyse secondary care records (n = 4,193,590) for 136 non-specialist Trusts between April 2014 and February 2016. The average bed occupancy rate across the study period was 90.4%. A 1% increase in bed occupancy was associated with a 0.49% rise in the discharge rate, and a 0.011% increase in the 30-day readmission rate for discharged patients. These associations became more pronounced once bed occupancy exceeded 95%. When bed occupancy rates were high, hospitals discharged a greater proportion of their patients. Those were mostly younger and less clinically complex, suggesting that hospitals are successfully prioritising early discharge amongst least vulnerable patients. However, while increased bed occupancy was not associated with a substantial increase in overall 30-day readmission rates, the relationship was more pronounced in older and sicker patients, indicating possible links with short-fallings in discharge processes.     

抗CCP抗体联合RF检测类风湿性关节炎诊断试验Meta分析

目的通过诊断试验Meta分析,综合评价抗环瓜氨酸肽抗体(CCP)和类风湿因子(RF)联合诊断类风湿关节炎(RA)的效果。方法通过检索万方、维普、CNKI等数据库,获得有关抗CCP和RF联合诊断RA的文献,提取相关数据;采用SAS 8.02进行诊断试验Meta分析。结果抗CCP/RF并联的准确度为0.803,诊断优势比为16.590;抗CCP+RF串联的准确度为0.841,诊断优势比为27.781;两种联合诊断准确度比较,差异无统计学意义(P0.05)。结论抗CCP和RF联合诊断效果较好,并联能够提高灵敏度,串联能够提高特异度,联合诊断对RA具有较高的诊断价值。     

The psychology and physiology of obesity: implications for screening and treatment

This article examines the psychological and physiological concomitants of obesity and presents practical methods for working with obese patients. Three areas of physiology are covered: fat cell theory, set point theory, and dietary obesity. The social and emotional consequences of obesity are discussed, as are the psychological stages experienced by both patients and professionals during a typical course of weight reduction. Screening is a most important aspect of a program. There are several methods for determining which patients will profit from treatment. Recent advances in treatment include a focus on physical activity, improvements in behavior modification, and the development of aggressive methods for promoting weight loss in moderately and morbidly overweight persons. Finally, social support is discussed, because the social context in which a program is administered may be more important than the nature of the program itself.     

Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations?

Chlamydia trachomatis is the most prevalent sexually transmitted bacterial pathogen. Nevertheless, selective, rather than universal, screening for chlamydia has been recommended, largely because testing is expensive and requires considerable technical expertise. A total of 1,348 women in four family planning clinics in San Francisco, California, were screened from March 1987 to January 1988 to identify criteria for selective screening. Of these, 9.2% had a positive chlamydia test using direct fluorescence. Logistic regression analysis identified five factors associated with infection: age less than 25 years, cervical friability, single marital status, a new sexual partner within the past 3 months, and lack of barrier contraceptive use. No single risk factor or combination of risk factors had both a high sensitivity and a high positive predictive value for infection. While screening all women who were unmarried would detect 93% of those with chlamydia, the positive predictive value of 10.7% was not much higher than the overall prevalence. Conversely, screening all women with cervical friability, which had a positive predictive value of 23.2%, would only detect 11% of those with chlamydia. On the basis of the authors' findings, selective screening should not be used in high prevalence populations in which all women are at risk and should be screened for chlamydia.     

A self-completed nutrition screening tool for community-dwelling older adults with high reliability: A comparison study

Objectives

Malnutrition is common in community-dwelling older adults and is associated with poor outcomes including hospitalization and mortality. Recently, a 6-question short form mini nutritional assessment (SF-MNA) was validated for rapid nutrition screening. Ideally, nutrition screening could be performed by individuals or their caregivers prior to or during an outpatient clinical visit, thus allowing for the ongoing monitoring of nutritional status among older adults.

Design

We compared the SF-MNA administered by a healthcare professional (HCP) to a 6-item self-administered screening tool (Self-MNA) in 463 community dwelling older adults who gave informed consent. The population was 60% women with a mean age of 76.8+6.8 years. The HCP was blinded to the results of the Self-MNA questionnaire.

Results

Using the SF-MNA, 27% of subjects were malnourished, 38% were at risk, and 35% had normal nutrition status. The agreement between the Self-MNA and the SF-MNA was 99% (Self-MNA sensitivity 99%, specificity 98%, false negative rate 1%, false positive rate 2%) for identifying Malnourished subjects and 83% (sensitivity 89%, specificity 77%, false negative rate 11%, false positive rate 23%) for identifying At Risk of Malnutrition compared to the MNA-SF administered by a HCP.

Conclusion

We found that the Self-MNA demonstrates sufficient inter-rater reliability for use in nutrition screening among community-dwelling older adults. Further validation studies and the possible impact of language translation should be pursued.     

Performance evaluation of tests used for tuberculin screening in adults: Randomised comparison between Tine and Mono

Between February 1993 and December 1994, 875 adults underwent tuberculin screening by the Public Health Service of Parma. The adults were randomly assigned to a multipuncture test, Tine or Mono, and contemporarily, as a reference test, received the intradermal Mantoux (IM) in the opposite arm. The tests were then read 72 hours later by two different trained nurses. The error quota due to IM was estimated by repeating both the tests done initially in patients with discordant results. The Mono test revealed a sensitivity of 95%, which was the same as that observed for the Mantoux test. As an 'operative index' of the screening, the number of false positives subsequently tested for every 10 correctly identified was used. The authors retain that the results obtained indicate the validity of the Mono test for screening in the adult population with a prevalence of tuberculous infection above 10%.     

Review of methods used to measure comorbidity in cancer populations: no gold standard exists

ObjectiveThis article reviews methods used to measure comorbidity in the context of cancer; summarizing methods, identifying contexts in which they have been used, and assessing the validity, reliability, and feasibility of each approach.Study Design and SettingStudies describing methods to measure comorbidity in epidemiological studies related to cancer were identified. Data relating to content, face, and criterion validity, reliability, and feasibility were collected.ResultsTwo thousand nine hundred seventy-five abstracts were reviewed and 21 separate approaches identified. Content and face validity varied but tended to be higher for measures developed for cancer populations. Some evidence supporting criterion validity of all approaches was found. Where reported, reliability tended to be moderate to high. Some approaches tended to score well on all aspects but were resource intensive in terms of data collection. Eight indices scored at least moderately well on all criteria, three of which demonstrated usefulness in relation to non-site specific cancer (Charlson Comorbidity Index, Elixhauser approach, and National Cancer Institute [Combined] Index).ConclusionsNo gold standard approach to measuring comorbidity in the context of cancer exists. Approaches vary in their strengths and weaknesses, with the choice of measure depending on the study question, population studied, and data available.     

Public health implications of rapid hepatitis C screening with an oral swab for community-based organizations serving high-risk populations

Objectives. Between April and September of 2009 we evaluated the accuracy of the OraQuick HCV rapid antibody test and assessed its feasibility for use by community-based organizations (CBOs) serving populations at high risk for HCV in New York City.Methods. We compared the results of screening by OraQuick (oral swab) and enzyme immunoassay (EIA; blood draw). We performed ribonucleic acid polymerase chain reaction testing for discordant results. We also assessed research staff perceptions through a survey and focus group.Results. Overall, 97.5% of OraQuick and EIA results matched. Testing of discordant samples indicated that the rapid test was more likely than the EIA to provide a correct diagnosis. Research staff preferred the rapid test and identified challenges that would be overcome with its use. CBOs could benefit from increased testing capacity, and clients might benefit from more rapid access to education, counseling, and referrals.Conclusions. OraQuick''s accuracy is comparable to the EIA. The oral swab rapid test could help HCV screening programs reach individuals unaware of their status and expand testing into nonclinical settings such as mobile units.The World Health Organization estimates that 170 million people—3% of the global population—are infected with HCV.¹ In the United States the prevalence of anti-HCV positivity is estimated to be 4.1 million, or 1.6% of the population.² The estimated 2.2% prevalence of anti-HCV positivity among New York City residents is higher than that of the US population.³Approximately 75% to 85% of HCV infections become chronic increasing the risk of liver disease and progression to cirrhosis and hepatocellular carcinoma.⁴ HCV is a major contributor to cirrhosis-related death and is the leading indication for liver transplantation in the United States.⁵ Treatment with the current standard-of-care regimens of pegylated interferon and ribavirin can achieve a sustained viral response in 40% to 70% of cases, depending on genotype.^6,7 However, many HCV-infected individuals are unaware of their status because of insufficient availability of HCV screening and education.^8–10The enzyme immunoassay (EIA) that tests for antibodies to HCV infection is the most commonly used HCV screening test. This EIA testing method poses several challenges in high-risk populations such as injection drug users (IDUs), the homeless, currently or formerly incarcerated people, and immigrants. Many in these groups are uninsured or underinsured and face barriers to accessing health care. EIA testing requires phlebotomy and laboratory analysis of specimens, but this limits testing in nonclinical settings and requires patients to return to the testing site to receive results.¹¹ Among current or former IDUs, phlebotomy creates additional challenges, such as finding a usable vein.¹²The adoption of HIV rapid testing has been shown to increase the proportion of people receiving posttest counseling and test results, as well as referral for medical evaluation and treatment, if indicated.^13,14 A rapid test for HCV would allow individuals to be tested and learn the result in a single visit, while still connected to a health care provider, facilitating follow-up polymerase chain reaction (PCR) testing to confirm the presence of HCV ribonucleic acid and entry into medical care and other supportive services.Rapid HCV testing via oral fluid may offer additional benefits for testing programs and their staff. With a reduced need for phlebotomy, risk of exposure to blood-borne pathogens through needlestick injuries is also decreased. Although training is required for test administration, the level of technical skill is less than that required to perform phlebotomy, thereby enabling a broader range of staff to administer tests. We compared the effectiveness of the OraQuick HCV rapid test and the EIA in detecting HCV antibodies and assessed the feasibility of OraQuick''s use in urban outreach testing programs serving populations at high risk for HCV infection. We did not determine the sensitivity of the OraQuick test.     

Geographically-based cancer control: methods for targeting and evaluating the impact of screening interventions on defined populations

Successful implementation of cancer control programs depends on efficient targeting to those at highest risk of developing and dying from the disease. This study presents a methodology for targeting cancer screening on the basis of population and disease variation among small geographic areas. Techniques for quantifying the impact of targeting on the predictive value of a positive test are demonstrated, using 329 New York City health areas. Age-truncated crude incidence, late-stage incidence and mortality rates for breast, cervix, and colorectal cancer are used, using site-specific truncation points relevant to the age groups appropriate for screening. Coefficient alpha was used to determine rate stability with 2, 3, 5 and 7 years of data. The stability of most small area rates was found to reach acceptable levels only with 5 and 7 years of data. Targeting into areas where breast cancer prevalence was high increased the expected predictive value of a positive test by as much as 50% when compared with areas of average prevalence. Geographic targeting will be most useful where between-area variability in prevalence is large and within-area variability is small. The implications of these results are discussed and future studies are suggested.     

The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis

OBJECTIVE: To perform a meta-analysis to assess diagnostic characteristics of the CAGE in screening for alcohol abuse or dependence in a general clinical population and to test a new method for pooling of ROC curves. METHODS: Medline search performed over the period 1/1/1974 to 31/12/2001. MEASUREMENT: Calculation of diagnostic values. RESULTS: We identified 35 articles using the DSM criteria as the gold standard to test the diagnostic value of the CAGE. Only 10 studies could be included for the meta-analysis. With a cutoff point > or =2, the pooled sensitivity is far better in inpatients (0.87) than in primary care patients (0.71) or ambulatory patients (0.60). The pooled specificity also differs for each group. The likelihood ratios seem to be relatively constant over the populations (overall LR+:3.44;LR-:0.18). We calculated a pooled AUC of 0.87 (95% CI 0.85-0.89). At low specificity values, the sensitivity was homogeneous over the studies, and at a low sensitivity, the specificity was heterogeneous. CONCLUSION: The diagnostic value of the CAGE is of limited value using this test for screening purposes at his recommended cutpoint of > or =2.     

妊娠期高血压疾病患者无痛分娩中麻醉应用效果比较

目的 探讨低浓度舒芬太尼复合0.1%罗哌卡因腰硬联合麻醉(CSEA)+自控硬膜外镇痛泵(PCEA)在妊娠期高血压疾病患者无痛分娩中的应用效果.方法 选择陕西省西安市第四医院2016年6月至2017年2月119例妊娠期高血压疾病产妇随机分为3组,先椎管内单纯预注不同浓度的舒芬太尼,A组37例0μg/mL、B组42例0.4μg/mL、C组40例0.6μg/mL,后用舒芬太尼复合0.1%罗哌卡因行PCEA.比较三组镇痛前、镇痛后10min、20min、30min视觉模拟评分(VAS)评分,第一、二产程的时间及血压变化,产后1h内出血量,剖宫产率,先兆子痫和不良反应发生率及新生儿Apgar评分.结果 三组镇痛后各时间点VAS评分比较差异均有统计学意义(F值分别为6.138、10.142、3.341、5.883,均P<0.05),B组镇痛后10min、20minVAS评分与A组比较差异均有统计学意义(t值分别为3.525、9.418,均P<0.05),镇痛后30min、宫口开全与A组比较差异无统计学意义(P>0.05);C组镇痛后10min、20min、30min VAS评分与A组差异有统计学意义(t值分别为5.376、13.650、2.365,均P<0.05),宫口开全与A组比较差异无统计学意义(P>0.05);B组与C组镇痛后各时间点比较差异均无统计学意义(均P>0.05).三组第一产程收缩压、舒张压比较差异均有统计学意义(F分别为7.119、6.202,均P<0.05),B、C组与A组比较差异均有统计学意义(t值分别为12.989、7.536;13.650、6.281,均P<0.05),B组与C组比较差异均无统计学意义(均P>0.05);三组第二产程收缩压、舒张压比较差异均有统计学意义(F分别为6.703、5.113,均P<0.05),B、C组与A组比较差异均有统计学意义(t值分别为6.938、8.627;7.489、7.343,均P<0.05),B组与C组比较差异均无统计学意义(t值分别为0.115、0.042,均P>0.05).三组第一、二产程时间、产后1h内出血量比较差异均有统计学意义(F值分别为2.572、4.589、2.664,均P<0.05),且剖宫产率比较差异有统计学意义(χ2=8.438,P<0.05),A组均最高.C组恶心呕吐发生率均明显高于A、B组(χ2值分别为7.112、5.319,均P<0.05),瘙痒发生率明显高于A、B组(χ2值分别为3.902、6.794,均P<0.05).结论 妊娠期高血压疾病患者分娩镇痛以0.1%罗哌卡因复合舒芬太尼0.4μg/mL为最佳,不仅镇痛效果好,而且可有效维持血压平稳、缩短产程进展,降低剖宫产率,减少不良反应.     

A comparison of the population diagnosed with chlamydia in primary care with that diagnosed in sexual health clinics: implications for a national screening programme

OBJECTIVES: To compare demographic, behavioural and HIV testing characteristics of individuals diagnosed with chlamydia infection in primary care with those in genitourinary medicine clinics, in the absence of a screening programme. The aim was to explore the current and potential contribution of primary care to the control of chlamydia. STUDY DESIGN AND METHODS: We analysed data on individuals who reported one or more chlamydia diagnoses in the past 5 years in a large probability sample survey of the resident, UK general population aged 16-44 years. Estimates were weighted and odds ratios calculated. RESULTS: Women diagnosed in primary care reported fewer sexual partners, and were less likely to have had an HIV test in the past 5 years than their counterparts diagnosed in genitourinary medicine clinics. Age, ethnicity, social class, educational attainment and urbanization of area of residence did not differ between the two groups. Too few men were diagnosed in primary care to allow for such a comparison. CONCLUSIONS: Primary care already diagnoses a large number of women with chlamydia infection, who may perceive themselves as low risk through age or sexual behaviour, yet are likely to comprise a substantial proportion of all infections. Few men are diagnosed in primary care. These groups need to be strategically targeted in the context of a future chlamydia screening programme, which will focus on the screening of younger women at high risk, and in which the role of primary care is still in development.     

Cost-effectiveness model for hepatitis C screening and treatment: Implications for Egypt and other countries with high prevalence

Hepatitis C virus (HCV) infection is a major cause of cirrhosis and liver cancer, and many developing countries report intermediate-to-high prevalence. However, the economic impact of screening and treatment for HCV in high prevalence countries has not been well studied. Thus, we examined the cost-effectiveness of screening and treatment for HCV infection for asymptomatic, average-risk adults using a Markov decision analytic model. In our model, we collected age-specific prevalence, disease progression rates for Egyptians and local cost estimates in Egypt, which has the highest prevalence of HCV infection (~15%) in the world. We estimated the incremental cost-effectiveness ratio and conducted sensitivity analyses to determine how cost-effective HCV screening and treatment might be in other developing countries with high and intermediate prevalence. In Egypt, implementing a screening programme using triple-therapy treatment (sofosbuvir with pegylated interferon and ribavirin) was dominant compared with no screening because it would have lower total costs and improve health outcomes. HCV screening and treatment would also be cost-effective in global settings with intermediate costs of drug treatment (~$8000) and a higher sustained viral response rate (70–80%).