Prevention, screening and therapy of thyroid diseases and their cost-effectiveness

Cost-effectiveness analyses focused on benign thyroid diseases are under-represented in the literature. The calculation of costs per additionally gained life year is difficult: The benefit of prevention is shifted into the distant future. The influence of an untreated subclinical thyroid disease on life expectancy can only be demonstrated by a long-term follow-up and by epidemiological databases. Iodine supplementation and programs for the prevention of tobacco smoking (primary prevention) are very cost-effective. Smoking increases the risk both of multinodular goiter and of Graves' disease. Screening programs (secondary prevention) are discussed for the laboratory parameters thyrotropin (TSH), calcium and calcitonin. TSH testing seems to be very cost-effective for epidemiological considerations in a certain lifespan (newborn, pregnancy, postpartal, older persons, hospitalisation due to acute diseases) and in persons with previously elevated TPO-antibodies or TSH-values >2 mU/l, but dedicated cost-effectiveness analyses are lacking. On the other hand, the cost-effectiveness of a routine TSH testing beyond the age of 35 years has been shown by a high-quality decision analysis. Therapeutic strategies (tertiary prevention) aim at the avoidance of complications (atrial fibrillation, myocardial infarction, death for cardiac reasons) and of iatrogenic complications. Examples of a tertiary prevention are: firstly the definitive therapy of Graves' disease in patients who have an increased risk of relapse after antithyroid drugs (ATD), secondly the radioiodine therapy for subclinical hyperthyroidism and the radioiodine therapy of large goiters in older patients or in patients suffering from a relevant comorbidity. Cost-effectiveness analyses for different therapeutic strategies of Graves' disease were published using a lifelong time-horizon. The ablative radioiodine dose-regime is cost-effective as a first line therapy if the risk of relapse after ATD exceeds 60%.     

Aspects in mammographic screening. Detection,prediction, recurrence and prognosis

Screening mammograms comprising of 32 first round, 10 interval and 32 second round detected cancers and 46 normal were examined by an expert screener, a screening radiologist, a clinical radiologist and a computer-assisted diagnosis (CAD) system. The expert screener, screening radiologist, clinical radiologist and the CAD detected 44, 41, 34 and 37 cancers, respectively, while their respective specificities were 80%, 83%, 100% and 22%. Later, with CAD prompting, the screening and the clinical radiologist detected 1 and 3 additional cancers each with unchanged specificities. Screening mammograms comprising 35 first round, 12 interval and 14 second round detected cancers and 89 normal findings were examined without and with previous mammograms by experienced screeners. Without previous mammograms, the screeners detected 40.3 cancers with a specificity of 87%. With previous mammograms, 37.7 cancers were detected with a 96% specificity. The decrease in sensitivity was not significant but the screeners showed significant increase in specificity. Local recurrences in 303 nonpalpable breast cancers with preoperative localizations and breast conservation therapy were evaluated for needle-caused implant metastasis. A total of 214 percutaneous biopsies were performed. There were 33 local recurrences. Needle-caused seeding or implantation as based on the location of the recurrence in comparison to the needle path in the mammograms was suspected in 3/44 (7%) invasive cancers without radiotherapy. The mammographic characteristics of 317 nonpalpable breast cancers were categorized. Logistic regression showed that the risk ratios for a spiculated mass without calcifications and calcifications alone were 12 and 19 for invasive cancer and ductal cancer in situ (DCIS), respectively. Invasive ductal grade 1, ductal grade 2, lobular and ductal grade 3, had a risk ratio (RR) of 28, 17, 11 and 4.6, respectively, for a spiculated mass without calcifications. DCIS nuclear grade 3 and invasive ductal grade 3 had an RR of 17 and 9.7, respectively, for sole casting calcifications. The eight-year survival of 96 1-9-mm invasive breast cancers were investigated in relation to their mammographic appearance, node status and histologic grade. After a median follow-up of 7 years, 6/96 died from breast cancer: 3/14 had calcifications alone, 2/56 had spiculated masses, 1/12 had rounded mass, 5/78 were node-negative and 1/4 was node-positive. The survival rate was 93%: 77% for the calcifications alone, 95% for spiculated masses, 91% for rounded masses, 92% for node-negative and 75% for node-positive. Calcifications alone and node positivity, each, carried a significantly higher risk of death.     

应重视腹部创伤腹腔镜技术的分层次应用

相对于腹腔镜技术在腹部疾病的广泛应用,腹腔镜技术在腹部创伤中的应用同时存在开展范围不广泛及过度强调腹腔镜治疗作用的问题。本文从腹腔镜的筛查、诊断及治疗作用三个层次论述腹腔镜技术的发展现状及其优劣势,强调应充分认识腹腔镜的对空实质器官损伤、腹腔或腹膜后器官损伤、开放或闭合性损伤等不同伤情在诊断及治疗层面上的优劣势差异,结合医院自身技术条件,从筛查、诊断及治疗三个不同层次积极、循序渐进地开展腹腔镜技术的应用,为腹部创伤患者提供更加微创、安全的诊断及治疗手段。     

Epidemiology of lung cancer in women: risk factors, survival, and screening

OBJECTIVE: Lung cancer remains the leading cause of cancer mortality in both men and women. Tobacco use causes the vast majority of lung cancer in women but does not explain all cases, because about one in five women who develop lung cancer have never smoked. CONCLUSION: Environmental exposures, genetic predisposition, hormonal factors, and viral infection may all play a role in lung cancer in women. A better understanding may provide an avenue to more effective screening, diagnosis, and therapy.     

PAR-Q, Canadian Home Fitness Test and exercise screening alternatives

Procedures for the preliminary screening of asymptomatic adults who wish to exercise are reviewed with particular reference to experience gained through the mass use of the physical activity readiness questionnaire (PAR-Q) and the Canadian Home Fitness Test (CHFT). It is argued that both a brief submaximal exercise test and a subsequent moderate increase of habitual activity are extremely safe tactics to recommend to a symptom-free adult. There are some useful minor modifications which could be made to the PAR-Q instrument, but its sensitivity and specificity relative to such criteria as medical examination, hypertension, CHFT completion and exercise-induced ECG abnormalities compare favourably with alternative self-administered procedures. The basic difficulty of screening an asymptomatic population (highlighted by Bayes theorem) is the high percentage of false positive and false negative test results. One remedy would be to stratify the population in terms of known cardiac risk factors and to restrict detailed pre-exercise screening to the high risk segment of the population.     

再次进行乳腺摄影筛查女性的特点与筛查结果

目的研究再次进行乳腺摄影筛查女性的特点和筛查结果。方法回顾性收集424703例连续的乳腺摄影筛查影像资料,以及发现乳腺癌的活检结果和手术报告。研究乳腺摄影情况,确定首次与二次检查是否存在相同的病变。结果总体的乳腺癌阳性预测值为38.6%(95%CI:37.3%～39.8%)。147例(2.6%)进行再次筛查的病人中,86例再次检查时存在不同的病变,其中32例为恶性(37.2%,95%CI:27.0%～47.4%)。61例女性再次检查的目的为相同病变,其中22例为恶性(36.1%,95%CI:24.1%～48.0%)。比较这些女性与首次乳腺摄影诊断为癌症的特点。与再次检查时相同病灶不为肿瘤者相比,患癌症者通常在乳腺摄影中表现为可疑高密度影(86.4%与53.8%,P=0.02),首次检查工作流程中的活检率较低(22.7%与61.5%,P=0.004)。结论对于再次进行乳腺筛查的女性,无论是由于相同病灶还是不同病灶而进行,再次筛查的恶性肿瘤风险与首次筛查者相当。     

Characteristics and screening outcome of women referred twice at screening mammography

Objectives

To determine the characteristics and screening outcome of women referred twice at screening mammography.

Methods

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

Results

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P?=?0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P?=?0.004).

Conclusions

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

Key Points

? Cancer risk was 36% for lesions referred twice at screening mammography ? The cancer risk was similar for lesions referred only once at screening ? Densities at first referral were associated with increased cancer risk at second referral ? No biopsy at first referral was associated with increased cancer risk at second referral ? Patient and tumour characteristics were similar for women with and without diagnostic delay     

Osteoporosis: screening for stronger, healthier lives

President Clinton has signed into law a provision to standardize Medicare coverage for bone mass measurements, authorizing coverage for certain high-risk people for bone density screening. The legislation also requires the Secretary of Health and Human Services to establish frequency standards for bone mass measurement for Medicare beneficiaries, effective July 1, 1998. By 2010, a significant portion of the American population will be older than 60; already, more than one-third of women in the U.S. are older than 50; The implications for the direction of medical care are extraordinary A recent National Institute's of Health study notes that osteoporosis will reach "epidemic" proportions in the next decade. Already the disease causes more than 1.5 million fractures annually at a cost of more than $13 billion per year. Such numbers will only rise as the population ages. New efforts focus on identifying the disease in its earliest stages, assessing the rate of bone loss and encouraging preventive approaches. The role of radiology will continue to be critical.     

Cardiovascular screening and the elite athlete: advances, concepts, controversies, and a view of the future

This article addresses programmatic cardiovascular screening and evaluation of the elite athlete at the intercollegiate, national team, professional, and Olympic levels. Although much of this content may apply to high-school and recreational sports at large, it is not specifically designed to address athletes participating in all sports activities.     

PET and cancer screening

Various carcinomas are discovered incidentally during FDG PET study. This points to the potential use of PET as a cancer screening modality. Our experience using three PET scanners showed that PET can be performed in many individuals, and a wide variety of carcinomas can be detected at potentially curable stages. PET screening targets various organs that conventional organ-specific screening tests cannot cover. PET used simultaneously with conventional tests can prevent the overlooking of cancer, reduce false-positive results, and assist in the interpretation of CT and MR images. Thus, PET can play a supportive role when used with conventional screening tests. To reduce false-positive and false-negative results in PET screening, however, experienced PET oncologists who can differentiate between distinct physiological FDG uptake and faint abnormal FDG uptake are needed. In Japan, more than half of the PET facilities offer PET examinations for cancer screening of asymptomatic persons. Not a few individuals pay for sophisticated cancer screenings. Guidelines concerning the use of PET for cancer screening were issued by the Japanese Society of Nuclear Medicine in 2004. The guidelines provide for maintenance of study quality and warn of overselling PET screening. It is unclear how much PET contributes to sophisticated cancer screening. Data are lacking as to whether mortality is reduced by PET screening. Scientific evidence should be presented demonstrating the value of PET in cancer screening.