Shift work and subfecundity: a causal link or an artefact?

Methods: From 1 March 1998 to 1 May 2000, 39 913 pregnant women were enrolled in the DNBC. Data on job characteristics and TTP (0–2, 3–5, 6–12, and >12 months) were used for 17 531 daytime workers and 3907 shift workers who had planned the pregnancy. Fecundity odds ratios (ORs) were calculated with 95% confidence intervals using the discrete time survival analysis techniques performed by logistic regression. An OR above 1 expresses a shorter TTP and then a higher fecundity. Potential confounders, such as age at conception, gravidity, prepregnant body mass index, smoking, and alcohol consumption, as well as occupational characteristics, were also included in the model.

Results: Fixed evening workers and fixed night workers had a longer TTP. Compared with daytime workers, the adjusted ORs were 0.80 (95% CI 0.70 to 0.92) for fixed evening workers, 0.80 (95% CI 0.63 to 1.00) for fixed night workers, 0.99 (95% CI 0.91 to 1.07) for rotating shift (without night) workers, and 1.05 (95% CI 0.97 to 1.14) for rotating shift (with night) workers. When analysis was restricted to nulliparous women, the estimates remained unchanged. The proportions of unplanned pregnancies and contraceptive failures were higher among fixed evening and fixed night workers.

Conclusions: There was no unequivocal evidence of a causal association between shift work and subfecundity. The slightly reduced fecundity among fixed evening workers and fixed night workers may be mediated by pregnancy planning bias or differential options for sexual contacts.

     

Screening for prostate cancer: who and how often?

Engage patients in shared decision making by discussing the benefits and risks of prostate cancer screening. Patients who review educational pamphlets before an office visit engage more fully in the decision-making process. If performing prostate cancer screening, limit to men with greater than 10 years life expectancy. Because the lead time of a diagnosis based on PSA screening is estimated to be 5 to 7 years, PSA screening every other year is unlikely to cause a loss of sensitivity. Men with tumors with a Gleason score less than 5 are the best candidates for "watchful waiting," having a favorable 20-year survival.     

Do benefits and barriers differ by stage of adoption for colorectal cancer screening?

In 2003, over 148,300 people were expected to be diagnosed and 56,000 to die from colorectal cancer (CRC). First-degree relatives (FDRs) of people with colon cancer have a two- to eight-fold increased risk for CRC. Despite evidence that screening is effective, adherence with screening recommendations in this at-risk population is low. This study's purposes were to (1) identify perceived benefits and barriers of fecal occult blood testing (FOBT), sigmoidoscopy and colonoscopy, and (2) compare demographic characteristics and perceived benefits and barriers by stage of adoption for CRC screening. Participating FDRs (n = 257) completed a 40-min structured telephone interview. Despite high rates of agreement with the benefits of screening, most FDRs were not contemplating being screened. Of those 50 and older, most were in precontemplation for FOBT, sigmoidoscopy and colonoscopy. Older age was related to stage for FOBT and sigmoidoscopy, but not colonoscopy. Lack of provider recommendation also was related to stage. Consistent with theoretical predictions, precontemplators had (1) higher rates of endorsement of specific barriers to screening and (2) lower rates of endorsement of benefits than contemplators or actors. For morbidity and mortality reduction, participation in routine, periodic screening is imperative. These findings can guide development of screening-promoting interventions.     

Breast cancer screening: Should it be introduced and how?

Summary This brief discussion of the papers by Gästrin and Paccaud is looking at differences in the results of different study types. Introducing screening means changing unsystematic to systematic screening: only the latter has been shown to be effective. The comparison between randomized trials, and follow-up of acceptors only, suggests that the non-acceptors have much higher risks. Programmes should therefore concentrate on trying to reach non-acceptors. The combination of mammographic screening and self-examination in a randomized trial could add to the existing evidence.

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Zusammenfassung Die Diskussion der beiden Arbeiten von Gästrin und Paccaud befasst sich mit den Unterschieden zwischen systematischem und unsystematischem screening: Nur ersteres hat in der Vergangenheit Effekte gezeigt. Nachuntersuchungen von Frauen, welche Screening akzeptiert haben, zeigen bessere Resultate als die randomisierten Studien; dies weist darauf hin, dass Frauen, welche in unsystematischem Screening nicht erfasst werden, ein höheres Risiko haben. Neue Programme sollten deswegen unbedingt darauf achten, auch diejenigen Frauen für Screening zu gewinnen, welche sonst nicht kommen. Die Kombination der zwei Ansätze: Mammographie Screening und Selbstuntersuchung der Brust in einer randomisierten Untersuchung könnte wichtige Hinweise zur Ergänzung der bestehenden Evidenz geben.

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Résumé La brève discussion des articles de Gästrin et Paccaud porte sur la diversité des résultats obtenus lors d'études de types différents. En introduisant le dépistage, le dépistage non-systématique fait place à un dépistage systématisé, qui s'est révélé être efficace. La comparaison entre des essais randomisés et des études de suivi chez des femmes acceptant le dépistage suggère que les femmes nonsoumises au dépistage ont un risque plus élevé. Les nouveaux programmes devraient porter leur attention sur la motivation de ces femmes à haut risque. La combinaison du dépistage par mammographie et de la palpation du sein par la femme elle-même pourrait, dans le cadre d'un essai clinique randomisé, apporter des éléments complémentaires renforçant l'evidence déjà existante.

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Paper presented at a symposium on The Public Health Perspective of Social and Preventive Medicine, in celebration of the 20th anniversary of the Department of Social and Preventive Medicine, University of Berne, 25 June 1992 in Berne.     

Salivary cortisol and alpha-amylase: Is there consistency between psychosocial stress test and burdensome work shifts?

This study examined the consistency of salivary cortisol and alpha-amylase (sAA) total daily secretion between laboratory and field circumstances. The 95 participants were shift working female health care professionals with high (n = 53) or low (n = 42) psychosocial stress (job strain) measured by the Job Content Questionnaire (JCQ). The Trier Social Stress Test including a 5-min free speech and a mental arithmetic task was conducted with four, and field measurements with three daily saliva samples of cortisol and sAA during circadian rhythm and inter-shift recovery controlled morning shift, night shift, and a day off. The associations of salivary cortisol and sAA area under the curve with respect to ground (AUCg) and area under the curve with respect to increase (AUCi) between laboratory and field were tested using OLS (Ordinary Least Squares) regression. The sAA AUCg output in the laboratory was correlated with the output during all field measurement days and similarly among high and low job strain groups (p < 0.001). SAA AUCi and salivary cortisol AUCg and AUCi were not correlated between laboratory and field measurement, neither in the whole sample nor among the low or high job strain group. In conclusion, a laboratory measure of sAA AUCg output is promising in predicting stress-related output during burdensome work shifts and leisure time, whereas sAA AUCi or salivary cortisol seem not to have this potential.     

Tailored breast cancer screening with ultrasound and MRI?

The ACRIN 6666 trial has shown that the addition of ultrasound or MRI to mammography screening detects more breast cancers in women with dense breasts and at least one other breast cancer risk factor. This higher detection yield is accompanied by an increase in false-positive findings. Unfortunately, this study was not randomized into groups with and without the addition of ultrasound and MRI. It is therefore impossible to investigate if the improved detection rate also results in a smaller number of interval tumours which would be the best indication of the ultimate goal - a decrease in breast cancer mortality. Before any new and costly imaging is added to the breast cancer screening program, it is necessary to investigate if this will not merely increase the detection of indolent tumours. If additional imaging is implemented too hastily it will be hard to turn it back, and impossible to assess it in a randomized study.     

Widening the cervical cancer screening net in a South African township: who are the underserved?

Cervical cancer screening services in South Africa have failed to reach the majority of the population and to significantly reduce mortality. A household survey in a predominantly Black African population living in a low-income township on the outskirts of Cape Town was undertaken to ascertain the characteristics of women reporting never having been screened. In our group of 664 representatively sampled women. 45% of women reported having had a cervical screening test. However, in what at first glance appears to be a fairly homogeneous population, there were significant differences in the types of women who access and who do not access cervical smear services. The underserved tend to be the older, poorer, less educated, and unemployed (or working in the informal sector) women. They tend to live in nonpermanent dwellings without a partner, they do not know anyone else who has had a cervical smear, and they have not recently sought care for other ailments, or used contraception. Cervical cancer is a slow-to-develop, eminently preventable disease, and yet opportunistic screening through antenatal and family planning services has failed to reach the women most at risk. Efforts in the future must include targeting older women in health centres where they present for other curative services (diabetes, hypertension). Most importantly, areas of the community with the greatest concentration of marginalized women need to be targeted through peer education and other innovative programs. As the underserved tend to be the poorer and less educated women in the community, we must ensure that messages are culturally relevant and appropriate and have a holistic focus on women's physical, mental, and emotional health.     

MDR-TB screening in a setting with molecular diagnostic techniques: who got tested,who didn't and why?

Setting: The Revised National Tuberculosis Control Programme, Puducherry, India, which has facilities for molecular diagnostic technique.Objective: To determine pre-diagnostic and pre-treatment attrition among presumptive multidrug-resistant tuberculosis (MDR-TB) patients and reasons for attrition.Methods: In this mixed-methods study, the quantitative component consisted of retrospective cohort analysis through record review of all presumptive MDR-TB patients recorded between October 2012 and September 2013. The qualitative component included in-depth interviews with key informants involved in programmatic management of drug-resistant tuberculosis services.Results: Of 341 eligible presumptive MDR-TB patients, pre-diagnostic and pre-treatment attrition was respectively 45.5% (155/341) and 29% (2/7). Patients with extra-pulmonary TB (RR = 2.3), those with human immuno-deficiency and TB co-infection (RR = 1.7), those registered during October–December 2012 (RR = 1.3) and those identified from primary/secondary health centres (RR = 1.8) were less likely to be tested. Themes that emerged during the analysis of the qualitative data were ‘lack of a systematic mechanism to track referrals for culture and drug susceptibility testing’, ‘absence of courier service to transport sputum’, ‘lack of knowledge and ownership among staff of general health system’, ‘shortage of diagnostic kits’ and ‘patient non-adherence’.Conclusion: Despite the introduction of molecular diagnostic techniques, operational issues in MDR-TB screening remain a concern and require urgent attention.     

Participation and screening programmes for colorectal cancer: more would be better?

In clinical terms, a screening compliance rate of 100% may be deemed optimal in that the number of abnormalities detected is thereby maximized. This paper explores optimum compliance rates from the cost-effectiveness point of view by modelling the individual's decision to participate in the screening programme. Using data derived from contemporary colorectal screening trials, it assesses the compliance and cost effects of utilizing differing methods of screening invitation, and explores the incremental cost and benefits associated with compliance enhancement techniques. Given the estimated costs and benefits, attempts to attain higher levels of compliance would appear justifiable.     

Breast screening and health issues among rural females in Malaysia: How much do they know and practice?

ObjectiveThis study investigated rural women's knowledge of breast cancer and screening methods by ethnicity and examined the predictors of breast screening methods.MethodsA cross-sectional survey was conducted in 2011 in five rural districts of Perak; 959 women were interviewed using a semi-structured questionnaire. ANOVA and regression analysis were used in data analysis.ResultsWomen below 50 years old, of Malay ethnicity and who had secondary education scored better than those older, of Chinese ethnicity and had primary education (p < 0.001). The uptake of breast self-examination (BSE), clinical breast examination (CBE) and mammogram was 59%, 51% and 6.8%, respectively. Multivariate analysis revealed knowledge of breast cancer and CBE as top predictors of BSE, being married and knowledge of breast cancer as top predictors for CBE; and CBE as the top predictor of mammography uptake. Support from husbands and family members for breast cancer screening was a predictor for CBE and BSE.ConclusionKnowledge of breast cancer and its screening uptake varies by ethnicity, location and the type of support received. Efforts and approaches to improve the women's knowledge of breast cancer and its screening uptake therefore should be customized to address the different influencing factors.     

HIV antibody testing: who benefits and who loses?

From a public health perspective, a significant milestone in the AIDS crisis so far has been the development of serologic tests to detect exposure to the HIV. With AIDS now reported in more than 124 countries and in every state of the Union, with the possibility that in excess of two million Americans have been infected and in the absence of a cure or vaccine, the issue of testing cannot be ignored anymore. Unfortunately, the testing debate has generated more heat than light. This paper examines the proposed "benefit" to public health in testing certain target groups deemed "at risk", and also discusses socio-ethical implications of such testing. The whole question of HIV antibody testing essentially raises the need for a balance between voluntary and mandatory testing; and society's commitment to protect public health as well as safeguard individual civil rights.     

Legal risk-management programs in nursing homes: who has them and do they work?

Legal risk-management systems are designed to identify, prevent, or mitigate the negative effects of situations that potentially expose a health care facility and its staff to avoidable legal and financial liability. This article reports findings on the current status of risk-management systems in nursing homes. The relative costs and benefits of such programs are also discussed.     

Clinical inquiries. Does anal cancer screening reduce morbidity and mortality in men who have sex with men?

It's unclear whether anal cancer screening benefits men who have sex with men because high-quality studies on this subject are lacking. In the absence of high-quality data, anal pap smears aren't recommended for routine screening of men who have sex with men (strength of recommendation: C, expert opinion).