Assessing risk factors as potential screening tests: a simple assessment tool

Many risk factors for disease are suggested as screening tests when there is little prospect that they could be useful in predicting disease. To avoid this, it is useful to know the relationship between the relative risk of a disease or disorder in people with high and low values of a risk factor, and the equivalent screening performance in terms of the detection rate (sensitivity) for a specified false-positive rate. We describe an interactive Risk-Screening Converter, accessible from the Internet (http://www.wolfson.qmul.ac.uk/rsc/), that transforms an odds ratio into the equivalent estimates of detection and false-positive rates. The converter is intended for general clinicians, for people engaged in research into risk factors and disease, and for those who give advice on applying such research findings into medical practice. It should help to distinguish effective screening methods from ineffective ones, and so improve clinical guidelines relating to screening and the prediction and prevention of disease.     

Arterial ultrasound screening as a tool for coronary risk assessment in asymptomatic men and women

One of the imaging tests most commonly used to assess cardiovascular diseases (CVDs) in daily practice is Doppler ultrasonography of the carotid and femoral arteries. We included 2709 participants with no history or symptoms of CVD; they had a risk factor assessment and a carotid and femoral ultrasonography at baseline. Incident cases of definite coronary events were recorded during a median follow-up of 6 years. Approximately, 63% of the sample presented abnormalities (carotid stenosis >50%, carotid plaque, femoral plaque, increased intima-media thickness [IMT]). A moderately increased IMT (>0.63 mm) or the presence of carotid or femoral artery plaque was related to prognosis. The associations persisted after adjustment for pretest risk, treatment with statins, and other Doppler ultrasonography abnormalities. The hazard ratio increased significantly with the number of abnormalities (varying from 2.35 [1.16-4.74] to 14.83 [6.47-33.9]).     

Self assessment in continuous professional development: a valuable tool for individual physicians and scientific societies

OBJECTIVES: To assess the appreciation of self assessment (SA) by multiple choice question (MCQ) tests during continuous professional development (CPD) meetings and to evaluate the attitude towards the option of recertification. METHODS: A questionnaire was completed at a meeting of the Swiss Societies of Rheumatology and Physical Medicine and Rehabilitation in 2003 (response rate 94.9% (223/235)). RESULTS: 60.9% of members found SA useful to assess rheumatological knowledge by MCQ tests; 71.3% thought it motivating to receive an anonymous feedback; 47.2% wanted an additional individualised feedback; 70.8% asked for SA to be continued every 2 years during CPD sessions; 26.3% favoured the option of recertification with identical standards to the Swiss certifying examination in rheumatology. Physicians in private practice less often chose the option of recertification than physicians employed by hospitals (OR = 2.09, 95% CI 1.03 to 4.18). No correlations between the type and duration of specialisation, personal reading time, frequency of attendance at CPD meetings, sex of the members, and the choices made were found. CONCLUSIONS: SA by MCQ tests during CPD meetings is highly accepted by Swiss rheumatologists. This reliable, valid, and economic method of learning needs assessment enables individual physicians and scientific societies to plan educational with specific goals in mind.     

The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea

Purpose  

Obstructive sleep apnea (OSA) remains underdiagnosed, despite our understanding of its impact on general health. Current screening methods utilize either symptoms or physical exam findings suggestive of OSA, but not both. The purpose of this study was to develop a novel screening tool for the detection of OSA, the NAMES assessment (neck circumference, airway classification, comorbidities, Epworth scale, and snoring), combining self-reported historical factors with physical exam findings.     

Quality of life research: a valuable tool for nephrology nurses

Findings from quality of life research provide nurses with valuable information for planning care. However, the instrument for measuring quality of life has to be carefully selected to ensure that it assesses accurately the impact on the patients' lives. The research tools reviewed in this article (QLI-H, and KDQOLTM) are well-established instruments that have contributed significantly to understanding issues surrounding quality of life in the end-stage renal disease population. This understanding will lead to improved patient care in the field of nephrology nursing practice.     

Peritoneoscopy: a valuable staging tool in ovarian carcinoma.

Peritoneoscopy was done within 1 month of exploratory laparotomy in 30 consecutive patients, with ovarian carcinoma as part of their pretreatment evaluation. Six of the 7 patients who were thought to have ovarian carcinoma localized to the pelvis (stages I and II) were found to have advanced disease (stage III) at peritoneoscopy and thus required a change in therapy. Metastatic diaphragmatic involvement in ovarian carcinoma is common and was found in 77 percent of all patients studied. The routine shielding if the liver area ordinarily used with total abdominal radiotherapy would select these patients for therapeutic failure. Peritoneoscopy supplied reevaluable finding in 2 of 7 patients having normal physical, roentgenologic, and laboratory examinations, as well as in 93 percent of all patients stuided. "Second look" peritoneoscopy precluded the need the laparotomy in 5 to 13 patients achieving as apparent clinical remission.     

The PFA-100: a potential rapid screening tool for the assessment of platelet dysfunction

The PFA-100 is a device that simulates high shear dependent platelet function in vitro and thus is particularly useful for screening for von Willebrand's disease (VWD). The aim of this study was to assess the overall potential of the PFA-100 as a primary clinical screening tool using the wide spectrum of clinical samples assessed for platelet function within our institution. The PFA-100 test was performed using both collagen/ADP (CADP) and collagen/epinephrine (CEPI) cartridges on samples from 337 patients with a wide variety of haemostatic defects. One hundred and eighty-two patients were defined as having normal platelet function based on classical laboratory tests and von Willebrand factor levels. The overall clinical sensitivity of the PFA-100 for platelet abnormalities (including VWD) was 81% for CADP and 86% for CEPI. The overall specificity was found to be 82% for CADP and 80% for CEPI. When utilizing both cartridges in combination (with both results either higher or lower than the upper cutoff of the normal ranges), the overall false positive and false negative rates were 12% and 6%, respectively. The PFA-100 proved to be sensitive in detecting classical defects by giving prolonged closure times in samples from patients with major platelet function defects (e.g. von Willebrand's disease, Glanzmann's thrombasthenia and Bernard Soulier syndrome). However, there were a small number of false negative results (6%) obtained with various milder platelet defects (e.g. Hermansky Pudlak syndrome, storage pool and release defects, type I VWD and macrothrombocytopenia). The PFA-100 test provides a useful rapid screening tool and should increase the efficiency and reduce the cost of the routine diagnosis of platelet dysfunction.     

Subjective global assessment: a simple and reliable screening tool for malnutrition among Indians.

BACKGROUND AND AIMS: Subjective global assessment (SGA) is a simple and reliable malnutrition-screening tool. The SGA has not been evaluated in India or in populations where chronic energy deficiency (CED) is rampant. We evaluated the value of preoperative nutrition, determined using the SGA, in predicting postoperative adverse outcomes in cancer patients. METHODS: Two hundred and ninety-four cancer patients undergoing elective surgery were screened for malnutrition using a modified version of the SGA, and 266 patients (aged 14-73 years [median 50]; 165 male) were eligible. All patients were followed up till discharge, and number of days on antibiotics, length of postoperative stay, occurrence of major adverse events, and death within 30 days were recorded. The association of preoperative SGA scores (A, B, or C) and BMI groups (< 18.5, 18.5-20 or> 20 Kg/m2) and four outcome variables were tested for statistical significance. RESULTS: The cancer sites included head and neck region in 112, gastrointestinal tract in 53, thoracic organs in 28, and other sites in 73 patients. The SGA scores were A in 152, B in 98, and C in 16 patients. The BMI was < 18.5 in 110 (41.8%) patients. The length of postoperative stay and the number of antibiotic days revealed a significant trend from SGA-A to SGA-C (p=0.000). Pre-defined adverse events occurred in 7.9%, 17.3% and 25% of SGA groups A, B, and C, respectively (p=0.025). The risk for adverse events was significantly higher in SGA-C group (OR 5.27, 95% CI 1.35-20.51, p< 0.016) compared to SGA-A group. Three patients in SGA-B group and one in SGA-C group died within 30 days (p=0.04). No significant association was detected between the three BMI groups and duration of antibiotic use, length of postoperative stay, adverse events or mortality. CONCLUSION: SGA is a simple and inexpensive way to identify clinically relevant malnutrition in Indian patients undergoing cancer surgery. Low BMI was not associated with postoperative adverse outcomes, and its use for nutritional screening is likely to overestimate severe malnutrition in Indian patients.     

High-sensitivity C-reactive protein as a risk assessment tool for cardiovascular disease

Almost half of first cardiovascular events occur in individuals with no known risk factors. Attempts in the last decade to predict cardiovascular risk more accurately have led to the emergence of a novel risk factor, C-reactive protein (CRP), which has proved to be as good a risk predictor as low-density lipoprotein cholesterol. C-reactive protein is an index of inflammation that is now believed to promote directly all stages of atherosclerosis, including plaque rupture. As measured by high-sensitivity assays, high-sensitivity CRP (hs-CRP) also independently predicts recurrent events in patients with known coronary artery diseases. Recent evidence implicates hs-CRP, and thus inflammation, in the metabolic syndrome and diabetes mellitus, particularly in women. As a clinical tool for cardiovascular risk assessment, hs-CRP testing enhances information provided by lipid screening or global risk assessment. Statin therapy and other interventions can lower hs-CRP. Whether or not such reductions can prevent cardiovascular events is under investigation.     

Sudomotor function assessment as a screening tool for microvascular complications in type 2 diabetes

Sudoscan, a non invasive, quick, and simple method to measure sweat function, was evaluated as a screening tool for microvascular complications in type 2 diabetes. AUC of the ROC curve for detection of microvascular complication was 0.75 for an autonomic risk score, with a sensitivity of 82% and a specificity of 61%.     

Role of variant Creutzfeldt-Jakob disease for safety of treatment with blood components: screening of lymphatic tissue is a potential tool for risk assessment

BACKGROUND: Transmissible spongiform encephalopathies (TSEs) are neuropathological diseases caused by prions. Prions are infectious particles (PrPSc) which can induce bovine spongiform encephalopathy and most likely also the related infectious disease, variant of Creutzfeldt-Jakob disease (vCJD). The exposure of humans to orally ingested BSE agent in contaminated meat products presumably led to the emergence of vCJD. In vCJD, prions can be detected immunohistochemically not only in neuronal tissue but also in lymphoreticular tissue. vCJD is of significance in transfusion medicine because of the hypothetical transmission of prions by blood products. METHODS: An immunohistochemistry method was used to allow screening for vCJD in human lymphoreticular tissue. RESULTS: PrPSc can be detected in the cerebrum and cerebellum of patients with sporadic Creutzfeldt-Jakob disease (sCJD) and in the lymph nodes, tonsils, and spleen of vCJD patients. This method has the major advantage of working in fixed specimens which are routinely saved in departments of pathology and therefore allows screening of large numbers of archived human lymphoreticular tissues in different regional areas and from different time points. Scrapie-positive lymphoreticular sheep tissue reacts similarly to human tissue of vCJD affected patients and is available in sufficient amounts to be used as positive control in screening programs. CONCLUSION: A method is provided which is a feasible tool for an epidemiological screening program to assess the prevalence of the assumed infectious agent of vCJD, PrPSc, in various populations.     

Development of a screening tool for identifying elderly people at risk of abuse by their caregivers

OBJECTIVE: This study developed and assessed an instrument to identify older people at high risk of abuse based on Reis and Nahmiash's Indicators of Abuse (IOA) screen. METHOD: A total of 108 people 65 and older, hospitalized in internal medicine departments at two major hospitals in Israel, were screened together with their principal caregivers. The interview was based on the expanded IOA (E-IOA) and a list of evident signs of abuse. RESULTS: Reliability and validity of the E-IOA were tested and confirmed. Indicators proved to be a significant predictor of evident signs of abuse. The E-IOA correctly discerned 92.7% of those at high risk for abuse and 97.9% of those who did not suffer abuse. The main indicators for risk were behavioral problems, emotional problems, and family problems of the caregiver and the elderly person. Fourteen (13%) experienced abuse. DISCUSSION: The proposed assessment tool can be an instrumental guide to identify elderly people who suffer abuse (unidentified) or who are at high risk.     

Predicting risk of venous thromboembolism in hospitalized cancer patients: Utility of a risk assessment tool

Inpatient venous thromboembolism (VTE) is a priority preventable illness; risk in cancer varies and prophylaxis is inconsistently used. A previously validated tool (Khorana Score, [KS]) identifies VTE risk in cancer outpatients with 5 easily available variables but has not been studied in the inpatient setting. We evaluated the validity of KS in predicting VTE risk in hospitalized cancer patients. We conducted a retrospective cohort study of consecutive oncology inpatients at the Cleveland Clinic from 11/2012 to 12/2014 (n = 3531). Patients were excluded for VTE on admission (n = 304), incomplete KS data (n = 439) or other reasons (n = 8). Data collected included demographics, cancer type, length of stay (LOS), anticoagulant use, and laboratory values. Multivariate risk factors were identified with stepwise logistic regression, confirmed with bootstrap analysis. Of 2780 patients included, 106 (3.8%) developed VTE during hospitalization. Median age was 62 (range, 19‐98) years and 56% were male. Median LOS was 5 (range, 0‐152) days. High risk KS (≥ 3) was significantly associated with VTE in uni‐ and multivariate analyses (OR 2.5, 95% [confidence interval] CI 1.3‐4.9). Other significant variables included male gender (OR 1.67, 1.1‐2.53), older age (OR 0.86, 0.75‐0.99) and use of anticoagulants (OR 0.57, 0.39‐0.85). Recursive partitioning analysis suggested optimal cut point for KS is 2 (OR 1.82, 1.23‐2.69). This is the first report validating KS as a risk tool to predict VTE in hospitalized cancer patients. Using this tool could lead to more consistent and successful application of inpatient thromboprophylaxis.     

Description of a new hepatitis C risk assessment tool

BACKGROUND: Because of the low prevalence of hepatitis C virus (HCV) infection in the general population, mass screening would be expensive and of low yield. Some researchers advocate targeted screening of persons at elevated HCV risk. METHODS: This cross-sectional study aimed to develop a patient-administered tool to assess HCV infection risk. Two hundred seven patients with unknown HCV status from a general medicine practice and 222 HCV-positive patients from a hepatology practice completed a 72-item survey about demographic, social, and clinical risk factors for HCV infection. General medicine patients also underwent HCV serologic testing. RESULTS: Three (1.5%) of 207 general medicine patients had positive HCV antibody test results. These patients plus the 222 hepatology patients were significantly more likely than HCV-negative patients to report an array of factors. In a multivariable model, 7 factors remained significantly associated with HCV infection: sex with a prostitute or an injecting drug user, exposure to blood products, refusal as a blood donor or as a life insurance applicant, witnessing illicit drug use, and self-reported HBV infection. A simplified model that assigned 1 point for each factor present predicted HCV infection as well as a weighted model (based on chi(2) testing and receiver operating characteristic curve comparison). In a population with a 2% prevalence of HCV infection, people who identified 2 risk factors had a 10% chance of HCV infection, whereas those with 4 or more risk factors had a 50% chance. CONCLUSIONS: A self-administered 72-item questionnaire can stratify patients into HCV risk groups. If validated in other primary care populations, this instrument could help target HCV screening.