Case-finding Methods Research Articles

Patterns of antidepressant use in cancer patients (pts): An analysis from SOAPP (ECOG E2Z02: Symptom Outcomes and Practice Patterns).

9016 Background: Antidepressant (AD) use is common in outpatient oncology, but the pattern and determinants of prescribing for commonly used AD are unknown. Methods: 3106 pts with cancer of the breast, prostate, colon/rectum, or lung were enrolled from multiple sites in a study of symptoms. Five depression case-finding methods were explored : 3 based on MDASI items reported by patients (1) sadness/ depression>=4, (2) distress>=4, (3) interference with mood>=7 or enjoyment>=7; 2 based on clinician’s report (4) presence of psychological distress, (5) depression being listed as one of top 3 symptoms. AD use (excluding tricyclic antidepressants and psychostimulants) was examined by depression status. Logistic regression models were used to examine the effect of demographic and clinical characteristics on AD use. Results: Rates of depressive symptoms varied by casefinding method (1=29%, 2=28%, 3=14%, 4=24%, 5=11%); 47% (1457) pts were defined as having depressive symptoms by at least one method. AD were prescribed in 25% of depressed pts compared to 14% of non-depressed pts. After adjusting for other covariates, factors associated with greater use of AD included depression (OR=1.7, P<0.01), family history of depression (OR=2.2, P<0.01), female sex (OR=1.8, P<0.01), younger age (OR=1.2, P=0.04), non-Hispanic White race (OR=2.0, P<0.01), prior chemo/immune/ hormonal treatment (OR=1.5, P<0.01), more concurrent medication use (OR=3.3, P<0.01), anxiolytics use (OR=2.0, P<0.01), sedative use (OR=2.1, P<0.01), receiving counseling (OR=1.6, P=0.04), patient’s perception of poor QOL (OR=1.3, P=0.02), duration of current treatment >1 year (OR=1.6, P<0.01), and being enrolled by a CCOP (OR=1.8, P=0.01). These significant associations remained regardless of the case-finding method used for depression, with only slight changes in the magnitude of ORs. Conclusions: Depressive symptoms are common in outpatients with cancer. One-fourth of solid tumor pts with depressive symptoms are taking an AD. Antidepressant prescribing varies by type of institution, race/ethnicity, age, concomitant medication exposure and several other clinical factors.

Variation in Reported Neonatal Group B Streptococcal Disease Incidence in Developing Countries

Group B Streptococcus (GBS) is a leading cause of neonatal sepsis in developed countries. Its burden in the developing world is less clear. Studies reporting neonatal GBS disease incidence from developing countries were identified from 5 literature databases. Studies were assessed with respect to case finding and culture methods. Only 20 studies were identified. The GBS incidence ranged 0-3.06 per 1000 live births with variation within and between geographic regions. All but 1 study identified GBS cases within a hospital setting, despite the potential for births in the community. Possible case under-ascertainment was only discussed in 2 studies. A higher GBS incidence was reported when using automated culture methods. Prospective, population-based surveillance is urgently needed in developing countries to provide an accurate assessment of the neonatal GBS disease burden. This will be crucial for the design of interventions, including novel vaccines, and the understanding of their potential to impact mortality from neonatal sepsis.

Clinically based surveillance of invasive meningococcal disease in young children admitted to selected US hospitals between January 2000 and June 2009

Invasive meningococcal disease (IMD) is under-reported in countries that do not employ polymerase-chain reaction for surveillance because culture-negative cases are omitted. To evaluate a clinically based, case-finding method, we developed case definitions for “probable,” “compatible with,” and “possible, but unlikely” IMD, respectively, based on supportive documentation (e.g., discharge diagnosis of meningococcal infection, culture-negative bacterial meningitis, petechiae/purpura, Gram-negative diplococci on Gram stain) and weight of clinical evidence, which we then applied to electronic health records for all children aged ≤5 y who were admitted to approximately 100 US hospitals between January 2000 and June 2009. Among 47,863 qualifying admissions, 16 children had culture-positive IMD, 5 had “probable” IMD, and 5 had illness “compatible with” IMD. Five additional children had disease considered “possible but unlikely” IMD. Our case-finding methods suggest that culture-based ascertainment may underestimate the number of IMD cases by 31–63%, supporting findings in other nations that culture-based reporting provides incomplete information on disease incidence and therefore underestimates the potential benefits of routine vaccination of young children against meningococcal disease.

Acceptability of mental health screening in routine addictions treatment

ObjectiveThe objective was to investigate patients' views on the application of case finding and screening methods for common mental disorders in an addiction treatment service. MethodQualitative thematic analysis of semistructured interviews with a purposive sample of 19 participants. Participants took part in diagnostic assessments (Revised Clinical Interview Schedule, CIS-R) and completed brief screening questionnaires for depression (Patient Health Questionnaire, PHQ-9) and anxiety (Generalized Anxiety Disorder Scale, GAD-7). ResultsPatients generally favored the use of screening questionnaires to detect psychological problems, to monitor changes in symptoms and to facilitate targeted and specialist treatment. On the whole, respondents seemed to find such methods familiar and easy to use. The need for staff support was strongly emphasized, both to deal with the emotional impact of screening and to overcome accessibility and literacy problems. Good therapeutic rapport with practitioners came across as an important factor that influences patients' willingness to discuss psychological problems. Patient readiness and the timeliness of assessments were additional factors influencing acceptability. Participants discussed how psychological problems and substance misuse are associated in complex ways, often resulting in discrimination, poor recognition of such problems and limited access to treatment. ConclusionsMental health screening is generally acceptable to patients and can help to identify comorbid mental disorders in order to provide appropriate support and treatment.

MLH1 promoter hypermethylation in the analytical algorithm of Lynch syndrome: a cost-effectiveness study

The analytical algorithm of Lynch syndrome (LS) is increasingly complex. BRAF V600E mutation and MLH1 promoter hypermethylation have been proposed as a screening tool for the identification of LS. The aim of this study was to assess the clinical usefulness and cost-effectiveness of both somatic alterations to improve the yield of the diagnostic algorithm of LS. A total of 122 colorectal tumors from individuals with family history of colorectal cancer that showed microsatellite instability and/or loss of mismatch repair (MMR) protein expression were studied. MMR germline mutations were detected in 57 cases (40 MLH1, 15 MSH2 and 2 MSH6). BRAF V600E mutation was assessed by single-nucleotide primer extension. MLH1 promoter hypermethylation was assessed by methylation-specific multiplex ligation-dependent probe amplification in a subset of 71 cases with loss of MLH1 protein. A decision model was developed to estimate the incremental costs of alternative case-finding methods for detecting MLH1 mutation carriers. One-way sensitivity analysis was performed to assess robustness of estimations. Sensitivity of the absence of BRAF mutations for depiction of LS patients was 96% (23/24) and specificity was 28% (13/47). Specificity of MLH1 promoter hypermethylation for depiction of sporadic tumors was 66% (31/47) and sensitivity of 96% (23/24). The cost per additional mutation detected when using hypermethylation analysis was lower when compared with BRAF study and germinal MLH1 mutation study. Somatic hypermethylation of MLH1 is an accurate and cost-effective pre-screening method in the selection of patients that are candidates for MLH1 germline analysis when LS is suspected and MLH1 protein expression is absent.

Low incidence and prevalence of primary biliary cirrhosis in Canterbury, New Zealand: a population-based study.

Epidemiological data on primary biliary cirrhosis (PBC) in the Southern Hemisphere is scarce. Our aim was to perform a population-based epidemiological study of PBC in Canterbury, New Zealand. Multiple case-finding methods were employed. All public and private, adult and pediatric outpatient clinics, hospital discharge summaries, and laboratory and pathology reports were searched to identify all cases in the region. Cases were included if at least two of the following criteria were fulfilled: (1) positive anti-mitochondrial antibodies, (2) elevated alkaline phosphatase for greater than 6months, and (3) compatible liver histology. A total of 71 cases of PBC were included. The incidence in 2008 was 0.8 (95% confidence interval (CI) 0.1-1.6) per 100,000. The point prevalence on December 31, 2008 was 9.9 (95% CI 7.1-12.7) per 100,000. Male to female ratio was 1:11. At presentation, 45% were asymptomatic. Age at diagnosis peaked at the seventh decade with mean age at diagnosis of 61 (95% CI 58-64). This is the first population-based epidemiological study of PBC conducted in New Zealand and only the second in the Southern Hemisphere. The incidence and prevalence are lower than the Northern Hemisphere, even though the majority of our population has shared genetic background with some of these countries. Our study has provided further support to the hypothesis that there may be a protective effect or lack of a risk factor for PBC in New Zealand.

Inflammatory Bowel Disease Is Associated With Poor Outcomes of Patients With Primary Sclerosing Cholangitis

Little is known about the exact etiology of primary sclerosing cholangitis (PSC); epidemiologic data are scarce. We performed a population-based epidemiologic study of PSC in Canterbury, New Zealand. By using multiple case-finding methods, we searched public and private adult and pediatric outpatient clinics, hospital discharge summaries, and radiology and pathology reports to identify all cases of PSC in the region. Cases were included if PSC was identified by endoscopic retrograde cholangiography, magnetic resonance cholangiography, or liver biopsy analysis (n = 79). The incidence of PSC in 2008 was 1.6 per 100,000 persons (95% confidence interval [CI], 0.5-2.7). The point prevalence on December 31, 2008, was 11.7 per 100,000 persons (95% CI, 8.7-14.8). The mean and median ages at diagnosis were 50 years (95% CI, 46-53 years) and 49 years (range, 17-80 years), respectively. Patients who had inflammatory bowel disease (IBD) presented with PSC earlier than those without IBD (P = .003), were more likely to develop serious malignant complications (P = .017), and were more likely to require liver transplantation or die (P = .03). In a population-based epidemiology study of PSC in Canterbury, New Zealand, we observed large differences between PSC patients with or without concurrent IBD in age at diagnosis, development of cancer, mortality, and requirement for liver transplantation. IBD therefore affects outcomes of patients with PSC, an important observation that requires further study.

P56 What is the best method of case finding for chronic viral hepatitis in migrant communities?

IntroductionThe prevalence of chronic viral hepatitis in people born in Pakistan living in the UK is 5% (2.7% Hepatitis C Virus (HCV) and 1.8% Hepatitis B Virus (HBV). Studies from...

Factors related to early case detection of tuberculosis in health service facilities for the elderly

The proportion of newly notified tuberculosis cases aged over 65 years has been rising and reached 49.2% in 2001. For this reason, the Ministry of Health, Labor and Welfare recommended in 1999 to give preventive therapy for tuberculosis to elderly persons with fibrous lesions on chest X-ray. However, our research pointed out many problems in the matter and low public health benefits of preventive therapy. At present, early case detection and treatment are considered to be the most effective tuberculosis control measures for the elderly in Japan. For the purpose of developing the most effective case finding method for the elderly, we investigated various aspects of tuberculosis in health service facilities for the elderly. Health service facilities for the elderly were established since 1988 to provide nursing care and rehabilitation services to enable elderly persons who no longer need hospitalized care to return home. Questionnaires were mailed to 358 health service facilities for the elderly in a metropolitan city and 4 prefectures. One hundred and sixty-nine facilities (47.2%) responded. Among them, 61 (36.1%) are attached to hospitals, 21 (12.4%) are attached to clinics, and 87 (51.5%) are not attached to any medical facilities. The median duration from the opening of the facility was 3.5 years, and 113 (66.9%) facilities were founded within 5 years. The mean age was 83.2 years for facility-care users and 79.6 years for day-care users. The mean duration of care was 7 months for facility-care users and 13 months for day-care users. Pre-admission chest X-ray was conducted for facility-care users in 72 (42.6%) facilities, and for day-care users in 40 (23.7%) facilities. Comparing with 84.3% (Shishido, 2002) in special nursing homes for the elderly, the rate was significantly lower in health service facilities for the elderly. Periodic TB screening during care utilization was also less frequently carried out in health service facilities for the elderly (45.6% for facility-care users and 15.4% day-care users). A possible reason is that special nursing homes for the elderly are mandated to conduct periodic TB screening as provided by the TB Control Law, while health service facilities for the elderly are not under such provision. Periodic TB screening for employees was carried out in 160 (94.7%) facilities. Respiratory symptoms were less frequently checked compared with anorexia or lassitude. Thirty-two facilities (18.9%) checked the facility-care user everyday for respiratory symptoms using a check-list, while 114 facilities (67.5%) checked only for anorexia or lassitude (p < 0.01). When persistent respiratory symptoms were observed in facility-care users, 157 (93.5%) facilities referred them to hospitals with letters explaining their symptoms and 108 (63.9%) facilities requested chest X-ray and sputum tests. However, for day-care users, most facilities only advised them to visit medical institution without any letter of referral. Within 5 years, 52 (30.8%) facilities reported 65 TB cases among facility users and 5 (3.0%) facilities reported 5 TB cases among employees. Based on person-year, case rate was calculated to be 104.6 per 100,000 among elderly facility users. This rate was compared with that of people aged 75 years over in the community. Rate ratio was 1.04 (95% CI: 0.82-1.34). The risk of developing tuberculosis was slightly higher in the elderly facility users, but the risk was not statistically significant. This result may be influenced by the low response rate from facilities with tuberculosis cases. We conclude that it is very important to detect TB cases at the early stage of disease not only to protect the elderly from tuberculosis death but also to prevent outbreak of tuberculosis infection in health service facilities for the elderly. Effective and feasible tuberculosis control for the elderly should be provided under the TB control Law and be implemented with the cooperation from related medical institutions and public health centers.

Surveillance of serious adverse events following immunization in resource poor settings

The development of vaccines is one of the most important public health achievements. However, as the incidence of vaccine-preventable diseases has decreased, the general public has become increasingly concerned about vaccine safety. Vaccine safety is evaluated extensively through animal safety studies, clinical trials, and post-licensure surveillance. Safety monitoring in post-licensure surveillance has relied mainly on passive reporting systems such as the Vaccine Adverse Event Reporting System in the United States and epidemiological studies. Vaccine safety profiles cannot necessarily be generalized to developing countries, where the incidence, type and severity of serious adverse events may differ significantly because of local environmental and genetic influences[1]. With the recent introduction of newly developed vaccines in sub-Saharan Africa (e.g., pneumococcal and rotavirus vaccines), the extensive use of established vaccines in preventive mass vaccination campaigns (e.g., yellow fever vaccine), and the planned introduction of vaccines for use primarily in resource-poor settings (e.g., malaria vaccine), there is an increased need for effective surveillance of serious adverse events following immunization (AEFI). Compared to high-income countries, few low-income economies have functional national pharmacovigilance (PV) systems in place, due primarily to a lack of resources, infrastructure and local PV expertise. The importance of functional national PV systems has recently been underlined with the implementation of yellow fever (YF) mass campaigns as part of the Yellow Fever Initiative (YFI). The recent and novel use of YF vaccine for preventative mass vaccination campaigns in sub-Saharan Africa has increased the urgency of establishing functional PV systems. Between 2006 and 2013, the YFI will distribute vaccines to residents of high-risk areas in 12 West and Central African countries. A condition of funding from the GAVI Alliance is the implementation of AEFI surveillance. To address this requirement, AMP and WHO have provided technical support, including the development of surveillance tools (e.g., operational guide, notification and investigation forms, standard operating procedures for taking and transporting biological samples), the introduction of active case finding methods, and the creation and training of national expert committees to review and classify suspected serious AEFIs. Reference laboratories, including the Institut Pasteur in Cameroon, and the Robert Koch Institute in Germany provided diagnostic test results to facilitate the YF AEFI classification process. Best practices have been shared between different countries and African-based consultants have been trained to become local experts. Their expertise is now being requested for AEFI surveillance of additional vaccines such as the serogroup A meningococcal conjugate vaccine.

Using Key Informant Method to Assess the Prevalence and Causes of Childhood Blindness in Xiu’shui County, Jiangxi Province, Southeast China

Background: Although childhood blindness is relatively rare, it is the leading cause of blind person years besides cataract. The aim of this study is to estimate the prevalence and causes of childhood blindness and severe visual impairment (BL/SVI) in southeast China.Methods: The study took place across four administrative units in Xiu’shui County. Sixty key informants were trained by an ophthalmologist to identify possible cases of childhood BL/SVI (children < 16 years with presenting visual acuity < 6/60 in the better eye) in their own communities. The possible cases were referred to a hospital for further examination by a pediatric ophthalmologist, to ascertain case status and determine the cause of BL/SVI.Results: In total we found 8 cases of childhood BL/SVI from a total population of approximately 27,000 children. The prevalence of childhood BL/SVI was therefore 0.3/1000 (95% Confidence Interval [CI]: 0.1–0.5/1000). The prevalence of blindness (< 3/60) was 0.2/1000 (95% CI: 0.04/1000–0.4/1000) and the prevalence of SVI (< 6/60–3/60) was 0.07/1000 (95% CI: 0–0.17/1000). The main cause of BL/SVI was posterior segment disease (87.5%). Half of the cases were potentially treatable.Conclusions: The study has documented a low prevalence of childhood BL/SVI in southeast China. Despite the low prevalence, half of the cases were potentially treatable if earlier medical action was taken, suggesting the prevalence could be reduced further still. The Key Informant Method is simple to implement and an efficient method for case finding in China.

High Rate of Uncaptured Myelodysplastic Syndrome Cases at the State Cancer Registry Level

AbstractAbstract 1890The myelodysplastic syndromes (MDS) became reportable malignancies to U.S. population-based cancer registries including the Surveillance, Epidemiology and End Results (SEER) Program in 2001. Registries capture information on MDS cases through reports sent by hospitals and physicians' offices. Electronic pathology (E-path) reports generated by private pathology laboratories are another potential source for finding cases; however, the sheer volume of E-path reports generated and the limited resources of cancer registries preclude the review of all E-path reports. Therefore, some registries rely on probability scoring based on keyword hits to identify reports most likely consistent with a diagnosis of cancer. Given the diverse morphologic features of MDS pathology and our earlier observation that MDS is often diagnosed and managed in the outpatient setting (Rollison, et al. Blood 2008), we hypothesized that MDS is often not captured by state cancer registries. To estimate the proportion of uncaptured MDS cases in Florida, all E-Path reports sent to Florida Cancer Data System (FCDS), the state cancer registry, in 2006 were queried using a unique keyword search strategy based on an algorithm of identifying bone marrow biopsy reports that met the inclusion and exclusion diagnostic terminology for MDS. Of 7,111 E-path reports identified, only 18% corresponded to individuals registered in FCDS as having been diagnosed with MDS. To estimate the percentage of uncaptured MDS cases in the remaining 82% of E-Path reports, a stratified random sample of E-path reports were reviewed by a single hematologist/oncologist to determine whether the E-path reports were consistent with MDS and to assign an MDS subtype. The strata for random sampling included: 1) reports that linked individuals registered as having been diagnosed with cancers other than MDS in FCDS (48%) versus those that did not link to FCDS (34%) and 2) four categories based on number of keyword hits. Overall, E-path reports corresponding to 285 individuals were reviewed, of which 71 were determined to have MDS. The percentage of uncaptured cases seemed to be lower for those individuals that were registered in FCDS as having a previous cancer (17%) than that for those who did not link to FCDS (28%) and increased with number of keyword hits. Based on the percentages of uncaptured cases estimated within each of the eight strata, and the distribution of those stratified factors in the total sampling frame, we estimated that 641 MDS cases were likely uncaptured, representing approximately 45% of the captured and uncaptured cases combined. Thus, current case finding mechanisms by population-based cancer registries capture approximately half of the true MDS cases. Compared to MDS cases captured by FCDS, uncaptured MDS cases were younger (< 65) (p=0.01), less likely to have Refractory Anemia (RA) and more likely to have Refractory Cytopenia with Multilineage Dysplasia (RCMD) (p=0.002). Gender and race seemed to be similar between the groups. Together, these data indicate that current population-based case finding methods are not capturing a large percentage of MDS cases. Application of a keyword search strategy to identify cases among E-Path reports is a feasible technique to improve MDS case ascertainment in population-based cancer registries until greater resources are committed. Disclosures:No relevant conflicts of interest to declare.

Cancer incidence in a rural population of South Africa, 1998–2002

Cancer incidence rates and patterns are reported for a rural population, living in the Eastern Cape Province of South Africa for the period 1998-2002. The population-based cancer registry has operated for 20 years, using both active and passive methods for case finding, through collaborations with 19 health facilities: 11 district hospitals, 7 referral hospitals and 1 regional laboratory. The age standardized incidence rates for all cancers were 73.1 per 100,000 in males and 64.1 per 100,000 in females. The leading top 5 cancers for males were oesophagus (32.7 per 100,000), lung (5.8 per 100,000), prostate (4.4 per 100,000), liver (4.4 per 100,000) and larynx (2.5 per 100,000) whereas for females they were cervix (21.7 per 100,000), oesophagus (20.2 per 100,000), breast (7.5 per 100,000), ovary (0.9 per 100,000) and liver (0.9 per 100,000). The incidence of Kaposi sarcoma was low, and higher for males (1.6 per 100,000) than females (0.3 per 100,000). Lung cancer in both males and females was relatively low compared to the high incidence of oesophagus cancer.

Incidence and Case Fatality of Subarachnoid Haemorrhage in Northern Greece: The Evros Registry of Subarachnoid Haemorrhage

Epidemiological data on subarachnoid haemorrhage incidence and case-fatality rates are scarce in the south-eastern Mediterranean region. We conducted a population-based study in Evros Province, located in north-eastern Greece, to determine subarachnoid haemorrhage incidence over a 5-year period (2001-2005). Evros Province has a well-defined, largely homogeneous population with healthcare organised around a single tertiary-care University Hospital. We organised a prospective computerised registry of permanent Evros residents admitted or transferred to our hospital with a diagnosis of subarachnoid haemorrhage. Standard World Health Organization definitions and overlapping case-finding methods were used to identify all cases of first ever in a lifetime subarachnoid haemorrhage in all age groups, occurring during the study period. The diagnosis was confirmed by computed tomography scan in all hospitalised cases. Sudden deaths attributable to subarachnoid haemorrhage were systematically recorded province-wide by our forensic department and are included in the study. During the 5-year period, 51 cases of subarachnoid haemorrhage were recorded (28 men, 23 women; mean age 59+/-17 years). The crude annual incidence rates were 8.3/100,000 persons (95% confidence interval: 5.5-12.0) for men, 7.5/100,000 (4.8-11.3) for women and 7.9/100,000 (5.9-10.4) for all subjects. The standardised incidence rates for groups aged 45-84 years in the European population were 9.3/100,000 (5.8-12.8) for men, 6.5/100,000 (3.7-9.4) for women and 7.9/100,000 (5.7-10.2). The 28-day case-fatality rates for men, women and all subjects were 36% (21-54%), 35% (19-55%) and 35% (24-49%), respectively. The incidence and case-fatality rate of subarachnoid haemorrhage haemorrhage in Greece appear to be similar to other developed countries. No gender differences in subarachnoid haemorrhage incidence and case-fatality rate were documented.

The prevalence of autism spectrum disorders: impact of diagnostic instrument and non-response bias

A large part of the variability in rates of autism spectrum disorders (ASD) across studies is non-aetiologic, and can be explained by differences in diagnostic criteria, case-finding method, and other issues of study design. To investigate the effects on ASD prevalence of two methodological issues; non-response bias and case ascertainment. We compared the findings of using a semi-structured parent interview versus in-depth clinical assessment, including an ASD specific interview. We further explored whether including information on non-responders affected the ASD prevalence estimate. A total population of 7- to 9-year olds (N = 9,430) was screened for ASD with the autism spectrum screening questionnaire (ASSQ) in the Bergen Child Study (BCS). Children scoring above the 98th percentile on parent and/or teacher ASSQ were invited to participate in the second and subsequently in the third phase of the BCS where they were assessed for ASD using the Development and Well-Being Assessment (DAWBA), and the Diagnostic Interview for Social and Communication disorders (DISCO), respectively. Clinical assessment using DISCO confirmed all DAWBA ASD cases, but also diagnosed additional cases. DISCO-generated minimum prevalence for ASD was 0.21%, whereas estimated prevalence was 0.72%, increasing to 0.87% when adjusting for non-responders. The DAWBA estimate for the same population was 0.44%. Large variances in prevalence rates across studies can be explained by methodological differences. Both information about assessment method and non-response are crucial when interpreting prevalence rates of ASD.

Improving the sensitivity of the Dutch guidelines for case finding in osteoporosis

In a previous paper1 we reported on the poor validity of the Dutch case finding method for GPs to identify patients with osteoporosis for Dual energy X-ray absorptiometry (DXA) measurement (NHG guidelines for osteoporosis2), as sensitivity was 19.5% and positive predictive value (PPV) was 18.6%.2 We suggested that a more appropriate tool is needed to apply case finding for osteoporosis. The problem, however, is that many GPs have poor knowledge of the different case finding methods that are available.3 Instead of designing a new method, one might rather evaluate alternative usage of current guidelines to achieve better results. Hence the aim of this research letter is to investigate alternative usage of the Dutch guidelines to select osteoporosis patients for DXA. As we discussed in our previous paper, the poor validity of the Dutch guidelines might result from the definition of the weighted scores. Therefore, we performed receiver operating characteristic (ROC) curves to evaluate whether ‘4’ is the best cut-off score to be used. As only 64 males were included, data analyses were performed of 345 females. Osteoporosis was diagnosed according to the World Health Organization (WHO) guidelines (T score ≤ −2.5 SD) and, in addition, according to the Dutch guidelines, using the WHO criteria in patients younger than 70 years and Z-scores in patients over 70 years (≤ −1.0 SD) to define osteoporosis. Osteopenia was not defined within this age group. We calculated sensitivity, specificity, and predictive value of the guidelines using varying cut-offs; 95% confidence intervals were calculated using binomial expansion. Statistical analyses were performed using SPSS (version 16.0) software. The ROC curve, as well as the results of sensitivity, specificity, and predictive value (Table 1), showed that the best cut-off for the current Dutch instrument is ‘1’. Using this cut-off and the WHO criteria of osteoporosis, sensitivity improved to 88%, specificity was 40%, PPV 14%, and NPV 97%. Slightly lower values were calculated if DXA outcome was based on the Dutch criteria of osteoporosis (using Z-scores in patients aged ≥70 years. Table 1 Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the original Dutch osteoporosis guidelines in 345 women. If the optimal threshold is ‘1’, it can be concluded that the weighted scores are of no added value. Moreover, it implies that screening is always recommended above the age of 60 years. In contrast, the US guidelines have recommended screening in women over 65 years, based on cost-effectiveness analysis.4 In addition, treatment of women with risk factors other than a prior fracture is cost-effective after the age of 65 years according to the European guidance.5 Therefore, we have investigated the validity of the Dutch guidelines in women, after changing the original model: in the original guidelines, 1 risk point is given for the age 60–70 years and 2 points for the age of ≥70 years. Instead, we now gave 1 risk point for the age of ≥65 years. The original and adapted guidelines are shown in Table 2. Sensitivity, specificity, and predictive values of the adjusted guidelines for women are summarised in Table 3. Values were slightly higher if WHO criteria were used to define osteoporosis instead of the Dutch criteria. Furthermore, Table 3 shows that, when using a cut-off of 1, there is little benefit if age is increased from 60 to 65 years. However, instead of 60 (original), the use of 65 years (adapted) as a risk factor is recommended when taking into account cost-effectiveness.5 Table 2 The original and adjusted Dutch osteoporosis guidelines for women. Table 3 Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the adjusted Dutch osteoporosis guidelines in 345 women. We showed that the clinical performance of the Dutch case finding instrument majorly improves with alternative use; sensitivity largely increases from 18% to 84%. Instead of missing five patients for each patient that is found with osteoporosis,2 only one patient is missed for each six patients that are found. This implies that the majority of patients with osteoporosis will be referred for DXA and hence are properly diagnosed. However, PPV and specificity remain low. Low PPV can be explained by the low prevalence of osteoporosis in our relatively young population. Moreover, as we discussed in our previous paper,2 an instrument with high sensitivity can be of great practical interest in primary care, even if PPV is low. So far, there is no universal policy on case finding in Europe. We suggest that the Dutch College of General Practitioners revises its policy on prevention and case finding for osteoporosis.

Period Prevalence of Epilepsy in Children in BC: A Population-Based Study

Most estimates of the prevalence of seizure disorders in Canada derive from national surveys which differ in sampling and case-finding methods. This study used health care utilization data to make a population-based estimate of the prevalence of epileptic seizures and of epilepsy in children in British Columbia (BC). All BC residents between 0-19 years-of-age in 2002-3 enrolled in the Medical Services Plan were included. Epileptic seizures were defined using ICD-9 codes; health care utilization data was obtained from BC Linked Health Database. The period prevalence of epileptic seizures and of epilepsy was determined by age, urban/rural region and socioeconomic status. 8,125 of 1,013,816 children were identified as having an epileptic seizure of which 5621 were classified as epilepsy--5.5 per 1000 children (95% CI: 5.4-5.7). The prevalence of epilepsy in infants and preschoolers was higher than that reported in the literature. A higher prevalence of epilepsy was observed also among those with low socioeconomic status. A higher prevalence of epilepsy was observed in those health regions with a higher proportion of First Nations and a lower prevalence was observed in health regions with a higher proportion of visible minorities. Age-specific prevalence rates in BC children for epilepsy, determined from population-based administrative records, were similar to published data except in children under five years. We found a gradient of increased prevalence with decreased level of income. Prevalence rates based on utilization data have the potential to guide program planning for children with epileptic seizures.

The Promise of Early Recognition and Treatment

&lt;p&gt;This issue of &lt;cite&gt;Psychiatric Annals&lt;/cite&gt; features a series of articles on Early Intervention of Psychotic Disorders, guest edited by Michael T. Compton, MD, MPH. This series, with articles from Norway, Australia, Canada, and the United States, is one of the most progressive and optimistic series of articles pertaining to schizophrenia that I have seen. This series makes a case for early recognition and treatment of high-risk youth as a method for early case finding of people with prodromal or at-risk symptoms for psychosis in order to increase the rate of social recovery and to increase functional outcomes. &lt;/p&gt;

Characteristics and patterns of healthcare utilization of patients with fibromyalgia in general practitioner settings in Germany

ABSTRACTObjective: To examine characteristics and patterns of healthcare utilization of patients with fibromyalgia (FM) under the care of general practitioners (GPs) in Germany.Research design and methods: Retrospective cohort study, using a large electronic database with information on GP encounters in Germany (IMS MediPlus). We identified all patients, aged ≥ 18 years, with any encounters for FM (ICD-10 diagnosis code M79.7) between February 1, 2004 and January 31, 2007. We also constituted a comparison group consisting of randomly selected patients with one or more GP encounters – but none for FM – during this period, who we matched to FM patients based on age and sex. Characteristics and healthcare utilization of patients in the FM and comparison groups were then examined over the 1-year period, February 1, 2006–January 31, 2007.Main outcome measures: Prevalence of co-morbidities; use of pain-related pharmacotherapy; number of GP office visits; number of specialist referrals; and number of sick notes (physician-excused absences from work).Results: The study sample consisted of 4983 FM patients and an identical number in the comparison group. Mean age was 58 years; 87% were women. The prevalence of various co-morbidities was greater among FM patients, including painful neuropathies (33% vs. 18% for comparison group) and depression (20% vs. 5%) (both p < 0.01); more FM patients also received pain-related pharmacotherapy (67% vs. 28%; p < 0.01). Compared with patients in the comparison group, FM patients averaged approximately twice as many GP visits (11.4 [SD = 10.1] vs. 5.8 [7.5]), referrals (4.5 [5.2] vs. 2.2 [3.6]), and sick notes (0.6 [1.8] vs. 0.3 [1.1]) (all p < 0.01).Limitations: Information in the study database is limited to GP encounters, and the sensitivity and specificity of our case-finding methods are unknown.Conclusions: Patients with FM under the care of GPs in Germany have comparatively more co-morbidities and higher levels of healthcare utilization.

Argentine Patagonia: prevalence and clinical features of multiple sclerosis

There are few studies reporting multiple sclerosis prevalence rates in the Buenos Aires region, Argentina (latitude 34°S) (between 12–18.5/100 000 inhabitants), and no studies have been performed in the larger region between parallels 36° and 55°S. The aim of this study is to determine the prevalence rates and clinical features of multiple sclerosis in residents of the Argentine Patagonia. Four cities from the region were selected for this study, giving a sample population of 417 666 inhabitants (~24% of the total Patagonia population). 1st March 2002 was determined as prevalence day. Patients were ascertained using multiple case-finding methods. The point prevalence rate was 17.2/100 000 (17.2 age-adjusted to the world population). Prevalence rates were higher for women than for men, 22.1 versus 12.2/100 000 inhabitants (21.4 versus 12.7 sex-adjusted to the world population). The study population was mainly of European descent and mestizoes. Clinical features were similar to those reported in other countries. This study shows that Argentine Patagonia is a medium-risk area with no south–north gradient between parallels 55° and 36°S. The Patagonia population shows recent internal migration that makes it difficult to determine whether the exposure to potential risk factors has been long enough to modify the disease incidence.