Non-screened Patients Research Articles

Lung Cancer Detection in Patients With Airflow Obstruction Identified in a Primary Care Outpatient Practice

Introduction This prospective study describes a community-based lung cancer identification project focusing on high-risk patients who receive general care in a primary care outpatient practice. Within 1 calendar year, a simple questionnaire was completed in 1,296 patients > 50 years old to identify 430 patients at high risk of lung cancer (smoking, family history of aerodigestive tract cancer, or occupational exposures). Spirometric abnormalities were found in 126 of these patients Methods Chest posteroanterior radiographs, thoracic CT scans, and sputum cytology were offered to subjects with airflow obstruction (n = 126). Eighty-eight patients underwent all tests. Thirty-eight patients refused or could not consent in a timely fashion Results Six cancers were found in the screened group, and all were treated. Two more cancers were found in the nonscreened patients with airflow obstruction. Both were treated by surgical resection or radiation therapy. Costs per cancer found were $11,925 per patient Conclusions Case finding in high-risk patients in a primary care population can be accomplished at a relatively low cost

Screening for retinoblastoma: presenting signs as prognosticators of patient and ocular survival.

To correlate 3 common presenting signs of retinoblastoma with patient and ocular survival and to assess the efficacy of current pediatric screening practices for retinoblastoma. A retrospective study was conducted of 1831 retinoblastoma patients from our center (1914-June 2000). Patient survival (excluding deaths from other primary neoplasms) and ocular survival (presenting eyes) rates were calculated and analyzed using the Kaplan-Meier method. Leukocoria correlated with excellent patient survival (>86%, 5 years) but poor ocular survival in unilateral (4%, 5 years) and bilateral patients (29%, 5 years). A total of 308 (19%) of 1654 patients presented with strabismus: patient survival was excellent (90%, 5 years), and ocular survival was poor (17%, 5 years) yet better than leukocoria. Patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger (8 months of age) and earlier (Reese Ellsworth group 1 = 26 [58%] of 45) and had better ocular survival than nonscreened patients with a family history. More patients were initially detected by family/friends (1315 [80%] of 1632) than pediatricians (123 [8%] of 1632) or ophthalmologists (156 [10%] of 1632). Most US children whose retinoblastoma is diagnosed initially present with leukocoria detected by a parent, despite routine pediatric screening for leukocoria via the red reflex test. Initial disease detection at the point of leukocoria or strabismus correlated with high patient survival rates and poor ocular survival rates for the presenting eye. Saving eyes and vision requires disease recognition before leukocoria, as demonstrated by the better ocular salvage rate among patients who had a positive family history and received clinical surveillance via early, routine dilated funduscopic examinations by an ophthalmologist.

Breast cancer risk in healthy and symptomatic women: results of a multivariate analysis. A case–control study

Several risk factors for breast cancer (BC) have been investigated in different reports, but none has been really useful in preventing BC development. The aim of this study was to evaluate the risk of BC in self-selected symptomatic women in comparison with the healthy population residing in an urban area of Italy. A group of 404 women (median age 59 years, range 26–89 years) with confirmed BC (cases) were age-matched with 389 healthy women (Group A), and 391 (Group B) symptomatic non-screened patients without BC, who were referred to our Breast unit. The results of univariate analysis showed a significant ( P < 0.01) difference between cases and controls in (1) age at menarche, (2) number of birth and age at first births, (3) lactation and months of lactation, and (4) estrogen replacement therapy (ERT) and duration of ERT. Multivariate analysis using a logistic regression model adjusted for age showed that five independent parameters (no pregnancy, age at first birth > 30 years, no lactation, use of ERT, ERT > 40 months) significantly ( P < 0.01) correlated with BC onset. The relative odds ratios (ORs) at 95% confidence interval (95% CI) were 5.25, 2.47, 2.82, 2.80, and 5.56, respectively. The cumulative OR (95% CI) calculated from the observed vs. predicted values was 7.15. No differences ( P = NS) were found between groups A and B. In conclusion, in our study population, the prolonged use (> 40 months) of ETR in menopausal women resulted in an increased risk of BC, and represented the only risk factor that could be removed.

Prostate cancer: Natural history and surgical treatment of localised disease

In summary, there is increasing and convincing evidence that radical prostatectomy is effective in locally confined, poorly differentiated prostate cancer. Diagnostic efforts, therefore, should be targeted toward this disease and probably also, based on the natural history evidence, toward moderately differentiated disease, mainly Gleason score 7. It is unclear, at present, how this can be achieved. Further improvement of our diagnostic capabilities is urgently needed. Hopefully ongoing randomised studies comparing radical prostatectomy to surveillance and studies comparing radical prostatectomy to radiotherapy are urgently desired. The randomised screening studies, which are ongoing, will provide important information with respect to the effect of treatment. If prostate cancer mortality in those men who are randomised to screening turns out to be better than in those randomised to control, this will also be an indication of the effectiveness of treatment. Also, the screening studies and associated natural history studies based on serum repositories and follow-up in non-screened patients will provide important information with respect to the natural history of prostate cancer in relation to PSA and changes of PSA over time. Finally, quality of life with and without treatment will have to be evaluated, in a prospective manner, in multicentre settings according to validated criteria such as those presented by Litwin. The outcomes of such studies will have to be added as utilities to data relating to traditional endpoints such as cancer-specific and overall survival. In the meantime, clinical practice will be determined by the fact that the only way to cure prostate cancer is early diagnosis and aggressive management. Encouragement comes from the increasing volume of evidence showing that poorly differentiated disease can be eradicated as long as it is locally confined.

Impediments to screening for hazardous alcohol use and dependence in general hospital psychiatric inpatients.

The Alcohol Use Disorders Identification Test (AUDIT) has been developed to screen for hazardous and harmful alcohol consumption. It has been used among a variety of primary care, general population and general hospital populations. However, with the exception of one study undertaken by the author and colleagues, the use of the AUDIT in general hospital psychiatric patients has not been reported. This paper reports on a substudy of this larger study whose aim was to determine the frequency of hazardous alcohol use and dependence among patients admitted to the psychiatric units of general hospitals in Perth, Western Australia, and discusses major reasons for non-AUDIT screening among this group. In a 12-month period 990 patients aged 18-64 years and residing in the Perth metropolitan area were admitted to the psychiatric unit of the two hospitals. Using the AUDIT alcohol use in patients with four major types of psychiatric disorder, namely mood, adjustment, anxiety and psychotic disorders, was assessed. Of the 834 admissions targeted for AUDIT screening 263 were not screened. This non-screening represented 27-42% of patients in each of the major diagnostic categories. There was no significant difference in the proportion of patients screened versus not screened for mood, adjustment or schizophrenia/psychosis. There were however, significantly fewer patients with anxiety disorder screened compared with mood disorder. Those non-screened patients in major psychiatric groups had significantly shorter hospital stays than their diagnostic counterparts who were screened. The major reason for non-screening in all groups was due to patients leaving the psychiatric facility before they could be accessed. This included discharge before screening, transfer to another psychiatric facility and short admission. To a lesser extent cognitive dysfunction accounted for non-screening among major diagnostic groups. Failure to screen patients was largely due to short hospital stays. Screening was impeded by the brief window period, commonly 1 or 2 days, between the absence of acute psychiatric sequelae and discharge. This situation contrasts dramatically to the medical or surgical admission where major sequelae are largely resolved in 2-3 days and AUDIT screening can take place over the remaining 3-4 days prior to discharge. To be effective in the general hospital psychiatric setting, alcohol screening needs to be incorporated into the routine ward assessment procedures. The brevity of the AUDIT makes this possible. This would maximize the time available to implement an intervention programme to those found to be consuming alcohol at a hazardous or harmful level.

Mortality rate of elective abdominal aortic aneurysm repair is lower in screened men

Abstract Background It is expected that the main benefit of abdominal aortic aneurysm (AAA) screening will be derived from differences in the mortality rate between elective and ruptured AAA repair. There may also be differences in elective AAA mortality rate between screened and non-screened patients, and the aim of this study was to compare mortality rates for these two groups using standard statistical analysis, Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and P-POSSUM scoring. Methods Patients undergoing elective AAA repair were either from a current screening programme to detect men over 65 years with AAA (screened) or were referred from other sources (non-screened). All patients were scored using the POSSUM scoring system. Mortality data were studied. Agreement between observed and expected deaths for POSSUM and P-POSSUM for screened and non-screened patients was determined. Results Some 276 elective AAA repairs were performed with an overall mortality rate of 6·9 per cent (see Table below). The mortality rate of 2·7 per cent for 111 screened patients was significantly less than that of 9·7 per cent for 165 non-screened patients (Pearson χ2 = 5·06, P = 0·02). Actual versus predicted death ratio for all elective patients was 0·93 for POSSUM and 2·38 for P-POSSUM. Conclusion Screened patients have a lower mortality rate than non-screened patients for AAA repair. POSSUM scoring provides the best prediction of death in this elective AAA group.

Contribution of mass screening system to resectability of hepatic lesions involving Echinococcus multilocularis.

The prognosis for patients with alveolar echinococcosis of the liver (AEL) is excellent when the lesion is completely resected. Early detection of the disease and subsequent resection of the lesion are thus indispensable; however, the usefulness of screening systems is now controversial. This study was designed to compare screened and non-screened patients according to stage classification and to re-evaluate the effect of screening. We studied a total of 82 patients (63 screened and 19 non-screened). The stage classification showed a significant intergroup difference (P < 0.002). The largest tumors ranged from 30 to 100 mm, and there was a significant intergroup difference (P < 0.0014). Ultrasonography showed even small lesions in the screened patients. The complete resection rate was 74.6% for the screened patients, and 21.1% for the non-screened patients, showing a significant difference (P < 0.0001). The rate of unresectable lesions was higher in the non-screened patients (32%) than in the screened patients (11%), showing a significant difference (P < 0.04). The present screening system contributes to early detection and subsequent resection of AEL, leading to a better outcome.

Failure to screen newborns for inborn disorders: a potential consequence of changes in newborn care.

To determine how changes in the structure of the hospital care of infants, such as shortened post-natal stays, affect the completeness of newborn screening. Cohort. Two large maternity hospitals. 8751 consecutive births at the study hospitals during 1993. The completeness of initial specimen collection and processing as determined by matching of birth and screening records. At least one specimen was received by the screening program for 8675 (99.1%) of the births. Most non-screened patients (71/76, 93%) had been admitted to the neonatal intensive care unit (NICU). Of these, 53/71 (75%) were low birth weight infants who died within 48 h of birth. Even after excluding these non-survivors, NICU patients were 37 times more likely to be unscreened than their healthy counterparts (22 vs. 0.6 per 1000 infants, 95% C.I. 12.8, 92.8 P < 0.01). A common characteristic of non-screened NICU survivors, (12/18) was interhospital transfer for sub-specialty care. Among patients in the healthy-baby nursery, early discharge (i.e. < 24 h of age) accounted for 2/5 (40%) of the cases of non-screening. The non-screening rate among patients discharged early was 25 times higher than for those discharged after 24 h (9.8 vs. 0.4 per 1000 infants, 95% C.I. 4.2, 149 P < 0.01). Although the overall rate of screening was high, NICU patients, especially those requiring transfer, are disproportionately at risk for non-screening. Early discharge of healthy newborns was also significantly associated with non-screening. This latter finding is of special importance given the current trend toward shorter hospital stays for newborns. Increased attention to ensuring the collection of specimens from these two high-risk populations is warranted.

Breast cancer in the elderly patient: early detection with mammography.

To determine the mammographic features and differences in stage of breast carcinomas in elderly women with malignancies detected with palpation or mammography at presentation. The mammograms and clinical records of 60 patients (aged 75 years or older) with 62 breast carcinomas, detected during 40 consecutive months, were retrospectively reviewed. A variety of dedicated devices and processing equipment were used. The histologic features, mammographic appearance, mode of detection, and stage of disease were determined. Statistically significant differences between subgroups were calculated with the Student t and chi 2 tests. Sixty cancers (97%) were seen on mammograms. Seventeen tumors detected with annual mammography differed significantly from the 45 carcinomas in nonscreened patients in diameter (1.1 vs 2.1 cm; P < .0005) and stage (14 minimal [82%] of 17 tumors vs 15 minimal [33%] of 45 tumors; P < .0005). Thirty-five nonpalpable malignancies differed significantly from 27 palpable masses in diameter (1.2 vs 2.3 cm; P = .01) and stage (25 tumors minimal [71%] vs four tumors minimal [15%]; P < .0005). Screening mammography enabled detection of statistically significantly smaller and earlier-stage tumors, most of which were minimal disease.

Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy.

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

Survival and clinical outcome in patients with cystic fibrosis, with or without neonatal screening

After an experimental neonatal screening program for cystic fibrosis had been carried out in the Netherlands during 1973 to 1979, a follow-up study to evaluate the effects of neonatal screening was started in 1980. Although before 1980 the management of patients with cystic fibrosis was partly left to local hospitals, from the start of the follow-up program all patients in the study received similar treatment. A cumulative survival rate, calculated with exclusion of the patients with meconium ileus, showed at the age of 11 years a significantly better survival rate (p less than 0.05) for the 19 patients from the screened population (88%) than for the 25 patients from the nonscreened population (60%). Clinical condition was assessed on entry and at the age of 9 years in 16 screened and 20 nonscreened patients. On entry, comparison showed significantly better chest radiograph scores for the screened patients but no other significant differences. At the age of 9 years, after several years of similar treatment for all patients in the study, significantly better clinical (p less than 0.02) and chest radiograph scores (p less than 0.01), lower IgG levels (p less than 0.05), and higher vitamin A levels (p less than 0.01) were observed in the screened patients. Our study results suggest that early diagnosis and appropriate treatment may prevent serious deterioration and death at a young age, and may reduce the extent of early irreversible lung damage in patients with cystic fibrosis.