Specific Surveillance Programs Research Articles

Active surveillance as a practical strategy to differentiate lethal and non-lethal prostate cancer subtypes

Differentiation between lethal and non-lethal prostate cancer subtypes has become a very important issue in avoiding excessive treatment in an era when prostate-specific antigen (PSA) screening has reduced the rate of prostate cancer deaths by more than 20%. However, it is difficult to determine the patients who may or may not benefit from immediate treatment interventions at the time of the initial diagnosis. The selection of candidate patients who can postpone immediate treatment and undergo follow-ups with a specific surveillance program, or 'active surveillance,' is a practical way to minimize overtreatment. In this review, the benefits and risks of active surveillance are discussed. Future perspectives, including imaging and new biomarkers for improving the outcomes of active surveillance programs, are also discussed.

Epidemiologic analysis on severe fever with thrombocytopenia syndrome in Hubei province, 2010

To identify the epidemic characteristics and risk factors of an emerging infectious disease-severe fever with thrombocytopenia syndrome (SFTS) in Hubei province. Active surveillance program on SFTS was set up in monitoring sites-hospitals, at the township level or above, in Suizhou, Huanggang and Wuhan from January to December, 2010. Specific surveillance program on SFTS was launched across the province in hospitals above the county level. Cases that matched the definition of surveillance case were identified and reported to Centers for Disease Control and Prevention (CDCs). Cases were interviewed and their blood samples collected and detected using PCR and virus isolation. We also conducted serum antibody surveys among healthy population and livestock and surveillance on vector ticks in those high-epidemic areas. 188 cases that matched the definition of surveillance case and 21 deaths were reported in 11 cities, 32 countries and 100 towns in 2010, with an incidence rate of 0.33/10(6). The fatality rate was 11.2%. Data showed that the patients were from hilly areas at the altitude elevated between 28-940 meters. The epidemic period was between April and December with the peak from May to September. The youngest case was an 11-year old, while the eldest was 81 with median age as 56-year old. 95.3% of the patients were farmers. All Patients did not have the history of traveling, two weeks before the onset of SFTS. 93.6% of the patients engaged in different kind of work which was associated with agriculture. 52.8% of the patients had been exposed to ticks. 22.0% of the patients had been bitten by ticks. Skin injury was found in 64.2% of the patients. Samples from 129 cases (68.6%) were collected and detected, with 67.4% of them (87 cases) showed positive by Real time-PCR for SFTS virus. An elevation in antibody titer by a factor of four or evidence of sero-conversion was observed in 11 patients; SFTS virus was isolated from 2 patients. The total antibody positive rates were 3.8%, 55.0% (6/11), 36.7% (2/3) and 80.0% (4/5) respectively in healthy population, dogs, sheep and cows. Ticks from grass, cattle and sheep were detected positive by Real time-PCR. Most cases of SFTS in Hubei were infected by SFTS virus, and cases of livestock were infected by SFTS virus. Ticks might serve as an important vector. Skin injury, exposure to tick bites seemed to be the risk factors.

GENETICS IN ENDOCRINOLOGY: The genetics of phaeochromocytoma: using clinical features to guide genetic testing

Phaeochromocytoma is a rare, usually benign, tumour predominantly managed by endocrinologists. Over the last decade, major advances have been made in understanding the molecular genetic basis of adrenal and extra-adrenal phaeochromocytoma (also referred to as adrenal phaeochromocytoma (aPCA) and extra-adrenal functional paraganglioma (eFPGL)). In contrast to the previously held belief that only 10% of cases had a genetic component, currently about one-third of all aPCA/eFPGL cases are thought to be attributable to germline mutations in at least nine genes (NF1, RET, SDHA, SDHB, SDHC, SDHD, TMEM127, MAX and VHL). Recognition of inherited cases of aPCA/eFPGL is critical for optimal patient management. Thus, the identification of a germline mutation can predict risks of malignancy, recurrent disease, associated non-chromaffin tumours and risks to other family members. Mutation carriers should be offered specific surveillance programmes (according to the relevant gene). In this review, we will describe the genetics of aPCA/eFPGL and strategies for genetic testing.

Inflammatory Responses to Individual Microorganisms in the Lungs of Children With Cystic Fibrosis

We hypothesized that the inflammatory response in the lungs of children with cystic fibrosis (CF) would vary with the type of infecting organism, being greatest with Pseudomonas aeruginosa and Staphylococcus aureus. A microbiological surveillance program based on annual bronchoalveolar lavage (BAL) collected fluid for culture and assessment of inflammation was conducted. Primary analyses compared inflammation in samples that grew a single organism with uninfected samples in cross-sectional and longitudinal analyses. Results were available for 653 samples from 215 children with CF aged 24 days to 7 years. A single agent was associated with pulmonary infection (≥10(5) cfu/mL) in 67 BAL samples, with P. aeruginosa (n = 25), S. aureus (n = 17), and Aspergillus species (n = 19) being the most common. These microorganisms were associated with increased levels of inflammation, with P. aeruginosa being the most proinflammatory. Mixed oral flora (MOF) alone was isolated from 165 BAL samples from 112 patients, with 97 of these samples having a bacterial density ≥10(5) cfu/mL, and was associated with increased pulmonary inflammation (P < .001). For patients with current, but not past, infections there was an association with a greater inflammatory response, compared with those who were never infected (P < .05). However, previous infection with S. aureus was associated with a greater inflammatory response in subsequent BAL. Pulmonary infection with P. aeruginosa, S. aureus, or Aspergillus species and growth of MOF was associated with significant inflammatory responses in young children with CF. Our data support the use of specific surveillance and eradication programs for these organisms. The inflammatory response to MOF requires additional investigation.

Is There Any Additional Psychological and/or Physical Job Constraint Associated With Informal Caregiving Status? Findings From the GAZEL Cohort Study

Is There Any Additional Psychological and/or Physical Job Constraint Associated With Informal Caregiving Status? Findings From the GAZEL Cohort Study

Relevance of differentiating between residential and non-residential premises for surveillance and control of Aedes aegypti in Rio de Janeiro, Brazil

Entomological surveys on Aedes aegypti (L.) often focus on residential premises, while ignoring non-residential premises. It has been proposed that the latter should be subject to specific monitoring strategies, since they have the potential to contribute a large proportion of the overall mosquito population. In this study, we used traps for ovipositing females to compare the levels of Ae. aegypti infestation in residential and non-residential premises and assess whether there was any evidence for a spatial association of infestation between non-residential premises and the surrounding homes. This information is important for designing specific surveillance programmes for these special sites and their surroundings. This study was conducted in three neighbourhoods of the city of Rio de Janeiro, Brazil, with distinct population densities, water services, dengue histories and vegetation coverage. Ae. aegypti abundance was measured using two types of traps (standard and sticky ovitraps) installed in five non-residential premises and 80 residential premises per neighbourhood. Mosquitoes were collected in the summer (January to March) and winter (June to September) of 2007. The distribution of captures per household per week did not differ significantly between the seasons, although larger numbers of eggs and adults were obtained during the summer. Most non-residential premises were not significantly more infested than homes, despite the larger quantities of containers. There were a few exceptions, including a transportation company, two recycling centres and a boat yard. These highly infested non-residential premises were also spatially associated with highly infested homes in the vicinity. Continuous monitoring with traps may be an effective way of evaluating non-residential premises as sources of dengue vectors for nearby communities.

Biomarkers in familial adenomatous polyposis role and significance

A biomarker, according to a generally accepted definition, is a substance or a manifestation used as indicator of a biologic state. It has the characteristic to be objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacological responses to therapeutic interventions. Biomarkers are important tools available to the clinicians with escalating perspectives in oncologic field. Clinical and genetic biomarkers are essential to properly individuate the disease, to address patients to specific surveillance programs and therapeutic strategies. An ideal biomarker should be absent in normal tissue/condition but present in precancerous lesions like dysplasia and so able to recognize early cancer. Coming from these considerations, several of the known genetic pathways in cancer pathogenesis could be considerate potential candidate biomarkers. In this review, we have reported clinical and molecular biomarkers helpful to manage the Familial Adenomatous Polyposis (FAP), a dominantly inherited colorectal cancer predisposition syndrome. Biomarkers, both clinical and molecular, are essential to reduce the high potential morbidity of FAP giving the opportunity to develop innovative diagnostic and therapeutic protocols.

Infrarenales Aortenaneurysma

Abdominal aortic aneurysms (AAA) confer a substantial healthcare burden in the Western world. Surgical or endovascular therapy is indicated in patients with a maximum diameter exceeding 5.5 cm. Patients with smaller AAA must undergo a specific ultrasound surveillance program aimed at avoiding exposure to an increased risk of rupture once their AAA exceeds the threshold for active treatment. Based on improved understanding of the pathophysiology of AAA, recent years provided initial insight into potential medical treatment options. The presence of AAA is currently regarded a coronary artery disease risk equivalent. ACE inhibitors, statins and JNK-inhibitors were shown to have the potential to slow down progression. Since cigarette smoking is the main risk factor for both the development and progression of AAA, smoking cessation remains a key goal. Further prospective studies will assess the clinical efficacy of various promising drug treatment approaches aimed at slowing disease progression of small AAA and after endovascular therapy.

Tumornachsorge beim Bronchuskarzinom – wie, wann, bei wem, durch wen?

The idea of follow-up visits in lung cancer patients treated in a curative intent is on one side early detection and management of treatment related complications and on the other side a long term surveillance program for early detection of new primary lung cancers or recurrences of the primary lung cancer allowing curative (re)-treatment. The first is best performed by the specialists (thoracic surgeons, oncologists, radiotherapists) and the intervals of the follow-up visits are 3-6 months. In this phase adjuvant therapies as well as a specific surveillance program should be determined. Smoking cessation is strongly recommended and an adequate support should be offered. Patients treated in a curative intent and who are in an adequate performance status should be seen in six months intervals in the first three years and thereafter annually by assessing the medical history, physical exam and for applying imaging modalities such as chest X-ray or CT-Scan of the chest and upper abdomen. The patient should be instructed to detect symptoms and react accordingly. Positron Emission Tomography, sputum cytology, tumor markers and blood tests as well as fluorescence bronchoscopy are not recommended for routine follow-up except in controlled randomized trial protocol. These statements are based on guidelines from several societies as well as from a literature research.

Analysis of the Ductile-to-Brittle Transition Temperature Shift in a Commercial Power Plant With High Nickel Containing Weld Material

Abstract Plant specific surveillance programs that ideally include all relevant materials and materials combinations that are subjected to neutron irradiation during operation address the degradation due to irradiation of the reactor pressure vessel material for nuclear electric power plants. Plant specific surveillance programs are not unique to the two power plants treated in this study. The current Swedish regulatory system does, however, call for a fairly rigid approach within the surveillance program. In the Swedish case, this means that there is a plant specific predetermined inspection∕test program that has to be followed in order to verify the operability of the power plant and also to verify the operational limits with respect to pressure∕temperature effects on a repetitive basis. The two pressurized water reactor plants Ringhals 3 and 4 have in common that the weld metal used for the butt welds of the reactor pressure vessel is a high nickel type material, above the current limits of the NUREG Reg. Guide 1.99, rev. 2. In the original state, the high nickel content provides excellent fracture toughness in the unirradiated material condition and a low ductile-to-brittle transformation temperature (DBTT). It has, however, been highlighted in several studies that high nickel materials exhibit a very large DBTT shift as a consequence of irradiation, and also that the precipitates that form during the irradiation are not as easily controlled during a heat treatment to remove the irradiation damage as are the copper rich clusters. This paper will present the current state of the art regarding these effects as observed in the weld metal specimens. The paper will present the results from the Charpy V notched and fracture mechanics specimen test encapsulated in the Ringhals Units 3 and 4 surveillance programs. The results from the Ringhals Units 3 and 4 surveillance programs show that there is a need for corrective action to be taken in order to ensure 60 y of operability for the two power plants.

Proactive surveillance of contact allergies: an important component of the risk management strategy for skin sensitizers

Risk assessment serves to ensure that dermal exposure to skin sensitizers does not result in the acquisition of allergic skin disease. Traditionally, the approach adopted was one of comparative analysis, involving benchmarking against other allergens of known potency. More recently, efforts have been made to embrace a quantitative risk assessment (QRA) approach. However, the accuracy of any risk assessment is reflected in the extent to which it meets the fundamental objective stated above. Thus, clinical experience is of key importance. There exists the possibility for the originators of risk assessments relating to chemicals that possess skin-sensitizing potential to work directly with the clinical community to proactively obtain this experience through specific surveillance programmes. This forms the focus of this review article. The current status of the QRA approach is considered initially. A recently published example of one such surveillance programme that was undertaken as a collaborative initiative between industry and the clinical community is then reviewed. Finally, a possible strategy for the future is presented, in which it is suggested that surveillance strategies might be deployed in certain situations as an adjunct to the initial risk assessment. It is hoped that such a framework might further improve the efficacy of future approaches to skin sensitization risk assessment.

Metalworking Fluid Mist Occupational Exposure Limits: A Discussion of Alternative Methods

NIOSH published a recommended exposure limit (REL) for metalworking fluids (MWF) in 1998 that was designed to prevent respiratory disorders associated with these industrial lubricants. The REL of 0.4 mg/m3 (as a time-weighted average for up to 10 hours) was for the fraction of aerosol corresponding to deposition in the thoracic region of the lungs. This nonregulatory occupational exposure limit (OEL) corresponded to approximately 0.5 mg/m3 for total particulate mass. Although this REL was designed to prevent respiratory disorders from MWF exposures, NIOSH acknowledged that exposures below the REL may still result in occupational asthma and hypersensitivity pneumonitis—two of the most significant respiratory illnesses associated with MWF. In the 8 years since the publication of the NIOSH MWF REL, neither the Occupational Safety and Health Administration (OSHA) nor the American Conference of Governmental Industrial Hygienists (ACGIH®) has recommended an exposure limit for water-soluble MWF specifically, other than their previous exposure limits for mineral oil. An informal effort to benchmark companies involved in the manufacture of automobiles and automotive parts in North America indicated that most companies are using the NIOSH MWF REL as a guide for the purchase of new equipment. Furthermore, most companies have adopted a goal to limit exposures to below 1.0 mg/m3. We failed to find any company that has strictly enforced an OEL of 1.0 mg/m3 through the use of either administrative controls or personal protective equipment, when engineering controls failed to bring the exposures to below this limit. We also found that most companies have failed to implement specific medical surveillance programs for those employees exposed to MWF mist above 1.0 mg/m3. Organization Resources Counselors (ORC) published in 1999 (on their website) a “best practices” manual for maintaining MWF systems and reducing the likelihood of MWF-related illnesses. The emphasis of this approach was on control techniques, and there was no assignment of a specific OEL for MWF due to the wide variety of fluids that exist. The ORC did suggest that maintaining exposure levels to below 2.0 mg/m3 would assist in minimizing upper respiratory complaints associated with MWF. Although the ORC manual indicated that MWF vary in composition and no single OEL is likely to be appropriate for all such fluids, it adopted a very similar concept to control banding, placing all MWF operations into a single band using similar (if not identical) controls. OSHA, in lieu of adopting a 6B health standard for MWF, has also published a voluntary “best practices” manual on their website. Their document drew heavily from the work of ORC and also incorporated information from the 1998 NIOSH MWF criteria document. Industrial users of MWF need to have guidance, such as an OEL, to determine when either engineering, administrative controls, or personal protective equipment must be implemented to protect their employees. The purpose of this article is to explore various approaches that might be taken to result in a single or multiple limits for exposures to MWF and its components. Approaches such as control banding are discussed in terms of an alternative to the use of an OEL.

Occult Nosocomial Infections

Even with a good surveillance program, nosocomial infections may be not recognized because of several reasons: absence of symptoms or prolonged incubation period (eg, viral bloodborne infections, tuberculosis); problems with the microbiological diagnosis, because adequate specimens may be difficult to obtain or special methods should be used (eg, fungal infections, virus, new agents); shorter hospital stays (eg, surgical-site infections); difficulty in distinguishing between nosocomial and community-acquired infections (eg, influenza); and failure to detect clinically relevant colonization (eg, multiresistant microorganisms). Because of the important potential consequences of occult nosocomial infections, specific surveillance programs should be designed to address these problems.

Occult nosocomial infections.

Even with a good surveillance program, nosocomial infections may be not recognized because of several reasons: absence of symptoms or prolonged incubation period (eg, viral bloodborne infections, tuberculosis); problems with the microbiological diagnosis, because adequate specimens may be difficult to obtain or special methods should be used (eg, fungal infections, virus, new agents); shorter hospital stays (eg, surgical-site infections); difficulty in distinguishing between nosocomial and community-acquired infections (eg, influenza); and failure to detect clinically relevant colonization (eg, multiresistant microorganisms). Because of the important potential consequences of occult nosocomial infections, specific surveillance programs should be designed to address these problems.

Diagnosis of Asbestosis: Primum Non Nocere

asbestosis since 1986, when a committee of experts proposed useful clinical diagnostic criteria that did not require lung biopsy.1 The most significant development over those 10 years has been the widespread availability of thin-section high-resolution CT of the chest. While providing a strikingly more detailed image of the lung parenchyma, high-resolution CT may not add diagnostic sensitivity or specificity for patients whose plain chest roentgenogram is on the borderline between normal and abnormal (International Labour Organization categories 0/1 to 1/0).2 Unfortunately, it remains true in 1997 that we have no therapy to offer the patient with asbestosis, although rapid advances in the understanding of the basic pathogenesis holds promise for intervention trials in the near future. A subcontext of this article is the frustration many pulmonologists feel in being called upon to make or exclude a diagnosis of asbestosis in patients whose disease is in a subclinical or very mild stage of progression. Like idiopathic pulmonary fibrosis, asbestosis begins as a silent alveolitis in the years after initial exposure. The alveolitis may be present and progressive for decades before it can be detected by symptoms, exam, roentgenogram, or lung function. Asbestosis characteristically progresses at a slow pace over decades, so that the clinical expression of an exposure in youth may not come until as late as the seventh or eighth decade. Unfortunately, there are also patients who progress much more rapidly. The factors that make one exposed individual progress to clinical asbestosis while his similarly exposed coworker remains apparently disease-free are currently being elucidated. A better understanding of cellular switching on the path from alveolitis to fibrosis may also lead to effective ways to modulate the lung’s chronic inflammatory response to inhaled asbestos, thus providing a form of secondary prevention in the exposed individual without disease. The legal culpability of several large asbestos manufacturing companies in actively suppressing scientific information about asbestos health effects over several decades produced outrage in thousands of employees exposed during those years. Many now seek out medical opinions to determine whether they qualify for compensation under class action lawsuits; others wish only to find out whether they are among the affected. A part of the frustration of clinicians stems from the difficult task of making a diagnosis in cases where the disease is still mild and the manifestations subtle. At this early stage of disease, diagnostic uncertainty is greater, and in the absence of treatment there is no clinical therapeutic advantage to be gained by early diagnosis, although many who are exposed desire prognostic information. A major point raised is whether claims of asbestosis are being made in excess of the true number of cases of asbestosis and other asbestos-related diseases. This would seem to be an easy question to answer, but in fact it is not. It is appropriately pointed out that the number of cases determined depends on the sensitivity and specificity of the criteria used in a case definition. But for asbestosis in the United States, we have no accurate means to estimate the true prevalence of the disease. There are neither uniform diagnostic criteria nor specific surveillance programs designed to capture even a representative sample of cases. Hence, any estimates of the numbers of cases must be just that— estimates based on reasonable assumptions, but estimates that are not currently subject to verification. The estimate cited by the National Institute of Occupational Safety and Health (NIOSH) in the 1994 Work-Related Lung Disease Surveillance Report,3 an authoritative resource on occupational lung disease and prevalence, is based on multiple cause of death data from the death certificates and collected from all reported deaths by the National Center for Health Statistics. The NIOSH authors caution that “limitations of multiple cause of death data include underor over-reporting of conditions on the death certificate by certifying physicians.”3 Estimates of the national prevalence of asbestosis *From the Occupational Medicine Division and Pulmonary and Critical Care Medicine, University of Rochester (NY) School of Medicine and Dentistry. Manuscript received November 18, 1996; accepted November 19.

Surveillance in environmental public health: issues, systems, and sources.

This article describes environmental public health surveillance and proposes a framework to enhance its practice in the United States. Special issues for surveillance in environmental public health are examined, and examples of existing systems useful for environmental public health practice are provided. Current and projected surveillance needs, as well as potential sources of data, are examined. The proposed framework for conducting environmental public health surveillance involves data from three points in the process by which an agent in the environment produces an adverse outcome in a host: hazards, exposures, and outcomes. Environmental health practitioners should build on efforts in other fields (e.g., infectious diseases and occupational health) to establish priorities in the surveillance of health conditions associated with exposure to environmental toxicants. For specific surveillance programs, existing data systems, as well as data gaps, should be identified. Coordinated surveillance systems can facilitate public health efforts to prevent and control disease, injury, and disability related to the interaction between people and their environment.

Life‐time risk of different cancers in hereditary non‐polyposis colorectal cancer (hnpcc) syndrome

Identification of hereditary non-polyposis colorectal cancer (HNPCC) indicates theoretical life-time risks of 50% for the descendants of an affected family member and of 100% for the true gene carriers. However, besides colorectal cancer (CRC), many other cancer types and sites are also involved, which gives reason to evaluate the magnitude of risk for various other cancer types. A detailed pedigree analysis of 40 families with HNPCC identified 414 patients affected with cancer. A Kaplan-Meier life-table analysis for the cumulative risk of various cancers was performed on the basis of the 293 putative gene carriers who had adequate clinical and histological documentation of their tumors. Cumulative risks were highest for colorectal (78%) and endometrial cancers (43%, women only), followed by gastric, biliary tract, urinary tract and ovarian cancers (19-9%). For the other probably HNPCC-related cancer types, such as small bowel carcinoma and brain tumors, the life-time risk was only 1%. The risk of any metachronous cancer reached 90% after treatment of CRC and 75% after endometrial cancer; the second tumor was most often a new CRC or endometrial cancer. CRC remains the most important cancer type in the HNPCC syndrome but does not develop in all gene carriers. This makes the decision of possible prophylactic colectomy for test-detected gene carriers difficult. Of the many other cancer types involved, at least endometrial cancer is common enough to necessitate a specific surveillance program.

The cancer-family syndrome

We report a family manifesting the cancer-family syndrome in which 11 family members had colonic carcinomas (predominantly involving the proximal colon, in the absence of polyposis), with an average age at onset of 35 years. Three women had endometrial or endocervical cancers. The kindred is notable in that its full evaluation was predicated upon the recognition of features consistent with the cancer-family syndrome in only two sisters. The ascertainment and evaluation of the kindred demonstrates the clinical utility of regarding such criteria (early cancer onset, multiple primary cancers, proximal colonic involvement) as a basis for selecting cases for more thorough family-history evaluation. Although such selection criteria are not pathognomonic for the syndrome, identification of a more extensive family cancer history sometimes enables the initiation of a highly specific cancer surveillance program. Specific attention has been given to the problems of screening patients at risk for the development of proximal colonic cancer, an important feature of the cancer-family syndrome. Innovative operative management is also indicated, such as total colectomy for initial colonic cancer, and consideration of prophylactic hysterectomy for women with colonic cancer (because of the high risk of development of endometrial carcinoma).