Symptomatic Screening Research Articles

Declining TB notification but high sustained mortality during scale-up of TB/HIV care in rural Swaziland

Scale-up of TB/HIV care in a high HIV prevalence setting changed the patterns of the TB epidemic. TB notification declined and gender disparity shifted from more women affected in earlier periods to more male TB cases in recent years. An explanation may be that women better accessed ART during TB/HIV care decentralization resulting in better immune reconstitution at population level and thus being less susceptible to TB. Decentralization of TB/HIV care should be prioritized for improved access to health care and ART to control the TB epidemic in high HIV prevalence settings. Special attention need to be paid to mortality in HIV co-infected TB cases. New programmatic approaches and diagnostic tools are deemed necessary for more rapid TB case detection and earlier treatment initiation in severely immunosuppressed patients. Methods Study eligibility was defined as all ≥16 year old patients initiating first line TB drug treatment at 3 secondary and 22 primary care facilities in Shiselweni region, from 01/2009 to 12/2013. i) We described temporal trends in TB epidemiology of new and recurrent first line drug treatment cases using frequency statistics (01/200912/2013). ii) For HIV/TB co-infected patients, logistic regression was used to assess associations between baseline factors (calendar year, primary/secondary care, sex, age, new-/re-treatment case, TB-site, CTX and ART status, CD4 count) and the composite endpoint LTFU/death/treatment failure (01/2009-12/2012). Background Tuberculosis (TB) is the main cause of mortality in HIV co-infected individuals. Swaziland has one of the highest HIV prevalence (31% [1]) and TB incidence (1,380/100,000) in the world. Since 2007, TB/HIV care was decentralized in the rural Shiselweni region (Swaziland) and coinciding with increasing antiretroviral-therapy (ART) coverage from an estimated 40% in 2009/10 to 80% in 2012. Concurrently, TB case finding was accelerated through changes in national TB guidelines, intensified TB symptomatic screening and role out of new diagnostic tools (GeneXpert, TLA (thin layer agar method)).

The Impact of Colorectal Cancer Screening in a Veteran Hospital Population

Colon and rectal cancer is the second most common cause of cancer death in the United States. Screening effectively decreases colorectal cancer mortality. This study aims to evaluate the impact of colorectal cancer screening within a Veterans Affairs Medical Center and treatment outcomes. Institutional Review Board approval was obtained for a retrospective analysis of all colorectal cancer cases that were identified through the Tumor Registry of the Robley Rex VA Medical Center from 2000 to 2009. Data collected included age at diagnosis, race, risk factors, diagnosis by screening versus symptomatic evaluation, screening test, tumor location and stage, operation performed, operative mortality, and survival. A value of P < 0.05 on Fisher's exact, χ(2), analysis of variance, or Cox regression analyses was considered significant. Three hundred fifty-four patients with colorectal cancer (255 colon, 99 rectal) were identified. One hundred twenty-one patients (34%) were diagnosed by screening. In comparison with those diagnosed by symptom evaluation (n = 233), these patients had earlier stage cancers, were more likely to have a curative intent procedure, and had improved 5-year survival rates. Older patients (older than 75 years old) were more likely to present with symptoms. High-risk patients were more likely to have colonoscopic screening than fecal occult blood testing. More blacks had Stage IV disease than nonblacks. Curative intent 30-day operative mortality was 2.1 per cent for colectomy and 0 per cent for rectal resection. Screening for colorectal cancer in the veteran population allows for better survival, detection at an earlier stage, and higher likelihood of resection.

Cost-effectiveness of Universal Serologic Screening to Prevent Nontraumatic Hip and Vertebral Fractures in Patients With Celiac Disease

Patients with asymptomatic or poorly managed celiac disease can experience bone loss, placing them at risk for hip and vertebral fractures. We analyzed the cost-effectiveness of universal serologic screening (USS) vs symptomatic at-risk screening (SAS) strategies for celiac disease because of the risk of nontraumatic hip and vertebral fractures if untreated or undiagnosed. We developed a lifetime Markov model of the screening strategies, each with male or female cohorts of 1000 patients who were 12 years old when screening began. We screened serum samples for levels of immunoglobulin A, compared with tissue transglutaminase and total immunoglobulin A, and findings were confirmed by mucosal biopsy. Transition probabilities and quality of life estimates were obtained from the literature. We used generalizable cost estimates and Medicare reimbursement rates and ran deterministic and probabilistic sensitivity analyses. For men, the average lifetime costs were $8532 and $8472 for USS and SAS strategies, respectively, corresponding to average quality-adjusted life year gains of 25.511 and 25.515. Similarly for women, costs were $11,383 and $11,328 for USS and SAS strategies, respectively, corresponding to quality-adjusted life year gains of 25.74 and 25.75. Compared with the current standard of care (SAS), USS produced higher average lifetime costs and lower quality of life for each sex. Deterministic and probabilistic sensitivity analyses showed that the model was robust to realistic changes in all the variables, making USS cost-ineffective on the basis of these outcomes. USS and SAS are similar in lifetime costs and quality of life, although the current SAS strategy was overall more cost-effective in preventing bone loss and fractures among patients with undiagnosed or subclinical disease. On the basis of best available supportive evidence, it is more cost-effective to maintain the standard celiac screening practices, although future robust population-based evidence in other health outcomes could be leveraged to reevaluate current screening guidelines.

Current Status and New Developments in Breast Cancer Diagnosis and Detection

Despite extensive research into new ways of imaging the breast x-ray mammography and breast ultrasound, supplemented where necessary by magnetic resonance imaging, remain the techniques used for the vast majority of breast imaging for screening and the assessment of symptomatic breast problems. Recent advances in these technologies mean that these three techniques are highly effective for both detecting disease and for confirming normality. X-ray based imaging of the breast has been around now for 100 years but it is only in the last 10 years or so that digital technology developments have allowed for major advances in the efficacy of this technique. Digital breast tomosynthesis is currently the most promising technology as it has the potential to both improve detection of breast cancer and greatly reduce the numbers of false positive events. Technological advances in grey scale high frequency ultrasound imaging mean that it is now universally used in both symptomatic diagnosis and breast screening. Newer ultrasound techniques such as 3D imaging, Doppler analyses and elastography add some additional value but so far none of these has achieved their hoped for additional potential. Magnetic resonance imaging is currently the most sensitive imaging technique for the detection and characterisation of breast disease, but its cost remains a barrier to its more widespread use. Nuclear medicine techniques have a role is special circumstances but are yet to show that they should be used in routine practice. There are a large number of potential alternative new imaging techniques for the breast, but, as yet, none of these have shown any significant benefits over the current techniques. Dedicated breast computed tomography has perhaps the best promise but clinically effective breast imaging at present remains in the application and refinement of recent developments in digital mammography, ultrasound and magnetic resonance imaging.

A Study of Prevalence and Association of Risk Factors for Diabetic Vasculopathy in an Urban Area of Gujarat.

Background:Peripheral arterial disease (PAD) is an aftermath of type 2 diabetes posing a significant health problem in developing countries. Its silent progression warrants presymptomatic screening by ankle brachial index (ABI), which cannot be applied to the whole population. We tried to measure the burden of PAD in diabetics of this region correlating various risk factors for it quantitatively and qualitatively.Materials and Methods:From various out-patient departments, 110 known under treatment type 2 diabetics were recruited. They underwent thorough assessment for general, symptomatic, medical history and risk factor screening that included 11 well-known risk factors. ABI was measured by Versadop instrument using the standard protocol with ABI <0.9 being considered as abnormal.Results:There was a high prevalence of asymptomatism, hypertension, positive family history and age <52 years in the study group. Relative risk was highest for asymptomatism followed by high body mass index, hyperlipidemia, cardiovascular disease and smoking, but less significant for age, gender, fasting sugar level, family history. More adverse ABI profile was noticed with the increase in number of five modifiable risk factors cumulatively.Conclusion:There was a high prevalence of low ABI in our region that is an evidence of PAD mainly affected by risk factors many of which were modifiable. Defining those who are at risk to develop PAD in Diabetes, one can use ABI better in early screening and prompt treatment of this complication to stop its further progression and primary prevention can be served as felt the need for health-care effectively.

Deciphering the epidemic synergy of herpes simplex virus type 2 (HSV-2) on human immunodeficiency virus type 1 (HIV-1) infection among women in sub-Saharan Africa

BackgroundHerpes Simplex Virus Type 2 (HSV-2) is highly prevalent in regions disproportionately affected by the human immunodeficiency virus (HIV-1) epidemic. The objective of our study was to identify the risk factors of HSV-2 and HIV-1 infections and to examine the association between the two infections.MethodsThe study participants were recruited through a community based cross-sectional study that was conducted from November 2002 to March 2003 in the Moshi urban district of Northern Tanzania. A two-stage sampling design was used in recruiting the study participants. Information on socio-demographics, alcohol use, sexual behaviors, and STIs symptoms were obtained. Blood and urine samples were drawn for testing of HIV-1, HSV-2 and other STIs.ResultsThe prevalence of HSV-2 infection among all study participants was 43%. The prevalence rate of HSV-2 among the HIV-negative and HIV-positive women was 40% and 65%, respectively. We found 2.72 times odds of having HIV-1 in an HSV-2 positive woman than in an HSV-2 negative woman. Furthermore, HIV-1 and HSV-2 shared common high-risk sexual behavior factors such as early onset of sexual debut, and testing positive for other STIs.ConclusionsOur findings suggest that HSV-2 may be both a biological and risk-associated cofactor for HIV-1 acquisition. In resource-limited countries, where both infections are prevalent efforts at symptomatic and diagnostic screening and treatment of HSV-2 should be part of HIV-1 prevention programs.

Incidence and outcome of 18-fluorodeoxyglucose positron emission tomography/computed tomography-detected breast lesions

Breast cancer accounts for around 16% of female deaths in the UK. Usual diagnosis is via the symptomatic pathway or screening. Positron emission tomography/computed tomography (PET/CT) is a modality with increasing applications in staging malignancies and investigating symptoms. It increasingly detects incidental breast lesions. The aim of this study was to evaluate the incidence and outcome of PET/CT-detected breast abnormalities.

Evaluating a training package for health professionals and community workers to spread breast cancer awareness messages

Introduction and aimsDelayed presentation in breast cancer leads to more advanced stage at diagnosis and ultimately poorer survival. Delays in presentation are associated with low breast cancer awareness.Breast Cancer Care...

Molecular biomarkers in malignant mesothelioma: state of the art

Malignant mesothelioma (MM) is an aggressive tumour affecting the mesothelial surfaces of the pleural and peritoneal cavities and, rarely, the pericardium and the tunica vaginalis testis. Despite a ban of asbestos in many industrialised nations, the present high incidence of MM is expected to continue, due to the long latency period between first asbestos exposure and occurrence of disease, making it an important health issue for the future. The diagnosis of MM can be difficult, both from a clinical and pathological perspective. It is not unusual for patients to undergo several medical investigations without definitive diagnosis early in their course of illness. Understandably, there is intense interest in the discovery of markers that can be assessed in pleural effusions, histological specimens, and serum to assist with the difficult early diagnosis of MM. Considering the primary aetiological role of asbestos, there is theoretically an easily identifiable target population for screening with a biomarker with adequate sensitivity and specificity or with a combination of biomarkers. In this review we focus on biomarkers that have been examined in the setting of either early diagnosis of MM in symptomatic patients or screening of asbestos-exposed individuals.

Role of CT colonography in symptomatic assessment, surveillance and screening

When 'whole colonic imaging' is indicated, clinicians must decide between optical colonoscopy, barium enema and CT colonography (CTC). CTC is a relatively new technique which has become increasingly accessible in the UK over the past 5years. As radiologists have gained experience and scanning parameters have standardised, there have been substantial improvements in both the accuracy and safety of CTC. We review evidence from observational studies and randomised trials, and draw on expert opinion, to provide a comprehensive discussion of the current role of CTC in both symptomatic and asymptomatic individuals. The emergence of CTC could soon entirely obviate the need for barium enema. CTC now has a complementary role alongside colonoscopy in symptomatic patients and a possible future role in colorectal cancer screening in the UK.

Detection of colorectal cancer

In a series of 47 patients with colorectal cancer, early-stage lesions were detected more frequently on routine screening than on symptomatic screening. Signs and symptoms tended to occur in combination rather than singly. Guaiac positivity was the sole sign in only one patient. Physicians must consider the possibility of colorectal cancer in patients with suggestive signs or symptoms.

Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm

Control of sexually transmitted infections (STIs) is feasible, leads to improved sexual and reproductive health and contributes to preventing HIV transmission. The most advanced HIV epidemics have developed under conditions of poor STI control, particularly where ulcerative STIs were prevalent. Several countries that have successfully controlled STIs have documented stabilization or reversal of their HIV epidemics. STI control is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: (i) targeting and outreach to populations at greatest risk; (ii) promoting and providing condoms and other means of prevention; (iii) effective clinical interventions; (iv) an enabling environment; and (v) reliable data. Clinical services include STI case management, screening and management of STIs in sex partners. Syndromic case management is effective for most symptomatic curable STIs and screening strategies exist to detect some asymptomatic infections. Presumptive epidemiologic treatment of sex partners and sex workers complement efforts to interrupt transmission and reduce prevalence. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.

Fibroepithelial neoplasms of the breast

Fibroepithelial neoplasms include a large number of common lesions encountered in both symptomatic and breast screening practice. Nearly all are fibroadenomas and are harmless, but they can present a range of differing histologies. The area of most concern is the separation of fibroadenomas from phyllodes tumours, arguably an arbitrary exercise. What is most important to achieve is the recognition of those lesions in the fibroadenoma–phyllodes spectrum with the potential to do harm, either in the form of recurrence or metastases. These are few in number and the key features to identify, with the rare exception of carcinoma arising in these lesions, are those that signify a progression to stromal autonomy. Such features include stromal outgrowth, stromal invasion and both stromal atypia and pleomorphism. These need to be analysed together, not in isolation. Necrosis and heterotypic elements in particular are suggestive of frank malignancy.

Can medio-lateral baseplate position and load sharing induce asymptomatic local bone resorption of the proximal tibia? A finite element study

BackgroundAsymptomatic local bone resorption of the tibia under the baseplate can occasionally be observed after total knee arthroplasty (TKA). Its occurrence is not well documented, and so far no explanation is available. We report the incidence of this finding in our practice, and investigate whether it can be attributed to specific mechanical factors.MethodsThe postoperative radiographs of 500 consecutive TKA patients were analyzed to determine the occurrence of local medial bone resorption under the baseplate. Based on these cases, a 3D FE model was developed. Cemented and cementless technique, seven positions of the baseplate and eleven load sharing conditions were considered. The average VonMises stress was evaluated in the bone-baseplate interface, and the medial and lateral periprosthetic region.ResultsSixteen cases with local bone resorption were identified. In each, bone loss became apparent at 3 months post-op and did not increase after one year. None of these cases were symptomatic and infection screening was negative for all. The FE analysis demonstrated an influence of baseplate positioning, and also of load sharing, on stresses. The average stress in the medial periprosthetic region showed a non linear decrease when the prosthetic baseplate was shifted laterally. Shifting the component medially increased the stress on the medial periprosthetic region, but did not significantly unload the lateral side. The presence of a cement layer decreases the stresses.ConclusionLocal bone resorption of the proximal tibia can occur after TKA and might be attributed to a stress shielding effect. This FE study shows that the medial periprosthetic region of the tibia is more sensitive than the lateral region to mediolateral positioning of the baseplate. Medial cortical support of the tibial baseplate is important for normal stress transfer to the underlying bone. The absence of medial cortical support of the tibial baseplate may lead to local bone resorption at the proximal tibia, as a result of the stress shielding effect. The presence of a complete layer of cement can reduce stress shielding, though. Despite the fact that the local bone resorption is asymptomatic and non-progressive, surgeons should be aware of this phenomenon in their interpretation of follow-up radiographs.

TU-C-210A-04: MR-Guided Near Infrared Spectral Tomography of the Breast

Near‐infrared (NIR)spectraltomography applies and records multiple wavelengths of light in the 700–850 nm range through a transceiving multi‐fiber array in order to estimate absorption chromophores and scattering parameters within tissue. The technique provides important functional information associated with local concentrations of oxygenated and deoxygenated hemoglobin, oxygen saturation, and water and lipid fractions but on a centimeter spatial scale. In an effort to improve the spatial discrimination of these molecular characteristics of tissue, the technique has been combined with high resolution anatomical information obtained from MRI. Technical developments have lead to a simultaneous multi‐modality breast exam which combines the spectralNIR information with the data obtained during a dynamic contrast‐enhanced breast MR study. Commercial and custom breast coils have been populated with a 16‐channel fiber optical array and concomitant data acquisition module to explore the clinical potential of the approach. Clinical breast exams involving women with asymptomatic and symptomatic screening and diagnostic ammography along longitudinal studies of women with locally advance breast cancer receiving neoadjuvant chemotherapy have been performed. Results will be presented from anecdotal case reports as well as statistically valid findings from small clinical study designs and phantom experiments which indicate that the technique produces quantitative estimates of the NIR functional parameters at substantially improved spatial resolution relative to NIRspectraltomography when used in the breast alone. Learning Objectives: 1. To learn the basic physical principles of NIRspectraltomography. 2. To learn the basic clinical and physical characteristics of combined MR and NIRspectraltomography. 3. To learn the latest clinical breast imaging results from the technology as developed by Dartmouth investigators.

The Value of Level III Clearance in Patients With Axillary and Sentinel Node Positive Breast Cancer

The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes. From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease. Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.

Large volume “mammotome” biopsy may reduce the need for diagnostic surgery in papillary lesions of the breast

Background:There is currently debate as to whether all papillary lesions diagnosed on breast needle core biopsy (BNCB) require surgical excision. The development of large volume “mammotome” biopsy now permits non-operative...

Clinical Aspects and Prognosis of Brugada Syndrome in Children

Brugada syndrome is an arrhythmogenic disease characterized by an ECG pattern of ST-segment elevation in the right precordial leads and augmented risk of sudden cardiac death. Little is known about the clinical presentation and prognosis of this disease in children. Thirty children affected by Brugada syndrome who were <16 years of age (mean, 8+/-4 years) were included. All patients displayed a type I ECG pattern before or after drug provocation challenge. Diagnosis of Brugada syndrome was made under the following circumstances: aborted sudden death (n=1), syncope of unexplained origin (n=10), symptomatic supraventricular tachycardia (n=1), suspicious ECG (n=1), and family screening for Brugada syndrome (n=17). Syncope was precipitated by fever in 5 cases. Ten of 11 symptomatic patients displayed a spontaneous type I ECG. An implantable cardioverter-defibrillator was implanted in 5 children; 4 children were treated with hydroquinidine; and 1 child received a pacemaker because of symptomatic sick sinus syndrome. During a mean follow-up of 37+/-23 months, 1 child experienced sudden cardiac death, and 2 children received an appropriate implantable cardioverter-defibrillator shock; all of them were symptomatic and had manifested a type I ECG spontaneously. One child had a cardioverter-defibrillator infection that required explantation of the defibrillator. In the largest population of children affected by Brugada syndrome described to date, fever represented the most important precipitating factor for arrhythmic events, and as in the adult population, the risk of arrhythmic events was higher in previously symptomatic patients and in those displaying a spontaneous type I ECG.

Differentiation of characteristic of attention in different subtypes of attention deficit hyperactivity disorder

目的 应用注意测验方法对注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD)各临床亚型进行比较研究,了解ADHD各临床亚型注意特征的特点及有无差异.方法 对七所小学三至六年级学生使用自编症状筛查表进行筛查,并根据美国精神障碍诊断与统计手册第4版分为3个ADHD亚型组,对ADHD各亚型组和正常对照组儿童进行数字划销测验、无意与有意注意、注意广度测验测试.结果 ADHD三个亚型组在数字划销测验的粗分[(88.83±30.07)分、(92.14±28.66)分、(83.79±24.33)分]、净分[(80.13±29.66)分、(84.86±30.39)分、(77.82±22.96)分]和失误率[(7.33±4.66)%、(10.29±11.93)%、(11.14±7.76)%],注意广度、有意注意和无意注意等注意特征方面,与对照组相比[(101.58±28.88)分、(95.37±27.59)分、(6.04±4.01)分],均差异有显著性(F值分别为3.97,4.60,4.33);但ADHD三个亚型组间的差异无显著性.结论 ADHD各临床亚型患儿的注意特征没有明显差异,但均较正常儿童受损。

PREOPERATIVE ULTRASOUND–GUIDED FINE NEEDLE BIOPSY OF DOUBTFUL TESTICULAR LESIONS

Purpose: Sonography is initial imaging technique in evaluation of symptomatic testis, routine screening or follow-up. Occasionally detected lesions are difficult to characterize and a decision for orchidectomy is questionable. We describe a technique of preoperative ultrasound-guided fine needle biopsy of testicular lesions, detected on sonography with non-specific US appearance. Methods and Materials: Six patients (mean age 32,6 years) with sonographically identified (five unpalpable, two palpable) testicular lesions underwent US guided fine needle biopsy, in one patient bilateraly. Spermatic cord was previously infiltrated with 5 mL of 2% Lydocain to eliminate pain. Procedures were performed on Toshiba Power Vision 6000, using 6–11MHz linear probe with a needle attachment for biopsy. Under US guidance a 21 G needle was placed through the centre of the lesion to aspirate cells by negative pressure. Results: Cytology showed no malignant cells in four patients obviating the need for orchidectomy, suspected malignancy in one, and two different tumours (embriocarcinoma, seminoma) in patient with bilateral lesions. Last two patients underwent orchidectomy. Definitive histology confirmed seminoma in first, and two types of different tumours in second patient. Conclusions: US guided fine needle biopsy allows characterisation of testicular lesions with non-specific sonographic appearance in order to evaluate the necessity of orchidectomy.