Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Cost-effectiveness of contrast-enhanced breast MRI in suspicious mammographic microcalcifications

OBJECTIVES

To evaluate the cost-effectiveness of supplemental breast magnetic resonance imaging (MRI) in women with BI-RADS 4 mammographic microcalcifications in order to avoid unnecessary stereotactic biopsies.

METHODS

Decision analysis and Markov modeling were used to compare the short-term costs and effects of two diagnostic strategies: supplemental breast MRI in women with mammographic microcalcifications to avoid needle biopsies in MRI negative cases vs stereotactic biopsies of all BI-RADS 4 microcalcifications.

RESULTS

Applying supplemental breast MRI resulted in comparable costs and outcomes. Average cumulative costs of US$ 56,918 and 2.932 quality adjusted life years (QALYs) per woman were achieved for the supplemental breast MRI-strategy, whereas stereotactic biopsies as standard of care resulted in cumulative costs of US$ 56,898 and 2.930 QALYs, resulting in an incremental cost effectiveness ratio (ICER) of US$ 10,047 per QALY gained.

CONCLUSION

Due to comparable diagnostic safety at similar costs, the non-invasive breast MRI alternative for workup of mammographically detected suspicious calcifications should be offered to patients within the context of shared decision making.

CRITICAL RELEVANCE STATEMENT

Contrast-enhanced MRI of the breast should be offered as an alternative to stereotactic biopsy within the context of shared decision-making.

KEY POINTS

Breast MRI and stereotactic biopsy enable accurate risk stratification of suspicious calcifications. Breast MRI and stereotactic biopsy yield comparable cost-effectiveness and clinical outcomes. Breast MRI should be considered as an option regarding shared clinical decision-making.

Brief multidimensional screening tools for young children's mental health and development for administration by primary care providers: a scoping review

INTRODUCTION

Many young children with mental health or developmental concerns go unidentified and untreated, underscoring the need for effective screening. Primary care offers unique opportunities for screening, yet rates are low. Primary care providers often cite time constraints, insufficient training, and costs as barriers to screening. Tools designed for administration by primary care providers hold promise for facilitating personalized assessments and improving communication, collaboration, and follow-up between providers and families. To improve early identification and intervention, it is crucial to understand provider-administered screening tools that align with their practical constraints.

AIM

To identify and describe the characteristics, limitations, and improvement areas of brief, multidimensional screening for young children's mental health and development, designed for administration by primary care providers.

METHODS

We conducted a scoping review according to published guidelines. We searched seven electronic databases and used hand-searching strategies. We sought English-language publications on screening tools (English or French) assessing at least one mental health and one development domain in children up to 6 years, designed for administration by primary care providers in under 20 minutes. Two reviewers assessed the articles' eligibility and then extracted, charted, and summarized relevant data.

RESULTS

Three screening tools from six articles were included. The tools were primarily administered by physicians or nurses to children aged 2 weeks to 4 years and required minimal training to use. The tools varied in their domains (4-6), items (10-110), psychometric properties, and scoring methods, but all included indicators of delayed or at-risk children. Article limitations included study recency and lack of data related to implementation and patient outcomes.

CONCLUSIONS

This review described the development and evaluation of multidimensional screening tools for young children's mental health and development designed for administration by primary care providers. It found that few tools have been published. This review identifies several knowledge gaps and emphasizes the need for research on the implementation, cost-effectiveness, and comparative performance of screening tools, as well as the development and evaluation of new screening tools that suit providers' needs. Future studies should investigate how these screening tools can improve identification, clinical care, and health outcomes.

Diagnostic value of contrast-enhanced ultrasound in ovarian cancer: a meta-analysis

BackgroundOvarian cancer has been reported to be the eighth most common cancer among women worldwide.PurposeTo assess the diagnostic efficacy of contrast-enhanced ultrasound (CEUS) in distinguishing between benign and malignant ovarian tumors.Material and MethodsA comprehensive search of scientific literature databases, including PubMed, Cochrane Library, Web of Science, Wanfang, and CNKI, was conducted from their inception to November 2019 to identify relevant studies on the use of CEUS in the differential diagnosis of benign and malignant ovarian tumors. Sensitivity (SEN), specificity (SPE), positive and negative likelihood ratios (LR+/LR-), diagnostic odds ratios (DORs), and their corresponding 95% confidence intervals (CIs) were retrieved and analyzed using Stata 15.0.ResultsAfter rigorous screening, a total of 15 high-quality clinical studies encompassing 934 patients with ovarian cancer, comprising 969 ovarian tumors (403 malignant tumors and 566 benign tumors), were included in the analysis. Data analysis revealed significant correlations between CEUS and various diagnostic indices for ovarian tumors: the combined SEN and SPE were 0.93 (95% CI = 0.88-0.96) and 0.93 (95% CI = 0.90-0.96), respectively, and the combined LR+ and LR- were 14.07 (95% CI = 9.46-20.92) and 0.08 (95% CI = 0.05-0.13), respectively, with a combined DOR of 185.15 (95% CI = 93.31-367.41). The area under the summary receiver operating characteristic curve (AUC) was 0.98 (95% CI = 0.96-0.99). No publication bias was detected in the meta-analysis (P = 0.62).ConclusionCEUS demonstrates significant value in the diagnosis and differential diagnosis of benign and malignant ovarian tumors.

Gynecologic Cancer Screening: Understanding Barriers Through Social Cognitive Theory and Health Belief Model

Despite advancements in screening technologies, gynecologic cancers remain among the deadliest and most overlooked cancers. Early detection is crucial, but many women are reluctant to undergo screening due to various barriers and misconceptions. This study explores the motivations and barriers influencing women's decisions regarding early gynecologic cancer screening in Malaysia. In-depth interviews were conducted with 20 professional women from diverse backgrounds using a qualitative approach. Data were analyzed through open and axial coding to identify key themes. An empathy map and user journey map captured the psychological and behavioral aspects of decision-making. The study identified themes such as lack of knowledge, reliance on social media and health care professionals, financial and time constraints, fear of results, and cultural stigmas. Participants with higher awareness were more likely to undergo screening, while those with personal or family cancer experiences showed greater vigilance. The findings emphasize the importance of culturally sensitive communication and health care professionals' role in reducing stigma and promoting early screening. The study's insights contribute to developing strategies to encourage early detection and improve health outcomes for women. These strategies align with the United Nations' Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being) and SDG 5 (Gender Equality), promoting health equity and empowering women. As emphasized by SDG 17 (Partnerships for the Goals), achieving these goals requires strong partnerships and collaborative efforts to create a supportive environment for early cancer screening initiatives. Policymakers can use these insights to foster health equity and empower women through supportive screening environments.

Psychosocial screening, in-patient care, and disposition planning: Clinicians' perspectives

ObjectiveOur objective was to explore clinicians' views on the MyHEARTSMAP screening report; whether this report has impacted their patient care, and if so, how. MyHEARTSMAP is a psychosocial self-screening tool for youth to identify mental health concerns.MethodsWe conducted a cross-sectional study as a sub-study of the MyHEARTSMAP In-Patient randomized control trial. Eligible clinicians (nurses and physicians who have cared for patients in one of our partnered specialties and have seen a MyHEARTSMAP report in their patients' charts) provided their perceptions of the screening report through a survey.ResultsSixty-five clinicians were enrolled; 60 (92.3%; 95% CI 85.8-98.8%) believe psychosocial screening is beneficial, with many finding it helpful for building rapport with patients/families and providing additional mental health information. Thirty-seven clinicians (56.9%; 95% CI 44.9-69%) had previously read or used the MyHEARTSMAP report, and 31 (83.8%; 95% CI 71.9-95.7%) of these clinicians found the report helpful. Clinicians specifically found the report helpful for communicating with the patient, and guiding patient-centered care.ConclusionClinicians' perceptions towards the MyHEARTSMAP report were positive amongst those who had previously encountered it. While clinicians believe psychosocial screening is beneficial, exploring options for better accessibility to the screening results is necessary to increase utilization.

Global Distribution of Colorectal Cancer Staging at Diagnosis: An Evidence Synthesis

BACKGROUND & AIMS

Stage at diagnosis is a key prognostic factor for colorectal cancer (CRC) survival. We aimed to assess the global distribution of CRC staging at diagnosis using population-based or hospital-based registry data.

METHODS

We systematically searched in MEDLINE and Embase from their inception until December 6, 2023. Gray literature was searched through published cancer reports. Studies from population-based or hospital-based cancer registries reporting the stage distribution of diagnosed CRC were included. We extracted stage-specific proportions among patients with CRC based on TNM; Surveillance, Epidemiology, and End Results; or Dukes staging systems. Subgroup analyses by sex, age, tumor site, calendar period, and status of population-based screening were performed. Correlations between the Human Development Index (HDI), Socio-Demographic Index (SDI), and the distant metastatic CRC proportion were also evaluated.

RESULTS

A total of 84 eligible studies/reports from 46 countries were analyzed, covering 3.8 million patients. Among 36 countries included in the main analysis, the most recent distant metastatic CRC proportions varied from 16.2% in Puerto Rico to 28.2% in Oman and Latvia, with a median of 23.7% (interquartile range, 21.8%-26.3%). Higher metastatic proportions were observed in younger patients, those with colon cancer, and those without screening implementation, with no apparent difference between males and females. Over time, some countries/regions, such as Southern Portugal (36.5% in 2000 to 22.2% in 2016), showed declining proportions of metastatic CRC, whereas others remained stable (eg, Austria, Belgium) or increased (eg, United States, Slovenia, Spain). Higher HDI and SDI were correlated with lower proportions of distant metastatic CRC (HDI: ρ = -0.48; SDI: ρ = -0.26).

CONCLUSION

Global disparities in CRC staging exist, indicating a need for targeted interventions to enhance early detection and management, especially in high-metastasis areas.

Pierre J. An Examination of Underlying Domains in Childhood Adversity: A Scoping Review of Studies Conducting Factor Analyses on Adverse Childhood Experiences

There is an abundance of research linking experiences of childhood adversity to negative physical and mental health outcomes. Areas that remain to be explored and expanded upon include the ideal set of events for inclusion in measures of childhood adversity and testing the models of risk (e.g., cumulative, specificity, dimensional). In the current paper, we performed a scoping review to develop a comprehensive list of studies that conducted factor analyses of childhood adversity measures. There were 89 articles that met the inclusion criteria; trends in the underlying factor structures are reported. Highly associated yet distinct constructs of adversity have demonstrated empirical utility in predicting outcomes in dozens of studies, with consensus that physical abuse, emotional abuse, sexual abuse, physical and emotional neglect, and household dysfunction offer important predictive value to understanding developmental mechanisms of change. We endorse revisions to one commonly used scale that could offer researchers a consistent and psychometrically robust measure of adversity.

Piloting the Coffs Harbour Executive Functioning Screen (CHEFS): An off-road tool to predict fitness to drive

Mental processes responsible for goal-oriented behavior - executive functioning (EF) - include working memory, flexible thinking, and cognitive control. A reliable and valid assessment of EF can inform appropriate interventions and decisions to drive. We investigated the feasibility and validity of a short, iPad-administered EF screening tool in a non-clinical sample: the Coffs Harbour Executive Functioning Screen (CHEFS). Participants (N = 55) completed the CHEFS alongside a neuropsychological assessment of EF used to assess fitness to drive. Discriminant function analysis (DFA) showed that the CHEFS correctly classified 87% of participants to normative clinical ranges on the Verbal Fluency Test. The results suggest that CHEFS is a novel, easily administered tool for assessing EF in a non-clinical sample. DFA is an appropriate within-tool analysis to support the widespread administration of a screening tool to determine fitness to drive and classify patient referral needs. Further assessment is required to determine CHEFS reliability and validity with a broader range of participants varying in neuropsychological functioning, age, ethnicity, test experience, and compared to on-road driving performance.

A Scoping Review of Fall-Risk Screening Tools in the Emergency Department for Future Falls in Older Adults

BACKGROUND

Approximately one-third of adults over the age of 65 experience falls annually, with half resulting in injury. Peak bodies have recommended the use of fall-risk screening tools in the emergency department (ED) to identify patients requiring in-depth assessment and potential fall-prevention intervention. This study aimed to examine the scope of published studies on fall-risk screening tools used in the ED and evidence of associations between screening and future falls.

SUMMARY

PubMed, Embase and CINAHL were searched for peer-reviewed journal articles published since 2012 that examined one or more screening tools to identify patient-level fall risk. Eligible studies described fall-risk tools applied in the ED. Data extracted included sample information, variables measured, and statistical analysis. Sixteen studies published since 2012 were included after full-text review. Fourteen unique screening tools were found. Eight tools were fall-risk screening tools, one tool was a functional screening tool, one tool was a frailty-screening tool, two tools were rapid physical tests, one tool was a trauma triage tool, and one tool was a component of a health-related quality-of-life measure. Studies that evaluated prognostic performance (n = 11) generally reported sensitivity higher than specificity. Previous falls (n = 10) and high-risk medications (n = 6) were consistently associated with future falls. Augmentation with additional variables from the electronic medical record (EMR) improved screening tool prognostic performance in one study.

KEY MESSAGES

Current evidence on the association between the use of fall-risk screening tools in the ED for future falls consistently identifies previous falls and high-risk medications as associated with future falls. Comparison between tools is difficult due to different evaluation methods and different covariates measured. Augmentation of fall-risk screening using the EMR in the ED requires further investigation.

[18F]FDG PET/CT versus [18F]FDG PET/MRI in the evaluation of liver metastasis in patients with primary cancer: A head-to-head comparative meta-analysis

PURPOSE

This meta-analysis aimed to compare the diagnostic effectiveness of [18F]FDG PET/CT with that of [18F]FDG PET/MRI in terms of identifying liver metastasis in patients with primary cancer.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched, and studies evaluating the diagnostic efficacy of [18F]FDG PET/CT and [18F]FDG PET/MRI in patients with liver metastasis of primary cancer were included. We used a random effects model to analyze their sensitivity and specificity. Subgroup analyses and corresponding meta-regressions focusing on race, image analysis, study design, and analysis methodologies were conducted. Cochrane Q and I2 statistics were used to assess intra-group and inter-group heterogeneity.

RESULTS

Seven articles with 343 patients were included in this meta-analysis. The sensitivity of [18F]FDG PET/CT was 0.82 (95 % CI: 0.63-0.96), and that of [18F]FDG PET/MRI was 0.91 (95 % CI: 0.82-0.98); there was no significant difference between the two methods (P = 0.32). Similarly, both methods showed equal specificity: 1.00 (95 % CI: 0.95-1.00) for [18F]FDG PET/CT and 1.00 (95 % CI: 0.96-1.00) for [18F]FDG PET/MRI, and thus, there was no significant difference between the methods (P = 0.41). Furthermore, the subgroup analyses revealed no differences. Meta-regression analysis revealed that race was a potential source of heterogeneity for [18F]FDG PET/CT (P = 0.01), while image analysis and contrast agent were found to be potential sources of heterogeneity for [18F]FDG PET/MRI (P = 0.02).

CONCLUSIONS

[18F]FDG PET/MRI has similar sensitivity and specificity to [18F]FDG PET/CT for detecting liver metastasis of primary cancer in both the general population and in subgroups. [18F]FDG PET/CT may be a more cost-effective option. However, the conclusions of this meta-analysis are tentative due to the limited number of studies included, and further research is necessary for validation.

A Roadmap for the Rational Use of Biomarkers in Oral Disease Screening

Oral health has witnessed a significant transformation with the integration of biomarkers in early-diagnostic processes. This article briefly reviews the types of biomarkers used in the screening and early detection of oral diseases, particularly oral cancer, periodontal diseases, and dental caries, with an emphasis on molecular biomarkers. While the advent of these biomarkers may represent a leap forward in oral healthcare, it also opens the door to potential overtesting, overdiagnosis, and overtreatment. To inform the selection of novel biomarkers and ensure their rational use in screening tests, it is imperative to consider some key characteristics, which are specific to the biomarker (e.g., surrogate biomarkers should reliably reflect the primary health outcome), to the test (e.g., sensitivity and specificity must be balanced based on the disease of interest), and to the disease (e.g., the efficacy of treatment should improve when the condition is diagnosed earlier). For systemic conditions associated with oral diseases, researchers should be extremely cautious when determining who is "at risk", particularly when such risk is small, non-existent, or inconsequent. This framework aims to ensure that advancements in oral health diagnostics translate into genuine improvements in patient care and well-being.

Exploring the facilitators and barriers to addressing social media's impact on anxiety within primary care: a qualitative study

BACKGROUND

Several researchers and policymakers have acknowledged the alarming association between social media (SM) usage and anxiety symptoms in young adults. While primary care holds a crucial role in the improvement of health outcomes for those presenting with anxiety, there has been no research on GPs' perceptions of the impact of SM on anxiety. Furthermore, there has been little discussion of SM as a risk factor in anxiety-related consultations. This study is the first to use empirical research to inform how primary care can adapt to address SM's impact on anxiety within young adults.

AIM

To identify the facilitators and barriers within primary care to addressing SM's impact on anxiety among young adults.

DESIGN & SETTING

A qualitative study of GPs in the UK.

METHOD

Following an exploratory pilot interview, semi-structured interviews with GPs (n = 7) were transcribed and thematically analysed, following an inductive approach.

RESULTS

The following six facilitators were identified: a framework to facilitate discussion; open GP attitudes; GP training; referral pathways; larger stakeholder influence; and young adult education of social media's impact on anxiety. The following three barriers were identified: a lack of GP awareness of SM's impact on anxiety; cautious GP attitudes; and increased pressure on the health service.

CONCLUSION

This qualitative study revealed a diversity of perceptions, and these novel findings are instructive in the adaptation of primary care services to meet the current mental health needs of young adults, as well as better assisting GPs in engaging in these conversations, especially within university practice.

Clinical Factors Associated with Binge-Eating Episodes or Purging Behaviors in Patients Affected by Eating Disorders: A Cross-Sectional Study

The aim of the present study was to investigate the potential associations between clinical/socio-demographic variables and the presence of purging/binge-eating episodes in eating disorders (EDs). Clinical/socio-demographic variables and psychometric scores were collected. Groups of patients were identified according to the presence or absence of purging or objective binge-eating episodes (OBEs) and compared through t-test and chi-square tests. Binary logistic regression analyses were run. A sample of 51 ED outpatients was recruited. Patients with purging behaviors had a longer duration of untreated illness (DUI) (t = 1.672; p = 0.019) and smoked a higher number of cigarettes/day (t = 1.061; p = 0.030) compared to their counterparts. A lower BMI was associated with purging (OR = 0.881; p = 0.035), and an older age at onset showed a trend towards statistical significance (OR = 1.153; p = 0.061). Patients with OBEs, compared to their counterparts, were older (t = 0.095; p < 0.001), more frequently presented a diagnosis of bulimia or binge-eating disorder (χ2 = 26.693; p < 0.001), a longer duration of illness (t = 2.162; p = 0.019), a higher number of hospitalizations (t = 1.301; p = 0.012), and more often received a prescription for pharmacological treatment (χ2 = 7.864; OR = 6.000; p = 0.005). A longer duration of the last pharmacological treatment was associated with OBE (OR = 1.569; p = 0.046). In contrast to purging, OBE was associated with a more complicated and severe presentation of ED. A lower BMI and a later age at onset, as well as long-lasting previous pharmacological treatments, may predict the presence of purging/binging. Further research is needed to thoroughly characterize ED features and corroborate our preliminary findings.

Integrating sexual and reproductive health into pre-travel consultations

BACKGROUND

Casual sex during travel is a major preventable factor in the global transmission of sexually transmissible infections (STI). Pre-travel consults present an excellent opportunity for practitioners to educate travellers about sexual and reproductive health (SRH) and safety. This scoping review aims to explore and understand the extent to which SRH is included in pre-travel consultations.

METHODS

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, Medline and Web of Science were systematically searched for primary research articles exploring whether health care practitioners (HCP) included SRH in pre-travel consultations. Extracted findings were synthesized and presented in narrative form.

RESULTS

Findings across 13 articles suggest HCPs infrequently broached SRH in pre-travel consultations with HCP discomfort, and lack of time and resources presented as key barriers. Urban practice settings, HCP experience, training in travel medicine and traveller characteristics such as sexual orientation were positively associated with discussions about SRH. SRH advice reported was general in nature, primarily focusing on safer sex, condoms or unspecified STI advice. Risk assessments based solely on age or stereotypes around sexual preferences led to key aspects of SRH care being missed for some (e.g. SRH was less likely to be discussed with older travellers).

CONCLUSIONS

HCPs frequently miss opportunities to integrate SRH into pre-travel consultations. Strategies to promote HCP confidence and awareness present a promising means to boost the frequency and quality of SRH advice disseminated. Integrating culturally safe and responsive SRH history-taking and advice into pre-travel consultations may contribute to global reductions in STI transmission and promote traveller SRH well-being.

Assessing intrinsic capacity in Taiwan: Initial psychometric properties of the Integrated Care for Older People Screening Tool for Taiwanese (ICOPES-TW)

BACKGROUND

The World Health Organization (WHO) proposed the concept of intrinsic capacity (comprising composite physical and mental capacity) which aligns with their concepts of healthy aging and functional ability. Consequently, the WHO promotes the Integrated Care for Older People (ICOPE) framework as guidance for geriatric care. Consequently, each government should have a screening tool corresponding to ICOPE framework to promote geriatric care. The present study examined the initial psychometric properties of the Taiwan version of ICOPE (i.e., ICOPES-TW).

METHODS

Older people (n = 1235; mean age = 72.63 years; 634 females [51.3%]) were approached by well-trained interviewers for participation. A number of measures were administered including the ICOPES-TW, WHOQOL-AGE (assessing quality of life [QoL]), Clinical Frailty Scale (assessing frailty), Barthel Index (assessing basic activity of daily living [BADL]), and Lawton Instrumental Activities of Daily Living Scale (assessing instrumental activity of daily living [IADL]).

RESULTS

The ICOPES-TW had a two-factor structure (body functionality [eigenvalue = 1.932] and life adaptation [eigenvalue = 1.170]) as indicated by the results of exploratory factor analysis. Internal consistency of the ICOPES-TW was low (Cronbach's α = 0.55 [entire ICOPES-TW], 0.45 (body functionality factor), and 0.52 (life adaptation factor). ICOPES-TW scores were significantly (i) positively correlated with age (r = 0.321), IADL (r = 0.313), and frailty (r = 0.601), and (ii) negatively correlated with QoL (r=-0.447), and BADL (r=-0.447), with all p-values < 0.001.

CONCLUSION

The ICOPES-TW could be a useful screening tool for healthcare providers to quickly evaluate intrinsic capacity for Taiwanese older people given that it has moderate to strong associations with age, BADL, IADL, QoL, and frailty.

An Evaluation of the Health Economics of Postnatal Depression Prevention and Treatment Strategies in China: A Cost-Effectiveness Analysis

OBJECTIVE

The primary objectives of this study are to assess the cost-effectiveness of early postnatal screening and prenatal psychological interventions for the prevention and treatment of postpartum depression (PPD) among Chinese pregnant women. Additionally, we aim to explore the most cost-effective prevention and treatment strategies for PPD in China.

METHODS

We used TreeAge 2019 to construct a decision tree model, with the model assuming a simulated queue size of 10,000 people. The model employed Monte Carlo simulation to assess the cost-effectiveness of PPD prevention and treatment strategies. Transfer probabilities were derived from published studies and meta-analyses. Cost and effectiveness data were obtained from published sources and relevant studies. Incremental cost-effectiveness ratios (ICERs) were used to describe the results, with willingness-to-pay (WTP) thresholds set at China's gross domestic product (GDP) per capita.

RESULTS

Compared to the usual care group, the cost per additional quality-adjusted life year (QALY) for the early postnatal screening group and the prenatal psychological interventions is USD 6840.28 and USD 3720.74, respectively. The cure rate of mixed treatments for PPD has the greatest impact on the model, while patient participation in treatment has a minor impact on the cost-effectiveness of prevention and treatment strategies.

CONCLUSION

Both early postnatal screening and prenatal psychological interventions are found to be highly cost-effective strategies for preventing and treating PPD in China. Prenatal psychological interventions for pregnant women are the most cost-effective prevention and treatment strategy. As such, from the perspective of national payers, we recommend that maternal screening for PPD be implemented in China to identify high-risk groups early on and to facilitate effective intervention.

Machine Learning-based Voice Assessment for the Detection of Positive and Recovered COVID-19 Patients

Many virological tests have been implemented during the Coronavirus Disease 2019 (COVID-19) pandemic for diagnostic purposes, but they appear unsuitable for screening purposes. Furthermore, current screening strategies are not accurate enough to effectively curb the spread of the disease. Therefore, the present study was conducted within a controlled clinical environment to determine eventual detectable variations in the voice of COVID-19 patients, recovered and healthy subjects, and also to determine whether machine learning-based voice assessment (MLVA) can accurately discriminate between them, thus potentially serving as a more effective mass-screening tool. Three different subpopulations were consecutively recruited: positive COVID-19 patients, recovered COVID-19 patients and healthy individuals as controls. Positive patients were recruited within 10 days from nasal swab positivity. Recovery from COVID-19 was established clinically, virologically and radiologically. Healthy individuals reported no COVID-19 symptoms and yielded negative results at serological testing. All study participants provided three trials for multiple vocal tasks (sustained vowel phonation, speech, cough). All recordings were initially divided into three different binary classifications with a feature selection, ranking and cross-validated RBF-SVM pipeline. This brough a mean accuracy of 90.24%, a mean sensitivity of 91.15%, a mean specificity of 89.13% and a mean AUC of 0.94 across all tasks and all comparisons, and outlined the sustained vowel as the most effective vocal task for COVID discrimination. Moreover, a three-way classification was carried out on an external test set comprised of 30 subjects, 10 per class, with a mean accuracy of 80% and an accuracy of 100% for the detection of positive subjects. Within this assessment, recovered individuals proved to be the most difficult class to identify, and all the misclassified subjects were declared positive; this might be related to mid and short-term vocal traces of COVID-19, even after the clinical resolution of the infection. In conclusion, MLVA may accurately discriminate between positive COVID-19 patients, recovered COVID-19 patients and healthy individuals. Further studies should test MLVA among larger populations and asymptomatic positive COVID-19 patients to validate this novel screening technology and test its potential application as a potentially more effective surveillance strategy for COVID-19.

Lung-function trajectories: relevance and implementation in clinical practice

Lung development starts in utero and continues during childhood through to adolescence, reaching its peak in early adulthood. This growth is followed by gradual decline due to physiological lung ageing. Lung-function development can be altered by several host and environmental factors during the life course. As a result, a range of lung-function trajectories exist in the population. Below average trajectories are associated with respiratory, cardiovascular, metabolic, and mental health comorbidities, as well as with premature death. This Review presents progressive research into lung-function trajectories and assists the implementation of this knowledge in clinical practice as an innovative approach to detect poor lung health early, monitor respiratory disease progression, and promote lung health. Specifically, we propose that, similar to paediatric height and weight charts used globally to monitor children's growth, lung-function charts could be used for both children and adults to monitor lung health status across the life course. To achieve this proposal, we introduce our free online Lung Function Tracker tool. Finally, we discuss challenges and opportunities for effective implementation of the trajectory concept at population level and outline an agenda for crucial research needed to support such implementation.

Potential mental health-related harms associated with the universal screening of anxiety and depressive symptoms in Australian secondary schools

BACKGROUND

Anxiety and depressive disorders typically emerge in adolescence and can be chronic and disabling if not identified and treated early. School-based universal mental health screening may identify young people in need of mental health support and facilitate access to treatment. However, few studies have assessed the potential harms of this approach. This paper examines some of the potential mental health-related harms associated with the universal screening of anxiety and depression administered in Australian secondary schools.

METHODS

A total of 1802 adolescent students from 22 secondary schools in New South Wales, Australia, were cluster randomised (at the school level) to receive either an intensive screening procedure (intervention) or a light touch screening procedure (control). Participants in the intensive screening condition received supervised self-report web-based screening questionnaires for anxiety, depression and suicidality with the follow-up care matched to their symptom severity. Participants in the light touch condition received unsupervised web-based screening for anxiety and depression only, followed by generalised advice on help-seeking. No other care was provided in this condition. Study outcomes included the increased risk of anxiety, depression, psychological distress, decreased risk of help-seeking, increased risk of mental health stigma, determined from measures assessed at baseline, 6 weeks post-baseline, and 12 weeks post-baseline. Differences between groups were analysed using mixed effect models.

RESULTS

Participants in the intensive screening group were not adversely affected when compared to the light touch screening condition across a range of potential harms. Rather, participants in the intensive screening group were found to have a decreased risk of inhibited help-seeking behaviour compared to the light touch screening condition.

CONCLUSIONS

The intensive screening procedure did not appear to adversely impact adolescents' mental health relative to the light touch procedure. Future studies should examine other school-based approaches that may be more effective and efficient than universal screening for reducing mental health burden among students. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12618001539224) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375821 .

On repeated diagnostic testing in screening for a medical condition: How often should the diagnostic test be repeated?

In screening large populations a diagnostic test is frequently used repeatedly. An example is screening for bowel cancer using the fecal occult blood test (FOBT) on several occasions such as at 3 or 6 days. The question that is addressed here is how often should we repeat a diagnostic test when screening for a specific medical condition. Sensitivity is often used as a performance measure of a diagnostic test and is considered here for the individual application of the diagnostic test as well as for the overall screening procedure. The latter can involve an increasingly large number of repeated applications, but how many are sufficient? We demonstrate the issues involved in answering this question using real data on bowel cancer at St Vincents Hospital in Sydney. As data are only available for those testing positive at least once, an appropriate modeling technique is developed on the basis of the zero-truncated binomial distribution which allows for population heterogeneity. The latter is modeled using discrete nonparametric maximum likelihood. If we wish to achieve an overall sensitivity of 90%, the FOBT should be repeated for 2 weeks instead of the 1 week that was used at the time of the survey. A simulation study also shows consistency in the sense that bias and standard deviation for the estimated sensitivity decrease with an increasing number of repeated occasions as well as with increasing sample size.

Screening tools used in primary health care settings to identify health behaviours in children (birth-16 years); A systematic review of their effectiveness, feasibility and acceptability

BACKGROUND

Child health behaviour screening tools have potential to enhance the effectiveness of health promotion and early intervention. This systematic review aimed to examine the effectiveness, acceptability and feasibility of child health behaviour screening tools used in primary health care settings.

METHODS

A systematic review of studies published in English in five databases (CINAHL, Medline, Scopus, PsycINFO and Web of Science) prior to July 2022 was undertaken. Eligible studies described: 1) screening tools for health behaviours (dietary, physical activity, sedentary or sleep-related behaviours) used in primary health care settings in children birth to 16 years; 2) tool effectiveness for identifying child health behaviours and changing practitioner behaviour; 3) tool acceptability or feasibility from child, caregiver or practitioner perspective and/or 4) implementation of the screening tool.

RESULTS

Of the 7145 papers identified, 22 studies describing 14 screening tools were included. Only four screening tools measured all four behaviour domains. Fourteen studies reported changes in practitioner self-reported behaviour, knowledge and practice. Practitioners and caregivers identified numerous benefits and challenges to screening.

CONCLUSIONS

Health behaviour screening can be an acceptable and feasible strategy to assess children's health behaviours in primary health care. Further evaluation is needed to determine effectiveness on child health outcomes.

From Pixels to Prognosis: A Narrative Review on Artificial Intelligence's Pioneering Role in Colorectal Carcinoma Histopathology

Colorectal carcinoma, a prevalent and deadly malignancy, necessitates precise histopathological assessment for effective diagnosis and prognosis. Artificial intelligence (AI) emerges as a transformative force in this realm, offering innovative solutions to enhance traditional histopathological methods. This narrative review explores AI's pioneering role in colorectal carcinoma histopathology, encompassing its evolution, techniques, and advancements. AI algorithms, notably machine learning and deep learning, have revolutionized image analysis, facilitating accurate diagnosis and prognosis prediction. Furthermore, AI-driven histopathological analysis unveils potential biomarkers and therapeutic targets, heralding personalized treatment approaches. Despite its promise, challenges persist, including data quality, interpretability, and integration. Collaborative efforts among researchers, clinicians, and AI developers are imperative to surmount these hurdles and realize AI's full potential in colorectal carcinoma care. This review underscores AI's transformative impact and implications for future oncology research, clinical practice, and interdisciplinary collaboration.

16S rRNA sequencing analysis of the oral and fecal microbiota in colorectal cancer positives versus colorectal cancer negatives in Iranian population

BACKGROUND

Colorectal cancer (CRC) poses a significant healthcare challenge, accounting for nearly 6.1% of global cancer cases. Early detection, facilitated by population screening utilizing innovative biomarkers, is pivotal for mitigating CRC incidence. This study aims to scrutinize the fecal and salivary microbiomes of CRC-positive individuals (CPs) in comparison to CRC-negative counterparts (CNs) to enhance early CRC diagnosis through microbial biomarkers.

MATERIAL AND METHODS

A total of 80 oral and stool samples were collected from Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, encompassing both CPs and CNs undergoing screening. Microbial profiling was conducted using 16S rRNA sequencing assays, employing the Nextera XT Index Kit on an Illumina NovaSeq platform.

RESULTS

Distinct microbial profiles were observed in saliva and stool samples of CPs, diverging significantly from those of CNs at various taxonomic levels, including phylum, family, and species. Saliva samples from CPs exhibited abundance of Calothrix parietina, Granulicatella adiacens, Rothia dentocariosa, and Rothia mucilaginosa, absent in CNs. Additionally, Lachnospiraceae and Prevotellaceae were markedly higher in CPs' feces, while the Fusobacteria phylum was significantly elevated in CPs' saliva. Conversely, the non-pathogenic bacterium Akkermansia muciniphila exhibited a significant decrease in CPs' fecal samples compared to CNs.

CONCLUSION

Through meticulous selection of saliva and stool microbes based on Mean Decrease GINI values and employing logistic regression for saliva and support vector machine models for stool, we successfully developed a microbiota test with heightened sensitivity and specificity for early CRC detection.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses

Background

Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening.

Purpose

To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening.

Materials and methods

The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed.

Results

Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes.

Conclusion

Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Quantifying the potential benefits of early detection for pancreatic cancer through a counterfactual simulation modeling analysis

The benefits of cancer early detection depend on various factors, including cancer type, screening method performance, stage at diagnosis, and subsequent treatment. Although numerous studies have evaluated the effectiveness of screening interventions for identifying cancer at earlier stages, there is no quantitative analysis that studies the optimal early detection time interval that results in the greatest mortality benefit; such data could serve as a target and benchmark for cancer early detection strategies. In this study, we focus on pancreatic ductal adenocarcinoma (PDAC), a cancer known for its lack of early symptoms. Consequently, it is most often detected at late stages when the 5-year survival rate is only 3%. We developed a PDAC population model that simulates an individual patient's age and stage at diagnosis, while replicating overall US cancer incidence and mortality rates. The model includes "cancer sojourn time," serving as a proxy for the speed of cancer progression, with shorter times indicating rapid progression and longer times indicating slower progression. In our PDAC model, our hypothesis was that earlier cancer detection, potentially through a hypothetical screening intervention in the counterfactual analysis, would yield reduced mortality as compared to a no-screening group. We found that the benefits of early detection, such as increased life-years gained, are greater when the sojourn time is shorter, reaching their maximum when identification is made 4-6 years prior to clinical diagnosis (e.g., when a symptomatic diagnosis is made). However, when early detection occurs even earlier, for example 6-10 years prior to clinical diagnosis, the benefits significantly diminish for shorter sojourn time cancers, and level off for longer sojourn time cancers. Our study clarifies the potential benefits of PDAC early detection that explicitly incorporates individual patient heterogeneity in cancer progression and identifies quantitative benchmarks for future interventions.

External validation of a cardiovascular risk model for Omani patients with type 2 diabetes mellitus: a retrospective cohort study

OBJECTIVES

To externally validate a recently developed cardiovascular disease (CVD) risk model for Omanis with type 2 diabetes mellitus (T2DM).

DESIGN

Retrospective cohort study.

SETTING

Nine primary care centres in Muscat Governorate, Oman.

PARTICIPANTS

A total of 809 male and female adult Omani patients with T2DM free of CVD at baseline were selected using a systematic random sampling strategy.

OUTCOME MEASURES

Data regarding CVD risk factors and outcomes were collected from the patients' electronic medical records between 29 August 2020 and 2 May 2021. The ability of the model to discriminate CVD risk was assessed by calculating the area under the curve (AUC) of the receiver-operating characteristic curve. Calibration of the model was evaluated using a Hosmer-Lemeshow χ2 test and the Brier score.

RESULTS

The incidence of CVD events over the 5-year follow-up period was 4.6%, with myocardial infarction being most frequent (48.6%), followed by peripheral arterial disease (27%) and non-fatal stroke (21.6%). A cut-off risk value of 11.8% demonstrated good sensitivity (67.6%) and specificity (66.5%). The area under the curve (AUC) was 0.7 (95% CI 0.60 to 0.78) and the Brier score was 0.01. However, the overall mean predicted risk was greater than the overall observed risk (11.8% vs 4.6%) and the calibration graph showed a relatively significant difference between predicted and observed risk levels in different subgroups.

CONCLUSIONS

Although the model slightly overestimated the CVD risk, it demonstrated good discrimination. Recalibration of the model is required, after which it has the potential to be applied to patients presenting to diabetic care centres elsewhere in Oman.

The sensitivity and specificity of the WHO's ICOPE screening tool, and the prevalence of loss of intrinsic capacity in older adults: A scoping review

BACKGROUND

The World Health Organization has developed the Integrated Care for Older People (ICOPE) program, a public health strategy to maintain older adults' functional abilities and promote healthier aging. The approach comprises a 5-step pathway. Step 1 is the screening for impairment in functions, and Step 2 is an in-depth evaluation to confirm the presence and severity of functional impairment. These initial two steps are crucial to determine the subsequent plan of care (Step 3) and follow-up (Step 4). The fifth step encompasses actions to support families and caregivers and to engage communities. This review gathers data from the literature on the prevalence of positive screenings regarding intrinsic capacity detected by the program's first-step screening tool, and on currently available results regarding the instrument's sensitivity and specificity.

METHODS AND FINDINGS

Electronic searches were conducted in the PubMed, Cochrane, Embase, and SciElo databases, the medRxiv platform, and recent human aging scientific events, looking for research analyzing the ICOPE screening instrument. Studies reporting data on the prevalence of positive screenings for loss of intrinsic capacity using the proposed screening tool and/or findings on the instrument's sensitivity and specificity were included. A total of 7 publications with participants aged 50 years or more were selected. The prevalence of at least one impairment in intrinsic capacity detected by the instrument varied among the studies from 17.1 % to 94.3 %. Sensitivity ranged from 26.4 % to 100 % and specificity from 22 % to 96 %, depending on the setting and the assessed domain.

CONCLUSION

Currently available data are heterogeneous, and different results were found among the studies due to diverse settings and methodologies. The evidence on the ICOPE screening tool's performance in different populations is still scarce and reinforces the need for further research worldwide.

A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework

BACKGROUND

Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021).

METHODOLOGY

A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively.

FINDINGS

This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators.

TRIAL REGISTRATION

PROSPERO: CRD42020188712 05/07/20.

Sensitivity and specificity of the Patient Health Questionnaire (PHQ-9, PHQ-8, PHQ-2) and General Anxiety Disorder scale (GAD-7, GAD-2) for depression and anxiety diagnosis: a cross-sectional study in a Peruvian hospital population

OBJECTIVES

The Patient Health Questionnaire (PHQ) and Generalised Anxiety Disorder Scale (GAD) are widely used screening tools, but their sensitivity and specificity in low-income and middle-income countries are lower than in high-income countries. We conducted a study to determine the sensitivity and specificity of different versions of these scales in a Peruvian hospital population.

DESIGN

Our study has a cross-sectional design.

SETTING

Our participants are hospitalised patients in a Peruvian hospital. The gold standard was a clinical psychiatric interview following ICD-10 criteria for depression (F32.0, F32.1, F32.2 and F32.3) and anxiety (F41.0 and F41.1).

PARTICIPANTS

The sample included 1347 participants. A total of 334 participants (24.8%) were diagnosed with depression, and 28 participants (2.1%) were diagnosed with anxiety.

RESULTS

The PHQ-9's≥7 cut-off point showed the highest simultaneous sensitivity and specificity when contrasted against a psychiatric diagnosis of depression. For a similar contrast against the gold standard, the other optimal cut-off points were: ≥7 for the PHQ-8 and ≥2 for the PHQ-2. In particular, the cut-off point ≥8 had good performance for GAD-7 with sensitivity and specificity, and cut-off point ≥10 had lower levels of sensitivity, but higher levels of specificity, compared with the cut-off point of ≥8. Also, we present the sensitivity and specificity values of each cut-off point in PHQ-9, PHQ-8, PHQ-2, GAD-7 and GAD-2. We confirmed the adequacy of a one-dimensional model for the PHQ-9, PHQ-8 and GAD-7, while all PHQ and GAD scales showed good reliability.

CONCLUSIONS

The PHQ and GAD have adequate measurement properties in their different versions. We present specific cut-offs for each version.

Features of Addiction in Binge-Eating Disorder: Considerations for Screening and Treatment

Similarities have been reported between the diagnostic and associated characteristics of binge-eating disorder (BED) and substance-related and non-substance-related disorders. This has resulted in interest in using addiction models to inform clinical care for people with BED. The purpose of this paper was to review features of addiction in BED with a focus on clinical implications. First, we briefly summarize similarities and differences in diagnostic and mechanistic features and symptoms for BED and food addiction, substance-related disorders, and non-substance-related disorders. Then we review aspects of addiction in BED that have clinical implications for screening and treatment of this condition. Similarities in diagnostic criteria between BED and substance-related and non-substance-related disorders include loss of control, greater use than intended, continued use despite adverse consequences, and marked distress. Addiction models may help inform aspects of clinical care of BED, particularly for shared antecedents and mechanisms underlying both disorders and to enhance engagement in treatment. Yet, there are large gaps in evidence regarding the effects of many aspects of addiction models to BED. More research is needed to examine the safety and efficacy of using addiction theories and frameworks for clinical strategies for BED.

Healthy Eating in the Australian Coal Mining Industry: Assessing the Efficacy of the 'Out of the Box' Workplace Health Promotion Program

Noncommunicable diseases are the world's leading cause of death. To curb the global rise in these diseases, using the workplace as a front to disseminate health communication messages and resources has been suggested. This study aimed to assess the efficacy of a workplace health promotion program, 'Out of the Box', that targeted nutrition outcomes and nutrition guideline knowledge. A 6-month workplace health promotion program was implemented within a coal mine site. Over the 6 months, there were four wellness focus areas, lasting 1 month each, including fruits, vegetables and portion controlling, label reading, alcohol awareness, and hydration promotion. The study utilized a quasi-experimental pre-test-post-test design, with measurements via self-reported paper-based surveys. At baseline there were 163 responses, and 106 at follow-up. At the 6-month follow-up, respondents had increased odds of recalling the current fruit (OR 1.29, p = 0.032) and vegetable (OR 1.76, p < 0.001) guidelines. Being male was associated with lower vegetable intake (B: -0.28), although this did not reach statistical significance. A nutrition-focused workplace health promotion program can be an efficacious strategy in improving knowledge of fruit and vegetable guidelines. Further research is needed to evaluate the effectiveness of these programs over time.

Intra- and inter-rater reliability, agreement, and minimal detectable change of the handheld dynamometer in individuals with symptomatic hip osteoarthritis

INTRODUCTION

The handheld dynamometer has been validated to measure muscle strength in different muscle groups. However, to date, it has not been tested in individuals who experience pain induced by hip osteoarthritis. The current study aimed to evaluate the intra- and inter-rater reliability, agreement, and minimal detectable change of the Lafayette handheld dynamometer, model 1165, to assess the peak force (Pk) and average peak force (Af) of hip muscles in individuals with symptomatic hip osteoarthritis.

METHODS

Twenty participants with hip osteoarthritis (mean ± SD age: 58.7±15.3 years; body mass index: 28.8±4.2 kg/m2) and pain intensity on the Visual Analogue Scale ≥ 4 (8.05±1.2) were recruited to participate in this study. Pk and Af of hip flexors (seated position), abductors and adductors (supine position), and extensors (prone position) were collected in a single day by two independent raters, each one obtaining test and retest in randomly ordered separate sessions.

RESULTS

The intra-rater intraclass correlation coefficient (ICC) was classified as good (>0.75) or excellent (≥0.90) for all muscle groups and all inter-rater ICCs were classified as excellent. Rater A had a lower standard error of measurement compared to rater B, ranging from 0.15 to 0.58 kilogram-force (Kgf) compared with 0.34 to 1.25 kg, respectively. However, the inter-rater comparison showed a minimal detectable change (MDC) of < 10% for all Pk and Af measures for hip adductors and extensors. Finally, the inter-rater Bland-Altman analysis demonstrated good agreement for abductors, adductors, and extensors.

CONCLUSION

Despite pain and dysfunction related to hip osteoarthritis, the mean of two measures using a handheld dynamometer was shown to be a reliable tool to assess hip muscle strength, with good to excellent intra- and inter-rater ICCs, satisfactory agreement, and small values for MDC.

Delayed cancer diagnosis in the pregnant patient: navigating a complex medical and ethical dilemma

Prompt diagnosis of cancer in pregnancy is necessary to ensure timely management and improve outcomes. However, there are a several reasons why diagnosis may be delayed in pregnancy. Three major contributors to delayed diagnosis and treatment are patient delay, provider delay, and referral delay. This article aims to (1) increase physician awareness of this problem by providing a detailed review of the main culprits of delayed diagnosis and treatment of cancer in the pregnant patient, (2) discuss the complex ethical issues at hand in these cases, and (3) provide suggestions on how to better address such cases with the goal of improving patient outcomes.

A Proof of Principle Proteomic Study Detects Dystrophin in Human Plasma: Implications in DMD Diagnosis and Clinical Monitoring

Duchenne muscular dystrophy (DMD) is a rare neuromuscular disease caused by pathogenic variations in the DMD gene. There is a need for robust DMD biomarkers for diagnostic screening and to aid therapy monitoring. Creatine kinase, to date, is the only routinely used blood biomarker for DMD, although it lacks specificity and does not correlate with disease severity. To fill this critical gap, we present here novel data about dystrophin protein fragments detected in human plasma by a suspension bead immunoassay using two validated anti-dystrophin-specific antibodies. Using both antibodies, a reduction of the dystrophin signal is detected in a small cohort of plasma samples from DMD patients when compared to healthy controls, female carriers, and other neuromuscular diseases. We also demonstrate the detection of dystrophin protein by an antibody-independent method using targeted liquid chromatography mass spectrometry. This last assay detects three different dystrophin peptides in all healthy individuals analysed and supports our finding that dystrophin protein is detectable in plasma. The results of our proof-of-concept study encourage further studies in larger sample cohorts to investigate the value of dystrophin protein as a low invasive blood biomarker for diagnostic screening and clinical monitoring of DMD.

Phase Angle as a Potential Screening Tool in Adults with Metabolic Diseases in Clinical Practice: A Systematic Review

BACKGROUND

Phase angle (PhA) has been used as mortality prognostic, but there are no studies about its possible use as a screening tool. Therefore, an assessment of the possible utility of PhA in clinical practice is required. The aim of this systematic review was to explore all recent available evidence of PhA, and its possible utility as a screening tool in clinical practice in subjects with chronic metabolic diseases.

MATERIALS AND METHODS

This systematic review was performed and written as stated in the PRISMA 2020 guidelines. The search was conducted in PubMed, ScienceDirect and SciElo. In order to be considered eligible, within the entire search, only articles involving PhA and their utility in metabolic diseases were included.

RESULTS

PhA was associated with hyperuricemia and vitamin D deficiency in obese subjects, and decreased cardiovascular risk and malnutrition in hospitalized patients.

CONCLUSION

PhA may be a potential screening tool in clinical practice to evaluate different biomarkers, cardiovascular risk, and nutritional diagnosis in metabolic diseases in adults.

Comparison of a Wearable Accelerometer/Gyroscopic, Portable Gait Analysis System (LEGSYS+TM) to the Laboratory Standard of Static Motion Capture Camera Analysis

Examination of gait patterns has been used to determine severity, intervention triage and prognostic measures for many health conditions. Methods that generate detailed gait data for clinical use are typically logistically constrained to a formal gait laboratory setting. This has led to an interest in portable analysis systems for near clinical or community-based assessments. The following study assessed with the wearable accelerometer/gyroscopic, gait analysis system (LEGSYS+^TM) and the standard of static motion capture camera (MOCAP) analysis during a treadmill walk at three different walking speeds in healthy participants (n = 15). To compare each speed, 20 strides were selected from the MOCAP data and compared with the LEGSYS+ strides at the same time point. Both scatter and bland-Altman plots with accompanying linear regression analysis for each of the parameters. Each stride parameter showed minimal or a consistent difference between the LEGSYS+ and MOCAP, with the phase parameters showing inconsistencies between the systems. Overall, LEGSYS+ stride parameters can be used in the clinical setting, with the utility of phase parameters needing to be taken with caution.

MASCoD-Multidimensional Assessment of Subjective Cognitive Decline

Subjective cognitive decline (SCD) is a subclinical cognitive impairment that is complained by the individual without being objectively supported at clinical, diagnostic, and neuropsychological levels. It can negatively impact on patient's frailty and quality of life, as well as on the caregiver's burden. Moreover, it can be prodromal to Mild Cognitive Impairment or dementia. Although the clinical manifestations of SCD can differ along with several cognitive domains, to date there are only screening tools to investigate subjective memory complaints. Thus, the first aim of this paper is to propose a preliminary English and Italian version of a new screening tool called MASCoD (Multidimensional Assessment of Subjective Cognitive Decline); the second aim is to propose its preliminary adoption on a pilot sample. This schedule is a brief test derived from the review of the literature and the clinical experience provided by an experts panelist. From pilot tests, it seems promising as it can help the professional to make differential diagnosis and to predict the risk of developing severe cognitive impairment over time, developing a personalized care path. This screening tool is brief, easily embeddable in usual clinical assessment, and administrable by different professionals. Furthermore, following validation, it will allow to collect manifold cognitive manifestations of SCD, addressing the shortage of previous validated instruments globally assessing cognition affected by this condition.

The Accuracy of a Screening Tool in Epidemiological Studies-An Example of Exhaled Nitric Oxide in Paediatric Asthma

Diagnostic tests are widely used in medicine, especially in the clinical setting. The doctor's decision regarding the treatment process is mostly based on the result of the diagnostic test. The value of the test is expressed by its accuracy. It is easier to verify the accuracy of a diagnostic test in a clinical setting in comparison to an epidemiological setting. Moreover, a very good test may not work in epidemiological settings in the same effective way as in a clinical setting, especially because the accuracy is affected by the prevalence of the disease. The aim of the study is to assess the accuracy of FeNO measurement in different respiratory disorders or symptoms, including their prevalence, in a childhood population. The secondary aim is to suggest the optimal FeNO cut-off for epidemiological screening for respiratory diseases and symptoms.

METHODS

The cross-sectional study included 447 children (50.8% boys and 49.2% girls) aged 6-9 years. An adapted version of the ISAAC questionnaire was used for the assessment of the respiratory status. FeNO was measured with an electrochemical device (Niox Mino) according to ERS/ATS recommendations. For interpretation, the FeNO cut-off values of 20 parts per billion (ppb), 25 ppb and 35 ppb were applied taking the real-life prevalence of the disease or symptoms into consideration and also for simulated prevalences of 20%, 30%, 40%, 50% for the interpretation of the accuracy of the test. The accuracy was calculated according to the following formula: Accuracy = (Prevalence) (Sensitivity) + (1- Prevalence) (Specificity). The area under the curve was calculated based on logistic regression.

RESULTS

For all respiratory outcomes, FeNO accuracy decreased with increasing prevalence, and in general the area under the curve (AUC) was low. The highest FeNO accuracy was found for any asthma diagnosis (with possible coexisting diseases/symptoms), i.e., 78.6%, 92.8% and 88.5% for FeNO cut-offs >19 ppb, >24 ppb and >34 ppb, respectively. The AUC was 0.628. For the same FeNO cut-offs, the accuracy of an asthma diagnosis without any coexisting diseases and symptoms was 81.2%, 87.5%, 92.9%, respectively, with an AUC of 0.757.

CONCLUSION

FeNO accuracy decreases with increasing prevalence of the respiratory disease and symptoms. The best accuracy for the FeNO cut-off in the screening of asthma for epidemiological purposes is 35 ppb. For isolated asthma, the best accuracy for FeNO was 92.9%.

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling

BACKGROUND

Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma.

OBJECTIVES

The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care.

DESIGN

(1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives.

DATA SOURCES

For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used.

REVIEW METHODS

For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed.

RESULTS

People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research.

LIMITATIONS

The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet.

CONCLUSIONS

Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia).

FUTURE WORK

Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019115506 and CRD42020170766.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.

Posttraumatic stress following childbirth: psychometric properties of the Brazilian version of the City Birth Trauma Scale

OBJECTIVE

To seek validity and reliability evidence of the Brazilian version of the City Birth Trauma Scale (BiTS-Br) and establish diagnostic accuracy.

METHOD

A total of 343 mothers (up to one year after childbirth, 30.8 years old on average) completed the BiTs-Br and other instruments screening for posttraumatic stress disorder (PTSD), depression, and anxiety for convergent validity analysis. Structural validity was verified using exploratory techniques (principal components analysis), while discriminant validity was checked using the known-groups method and ROC curve. The Structured Clinical Interview for DSM-5 was applied via telephone interviews. Test-retest reliability was obtained in a 15-30-d interval.

RESULTS

A two-factor structure was found (birth-related and general symptoms), with excellent test-retest reliability (0.73) and internal consistency (0.91). Moderate/strong associations (>0.62) were found with correlated symptoms and posttraumatic stress. The scale had a diagnostic accuracy of 86.7% and a cutoff point >28 was the most appropriate, with a sensitivity of 72% and specificity of 83%.

CONCLUSIONS

BiTS-Br presented excellent psychometric indexes, similar to the original version and other cross-culturally adapted versions. Thus, it can be widely used in scientific research and clinical settings to support the identification and treatment of PTSD.

Early detection of obstructive sleep apnea in patients with atrial fibrillation

BACKGROUND

Obstructive sleep apnea (OSA) is an independent and modifiable risk factor for atrial fibrillation (AF) and correlates with a three-fold higher risk of incident AF. Although OSA is prevalent in patients with AF, it remains underdiagnosed. Guidelines for OSA screening are ambiguous.

LOCAL PROBLEM

A small community hospital in the southeast United States lacked standardized OSA screening and consistent sleep clinic referral for hospitalized patients with AF.

METHODS

Over 3 months, an OSA bundle (including screening, education, and referral) was implemented for hospitalized patients with AF. A retrospective electronic health record (EHR) review established a baseline comparison group. Descriptive analyses between the intervention and comparison groups evaluated the effectiveness of the OSA bundle.

INTERVENTIONS

Eligible patients received OSA screening with the STOP-Bang questionnaire. A STOP-Bang score of 3 or higher triggered patient education about the arrhythmogenic relationship of OSA and AF. At discharge, patients received an ambulatory sleep clinic referral. After 3 months, an EHR review assessed the rate of sleep clinic follow-up, sleep testing, OSA diagnosis, and initiation of positive airway pressure.

RESULTS

Of the 68 patients in the comparison group and 33 patients in the intervention group, the rate of OSA screening increased from 4.4% to 100%. Sleep clinic referral increased from 66.7% to 93.5%. Sleep clinic follow-up increased from 0% to 10%.

CONCLUSION

Screening for OSA and sleep clinic referral improved with the OSA bundle; however, sleep clinic follow-up remained low. Further quantitative and qualitative investigation is needed to better understand barriers to sleep clinic follow-up.

Identification of four serum miRNAs as potential markers to screen for thirteen cancer types

Introduction

Cancer consistently remains one of the top causes of death in the United States every year, with many cancer deaths preventable if detected early. Circulating serum miRNAs are a promising, minimally invasive supplement or even an alternative to many current screening procedures. Many studies have shown that different serum miRNAs can discriminate healthy individuals from those with certain types of cancer. Although many of those miRNAs are often reported to be significant in one cancer type, they are also altered in other cancer types. Currently, very few studies have investigated serum miRNA biomarkers for multiple cancer types for general cancer screening purposes.

Method

To identify serum miRNAs that would be useful in screening multiple types of cancers, microarray cancer datasets were curated, yielding 13 different types of cancer with a total of 3352 cancer samples and 2809 non-cancer samples. The samples were divided into training and validation sets. One hundred random forest models were built using the training set to select candidate miRNAs. The selected miRNAs were then used in the validation set to see how well they differentiate cancer from normal samples in an independent dataset. Furthermore, the interactions between these miRNAs and their target mRNAs were investigated.

Result

The random forest models achieved an average of 97% accuracy in the training set with 95% bootstrap confidence interval of 0.9544 to 0.9778. The selected miRNAs were hsa-miR-663a, hsa-miR-6802-5p, hsa-miR-6784-5p, hsa-miR-3184-5p, and hsa-miR-8073. Each miRNA exhibited high area under the curve (AUC) value using receiver operating characteristic analysis. Moreover, the combination of four out of five miRNAs achieved the highest AUC value of 0.9815 with high sensitivity of 0.9773, indicating that these miRNAs have a high potential for cancer screening. miRNA-mRNA and protein-protein interaction analysis provided insights into how these miRNAs play a role in cancer.

Predictors of central and general obesity in Iranian preschool children: which anthropometric indices can be used as screening tools?

AIM

To compare the ability of anthropometric indices [waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), neck-to-height ratio (NHR), conicity index (CI), body adiposity index (BAI), tri-ponderal mass index (TMI) and body mass index (BMI)] and,measuerments like neck(NC), hip(HC) and waist circumferences to predict overweight and obesity in Iranian preschool children.

MATERIALS AND METHODS

A total of 498 Iranian preschool children were included in this case-control study conducted in Tehran, Iran. The participants were selected using the stratified random sampling procedure based on gender and school. Using sex-based receiver operating curve (ROC) analysis, we compared the area under the curve and defined the cut-off points for detecting central and general obesity for each index in order to identify the most suitable tools in predicting obesity.

RESULTS

Boys had significantly higher values for NC, WC, WHR, NHR, CI, TMI and BMI as compared to girls, whereas BAI and HC were higher in girls. The area under the curve was calculated for all the possible predictors of central obesity, i.e., NC (0.841-0.860), WC (0.70-0.679), HC (0.785-0.697), WHR (0.446-0.639) and CI (0.773-0.653) in boys and girls, respectively. And according to the ROC curve analysis, BMI (0.959-0.948), TMI (0.988-0.981), WHtR (0.667-0.553) and NHR (0.785-0.769) were predictors of general obesity and NC (0.841-0.860) as predictor of central obesity in boys and girls, respectively. The optimal cut-off points for TMI (13.80-15.83), NC (28.68-27.5) and for other anthropometric indices were estimated in both boys and girls.

CONCLUSION

TMI and NC seem to predict general and central obesity in Iranian preschool children.

Predictors of central and general obesity in Iranian preschool children: which anthropometric indices can be used as screening tools?

AIM

To compare the ability of anthropometric indices [waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), neck-to-height ratio (NHR), conicity index (CI), body adiposity index (BAI), tri-ponderal mass index (TMI) and body mass index (BMI)] and,measuerments like neck(NC), hip(HC) and waist circumferences to predict overweight and obesity in Iranian preschool children.

MATERIALS AND METHODS

A total of 498 Iranian preschool children were included in this case-control study conducted in Tehran, Iran. The participants were selected using the stratified random sampling procedure based on gender and school. Using sex-based receiver operating curve (ROC) analysis, we compared the area under the curve and defined the cut-off points for detecting central and general obesity for each index in order to identify the most suitable tools in predicting obesity.

RESULTS

Boys had significantly higher values for NC, WC, WHR, NHR, CI, TMI and BMI as compared to girls, whereas BAI and HC were higher in girls. The area under the curve was calculated for all the possible predictors of central obesity, i.e., NC (0.841-0.860), WC (0.70-0.679), HC (0.785-0.697), WHR (0.446-0.639) and CI (0.773-0.653) in boys and girls, respectively. And according to the ROC curve analysis, BMI (0.959-0.948), TMI (0.988-0.981), WHtR (0.667-0.553) and NHR (0.785-0.769) were predictors of general obesity and NC (0.841-0.860) as predictor of central obesity in boys and girls, respectively. The optimal cut-off points for TMI (13.80-15.83), NC (28.68-27.5) and for other anthropometric indices were estimated in both boys and girls.

CONCLUSION

TMI and NC seem to predict general and central obesity in Iranian preschool children.

Smartphone as a Disease Screening Tool: A Systematic Review

Disease screening identifies a disease in an individual/community early to effectively prevent or treat the condition. COVID-19 has restricted hospital visits for screening and other healthcare services resulting in the disruption of screening for cancer, diabetes, and cardiovascular diseases. Smartphone technologies, coupled with built-in sensors and wireless technologies, enable the smartphone to function as a disease-screening and monitoring device with negligible additional costs and potentially higher quality results. Thus, we sought to evaluate the use of smartphone applications for disease screening and the acceptability of this technology in the medical and healthcare sectors. We followed a systematic review process using four databases, including Medline Complete, Web of Science, Embase, and Proquest. We included articles published in English examining smartphone application utilisation in disease screening. Further, we presented and discussed the primary outcomes of the research articles and their statistically significant value. The initial search yielded 1046 studies for the initial title and abstract screening. Of the 105 articles eligible for full-text screening, we selected nine studies and discussed them in detail under four main categories: an overview of the literature reviewed, participant characteristics, disease screening, and technology acceptance. According to our objective, we further evaluated the disease-screening approaches and classified them as clinically administered screening (33%, n = 3), health-worker-administered screening (33%, n = 3), and home-based screening (33%, n = 3). Finally, we analysed the technology acceptance among the users and healthcare practitioners. We observed a significant statistical relationship between smartphone applications and standard clinical screening. We also reviewed user acceptance of these smartphone applications. Hence, we set out critical considerations to provide equitable healthcare solutions without barriers when designing, developing, and deploying smartphone solutions. The findings may increase research opportunities for the evaluation of smartphone solutions as valid and reliable screening solutions.

Stress Measurement in Primary Care: Conceptual Issues, Barriers, Resources, and Recommendations for Study

OBJECTIVE

Exposure to stressors in daily life and dysregulated stress responses are associated with increased risk for a variety of chronic mental and physical health problems, including anxiety disorders, depression, asthma, heart disease, certain cancers, and autoimmune and neurodegenerative disorders. Despite this fact, stress exposure and responses are rarely assessed in the primary care setting and infrequently targeted for disease prevention or treatment.

METHOD

In this narrative review, we describe the primary reasons for this striking disjoint between the centrality of stress for promoting disease and how rarely it is assessed by summarizing the main conceptual, measurement, practical, and reimbursement issues that have made stress difficult to routinely measure in primary care. The following issues will be reviewed: a) assessment of stress in primary care, b) biobehavioral pathways linking stress and illness, c) the value of stress measurements for improving outcomes in primary care, d) barriers to measuring and managing stress, and e) key research questions relevant to stress assessment and intervention in primary care.

RESULTS

On the basis of our synthesis, we suggest several approaches that can be pursued to advance this work, including feasibility and acceptability studies, cost-benefit studies, and clinical improvement studies.

CONCLUSIONS

Although stress is recognized as a key contributor to chronic disease risk and mortality, additional research is needed to determine how and when instruments for assessing life stress might be useful in the primary care setting, and how stress-related data could be integrated into disease prevention and treatment strategies to reduce chronic disease burden and improve human health and well-being.

Workup and Clinical Assessment for Allergen Immunotherapy Candidates

Allergen Immunotherapy (AIT) is a well-established, efficient, and safe way to treat respiratory and insect-venom allergies. After determining the diagnosis of the clinically relevant culprit allergen, AIT can be prescribed. However, not all patients are eligible for AIT, since some diseases/conditions represent contraindications to AIT use, as described in several guidelines. Allergists are often preoccupied on whether an extensive workup should be ordered in apparently healthy AIT candidates in order to detect contra-indicated diseases and conditions. These preoccupations often arise from clinical, ethical and legal issues. The aim of this article is to suggest an approach to the workup and assessment of the presence of any underlying diseases/conditions in patients with no case history before the start of AIT. Notably, there is a lack of published studies on the appropriate evaluation of AIT candidates, with no globally accepted guidelines. It appears that Allergists are mostly deciding based on their AIT training, as well as their clinical experience. Guidance is based mainly on experts’ opinions; the suggested preliminary workup can be divided into mandatory and optional testing. The evaluation for possible underlying neoplastic, autoimmune, and cardiovascular diseases, primary and acquired immunodeficiencies and pregnancy, might be helpful but only in subjects for whom the history and clinical examination raise suspicion of these conditions. A workup without any reasonable correlation with potential contraindications is useless. In conclusion, the evaluation of each individual candidate for possible medical conditions should be determined on a case-by-case basis.