The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one.

BACKGROUND: The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure. METHODS: 144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review. RESULTS: There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44-0.70), with no significant difference in agreement between the different categories. CONCLUSION: The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.

Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer's Disease (AD) in the elderly?

ABSTRACTObjective:To compare the accuracy of Mini-Mental State Examination (MMSE) and of the Montreal Cognitive Assessment (MoCA) in tracking mild cognitive impairment (MCI) and Alzheimer's Disease (AD). METHOD: A Systematic review of the PubMed, Bireme, Science Direct, Cochrane Library, and PsycInfo databases was conducted. Using inclusion and exclusion criteria and staring with 1,629 articles, 34 articles were selected. The quality of the selected research was evaluated through the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2). RESULT: More than 80% of the articles showed MoCA to be superior to MMSE in discriminating between individuals with mild cognitive impairment and no cognitive impairment. The area under the curve varied from 0.71 to 0.99 for MoCA, and 0.43 to 0.94 for MMSE, when evaluating the ability to discriminate MCI in the cognitively healthy elderly individuals, and 0.87 to 0.99 and 0.67 to 0.99, respectively, when evaluating the detection of AD. The AUC mean value for MoCA was significantly larger compared to the MMSE in discriminating MCI from control [0.883 (CI 95% 0.855-0.912) vs MMSE 0.780 (CI 95% 0.740-0.820) p < 0.001]. CONCLUSION: The screening tool MoCA is superior to MMSE in the identification of MCI, and both tests were found to be accurate in the detection of AD.

[Clinical and ethical differences between diagnosing and screening].

Screening is often defined as systematic examinations of healthy citizens to identify those with asymptomatic disease. In our modern society many persons have chronic conditions and it is not so easy to draw the line between healthy and unhealthy citizens. Today, many health-care activities aim at detecting conditions at an early non-symptomatic stage of the disease process in order to be able to avoid possible progression to the next stage. On this basis, we suggest to broaden the definition of screening to reflect the realities of modern health care.

Effective classification of the prevalence of Schistosoma mansoni.

OBJECTIVE: To present an effective classification method based on the prevalence of Schistosoma mansoni in the community. METHODS: We created decision rules (defined by cut-offs for number of positive slides), which account for imperfect sensitivity, both with a simple adjustment of fixed sensitivity and with a more complex adjustment of changing sensitivity with prevalence. To reduce screening costs while maintaining accuracy, we propose a pooled classification method. To estimate sensitivity, we use the De Vlas model for worm and egg distributions. We compare the proposed method with the standard method to investigate differences in efficiency, measured by number of slides read, and accuracy, measured by probability of correct classification. RESULTS: Modelling varying sensitivity lowers the lower cut-off more significantly than the upper cut-off, correctly classifying regions as moderate rather than lower, thus receiving life-saving treatment. The classification method goes directly to classification on the basis of positive pools, avoiding having to know sensitivity to estimate prevalence. For model parameter values describing worm and egg distributions among children, the pooled method with 25 slides achieves an expected 89.9% probability of correct classification, whereas the standard method with 50 slides achieves 88.7%. CONCLUSIONS: Among children, it is more efficient and more accurate to use the pooled method for classification of S. mansoni prevalence than the current standard method.

The reporting of anal cytology and histology samples: establishing terminology and criteria.

Our understanding of the human papillomavirus (HPV) related cytomorphology and histopathology of the anal canal is underpinned by our knowledge of HPV infection in the cervix. In this review, we utilise cervical reporting of cytological and histological specimens as a foundation for the development of standardised and evidence-based terminology and criteria for reporting of anal specimens. We advocate use of the Australian Modified Bethesda System 2004 for reporting anal cytology. We propose the use of a two-tiered histological reporting system for noninvasive disease - low-grade and high-grade anal intraepithelial neoplasia. These classification systems reflect current understanding of the biology of HPV and enhance diagnostic reproducibility. Biomarkers such as p16(INK4A) may prove useful in further improving diagnostic accuracy. Standardisation is important because it will increase the value of the data collected as Australian centres develop programs for screening for anal neoplasia.

Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years.

BACKGROUND: The National Cervical Screening Program in Australia currently recommends that sexually active women between the ages of 18-70 years attend routine screening every 2 years. The publically funded National HPV Vaccination Program commenced in 2007, with catch-up in females aged 12-26 years conducted until 2009; and this may prompt consideration of whether the screening interval and other aspects of the organized screening program could be reviewed. The aim of the current evaluation was to assess the epidemiologic outcomes and cost implications of changing the recommended screening interval in Australia to 3 years. METHODS: We used a modelling approach to evaluate the effects of moving to a 3-yearly recommended screening interval. We used data from the Victorian Cervical Cytology Registry over the period 1997-2007 to model compliance with routine screening under current practice, and registry data from other countries with 3-yearly recommendations to inform assumptions about future screening behaviour under two alternative systems for screening organisation--retention of a reminder-based system (as in New Zealand), or a move to a call-and-recall system (as in England). RESULTS: A 3-yearly recommendation is predicted to be of similar effectiveness to the current 2-yearly recommendation, resulting in no substantial change to the total number of incident cervical cancer cases or cancer deaths, or to the estimated 0.68% average cumulative lifetime risk of cervical cancer in unvaccinated Australian women. However, a 3-yearly screening policy would be associated with decreases in the annual number of colposcopy and biopsy procedures performed (by 4-10%) and decreases in the number of treatments for pre-invasive lesions (by 2-4%). The magnitude of the decrease in the number of diagnostic procedures and treatments would depend on the method of screening organization, with call-and-recall screening associated with the highest reductions. The cost savings are predicted to be of the order of A$10-18 M annually, equivalent to 6-11% of the total cost of the current program (excluding overheads), with call-and-recall being associated with the greatest savings. CONCLUSIONS: Lengthening the recommended screening interval to 3 years in Australia is not predicted to result in increases in rates of cervical cancer and is predicted to decrease the number of women undergoing diagnostic and treatment procedures. These findings are consistent with a large body of international evidence showing that screening more frequently than every three years with cervical cytology does not result in substantial gains in screening effectiveness.

TRICARE: changes included in the National Defense Authorization Act for Fiscal Year 2007; improvements to descriptions of cancer screening for women. Final rule.

The Department is publishing this final rule to implement section 703 of the National Defense Authorization Act (NDAA) for Fiscal Year 2007 (FY07), Public Law 109-364. Specifically, that legislation authorizes breast cancer screening and cervical cancer screening for female beneficiaries of the Military Health System, instead of constraining such testing to mammograms and Papanicolaou smears. The rule allows coverage for "breast cancer screening" and "cervical cancer screening" for female beneficiaries of the Military Health System, instead of constraining such testing to mammograms and Papanicolaou tests. This rule ensures new breast and cervical cancer screening procedures can be added to the TRICARE benefit as such procedures are proven to be a safe, effective, and nationally accepted medical practice. This amends the cancer specific recommendations for breast and cervical cancer screenings to be brought in line with the processes for updating other cancer screening recommendations. In response to public comment on the proposed rule, this final rule includes a clarification that the benefit encompasses screening based on Health and Human Services guidelines.

Primary care practice organization influences colorectal cancer screening performance.

OBJECTIVE: To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. DATA SOURCES/STUDY SETTING: Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). STUDY DESIGN: Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. DATA COLLECTION/EXTRACTION METHODS: Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. PRINCIPAL FINDINGS: After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001). CONCLUSIONS: Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.

BI-RADS classification for management of abnormal mammograms.

The Breast Imaging Reporting and Data System (BI-RADS), developed by the American College of Radiology, provides a standardized classification for mammographic studies. This system demonstrates good correlation with the likelihood of breast malignancy. The BI-RADS system can inform family physicians about key findings, identify appropriate follow-up and management and encourage the provision of educational and emotional support to patients.

Comparison of the validity and reliability of two image classification systems for the assessment of mammogram quality.

OBJECTIVE: To compare the reliability and validity of two classification systems used to evaluate the quality of mammograms: PGMI ('perfect', 'good', 'moderate' and 'inadequate') and EAR ('excellent', 'acceptable' and 'repeat'). SETTING: New South Wales (Australia) population-based mammography screening programme (BreastScreen NSW). METHODS: Thirty sets of mammograms were rated by 21 radiographers and an expert panel. PGMI and EAR criteria were used to assign ratings to the medio-lateral oblique (MLO) and cranio-caudal (CC) views for each set of films. Inter-observer reliability and criterion validity (compared with expert panel ratings) were assessed using mean weighted observed agreement and kappa statistics. RESULTS: Reliability: Kappa values for both classification systems were low (0.01-0.17). PGMI produced significantly higher values than EAR. Agreement between raters was higher using PGMI than EAR for the MLO view (77% versus 74%, P < 0.05), but was similar for the CC view. Dichotomized ratings ('acceptable' or 'needs repeating') did not improve reliability estimates. VALIDITY: Kappa values between raters and the reference standard were low for both classification systems (0.05-0.15). Agreement between raters and the reference standard was higher using PGMI than EAR for the MLO view (74% versus 63%), but was similar for the CC view. Dichotomized ratings of the MLO view showed slightly higher observer agreement. CONCLUSIONS: Both PGMI and EAR have poor reliability and validity in evaluating mammogram quality. EAR is not a suitable alternative to PGMI, which must be improved if it is to be useful.

Assessment of the possibility to classify patients according to cholesterol guideline screening criteria using routinely recorded electronic patient record data.

BACKGROUND: Computerised decision support systems (CDSS) can be categorised as either being inquisitive or non-inquisitive. The non-inquisitive system uses routinely entered electronic patient data, to generate patient specific feedback based on guidelines. The Dutch College of General Practitioners' (DCGP) cholesterol guideline classifies patients into risk groups, eligible for screening. The availability of sufficient routinely recorded electronic patient data to classify patients according to the DCGP cholesterol guideline is unknown. OBJECTIVE: To assess whether it is possible to classify patients according to the screening criteria of the DCGP cholesterol guideline, using data routinely recorded by general practitioners. METHODS: We analysed the DCGP cholesterol guideline to identify selection criteria for screening. These selection criteria were subsequently used to create a cohort of patient records eligible for screening in the Integrated Primary Care Information (IPCI) Database. We calculated incidence and prevalence of risk factors and selected patient records for active management according to the identified screening selection criteria. RESULTS: 145866 valid patient records were selected for classification. In the retrieved records 9741 (13.6%) males and 5756 (7.8%) females were identified for active management according to the selection criteria of the DCGP cholesterol guideline. CONCLUSION: The classification of patients into risk groups, eligible for screening, according to the criteria of the DCGP cholesterol guideline using routinely recorded electronic patient data is feasible. Care should be taken when using only diagnostic codes, as it gives higher than expected incidence and prevalence of risk factors. Based on these findings we are currently building Cholgate, a non-inquisitive decision support system for cholesterol management.

A classification system of social problems: concepts and influence on GPs' registration of problems.

OBJECTIVES: (1) To test lists of problems in the three axes of well-being (physical, mental, and social) with the GPs' collaboration (2) To place the resulting classification in the context of other ones aiming at collecting data about psycho-social aspects of life (assessment, index and classification systems). (3) To test if GPs would be induced to record psychological and social problems more often in their everyday practice, after having been trained to look more closely at them, inter allia with the use of classification and codes. METHOD: The lists of problems have been initiated by the WHO Department of Mental Health and discussed at an international symposium; they were then tested on the field, first at an international level, then in Belgium. After discussion by 4 Belgian GPs' Teaching Units, they were then improved. In all surveys concerned, general practitioners were asked to collaborate in three ways: opening their usual medical records and collaborating to prospective phases, including one "test phase," i.e., a training session, recording problems with the use of coding lists, and looking for the proper code. Retrospective and prospective approaches were used both before and after this test phase. RESULTS: (1) The original lists of problems have been improved on the basis of the findings in medical files and in the survey. (2) A conceptual framework is presented for recording social problems, either in everyday practice (i.e., in health records) or in research settings, e.g., for social surveys. It is biaxial: domains and types of problem. (3) Training GPs for using such a coding system drastically increases the number of psycho-social problems, but only during the prospective phases. In the long run older habits prevail again; only the overall number of contacts mentioning a reason increases, together with the number of "other" reasons for encounter (requests, ...). CONTENTS: (1) Main concepts (section 1). (2) Various tools for measuring psychosocial problems and well-being (section 2). (3) New conceptual fanmework for a classification of psychosocial problems ( 2.2.3). (4) Using the lists: influence on MDs' recording propensity (section 3).

Screening for cancers of the head and neck: addressing the problem.

More than 90% of upper aerodigestive tract (UADT) cancers occur in people with specific lifestyle risks, including tobacco and alcohol use. More than 90% of tumors occur in easily examined parts of the head and neck, therefore, there is the possibility of identifying the vast majority of patients through selective screening. Physicians should keep in mind that the mucosa's sojourn from visually suspicious (and possibly malignant) tissue is most likely less than two years, and frequent examination of asymptomatic patients is necessary. When patients wait to bring symptoms to medical attention, their cancers will be advanced 60% of the time when the chance of cure is less than 30%. Given the difficulty of implementing regular examinations in a poorly compliant, high risk population, genetic and molecular screening tools may allow very high risk individuals to be identified.

Casting the screening net: separating big fish from little fish.

Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non-selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit.