Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection.

OBJECTIVES: To investigate epidemiological, social, diagnostic and economic aspects of chlamydia screening in non-genitourinary medicine settings. METHODS: Linked studies around a cross-sectional population-based survey of adult men and women invited to collect urine and (for women) vulvovaginal swab specimens at home and mail these to a laboratory for testing for Chlamydia trachomatis. Specimens were used in laboratory evaluations of an amplified enzyme immunoassay (PCE EIA) and two nucleic acid amplification tests [Cobas polymerase chain reaction (PCR), Becton Dickinson strand displacement amplification (SDA)]. Chlamydia-positive cases and two negative controls completed a risk factor questionnaire. Chlamydia-positive cases were invited into a randomised controlled trial of partner notification strategies. Samples of individuals testing negative completed psychological questionnaires before and after screening. In-depth interviews were conducted at all stages of screening. Chlamydia transmission and cost-effectiveness of screening were investigated in a transmission dynamic model. SETTING AND PARTICIPANTS: General population in the Bristol and Birmingham areas of England. In total, 19,773 women and men aged 16-39 years were randomly selected from 27 general practice lists. RESULTS: Screening invitations reached 73% (14,382/19,773). Uptake (4731 participants), weighted for sampling, was 39.5% (95% CI 37.7, 40.8%) in women and 29.5% (95% CI 28.0, 31.0%) in men aged 16-39 years. Chlamydia prevalence (219 positive results) in 16-24 year olds was 6.2% (95% CI 4.9, 7.8%) in women and 5.3% (95% CI 4.4, 6.3%) in men. The case-control study did not identify any additional factors that would help target screening. Screening did not adversely affect anxiety, depression or self-esteem. Participants welcomed the convenience and privacy of home-sampling. The relative sensitivity of PCR on male urine specimens was 100% (95% CI 89.1, 100%). The combined relative sensitivities of PCR and SDA using female urine and vulvovaginal swabs were 91.8% (86.1, 95.7, 134/146) and 97.3% (93.1, 99.2%, 142/146). A total of 140 people (74% of eligible) participated in the randomised trial. Compared with referral to a genitourinary medicine clinic, partner notification by practice nurses resulted in 12.4% (95% CI -3.7, 28.6%) more patients with at least one partner treated and 22.0% (95% CI 6.1, 37.8%) more patients with all partners treated. The health service and patients costs (2005 prices) of home-based postal chlamydia screening were 21.47 pounds (95% CI 19.91 pounds, 25.99) per screening invitation and 28.56 pounds (95% CI 22.10 pounds, 30.43) per accepted offer. Preliminary modelling found an incremental cost-effectiveness ratio (2003 prices) comparing screening men and women annually to no screening in the base case of 27,000 pounds/major outcome averted at 8 years. If estimated screening uptake and pelvic inflammatory disease incidence were increased, the cost-effectiveness ratio fell to 3700 pounds/major outcome averted. CONCLUSIONS: Proactive screening for chlamydia in women and men using home-collected specimens was feasible and acceptable. Chlamydia prevalence rates in men and women in the general population are similar. Nucleic acid amplification tests can be used on first-catch urine specimens and vulvovaginal swabs. The administrative costs of proactive screening were similar to those for opportunistic screening. Using empirical estimates of screening uptake and incidence of complications, screening was not cost-effective.

A specific GFP expression assay, penetrance estimate, and histological assessment for a putative splice site mutation in BRCA1.

Genetic testing for cancer predisposing mutations in BRCA1 and BRCA2 has been of benefit to many individuals from breast and ovarian cancer-prone kindreds. However, a function has not been assigned to many of the domains that make up these complex proteins and hence, the significance of many sequence variants, including missense mutations, splice-site mutations, and in-frame deletions/insertions, remains unclear. We identified a putative splice site mutation (IVS6-2delA) in BRCA1 in a family attending a Familial Cancer Centre that had a significant history of both breast and ovarian cancer. This sequence variant was not novel but the exact effect on mRNA splicing and hence the biological impact of this sequence variation was unclear and therefore the finding was unable to be used in genetic counseling of the family. Via the construction of novel GFP-based expression fusion constructs, we demonstrated that this sequence variation prevented normal splicing of the BRCA1 transcript. By combining these data with an assessment of the histopathological features of the breast carcinomas in this family and mutation penetrance estimate we were able to conclude that this BRCA1 variant conveyed an increased risk of breast cancer.

Opportunities for PSOs: an interview with Albert Holloway.

The Balanced Budget Act of 1997 authorizes provider-sponsored organizations (PSOs) to contract directly with Medicare as one of the new Medicare+Choice risk plan options for beneficiaries. The act allows HHS to waive state insurance licensure requirements in some circumstances and makes it easier for PSOs and other risk plans to operate. The act includes additional implications for PSOs. Recently, Albert Holloway, president and CEO, The IPA Association of America, Oakland, California, and a member of HFMA's Board of Directors, granted HFM the following interview to discuss opportunities the new PSO legislation affords hospitals and physicians.

The spectrum and angular distribution of x rays scattered from a water phantom.

To calculate the response of an image receptor to the x rays emerging from a scattering medium, it is necessary to know the x-ray spectrum and intensity as a function of the angle of incidence on the receptor. To permit this calculation for any x-ray spectrum incident on a medium, these functions must be known for monoenergetic x rays. For monoenergetic x rays in the range 20-70 keV we have measured with a high-purity germanium detector the spectrum and intensity of x rays emitted from a water phantom at angles of 0 degree-50 degrees to the direction of the primary beam. The spectrum and intensity of emitted x rays have also been calculated by the Monte Carlo method. At small exit angles, most of the x rays have energies close to the incident energy. As the exit angle increases, the fraction of multiply scattered x rays increases. At very large exit angles, the dominant feature of the spectrum is the peak due to these multiply scattered x rays. For small scattering angles the Monte Carlo calculations are in good agreement with the measurements over the range of energies. For large scattering angeles the scattered photon fluence predicted by Monte Carlo modeling is consistently lower than the measurement in the region just below the full energy peak. The cause of the discrepancies is not fully understood, but cannot be accounted for by Compton broadening alone. An alternate approach to model incoherent scattering is proposed.

Dose and quality control (DQC) in diagnostic radiology.

Dose and quality control in diagnostic radiology can play an important role in reducing x-ray exposure and costs whilst maintaining a high level of imaging quality and diagnostic benefit. It can also become very costly. Current government regulations demand unnecessary accuracy in the measurement and performance of certain parameters of x-ray generators whilst ignoring others which are more important. They totally neglect imaging systems. We urge a more critical approach to the requirements for dose and quality control programs. We propose the exchange of information through a user's club and a less regulatory but equally important role for government.