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A study was conducted to evaluate the accuracy of dried blood spot (DBS) real-time polymerase chain reaction (PCR) assays in the screening of newborn infants with congenital cytomegalovirus (CMV) infection. Results indicated that the screening method had lower sensitivity and thus was limited in its scope.

The effects of a depression outreach-treatment program on workplace are evaluated. The program proves to be beneficial to both clinical and workplace outcomes by identifying depression and providing enhanced care for the same.

It may be necessary to repeat a sigmoidoscopy every three years to screen older people for colorectal cancer, according to a study of 9,317 people. All had a sigmoidoscopy three years after a negative sigmoidoscopy and 14% were found to have a polyp or mass in the colon. In many cases, it was a new growth because it was not seen during the first sigmoidoscopy. Sigmoidoscopy uses a flexible tube containing a small video camera to examine the inside of the colon.

A description of the most common tests for colorectal cancer and their cost-effectiveness is presented. Testing people 50 years old and older for colorectal cancer can reduce the death rate from the disease. However, most elderly people are not tested.

There is evidence that regular health screening for colorectal cancer can lower the death rate from the disease. Health screening means testing people who do not have symptoms for a particular disease. For colorectal cancer, the most common tests are a fecal occult blood test, sigmoidoscopy, and colonoscopy. Most doctors recommend screening beginning at the age of 50 but it is not yet clear which tests are most beneficial.

One-quarter of all cases of prostate cancer actually may have been detected by chance rather than by diagnostic tests. The digital rectal exam and prostate-specific antigen (PSA) blood test, if suspicious, are usually followed by prostate biopsy to definitively diagnose cancer. A review of studies found that sometimes noncancerous conditions cause abnormal test results, then lead to biopsies that find cancers too small to have affected the test. About 1/4 of cancers found after either diagnostic test appear to be by chance. The detection of small tumors by chance may lead to overly-aggressive treatment and may not improve clinical outcomes., An underappreciated characteristic of prostate cancer screening is that it may detect some prostate cancers solely by serendipity or chance. Serendipity, previously described in the detection of colonic neoplasms, could affect prostate cancer detection when a screening test result is abnormal for reasons other than the presence of prostate cancer, but prostate cancer is coincidentally detected during the subsequent evaluation of the abnormal screening result. We reviewed published articles about prostate cancer screening, searching for evidence of serendipity. We defined serendipity in digital rectal examination (DRE) screening as the discovery of a prostate cancer by the random biopsy of an area of the prostate gland other than the palpable suspicious area that prompted the biopsy. We defined serendipity in prostate-specific antigen (PSA) screening as the discovery of a prostate cancer by the random biopsy of a nonpalpable (stage T1c) prostate cancer less than 1.0 [cm.sup.3] in volume, since tumors less than 1.0 [cm.sup.3] are generally too small to cause elevated PSA levels. We found that serendipity may be responsible for the detection of more than one quarter of apparently DRE-detected prostate cancers and up to one quarter of apparently PSA-detected cancers. Additionally, serendipity played a larger role in the detection of smaller tumors that are common but of uncertain clinical significance. We conclude that serendipity-detected prostate cancers contribute to an overestimation of the true information value of DRE and PSA screening. Whether serendipity is advantageous in prostate cancer screening depends on the as yet uncertain outcomes for men with smaller prostate cancers. However, given our estimates of the potential magnitude of the impact of serendipity, the currently popular DRE-and PSA-based screening strategy may not be optimal. If smaller prostate cancers are important, then we are not finding enough; if they are unimportant, then we are finding too many that we may feel compelled to treat aggressively. JAMA 1997;278;1516-1519

A small percentage of elderly people appear to have a drinking problem and it may not be diagnosed using the standard diagnostic tool, the CAGE questionnaire. The CAGE questionnaire asks people if they have thought about cutting back on drinking, are annoyed when others suggest doing so, feel guilty about drinking or must have a drink upon awakening. A survey of 5,065 elderly patients of 88 primary care physicians found that 9% of men and 2% of women drank more than 21 drinks per week and 15% of men and 12% of women drank more than 14 or 7 drinks per week, respectively. The CAGE questionnaire did not identify half of the heavy drinkers., Objectives.--To describe potentially hazardous alcohol use among elderly patients in the primary care setting and to assess the widely used CAGE questionnaire (cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) as a tool for detecting self-reported heavy and binge drinking among these patients. Design.--Cross-sectional study. Setting.--The offices of 88 primary care physicians at 21 sites in southeastern Wisconsin. Patients,---A total of 5065 consecutive consenting patients older than 60 years. Measures.--A previously validated self-administered questionnaire that included beverage-specific questions about the quantity and frequency of regular drinking in the last 3 months, the number of episodes of binge drinking (->6 drinks per occasion), and the CAGE questionnaire. Results.--Fifteen percent of men and 12% of women regularly drank in excess of limits recommended by the National Institute of Alcohol Abuse and Alcoholism (>7 drinks per week for women and >14 drinks per week for men). Nine percent of men and 2% of women reported regularly consuming more than 21 drinks per week. When we administered the CAGE questionnaire, 9% of men and 3% of women screened positive for alcohol abuse within 3 months. The CAGE performed poorly in detecting heavy or binge drinkers; fewer than half were CAGE positive when the standard cutoff of 2 positive answers was used. Conclusions.--Alcohol consumption in excess of recommended limits is common among elderly outpatients. The CAGE questionnaire alone is insufficient to detect such drinking. Asking questions on the quantity and frequency of drinking in addition to administering the CAGE increases the number of problem drinkers detected. JAMA. 1996;276:1964-1967

Long-term screening with prostate-specific antigen (PSA) appears to reduce the detection rate of prostate cancer and result in earlier diagnoses. Researchers gave PSA tests to 10,248 men 50 years or older every 6 months for at least four years. Seventy-nine percent of the men returned for a PSA test throughout the study. During this time, the percentage of men with a high PSA level declined, as did the percentage diagnosed with prostate cancer and the percentage diagnosed with advanced cancer. By the end of the study, cancer detection rates had fallen to less than 1%., Objective.--To determine for the first 4 years of serial prostate-specific antigen (PSA)-based screening trends in compliance, prevalence of abnormal screening test results, cancer detection rates, and stage and grade of cancers detected. Design.---A community-based study of serial screening for prostate cancer with serum PSA measurements. Setting.--University medical center. Subjects.--A total of 10 248 male volunteers at least 50 years old who were screened at 6-month intervals for a minimum of 48 months. Main Outcome Measures.--The proportion of men who returned for serial screening, the proportion with elevated PSA levels, the proportion with newly elevated PSA levels, prostate cancer detection rates, and the distribution of tumor stages and grades at diagnosis. Results.--At 48 months, 79% of volunteers returned for screening. During this interval there was a decrease in the proportion of volunteers with serum PSA levels higher than 4.0 ng/mL (from 10% to 6%-7%), in cancer detection rates (from 3% to Conclusions.--With serial PSA-based screening, the proportion of men with abnormal test results decreased, and the prostate cancer detection rate decreased to near the reported population-based incidence rate. There was also a shift to detection of cancers at an earlier clinical stage and detection of lower-grade cancers. If PSA screening is ultimately shown to be beneficial, then appropriate cost-benefit analyses will be required to determine how the shifts in cancer detection rate and cancer stage will affect the economics of serial PSA-based screening. JAMA. 1996;276:1309-1315

Unnecessary prostate biopsies may be reduced by measuring the percentage of free serum prostate-specific antigen (PSA) and bound forms of PSA in serum. PSA measurement is a screening test for prostate cancer. Researchers measured total serum PSA levels in 10,249 healthy men aged 50 and older. A total of 113 men had serum PSA concentrations of 4.1 to 10.0 ng/mL. Men whose serum PSA concentrations were higher than 4.0 ng/mL had prostatic ultrasonography and digital rectal exams. Needle biopsies were performed on the men with abnormal results. A monoclonal antibody immunoassay specific for free PSA and another antibody immunoassay recognizing both free and bound PSA were used to determine if the percentage of free PSA was a predictor of prostate cancer. The median percentage of free PSA was 9.2% in men with cancer and a normal gland, 15.9% in men with cancer and an enlarged gland, and 18.8% in men with benign prostatic hyperplasia. Common causes of elevated PSA are benign prostatic hyperplasia and prostatitis., Objective. - To evaluate measurement of percentage of free prostate-specific antigen (PSA) in serum to improve the specificity of prostate cancer screening in men with serum PSA levels between 4.1 and 1 0.0 ng/mL. Design. - Retrospective, nonrandomized analysis using a research assay for measuring free PSA in frozen serum from men with a spectrum of prostate sizes and digital rectal examination results. Setting. - General community outpatient prostate cancer screening program at a university center. Patients.- One hundred thirteen men aged 50 years or older, 99% of whom were white, with serum PSA concentrations of 4.1 to 1 0.0 ng/mL, including 63 men with histologically confirmed benign prostatic hyperplasia, 30 with prostate cancer with an enlarged gland, and 20 with cancer with a normal-sized gland. All study volunteers had undergone prostatic ultrasonography and biopsy. Main Outcome Measures. - Percentage of free PSA in serum and percentage of free PSA cutoff that maintained at least 90% sensitivity for prostate cancer detection. Results. - Median percentage of free PSA was 9.2% in men with cancer and a normal-sized gland, 15.9% in men with cancer and an enlarged gland, and 18.8% in men with benign prostatic hyperplasia (P

Cost and level of effectiveness should guide decisions on the type of mammography program used to screen for breast cancer. A model was adapted to compare women screened for breast cancer using mammography to women who were observed but not screened. Marginal cost per year of life saved (MCYLS) was calculated as a measure of cost effectiveness. Researchers determined that the most effective screening method used biennial mammography for women 50 to 79 years old, which yielded an MCYLS of $16,000. The method determined the least cost effective involved using annual mammography on high-risk women aged 40 to 79 years old with an MCYLS of $31,000. Screening methods that include women in their 40s also appear to be cost effective with an MCYLS of $20,000.

The prostate specific antigen (PSA) test seems to be highly accurate in detecting prostate cancer. The PSA test measures blood levels of an enzyme secreted by prostate cells. Men with prostate cancer have elevated blood levels of this enzyme. Researchers took blood samples from 1,464 healthy men to evaluate the ability of the PSA test to detect future cases of prostate cancer. Over the next 10 years, 366 men developed prostate cancer. The PSA test detected 46% of all prostate cancer cases. As the length of time between blood sample collection and cancer diagnosis increased, fewer prostate cancer cases were detected by the PSA test. The test was negative in 91% of men who did not have prostate cancer. The risk of prostate cancer was more than twice as great in men with PSA levels between 1.10 and 1.50 nanograms per milliliter (ng ml) compared to men with PSA levels of 1.0 ng ml or lower., Objective. - To evaluate the validity of prostate-specific antigen (PSA) in identifying men who subsequently were or were not clinically diagnosed with prostate cancer, assess optimal test cutoff, measure lead time, and estimate relative risks (RRs) associated with discrete PSA levels. Design. - Nested case-control study of men providing plasma samples before a 10-year follow-up. Setting. - The Physicians' Health Study, an ongoing randomized trial that enrolled 22 071 men aged 40 to 84 years in 1982. Participants. - A total of 366 men (cases) diagnosed with prostate cancer and 1098 men (three controls per case), matched by age, randomly selected from all cohort members at risk at the time of case diagnosis. Main Outcome Measures. - Sensitivity and specificity for each year of follow-up and for aggressive and nonaggressive cancers separately. Results. - At a cutoff of 4.0 ng/mL, sensitivity for the entire 10-year follow-up was 46% for total cases. Sensitivities for detection of total, aggressive, and nonaggressive cancers occurring in the first 4 years were 73%, 870/o, and 53%. Overall, specificity was 91% and changed little by year of follow-up. Optimal validity was achieved at a cutoff of 3.3 ng/mL. Estimated mean lead time for all cancers was 5.5 years. Only 40% of cancers detected more than 5 years from baseline were nonaggressive. Compared with men with PSA levels less than 1.0 ng/mL, those with PSA levels between 2.0 and 3.0 ng/mL had an RR of 5.5 (95% confidence interval, 3.7 to 9.2). Conclusions. - A single PSA measurement had a relatively high sensitivity and specificity for detection of prostate cancers that arose within 4 years. Prostate-specific antigen values less than the usual cutoff were associated with substantial increases in risk compared with the lowest levels. Final evaluation of PSA screening must also consider cost and the ability of current treatments to improve the prognosis of screen-detected cases.

Severely impaired elderly patients in long term care facilities may not benefit from blood screening tests. During an 18-month period, researchers evaluated the effects of blood screening tests on 108 impaired elderly patients. All patients were at least 60 years old and resided in a long-term care facility. A total of 6,771 individual blood screening tests were performed. Approximately 17% of these tests were abnormal. Fewer than one percent of the tests prompted medical intervention. Only 0.2% of the tests resulted in an intervention that benefited the patient. A total of 989 blood panels were performed, 31% of which contained an abnormality. Medical interventions were undertaken in response to 3.4% of abnormalities. Only one percent of the blood panels resulted in patient benefit. Screening tests identified significantly fewer blood abnormalities and resulted in fewer patient interventions and patient benefits than monitoring, follow-up, or diagnostic tests., Objective.--To determine the usefulness of a routine, comprehensive battery of laboratory tests in a severely impaired elderly nursing home population. Design.--Prospective observational survey. Setting.--Skilled nursing facility wards of a geriatric and extended care veterans hospital. Patients.--Consecutive sample of 108 veterans with severe cognitive and functional impairments, who had been hospitalized at least 6 months. Main Outcome Measures.--Proportions of tests categorized as screening, monitoring, follow-up, or diagnostic; frequency of abnormal test results, interventions warranted and performed on the basis of these abnormalities, and beneficial or adverse effects. Results.--Of 6771 individual nondiagnostic tests performed, 17.2% yielded abnormal results; of these, 33.3% were new. However, only 0.2% of tests resulted in patient benefit. Of 989 panels performed, 31.0% contained at least one abnormality, but only 1.0% of panels (10 patients) yielded any benefit. Overall usefulness was related to the purpose of the testing, with 31.5% of screening tests yielding abnormalities, compared with 45.5%, 78.2%, and 68.7% of monitoring, follow-up, and diagnostic panels, respectively (P Conclusions.--Routine comprehensive laboratory panels may not be warranted in the most severely impaired elderly patients in long-term care settings. Discontinuing true screening tests and limiting testing strictly to monitoring, follow-up, or diagnostic purposes could minimize the costs of laboratory assessment without losing its potential benefits.

Screening for prostate cancer may slightly reduce the prostate cancer death rate but the benefits may be outweighed by complications that result from cancer treatment and the costs of screening. Using published data on prostate cancer, researchers performed a cost-benefit analysis to compare four screening programs with the strategy of not screening. Each program used a combination of techniques including digital rectal exam, prostate specific antigen test, and transrectal ultrasound. Life expectancy, the quality of life, and a cost-effectiveness ratio were predicted for the general population and subgroups with high prostate cancer rates. Results revealed that all screening programs increased the average life expectancy in 50 to 70-year-old men by one or two days but decreased the patients' quality of life. All screening programs increased costs. Screening of at-risk populations mirrored the results reported for the general population., Objective. - To determine the clinical and economic effects of screening for prostate cancer with prostate-specific antigen (PSA), transrectal ultrasound (TRUS), and digital rectal examination (DRE). Design. - Decision analytic cost-utility analysis comparing four screening strategies with a strategy of not screening. We assumed that the cancer detection rate and stage distribution were predicted by each combination of tests and that localized cancer was treated with radical prostatectomy. For each strategy, we calculated life expectancy, quality-adjusted life expectancy (QALE)), and cost-utility ratios for unselected and high-prevalence populations. Data. - Probabilities and rates for clinical events were gathered from published data. We assessed utilities by the time-trade-off method using urologists, radiation oncologists, and internists as subjects. The Clinical Cost Manager at the New England Medical Center provided cost data. Results. - In unselected men between the ages of 50 and 70 years, screening with PSA or TRUS prolonged unadjusted life expectancy but diminished QALE. Screening with DRE alone yielded no reduction in mortality at any age. All programs increased costs. Results were sensitive only to assumptions about the efficacy of treatment. In high-prevalence populations, screening produced a similar pattern: gains in unadjusted life expectancy, losses in QALE, and increased costs. Conclusions. - Our analysis does not support using PSA, TRUS, or DRE to screen asymptomatic men for prostatic cancer. Screening may result in poorer health outcomes and will increase costs dramatically. Assessment of comorbidity, risk attitude, and valuation of sexual function may identify individuals who will benefit from screening, but selecting high-prevalence populations will not improve the benefit of screening.

Mammography appears to be most effective in detecting breast cancer in women 50 years or older or in women 40 years or older with a family history of breast cancer. A total of 31,814 women 30 years old or older had mammograms during a seven-year period. The number of breast cancers detected for each abnormal examination increased with the age of the women. Women aged 50 years and older accounted for 38.3% of all women screened, yet 74% of all breast cancers were found in these women. In the group of women 50 years and older without a family history of breast cancer, 10 cancers were detected for each 1,000 exams. For women younger than 50, the number dropped to two cancers for each 1,000 exams. Nine cancers were detected for each 1,000 exams of women between the ages of 40 and 49 with a family history of breast cancer. For women aged 50 to 59 years with a family history of breast cancer, the number rose to 26 cancers detected in every 1,000 exams., Objective. - To determine the positive predictive value (PPV) of low-cost screening mammography according to age and family history of breast cancer. Design. - Cross-sectional. Setting. - Six counties in northern California. Participants. - A total of 31 814 women aged 30 years and older referred for mammography to the University of California, San Francisco, Mobile Mammography Screening Program from April 18, 1985, through November 20, 1992. Measurements. - Breast cancer risk profile, two standard mammographic views per breast, and follow-up of abnormal screening examinations. Results. - Although women aged 50 years or older constituted only 38.3% of all women who received first-screening mammography, 74% of breast cancers were detected in this group. Ten cancers were diagnosed per 1000 first-screening examinations in women aged 50 years or older, with 14.8 diagnostic procedures per cancer diagnosed compared with two cancers per 1000 screening examinations and 48.3 diagnostic tests per cancer diagnosed in women younger than 50 years. The PPV of first-screening mammography (number of breast cancers detected per abnormal examination) increased with age: .03 for those aged 30 to 39 years; .04 for those aged 40; .09 for those aged 50 to 59; .17 for those aged 60 to 69; and .19 for those aged 70 years or older ([chi.sup.2] for trend, P

The combination of a non-specific test for infection with a later, more specific test only if warranted appears to be an effective means of screening men for chlamydial infections. A total of 618 men between the ages of 12 and 35 were tested for infection with Chlamydia trachomatis. None of the men had symptoms of infection. Overall, 7% of the participants had chlamydial infections. The most clinically and cost-effective tests involved pre-screening first-void urine with leukocyte esterase test strips or identifying polymorphonucleocytes. Positive samples were then tested more specifically with enzyme immunoassay confirmed by direct fluorescent antibody testing. This combination of tests was highly accurate and cost effective.

* Objective. - To determine the sensitivity and specificity of the 2-minute, 12-step, orthopedic screening examination. Design. - Prospective, single-blind study. Setting. - National Collegiate Athletic Association Division 1 athletics program. Participants. - Two hundred fifty-nine male and female varsity athletes. Interventions. - The athletes were screened by five primary care physicians who were 'blind' to each patient's history. The athletes were then evaluated by a team of orthopedic surgeons who had knowledge of each patient's history. Significant injuries were injuries that would limit participation, predispose to injury, or need further evaluation or rehabilitation. Main Results. - A total of 120 significant injuries were identified by compiling the results of the history and both physical examinations. Of the significant injuries, 91.6% were detected by history alone. Fourteen of the significant injuries were missed by the detailed orthopedic examination, but they were detected by the screening examination. The overall sensitivity of the screening examination compared with the results of all three methods was 50.8%, with a specificity of 97.5 %, positive predictive value of 40.9%, and negative predictive value of 98.3%. Almost half of the false-positive screening findings were shoulder asymmetries. Conclusions. - Even in mass screenings, the screening orthopedic examination should be used only in conjunction with an orthopedic history. Some modifications may improve the sensitivity of the screening examination., Researchers suggest that a screening orthopedic examination should be used only in conjunction with an orthopedic history, on the basis of the outcome of a 2-minute, 12-step orthopedic examination performed on 259 male and female varsity athletes. The National Collegiate Athletic Association (NCAA) Division 1 athletes were screened by five primary care physicians who did not know each patient's history. Then the athletes were evaluated by a team of orthopedic surgeons who knew each patient's history. Injuries that were considered significant were those that would limit a player's participation, predispose him or her to injury or require further evaluation or treatment. One hundred twenty significant injuries were identified from the results of the history and both physical examinations. History alone identified 91.6% of significant injuries. Some modifications might make the screening examination more sensitive.

* The pediatric approach to the primary prevention of coronary artery disease in adults remains controversial. Measurement and intervention to lower serum cholesterol levels have been advocated recently in a selected group of American children by the Expert Panel on Blood Cholesterol Levels in Children and Adolescents of the National Cholesterol Education Program. This article reviews the clinical and scientific data contributing to the controversy surrounding cholesterol in American children. Arguments in favor of and opposed to an aggressive approach to identifying American children with elevated serum cholesterol levels are presented. The rationale for a selective screening approach is demonstrated. (AJDC. 1993;147:386-392), Childhood screening for elevated cholesterol levels remains controversial. While the relationship between elevated blood cholesterol levels and the risk of coronary artery disease in adults is clear, there have been no long range studies on the benefits as adults of reducing cholesterol levels as children. Identifying children with high cholesterol levels does not predict coronary artery disease in later life, it predicts high cholesterol later in life. If mass screening were implemented, many children would be falsely labelled as having a high risk for coronary artery disease. Cholesterol screening is also complicated because cholesterol levels vary from day to day. Currently the National Cholesterol Education Program recommends selectively screening children at high risk, such as those whose parents or grandparents had premature heart disease.

Measuring levels of the tumor marker CA-125 does not appear to be a sensitive enough means of detecting ovarian cancer. CA-125 levels were monitored in 37 women diagnosed with ovarian cancer and in 73 healthy women who served as controls. CA-125 levels among the women with ovarian cancer did not vary significantly with the extent or duration of the disease. Sensitivity, which is the probability that a woman with ovarian cancer will be correctly identified, was only 24% using this technique. Specificity, which is the probability that a woman without ovarian cancer will be correctly identified, was 96%. Even if the specificity were 99% however, widespread screening would still result in too many false-positive results, raising health care costs and emotional anxiety among misdiagnosed women. Elevated levels of CA-125 were associated with a higher risk of ovarian cancer, but widespread screening using this procedure would cause up to 41% of women to be incorrectly classified as being at high risk for ovarian cancer., Objective.--To evaluate prospectively the sensitivity and specificity of serum CA-125 levels for the detection of ovarian cancer. Design.--Case-control study nested within a cohort of women who donated blood to a community-based serum bank established in 1974. Setting.--Washington County, Maryland. Population.--Cases consisted of 37 women who developed ovarian cancer from 1975 through 1989. Controls consisted of 73 women, matched on age and time since last menstrual period, and free of cancer until the cases' diagnoses. Study Variable.--Serum CA-125 levels. Outcome Measure.--Histologically confirmed ovarian cancer. Results.--Levels of serum CA-125 among cases were higher than among controls for each 3-year interval up to 12 years prior to the time of the cases' diagnoses. The median level for cases diagnosed within the first 3 years of follow-up was 35.4 U/mL compared with 9.0 U/mL for controls (P=.002). The sensitivity of a serum CA-125 level greater than 35 U/mL within the first 3 years was 57% (95% confidence interval, 20% to 88%) and the specificity was 100% (95% confidence interval lower limit, 73%). Sensitivity and specificity decreased with increasing time to diagnosis. Conclusions.--Measurement of serum CA-125 levels, particularly at a reference value of 35 U/mL, is not sufficiently sensitive to be used alone as a screening test for the detection of ovarian cancer. Lower CA-125 reference values could identify women at higher risk of developing ovarian cancer, but CA-125 measurement cannot be recommended for this purpose because of the high proportion of women who would be falsely classified as being at high risk for developing ovarian cancer.

A review of 21 cases of congenital rubella syndrome in infants born in Southern California found that many of the mothers had never been screened or vaccinated for rubella. Twelve of the women had missed at least one opportunity to be screened or vaccinated. Nine of the women had had a previous pregnancy, but none of the eight who had either a negative or equivocal rubella test were vaccinated. Of seven women who had had abortions in previous pregnancies, none were screened for rubella at the abortion clinic. There were many reasons why these women were never tested or vaccinated. California requires premarital rubella screening, but only four of the women had been married in California. Many of the women had not been vaccinated in school, and the colleges they were attending did not require proof of vaccination. Rubella screening and vaccination should be offered by all universities, and by all family planning, abortion, sexually transmitted disease and drug treatment clinics.

Elevated blood cholesterol places an individual at increased risk for developing atherosclerosis and coronary heart disease; fatty plaques accumulate within the coronary arteries, narrowing the internal diameters of the vessels, reducing the flow of blood to the heart muscle, and compromising heart function. When a physician interprets measurements of blood cholesterol, he or she must decide what the patient's true blood cholesterol level is, or how the level has changed in response to some type of cholesterol-lowering intervention. Factors such as biological and technical variability may cause the measurement of a person's cholesterol to differ from its true level. There is particular concern regarding people with cholesterol screening measurements below 5.2 mmol/L (millimoles per liter) who are told that their cholesterol levels are 'normal' when, in fact, their true levels are high and require dietary intervention and/or drug treatment. The purpose of cholesterol screening is to correctly identify people who have values higher than a recommended threshold so that some type of intervention, such as dietary changes, can be initiated. An analysis was undertaken to identify the confidence interval of true cholesterol levels around the observed measurements; that is, the chance or probability that the true value lies within the range of the observed measurements. It was determined that following a low-cholesterol diet, if there is no change in a person's cholesterol (based on three measurements obtained before and after the dietary change), there is an 80 percent chance that the true cholesterol level lies within a range that is 4 percent higher and 9 percent lower than the measured value. In addition to blood cholesterol levels, individual risk factors must be considered when counselling patients and planning care. (Consumer Summary produced by Reliance Medical Information, Inc.)

The best method of screening children for elevated cholesterol has not been established. Current recommendations are to screen children who have a family history of either elevated blood lipid (fat) levels or early onset of coronary heart disease. It has been suggested that this method of screening may miss many children with hypercholesterolemia (elevated cholesterol levels in the blood). A study was undertaken to determine if detailed family histories would have identified children later known to have moderate or severe hypercholesterolemia. A group of 114 children was studied. The age range of the children was 2 to 18 (average age 8.2 years) and 73 percent of the children were white. Most children came from upper-middle-class families. The guidelines of the American Academy of Pediatrics were used to define a positive family history. It was found that of children having total cholesterol levels greater than the 75th percentile, 22 percent did not have family histories for either hypercholesterolemia or premature coronary heart disease. Of children whose levels were greater than 95th percentile, 18.3 percent had negative histories. Seventy-eight children had both hypercholesterolemia and positive family history; 72 families reported hyperlipidemia and 27 premature coronary heart disease. These results suggest that a detailed family history fails to identify many children with hypercholesterolemia, as well as a high proportion of children with elevated cholesterol. Children who have hypercholesterolemia more often have family histories of hyperlipidemia rather than of early coronary heart disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Several findings observed that nonmammographic screening mechanisms have been found to be quite successful for screening of breast cancer. Studies have proved that ultrasound is quite effective in the detection of breast cancer.

The total leukocyte count refers to the total number of white blood cells, whereas the differential leukocyte count is a measure of the number of each type of white blood cell in a given volume of blood. These measurements are included in a complete blood cell count (CBC) and are often used as a method for monitoring illness in adults and children. However, two studies have shown that these tests were not useful in screening adults, in that they did not help to diagnose any unsuspected disease. The value of total and differential leukocyte counts as a way of detecting disease in children was assessed. Because no data from patients had been previously reported in the literature, medical charts were reviewed for all CBCs ordered by one group of pediatricians over a one-year period. There were 387 CBCs from children who were clinically healthy; most the children were preschoolers but the ages ranged from 1 month to 17 years. One or more of the values for the total or differential leukocyte count was shown of be out of the normal range in 75 percent of these children, who appeared clinically well and were not found to have any medical problem. It is concluded that abnormal values on total and differential leukocyte counts did not represent unsuspected illness in these healthy children. (Consumer Summary produced by Reliance Medical Information, Inc.)

Huntington's disease is a degenerative brain disease which is inherited as an autosomal dominant trait. Therefore, half the children of affected individuals are likely to inherit this fatal disease. Recently, a genetic marker has become available which provides a direct method for evaluating patients at high risk for developing Huntington's disease later in life. However, since the method is not informative in all cases, it would still be of value to have alternate methods of evaluating the high-risk patients. One research group has claimed that specific neuropsychological tests, when properly administered, are capable of distinguishing subtle deficits which appear before the symptoms of the disease. However, another research group, studying a much larger group of patients at risk for Huntington's disease, have failed to confirm these findings. A total of 42 at-risk patients, none of whom had symptoms of HD, were evaluated using the DNA markers for the disease; 12 were found to be positive and the remaining 30 negative. These subjects were administered a series of neuropsychological tests, including the Wechsler Adult Intelligence Scale, the Wisconsin Card Sort, the Stroop Color-Word Test, and others. An analysis of the results found there were no differences between the group of patients positive for the Huntington's marker gene, and the group of patients without the marker. The results indicate that it would be premature to conclude that cognitive deficits may be detected in individuals with the Huntington's disease gene prior to the onset of disease symptoms. (Consumer Summary produced by Reliance Medical Information, Inc.)

Newborns are screened for hemoglobinopathies (diseases involving the hemoglobin blood component) primarily to detect sickle-cell anemia, which is a significant cause of infant mortality during the second six months of life. A 10-year study of newborn screening in Colorado indicated that reduced mortality was associated with early diagnosis of the disease when accompanied by treatment with antibiotics and other comprehensive care, and parental education and counseling. Out of 528,711 newborns screened in this study, 47 cases of sickle-cell anemia, and 27 cases of other hemoglobin abnormalities were found. No parents with previously undiagnosed hemoglobin disease were found, and only 40 couples were at risk for having children with sickle-cell disease. These low rates may be a result of many factors including lack of confirmatory testing, incomplete reporting, and refusal of parents to be tested. In formulating mass screening programs, cost effectiveness must be considered. Some have argued that mass testing should be performed only in high-risk populations, such as blacks. However, in this study the sickle-cell trait was not limited to blacks; 12.9 percent of the infants born with the disorder were of non-black parents. Additionally, the reliability of ethnic data on questionnaires is questionable. In many cases it is less costly to perform testing on all newborns rather than to try to determine which population groups should be tested. (Consumer Summary produced by Reliance Medical Information, Inc.)

The accuracy of portable cholesterol analyzers was evaluated during cholesterol screenings at four organizations. Blood was obtained from participants by finger-stick and analyzed for cholesterol levels using a portable cholesterol analyzer. Blood was also obtained from the same individuals by venipuncture (sampling from the vein), and venous blood cholesterol levels were determined in a laboratory. Results were compared to those obtained by the finger-stick/portable analyzer method. Only one of the organizations produced cholesterol levels within the acceptable range, whereas the accuracy of the other three organizations varied from about 77 to 96 percent, with a tendency towards underestimating cholesterol levels. The portable cholesterol analyzers tended to produce false-negative values, in that persons with cholesterol levels greater than normal may not have been detected. The variability of the results may have resulted from the lack of experience of those operating the portable cholesterol analyzers, inadequate quality-control procedures, and dilution or watering down of blood samples obtained by the finger-stick procedure. (Consumer Summary produced by Reliance Medical Information, Inc.)

Doctors now have a chance to determine whether mass screening of newborn babies for specific diseases is cost-effective. Twenty-four US states now specify that all newborn babies must be screened using tandem mass spectrometry to test blood samples. The other states can be used as comparison states to see if mass screening improves outcomes.

Many high schools do not screen athletes adequately for cardiovascular problems before competitions. Researchers surveyed preparticipation screening guidelines of high school districts in all 50 states and the District of Columbia and compared them to standards promoted by the American Heart Association (AHA). Forty percent of the states either had no formal screening guidelines or used guidelines that were inadequate by AHA standards. Many states allow athletes to be examined by physicians assistants and chiropractors, who have limited experience in diagnosing heart disease.

The safety and effectiveness of screening cholesterol levels in children and treating those with high blood levels of cholesterol have been questioned. It was recently concluded by some researchers that many children found to have elevated cholesterol levels will not have high levels when they are adults. The authors believe that the data and reasoning behind this conclusion are erroneous. In one study, the methods used to determine sensitivity (those who actually had high cholesterol levels) were biased. Using a different cut-off point could have led to a different conclusion, and shown a more significant correlation with high cholesterol levels in adulthood. In this study, the cholesterol levels of the children were actually higher than those reported in other studies. These measurements were used as baselines and could alter the interpretation of adult cholesterol levels. Other studies have shown that cholesterol levels change with age, while this study did not show a change. The possibility that the diets of children with high levels of cholesterol were altered and may have affected adults levels was not taken into consideration, although concern about undernutrition with low-fat diets was discussed. Another study concluded that to reduce high cholesterol levels in children, treatment methods must be more effective than those used in adults. However, the authors feel that all methods of reduction are significant, regardless of patient age. It is felt that early screening and prevention of high levels of cholesterol are beneficial; recent studies that come to different conclusions have flaws in their data, reasoning and conclusions. (Consumer Summary produced by Reliance Medical Information, Inc.)

Many states now routinely screen newborns for sickle cell (SC) disease. Sickle cell disease is a serious, chronic anemic condition that occurs in people who are homozygous (have two genes) for hemoglobin S. This abnormal hemoglobin results in crescent-shaped red blood cells, causing crises of joint pain and fever with enlargement of the spleen, lethargy and weakness. Success of the screening program depends on prompt follow-up. Parents of babies identified must be notified immediately so that treatment and parent education and counseling can begin. In order to reduce illness and risk of death, this should occur before the baby reaches the age of four months. Contacting parents may be difficult, particularly in large urban areas. In an effort to define the problems encountered in achieving prompt parent notification and initiation of treatment, a study was undertaken of patients identified by routine newborn screening during a seven-month period. There were 25 babies identified to have SC disease; only nine of these babies (36 percent) arrived for their initial appointment. By the age of four months, only 64 percent of infants had been seen; at seven months one baby still had not been seen. All infants who had been initially seen were seen before they experienced any clinical complications. The authors suggest that institutions serving a large population at risk for SC disease designate one person to be contacted by the screening laboratory and to initiate the notification process. It is important that resources be made available to prevent a baby with SC disease from arriving at the emergency room, dead from a preventable complication of SC. (Consumer Summary produced by Reliance Medical Information, Inc.)

The fecal occult blood test (FOBT), a test performed to detect blood in the feces, is currently recommended for people over the age of 50. A positive FOBT may be indicative of cancer or large adenomas (benign tumors, greater than one centimeter in diameter) that can be surgically removed. Approximately 30 percent of the adenomas detected by the FOBT are small adenomas (less than one centimeter), the most common size. Since people with small adenomas are considered at risk for subsequent tumors, including malignant ones, detection of these lesions with FOBT is considered advantageous. When small adenomas are found, periodic colonoscopy (examination of the large bowel under strong illumination) is recommended after their removal. However, false-negatives (an incorrectly negative test result) and false-positives (an incorrectly positive test result, possibly caused by diet or bleeding from a cause unrelated to a tumor) can occur with FOBT. Serendipity plays an important role in FOBT results. A 'lucky hit' is said to occur when a nonbleeding adenoma (which would not normally show up on FOBT) tests positive because of other factors. In fact, serendipity is a frequent cause of detection, since relatively few small adenomas bleed. This is demonstrated by calculating several false-negative, false-positive, true-negative, and true-positive probabilities. The best way to reduce the contribution of serendipity to FOBT results is to increase the test's specificity (number of true negatives divided by the sum of the true negatives and false positives). This means reducing the number of false positives, possibly by restricting the patient's diet or medication prior to testing. Another issue is the actual importance of detecting small adenomas during FOBT. The removal of all such growths, most of which do not progress to cancer, would be inefficient. Questions may also be raised about the need for repeated surveillance colonoscopy after adenomas are removed, and about the effectiveness of this procedure. Aggressive surveillance of a condition discovered by chance contains a built-in paradox. (Consumer Summary produced by Reliance Medical Information, Inc.)

Total cholesterol levels of less than 200 milligrams per deciliter (mg/dL) and low-density lipoprotein cholesterol levels of less than 130 mg/dL are considered desirable, whereas levels of 240 mg/dL and 160 mg/dL respectively, are high and associated with an increased risk of coronary artery disease, or disease of the major blood vessels supplying the heart. Chemistry analyzers are used in public screening programs for measuring cholesterol levels to identify persons at increased risk for coronary artery disease; the inexperience of persons operating these machines may contribute to the inaccuracy of cholesterol determinations. The variability in cholesterol measurements may result from biological, collection and handling, and clinical sources. Analytic variability is also very common in clinical laboratories. Because of this variability, it may be more useful to know the range of cholesterol values rather than the actual cholesterol number. This would give information about the variability of each individual's cholesterol levels, and provide a basis for defining the risk for coronary artery disease. A range of values makes it easier to follow-up the blood cholesterol trends that occur after treatment, and allows patients to better determine their cardiac risk. However, a more accurate and reliable cholesterol testing method would reduce the number of samples required to determine the effectiveness of treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)