Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC.
General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis.
BMJ. 2012 Nov 20;345:e7191. doi: 10.1136/bmj.e7191. Epub 2012 Nov 20.
Abstract/Text
OBJECTIVES: To quantify the benefits and harms of general health checks in adults with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes.
DESIGN: Cochrane systematic review and meta-analysis of randomised trials. For mortality, we analysed the results with random effects meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.
DATA SOURCES: Medline, EMBASE, Healthstar, Cochrane Library, Cochrane Central Register of Controlled Trials, CINAHL, EPOC register, ClinicalTrials.gov, and WHO ICTRP, supplemented by manual searches of reference lists of included studies, citation tracking (Web of Knowledge), and contacts with trialists.
SELECTION CRITERIA: Randomised trials comparing health checks with no health checks in adult populations unselected for disease or risk factors. Health checks defined as screening general populations for more than one disease or risk factor in more than one organ system. We did not include geriatric trials.
DATA EXTRACTION: Two observers independently assessed eligibility, extracted data, and assessed the risk of bias. We contacted authors for additional outcomes or trial details when necessary.
RESULTS: We identified 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (11,940 deaths), and they gave a risk ratio of 0.99 (95% confidence interval 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (4567 deaths), risk ratio 1.03 (0.91 to 1.17), and eight on cancer mortality (3663 deaths), risk ratio 1.01 (0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings. We did not find beneficial effects of general health checks on morbidity, hospitalisation, disability, worry, additional physician visits, or absence from work, but not all trials reported on these outcomes. One trial found that health checks led to a 20% increase in the total number of new diagnoses per participant over six years compared with the control group and an increased number of people with self reported chronic conditions, and one trial found an increased prevalence of hypertension and hypercholesterolaemia. Two out of four trials found an increased use of antihypertensives. Two out of four trials found small beneficial effects on self reported health, which could be due to bias.
CONCLUSIONS: General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although they increased the number of new diagnoses. Important harmful outcomes were often not studied or reported.
SYSTEMATIC REVIEW REGISTRATION: Cochrane Library, doi:10.1002/14651858.CD009009.
Kahn R, Buse J, Ferrannini E, Stern M.
The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes.
Diabetologia. 2005 Sep;48(9):1684-99. doi: 10.1007/s00125-005-1876-2.
Abstract/Text
BACKGROUND: The term 'metabolic syndrome' refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathophysiology is thought to be related to insulin resistance.
METHODS: Since the term is widely used in research and clinical practice, we undertook an extensive review of the literature in relation to the syndrome's definition, underlying pathogenesis, association with cardiovascular disease and to the goals and impact of treatment.
DISCUSSION: While there is no question that certain CVD risk factors are prone to cluster, we found that the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a CVD risk marker. Our analysis indicates that too much critically important information is missing to warrant its designation as a 'syndrome'.
CONCLUSION: Until much-needed research is completed, clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the 'metabolic syndrome'.
Hata J, Doi Y, Ninomiya T, Tanizaki Y, Yonemoto K, Fukuhara M, Kubo M, Kitazono T, Iida M, Kiyohara Y.
The effect of metabolic syndrome defined by various criteria on the development of ischemic stroke subtypes in a general Japanese population.
Atherosclerosis. 2010 May;210(1):249-55. doi: 10.1016/j.atherosclerosis.2009.10.044. Epub 2009 Nov 10.
Abstract/Text
OBJECTIVE: We evaluated the impact of metabolic syndrome (MetS) defined by various criteria on the occurrence of ischemic stroke subtypes in a general Japanese population.
METHODS: A total of 2452 residents of a Japanese community, Hisayama, aged 40 years or older, were followed up for 14 years. To define MetS, we used the original Japanese criteria, the modified Japanese criteria, the International Diabetes Federation (IDF) criteria, the original National Cholesterol Education Program's Adult Treatment Panel III (NCEP) criteria, and the modified NCEP criteria. We substituted a waist circumference of > or = 90 cm in men and > or = 80 cm in women for the values of > or = 85 cm and > or = 90 cm, respectively, in the modified Japanese criteria and for > 102 cm and > 88cm, respectively, in the modified NCEP criteria.
RESULTS: Only MetS defined by the modified Japanese criteria showed a significant association with the development of lacunar infarction, and its hazard ratios (HRs) for the development of atherothrombotic and cardioembolic infarction were significant and greater than those of MetS defined by the other criteria: adjusted HRs for lacunar, atherothrombotic and cardioembolic infarction were 1.94 (95% confidence interval (CI), 1.13-3.32; P=0.02), 2.55 (95% CI, 1.25-5.18; P=0.01) and 3.94 (95% CI, 1.89-8.22, P<0.001), respectively, after adjustment for confounding factors.
CONCLUSION: Our findings suggest that MetS defined by the Japanese criteria with the modification of a waist circumference of > or = 90 cm in men and > or = 80 cm in women is a better predictor of each ischemic stroke subtype in the Japanese population.
Copyright 2009 Elsevier Ireland Ltd. All rights reserved.
Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008.
Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R.
Primary care validation of a single-question alcohol screening test.
J Gen Intern Med. 2009 Jul;24(7):783-8. doi: 10.1007/s11606-009-0928-6. Epub 2009 Feb 27.
Abstract/Text
BACKGROUND: Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.
OBJECTIVE: To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
DESIGN: Cross-sectional study.
PARTICIPANTS: Adult English-speaking patients recruited from primary care waiting rooms.
MEASUREMENTS: Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of 1 or greater [corrected] is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.
MAIN RESULTS: Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.
CONCLUSIONS: The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.
Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR.
AUDIT-C as a brief screen for alcohol misuse in primary care.
Alcohol Clin Exp Res. 2007 Jul;31(7):1208-17. doi: 10.1111/j.1530-0277.2007.00403.x. Epub 2007 Apr 19.
Abstract/Text
BACKGROUND: The Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questions have been previously validated as a 3-item screen for alcohol misuse and implemented nationwide in Veterans Affairs (VA) outpatient clinics. However, the AUDIT-C's validity and optimal screening threshold(s) in other clinical populations are unknown.
METHODS: This cross-sectional validation study compared screening questionnaires with standardized interviews in 392 male and 927 female adult outpatients at an academic family practice clinic from 1993 to 1994. The AUDIT-C, full AUDIT, self-reported risky drinking, AUDIT question #3, and an augmented CAGE questionnaire were compared with an interview primary reference standard of alcohol misuse, defined as a Diagnostic and Statistical Manual, 4th ed. alcohol use disorder and/or drinking above recommended limits in the past year.
RESULTS: Based on interviews with 92% of eligible patients, 128 (33%) men and 177 (19%) women met the criteria for alcohol misuse. Areas under the receiver operating characteristic curves (AUROCs) for the AUDIT-C were 0.94 (0.91, 0.96) and 0.90 (0.87, 0.93) in men and women, respectively (p=0.04). Based on AUROC curves, the AUDIT-C performed as well as the full AUDIT and significantly better than self-reported risky drinking, AUDIT question #3, or the augmented CAGE questionnaire (p-values <0.001). The AUDIT-C screening thresholds that simultaneously maximized sensitivity and specificity were > or =4 in men (sensitivity 0.86, specificity 0.89) and > or =3 in women (sensitivity 0.73, specificity 0.91).
CONCLUSIONS: The AUDIT-C was an effective screening test for alcohol misuse in this primary care sample. Optimal screening thresholds for alcohol misuse among men (> or =4) and women (> or =3) were the same as in previously published VA studies.
Maisto SA, Saitz R.
Alcohol use disorders: screening and diagnosis.
Am J Addict. 2003;12(s1):s12-s25. doi: 10.1111/j.1521-0391.2003.tb00493.x.
Abstract/Text
The purpose of this article is to provide an overview of empirically supported, primarily self-report methods of screening and diagnosis related to alcohol use disorders (AUDs). The discussion of screening instruments focuses on the primary care setting, and the diagnosis instruments discussion centers on the alcohol (and other drug) treatment setting. The literature shows that the AUDIT and the CAGE are the most widely validated methods of screening for AUDs in primary care and may be applied readily in that context. Similarly, a number of instruments designed to derive DSM-IV (and ICD-10) AUD diagnoses, as well as constructs related to how AUDs are defined, are available and can meet a variety of clinical needs. Future research priorities include further development of brief methods to identify hazardous drinkers or individuals who have an AUD, as well as refinement of diagnosis instruments to increase their application across treatment settings and subpopulations.
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Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health.
Obes Res. 1998 Sep;6 Suppl 2:51S-209S.
Abstract/Text
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Obesity: preventing and managing the global epidemic. Report of a WHO consultation.
World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253.
Abstract/Text
Overweight and obesity represent a rapidly growing threat to the health of populations in an increasing number of countries. Indeed they are now so common that they are replacing more traditional problems such as undernutrition and infectious diseases as the most significant causes of ill-health. Obesity comorbidities include coronary heart disease, hypertension and stroke, certain types of cancer, non-insulin-dependent diabetes mellitus, gallbladder disease, dyslipidaemia, osteoarthritis and gout, and pulmonary diseases, including sleep apnoea. In addition, the obese suffer from social bias, prejudice and discrimination, on the part not only of the general public but also of health professionals, and this may make them reluctant to seek medical assistance. WHO therefore convened a Consultation on obesity to review current epidemiological information, contributing factors and associated consequences, and this report presents its conclusions and recommendations. In particular, the Consultation considered the system for classifying overweight and obesity based on the body mass index, and concluded that a coherent system is now available and should be adopted internationally. The Consultation also concluded that the fundamental causes of the obesity epidemic are sedentary lifestyles and high-fat energy-dense diets, both resulting from the profound changes taking place in society and the behavioural patterns of communities as a consequence of increased urbanization and industrialization and the disappearance of traditional lifestyles. A reduction in fat intake to around 20-25% of energy is necessary to minimize energy imbalance and weight gain in sedentary individuals. While there is strong evidence that certain genes have an influence on body mass and body fat, most do not qualify as necessary genes, i.e. genes that cause obesity whenever two copies of the defective allele are present; it is likely to be many years before the results of genetic research can be applied to the problem. Methods for the treatment of obesity are described, including dietary management, physical activity and exercise, and antiobesity drugs, with gastrointestinal surgery being reserved for extreme cases.
Peeters A, Barendregt JJ, Willekens F, Mackenbach JP, Al Mamun A, Bonneux L; NEDCOM, the Netherlands Epidemiology and Demography Compression of Morbidity Research Group.
Obesity in adulthood and its consequences for life expectancy: a life-table analysis.
Ann Intern Med. 2003 Jan 7;138(1):24-32. doi: 10.7326/0003-4819-138-1-200301070-00008.
Abstract/Text
BACKGROUND: Overweight and obesity in adulthood are linked to an increased risk for death and disease. Their potential effect on life expectancy and premature death has not yet been described.
OBJECTIVE: To analyze reductions in life expectancy and increases in premature death associated with overweight and obesity at 40 years of age.
DESIGN: Prospective cohort study.
SETTING: The Framingham Heart Study with follow-up from 1948 to 1990.
PARTICIPANTS: 3457 Framingham Heart Study participants who were 30 to 49 years of age at baseline.
MEASUREMENTS: Mortality rates specific for age and body mass index group (normal weight, overweight, or obese at baseline) were derived within sex and smoking status strata. Life expectancy and the probability of death before 70 years of age were analyzed by using life tables.
RESULTS: Large decreases in life expectancy were associated with overweight and obesity. Forty-year-old female nonsmokers lost 3.3 years and 40-year-old male nonsmokers lost 3.1 years of life expectancy because of overweight. Forty-year-old female nonsmokers lost 7.1 years and 40-year-old male nonsmokers lost 5.8 years because of obesity. Obese female smokers lost 7.2 years and obese male smokers lost 6.7 years of life expectancy compared with normal-weight smokers. Obese female smokers lost 13.3 years and obese male smokers lost 13.7 years compared with normal-weight nonsmokers. Body mass index at ages 30 to 49 years predicted mortality after ages 50 to 69 years, even after adjustment for body mass index at age 50 to 69 years.
CONCLUSIONS: Obesity and overweight in adulthood are associated with large decreases in life expectancy and increases in early mortality. These decreases are similar to those seen with smoking. Obesity in adulthood is a powerful predictor of death at older ages. Because of the increasing prevalence of obesity, more efficient prevention and treatment should become high priorities in public health.
McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, Lohr KN.
Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med. 2003 Dec 2;139(11):933-49. doi: 10.7326/0003-4819-139-11-200312020-00013.
Abstract/Text
BACKGROUND: Obesity poses a considerable and growing health burden. This review examines evidence for screening and treating obesity in adults.
DATA SOURCES: MEDLINE and Cochrane Library (January 1994 through February 2003).
STUDY SELECTION: Systematic reviews; randomized, controlled trials; and observational studies of obesity's health outcomes or efficacy of obesity treatment.
DATA EXTRACTION: Two reviewers independently abstracted data on study design, sample, sample size, treatment, outcomes, and quality.
DATA SYNTHESIS: No trials evaluated mass screening for obesity, so the authors evaluated indirect evidence for efficacy. Pharmacotherapy or counseling interventions produced modest (generally 3 to 5 kg) weight loss over at least 6 or 12 months, respectively. Counseling was most effective when intensive and combined with behavioral therapy. Maintenance strategies helped retain weight loss. Selected surgical patients lost substantial weight (10 to 159 kg over 1 to 5 years). Weight reduction improved blood pressure, lipid levels, and glucose metabolism and decreased diabetes incidence. The internal validity of the treatment trials was fair to good, and external validity was limited by the minimal ethnic or gender diversity of volunteer participants. No data evaluated counseling harms. Primary adverse drug effects included hypertension with sibutramine (mean increase, 0 mm Hg to 3.5 mm Hg) and gastrointestinal distress with orlistat (1% to 37% of patients). Fewer than 1% (pooled samples) of surgical patients died; up to 25% needed surgery again over 5 years.
CONCLUSIONS: Counseling and pharmacotherapy can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety has not been as strongly established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee.
Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Hypertension. 2003 Dec;42(6):1206-52. doi: 10.1161/01.HYP.0000107251.49515.c2. Epub 2003 Dec 1.
Abstract/Text
The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.
Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, Franklin BA, Goldstein LB, Greenland P, Grundy SM, Hong Y, Miller NH, Lauer RM, Ockene IS, Sacco RL, Sallis JF Jr, Smith SC Jr, Stone NJ, Taubert KA.
AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee.
Circulation. 2002 Jul 16;106(3):388-91. doi: 10.1161/01.cir.0000020190.45892.75.
Abstract/Text
Summary of Recommendations for Clinical Preventive Services. Revision 6.0; August 2005.
Chou R, Arora B, Dana T, Fu R, Walker M, Humphrey L.
Screening asymptomatic adults with resting or exercise electrocardiography: a review of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med. 2011 Sep 20;155(6):375-85. doi: 10.7326/0003-4819-155-6-201109200-00006.
Abstract/Text
BACKGROUND: Coronary heart disease is the leading cause of death in adults. Screening for abnormalities by using resting or exercise electrocardiography (ECG) might help identify persons who would benefit from interventions to reduce cardiovascular risk.
PURPOSE: To update the 2004 U.S. Preventive Services Task Force evidence review on screening for resting or exercise ECG abnormalities in asymptomatic adults.
DATA SOURCES: MEDLINE (2002 through January 2011), the Cochrane Library database (through the fourth quarter of 2010), and reference lists.
STUDY SELECTION: Randomized, controlled trials and prospective cohort studies.
DATA EXTRACTION: Investigators abstracted details about the study population, study design, data analysis, follow-up, and results and assessed quality by using predefined criteria.
DATA SYNTHESIS: No study evaluated clinical outcomes or use of risk-reducing therapies after screening versus no screening. No study estimated how accurately resting or exercise electrocardiography classified participants into high-, intermediate-, or low-risk groups, compared with traditional risk factor assessment alone. Sixty-three prospective cohort studies evaluated abnormalities on resting or exercise ECG as predictors of cardiovascular events after adjustment for traditional risk factors. Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST-segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1). Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG). No study estimated harms from subsequent testing or interventions, although rates of angiography after exercise ECG ranged from 0.6% to 2.9%.
LIMITATIONS: Only English-language studies were included. Statistical heterogeneity was present in several of the pooled analyses.
CONCLUSION: Abnormalities on resting or exercise ECG are associated with an increased risk for subsequent cardiovascular events after adjustment for traditional risk factors, but the clinical implications of these findings are unclear.
Yano E, Tagawa K, Yamaoka K, Mori M.
Test validity of periodic liver function tests in a population of Japanese male bank employees.
J Clin Epidemiol. 2001 Sep;54(9):945-51. doi: 10.1016/s0895-4356(01)00355-9.
Abstract/Text
The validity (sensitivity and specificity) of annual liver function tests, determined by assaying blood levels of aspartate aminotransferase, alanine aminotransferase and gammaglutamyl transpeptidase, was evaluated using the results of health checkups of male bank workers. The specificity of each liver function test to detect persons with fatty liver, excess alcohol users, and hepatic virus carriers, diagnosed respectively by ultrasound, detailed inquiry, and virus marker tests, was always higher than 80%, except for alanine aminotransferase in excess alcohol users (63.5%). However, the highest sensitivity to detect virus carriers was alanine aminotransferase to detect HCV antibody-positive workers, but it was only 45.5%. The highest sensitivity of the liver function tests to detect excess alcohol users in obese subjects was only 33.3%. The highest sensitivity by liver function tests to detect fatty liver was 35.7% which was inferior to that of the body mass index. These results indicate that the liver function tests mandated in the workplace periodic health checkups in Japan exhibit very low sensitivity for the detection of any of the proposed target clinical conditions.
American Diabetes Association.
Standards of medical care in diabetes--2012.
Diabetes Care. 2012 Jan;35 Suppl 1(Suppl 1):S11-63. doi: 10.2337/dc12-s011.
Abstract/Text
Simmons RK, Echouffo-Tcheugui JB, Sharp SJ, Sargeant LA, Williams KM, Prevost AT, Kinmonth AL, Wareham NJ, Griffin SJ.
Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial.
Lancet. 2012 Nov 17;380(9855):1741-8. doi: 10.1016/S0140-6736(12)61422-6. Epub 2012 Oct 4.
Abstract/Text
BACKGROUND: The increasing prevalence of type 2 diabetes poses a major public health challenge. Population-based screening and early treatment for type 2 diabetes could reduce this growing burden. However, uncertainty persists around the benefits of screening for type 2 diabetes. We assessed the effect of a population-based stepwise screening programme on mortality.
METHODS: In a pragmatic parallel group, cluster-randomised trial, 33 general practices in eastern England were randomly assigned by the method of minimisation in an unbalanced design to: screening followed by intensive multifactorial treatment for people diagnosed with diabetes (n=15); screening plus routine care of diabetes according to national guidelines (n=13); and a no-screening control group (n=5). The study population consisted of 20,184 individuals aged 40-69 years (mean 58 years), at high risk of prevalent undiagnosed diabetes, on the basis of a previously validated risk score. In screening practices, individuals were invited to a stepwise programme including random capillary blood glucose and glycated haemoglobin (HbA(1c)) tests, a fasting capillary blood glucose test, and a confirmatory oral glucose tolerance test. The primary outcome was all-cause mortality. All participants were flagged for mortality surveillance by the England and Wales Office of National Statistics. Analysis was by intention-to-screen and compared all-cause mortality rates between screening and control groups. This study is registered, number ISRCTN86769081.
FINDINGS: Of 16,047 high-risk individuals in screening practices, 15,089 (94%) were invited for screening during 2001-06, 11,737 (73%) attended, and 466 (3%) were diagnosed with diabetes. 4137 control individuals were followed up. During 184,057 person-years of follow up (median duration 9·6 years [IQR 8·9-9·9]), there were 1532 deaths in the screening practices and 377 in control practices (mortality hazard ratio [HR] 1·06, 95% CI 0·90-1·25). We noted no significant reduction in cardiovascular (HR 1·02, 95% CI 0·75-1·38), cancer (1·08, 0·90-1·30), or diabetes-related mortality (1·26, 0·75-2·10) associated with invitation to screening.
INTERPRETATION: In this large UK sample, screening for type 2 diabetes in patients at increased risk was not associated with a reduction in all-cause, cardiovascular, or diabetes-related mortality within 10 years. The benefits of screening might be smaller than expected and restricted to individuals with detectable disease.
FUNDING: Wellcome Trust; UK Medical Research Council; National Health Service research and development support; UK National Institute for Health Research; University of Aarhus, Denmark; Bio-Rad.
Copyright © 2012 Elsevier Ltd. All rights reserved.
Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR.
Screening for proteinuria in US adults: a cost-effectiveness analysis.
JAMA. 2003 Dec 17;290(23):3101-14. doi: 10.1001/jama.290.23.3101.
Abstract/Text
CONTEXT: Chronic kidney disease is a growing public health problem. Screening for early identification could improve health but could also lead to unnecessary harms and excess costs.
OBJECTIVE: To assess the value of periodic, population-based dipstick screening for early detection of urine protein in adults with neither hypertension nor diabetes and in adults with hypertension.
DESIGN, SETTING, AND POPULATION: Cost-effectiveness analysis using a Markov decision analytic model to compare a strategy of annual screening with no screening (usual care) for proteinuria at age 50 years followed by treatment with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB).
MAIN OUTCOME MEASURE: Cost per quality-adjusted life-year (QALY).
RESULTS: For persons with neither hypertension nor diabetes, the cost-effectiveness ratio for screening vs no screening (usual care) was unfavorable (282 818 dollars per QALY; incremental cost of 616 dollars and a gain of 0.0022 QALYs per person). However, screening such persons beginning at age 60 years yielded a more favorable ratio (53 372 dollars per QALY). For persons with hypertension, the ratio was highly favorable (18 621 dollars per QALY; incremental cost of 476 dollars and a gain of 0.03 QALYs per person). Cost-effectiveness was mediated by both chronic kidney disease progression and death prevention benefits of ACE inhibitor and ARB therapy. Influential parameters that might make screening for the general population more cost-effective include a greater incidence of proteinuria, age at screening (53 372 dollars per QALY for persons beginning screening at age 60 years), or lower frequency of screening (every 10 years: 80 700 dollars per QALY at age 50 years; 6195 dollars per QALY at age 60 years; and 5486 dollars per QALY at age 70 years).
CONCLUSIONS: Early detection of urine protein to slow progression of chronic kidney disease and decrease mortality is not cost-effective unless selectively directed toward high-risk groups (older persons and persons with hypertension) or conducted at an infrequent interval of 10 years.
Craig JC, Barratt A, Cumming R, Irwig L, Salkeld G.
Feasibility study of the early detection and treatment of renal disease by mass screening.
Intern Med J. 2002 Jan-Feb;32(1-2):6-14.
Abstract/Text
AIM: To determine whether mass screening for proteinuria may be worthwhile in the detection of early renal disease in Australians.
METHODS: A feasibility study was conducted using systematic review, meta-analysis and cost-effectiveness methods.
RESULTS: End-stage renal disease (ESRD) develops in about 1500 Australians each year. Of these, about 1000 are over 50 years of age (an incidence of about 200 per million, per year). Proteinuria, which is present in about 5% of the general population, confers an approximately 15-fold increased risk for ESRD. Twelve randomized trials of angiotensin-converting enzyme inhibitors (ACEi), in 1943 patients with varying degrees of renal impairment, hypertension and proteinuria, showed that the risk of developing ESRD can be reduced by about 30% over a 2- to 3-year period. In a general-practice-based screening model involving: (i) an opportunistic single dipstick test for protein, (ii) a confirming 24-h urine test for protein and (iii) commencement of ACEi in appropriate individuals, 20 000 people over 50 years of age would need to be screened to prevent one case of ESRD. To achieve this, approximately 100 people would need to be treated with ACEi for 2 to 3 years, and 1,000 would need to have a 24-h urine protein test (and of these, 700 would be false positives). Such a strategy may save health dollars but some critical research questions are still unanswered. What is an individual's risk of developing ESRD, given values for proteinuria, blood pressure and renal function? What is the benefit of ACEi in screen-detected cases, which are at low risk of ESRD? What psychological and physical harm is caused by screening, including the specific renal investigations and treatments that follow on from proteinuria detection?
CONCLUSIONS: Given available data, screening middle-aged and older Australians for proteinuria and treating some with ACEi is, at best, a promising primary prevention strategy for preventing ESRD. However, a large population-based cohort study, with nested trial of ACEi, is still required to evaluate whether this model of screening for renal disease does more harm than good.
Pignone MP, Phillips CJ, Atkins D, Teutsch SM, Mulrow CD, Lohr KN.
Screening and treating adults for lipid disorders.
Am J Prev Med. 2001 Apr;20(3 Suppl):77-89. doi: 10.1016/s0749-3797(01)00255-0.
Abstract/Text
CONTEXT: Screening and treatment of lipid disorders in people at high risk for future coronary heart disease (CHD) events has gained wide acceptance, especially for patients with known CHD, but the proper role in people with low to medium risk is controversial.
OBJECTIVE: To examine the evidence about the benefits and harms of screening and treatment of lipid disorders in adults without known cardiovascular disease for the U.S. Preventive Services Task Force.
DATA SOURCES: We identified English-language articles on drug therapy, diet and exercise therapy, and screening for lipid disorders from comprehensive searches of the MEDLINE database from 1994 through July 1999. We used published systematic reviews, hand searching of relevant articles, the second Guide to Clinical Preventive Services, and extensive peer review to identify important older articles and to ensure completeness.
DATA SYNTHESIS: There is strong, direct evidence that drug therapy reduces CHD events, CHD mortality, and possibly total mortality in middle-aged men (35 to 65 years) with abnormal lipids and a potential risk of CHD events greater than 1% to 2% per year. Indirect evidence suggests that drug therapy is also effective in other adults with similar levels of risk. The evidence is insufficient about benefits and harms of treating men younger than 35 years and women younger than 45 years who have abnormal lipids but no other risk factors for heart disease and low risk for CHD events (less than 1% per year). Trials of diet therapy for primary prevention have led to long-term reductions in cholesterol of 3% to 6% but have not demonstrated a reduction in CHD events overall. Exercise programs that maintain or reduce body weight can produce short-term reductions in total cholesterol of 3% to 6%, but longer-term results in unselected populations have found smaller or no effect. To identify accurately people with abnormal lipids, at least two measurements of total cholesterol and high-density lipoprotein cholesterol are required. The role of measuring triglycerides and the optimal screening interval are unclear from the available evidence.
CONCLUSIONS: On the basis of the effectiveness of treatment, the availability of accurate and reliable tests, and the likelihood of identifying people with abnormal lipids and increased CHD risk, screening appears to be effective in middle-aged and older adults and in young adults with additional cardiovascular risk factors.
日本動脈硬化学会編：動脈硬化性疾患予防ガイドライン2007年版.
Matsuzaki M, Kita T, Mabuchi H, Matsuzawa Y, Nakaya N, Oikawa S, Saito Y, Sasaki J, Shimamoto K, Itakura H; J-LIT Study Group. Japan Lipid Intervention Trial.
Large scale cohort study of the relationship between serum cholesterol concentration and coronary events with low-dose simvastatin therapy in Japanese patients with hypercholesterolemia.
Circ J. 2002 Dec;66(12):1087-95. doi: 10.1253/circj.66.1087.
Abstract/Text
Hyperlipidemia is a well-established risk factor for primary coronary heart disease (CHD). Although simvastatin is known to lower serum lipid concentrations, the protective effect of such lipid-lowering therapy against primary CHD has not been established in Japanese patients with hypercholesterolemia. The Japan Lipid Intervention Trial was a 6-year, nationwide cohort study of 47,294 patients treated with open-labeled simvastatin (5-10 mg/day) and monitored by physicians under standard clinical conditions. The aim of the study was to determine the relationship between the occurrence of CHD and the serum lipid concentrations during low-dose simvastatin treatment. Simvastatin reduced serum concentrations of total cholesterol (TC), low-density lipoprotein- cholesterol (LDL-C) and triglyceride (TG), by 18.4%, 26.8% and 16.1% on average, respectively, during the treatment period. The risk of coronary events was higher when the average TC concentration was > or =240 mg/dl and the average LDL-C concentration was > or =160 mg/dl. The incidence of coronary events increased in the patients with TG concentration > or =300 mg/dl compared with patients with TG concentration <150 mg/dl. The high-density lipoprotein cholesterol (HDL-C) inversely correlated with the risk of coronary events. The J-curve association was observed between average TC or LDL-C concentrations and total mortality. Malignancy was the most prevalent cause of death. The health of patients should be monitored closely when there is a remarkable decrease in TC and LDL-C concentrations with low-dose statin. A reasonable strategy to prevent coronary events in Japanese hypercholesterolemic patients without prior CHD under low-dose statin treatment might be regulating the serum lipid concentrations to at least <240 mg/dl for TC, <160 mg/dl for LDL-C, <300 mg/dl for TG, and >40 mg/dl for HDL-C.
Brodaty H, Low LF, Gibson L, Burns K.
What is the best dementia screening instrument for general practitioners to use?
Am J Geriatr Psychiatry. 2006 May;14(5):391-400. doi: 10.1097/01.JGP.0000216181.20416.b2.
Abstract/Text
OBJECTIVE: The objective of this study was to review existing dementia screening tools with a view to informing and recommending suitable instruments to general practitioners (GPs) based on their performance and practicability for general practice.
METHOD: A systematic search of pre-MEDLINE, MEDLINE, PsycINFO, and the Cochrane Library Database was undertaken. Only available full-text articles about dementia screening instruments written in English or with an English version were included. Articles using a translation of an English language instrument were excluded unless validated in a general practice, community, or population sample.
RESULTS: The General Practitioner Assessment of Cognition (GPCOG), Mini-Cog, and Memory Impairment Screen (MIS) were chosen as most suitable for routine dementia screening in general practice. The GPCOG, Mini-Cog, and MIS were all validated in community, population, or general practice samples, are easy to administer, and have administration times of 5 minutes or less. They also have negative predictive validity and misclassification rates, which do not differ significantly from those of the Mini-Mental Status Examination.
CONCLUSIONS: It is recommended that GPs consider using the GPCOG, Mini-Cog, or MIS when screening for cognitive impairment or for case detection.
Carnero-Pardo C, Espejo-Martínez B, López-Alcalde S, Espinosa-García M, Sáez-Zea C, Hernández-Torres E, Navarro-Espigares JL, Vílchez-Carrillo R.
Diagnostic accuracy, effectiveness and cost for cognitive impairment and dementia screening of three short cognitive tests applicable to illiterates.
PLoS One. 2011;6(11):e27069. doi: 10.1371/journal.pone.0027069. Epub 2011 Nov 2.
Abstract/Text
BACKGROUND: Illiteracy, a universal problem, limits the utilization of the most widely used short cognitive tests. Our objective was to assess and compare the effectiveness and cost for cognitive impairment (CI) and dementia (DEM) screening of three short cognitive tests applicable to illiterates.
METHODS: Phase III diagnostic test evaluation study was performed during one year in four Primary Care centers, prospectively including individuals with suspicion of CI or DEM. All underwent the Eurotest, Memory Alteration Test (M@T), and Phototest, applied in a balanced manner. Clinical, functional, and cognitive studies were independently performed in a blinded fashion in a Cognitive Behavioral Neurology Unit, and the gold standard diagnosis was established by consensus of expert neurologists on the basis of these results. Effectiveness of tests was assessed as the proportion of correct diagnoses (diagnostic accuracy [DA]) and the kappa index of concordance (k) with respect to gold standard diagnoses. Costs were based on public prices at the time and hospital accounts.
RESULTS: The study included 139 individuals: 47 with DEM, 36 with CI, and 56 without CI. No significant differences in effectiveness were found among the tests. For DEM screening: Eurotest (k = 0.71 [0.59-0.83], DA = 0.87 [0.80-0.92]), M@T (k = 0.72 [0.60-0.84], DA = 0.87 [0.80-0.92]), Phototest (k = 0.70 [0.57-0.82], DA = 0.86 [0.79-0.91]). For CI screening: Eurotest (k = 0.67 [0.55-0.79]; DA = 0.83 [0.76-0.89]), M@T (k = 0.52 [0.37-0.67]; DA = 0.80 [0.72-0.86]), Phototest (k = 0.59 [0.46-0.72]; DA = 0.79 [0.71-0.86]). There were no differences in the cost of DEM screening, but the cost of CI screening was significantly higher with M@T (330.7 ± 177.1 €, mean ± sd) than with Eurotest (294.1 ± 195.0 €) or Phototest (296.0 ± 196. 5 €). Application time was shorter with Phototest (2.8 ± 0.8 min) than with Eurotest (7.1 ± 1.8 min) or M@T (6.8 ± 2.2 min).
CONCLUSIONS: Eurotest, M@T, and Phototest are equally effective. Eurotest and Phototest are both less expensive options but Phototest is the most efficient, requiring the shortest application time.
加藤伸司, 下垣光, 小野寺敦志: 改訂長谷川式簡易知能評価スケール（HDS-R）の作成．老年精医誌1991;2(11):1339-1347.
Kim KW, Lee DY, Jhoo JH, Youn JC, Suh YJ, Jun YH, Seo EH, Woo JI.
Diagnostic accuracy of mini-mental status examination and revised hasegawa dementia scale for Alzheimer's disease.
Dement Geriatr Cogn Disord. 2005;19(5-6):324-30. doi: 10.1159/000084558. Epub 2005 Mar 22.
Abstract/Text
To compare the diagnostic accuracies of the Revised Hasegawa Dementia Scale (HDS-R) and Mini-Mental Status Examination (MMSE) for Alzheimer's diseases (AD), we administered them simultaneously to 82 AD patients and 82 age- and sex-matched nondemented control subjects. The area under the receiver operator curve (AUC) for AD of the HDS-R (AUC(HDS-R)) and MMSE (AUC(MMSE)) were bigger than 0.90 indicating that both tests are useful for detecting AD. However, AUC(HDS-R) (0.952) was significantly larger than that of the AUC(MMSE )(0.902) regardless of the educational level of the subjects, indicating that the HDS-R is more accurate than MMSE in diagnosing AD. Moreover, the superiority of the HDS-R (AUC(HDS-R) = 0.894) to the MMSE (AUC(MMSE) = 0.704) remained significant in mild AD patients alone, who are the focus of screening. In conclusion, the HDS-R is better than the MMSE as a screening instrument for AD.
Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology.
American College of Gastroenterology guideline on the management of Helicobacter pylori infection.
Am J Gastroenterol. 2007 Aug;102(8):1808-25. doi: 10.1111/j.1572-0241.2007.01393.x. Epub 2007 Jun 29.
Abstract/Text
Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignanc and dyspeptic symptoms. Whether to test for H. pylori in patients with functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal antiinflammatory drugs, with iron deficiency anemia, or who are at greater risk of developing gastric cancer remains controversial. H. pylori can be diagnosed by endoscopic or nonendoscopic methods. A variety of factors including the need for endoscopy, pretest probability of infection, local availability, and an understanding of the performance characteristics and cost of the individual tests influences choice of evaluation in a given patient. Testing to prove eradication should be performed in patients who receive treatment of H. pylori for peptic ulcer disease, individuals with persistent dyspeptic symptoms despite the test-and-treat strategy, those with H. pylori-associated MALT lymphoma, and individuals who have undergone resection of early gastric cancer. Recent studies suggest that eradication rates achieved by first-line treatment with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin have decreased to 70-85%, in part due to increasing clarithromycin resistance. Eradication rates may also be lower with 7 versus 14-day regimens. Bismuth-containing quadruple regimens for 7-14 days are another first-line treatment option. Sequential therapy for 10 days has shown promise in Europe but requires validation in North America. The most commonly used salvage regimen in patients with persistent H. pylori is bismuth quadruple therapy. Recent data suggest that a PPI, levofloxacin, and amoxicillin for 10 days is more effective and better tolerated than bismuth quadruple therapy for persistent H. pylori infection, though this needs to be validated in the United States.
日本ヘリコバクター学会：Helicobacter pylori感染の診断と治療のガイドライン2009改訂版.
Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN.
Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med. 2002 May 21;136(10):765-76. doi: 10.7326/0003-4819-136-10-200205210-00013.
Abstract/Text
PURPOSE: To clarify whether screening adults for depression in primary care settings improves recognition, treatment, and clinical outcomes.
DATA SOURCES: The MEDLINE database was searched from 1994 through August 2001. Other relevant articles were located through other systematic reviews; focused searches of MEDLINE from 1966 to 1994; the Cochrane depression, anxiety, and neurosis database; hand searches of bibliographies; and extensive peer review.
STUDY SELECTION: The researchers reviewed randomized trials conducted in primary care settings that examined the effect of screening for depression on identification, treatment, or health outcomes, including trials that tested integrated, systematic support for treatment after identification of depression.
DATA EXTRACTION: A single reviewer abstracted the relevant data from the included articles. A second reviewer checked the accuracy of the tables against the original articles.
DATA SYNTHESIS: Compared with usual care, feedback of depression screening results to providers generally increased recognition of depressive illness in adults. Studies examining the effect of screening and feedback on treatment rates and clinical outcomes had mixed results. Many trials lacked power to detect clinically important differences in outcomes. Meta-analysis suggests that overall, screening and feedback reduced the risk for persistent depression (summary relative risk, 0.87 [95% CI, 0.79 to 0.95]). Programs that integrated interventions aimed at improving recognition and treatment of patients with depression and that incorporated quality improvements in clinic systems had stronger effects than programs of feedback alone.
CONCLUSION: Compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow-up.
Whooley MA, Avins AL, Miranda J, Browner WS.
Case-finding instruments for depression. Two questions are as good as many.
J Gen Intern Med. 1997 Jul;12(7):439-45. doi: 10.1046/j.1525-1497.1997.00076.x.
Abstract/Text
OBJECTIVE: To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.
DESIGN: The test characteristics of a two-question case-finding instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.
SETTING: Urgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.
PARTICIPANTS: Five hundred thirty-six consecutive adult patients without mania or schizophrenia.
MEASUREMENTS AND MAIN RESULTS: Measurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Book Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90-99%) and a specificity of 57% (95% CI 53-62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.
CONCLUSIONS: The two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.
Singer ME, Younossi ZM.
Cost effectiveness of screening for hepatitis C virus in asymptomatic, average-risk adults.
Am J Med. 2001 Dec 1;111(8):614-21. doi: 10.1016/s0002-9343(01)00951-2.
Abstract/Text
PURPOSE: To estimate the cost effectiveness of screening for hepatitis C in asymptomatic, average-risk adults.
METHODS: We used a Markov decision analysis model to estimate the lifetime cost effectiveness of three screening strategies: (1) initial screening for hepatitis C antibody by third-generation enzyme-linked immunosorbent assay (ELISA), followed by confirmatory testing for hepatitis C virus ribonucleic acid (RNA) using polymerase chain reaction (PCR); (2) initial screening for hepatitis C virus RNA by PCR only; and (3) the current practice of not screening. The patient population comprised a hypothetical cohort of average-risk adults presenting to their regular primary health care provider for routine physical examination. The main outcome measure was cost per additional quality-adjusted life-year (QALY) gained.
RESULTS: The no screening strategy was the dominant strategy in the baseline analysis. The model was most sensitive to the reduction in quality of life related to patient awareness of hepatitis C infection. Screening with ELISA and PCR was preferred when this value was <0.01 and was cost effective if more than half of the patients who tested positive for hepatitis C actually initiated treatment, or if the annual rate of progression to cirrhosis was greater than 2.5%. Screening with PCR only was never cost effective.
CONCLUSIONS: This analysis does not support the widespread screening for hepatitis C among asymptomatic, average-risk adults.
Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R.
Screening for osteoporosis: an update for the U.S. Preventive Services Task Force.
Ann Intern Med. 2010 Jul 20;153(2):99-111. doi: 10.7326/0003-4819-153-2-201007200-00262. Epub 2010 Jul 5.
Abstract/Text
BACKGROUND: This review updates evidence since the 2002 U.S. Preventive Services Task Force recommendation on osteoporosis screening.
PURPOSE: To determine the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and the efficacy and harms of medications to reduce primary fractures.
DATA SOURCES: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2009), MEDLINE (January 2001 to December 2009), reference lists, and Web of Science.
STUDY SELECTION: Randomized, controlled trials of screening or medications with fracture outcomes published in English; performance studies of validated risk-assessment instruments; and systematic reviews and population-based studies of bone measurement tests or medication harms.
DATA EXTRACTION: Data on patient populations, study design, analysis, follow-up, and results were abstracted, and study quality was rated by using established criteria.
DATA SYNTHESIS: Risk-assessment instruments are modest predictors of low bone density (area under the curve, 0.13 to 0.87; 14 instruments) and fractures (area under the curve, 0.48 to 0.89; 11 instruments); simple and complex instruments perform similarly. Dual-energy x-ray absorptiometry predicts fractures similarly for men and women; calcaneal quantitative ultrasonography also predicts fractures, but correlation with dual-energy x-ray absorptiometry is low. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures. Trials are lacking for men. Bisphosphonates are not consistently associated with serious adverse events; raloxifene and estrogen increase thromboembolic events; and estrogen causes additional adverse events.
LIMITATION: Trials of screening with fracture outcomes, screening intervals, and medications to reduce primary fractures, particularly those enrolling men, are lacking.
CONCLUSION: Although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
U.S. Preventive Services Task Force.
Screening for osteoporosis: U.S. preventive services task force recommendation statement.
Ann Intern Med. 2011 Mar 1;154(5):356-64. doi: 10.7326/0003-4819-154-5-201103010-00307. Epub 2011 Jan 17.
Abstract/Text
DESCRIPTION: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for osteoporosis.
METHODS: The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment instruments for osteoporosis and fractures, the performance of dual-energy x-ray absorptiometry and peripheral bone measurement tests in predicting fractures, the harms of screening for osteoporosis, and the benefits and harms of drug therapy for osteoporosis in women and men.
RECOMMENDATIONS: The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I statement).
Fink HA, Ishani A, Taylor BC, Greer NL, MacDonald R, Rossini D, Sadiq S, Lankireddy S, Kane RL, Wilt TJ.
Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline.
Ann Intern Med. 2012 Apr 17;156(8):570-81. doi: 10.7326/0003-4819-156-8-201204170-00004.
Abstract/Text
BACKGROUND: Screening and monitoring for chronic kidney disease (CKD) could lead to earlier interventions that improve clinical outcomes.
PURPOSE: To summarize evidence about the benefits and harms of screening for and monitoring and treatment of CKD stages 1 to 3 in adults.
DATA SOURCES: MEDLINE (1985 through November 2011), reference lists, and expert suggestions.
STUDY SELECTION: English-language, randomized, controlled trials that evaluated screening for or monitoring or treatment of CKD and that reported clinical outcomes.
DATA EXTRACTION: Two reviewers assessed study characteristics and rated quality and strength of evidence.
DATA SYNTHESIS: No trials evaluated screening or monitoring, and 110 evaluated treatments. Angiotensin-converting enzyme inhibitors (relative risk, 0.65 [95% CI, 0.49 to 0.88]) and angiotensin II-receptor blockers (relative risk, 0.77 [CI, 0.66 to 0.90]) reduced end-stage renal disease versus placebo, primarily in patients with diabetes who have macroalbuminuria. Angiotensin-converting enzyme inhibitors reduced mortality versus placebo (relative risk, 0.79 [CI, 0.66 to 0.96]) in patients with microalbuminuria and cardiovascular disease or high-risk diabetes. Statins and β-blockers reduced mortality and cardiovascular events versus placebo or control in patients with impaired estimated glomerular filtration rate and either hyperlipidemia or congestive heart failure, respectively. Risks for mortality, end-stage renal disease, or other clinical outcomes did not significantly differ between strict and usual blood pressure control. The strength of evidence was rated high for angiotensin II-receptor blockers and statins, moderate for angiotensin-converting enzyme inhibitors and β-blockers, and low for strict blood pressure control.
LIMITATIONS: Evidence about outcomes was sometimes scant and derived from post hoc analyses of subgroups of patients enrolled in trials. Few trials reported or systematically collected information about adverse events. Selective reporting and publication bias were possible.
CONCLUSION: The role of CKD screening or monitoring in improving clinical outcomes is uncertain. Evidence for CKD treatment benefit is strongest for angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, and in patients with albuminuria combined with diabetes or cardiovascular disease.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R.
Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med. 2007 Dec 18;147(12):860-70. doi: 10.7326/0003-4819-147-12-200712180-00006.
Abstract/Text
BACKGROUND: Cerebrovascular disease is the third leading cause of death in the United States. The proportion of all strokes attributable to previously asymptomatic carotid artery stenosis (CAS) is low. In 1996, the U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening of asymptomatic persons for CAS by using physical examination or carotid ultrasonography.
PURPOSE: To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasonography and treatment with carotid endarterectomy for CAS.
DATA SOURCES: MEDLINE and Cochrane Library (search dates January 1994 to April 2007), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts.
STUDY SELECTION: English-language randomized, controlled trials (RCTs) of screening for CAS; RCTs of carotid endarterectomy versus medical treatment; systematic reviews of screening tests; and observational studies of harms from carotid endarterectomy were selected to answer the following questions: Is there direct evidence that screening with ultrasonography for asymptomatic CAS reduces strokes? What is the accuracy of ultrasonography to detect CAS? Does intervention with carotid endarterectomy reduce morbidity or mortality? Does screening or carotid endarterectomy result in harm?
DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined Task Force criteria.
DATA SYNTHESIS: No RCTs of screening for CAS have been done. According to systematic reviews, the sensitivity of ultrasonography is approximately 94% and the specificity is approximately 92%. Treatment of CAS in selected patients by selected surgeons could lead to an approximately 5-percentage point absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from carotid endarterectomy vary from 2.7% to 4.7% in RCTs; higher rates have been reported in observational studies (up to 6.7%).
LIMITATIONS: Evidence is inadequate to stratify people into categories of risk for clinically important CAS. The RCTs of carotid endarterectomy versus medical treatment were conducted in selected populations with selected surgeons.
CONCLUSION: The actual stroke reduction from screening asymptomatic patients and treatment with carotid endarterectomy is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.
Jahromi AS, Cinà CS, Liu Y, Clase CM.
Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: a systematic review and meta-analysis.
J Vasc Surg. 2005 Jun;41(6):962-72. doi: 10.1016/j.jvs.2005.02.044.
Abstract/Text
BACKGROUND: Duplex ultrasound is widely used for the diagnosis of internal carotid artery stenosis. Standard duplex ultrasound criteria for the grading of internal carotid artery stenosis do not exist; thus, we conducted a systematic review and meta-analysis of the relation between the degree of internal carotid artery stenosis by duplex ultrasound criteria and degree of stenosis by angiography.
METHODS: Data were gathered from Medline from January 1966 to January 2003, the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, ACP Journal Club, UpToDate, reference lists, and authors' files. Inclusion criteria were the comparison of color duplex ultrasound results with angiography by the North American Symptomatic Carotid Endarterectomy Trial method; peer-reviewed publications, and >/=10 adults.
RESULTS: Variables extracted included internal carotid artery peak systolic velocity, internal carotid artery end diastolic velocity, internal carotid artery/common carotid artery peak systolic velocity ratio, sensitivity and specificity of duplex ultrasound scanning for internal carotid artery stenosis by angiography. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria were used to assess study quality. Sensitivity and specificity for duplex ultrasound criteria were combined as weighted means by using a random effects model. The threshold of peak systolic velocity >/=130 cm/s is associated with sensitivity of 98% (95% confidence intervals [CI], 97% to 100%) and specificity of 88% (95% CI, 76% to 100%) in the identification of angiographic stenosis of >/=50%. For the diagnosis of angiographic stenosis of >/=70%, a peak systolic velocity >/=200 cm/s has a sensitivity of 90% (95% CI, 84% to 94%) and a specificity of 94% (95% CI, 88% to 97%). For each duplex ultrasound threshold, measurement properties vary widely between laboratories, and the magnitude of the variation is clinically important. The heterogeneity observed in the measurement properties of duplex ultrasound may be caused by differences in patients, study design, equipment, techniques or training.
CONCLUSIONS: Clinicians need to be aware of the limitations of duplex ultrasound scanning when making management decisions.
U.S. Preventive Services Task Force.
Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med. 2008 Apr 1;148(7):529-34. doi: 10.7326/0003-4819-148-7-200804010-00212. Epub 2008 Mar 3.
Abstract/Text
DESCRIPTION: New U.S. Preventive Services Task Force (USPSTF) recommendation about screening for chronic obstructive pulmonary disease (COPD) using spirometry.
METHODS: The USPSTF weighed the benefits (prevention of > or =1 exacerbation and improvement in respiratory-related health status measures) and harms (time and effort required by both patients and the health care system, false-positive screening tests, and adverse effects of subsequent unnecessary therapy) of COPD screening identified in the accompanying review of the evidence. The USPSTF did not consider the financial costs of spirometry testing or COPD therapies.
RECOMMENDATION: Do not screen adults for COPD using spirometry. (Grade D recommendation).
Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB; U.S. Preventive Services Task Force.
Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med. 2008 Apr 1;148(7):535-43. doi: 10.7326/0003-4819-148-7-200804010-00213. Epub 2008 Mar 3.
Abstract/Text
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. Fewer than half of the estimated 24 million Americans with airflow obstruction have received a COPD diagnosis, and diagnosis often occurs in advanced stages of the disease.
PURPOSE: To summarize the evidence on screening for COPD using spirometry for the U.S. Preventive Services Task Force (USPSTF).
DATA SOURCES: English-language articles identified in PubMed and the Cochrane Library through January 2007, recent systematic reviews, expert suggestions, and reference lists of retrieved articles.
STUDY SELECTION: Explicit inclusion and exclusion criteria were used for each of the 8 key questions on benefits and harms of screening. Eligible study types varied by question.
DATA EXTRACTION: Studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.
DATA SYNTHESIS: Pharmacologic treatments for COPD reduce acute exacerbations in patients with severe disease. However, severe COPD is uncommon in the general U.S. population. Spirometry has not been shown to independently increase smoking cessation rates. Potential harms from screening include false-positive results and adverse effects from subsequent unnecessary therapy. Data on the prevalence of airflow obstruction in the U.S. population were used to calculate projected outcomes from screening groups defined by age and smoking status.
LIMITATION: No studies provide direct evidence on health outcomes associated with screening for COPD.
CONCLUSION: Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction who would not experience additional health benefits if labeled as having COPD. Hundreds of patients would need to undergo spirometry to defer a single exacerbation.
