Exploring general practitioners' experience of informing women about prenetal screening tests for foetal abnomalities : a qualitative focus group study

Background: Recent developments have made screening tests for foetal abnormalities available earlier in pregnancy and women have a range of testing options accessible to them. It is now recommended that all women, regardless of their age, are provided with information on prenatal screening tests. General Practitioners (GPs) are often the first health professionals a woman consults in pregnancy. As such, GPs are well positioned to inform women of the increasing range of prenatal screening tests available. The aim of this study was to explore GPs experience of informing women of prenatal genetic screening tests for foetal abnormality.
Methods: A qualitative study consisting of four focus groups was conducted in metropolitan and rural Victoria, Australia. A discussion guide was used and the audio-taped transcripts were independently coded
by two researchers using thematic analysis. Multiple coders and analysts and informant feedback were employed to reduce the potential for researcher bias and increase the validity of the findings.
Results: Six themes were identified and classified as 'intrinsic' if they occurred within the context of the consultation or 'extrinsic' if they consisted of elements that impacted on the GP beyond the scope of the
consultation. The three intrinsic themes were the way GPs explained the limitations of screening, the extent to which GPs provided information selectively and the time pressures at play. The three extrinsic
factors were GPs' attitudes and values towards screening, the conflict they experienced in offering screening information and the sense of powerlessness within the screening test process and the health
care system generally. Extrinsic themes reveal GPs' attitudes and values to screening and to disability, as well as raising questions about the fundamental premise of testing.
Conclusion: The increasing availability and utilisation of screening tests, in particular first trimester tests,has expanded GPs' role in facilitating women's informed decision-making. Recognition of the importance
of providing this complex information warrants longer consultations to respond to the time pressures that GPs experience. Understanding the intrinsic and extrinsic factors that impact on GPs may serve to shape
educational resources to be more appropriate, relevant and supportive.

Nutrition screening in long-term care facilities : an evaluation of the methodological quality of available instruments

A variety of nutrition screening instruments have been developed and implemented for identifying the risk of undernutrition among community and hospitalized older adults. Despite the high prevalence of undernutrition amongst older adults in long-term care, few screening instruments have been developed or evaluated in this setting. This review aims to evaluate the validity, reproducibility and feasibility of nutrition screening instruments developed for use, or described as being used, with older adults in long-term care. Ten publications encompassing nine independent nutrition screening tools were identified using electronic databases and manual searches of reference lists. The Mini Nutritional Assessment-Short Form (MNA-SF) was the most widely evaluated nutrition screening instrument and met the requirements for a valid instrument (sensitivity and specificity >0.9) for use in the long-term care setting. Modified versions of the MNA for use in China and South Africa also demonstrated acceptable levels of sensitivity and specificity. Other nutrition screening instruments were found to have variable levels of sensitivity and specificity and while some demonstrated levels consistent with the MNA-SF, only two were evaluated across more than one study population, Body Mass Index (BMI)+weight loss and BMI+albumin. These same instruments reported the highest levels of inter-rater and test-retest reproducibility, although this was only tested in one other instrument (Chinese Nutrition Screen -modified MNA). In conclusion, it is evident from this review that further work in this area is needed. Based on validity, reproducibility and feasibility it appears that BMI+weight loss is the most suitable nutrition screening instrument for use in the long-term care setting at this time. MNA-SF is promising; however, there is currently no data for inter-rater or test-retest reproducibility in the long-term care setting.

Screening pregnant women for chlamydia : what are the predictors of infection?

Objectives: To determine the risk factors associated with chlamydial infection in pregnancy and the sensitivity and specificity of these when used for selective screening.

Methods: A prospective, cross-sectional study of pregnant women aged 16–25 years attending four major public antenatal services across Melbourne, Australia. Between October 2006 and July 2007, women were approached consecutively and asked to complete a questionnaire and to provide a first-pass urine specimen for Chlamydia trachomatis testing using PCR.

Results: Of 1180 eligible women, 1087 were approached and 1044 (88%) consented to participate. Among the 987 women for whom a questionnaire and a definitive diagnostic assay were available, the prevalence of chlamydia was 3.2% (95% CI 1.8 to 5.9). In a multiple logistic regression model, more than one sexual partner in the past year (AOR 11.5; 95% CI 7.1 to 18.5) was associated with chlamydia infection. The use of any antibiotic within 3 months (AOR 0.2; 95% CI 0.1 to 0.6) was associated with a decreased risk of infection. Screening restricted to women who reported more than one sexual partner in the past year would have detected 44% of infections in women aged 16–25 years and would have required only 7% of women to be screened. The addition of those women aged 20 years and under would have required 27% of women to be screened and detection of 72% of infections.

Conclusions: Selective chlamydia screening of pregnant women based on risk factors can improve the yield from screening. However, the potential harm of missed infections among excluded women would need to be considered.

Retrospective screening program

A peek into the past of an Australian experimental cinema legend. Glorious 16mm film program with sympathetic vibrations by Jon Dale, Joel Stern, Lloyd Barrett & Joe Musgrove.

Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis.

Introduction: Fall risk screening tools are frequently used as a part of falls prevention programs in hospitals. Design-related bias in evaluations of tool predictive accuracy could lead to overoptimistic results, which would then contribute to program failure in practice.

Methods: A systematic review was undertaken. Two blind reviewers assessed the methodology of relevant publications into a four-point classification system adapted from multiple sources. The association between study design classification and reported results was examined using linear regression with clustering based on screening tool and robust variance estimates with point estimates of Youden Index (= sensitivity + specificity - 1) as the dependent variable. Meta-analysis was then performed pooling data from prospective studies.

Results: Thirty-five publications met inclusion criteria, containing 51 evaluations of fall risk screening tools. Twenty evaluations were classified as retrospective validation evaluations, 11 as prospective (temporal) validation evaluations, and 20 as prospective (external) validation evaluations. Retrospective evaluations had significantly higher Youden Indices (point estimate [95% confidence interval]: 0.22 [0.11, 0.33]). Pooled Youden Indices from prospective evaluations demonstrated the STRATIFY, Morse Falls Scale, and nursing staff clinical judgment to have comparable accuracy.

Discussion: Practitioners should exercise caution in comparing validity of fall risk assessment tools where the evaluation has been limited to retrospective classifications of methodology. Heterogeneity between studies indicates that the Morse Falls Scale and STRATIFY may still be useful in particular settings, but that widespread adoption of either is unlikely to generate benefits significantly greater than that of nursing staff clinical judgment.

Isolation and characterization of polyunsaturated fatty acid producing Thraustochytrium species : screening of strains and optimization of omega-3 production

An isolation program targeting Thraustochytrids (marine fungoid protists) from 19 different Atlantic Canadian locations was performed. Sixty-eight isolates were screened for biomass, total fatty acid (TFA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) content. Analysis of fatty acid methyl ester results discerned four distinctive clusters based on fatty acid profiles, with biomass ranging from 0.1 to 2.3 g L−1, and lipid, EPA, and DHA contents ranging from 27.1 to 321.14, 2.97 to 21.25, and 5.18 to 83.63 mg g−1 biomass, respectively. ONC-T18, was subsequently chosen for further manipulations. Identified using 18S rRNA gene sequencing techniques as a Thraustochytrium sp., most closely related to Thraustochytrium striatum T91-6, ONC-T18 produced up to 28.0 g L−1 biomass, 81.7% TFA, 31.4% (w/w biomass) DHA, and 4.6 g L−1 DHA under optimal fermentation conditions. Furthermore, this strain was found to produce the carotenoids and xanthophylls astaxanthin, zeaxanthin, canthaxanthin, echinenone, and β-carotene. Given this strain’s impressive productivity when compared to commercial strains, such as Schizochytrium sp. SR21 (which has only 50% TFA), coupled with its ability to grow at economical nitrogen and very low salt concentrations (2 g L−1), ONC-T18 is seen as an ideal candidate for both scale-up and commercialization.

Chemiluminescence as a screening tool for bioactive phytochemicals

The health benefits of antioxidant-rich ‘Mediterranean’ type diets high in grain, olives and red wine are well recognised. Since these foodstuffs consist of a complex matrix of chemical components, to date, the primary challenge lies in prioritising and isolating molecules for a physiologically relevant cell culture assay to assess their human health benefits. Currently, the most common approach requires arduous sample fractionation into smaller ‘crude’ extracts, followed by costly cell culture assays, with the bioactive identified only after a positive response in the cell. The work presented within this poster demonstrates the potential for an acidified potassium permanganate chemiluminescence detector as a much simpler screening tool to identify the best bioactive candidates from a complex sample matrix.

The use of auricular examination for screening heaptic disorders

Researches on auricular acupuncture (AA) have examined mainly its treatment effects. This study aimed to investigate the accuracy and precision of using auricular examination (AE) as a complementary diagnostic tool for screening hepatic disorders. Twenty patients suffering from liver dysfunction and 25 controls aged 18–60 years were recruited from an acute hospital. Participants were examined using three AE methods including visual inspection, electrical skin resistance measurement, and tenderness testing on the liver AA zone of both ears. Significant differences were found in visual inspection and electrical skin resistance on the AA zones between the two groups. Patients suffering from liver dysfunction tended to have at least one abnormality in skin color, appearance, presence of papules, abundance of capillary and desquamation on the ear (Relative Risk—Right ear: RR = 2.9, 95% confidence interval (CI) 1.4, 6.2; Left: RR = 1.8, 95% CI, 1.01, 3.1). The sensitivity for visual inspection was 0.7 for both ears; specificity was 0.76 for the (R) and 0.6 for the (L) ear. The mean difference in electrical skin resistance was 4.3 MΩ (95% CI, 1.7, 6.9) for the (L) ear; 4.5 MΩ (95% CI, 1.5, 7.6) for the (R) ear. Our results suggest that malfunction of the liver appeared to be reflected by the presence of morphological changes on the liver AA zone. Visual inspection and electrical skin resistance on the liver AA zone are potentially sensitive to screen hepatic disorders.

Fractal analysis of bone texture : a screening tool for stress fracture risk?

Background The aim of this study was to identify specific bone characteristics of stress fracture (SF) cases in sportswomen. To date, no tool is able to distinguish individuals who are at risk, limiting preventive measures.

Material and methods We investigated the skeletal system of sportswomen who did sustain SF in the past (n = 19) and compared it with that of female controls (C) with a similar sporting history but without any fracture history (n = 20).

Bone mass and body composition were measured using dual-energy X-ray absorptiometry. Bone micro-architecture was investigated by calcaneal ultrasound and fractal analysis of calcaneus radiographic images. Oestradiol levels were measured by E.I.A, and IGF-1 by R.I.A. Menstrual characteristics, nutrient intake, and training were assessed using questionnaires.

Results The result of the fractal analysis, expressed by the Hmean parameter, was significantly lower in the SF group, reflecting a more complex structure of the trabecular micro-architectural organization (P < 0·005). Body mass index (BMI) at birth was also found to be lower in the SF cases as compared with their C (P < 0·03).

Multivariate analysis revealed that the fractal parameter Hmean, bone mineral content (BMC) at Ward's triangle and the BMI at birth correctly assigned 84·85% of the female athletes into their respective SF or C groups (P = 0·001).

Conclusion These results suggest that the fractal parameter and the BMI at birth may be able to identify female athletes most at risk for this overuse bone injury, as their low indexes might reflect a greater skeletal sensitivity.

Screening for type 2 diabetes and impaired glucose metabolism – the Australian experience

OBJECTIVE--To assess the Australian protocol for identifying undiagnosed type 2 diabetes and impaired glucose metabolism.

RESEARCH DESIGN AND METHODS--The Australian screening protocol recommends a stepped approach to detecting undiagnosed type 2 diabetes based on assessment of risk status, measurement of fasting plasma glucose (FPG) in individuals at risk, and further testing according to FPG. The performance of and variations to this protocol were assessed in a population-based sample of 10,508 Australians.

RESULTS--The protocol had a sensitivity of 79.9%, specificity of 79.9%, and a positive predictive value (PPV) of 13.7% for detecting undiagnosed type 2 diabetes and sensitivity of 51.9% and specificity of 86.7% for detecting impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). To achieve these diagnostic rates, 20.7% of the Australian adult population would require an oral glucose tolerance test (OGTT). Increasing the FPG cut point to 6.1 mmol/l (110 mg/dl) or using Hb[A.sub.1c], instead of FPG to determine the need for an OGTT in people with risk factors reduced sensitivity, increased specificity and PPV, and reduced the proportion requiring an OGTT. However, each of these protocol variations substantially reduced the detection of IGT or IFG.

CONCLUSIONS--The Australian screening protocol identified one new case of diabetes for every 32 people screened, with 4 of 10 people screened requiring FPG measurement and 1 in 5 requiring an OGTT. In addition, 1 in 11 people screened had IGT or IFG. Including Hb[A.sub.1c] measurement substantially reduced both the number requiring an OGTT and the detection of IGT or IFG.

HbA1c as a screening tool for detection of type 2 diabetes: A systematic review

Aim: To assess the validity of glycated haemoglobin A1c (HbA1c) as a screening tool for early detection of Type 2 diabetes.

Methods: Systematic review of primary cross-sectional studies of the accuracy of HbA1c for the detection of Type 2 diabetes using the oral glucose tolerance test as the reference standard and fasting plasma glucose as a comparison.

Results: Nine studies met the inclusion criteria. At certain cut-off points, HbA1c has slightly lower sensitivity than fasting plasma glucose (FPG) in detecting diabetes, but slightly higher specificity. For HbA1c at a Diabetes Control and Complications Trial and UK Prospective Diabetes Study comparable cut-off point of ≥ 6.1%, the sensitivity ranged from 78 to 81% and specificity 79 to 84%. For FPG at a cut-off point of ≥ 6.1 mmol/l, the sensitivity ranged from 48 to 64% and specificity from 94 to 98%. Both HbA1c and FPG have low sensitivity for the detection of impaired glucose tolerance (around 50%).

Conclusions: HbA1c and FPG are equally effective screening tools for the detection of Type 2 diabetes. The HbA1c cut-off point of > 6.1% was the recommended optimum cut-off point for HbA1c in most reviewed studies; however, there is an argument for population-specific cut-off points as optimum cut-offs vary by ethnic group, age, gender and population prevalence of diabetes. Previous studies have demonstrated that HbA1c has less intra-individual variation and better predicts both micro- and macrovascular complications. Although the current cost of HbA1c is higher than FPG, the additional benefits in predicting costly preventable clinical complications may make this a cost-effective choice.

The implementation of chlamydia screening : a cross-sectional study in the South East of England

Background England's National Chlamydia Screening Programme (NCSP) provides opportunistic testing for under 25 year-olds in healthcare and non-healthcare settings. The authors aimed to explore relationships between coverage and positivity in relation to demographic characteristics or setting, in order to inform efficient and sustainable implementation of the NCSP.

Methods The authors analysed mapped NCSP testing data from the South East region of England between April 2006 and March 2007 inclusive to population characteristics. Coverage was estimated by sex, demographic characteristics and service characteristics, and variation in positivity by setting and population group.

Results Coverage in females was lower in the least deprived areas compared with the most deprived areas (OR 0.48; 95% CI 0.45 to 0.50). Testing rates were lower in 20–24-year-olds compared with 15–19-year-olds (OR 0.69; 95% CI 0.67 to 0.72 for females and OR 0.67; 95% CI 0.64 to 0.71 for males), but positivity was higher in older males.

Females were tested most often in healthcare services, which also identified the most positives. The greatest proportions of male tests were in university (27%) and military (19%) settings which only identified a total of 11% and 13% of total male positives respectively. More chlamydia-positive males were identified through healthcare services despite fewer numbers of tests.

Conclusions Testing of males focused on institutional settings where there is a low yield of positives, and limited capacity for expansion. By contrast, the testing of females, especially in urban environments, was mainly through established healthcare services. Future strategies should prioritise increasing male testing in healthcare settings.