Index of suspicion: feeling not believing

Throughout the U.S., state laws require professionals who work with children to report cases of suspected child abuse to child protection services. Both practically and conceptually, however, significant problems arise from a lack of clarity regarding the threshold that has been set for reporting. Specifically, there is no consensus as to what constitutes reasonable suspicion, and little direction for how mandated reporters should gauge their legal and professional responsibilities when they harbor suspicion. In this paper we outline the context of the problem, discuss the nature and scope of its conceptual underpinnings, and offer recommendations for moving towards a concrete, practical solution.

Legal barriers to implementing recommendations for universal, routine prenatal HIV testing

Administraation of antiretroviral therapy to women during pregnancy, labor and delivery, and to infants postnatally can dramatidy reduce mother-to- child HIV transmission (MTCT). However, pregnant women need to know that they are HIV-infected to take advantage of antiretroviral therapy, and many women do not know their HIV status. One-half of HIV-infected infants in the United States were bornto women who had not been tested for HIV or for whom the time of testing was not known. Although fewer than 400infants are infected perinatally in the United States each year, that number could be reduced even further through policies aimed at HIV testing during pregnancy.

The reasons toadopt such a policy are strong: the pathophysiology of perinatal transmission is clear, prophylaxis is effective and safe, and the intended beneficiaries of the intervention - babies - cannot protect themselves.

[Immunochemical screening: manipulation, handling and interpretation errors, exemplified by benzodiazepines]

The article describes problems related to immunochemical screening-tests with special regard to benzodiazepines, which are commonly used for therapeutic purposes. Focal points are adulteration, manipulation and handling of samples, the selection of cut-off-values, specificity and cross-reactivity, influence of biotransformation and frequently observed pitfalls in the interpretation of the analytical results.

HPV: from the cervical smear to the research bench to the court room

The human papillomavirus (HPV) is one of the most common sexually transmitted viruses in our culture, yet there is a high level of misunderstanding about its detection and usual biological course. The Pap smear, one of the most common specimens in a cytology laboratory, is one of the easiest ways to detect HPV infection. However, this is a screening test and comes with many diagnostic and laboratory management problems. The Pap smear accounts for one of the highest themes for malpractice suits, putting a great need on laboratories to maintain superb quality assurance measures. Much effort is underway toward better prevention and treatment of this virus. Decades from now, this now almost ubiquitous virus may prove to be a rare infection.

Atypical squamous cells of undetermined significance: audit and the impact of potential litigation. Retrospective review of 682 cases

For quality assurance purposes, the frequency of 'abnormal' cytological diagnoses of the non-systematic National Cervical Cancer Screening Programme (NCCSP) was evaluated. In 1999, an unexpected high number of Class (Cl) III cases (i.e. atypical squamous cells of undetermined significance) was reported. The cytological and histological results were reviewed in order to detect a possible cause for this threefold increase. The abnormal Papanicolaou (PAP) smears examined by conventional methods from 1 January 1990 to 31 December 2002 were analysed. The smears of 682 cases diagnosed in 1999 with a Cl III category were reviewed in 2000 and correlated with the available histological diagnoses provided by the Central Department of Pathology. Of the 682 Cl III cases, 176 cases (26.1%) had no follow-up, 314 cases (46.0%) had repeat cytology and 192 cases (28.2%) an histological correlate corresponding to 90 (46.9%) benign lesions, 78 (40.6%) squamous intraepithelial lesions, two (1%) invasive cervical cancers (one squamous and one glandular). Twenty-two Cl III cases (11.5%) were histologically within normal limits. Retrospective smear review confirmed 330 Cl III diagnoses (48.3%), 127 cases (18.6%) were recategorized as Cl IIIG (i.e. atypical glandular cells of undetermined significance), 22 cases (3.2%) as Cl IIID (i.e. mild to moderate dysplasia) and six cases (0.9%) as Cl IVa (i.e. severe dysplasia and/or carcinoma in situ). A total of 197 original Cl III cases had to be reclassified in the Cl II category (28.9%), only two cases showing mild and moderate dysplasia on histology. Thus, 195 cases (28.6%) comprised cytological overdiagnoses. The Cl III category being, by definition, a delicate and often subjective diagnosis, all external influences such as pressure of litigation should be avoided to reduce cytological overdiagnoses as a result of an unnecessary 'fear-factor'.

Preschool Vision Screening in Primary Care after a Legislative Mandate for Diagnostic Eye Examinations

BACKGROUND

Kentucky legislation now requires that children entering public school receive a diagnostic eye examination.

METHODS

Mail survey of randomly selected office-based primary care pediatricians (PDs, n = 221) and family physicians (FPs, n = 207) in Kentucky to assess the impact of the mandated eye examination.

RESULTS

The response rate was 71% PDs and 51% FPs. Most offer preschool vision screening (PD 86%; FP 79%; P = 0.16), but many report they will be less likely to offer it in the future because of the mandated diagnostic eye examination (PD 61%; FP 50%; P = 0.09). Perceived barriers to the diagnostic eye examination include lack of parental knowledge about the requirement, belief by parents that they will need to pay, difficulty in getting an appointment, and lack of endorsement by primary care physicians.

CONCLUSION

Most primary care physicians in Kentucky offer preschool vision screening, but many now are likely to reduce their screening effort. Until more data are available regarding the impact of the required eye examination, primary care providers should not change their screening practices.

Newborn screening for congenital hypothyroidism: the Texas experience

Routine screening of asymptomatic newborns allows detection and treatment of infants affected by congenital hypothyroidism. Implemented by legislation enacted in 1980, the Texas Newborn Screening Program detects 120-150 cases of primary hypothyroidism a year. The responsibility and, ultimately, the success of hypothyroid screening in the newborn period largely depends upon the medical provider, necessitating a clear understanding of the screening process, appropriate diagnostic tests for confirmation, and timely treatment.

Should the Centers for Disease Control and Prevention's childhood lead poisoning intervention level be lowered?

The US Centers for Disease Control and Prevention (CDC) in 1991 chose 10 micro g/dL as an initial screening level for lead in children's blood. Current data on health risks and intervention options do not support generally lowering that level, but federal lead poisoning prevention efforts can be improved by revising the follow-up testing schedule for infants aged 1 year or less with blood lead levels of 5 micro g/dL or higher; universal education about lead exposure risks; universal administration of improved, locally validated risk-screening questionnaires; enhanced compliance with targeted screening recommendations and federal health program requirements; and development by regulatory agencies of primary prevention criteria that do not use the CDC's intervention level as a target "safe" lead exposure.

An analysis of the proposal for population based screening for hereditary hemochromatosis in Massachusetts

The Massachusetts Senate is considering a bill which would require a screening test for iron overload diseases when such a test is medically necessary. The legislation is also authorized to establish, promote, and administer a statewide early detection program for the detection of hereditary hemochromatosis. Despite the challenges to a successful screening program which have been documented in the medical literature and the potential for genetic discrimination, the public health benefits justify this legislation as long as the necessary modifications and precautions are established.

"Do-it-yourself" dementia testing: issues regarding an Alzheimer's home screening test

The Early Alert Alzheimer's Home Screening Test (AHST) is a variant of the Smell Identification Test (SIT) and the Cross-Cultural Smell Identification Test (CC-SIT), and recently became available for purchase by the general public. The validity and the practical utility of routine screening for individuals with asymptomatic cognitive impairment has not been established. There are considerable specific methodological concerns regarding the use of the AHST including the association of olfactory impairment with (a) age in the absence of cognitive impairment, (b) numerous acute and/or chronic medical conditions, and (c) lifestyle habits and social and/or demographic variables. General public misunderstanding of the difference between a screening and a diagnostic test, primary care physicians' frequent confusion about follow-up mechanisms for newly diagnosed patients with dementia, the possible lack of perceived counseling options for those self-diagnosed, and abuse of test findings create distinct possibilities for misuse of this test. The marketing of the AHST and its general use without appropriate public health educational safeguards is inappropriate and may be unethical.

[Procedures for diagnosis of occupational diseases]

There are many diseases that are of occupational origin, but they are often ignored. To prove an occupational factor requires measures of prevention and repair, and it should therefore be searched for systematically. Screening relies on the fact that the treating physician and company doctor who, in the case of a suspected occupational disease, are able to orient the patient in his/her administrative steps. All physicians are therefore concerned by the procedures for the declaration of an occupational disease. The different possibilities for the recognition of such diseases, not only for agricultural employees but also in the private and public sectors, must therefore be known.

Genetic counseling gone awry: miscommunication between prenatal genetic service providers and Mexican-origin clients

Amniocentesis, and other prenatal genetic tests, have become a well-established feature of modern prenatal care. But these tests place a considerable decision-making burden on the expectant mothers to whom they are offered: the genetic issues involved are complex and the appropriate course of action sometimes ambiguous. Genetic counseling aims to help pregnant clients make an informed decision about prenatal genetic tests. But the clientele of prenatal genetic counseling has changed significantly in the years since the practice was established. Clients were once a self-selected group of women well-informed about the genetic services being offered. In contrast, clients now include an increasing number of women, particularly ethnic minority women, who had no prior knowledge of genetic testing, but were found to be at risk of birth defects after routine screening. Little is known about how well genetic counseling serves the needs of this new clientele. This paper investigates the possibility that miscommunication between genetic counselors and their Mexican-origin clients contributed to the higher rates of amniocentesis refusal. We interviewed 156 pregnant Mexican-origin women who screened positive on a blood test routinely offered in California to detect birth defects. We also observed the genetics consultations of a sub-sample of the women. We identified five common sources of miscommunication: (1) Medical jargon; (2) The non-directive nature of counseling; (3) The inhibitions of counselors stemming from misplaced cultural sensitivity; (4) Problems of translation; (5) Problems of trust. We found that many Mexican-origin women are skeptical of genetic testing and do not easily surrender their own lay theories about the causes of their condition. In order to dislodge the misunderstandings of their clients, counselors must give clients the opportunity to air their own views, however contrary to those of genetics professionals these may be.

A disease-specific Medicaid expansion for women. The Breast and Cervical Cancer Prevention and Treatment Act of 2000

The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) allows states the option of extending Medicaid eligibility to women diagnosed with breast or cervical cancer through a large federal screening program that does not include resources for treatment. Using qualitative data from interviews with 22 key informants and other sources, we present an analysis of the history and passage of the BCCPTA as a policy response to a perceived "treatment gap" in a national screening program. The results suggest that organizational policy entrepreneurs-primarily the National Breast Cancer Coalition-constructed an effective problem definition (that the government screening program was "unethical" and "broken") with a viable policy solution (an optional disease-specific Medicaid expansion), and pushed this proposal through a policy window opened by a budget surplus and an election year in which women's health issues had broad bipartisan appeal.

Mandatory reporting of HIV infection and opt-out prenatal screening for HIV infection: effect on testing rates

BACKGROUND

Mandatory reporting of HIV infection to public health authorities, although now common, may deter people from undergoing testing. We examined HIV testing frequency in Alberta before and after mandatory reporting was implemented. We also examined the effect on testing rates among pregnant women when Alberta adopted an opt-out approach to prenatal HIV screening.

METHODS

Using data from the Provincial Laboratory for Public Health, we determined the number of HIV tests done between Jan. 1, 1993, and Dec. 31, 2000, for males and females in Alberta. We used data from the Canadian Blood Services laboratories to obtain the number of tests conducted as part of the opt-out prenatal HIV testing program. Reporting of HIV infection became mandatory on May 1, 1998, and opt-out prenatal HIV testing was introduced on Sept. 1, 1998.

RESULTS

Among males, the average annual percent increase in the number of HIV tests was 4.0% for the period before mandatory testing, as compared with 4.3% for the period after mandatory reporting was implemented; the difference in yearly trend was significant (p < 0.001). Among females, the average annual percent increase in the number of HIV tests was 9.2% for the period before mandatory reporting. In the month immediately following the adoption of opt-out prenatal HIV testing, the rate increased by 28%. Between 1999 and 2000, the average annual percent increase in the number of HIV tests among females was 1.4%.

INTERPRETATION

The introduction of mandatory reporting of HIV infection did not appear to have a deterrent effect on rates of HIV testing. The implementation of an opt-out prenatal HIV testing policy resulted in a dramatic increase in the number of females being tested for HIV infection.

Evaluation of the concomitant use of two different EIA tests for HIV screening in blood banks

OBJECTIVE

In 1998, the Brazilian Ministry of Health made it mandatory for all blood banks in the country to screen donated blood for human immunodeficiency virus (HIV) concomitantly using two different enzyme immunoassay (EIA) tests. Concerned with the best use of available resources, our objective with this study was to evaluate the usefulness of conducting two EIA screening tests instead of just one.

METHODS

We analyzed data from 1999 through 2001 obtained by testing 698 191 units of donated blood using two EIA HIV screening tests concomitantly at the Pro-Blood Foundation/Blood Center of São Paulo (Fundação Pró-Sangue/Hemocentro de São Paulo), which is a major blood center in the city of São Paulo, Brazil. All samples reactive in at least one of the two EIA tests were submitted for confirmation by a Western blot (WB) test, and the persons who had donated those samples were also asked to return and provide a follow-up sample.

RESULTS

Out of the 698 191 blood units that were donated, 2 718 of them (0.4%) had to be discarded because they were reactive to at least one of the EIA tests. There were two WB-positive donation samples that were reactive in only one HIV EIA screening test. On their follow-up samples, both donors tested WB-negative. These cases were considered false positive results at screening. Of the 2 718 donors who were asked to return and provide a follow-up sample, 1 576 of them (58%) did so. From these 1 576 persons, we found that there were two individuals who had been reactive to only one of the two EIA screening tests and who had also been negative on the WB at screening but who were fully seroconverted on the follow-up sample. We thus estimated that, in comparison to the use of a single EIA screening test, the use of two EIA screening tests would detect only one extra sample out of 410 700 units of blood.

CONCLUSIONS

Our data do not support the use of two different, concomitant EIA screening tests for HIV. The great majority of HIV-positive donors have already seroconverted and will be detected using only a single EIA screening test. Only persons who are going through the process of seroconversion may be missed by using a single EIA test and detected using two EIAs for screening. To screen out these individuals and decrease the residual risk of HIV transmission from the blood donated in our center, the use of other techniques, such as nucleic acid testing (NAT) or a p24 antigen assay, would be more effective.

[Legal liability of the radiologist in missed breast cancer diagnosis]

There have been few lawsuits alleging missed breast cancer diagnosis in Belgium so far. However, since the introduction of the Flemish organised breast cancer screening program in June 2001, one might expect an increase in the years to come. In the present paper, we focus on risk management pointers that minimize the risk of incurring a malpractice lawsuit.

Finding a way through the hospital door: the role of EMTALA in public health emergencies

This article examines the Emergency Medical Treatment and Labor Act (EMTALA) in a public health emergency context. Congress enacted EMTALA in 1986 to prohibit the practice of “patient clumping,” which involved hospitals’ refusal to undertake emergency screening and stabilization services for individual patients who sought emergency room care, typically because of insurance status, inability to pay, or other grounds unrelated to the patient’s need for the services or the hospital’s ability to provide them. But in fact EMTALA, whose conceptual roots can be found in the Hospital Survey and Construction Act of 1946 (Hill Burton) as well as an evolution in both the common law and state statutes related to hospital licensure, can be viewed as having a far broader purpose than protection of individuals, and indeed, one that is related to the protection of communities and the public health.

[Cancer screening: medico-legal aspects]

The cancer screening programmes need a particular considerations for their medico-legal implications: above all in order to the information toward the persons recruited, those must be aware about their diagnostic limits and about the ineluctable recurrence of false positive and false negative results.

[Obstetrical ultrasonography]

BACKGROUND

As with all new diagnostic options in medicine, great hope was placed in the introduction of high-resolution prenatal sonography. Progress tends to induce higher expectations. Patients and doctors alike may initially overestimate the possibilities of medical advances.

QUESTION

The question at hand is whether we can validate a positive influence of prenatal ultrasound on the fetal and/or maternal pregnancy outcome, and how a sonographic routine screening should be structured.

MATERIAL AND METHODS

This is an attempt to survey the heterogeneous pool of internationally published data with regard to these critical questions.

RESULTS AND CONCLUSION

Different studies lead to a positive conclusion on the benefits of ultrasound monitoring in pregnant women. Ultrasound screening has a positive effect on medical as well as economic issues. Nevertheless litigation concerning prenatal diagnosis remains a growing problem.

Transfusion transmission of HCV infection before anti-HCV testing of blood donations in England: results of the national HCV lookback program

BACKGROUND

An HCV lookback program started in England in 1995.

STUDY DESIGN AND METHODS

Data from all English blood centers were collated to describe the outcomes of the HCV lookback program in England and to create a retrospective cohort for study. Numbers of recipients identified, numbers that were tested, and numbers that were found to be HCV infected were summarized. The data set created was used to describe the outcomes of the lookback and the HCV infections detected.

RESULTS

A total of 4424 recipients of 9222 blood components made before donation testing for anti-HCV from the donations of 1286 donors found, on subsequent testing, to be anti-HCV positive or indeterminate were identified. Of these, 1351 blood recipients were reported as having been traced for testing. Fifty percent of tested recipients were found to be HCV infected. Factors positively associated with HCV infection in tested recipients were more recent year of transfusion and PCR positivity of the donor at the time of their testing.

CONCLUSIONS

The majority of components entering lookback did not result in a tested recipient. However, this lookback has identified a large group of HCV-infected individuals. Follow-up of this group for disease progression will inform the natural history of HCV infection.

Probability of receiving testing in a national lookback program: the English HCV experience

BACKGROUND

The HCV lookback program was designed to trace and offer testing to recipients who received transfusion of blood components from donors subsequently found to be anti-HCV positive. Only approximately 20 percent of transfusable components entering lookback did result in a recipient obtaining testing through this program.

STUDY DESIGN AND METHODS

Data from English blood centers were collated to describe the outcomes of the HCV lookback program. The data were used to assess factors affecting the likelihood that recipients of lookback components received testing by the program.

RESULTS

In total, 4424 recipients of 6687 blood components that had been issued for transfusion were identified. The lookback resulted in a tested recipient for 1067 components. Factors positively associated with receiving testing in identified recipients were younger age at transfusion, more recent year of transfusion, certain component types, and transfusion under the care of certain medical specialties; these effects were largely explained by the association of these factors with survival after transfusion.

CONCLUSIONS

Not accepting testing through this program was largely due to death before the lookback and partly due to inability to access information from records and to decisions that testing was not in recipients' best interests. The probability of obtaining testing through this lookback was associated with several factors that could be used to focus the efforts of similar lookbacks in the future.