Screening: part 19 of a series on evaluation of scientific publications

[A comprehensive screening for hepatitis B and C as an effective means of cancer prevention and as a prerequisite for elimination of chronic viral hepatitis - Data and comments on a discussion]

Since October 2021 in Germany all people with a statutory health insurance aged 35 and older have the right to be tested once for hepatitis B and C in a general preventative examination, regardless of specific risk-factors. This is a milestone on the way of eliminating these infections and also a great contribution to cancer prevention.In the USA the Centers of Disease Control and Prevention in April 2020 recommended a one-time screening for all adults aged 18 and older in addition to testing people with known risk-factors, because a significant part of the affected population cannot be identified with risk-based screening. Corresponding CDC-Recommendations for HBV are currently elaborated. According to available Data this screening strategy combined with a vaccination for HBV is necessary in Germany too to reach the agreed elimination goals till the year of 2030. Furthermore, an offer of such a testing for all adults can be regarded as ethically imperative to prevent as many life-threatening consequences or deaths as possible by effective therapies.

Gestational diabetes in Germany: Development of screening participation and prevalence

Gestational diabetes mellitus (GDM) is an important risk factor for pregnancy complications. Since 2012, the Federal Joint Committee's maternity directive recommends a two-step screening for GDM with a pre-test and subsequent diagnostic test if the pre-test is positive. This study analyses the implementation and development over time of GDM screening participation and prevalence in Germany. The data basis is the external inpatient obstetrics quality assurance documentation, which covers all births in hospital. Women with diabetes before pregnancy were excluded. The study defined women as GDM cases if the condition was documented in maternity records or if the ICD-10 diagnosis O24.4 was coded for inpatients at discharge and figures were determined for the years 2013 to 2018. As the documentation of screening tests has only been included in the data set since 2016, screening participation for the years 2016 to 2018 were estimated and evaluated based on the pre-test and/or diagnostic tests documented in maternity records. In 2018, the majority of all women who gave birth in hospitals had had a pre-test conducted (65.0%) or a pre-test and diagnostic test (18.2%) in line with the two-step procedure. A further 6.7% received a diagnostic test alone. GDM screening participation increased over time from 83.4% in 2016 to 89.9% in 2018. The prevalence of a documented GDM increased from 4.6% to 6.8% between 2013 and 2018. In 2018, this equates to 51,318 women with GDM. Reliably assessing the extent and causes of this development will require continuous analyses of screening implementation, documentation and changes in maternal risk factors.

To zoom or not to zoom - the training of communicative competencies in times of Covid 19 at Witten/Herdecke University illustrated by the example of "sharing information"

Since October 2018, a longitudinal communication curriculum for medical students has been implemented at Witten/Herdecke University. In the summer semester 2020, the concept for the 4th preclinical semester included a practical training on "sharing information", which consisted of three two-hour face-to-face sessions with simulated patients (SP). Due to the Covid 19 pandemic, teaching was changed to an inverted classroom concept combining asynchronous and synchronous teaching. The students worked at the beginning of the semester on an e-learning module of the learning platform docCom.deutsch on the topic "sharing information" using reflection and processing tasks. In two digital sessions, the students then were able to practice discharge interviews and discussions about risk communication illustrated by the example of screening methods for cancer prevention. In the first zoom session, students practiced in role-plays among themselves. In the second zoom session, they practiced with SP. The evaluation results revealed that 76% of the responding students considered working with the e-learning module as a good preparation for the interviews. According to the evaluation results, satisfaction with the Zoom meeting including SP contact was slightly higher than those with role-plays among themselves. Although the group atmosphere was rated by all responding students as conducive to learning, almost half of them confirmed that using Zoom significantly impaired the atmosphere (47%). In retrospect, the conversion of the communication training to a digital format worked better than expected from both the perspective of teachers and students. The students explicitly appreciated working with SP. From the teachers' perspective, some specific aspects of successful communication were difficult to reflect on, e.g. non-verbal communication. The use of e-learning as a preparation for practical exercises has proven successful and will be continued in the future.

The Determination of the Plaque Burden on the Carotid Artery With Ultrasound Significantly Improves the Risk Prediction in Middle-Aged Subjects Compared to PROCAM: An Outcome Study

Background

There are only few data about the predictive value of atherosclerosis imaging beyond traditional risk calculators in younger subjects.

Methods

We assessed cardiovascular risk prediction with the PROCAM (the Prospective Cardiovascular Munster Study) risk equation and with carotid plaque imaging (determination of total plaque area (TPA) and the maximum plaque thickness with ultrasound) in subjects without known cardiovascular diseases. The follow-up was generated during follow-up examinations as part of preventive medical examinations or by telephone calls.

Results

In 2,508 subjects aged 35 - 64 years (50 ± 8 years, 34% women), 132 (5.3%) cardiovascular events occurred (42 myocardial infarction, 17 bypass surgery, 31 stent implantation, 42 coronary artery disease defined by invasive angiography) during a mean follow-up period of 5.4 (1 - 12) years. TPA in combination with the maximum plaque thickness (type III - IV b plaques ) tended to be superior compared to TPA, and both plaque imaging methods were superior to PROCAM: area under the curve (AUC) 0.9 (95% confidence interval (CI): 0.91 - 0.89) vs. 0.89 (95% CI: 0.90 - 0.88), P = 0.2 vs. 0.82 (95% CI: 0.84 - 0.81), P = 0.001; positive predictive value (PPV) 27% (95% CI: 0.31 - 0.22) vs. 19% (95% CI: 0.22 - 0.16) vs.19% (95% CI: 0.27 - 0.13).

Conclusions

Amount of carotid plaque assessed by carotid plaque imaging significantly improves cardiovascular risk prediction beyond the PROCAM risk equation.

Epidemiological Measures in the Context of the COVID-19 Pandemic

BACKGROUND

The various epidemiological indicators used to communicate the impact of COVID-19 have different strengths and limitations.

METHODS

We conducted a selective literature review to identify the indicators used and to derive appropriate definitions. We calculated crude and age-adjusted indicators for selected countries.

RESULTS

The proportion of deaths (case fatality proportion [CFP]; number of deaths/ total number of cases) is commonly used to estimate the severity of a disease. If the CFP is used for purposes of comparison, the existence of heterogeneity in the detection and registration of cases and deaths has to be taken into account. In the early phase of an epidemic, when case numbers rise rapidly, the CFP suffers from bias. For these reasons, variants have been proposed: the "confirmed CFP" (number of deaths/total number of confirmed cases), and the "delay-adjusted CFP," which considers the delay between infection with the disease and death from the disease. The indicator mortality (number of deaths/total population) has at first sight the advantage of being based on a defined denominator, the total population. During the outbreak of a disease, however, the cumulative deaths rise while the total population remains stable. The phase of the epidemic therefore has to be considered when using this indicator. In this context, R0 and R(t) are important indicators. R0 estimates the maximum rate of spread of a disease in a population, while R(t) describes the dynamics of the epidemic at a given time. Age-adjusted analysis of the CFP shows that the differences between countries decrease but do not dis - appear completely. If the test strategies depend on age or symptom severity, however, the bias cannot be entirely eliminated.

CONCLUSION

Various indicators of the impact of the COVID-19 epidemic at population level are used in daily communication. Considering the relevance of the pandemic and the importance of relevant communications, however, the strengths and the limitations of each parameter must be considered carefully.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[Principles and fields of application of screening procedures]

This article explains some important concepts of screening and early detection. It also discusses under which circumstances screening is useful, who can profit from screening and which persons may be at risk from screening procedures. Before the introduction of a screening program, empirical studies on the effectiveness are necessary to evaluate whether a screening program could be successful.

Methodological issues for determining intervals of subsequent cancer screening

The gap between nationwide recommendations of cancer screening and the related evidences obtained from Korean adults should be filled. Estimation of the mean sojourn time (MST) in a specific cancer is important to determine the intervals of subsequent screening. This author arranged the methods for calculating MST into 5 categories based on the parameters used. Under the legal barrier for protection of individual privacy and confidentiality in a Korean academic situation, the methods involving the use of transition rates or prevalence/incidence ratio would be applicable among these methods.

Cervical Cancer Screening: Defining the Need for Research

With the development of a National Cancer Plan published in 2012, Germany has followed the recommendations of the WHO and the EU. The first area of action listed in Germany's National Cancer Plan is improving the early detection of cancer. Both citizens and medical specialists are encouraged to take responsibility themselves and contribute to the efforts being made to meet the challenge of cancer. Screening for cervical cancer has long been an integral part of the German Directive for the Early Detection of Cancer and now - following the recommendations given in the European Guideline - an organised screening approach shall be developed to maximise the benefits and minimise the risks through a partial reorganisation of existing structures. Before this can be rolled out nationwide, it will be necessary to check the feasibility and suitability of new contents and organisational structures. The Federal Joint Committee which is largely responsible for the process according to the draft law on the implementation of the National Cancer Plan has emphasised the importance of evidence-based medicine and of collaboration between the autonomous governing bodies within the healthcare system to obtain viable results. For medical specialists, the follow-on question is which areas will need more research in future. New process steps need to be developed and verified to see whether they offer evidence which will support defined approaches or whether such evidence needs to be newly compiled, e.g. by testing invitation procedures for screening in trial schemes. The experience gained during the implementation of the existing directive on early detection of cancer should be integrated into the new process. Research initiated by specialists could encourage the development of a new version of the Directive for the Early Detection of Cancer suitable for the Germany's healthcare system.