Randomized evaluation trial on automation-assisted screening for cervical cancer: results after 777,000 invitations

OBJECTIVES

New cervical screening methods have been developed. They seem to become accepted in routine use without randomized trials, within existing screening programmes. Our aim was to evaluate, in a randomized setting, the performance of automation-assisted cytological screening in routine use compared with conventional Papanicoalou (Pap) screening.

SETTING

This prospective study was based on a 1:2 individually randomized design. Altogether 777,144 women were invited to attend the routine screening programme.

RESULTS

Automation-assisted screening found more Pap class III (LSIL+) findings compared with conventional study arm, relative risk (RR) 1.08 (confidence interval 1.01-1.15). Also, detection rates of verified pre-cancers were more common in automation-assisted arm, RR 1.11 (1.02-1.21).

CONCLUSIONS

Automation-assisted screening performed well compared with conventional screening. The difference was smaller than reported in non-randomized studies. A new technique may assume several years to reach the ultimate quality and can add costs without improving efficacy. Follow-up of prevented cervical cancers is required.

Significant variation in performance does not reflect the effectiveness of the cervical cancer screening programme in Finland

AIM

To characterise the variation in performance indicators of the Finnish cervical screening programme by screening laboratory and to assess whether the performance affects cervical cancer incidence.

METHODS

Cervical cancer screening data from 1999 to 2003 from six well-established laboratories were used to analyse rates for follow-up recommendations, referrals and histologically confirmed dysplastic lesions. Laboratory-specific cervical cancer incidences for 1954-2003 were assessed using the cancer registry files.

RESULTS

Differences in follow-up recommendations were up to 3.1-fold and 2.2-fold in referrals; differences in the rates for CIN1, CIN2 and CIN3+ were up to 4.5-, 4.7-, and 1.5-fold, respectively. Pre-screening incidence rates for cervical cancer varied 1.5-fold by laboratory, with no major differences in the incidence trends since the onset of screening.

CONCLUSION

The performance of a cervical screening programme differs by screening laboratory but does not materially affect the overall programme effectiveness. This leads to variation in cost-effectiveness and probably in avoidable adverse effects. In cervical cancer screening studies, the outcome should be selected as closely as possible to the true measure of programme effectiveness, prevented invasive cervical cancers and subsequent deaths.

A randomised public-health trial on automation-assisted screening for cervical cancer in Finland: performance with 470,000 invitations

Our objective was to evaluate automation-assisted screening, in comparison to the conventional method, in a routine population-based cervical cancer-screening programme. Our study is based on an individually randomised design involving approximately 160,000 invitees and 110,000 attendees every year. From 1999 to 2001, 471,297 women were invited to attend and 330,445 smears were screened (attendance rate 70.1%), of which 220,254 were tested conventionally and 110,191 were tested using the automation-assisted method. Cytologic Papanicolaou group II findings were reported slightly more often (RR = 1.04) in the automation-assisted method than in the conventional screening arm. There were 1,291 cases of histologically confirmed dysplasia or carcinoma (0.4% of the screened), one-third of which were severe dysplasia or a more severe finding (CIN3+). The detection rates of histologically verified findings were similar between the 2 screening arms. In Finland, the screening programme has been effective. As the detection rates, particularly of CIN3+, were similar between the screening arms, we will continue the automation-assisted method in the routine screening programme. Further follow-up for interval cancer incidence is required, however, to measure if the effect of screening is the same between the arms. A similar evaluation design is feasible to any other major or competing modification of the screening test or other element in the programme.

Frequency of daily over-the-counter drug use and potential clinically significant over-the-counter-prescription drug interactions in the Finnish adult population

OBJECTIVE

To explore the frequency of continuous use of over-the-counter (OTC) drugs among the Finnish adult population and the potential for harmful interactions between OTC drugs and prescribed (Rx) drugs.

METHODS

Data were extracted from a 1995-1996 population-based interview survey on health care (n = 10,477, response rate 86%). The drug interaction classification system from the Swedish Drug Compendium FASS 1997 was used to identify OTC drugs likely to have clinically significant interactions with prescription drugs. Logistic regression was used to study factors related to continuous use and risks for interactions.

RESULTS

Seventeen percent of the population had used OTC drugs and 15% had used OTC vitamins during the 2 days prior to the interview. Daily use of OTC drugs and of vitamins was reported by 7% and 9%, respectively. Continuous use of OTC drugs was related to older age, female gender, higher education, poor health status, long-term morbidity, psychosomatic symptoms (fatigue) and use of prescription drugs, but not to poor lifestyle. Four percent of the OTC drug users had taken drug combinations with potential for clinically significant interactions. Interactions were most common for ketoprofen (15% of ketoprofen users), ibuprofen (10%), and acetylsalicylic acid (ASA) (6%). The number of prescription drugs, long-term illness and lower education best explained the risk for interactions.

CONCLUSION

Continuous use and potentially harmful Rx/ OTC drug interactions occur among OTC drug users. Further studies should be done to investigate whether potential combinations will actually lead to clinical problems. The possible interactions of non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics with prescription drugs should especially be taken into account in drug information.

Nationwide survey of comorbidity, use, and costs of all medications in Finnish diabetic individuals

OBJECTIVE

To investigate comorbidity and overall use and costs of medication for all Finnish individuals with diabetes treated with drugs compared with sex- and age-matched control subjects.

RESEARCH DESIGN AND METHODS

According to a cross-sectional population study using national registries, 116,224 individuals purchased antidiabetic medications in Finland in 1995. The same number of nondiabetic individuals matched for sex, age, and area of residence were chosen as control subjects. Age at onset of diabetes was used as a criterion for distinguishing between type 1 and type 2 diabetes. The criterion could be applied in 74% of cases. A total of 16,955 individuals were defined as having type 1 diabetes, and 68,517 were defined as having type 2 diabetes. Comorbidity was determined by linkage with a national register including all individuals entitled to special reimbursement for drug treatment for a range of chronic diseases. Data on use and costs of all medications prescribed were obtained from drug purchase records.

RESULTS

Cardiovascular diseases and uremia were, as expected, the chronic diseases most closely associated with diabetes. Use of almost all kinds of medication was significantly greater in individuals with type 1 and type 2 diabetes than in control subjects. The greatest differences were observed in relation to cardiovascular drugs and antibiotics. Unexpectedly low use of antiasthmatics was observed in individuals with both types of diabetes, low use of neuroleptics was observed in type 1 diabetic individuals, and low use of hormone replacement therapy was observed in women with type 2 diabetes. Total costs of medications for individuals with diabetes were 3.5 times greater than those for nondiabetic control subjects. The higher costs were mostly attributable to insulin therapy for individuals with type 1 diabetes. The higher costs for individuals with type 2 diabetes were related to the cost of medications other than antidiabetic medication. The possible selection bias in omitting diabetic individuals treated with diet only and individuals in whom diabetes type could not be determined must be considered in interpreting the results.

CONCLUSIONS

Greater use by and costs of medications for individuals with diabetes than for nondiabetic individuals is related not only to antidiabetic treatment but also to all other kinds of medications. Although drug treatment and the prevalence of several chronic conditions were overall greater in individuals with diabetes versus other individuals, some exceptions merit further study

Recent trends in the consumption of lipid-lowering drugs in Finland

The consumption of lipid-lowering drugs in Finland and in other Nordic countries increased almost steadily in 1988-1993. The exceptions were the year 1992 in Finland and 1993 in Iceland, when consumption was lower than in the previous year. In both cases the temporary decline in consumption was associated with a reduction in reimbursement for the costs of lipid-lowering drugs. In 1993, the consumption level was 2.7 defined daily doses/1000 inhabitants/day in Finland and ranged from 2.3 to 4.0 in other Nordic countries. According to the Finnish nationwide prescription register, 0.5% of men and 0.6% of women purchased lipid-lowering drugs in the period from January to September, 1994. The rate of use was highest among people of middle age. In the early 1990s, statins took the lead in the consumption of lipid-lowering drugs, accounting for 70% of prescriptions in 1993; the percentages of fibrates, resins, and nicotinic acid derivatives declined in the same period. In 1994 the prevalence of familial hypercholesterolemia (FH) according to strictly predetermined criteria was 0.8 per 1000 among Finns, and the proportion of FH patients among all users of lipid-lowering drugs was 11%. The use of lipid-lowering drugs is not particularly high in Finland and seems to be reasonably targeted.

Multiuse of medicines in Finland

The purpose of this study was to investigate the occurrence of multiuse of prescription drugs and its major determinants among Finnish adults. The data were based on three nationally representative and intercomparable health surveys in 1976, 1978-80, and 1987. The study populations were 16,413 in 1976, 13,138 in 1987, and 7,217 in 1978-80. The simultaneous use of at least five prescription drugs was the main outcome measure. In 1976, 4.7% of the study population, and 6.3% in 1987 were multiusers. Of all users of prescription drugs, the proportion of multiusers was 14% both in 1976 and 1987. In 1987, the elderly comprised 55% of all multiusers, whereas their share in 1976 was 44%. The strongest predictor of the multiuse was, as expected, chronic morbidity. Of the various diagnostic groups, the main determinants were cardiac insufficiency, hypertension, asthma, mental disorders, and coronary heart disease. Even allowing for chronic morbidity, age was significantly associated with multiuse, but sex was not. The number of visits to a primary care physician correlated also independently with the multiuse. These findings indicate that the elderly may in part get prescriptions indiscriminately.

Consumption of analgesics and anti-inflammatory drugs in the nordic countries between 1978-1988

Comparative wholesale statistics from the five Nordic countries show an increase of 15-42% in the total consumption of analgesics and anti-inflammatory drugs (including antirheumatics) in the period 1978-1988. Denmark had the highest total consumption (112 DDD/1000 inhab/day in 1988) and Norway had the lowest (61 DDD/1000 inhab/day). Iceland and Finland, with the highest increases in total consumption (45% and 35%), overtook Norway in the early to mid 1980's. Division of total consumption into subgroups showed that Denmark had the highest consumption of analgesics (90 DDDs) and that Finland and Iceland had the lowest figure. The latter countries, however, had the highest consumption of nonsteroidal anti-inflammatory drugs (NSAID), 35 and 30 DDDs, respectively, in 1988. The increase in NSAID consumption was 57% in Finland and 54% in Iceland, while Denmark had only an 18% increase. The new NSAIDs introduced in the 1970's appear to have increased the overall consumption of pain relievers in the Nordic countries, especially in Finland and Iceland.

Why has the utilization of antiasthmatics increased in Finland?

The sales of antiasthmatics have increased rapidly in the Nordic countries during the 1980s. The causes for this growth in Finland were studied. Four nationwide population surveys show that the prevalence of self-reported asthma has risen, a larger proportion of asthmatic patients are under medication, the number of antiasthmatics per patient has increased, and the dosage recommendations of inhalation glucocorticoids and beta-agonists have grown. The average cost of medical treatment of an asthmatic patient was FIM 1848 (approximately U.S. $510.00) in 1990. The highest average expenses in the 21 districts studied were FIM 2171 and the lowest FIM 1535. To identify the consequences of these variations, the frequency of symptomatic periods as well as the quality of life of the asthmatic patients should be studied.

The use of prescription drugs among elderly Finnish men

The extent and factors that influence drug use were studied in two rural cohorts of Finnish men. The men aged between 65 and 84 years belonged to the Finnish study population of the 25-year follow-up of the 'Seven Countries Study'. Of the original 1,711 men in 1959, 766 were still alive in 1984. The participation rate in the follow-up was 93%. Of the non-institutionalized men (n = 675), 66% had used prescription drugs, and 36% non-prescription drugs, while 25% had not used any drugs during the week preceding the study. The number of drugs in use was highly dependent on the time period covered in the assessment. The number of prescribed drugs was associated with the number of symptoms experienced (P less than 0.001) and the use of OTC-drugs (P less than 0.05). Drug use was not associated with socio-economic variables. Standardized measurement methods are needed in the assessment of drug use to obtain more reliable and comparable results in different populations.

Production of basement membrane laminin and type IV collagen by tumors of striated muscle: an immunohistochemical study of rhabdomyosarcomas of different histologic types and a benign vaginal rhabdomyoma

Immunohistochemical methods were used to demonstrate the distribution of basement membrane laminin and type IV collagen in eight tumors derived from striated muscle (three botryoid, two alveolar, and two adult-type rhabdomyosarcomas; one benign vaginal rhabdomyoma). All of the tumors produced significant amounts of both basement membrane components. Stainings clearly revealed the alveolar nature of the rhabdomyosarcomas, with the alveolar spaces surrounded by distinct basement membranes. Different stages of cellular development were identified in the botryoid sarcomas, with the most immature cells of the cambium layer devoid of external basement membrane around the tumor cells, although the stroma contained finely dispersed basement membrane material and some cells contained intracytoplasmic laminin or type IV collagen, indicative of the synthesis of these proteins. The more mature cells, which had abundant granular cytoplasm, were enveloped by distinct basement membranes and seemed to have coalesced, forming structures resembling myotubes. The adult-type rhabdomyosarcomas were composed of large pleomorphic cells that were surrounded by basement membranes, either individually or in small groups. Some giant cells contained intracytoplasmic laminin. The vaginal rhabdomyoma was composed of round rhabdoblastic cells or elongated strap cells with cross-striations. Cells of both of these types were surrounded by thin but distinct basement membranes. The results suggest that demonstration of basement membranes would be helpful in the diagnosis of tumors derived from striated muscle. The findings concerning different stages of maturation of tumor cells are in accordance with previous in vitro observations of myoblastic cells.

Pirenzepine in the treatment of reflux oesophagitis. A placebo-controlled, double-blind study

The efficacy of 50 mg pirenzepine twice daily in the treatment of reflux oesophagitis was compared with that of placebo in 47 patients over a period of 12 weeks. The 23 patients receiving pirenzepine experienced decreases in symptoms after 4 weeks (p less than 0.001) and 12 weeks (p less than 0.02) of treatment significantly greater than those in the 24 patients receiving placebo. The decreases in symptoms were associated with significantly less use of antacids by the pirenzepine group (p less than 0.01) during the first 4 weeks. Endoscopically, oesophagitis was healed or improved in 54.5% of patients receiving pirenzepine and in 18.2% of patients receiving placebo (p less than 0.05) after 4 weeks of treatment. After 12 weeks of treatment healing or improvement was seen in 55.0% and 35.0% of patients, respectively (difference not significant). Histologic improvement did not differ significantly between the groups. Our results suggest that pirenzepine is useful in the management of reflux oesophagitis.

Ranitidine, 150 mg three times a day, in the treatment of reflux oesophagitis. A placebo-controlled, double-blind study

The effect of ranitidine, 150 mg three times a day, in the treatment of reflux oesophagitis was studied. A double-blind method was used, and 41 patients with endoscopically verified symptomatic oesophagitis were randomly allocated to ranitidine or placebo. In addition, antacid tablets could be taken as needed. Eighteen patients in both the ranitidine and the placebo groups completed the study. Endoscopically, the healing rate was significantly higher in the ranitidine group after both 6 weeks' (p less than 0.05) and 12 weeks' (p less than 0.01) treatment. The proportion of patients whose oesophagitis healed or improved was also higher in the ranitidine group (p less than 0.05). The patients receiving ranitidine used significantly (p less than 0.002) less antacids than the controls, suggesting a favourable effect of ranitidine on the symptoms of oesophagitis. The histological study did not show significant differences between the ranitidine and the placebo groups. No serious side effects were noted. Ranitidine in a dose of 150 mg three times a day is effective and safe in the treatment of reflux oesophagitis.

Occurrence of cysteine proteinase inhibitors in cells of the monocytic-histiocytic system. An immunohistochemical investigation

Human tissues are known to contain two low molecular weight (MW about 12,000) cysteine proteinase inhibitors, i.e. an acid inhibitor (ACPI) with pI 4.7-5.0 and a neutral inhibitor (NCPI) with pI 6.0-6.5. ACPI is abundant in cornifying epithelial tissues and in the dendritic reticulum cells of germinal centres of the lymph nodes. NCPI is abundant in lymphatic tissue and is known to be synthesized and released by mononuclear phagocytes. In this report NCPI was localized immunohistochemically in the epitheloid cells of most sarcoidotic lymph nodes, in lymph node macrophages after lymphangiography and in alveolar macrophages, while no ACPI could be demonstrated in the same cells by similar methods. These inhibitors were not demonstrable in lymph node sinus histiocytosis. Peripheral blood monocytes did not exhibit any NCPI immunoreactivity. In occasional blood monocytes anti-ACPI serum gave a weak reaction, the specificity of which is questionable. These data suggest that studies on cysteine proteinase inhibitors reveal basic differences in the various histiomonocytic cells and possibly differences in their functional stages.

Demonstration of immunoreactive acid cysteine-proteinase inhibitor in reticulum cells of lymph node germinal centres

Seven human lymph nodes showing different types of reactive change, were examined for the presence of acid cysteine-proteinase inhibitor (ACPI) by the peroxidase-antiperoxidase method. A clear positive reaction was found in the germinal centres. The staining pattern indicated immunoreactivity of the dendritic reticulum cells, but the possibility that other cells, particularly histiocytic reticulum cells, may also react with antiserum raised against ACPI cannot be excluded.