Background: National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent. Purpose: To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions. Data Sources: MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009. Study Selection: Two reviewers independently selected studies that addressed the study questions and met eligibility criteria. Data Extraction: Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process. Data Synthesis: Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse. Limitations: Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain. Conclusion: Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed. Primary Funding Source: Agency for Healthcare Research and Quality.
 
The full text may be available from PubMed

It is difficult to identify the successful component(s) related to changes in metabolic syndrome (MetS) from lifestyle interventions: the weight loss, the behavior change, or the combination. The purpose of this study is to determine the effects of a weight-stable randomized controlled trial of low-fat diet and exercise, alone and in combination, on MetS. Men (n = 179) and postmenopausal women (n = 149) with elevated low-density lipoprotein cholesterol (LDL-C) and low high-density lipoprotein cholesterol (HDL-C) were randomized into a 1-year, weight-stable trial with four treatment groups: control (C), diet (D), exercise (E), or diet plus exercise (D+E). MetS was defined using a continuous score. Changes in MetS score (DeltaMetS) were compared between groups using analysis of covariance, stratified by gender and using two models, with and without baseline and change in percent body fat (DeltaBF) as a covariate. In men, DeltaMetS was higher for D vs. C (P = 0.04), D+E vs. C (P = 0.0002), and D+E vs. E (P = 0.02). For women, DeltaMetS was greater for D vs. C (P = 0.045), E vs. C (P = 0.02), and D+E vs. C (P = 0.004). After adjusting for DeltaBF, all differences between groups were attenuated and no longer significant. DeltaMetS were associated with DeltaBF for both men (P < 0.0001) and women (P = 0.004). After adjustment for DeltaBF, low-fat diet alone and in combination with exercise had no effect on MetS. The key component for MetS from low-fat diet and/or increased physical activity appears to be body fat loss.
 
The full text may be available from PubMed

OBJECTIVE: The incidence of nosocomial infections, predominantly gastrointestinal and respiratory, in children in developed countries is high, ranging from 5% to 44%. There is no effective strategy for preventing these infections. The objective of our study was to investigate the role of Lactobacillus GG (LGG) in preventing nosocomial gastrointestinal and respiratory tract infections at a pediatric hospital. METHODS: We conducted a randomized, double-blind, placebo-controlled trial of 742 hospitalized children. They were randomly allocated to receive for their hospitalization LGG at a dose of 10(9) colony-forming units in 100 mL of a fermented milk product (LGG group, n = 376) or placebo that was the same postpasteurized fermented milk product without LGG (placebo group, n = 366). RESULTS: In the LGG group, compared with the placebo group, we found a significantly reduced risk for gastrointestinal infections (relative risk [RR]: 0.40 [95% confidence interval (CI): 0.25-0.70]; number needed to treat: 15 [95% CI: 9-34)], respiratory tract infections (RR: 0.38 [95% CI: 0.18-0.85]; number needed to treat: 30 [95% CI: 16-159]), vomiting episodes (RR: 0.5 [95% CI: 0.3-0.9]), diarrheal episodes (RR: 0.24 [95% CI: 0.10-0.50]), episodes of gastrointestinal infections that lasted >2 days (RR: 0.40 [95% CI: 0.25-0.70]), and episodes of respiratory tract infections that lasted >3 days (RR: 0.4 [95% CI: 0.2-0.9]). Groups did not differ in hospitalization duration (P = .1). CONCLUSIONS: LGG administration can be recommended as a valid measure for decreasing the risk for nosocomial gastrointestinal and respiratory tract infections in pediatric facilities.
 
The full text may be available from PubMed

OBJECTIVE: To compare the National Institutes of Health`s (NIH) body mass index (BMI)-based classification to identify obesity in comparison with the World Health Organization (WHO), which uses percent body fat, among white, black, and Hispanic reproductive-aged women. METHODS: Body weight, height, BMI, and percent body fat (dual-energy X-ray absorptiometry generated) were determined for 555 healthy adult women aged 20-33 years (mean+/-standard deviation 26.5+/-4.0 years). Diagnostic accuracy of the NIH-based obesity definition (BMI of 30 kg/m or higher) was determined using the WHO criterion standard (percent body fat greater than 35%). RESULTS: Obesity as defined by the NIH (BMI 30 kg/m or higher) and by WHO (percent body fat greater than 35%) classified 205 (36.9%) and 350 (63.1%) of the women as obese, respectively. The NIH-defined obesity cutoff values had 47.8%, 75.0%, and 53.9% sensitivity in white, black and Hispanic, women, respectively. White and Hispanic women had 2.9% greater percent body fat than black women for a given BMI. Receiver operating characteristics curves analyses showed that the respective sensitivities improved to 85.6%, 81.3%, and 83.2%, and that 311 women (56.0%) were classified as obese as a whole when race or ethnic-specific BMI cutoff values driven by our data (BMI at or above 25.5, 28.7, and 26.2 kg/m for white, black, and Hispanic women, respectively) were used to detect percent body fat-defined obesity. CONCLUSION: Current BMI cutoff values recommended by the NIH failed to identify nearly half of reproductive-aged women who met the criteria for obesity by percent body fat. Using race or ethnic-specific BMI cutoff values would more accurately identify obesity in this population than the existing classification system.
 
The full text may be available from PubMed

BACKGROUND: Clinical roles of QuantiFERON-TB Gold (QFT-G)/Gold in-Tube (QFT-G-IT) and T-SPOT.TB in tuberculosis require clarification. METHODS: MEDLINE and EMBASE were searched for relevant English papers. Summary estimates of likelihood ratios (LR) of QFT-G/QFT-G-IT and T-SPOT.TB for latent tuberculosis infection (LTBI) and tuberculosis disease in adults were obtained by bivariate and univariate random effects meta-analyses after assessing heterogeneity. Probable ranges of prevalence for LTBI and tuberculosis disease were estimated. Critical values of positive LR (PLR) and negative LR (NLR) corresponding to a 90% certainty threshold were calculated over probable prevalence ranges. It was considered reliable to rule in when the best estimated PLR exceeds the corresponding critical value and to rule out when the best estimated NLR is less than the corresponding critical value. RESULTS: 35 studies involving predominantly immunocompetent adults were identified. Based on bivariate meta-analysis, PLR (95% CI) for LTBI were 7.9 (3.6 to 17.3) for T-SPOT.TB and 48.1 (19.7 to 117.6) and 10.8 (5.3 to 21.8) for QFT-G/QFT-G-IT based on Japanese and other studies, respectively. Corresponding NLR (95% CI) were 0.10 (0.06 to 0.18), 0.11 (0.07 to 0.18) and 0.23 (0.16 to 0.32). PLR (95% CI) for tuberculosis disease were 3.6 (2.3 to 5.6) for QFT-G, 2.1 (1.1 to 4.0) for QFT-G-IT and 4.7 (2.4 to 9.1) and 2.3 (1.3 to 4.0) for T-SPOT.TB based on studies with mean or median age >47. 1 years and < or = 47.1 years, respectively. Corresponding NLR (95% CI) were 0.18 (0.12 to 0.27), 0.38 (0.22 to 0.68), 0.11 (0.06 to 0.20) and 0.20 (0.10 to 0.40). Estimated prevalence ranges were 10-55% for LTBI and 40-60% for tuberculosis disease. CONCLUSIONS: At a 90% certainty threshold, LTBI is best diagnosed by QFT-G/QFT-G-IT and excluded by T-SPOT.TB or QFT-G/QFT-G-IT; none can diagnose tuberculosis disease, whereas. T-SPOT.TB can exclude tuberculosis disease among middle-aged and older patients.
 
The full text may be available from PubMed

OBJECTIVE: To review published literature on the equity of participation in colorectal cancer screening amongst different population subgroups, in addition to identifying factors identified as barriers and facilitators to equitable screening. Studies were included in the review if they included FOBT as at least one of the screening tests. METHOD: Relevant published articles were identified through systematic electronic searches of selected databases and the examination of the bibliographies of retrieved articles. Studies of the association with colorectal cancer screening test participation, barriers to equitable participation in screening, and studies examining interventional actions to facilitate screening test participation were included. Data extraction and analysis was undertaken using an approach to the synthesis of qualitative and quantitative studies called Realist Review. RESULTS: Sixty-three articles were identified that met the inclusion criteria. SES status, ethnicity, age and gender have been found as predictors of colorectal cancer screening test participation. This review also found that the potential for equitable cancer screening test participation may be hindered by access barriers which vary amongst population sub-groups. CONCLUSION: This review provides evidence of horizontal inequity in colorectal cancer screening test participation, but limited understanding of the mechanism by which it is sustained, and few evidence-based solutions.
 
The full text may be available from PubMed

We reviewed 25 randomized clinical trials that assessed the effect of peer-based interventions on health-related behaviors in adults. Effect sizes were calculated as odds ratios or standardized mean differences. We grouped most of the studies by 7 measured outcomes, with effect sizes ranging from -0.50 to 2.86. We found that peer-based interventions facilitated important changes in health-related behaviors, including physical activity, smoking, and condom use, with a small- to medium-sized effect. However, the evidence was mixed, possibly because of the heterogeneity we found in methods, dose, and other variables between the studies. Interventions aimed at increasing breastfeeding, medication adherence, women`s health screening, and participation in general activities did not produce significant changes.
 
The full text may be available from PubMed

OBJECTIVE: Invasive pneumococcal disease rates have declined since immunization with 7-valent pneumococcal conjugate vaccine (PCV7) (Prevenar/Prevnar [Wyeth Pharmaceuticals, Philadelphia, PA]) became routine. Certain nonvaccine Streptococcus pneumoniae serotypes (1, 3, 5, 6A, 7F, and 19A) still cause significant morbidity and mortality. The safety and immunogenicity of PCV7 were compared with those of 13-valent PCV (PCV13), which contains saccharides from serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F conjugated to CRM(197). PATIENTS AND METHODS: Infants were randomly assigned to receive PCV13 or PCV7 at ages 2, 4, and 6 months with other vaccines. Post-third-dose antibodies to each pneumococcal polysaccharide were measured by immunoglobulin G enzyme-linked immunosorbent assay. Antibacterial functional antibodies were measured by opsonophagocytic assay (OPA). RESULTS: Subjects received PCV13 (n = 122) or PCV7 (n = 127). All PCV13 serotypes were immunogenic, with 88% to 98% of infants achieving antibody concentrations of > or =0.35 microg/mL to shared PCV7 serotypes. For the 6 additional serotypes, 97% to 100% of PCV13-vaccinated infants achieved antibody concentrations of > or =0.35 microg/mL. Geometric mean antibody concentration for PCV13 recipients ranged from 1.32 microg/mL (serotype 23F) to 4.26 microg/mL (serotype 14). The ratio of OPA geometric mean titers for the 7 shared serotypes (PCV13:PCV7) ranged from 0.6 to 1.4, suggesting no clinically meaningful differences. For PCV13-only serotypes, OPA geometric mean titers were significantly higher in the PCV13 group than in the PCV7 group. Local reactions and systemic events were similar between groups. CONCLUSIONS: PCV13 was well tolerated and immunogenic, with most infants developing antipolysaccharide antibody concentrations of > or =0.35 microg/mL, as well as OPA responses, to each of the 13 serotypes.
 
The full text may be available from PubMed

OBJECTIVE: To estimate the potential population impact of different screening strategies for identifying and treating people at high risk of cardiovascular disease, including strategies using routine data for cardiovascular risk stratification, in light of the UK government`s recommended national strategy to screen all adults aged 40-74 for cardiovascular risk. DESIGN: Modelling study using data from a prospective cohort, EPIC-Norfolk (European Prospective Investigation of Cancer-Norfolk). SETTING: An English county. PARTICIPANTS: 16,970 men and women aged 40-74 and free from cardiovascular disease and diabetes at baseline. MAIN OUTCOME MEASURES: The main outcomes were the population attributable fraction, the number needed to screen to prevent one new case of cardiovascular disease, the number needed to treat to prevent one new case of cardiovascular disease, and the number of new cardiovascular events that could be prevented. Relative risk reductions for estimated treatment effects were derived from meta-analyses of clinical trials or guidelines from the National Institute for Health and Clinical Excellence. RESULTS: 1362 cardiovascular events occurred over 183 586 person years of follow-up. Compared with the recommended government strategy, a stepwise screening approach using a simple risk score incorporating routine data could prevent a similar number (lower to upper estimates) of new cardiovascular events annually in the United Kingdom (26,789, 20,778 to 36,239) and 25,134 (19,450 to 34,134), respectively) but requiring only 60% of the population to be invited to attend a vascular risk assessment. A similar number of cardiovascular events (25,016, 19,563 to 33,372) could also be prevented by inviting everyone aged 50-74 for a vascular assessment. Using a participant completed Finnish diabetes risk score questionnaire or anthropometric cut-off points for risk prestratification was less effective. CONCLUSIONS: Compared with the UK government`s recommended national strategy to screen all adults aged 40-74 for cardiovascular risk, an approach using routine data for cardiovascular risk stratification before inviting people at high risk for a vascular risk assessment may be similarly effective at preventing new cases of cardiovascular disease, with potential cost savings.
 
The full text may be available from PubMed

BACKGROUND: The herpes zoster vaccine is effective in preventing herpes zoster and postherpetic neuralgia in immunocompetent older adults. However, its safety has not been described in depth. OBJECTIVE: To describe local adverse effects and short- and long-term safety profiles of herpes zoster vaccine in immunocompetent older adults. DESIGN: Randomized, placebo-controlled trial with enrollment from November 1998 to September 2001 and follow-up through April 2004 (mean, 3.4 years). A Veterans Affairs Coordinating Center generated the permutated block randomization scheme, which was stratified by site and age. Participants and follow-up study personnel were blinded to treatment assignments. (ClinicalTrials.gov registration number: NCT00007501) SETTING: 22 U.S. academic centers. PARTICIPANTS: 38 546 immunocompetent adults 60 years or older, including 6616 who participated in an adverse events substudy. INTERVENTION: Single dose of herpes zoster vaccine or placebo. MEASUREMENTS: Serious adverse events and rashes in all participants and inoculation-site events in substudy participants during the first 42 days after inoculation. Thereafter, vaccination-related serious adverse events and deaths were monitored in all participants, and hospitalizations were monitored in substudy participants. RESULTS: After inoculation, 255 (1.4%) vaccine recipients and 254 (1.4%) placebo recipients reported serious adverse events. Local inoculation-site side effects were reported by 1604 (48%) vaccine recipients and 539 (16%) placebo recipients in the substudy. A total of 977 (56.6%) of the vaccine recipients reporting local side effects were aged 60 to 69 years, and 627 (39.2%) were older than 70 years. After inoculation, herpes zoster occurred in 7 vaccine recipients versus 24 placebo recipients. Long-term follow-up (mean, 3.39 years) showed that rates of hospitalization or death did not differ between vaccine and placebo recipients. LIMITATIONS: Participants in the substudy were not randomly selected. Confirmation of reported serious adverse events with medical record data was not always obtained. CONCLUSION: Herpes zoster vaccine is well tolerated in older, immunocompetent adults. PRIMARY FUNDING SOURCE: Cooperative Studies Program, Department of Veterans Affairs, Office of Research and Development; grants from Merck to the Veterans Affairs Cooperative Studies Program; and the James R. and Jesse V. Scott Fund for Shingles Research.
 
The full text may be available from PubMed