Extending fecal immunochemical tests for hemoglobin (FITs) to primary care patients with high-risk symptoms suggestive of colorectal cancer (CRC) could reduce colonoscopy waiting lists, enabling earlier treatment. Higher FIT thresholds could decrease referrals but increase missed disease compared with lower thresholds. We aimed to systematically review and synthesize test accuracy data across thresholds for use in a cost-effectiveness analysis.

Searches across ten sources were conducted (December 2022). Included were diagnostic accuracy studies of HM-JACKarc, OC-Sensor, FOB Gold, QuikRead go, NS-Prime, and four Immunodiagnostik (IDK) tests in patients presenting to, or referred from, primary care with symptoms suggestive of CRC using any reference standard. Risk of bias was assessed with QUADAS-2. Syntheses of sensitivity and specificity at all reported thresholds were planned for each test to provide summary estimates at all possible thresholds within the observed range. Sensitivity analyses investigating population type and reference standard, and subgroup analyses by patient characteristics (e.g., anemia, age, sex, ethnicity) were conducted.

HM-JACKarc (n=16 studies) sensitivity ranged from 95.9 percent (95 percent credible interval [95% CrI]: 92.7, 97.9) to 46.3 percent (95% CrI: 37.4, 54.9) and specificity from 65.1 percent (95% CrI: 55.6, 74.8) to 97.7 percent (95% CrI: 94.7, 99.2) (thresholds 2 and 400 μg hemoglobin/g feces [μg/g], respectively). OC-Sensor (n=11) sensitivity ranged from 94.2 percent (95% CrI: 91.2, 96.7) to 54.2 percent (95% CrI: 48.4, 60.2) and specificity from 62.7 percent (95% CrI: 47.4, 77.2) to 97.3 percent (95% CrI: 92.9, 99.3) (thresholds 4 and 200 μg/g, respectively). FOB Gold (n=3) sensitivity ranged from 91.4 percent (95% CrI: 71.6, 99.6) to 73.9 percent (95% CrI: 53.8, 91.2) and specificity from 78.1 percent (95% CrI: 70.0, 86.0) to 96.4 percent (95% CrI: 92.6, 98.9) (thresholds 2 and 150 μg/g, respectively). There were limited or no data on the other tests.

Sensitivity and specificity were synthesized for three tests only, since data for the remaining tests were extremely limited or absent. Even at the lowest threshold, none of the tests had perfect sensitivity. Future studies should further investigate comparative accuracy and the impact of patient characteristics, patient recruitment criteria, and the reference standard on estimates of diagnostic test accuracy.

Approximately 42,000 new cases of colorectal cancer (CRC) are diagnosed annually in the United Kingdom with 16,800 deaths. Evidence suggests that quantitative fecal immunochemical tests (FIT) are a good predictor of CRC risk in symptomatic patients presenting to primary care. We aimed to assess the cost-effectiveness of FIT in this setting, considering capacity constraints and waiting times for subsequent colonoscopy.

We compared two diagnostic FIT strategies, at various thresholds, in the model: (i) FIT for all patients and (ii) current practice where only low-risk patients received FIT. Patients with positive FIT scores and high-risk patients in current practice received colonoscopy. Diagnostic accuracy evidence from published literature, standard UK cost sources, and other sources were used to estimate health outcomes and costs. Waiting times before colonoscopy were assumed proportional to the numbers referred, with the impact of delayed colonoscopy taken from published models. Savings per quality-adjusted life years (QALYs) lost and incremental net monetary benefit (INMB) were used. Uncertainty was evaluated.

Model results suggested that, compared to current practice, FIT generated a positive INMB for the majority of thresholds assessed (GBP200 [USD254] to GBP350 [USD445] per patient at a willingness to pay of GBP20,000 [USD25,474] per QALY gained). A reduction in the number of patients sent to colonoscopy led to cost savings. However, these thresholds were associated with slight QALY losses due to a small proportion of false negative results associated with significantly delayed diagnosis, which outweighed the benefits associated with quicker times to colonoscopy for those with positive FIT results. Savings of over GBP100,000 (USD127,374) per QALY lost were generated. Conclusions were robust to the sensitivity analyses undertaken.

With capacity constraints explicitly represented in the economic modeling, offering FIT to all patients presenting to primary care with symptoms suggestive of CRC was cost effective when compared to current practice. However, the optimal threshold could not be robustly determined due to limited diagnostic accuracy data, parameter uncertainty, and limitations in the model structure; additional primary research could reduce uncertainty.

Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.

This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.

The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3–5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).

In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI –1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.

Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

In the fast growing city of Nairobi, women often combine the roles of mother and worker in trying to achieve better standards of living. The objective of this study was to document the effect of returning to work on breast-feeding by mothers in Kenya.

A cross-sectional survey.

Outpatient clinics of two major hospitals in Nairobi, one government hospital in an economically deprived area and one high-fee private hospital.

Four hundred and forty-four working mothers from low and higher socio-economic areas in Nairobi. All working mothers with infants aged 4 to 12 months attending during the survey period were invited to participate.

The prevalence of breast-feeding at the time of interview was found to be 94.1%. The lower socio-economic group exhibited a higher prevalence of breast-feeding (99%), 10% greater than the higher socio-economic group. The mean number of hours the mothers were away from home due to work was 46.2 hours each week. The majority (54.4%) of the mothers employed a ‘house-girl’ to care for their infant while they were at work, while 28.4% were able to take their infants to work. Most of the breast-feeding mothers (95%) breast-fed their infants at least three times a day and only 23 mothers reported not being able to breast-feed their infants during the day. The lower socio-economic group had a mean of 5.09 breast-feeding times per day while the higher socio-economic group had a mean of 3 times a day. In a logistic regression analysis the mode of work (fixed working hours vs. shift working hours) was associated with exclusive breast-feeding at one month (odds ratio (OR) = 0.45) and two months (OR = 0.39).

In Western countries ‘return to work’ is often cited as the reason that breast-feeding is discontinued prematurely. In this study we have shown how mothers in Kenya are able to successfully continue breast-feeding after they have returned to work, often for very long hours.

To compare the efficacy of the polysaccharide pneumococcal vaccine in older adults between clinical trial and observational studies and to discuss the implications for long-term–care facilities (LTCFs).

A Medline search (to April 2003).

All meta-analyses of randomized and quasi-randomized trials of pneumococcal vaccines with placebo or no treatment were sought. All cohort or case–control studies were sought.

Of the 16 individual randomized clinical trials included in the reviews, 8 compared pneumococcal vaccine in individuals 55 years and older individuals. Only one study specifically addressed LTCF residents. Although no significant protective effect of the vaccine in elderly subpopulations was found, on the basis of wide confidence intervals and small subpopulation sample sizes, beneficial effects, particularly for pneumococcal bacteremia, could not be ruled out. Of the individual observational studies, 11 specifically evaluated vaccine efficacy in older adults. Vaccine efficacy was demonstrated in 9 of the 11 studies with no protective effect was shown in 2 studies.

Although the pooling of clinical trial data does not demonstrate significant efficacy of the pneumococcal polysaccharide vaccine in subgroups of older adults, these subgroup studies lacked power to show significant differences. Observational studies repeatedly demonstrate efficacy in older adults, and the vaccine has been demonstrated to be cost-effective and safe. It is strongly promoted by U.S. and Canadian advisory committees. On the basis of this available evidence, the pneumococcal polysaccharide vaccine should currently be recommended for older adults, especially those who are residents of LTCFs.