Report on Healthcare Screening
"REPORT ON SCREENING"
Helen Lyford-smith
This report is a study on Screening. Living in the 21st century and as a result of this we have a large amount of knowledge established about various diseases, some of which can be cured, some of which scientists are still attempting to research and find solutions to, and some we can only endeavour to prevent.
The aspect of prevention is the key focus for this assignment. During this study I will go into the various aspects of Screening, looking specifically into each type in exploratory analysis and evaluation looking at the positive and negative sides of each type of screening and the problems associated with each of them.
Screening - an introduction
Screening is a systematic examination or assessment, done especially to detect an unwanted substance or attribute. Screening can be carried out through the National Health Service in general hospitals or by your GP, or can be carried out in private organisations such as BUPA. The UK Health Screening Programme covers a vast array of medical examination and assessment ranging from dentistry through to screening for cancer cells - all of which I will be going into further depth with during the course of this report. According to a popular health study by the UK National Screening Committee, (http://www.nsc.nhs.uk) Screening is a public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications.
Conditions and Regulations of Screening
There is no point in testing for conditions that do not respond differently when detected early. Yet in some cases it is vital for a person's survival of a disease to discover its presence as early on as possible, for example when screening for cancerous cells in a growth. It is vital that people attend routine tests and screenings, however people will not attend for routine tests if put to inconvenience and discomfort.
Such test should also be reliable and accurate, not giving figures of false positives or false negatives. These occur when the test result is judged to be different to the actual result; this has happened in the past for example with cervical smear screening results, and the modern UK media are quick to highlight such errors. This in turn causes negative views of screening as an entirety, putting people off having the screenings in the first place and causing raises levels of fatalities due to diseases failing to be detected early enough. Subsequently when considering a diagnostic test for screening populations it is important to consider the number of false negative and false positive results you will have to deal with. The quality of a diagnostic test is often expressed in terms of sensitivity and specificity. Sensitivity is the ability of the test to pick up what you are looking for and specificity is the ability of the test to reject what you are not looking for. One area of concern within the largely successful UK National Health Service breast screening programme is the relatively high proportion of women showing mammographic abnormalities who undergo further diagnostic tests that prove negative. Previous studies suggest that, in addition to increasing anxiety, such false-positive mammography is associated with increased risk of subsequent interval cancer. In a very recent study conducted by our Breast Cancer Research, (http://breast-cancer-research.com) concluded that last year in the UK there were around 11 unnecessary recalls for every cancer detected within the National Health Service breast screening programme, and the consequences of this are that large quantities of women were not attending recalls for later screenings, the likely cause of this being mistrust in the practice.
Nevertheless, screening provides valuable information that protects the health of different client groups and saves many lives. In a general overview, it is regarded as an integral part of our health care service.
Antenatal Screening Tests
Knowing a fetus is abnormal before birth allows parents to plan for any health needs of their baby in advance of it being born. It can also prepare them for the birth, enabling them to receive counselling before birth, reducing the shock and other reactions when the baby is born. As well as this, it gives the option of abortion of the fetus. Healthcare staff can also prepare for the delivery, and have suitable treatment ready for when the baby is born. The type of prenatal diagnosis done depends on the situation of the parents. In an older mother (for instance over 35), or a parent with an inheritable genetic condition, a more invasive technique may need to be done. This can detect chromosome abnormalities (such as Down's syndrome) which are more common as a woman's age increases, or a specific genetic problem that might run in the family. Genetic counseling is often offered to help parents decide what type of testing is right for their situation.
According to a popular study by Sahin Aksoy of the Department of Antentala Helath Screening, (www.biomedcentral.com/content) risk factors qualifying a woman for prenatal testing are the following, "pregnant women over the age of 35, women who have previously had premature babies or babies with a birth defect, especially heart or genetic problems, women who have high blood pressure, lupus, diabetes, asthma or epilepsy, or women whose partners have ethnic backgrounds prone to genetic disorders" During the course of a non high risk, normal pregnancy women are entitled to at least one scan - more would correlate with high risk pregnancies, such as those I have just described.
In some genetic conditions, for instance cystic fibrosis, an abnormality can only be detected if DNA is obtained from the baby. Usually an invasive method is needed to do this. If a genetic disease is detected, there is often no treatment that can help the fetus until it is born. It does give parents the option to consider abortion of the baby.
If abortion isn't an option for a particular couple (because of their own beliefs, such as catholicism), invasive prenatal diagnosis of such a condition is unhelpful as the test puts the child at risk, and knowing the result doesn't help the child. Genetic counseling can help families make informed decisions regarding results of prenatal diagnosis.
There is also the risks of ralse negatives and false positives to consider when evalutating the results of antenatal screenoing; Ultrasound, which is considered a screening test, of an unborn baby can sometimes miss subtle abnormalities. For example studies show that a detailed ultrasound, also called a level 2 ultrasound, can detect about 80% of spina bifida. Ultrasound results may also show "soft signs," such an Echogenic intracardiac focus or Choroid plexus cyst, which are usually normal, but can be associated with an increased risk for chromosome abnormalities. Other screening tests, such as the AFP triple test, can have false positives and false negatives. Even when the AFP triple test results are positive, usually the pregnancy is normal, but additional diagnostic tests may be offered. Both false positives and false negatives will have a large impact to a couple when they are told the result, or when the child is born. Diagnostic tests, such as amniocentesis, are considered to be very accurate for the defects they check for. No prenatal tests can detect all forms of virth defects and abnormalities.
There are definite ethical and practical issues involved in prenatal testing. The option to continue a pregnancy or to abort is the main choice after most prenatal testing. The risks must be weighed up - are the risks of prenatal diagnosis such as amniocentesis worth the potential benefit? In addition some fear that giving parents the option to abort 'unsatisfactory' babies may lead to being able to pick and choose what children parents would like to have. This could lead to choice in sex, physical characteristics, and personality in the children, creating a lot more abortions, and uneven population and ethnicity - it would also encourage the viewpoint of abortion being passable, with the birth of a child no longer holding any ethical or emotional value. Knowing about certain birth defects, such as spina bifida, before birth may give the option of foetal surgery during pregnancy, or to assure that the appropriate treatment and/or surgery is immediately available after birth - essentially giving the health care professionals and the parent's time to prepare. The choice also exposes the debate of whether mentally or physically disabled children are any less valuable in our society - health care professionals must ensure in this area of decision that they do not lead the parents into any one decision in their description of the child when informing the parents of the condition discovered. There are various antenatal screenings in use, which fall into two categories;
Non invasive methods (to the baby)
* Examination of the mother's uterus from outside the body. (i.e. Feeling the mother's stomach.)
* Ultrasound detection - Commonly used to check the baby's sex, to look for twins, and also to check for any abnormal development.
* AFP screening can check levels of alpha fetoprotein, ß-hCG, and estriol in the mother's serum.
* Detection of fetal blood cells in maternal blood. The mothers blood provides vital dissolved oxygen for the growing foetus anf this exchange takes place across the placenta. When the mother is aenemic then her foetus will not receive the desired amount of oxygen for its needs. The baby will be small for date and function may be imparied. A smaple of bloody taken from a vein in the mothers forearm will enable labarotory determination of the level of iron-containing haemoglobin in the red blood cells. When this is deemed inadaquate the pregnant mother can be supplied with the relevant medication. At the same time, this blood test can be analysed for certain chemicals, for exmaple high levels of alfafetoprotein, which would suggest the baby might have spina bifida. In addition, this blood test can be analysed to see whether the mother and baby have incompatable blood groups. This would require special precautions being taken so as not to mix the blood at birth, and in cases of complication, blood transfusions may be necessary. Essentially, if the mother has Rhesus negative (D-ve) blood and the foetus has Rhesus positive (D+ve) the first foetus may sensetise the mother by causing Rhesys antibodies to develop. This usually happens during the birth as the placenta is breaking away from the uterine wall. An injection of anti-D serum will take away the antibodies and prevent sensetisation. This is necessary because in a second or subsequent pregnancy with Rhesus positive baby, the mothers anitbodies will start to destroy the blood of the foetus, causing severe jaundice and in some cases, death.
Invasive methods (to the baby)
* Chorionic villus sampling - Taken at ten weeks, CVS involves getting a sample of the chorionic villus and testing it. This can be done earlier than amniocentesis, but is a more risky procedure. Typical gentetic abnormalities investigated using CVS are Down's syndrome, heamophilia, thalassaemia, muscular dystrophy and sickle cell disorders. The test is carried out as an outpatient and takes around 30 minutes. The sample can be obtained from the foetal side of the edge of the placenta by a cannula attached to a syringe. Access is either trhough the vagina ...
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Invasive methods (to the baby)
* Chorionic villus sampling - Taken at ten weeks, CVS involves getting a sample of the chorionic villus and testing it. This can be done earlier than amniocentesis, but is a more risky procedure. Typical gentetic abnormalities investigated using CVS are Down's syndrome, heamophilia, thalassaemia, muscular dystrophy and sickle cell disorders. The test is carried out as an outpatient and takes around 30 minutes. The sample can be obtained from the foetal side of the edge of the placenta by a cannula attached to a syringe. Access is either trhough the vagina and uterus or the abdominal wall. When evidence of a serious chromosome abnormality is found, the parents can be given the choice of termination or not. The advantages of CVS over amniocentisis are that earlier termination carries less emotional stress and less risk to the health of the mother. Disadvnatageous risks are the puncturing of the sac, bleeding and infection.
* Amniocentesis - This can be done once enough amniotic fluid has developed to sample. Cells from the baby will be floating in this fluid, and can be separated and tested. The technique is performed during the sixteenth and eighteenth week of the pregnancy, and the positions of the foetus and placenta are located by ultrasound scanning to allow the free passage of a hollow needle to remove a small amount of fluid. The neddle penetrates the abdominal and uterine walls with local or no anaesthetic. There is a slightly increased risk of 1 per cent that the mother will miscarry with this procedure. Results take three to four weeks, as cells have to be grown for chromosome analysis. Alphafetoprotein levels and foetal blood groups can also be determined from amniotic fluid although the main function is to investigate chromosomal abnormalities.
* Embroscopy and fetoscopy - These involve putting a probe into a women's uterus to observe (with a video camera), or to sample blood or tissue from the baby.
Amniocentesis has become the standard of care for prenatal care visits for women who are "at risk" or over a certain age. All obstetricians offer patients the AFP triple test, HIV test and ultrasounds routinely. However, almost all women meet with a genetic counselor before deciding whether to have prenatal diagnosis. It is the role of the genetic counselor to accurately inform women of the risks and benefits of prenatal diagnosis. Genetic counselors are trained to be non-directive and to support the patient's decision. Some doctors do advise women to have certain prenatal tests and patient's partner may also influence the woman's decision.
Some say the argument not to have prenatal diagnosis is a Right-to-life argument. Pro-life activists believe that "because in utero treatment is in its infancy, prenatal diagnosis today is used to seek out and destroy 'defective' infants. However, this view assumes that the goal of prenatal diagnosis is simply to abort abnormal pregnancies. Some believe that knowing about a baby's health problems before birth can prepare the family, allow them to make informed decisions about treatment or surgery options, and alert the medical professionals who would be caring for the abnormal baby. Also, many women decide not to have prenatal diagnosis because of the risks of complications associated with the invasive procedures. It is the decision of the pregnant woman whether to have testing and what to do with the information if the results show a problem.
Infant and Child Screening Tests
After an infant is born, and throughout their childhood, certain screening tests are carried out to ensure that the child is not affected by detectable conditions that were not apparent during antental care.
Blood tests for CH, PKU and thalassaemia
To take a blood test, a tourniquet (tight band) is placed to make the vein fill with blood, making it easier to take the blood sample. The blood is usually taken from the vein inside of the elbow or the back of the wrist. The skin is first cleaned with an antispetic wipe so that no germs are oushed into the skin when the needle is insterted. The needle is then insterted, and blood naturally comes out. Then when a sufficient sample has been taken, the needle is removed, the sample is sealed, and the bottle labelled. It is of extreme importance to label samples effeiciently, otherwise patients may be given the result of someone elses test, giving them a false diagnosis. Cotton wool is pressed onto the small wound left, to stop the blood. When large amounts are taken, for example for donation, a biscuit is given to the patient, due the blood sugar levels dropping. Blood tests are for the purpose of screening for various diseases, to test for inflammation, blood grouping, blood clotting, glucose levels (diabetes) kidney functions, hormone levels, anemia, checking for correct dosage of medicine in the blood, and for pregnancy testing as it shows signs of pregnancy for urine tests do.
According to a recent study by Dianne Tamburrino, (www.magicfoundation.org), Congential hypothyroidism, more commonly referred to as CH, is a disorder that affects infants from birth (congenital), resulting from the loss of thyroid function (hypothyroidism), normally due to failure of the thyroid gland to develop correctly. Sometimes the thyroid gland is absent, or ectopic (in an abnormal location). As a result, the thyroid gland does not produce enough thyroxine/T4 after birth. This may result in abnormal growth and development, as well as slower mental function. According to a study by The national centre for biotechnology information, (www.ncbi.nlm.nih.gov) states that Phenylketonuria, more commonly known as PKU is an inherited error of metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Loss of this enzyme results in mental retardation, organ damage, unusual posture and can, in cases of maternal PKU, severely compromise pregnancy. Both of these conditions should never be missed, as both seriously affect growth and development, particularly mental development, and both are treatable conditions. PKU is tested by a small prick on the heel, called a Guthrie test. It looks for high levels of phenylalanine that the infant is unable to metabolise due to a genetic inborn error of metabolism. All new babies are given the test, which produces a drop of blood which is mopped up on a specially treated card.
Thalassaemia is an inherited blood disorder and is most common in families originally from the Mediterranean area, South East Asia and the Middle East. Not many people have pure 'Anglo-Saxon' blood though, and there is often some link to these areas in peoples family history, if not in direct parentage. Distribution coincides with Malaria - it is thought that it confers some form of protection against malaria. Carriers have very few symptoms. Two carriers have a one in four chances of having an affected baby. In Thalassaemia major, (TT) there will be prevalent severe anaemia, a symptom, and in addition, symptoms would be that the bone marrow proliferates and distorts the bones and the spleen enlarges. Also, the red blood cells are easily broken, and are pale due to a fault in hemoglobin manufacture (causing the anemia). The condition is treated with frequent blood transfusions and injections to remove the build up of iron. It is a condition found in the blood, so there is no need for DNA testing. Testing is offered to both the carriers' parents. A microscopic analysis of blood and hemoglobin estimation will diagnose this condition. In Britain, we live in a hugely diverse multicultural population, which mans the chances of Thallassaemia are a lot higher as mixed race unions increase.
Dental Examination for dental caries
It is of general knowledge that children should have regular examinations of their milk or deciduous teeth from an early age so that monitoring of dental caries (decay) and the formation of the permanent teeth can be carried out. At the same time advice regarding good personal mouth hygiene can be given. The dentist will examine and record the status of each tooth using a mirror and a probe. Classes are sometimes offered at dentists surgeries to teach children the values of taking good care of their teeth from an early age, and to teach them how to clean their teeth properly.
According to the current NHS health pages (www.nhsdirect.nhs.uk/articles) Babies start to develop teeth before they are born. The first teeth (also known as milk teeth or deciduous teeth) normally start to break through the gum from at around six to nine months old. Most children will have around eight teeth by their first birthday, although this is just an average. The complete set of twenty milk teeth is usually through by 2 and a half years. And even small babies are exposed to sugar - the natural sugars in breast milk - which can cause tooth decay, so it is important to start looking after your children's teeth as soon as they appear.
Currently, depending on the individual and the health status of the teeth, the dentist will determine the interval between examinations; although this used to be half yearly, the shortage of dentists working for the NHS has determined re-planning. In some areas, there are no NHS dentists and the community is experiencing extended periods of delay. A lot of people cannot afford to pay for private dentistry treatment, and so do not attend or take their children, getting them into the habit. This means that they are far more likely to have dental caries, and other dentistry problems.
Eye Tests for visual defects
There are certain regulation visual tests done for infants and children, and for adults. The purpose of an eye test is to establish development of sight from an early age, and to check that there are not any impairment as the child or adult ages. There are various types of visual impairment, of which I have summarized below, firstly in the area of infant visual testing, and secondly for adults;
Visual testing for infants and children
According to a publicly released report by the NHS (www.nhsdirect.nhs.uk/articles) the eyes of newborn babies are examined for any obvious physical defects, include cross-eyes, cloudiness (a sign of cataracts), and redness.
The pupil reflex is checked by shining a light into each eye from a distance of 10cm. The pupils should automatically shrink in response to brightness. A test called eliciting the red reflex is carried out using a magnifying instrument with a light on the end, called an ophthalmoscope. Light is directed into the baby's eyes and a red reflection should be seen as the light is reflected back. If the reflection is white instead, the child should be referred to a specialist immediately, as it can be a sign of a cataract or other eye condition. To test whether the newborn baby pays attention to visual objects, the midwife or doctor catches the baby's attention with an interesting object such as a face, then moves it and sees if the child's eyes follow.
In older babies and toddlers up to around 2 years, the focus and sharpness of eyesight can be checked using the rolling ball test. This involves rolling differently sized white balls rolled across the floor, and shows the range of vision and how small an object can be spotted. Another simple test is to use small blocks or tiny objects like buttons, to find out whether the child can see them and reaches for them. Each eye can be tested separately by covering the other with a patch. Older children can be asked to count the number of fingers held up. From age 5 years, charts with rows of letters of decreasing sizes can be held up at a distance of several metres, and the child reads out as many of the letters as he or she can see.
To test the range of movement of each eye, the child's attention is drawn to an interesting object, which is then moved to eight positions: up, down, left, right, and half-way in between each of these points. The test involves checking how well each eye follows and how far the movement of the eye stretches in each direction. In children 5 years and older, the visual field is often tested with the 'wiggly finger' test. Each eye is covered in turn, and the examiner gradually brings a wiggly finger into the child's field of vision.
Colour blindness (colour vision deficiency) tests are not carried out at primary school age, but usually around age 11 if a problem is suspected. These use the Ishihara colour vision tests, which involve images made up of two different colours of dots. If colour vision is normal, the child will be able to recognise the letter or number that is highlighted. A child, who cannot tell the difference between two colours (such as red and green) and therefore cannot see the picture, may have a colour vision problem.
There is some controversy around pre-school and school children's visual testing - many visual impairments are not picked up until later in life, suggesting the testing is not rigorous or effective enough. It is important for visual impairment to be diagnosed early for schoolwork, reading and playing to be at its best. Infants who fail to see properly from an early age will not develop full vision, putting them at a disadvantage educationally and developmentally.
In addition, there is the long standing debate over the need for toddler's eye tests. A new research paper by William C Northstone has addressed the issue recently - contraversially, pre school screening for amblyopia (lazy eye) has been abandoned in much of the UK on the grounds that it can be done more effectively at school age and that ge at starting treatment is irrelevant. Amblyopia is a condition that affects 3% of children and is treated usually with an eye patch - however if left untreated until the age of 7 or 8, the sight in the weaker eye will never improve. Researchers based at Bristol examined the eyesight of 6,000 children at the age of seven. Of these, almost 25% had been offerd pre-school screening at age 3, and two thirds of them had attended. All children had been screened when they started school, as is currently recommended by the NHS. The researchers found that the seven year olds who had been tested and had been treated from age 3 got better vision test results, and primarily the prevalence of amblyopia was 45% lower in the children who had relieved the 3 year test. But because only two thirds attended Northstone it raises doubts of the practicalities and overall population benefit of testing at three rather than at school entry - the results emphasize that the patching treatment is more effective the younger its given, yet in order to make a real impact on numbers of children with sight problems, testing must be received by all of the population - this would prove expensive to the NHS, and that may be a reason why it would be difficult to put a national screening programme in place, in addition to the fact that some mothers may not take their children, due to various lifestyle issues and barriers (see 'barriers to screening' section)
Visual testing for impairments in adults
Ophthalmologists are doctors who specialise in eye disorders and treatment; ophthalmic opticians are trained to perform eye examinations and prescribe glasses to correct visual defects. Opticians are not doctors who treat eye disorders and will refer any concerns in this regard to ophthalmologists.
* Glaucoma - The eye ball is fluid-filled to enable the shape of the eye to be maintained. The volume of fluid entering the eye must balance with the volume leaving the eye. However when a person has glaucoma, the exit of fluid is narrowed so more fluid enters than leave, causing the pressure inside the eyeball to rise. Subsequently, raider inter-ocular pressure damages the optic nerve at the back of the eye, causing patchy loss of vision. The extent of visual loss depends on the type of glaucoma and how long the raised pressure has been left undiagnosed - hence increasing the value of early detection through effective optical care and examination. Any long standing damage will cause the visual loss to be permanent - although the individual will not necessarily be aware of the patchy vision because most daily activities use central vision such as reading for example, and central vision only becomes affected at the later stages of glaucoma. Usually glaucoma affects both eyes. People over the age of 40 are generally recommended to be tested regularly, and those with a family history of the condition must be tested from the age of 35 due to their increased risk factor. People who smoke, diabetics, Afro-Caribbean's, and people with myopia (nearsightedness) must be tested younger, as they are significantly more likely to develop Glaucoma. The condition accounts for 15% of blindness in adults in the UK and is the most common major eye disorder in people over 60 years of age.
An applanation tonometer is used to measure the intro-ocular pressure, a specialist piece of equipment. The ophthalmoscope is also used to examine the back of the eye where the optic nerve disk can be viewed. Measurement of visual fields can also be important for checking on peripheral vision and clearly the accuracy of vision using Snellen charts is vital (as I mentioned before in, 'infant and child vision tests')
* Astigmatism - is a 'bumpy' cornea that causes some parts of vision to be clearer than others are; It is often tested for using a series of black lines arranged as spokes of a wheel on green and red backgrounds. Some spokes appear blacker than others do. Corrective lenses in glasses are able to cancel the effect out. It's not only adults who can be astigmatic. Dr. Karla Zadnik, an optometrist at Ohio State University School of Optometry, found in a recent study of 2,523 children that more than 28 percent of them had astigmatism. Children may be even more unaware of the condition than adults, and they are unlikely to complain of the blurred or distorted vision. Unfortunately, astigmatism can affect their ability to see well in school and during sports, so it's important to have their eyes examined at regular intervals in order to detect any astigmatism early on.
* Myopia, hypermetropia, and presbyopia - These are all investigated using trial spectacles into which loose lenses can be placed until vision is near perfect. Myopia is short sight, hypertropia is long-sight, and presbyopia is long sight of old age.
Hearing tests for deafness
In the UK about 700 children are discovered to have severely impaired hearing each year. According to the RNID "There are about 9 million people who are deaf or hard of hearing in the UK. Most of them have lost their hearing gradually with increasing age. Over half of people aged over 60 are hard of hearing or deaf." This essentially tells us that people with hearing problems are not a minority. In addition, they said that, "Early treatment leads to improved language skills and fewer emotional problems." However, like visual tests, there is much controversy over current hearing tests and these may be replaced in time with some form of electronic tests that may be more reliable and effective.
Hearing tests for deafness in children and infants
Infants are observed for their reactions to noise, particularly voices. Babies will usually quieten in these conditions. From eight months onwards, infants will move their heads sideways to locate noise and a little later up and down movements are added, giving full rotating head movement towards sound. This is used in distraction testing - various noises, like a shaken rattle toy siren or whistle, are made in different locations to watch if the infant turns the head to the sound, showing they are able to hear it and can work out where its coming from. After a child's second birthday, word object testing is used; the care professional whispers the name of an object and asks the child to point to it. A further test requests the child to carry out a
particular task when certain sounds are made, such as placing a brick in front of the child and asking them to pick it up when asked - the volume is lowered until it can only faintly be heard, to see at what point if at all the child stops being able to hear the instructions. If there is any doubt about the child's hearing, specialist advice is sought.
The difficulty with testing a child's hearing is co-operation. If the child is shy, or even stubborn, they may not follow instruction, making it difficult to deduce whether they have a hearing problem or not. There is also additional difficulty in that children are often put forward for hearing test if their parents inform the health professionals - unfortunately in some less educated areas, or in situations of deprivation the child may not be taken to the doctors, and no help may be sought, leaving them untreated and worsening their condition often irreversibly - this causes controversy over whether there should be a national screening program for children to be tested at certain stages, top keep track of their hearing progress rather than just as babies.
Physical examination for hip dislocation
The femur is the longest and strongest bone in the body; the head is a round ball that fits snugly in a cup shaped depression in the pelvis. Sometimes the cup is not deep enough to hold the femoral head and it moves outwards, so called dislocation. Some infants are born with permanent dislocated hips (one or both). This condition has been renamed developmental dysplasia, or DDH. When the condition is left undiscovered, the child may begin to walk with a painless limp, but osteoarthritis of the joint occurs much earlier in life than normal and the hip joint becomes very painful. With early diagnosis and treatment, there is no limp and no early onset of arthritis - strengthening the need for the condition to be diagnosed as early as possible in life. The physical examination should take place at birth, at six to eight weeks old, and six to eight months old. With the infant lying on its back, the doctor flexes the hip and knee 90? vertically, with the thumb on the inner side of the knee and the forefinger on the outer bump of the head of the femur, the hip is turned smoothly and gently outwards. (see the diagram to the right) When the hip joint is unstable, there is a 'clunk' that can felt and heard as the head of the femur slips out of the socket (acetabulum) on the pelvis. The absence of this 'clunk' sound indicates to the doctor that the hip joints are stable. The cause of this condition is still unknown.
Treatment of dislocation depends on the child's age. In a newborn or very young infant, for example, a soft positioning device called a Pavlik harness will keep the hip bone in the socket and stimulate normal hip development. If that method doesn't work, the hip bone can often be pushed back into place in children aged 6 months to 2 years. The procedure, called closed reduction, is done under anesthesia. If closed reduction fails to remedy the problem, open surgery to reposition the hip may be necessary. Once the child is over 2 years of age, closed reduction is no longer an option. Following either the closed or open procedure, the child will wear a cast and/or braces for several months. This will help keep the hip bone in the socket while it heals. Very young children may experience a delay before walking because of the cast. Although a difference in leg lengths may remain, early treatment of congenital hip dislocation can promote normal hip joint function and ultimately permit an active lifestyle.
However, this examination is sometimes not effective enough, and the condition can fail to be picked up by doctors, and recent research has shown that two out of three children with the condition failed to be diagnosed by this test first time - babies often have slack limbs as infants due to a hormone circulating in pregnant mothers, plus their muscles are weak at that point anyay, making the examination hard to define - they may be deemed fine yet they might have the condition but it is undetected due to the looseness of their limbs and muscles at that time. This has caused great concern, and health professionals are currently trying to have the examination replaced by ultrasound scanning which is believed to be more reliable, as well as being portable, fairly low cost, and of a non invasive nature.
Blood pressure test for hypertension
There are various causes for hypertension, more commonly known as high blood pressure. There are multiple factors that contribute to the condition, but the main elements are usually the following; salty diet, kidney disease, stress, aging, being overweight, excess alcohol, genetics, and certain medications. Increasingly more young adults are affected by hypertension, whereas the condition used to be thought of as relevant only to middle-aged and older people. GP's are now urged to routinely measure blood pressures of service users when they visit the surgery. Other clients are urged to visit the practice at least once a year to be checked. People with hypertension are advised to attend regular clinics for monitoring purposes. Hypertension increases the chances of life-threatening conditions such as strokes and heart disease, particularly coronary thrombosis.
It is normal to experience raised blood pressure during times of stress or physical exertion - hypertension is when a person has high blood pressure when at rest. Blood pressure rises naturally with age, because of the hardening and narrowing of the elastic arteries. Once the condition is found, the person must work closely with their doctor to determine the best treatment. The primary treatment is change in lifestyle. For example; lowing salt intake, including more potassium, magnesium, and calcium in their diet, limit alcohol intake, quit smoking, lose weight, and take regular exercise. These things will dramatically reduce high blood pressure. However, the reason so many people have high blood pressure, is that a lot of people do not commit to these lifestyle changes, because of the trend for fast living lifestyles, which involve instant high salt high fat ready foods, no time for exercise, and stressful daily life.
Blood pressure is measured electronically as the old mercury devices are now banned. A device for measuring the blood is called a sphygmomanometer or 'sphygmo'. It's usually used on the upper arm over the position of the artery. An inflatable cuff is blown up to stop the blood flowing through the artery and slowly deflated to the point when blood is just about able to push through. This is the systolic pressure and represents the force, which the blood is pressing on the artery walls, when the heart ventricles are contracting. The cuff is further deflated until blood is first flowing naturally and the heartbeat disappears; this is the diastolic pressure measuring the resistance of the arteries against which the heart has to pump blood. This is seen as the most important reading, , as the systolic pressure is often raised due to excitement, anxiety or physical exertion. Individuals should sit quietly before having their blood pressure taken, for purposes of accuracy and effective testing. The two recorded pressures are usually given as a fraction with the larger systolic as the numerator and the diastolic as the denominator. Most healthy young people have a reading of 110/175 or less, although the average is 120/80. Hypertension is quoted to be a BP of 160/95, although this is more guideline than definition. Males are also more often affected by hypertension, although some have the condition with no apparent cause.
The second option, is medication. There are many types of medications for treating hypertension, together called antihypertensives, which act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease. Which type of medication to use initially for hypertension has been the subject of several large studies. Despite thiazides being cheap, effective, and recommended as the best first-line drug for hypertension by many experts, they are not prescribed as often as some newer drugs. Arguably, this is because they are off-patent and thus rarely promoted by the drug industry.
According to a study by Mary P.McGowan, (The Hypertension sourcebook, p7) Commonly used drugs include:
* Beta blockers
* ACE inhibitors
* Angiotension receptor blockers
* Calcium channel blockers
* Diuretics
* Combination products
McGowan staes in her study that, "The aim of treatment should be blood pressure control (<140/90 mmHg for most patients, and lower in certain contexts such as diabetes or kidney disease). Each added drug may reduce the systolic blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure control."
Cancer
According to a study on Cancer by Maria Stroud, (Face to face with Cancer, p15) "Cancer is in fact an umbrella term for more than a hundred diseases in which there uncontrolled growth of body cells. Normal tissues are made up of individual building block cells, which are constantly growing and dividing to replace cells that have died. In a healthy body, cells grow and die at roughly the same rate. However sometimes this system fails allowing some cells to change their shape and grow faster than is needed. This results in a population explosion of cells, and if the body does not deal with them itself, they grow into a lump or tumour." This study will focus on the screening of three cancers in particular; cervical, breast and testicular.
Smear test for cervical cancer
It is recommended by the NHS that the cervical smear test is taken six months after first sexual intercourse, then after one year, and every three years thereafter ideally until the end of their lives. In the UK at present, cervical smear tests cease at the age of sixty-five unless there is a particular reason to continue monitering. The test detects abnormal cells in the cervix; abnormal cells usually indicate a pre-cancerous condition and the smear test has 95% chance of detecting these. Cancer of the cervix is one of the most common cancers in the world and the chances of cure are very much improved with early detection. Herpes simplex and gential warts can also be detected with this screening test.
The method is that; the woman lies on her back, with knees raised and open, and an instrument (speculum) opens the vagina so that a specially shaped spatula can be inserted to scrape off some cells to be smeared on to a microscopic slide. It is a quick test, carried out in well woman and family planning clinics, or by a GP, but the results are not ready for several weeks. When abnomral cells are detected, the test is usually repeated and the abnomrality graded by experts. Sometimes a biopsy is carried out to determine the full nature and extent of the abnormality. When the abnormality is well defined this can be eradicated and destroyed by extreme hot or cold.
The cervical smear test is free under the NHS, a good thing as this should encourage more women to have the test, heightening the chances of early detection and lowering death rates of the disease. However the test is very personal, and a lot of women may be put off due to embarressment and possibly even in some cases, reasons of religion such as Muslim women having to cover their bodies if the GP or health professional is male.
Mammography for breast cancer
A mammography is the screening test for breast cancer. It is an X-ray procedure to screen for breast cancer and lumps. Like the cervical smear test, mammography can reveal small lumps that are not apparent to touch even if the woman practises breast self examination. As with all cancers, early diagnosis is an important factor in the reduction of fatalities from this disease.
The method for mammograohy is the following; each breast in turn is gently compressed between a plastic plate and the X-ray plate to spread the tissue over a wide area. Views are taken in more than one plane. Specialists inspect the X-ray photographs looking for dense masses of tissue. When a lump is found a biopsy is arranged to determine further treatment. Currently most small tumours are surgically removed and combined with radiotherpay and/or anti-cancer drugs.
Mammograohy is available routine screening for anyone aged 40 with a family history of the disease and, for other women, from 50 to 65 years. It is simple, effective and safe as it has a low dose of radiation. Screening should be repeated every three to four years, as this is the most common cancer in women. Mammography is free under the NHS, again encouraging women to have it yet unlike the smear test is less invasive although embarressment could still be an issue for some women.
Physical examination for testicular cancer
Testicular cancer is rare in puberty and old age; it is most common in young adults and middle aged men. Both testes should regularly felt over the whole surface, moving the loose skin of the scrotum from side to side. Any firm lumps, not usually painful or tender should be then be exmained by the GP who will treat any lump as malignant until proven otherwise. Testicular cancer has an extremely good cure rate when caught in the early stages. The physical examination itself is simple and can be done at any time without the presence or assistance of any health professionals, so in theory should be done by all men. However a lot of men fail to check themselves, deeming it unimportant or simply not making the time to. Health awareness campaigns are key to getting out the message to men, and it is felt that they should be more prevalent.
Evaluation
As I have just investigated and reported, there are many diverse screening tests for a variety of conditions and diseases, some straightforward, others rather less so. Yet they all amount to the detection of diseases and conditions hopefully at the earliest possible stage, for the purposes of immediate and most effective treatment.
I can understand from my research into screening that there are principles that all screening tests have in common, if they are to be effective when in use. These are that, they must be inexpensive, so that a great many people can be screened without running out or greatly draining NHS resources, they must be sensetive to minimise the occurrence of false negative, they must be specific to minimise the rate of false positives, they must be simple and straightforward so as not to put off a potential service user when considering the screening in theory, and detection must result in treatment or other action, so as the screening does not become pointless.
I can also evaluate at this point, that although some of these screening tests are free, others not requiring any visit to a health care professional, a lot of people choose not to have them. This is for a number of reasons; They may not have time, as modern living can prove to be hectic and busy. It may also not be conveniant, for example if a single mother lives out of town and cannot get in to take her children to the dentist or GP. In addition, some may actively choose not to, due to embarressment for example with smear tests, as they are very personal and can make the individual feel uncomfortable. Most commonly, people may feel that it is not necessary, only visiting the doctor when they feel physically unwell. Others may feel unwell but are afraid of diagnosis, actual confirmation of a disease resulting in surgery or a course of treatment. Some people from poorer less educated areas may not have the knowledge of the healthcare available to them. Reminders for screening tests may not even reach people, due to change of address. These are some of the denominating factors for people not attending screening tests.
However no matter what cause for the avoidance of screening, essentially early detection is proved to be key for all of the conditions and diseases I have investigated. It is of primary importance for the message of screening as an essential part of lifestyle to become heard, by people of all ages and backgrounds. It is really only then that we can begin to understand, treat and even discover the cause or cure for these conditions, illnesses and diseases.
Bibliography
"Report on Screening"
Helen Lyford-Smith
2nd May 2006
WEBSITES:
* www.wikipedia.co.uk - Most topics
* www.biomedcentral.com/content/ - Medical information, most topics
* http://www.magicfoundation.org/www/docs - Congential hypothyoidism
* www.ncbi.nlm.nih.gov - Congential hypothyoidism
* http://www.nhsdirect.nhs.uk/articles - Most topics
* www.allaboutvision.com - Sight screening (child and adult)
* http://optometry.osu.edu/ - Sight screening (child and adult)
* http://www.bris.ac.uk/news/2003/240 - Sight screening contraversy (child)
* http://www.rnib.org.uk - Research into blindness (sight screening)
* http://www.rnid.org.uk/ - Research into deafness (hearing screening)
BOOKS:
* "An antenatal report" by Mittendorf R, Williams MA,
Publisher : Berkey CS (1990)
* "AS level Health&Social Care" By Neil Moonie,
Publisher: Heinemann (2005)
* "The Hypertension Sourcebook" By Mary P. McGowan MD,
Publisher: Contemporary Books (2001)
* "Face to face with cancer" By Marion Stroud
Publisher: Lion Hudson (2004)
