Quality assurance and risk reduction guidelines

Cervical cancer continues to be a major cause of death in women worldwide. The major problem facing most women is the unavailability of screening Pap tests in poor and underdeveloped countries. While rates of cancer deaths have decreased 60-80% in developed countries since the Pap test became available, the accuracy of Paps was challenged recently. In order to instill public confidence and promote optimal patient care, measures to improve the quality of the entire screening process should be undertaken. Continuous quality improvement processes are more appropriate than traditional quality assurance monitors. Although no standards can be defined that are applicable to all laboratory settings and nations, this document provides current views on universal quality procedures and risk reduction. Procedure/policy manuals, workload assessment, hierarchic/peer review, discrepancy analysis, rescreening studies and cytohistologic correlation are examples of universally applicable quality tools. The variability in practices in different parts of the world is also discussed.     

Bioactive food components and cancer risk reduction

Research over the last three decades has provided convincing evidence to support the premise that diets rich in fruits and vegetables may be protective against the risk of different types of cancers. Initial evidence for protective effect of fruits and vegetables against cancer risk came from population-based case-control studies, which prompted intense research aimed at (a) identification of bioactive component(s) responsible for the anticancer effects of fruits and vegetables, (b) elucidation of the mechanisms by which bioactive food components may prevent cancer, and (c) determination of their efficacy for prevention of cancer in animal models. The bioactive components responsible for cancer chemopreventive effects of various edible plants have now been identified. For instance, anticancer effect of Allium vegetables including garlic is attributed to organosulfur compounds (e.g., diallyl trisulfide). Interestingly, unlike cancer chemotherapy drugs, many bioactive food components selectively target cancer cells. Molecular basis for selectivity of anticancer bioactive food components towards cancer cells remains elusive, but these agents appear promiscuous and target multiple signal transduction pathways to inhibit cancer cell growth in vitro and in vivo. Despite convincing observational and experimental evidence, however, limited effort has been directed towards clinical investigations to determine efficacy of bioactive food components for prevention of human cancers. This article reviews current knowledge on cancer chemopreventive effects of a few highly promising dietary constituents, including garlic-derived organosulfides, berry compounds, and cruciferous vegetable-derived isothiocyanates, and serves to illustrate complexity of the signal transduction mechanisms in cancer chemoprevention by these promising bioactive food components.     

Risk factors and risk reduction of breast cancer

Because of its increasing incidence, breast cancer is a significant burden for women worldwide. In industrialized countries, breast cancer is the second-leading cause of cancer-related deaths among women, and it is estimated that 1 in every 8 women will develop the disease during her lifetime. Sufficient evidence indicates that a number of genetic, environmental and lifestyle risk exposures during life may play important roles in the etiology of this disease. The purpose of this paper is to review some etiologic factors and underlying mechanisms in relation to breast cancer risk. Based on the published literature, there is sufficient evidence that some established factors are associated with breast cancer risk. Age, early age at menarche, late menopause, height, post-menopausal obesity, family history of breast cancer, ionizing radiation, oral contraceptives, hormonal replacement therapy, mammographic density, some gene mutations and clinical conditions, such as benign breast disease, are associated with an increased risk of breast cancer. The risk decreases with early childbearing, high parity and physical activity, and breastfeeding. Alcohol increases the risk, while caloric restriction may confer protection from breast cancer. Epidemiological evidence for other nutritional factors is insufficient. These results suggest that breast cancer is a multifactorial disease where genetic susceptibility, environment, nutrition and other lifestyle risk factors interact. Better identification of modifiable risk factors and risk reduction of breast cancer may allow implementation of useful strategies for prevention.     

Multiple predators induce risk reduction in coexisting vole species

Large predators may affect the hunting efficiency of smaller ones directly by decreasing their numbers, or indirectly by altering their behaviour. Either way this may have positive effects on the density of shared prey. Using large outdoor enclosures, we experimentally studied whether the presence of the Tengmalm's owl Aegolius funereus affects the hunting efficiency of the smallest member of the vole-eating predator guild, the least weasel Mustela nivalis, as measured by population responses of coexisting prey species, the field vole Microtus agrestis and the sibling vole M. levis . We compared the density and survival probability of vole populations exposed to no predation, weasel predation or combined predation by a weasel and an owl. The combined predation of both owl and weasel did not result in obvious changes in the density of sibling and field vole populations compared to the control populations without predators, while predation by least weasel alone decreased the densities of sibling voles and induced a similar trend in field vole densities. Survival of field voles was not affected by predator treatment while sibling vole survival was lower in predator treated populations than in control populations. Our results suggest that weasels are intimidated by avian predators, but without changing the effects of predators on competitive situations between the two vole species. Non-lethal effects of intraguild predation therefore will not necessarily change competitive interactions between shared prey species.     

Design of forest management planning DSS for wildfire risk reduction

Forest management planning is generally a complicated task. The amount of data, information and knowledge involved in the management process is often overwhelming. Decision support systems can help forest managers make well documented decisions concerning forest management planning. These systems include a wide variety of components, depending on the management goals of the forested land. Although an increased growth of decision support systems in specific domains of forest management planning exists, there is no special design model for the deployment of forest management planning. To this direction, this paper has the following objectives: Firstly, to propose a conceptual design model for developing goal-driven forest management planning decision support systems. Secondly, to apply the design model for a particular case of these systems, the wildfire risk reduction decision support systems. Thirdly, to present the deployment of a wildfire risk reduction decision support system as well as its results for a specific forest area.     

A note on the reduction of a risk of death

Abstract

Methods for assessing the gain of life expectancy by reducing the risks of death are examined. Depending on the method used, overestimation and underestimation of life expectancy may occur. Although the gain in life expectancy is not a linear function of the per cent reduction in mortality, a linear approximation may be used when the mortality rate is low. When the mortality rate is high, linear approximations tend to overestimate the years gained. A method using the parameter H⁽ⁱ⁾ developed by Keyfitz (1977) is adequate for low mortality rates such as with neoplasms. However, when mortality rates are high, as they are for cardiovascular‐renal diseases (CVD), Keyfitz's method tends to underestimate the gain in life expectancy. For CVD, Keyfitz's estimation is adequate below the 20 per cent reduction range. The magnitude of overestimation and underestimation are numerically evaluated based on the 1964 United States male mortality statistics.     

Population kinetics of homoarginine and optimized supplementation for cardiovascular risk reduction

Homoarginine is an endogenous amino acid whose levels are reduced in patients with renal, cardio- and cerebrovascular disease. Moreover, low homoarginine concentrations independently predict morbidity and mortality in these patients. Besides endogenous synthesis, homoarginine is also a constituent of the human diet. The objective of the present study was to analyze the kinetics of orally supplemented homoarginine in human plasma by means of a pharmacometric approach. We developed a pharmacometric model to evaluate different dosing regimens, especially the regimen of 125 mg once weekly, based on a previous clinical study (n?=?20). The model was adapted to account for differences in baseline homoarginine plasma concentrations between healthy and diseased individuals. A novel dosing regimen of 25 mg once daily led to higher attainment of homoarginine reference concentrations using clinical trial simulations. With 25 mg/day, the trough concentration of only 6% of the older and 3.8% of the younger population was predicted to be below the target concentration of 2.0–4.1 µmol/L. In synopsis, the new dosing regimen recapitulates the kinetics of homoarginine in healthy individuals optimally.

     

Nutritional interactions in intestinal cadmium uptake - Possibilities for risk reduction

Effects of dietary composition and trace element status on fractional intestinal cadmium uptake is reviewed below. Fractional cadmium uptake is of fundamental importance for internal dose, related individual susceptibility to cadmium, induced renal damage and eventually bone disease. Diet composition with regard to macronutrients has some effects on cadmium bioavailability. Major determinants of intestinal cadmium uptake are however diet composition with regard to crude fibres and trace elements, especially iron. Deficiencies may increase intestinal cadmium uptake 5-8 times. Ultimate risk management would be not to raise crops on cadmium polluted soil. Provisionally, assurance of optimal trace element statusin persons exposed to cadmium is essential for risk reduction.     

Quantitative assessment of risk reduction from hand washing with antibacterial soaps

The Centers for Disease Control and Prevention have estimated that there are 3,713,000 cases of infectious disease associated with day care facilities each year. The objective of this study was to examine the risk reduction achieved from using different soap formulations after diaper changing using a microbial quantitative risk assessment approach. To achieve this, a probability of infection model and an exposure assessment based on micro-organism transfer were used to evaluate the efficacy of different soap formulations in reducing the probability of disease following hand contact with an enteric pathogen. Based on this model, it was determined that the probability of infection ranged from 24/100 to 91/100 for those changing diapers of babies with symptomatic shigellosis who used a control product (soap without an antibacterial ingredient), 22/100 to 91/100 for those who used an antibacterial soap (chlorohexadine 4%), and 15/100 to 90/100 for those who used a triclosan (1.5%) antibacterial soap. Those with asymptomatic shigellosis who used a non-antibacterial control soap had a risk between 49/100,000 and 53/100, those who used the 4% chlorohexadine-containing soap had a risk between 43/100,000 and 51/100, and for those who used a 1.5% triclosan soap had a risk between 21/100,000 and 43/100. The adequate washing of hands after diapering reduces risk and can be further reduced by a factor of 20% by the use of an antibacterial soap. Quantitative risk assessment is a valuable tool in the evaluation of household sanitizing agents and low risk outcomes.     

Long-chain omega 3 fatty acids, blood lipids and cardiovascular risk reduction

Increasing evidence suggests that omega 3 fatty acids derived from fish and fish oils may play a protective role in coronary heart disease and its many complications, through a variety of actions, including effects on lipids, blood pressure, cardiac and vascular function, prostanoids, coagulation and immunological responses. Interesting differences between the effects of highly purified eicosapentaenoic acid and docosahexaenoic acid are emerging, which may be relevant in the choice of omega 3 fatty acid for incorporation into food products. On the basis of our current knowledge, we believe it is justified to recommend, particularly to high-risk populations, an increased dietary intake of omega 3 fatty acids through the consumption of fish.     

A cohort study of breast cancer risk in breast reduction patients.

Surgical reduction of the female breast (reduction mammaplasty) is very common in plastic surgery. The purpose of this study was to determine whether women who have undergone breast reduction surgery are at the same, greater, or lesser risk of developing breast cancer than women who have not undergone breast reduction surgery. This study incorporates a population-based, non-concurrent cohort linkage methodology. The Canadian Institute for Health Information hospital records were used to identify all Ontario women who had undergone breast reduction surgery in Ontario between 1979 and 1992. Three computerized probabilistic record linkages were performed. The first linkage was between a file of the 28,042 Ontario women who had undergone bilateral breast reduction surgery between April 1, 1979, and December 31, 1992, and a file of incident cancer cases among Ontario women for the calendar period 1979 to 1993. Follow-up of the cohort was undertaken starting from the date of breast reduction surgery, and vital status was ascertained as of December 31, 1993, by record linkage with the Ontario Mortality Database maintained at the Ontario Cancer Registry. The incidence of cancer in the Ontario breast reduction cohort was compared with the cancer incidence of the general Ontario population after appropriate adjustments for age and calendar time period. The expected number of cancers was calculated using the "PERSON YEARS" computer program. Within the cohort, followed for an average of 6.5 years after bilateral breast reduction surgery, 101 breast cancers were observed and 165.8 were expected, for a standardized incidence ratio of 0.61 (0.50 to 0.74, 95 percent confidence interval). This effect was independent of patient age at breast reduction. This study demonstrates that there is no increased risk of breast cancer after bilateral breast reduction surgery and, in fact, a significant decreased risk existed in women followed for an average of 6.5 years.     

Cardiac evaluation and risk reduction in patients undergoing major vascular operations.

Occult coronary artery disease often accompanies symptomatic peripheral vascular disease and has an important effect on survival. Most perioperative and late fatalities after peripheral vascular operations are due to cardiac causes. Noninvasive cardiac testing can identify patients at increased risk for postoperative cardiac complications, although controversy exists regarding the optimal preoperative evaluation. Risk reduction strategies for patients known to be at high risk are also controversial. Some authors advocate coronary revascularization with coronary artery bypass grafting or percutaneous transluminal coronary angioplasty before the vascular procedure. Others believe that the combined morbidity and mortality of 2 operations exceed those of a peripheral vascular operation performed with aggressive monitoring and medical therapy. Continuous electrocardiographic monitoring after an operation has identified silent myocardial ischemia as a powerful predictor of cardiac complications. Ongoing research is likely to provide insights into the pathogenesis of postoperative cardiac complications and may lead to specific therapeutic interventions. Few prospective studies have been done in this area, and the threshold for preoperative and postoperative intervention is unknown. I review the literature and present an algorithm to guide cardiac testing and risk reduction in patients undergoing elective vascular surgical procedures.     

Genetic risk of domestication in artificial fish stocking and its possible reduction

Genetic hazards associated with the stocking of fish juveniles produced in hatcheries were studied with simple mathematical models. Domestication is the process of acquiring a genetic characteristics that are advantageous in a hatchery environment but that are disadvantageous in a natural environment due to the selection pressure in the hatchery differing from that in the natural environment. Conditions for the propagation of mutants enhancing domestication were obtained for a variety of stocking strategies specified by parameters related to hatchery productivity and kind of brood stock used. By using this, the possibility of reducing the risk of domestication was studied. As a means of reducing the risk, selective use of wild-born individuals for brood stock was considered. The effectiveness of this was analyzed for both the cases where all brood stock is collected from the wild, and the male brood stock is collected from the wild and the female brood stock is born and reared in a hatchery. We also estimate how much hatchery release can be increased without increasing the risk by employing these means. It is concluded that the use of only male brood stock from the wild is not very effective in reducing the risk of domestication. Further, it is concluded that selective use of the wild-born individuals of both sexes for brood stock is highly desirable if the contribution of released individuals to the natural reproduction is high. In other words, substantial increase of hatchery release may be possible while keeping risk at a level comparable to that under moderate hatchery release, if it is accompanied by the selective use of wild-born individuals for brood stock.