Rapid Evidence Review of Digital Cognitive-Behavioral Therapy for Adolescents With Depression.

PURPOSE: We conducted a rapid evidence review to explore the benefits and harms of digital cognitive-behavioral therapy (dCBT) and the barriers to and facilitators of implementing dCBT for adolescents. METHODS: We searched MEDLINE, PsycINFO, CENTRAL through December 6, 2021, for controlled trials conducted in settings highly applicable to the United States. Additionally, we searched relevant systematic reviews for eligible studies. Results were summarized qualitatively. RESULTS: We included 12 trials (n = 1,575) that examined the effects of nine dCBT programs. Overall, dCBT was slightly superior to comparators in improving depression symptoms immediately post-intervention, but not at a longer follow-up. The use of dCBT did not appear to result in an increased risk for suicidal attempts or ideation; however, the number of events was very small. Potential barriers to implementing/maintaining dCBT are challenges engaging/retaining patients, developing infrastructure, and training therapists to facilitate dCBT. Data on harms or unintended negative consequences were not reported in the included studies. CONCLUSIONS: A limited body of evidence suggests that dCBT programs might outperform control interventions for reducing depressive symptoms immediately post-intervention, but not at a longer follow-up. The safety of dCBT programs for adolescents with depression is understudied.

Primary Care Screening for Abdominal Aortic Aneurysm: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%. Objective: To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019. Study Selection: Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality. Main Outcomes and Measures: AAA and all-cause mortality; AAA rupture; treatment complications. Results: Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124 926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124 929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175 085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124 929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175 085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14 424]) showed that women had higher surgical complications and postoperative mortality compared with men. Conclusions and Relevance: One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Falls are the most common cause of injury-related morbidity and mortality among older adults. Objective: To systematically review literature on the effectiveness and harms of fall prevention interventions in community-dwelling older adults to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials for relevant English-language literature published through August 2016, with ongoing surveillance through February 7, 2018. Study Selection: Randomized clinical trials of interventions to prevent falls in community-dwelling adults 65 years and older. Data Extraction and Synthesis: Independent critical appraisal and data abstraction by 2 reviewers. Random-effects meta-analyses using the method of DerSimonian and Laird. Main Outcomes and Measures: Number of falls (number of unexpected events in which a person comes to rest on the ground, floor, or lower level), people experiencing 1 or more falls, injurious falls, people experiencing injurious falls, fractures, people experiencing fractures, mortality, hospitalizations, institutionalizations, changes in disability, and treatment harms. Results: Sixty-two randomized clinical trials (N = 35 058) examining 7 fall prevention intervention types were identified. This article focused on the 3 most commonly studied intervention types: multifactorial (customized interventions based on initial comprehensive individualized falls risk assessment) (26 trials [n = 15 506]), exercise (21 trials [n = 7297]), and vitamin D supplementation (7 trials [n = 7531]). Multifactorial intervention trials were associated with a reduction in falls (incidence rate ratio [IRR], 0.79 [95% CI, 0.68-0.91]) but were not associated with a reduction in other fall-related morbidity and mortality outcomes. Exercise trials were associated with statistically significant reductions in people experiencing a fall (relative risk, 0.89 [95% 13 CI, 0.81-0.97]) and injurious falls (IRR, 0.81 [95% CI, 0.73-0.90]) and with a statistically nonsignificant reduction in falls (IRR, 0.87 [95% CI, 0.75-1.00]) but showed no association with mortality. Few exercise trials reported fall-related fractures. Seven heterogeneous trials of vitamin D formulations (with or without calcium) showed mixed results. One trial of annual high-dose cholecalciferol (500 000 IU), which has not been replicated, showed an increase in falls, people experiencing a fall, and injuries, while 1 trial of calcitriol showed a reduction in falls and people experiencing a fall; the remaining 5 trials showed no significant difference in falls, people experiencing a fall, or injuries. Harms of multifactorial and exercise trials were rarely reported but generally included minor musculoskeletal injuries. Conclusions and Relevance: Multifactorial and exercise interventions were associated with fall-related benefit, but evidence was most consistent across multiple fall-related outcomes for exercise. Vitamin D supplementation interventions had mixed results, with a high dose being associated with higher rates of fall-related outcomes.

Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence review for the U.S. Preventive Services Task Force.

BACKGROUND: Long-term follow-up of population-based randomized, controlled trials (RCTs) has demonstrated that screening for abdominal aortic aneurysms (AAAs) measuring 3 cm or greater decreases AAA-related mortality rates in men aged 65 years or older. PURPOSE: To systematically review evidence about the benefits and harms of ultrasonography screening for AAAs in asymptomatic primary care patients. DATA SOURCES: MEDLINE, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials (January 2004 through January 2013), clinical trial registries, reference lists, experts, and a targeted bridge search for population-based screening RCTs through September 2013. STUDY SELECTION: English-language, population-based, fair- to good-quality RCTs and large cohort studies for AAA screening benefits as well as RCTs and cohort and registry studies for harms in adults with AAA. DATA EXTRACTION: Dual quality assessment and abstraction of study details and results. DATA SYNTHESIS: Reviews of 4 RCTs involving 137,214 participants demonstrated that 1-time invitation for AAA screening in men aged 65 years or older reduced AAA rupture and AAA-related mortality rates for up to 10 and 15 years, respectively, but had no statistically significant effect on all-cause mortality rates up to 15 years. Screening was associated with more overall and elective surgeries but fewer emergency operations and lower 30-day operative mortality rates at up to 10- to 15-year follow-up. One RCT involving 9342 women showed that screening had no benefit on AAA-related or all-cause mortality rates. LIMITATIONS: Trials included mostly white men outside of the United States. Information for subgroups and about rescreening was limited. CONCLUSION: One-time invitation for AAA screening in men aged 65 years or older was associated with decreased AAA rupture and AAA-related mortality rates but had little or no effect on all-cause mortality rates. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Challenges in synthesizing and interpreting the evidence from a systematic review of multifactorial interventions to prevent functional decline in older adults.

A systematic review of multifactorial assessment and management interventions to prevent functional decline in older adults was undertaken for the U.S. Preventive Services Task Force. It was not possible to determine net benefit because of heterogeneity of studies, including how older adults were selected and their risk of functional decline; the broad spectrum and multifactorial nature of interventions evaluated; the suboptimal and inconsistent use of outcomes measured; and the inconsistent and inadequate reporting of data that might allow comparison of populations, interventions, and outcomes between studies. This review process illustrated the complexities encountered when synthesizing and interpreting the evidence in geriatric research and methods of reviewing complex interventions and multiple interrelated health outcomes. This article summarizes the review findings, focusing on methodological challenges, and offers suggestions to researchers on the design, reporting, and analysis of trials that would help address these challenges and allow for better interpretation of evidence in the future.

Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: Poor diet and lack of physical activity can worsen cardiovascular health, yet most Americans do not meet diet and physical activity recommendations. PURPOSE: To assist the U.S. Preventive Services Task Force in updating its previous recommendations by systematically reviewing trials of physical activity or dietary counseling to prevent cardiovascular disease. DATA SOURCES: MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (2001 to January 2010), experts, and existing systematic reviews. STUDY SELECTION: Two investigators independently reviewed 13 562 abstracts and 481 articles against a set of a priori inclusion criteria and critically appraised each study by using design-specific quality criteria. DATA EXTRACTION AND ANALYSIS: Data from 73 studies (109 articles) were abstracted by one reviewer and checked by a second reviewer. Random-effects meta-analyses were conducted for multiple intermediate health and behavioral outcomes. DATA SYNTHESIS: Long-term observational follow-up of intensive sodium reduction counseling showed a decrease in the incidence of cardiovascular disease; however, other direct evidence for reduction in disease morbidity is lacking. High-intensity dietary counseling, with or without physical activity counseling, resulted in changes of -0.3 to -0.7 kg/m(2) in body mass index (adiposity), -1.5 mm Hg (95% CI, -0.9 to -2.1 mm Hg) in systolic blood pressure, -0.7 mm Hg (CI, -0.6 to -0.9 mm Hg) in diastolic pressure, -0.17 mmol/L (CI, -0.09 to -0.25 mmol/L) (-6.56 mg/dL [CI, -3.47 to -9.65 mg/dL]) in total cholesterol level, and -0.13 mmol/L (CI, -0.06 to -0.21 mmol/L) (-5.02 mg/dL [CI, -2.32 to -8.11 mg/dL]) in low-density lipoprotein cholesterol level. Medium- and high-intensity counseling resulted in moderate to large changes in self-reported dietary and physical activity behaviors. LIMITATIONS: Meta-analyses for some outcomes had large statistical heterogeneity or evidence for publication bias. Only 11 trials followed outcomes beyond 12 months. CONCLUSION: Counseling to improve diet or increase physical activity changed health behaviors and was associated with small improvements in adiposity, blood pressure, and lipid levels. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF.

CONTEXT: Targeted systematic review to support the updated US Preventive Services Task Force (USPSTF) recommendation on screening for obesity in children and adolescents. OBJECTIVES: To examine the benefits and harms of behavioral and pharmacologic weight-management interventions for overweight and obese children and adolescents. METHODS: Our data sources were Ovid Medline, PsycINFO, the Education Resources Information Center, the Database of Abstracts of Reviews of Effects, the Cochrane databases, reference lists of other reviews and trials, and expert recommendations. After 2 investigators reviewed 2786 abstracts and 369 articles against inclusion/exclusion criteria, we included 15 fair- to good-quality trials in which the effects of treatment on weight, weight-related comorbidities, and harms were evaluated. Studies were quality rated by 2 investigators using established criteria. Investigators abstracted data into standard evidence tables. RESULTS: In the available research, obese (or overweight) children and adolescents aged 4 to 18 years were enrolled, and no studies targeted those younger than 4 years. Comprehensive behavioral interventions of medium-to-high intensity were the most effective behavioral approach with 1.9 to 3.3 kg/m(2) difference favoring intervention groups at 12 months. More limited evidence suggests that these improvements can be maintained over the 12 months after the end of treatments and that there are few harms with behavioral interventions. Two medications combined with behavioral interventions resulted in small (0.85 kg/m(2) for orlistat) or moderate (2.6 kg/m(2) for sibutramine) BMI reduction in obese adolescents on active medication; however, no studies followed weight changes after medication use ended. Potential adverse effects were greater than for behavioral interventions alone and varied in severity. Only 1 medication (orlistat) has been approved by the US Food and Drug Administration for prescription use in those aged > or =12 years. CONCLUSIONS: Over the past several years, research into weight management in obese children and adolescents has improved in quality and quantity. Despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents.

Screening for depression in adult patients in primary care settings: a systematic evidence review.

BACKGROUND: In primary care settings, prevalence estimates of major depressive disorder range from 5% to 13% in all adults, with lower estimates in those older than 55 years (6% to 9%). In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems to ensure accurate diagnosis, effective treatment, and follow-up. PURPOSE: To conduct a targeted, updated systematic review for the U.S. Preventive Services Task Force about the benefits and harms of screening adult patients for depression in a primary care setting, the benefits of depression treatment in older adults, and the harms of depression treatment with antidepressant medications. DATA SOURCES: MEDLINE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO (1998 to 2007), expert suggestions, and bibliographies of recent systematic reviews. STUDY SELECTION: Fair- to good-quality randomized clinical trials or controlled clinical trials; systematic reviews; meta-analyses; and large observational studies of serious adverse events and early discontinuation due to adverse effects. All studies were published in English. DATA EXTRACTION: Two investigators abstracted, critically appraised, and synthesized 33 articles that met inclusion criteria. DATA SYNTHESIS: Nine fair- or good-quality trials indicate that primary care depression screening and care management programs with staff assistance, such as case management or mental health specialist involvement, can increase depression response and remission. Benefit was not evident in screening programs without staff assistance in depression care. Seven regulatory reviews or meta-analyses and 3 large cohort studies indicate no increased risk for completed suicide deaths with antidepressant treatment. Risk for suicidal behaviors was increased in young adults (aged 18 to 29 years) who received antidepressants, particularly those who received paroxetine, but was reduced in older adults. LIMITATION: Examination of harms was limited to serious adverse events, and existing systematic reviews were primarily used. Additional studies published from 2007 to 2008 extend this review. CONCLUSION: Depression screening programs without substantial staff-assisted depression care supports are unlikely to improve depression outcomes. Close monitoring of all adult patients who initiate antidepressant treatment, particularly those younger than 30 years, is important both for safety and to ensure optimal treatment.

Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended colorectal cancer screening for adults 50 years of age or older but concluded that evidence was insufficient to prioritize among screening tests or evaluate newer tests, such as computed tomographic (CT) colonography. PURPOSE: To review evidence related to knowledge gaps identified by the 2002 recommendation and to consider community performance of screening endoscopy, including harms. DATA SOURCES: MEDLINE, Cochrane Library, expert suggestions, and bibliographic reviews. STUDY SELECTION: Eligible studies reported performance of colorectal cancer screening tests or health outcomes in average-risk populations and were at least of fair quality according to design-specific USPSTF criteria, as determined by 2 reviewers. DATA EXTRACTION: Two reviewers verified extracted data. DATA SYNTHESIS: Four fecal immunochemical tests have superior sensitivity (range, 61% to 91%), and some have similar specificity (97% to 98%), to the Hemoccult II fecal occult blood test (Beckman Coulter, Fullerton, California). Tradeoffs between superior sensitivity and reduced specificity occur with high-sensitivity guaiac tests and fecal DNA, with other important uncertainties for fecal DNA. In settings with sufficient quality control, CT colonography is as sensitive as colonoscopy for large adenomas and colorectal cancer. Uncertainties remain for smaller polyps and frequency of colonoscopy referral. We did not find good estimates of community endoscopy accuracy; serious harms occur in 2.8 per 1000 screening colonoscopies and are 10-fold less common with flexible sigmoidoscopy. LIMITATION: The accuracy and harms of screening tests were reviewed after only a single application. CONCLUSION: Fecal tests with better sensitivity and similar specificity are reasonable substitutes for traditional fecal occult blood testing, although modeling may be needed to determine all tradeoffs. Computed tomographic colonography seems as likely as colonoscopy to detect lesions 10 mm or greater but may be less sensitive for smaller adenomas. Potential radiation-related harms, the effect of extracolonic findings, and the accuracy of test performance of CT colonography in community settings remain uncertain. Emphasis on quality standards is important for implementing any operator-dependent colorectal cancer screening test.

Screening for gestational diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: In 2003, the U.S. Preventive Services Task Force concluded that evidence was insufficient to advise for or against routinely screening all pregnant women for gestational diabetes mellitus. PURPOSE: To review evidence about the benefits and harms of screening for gestational diabetes. DATA SOURCES: Databases (MEDLINE, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, National Institute for Health and Clinical Effectiveness, and Cochrane Library) were searched for reports published from January 2000 to 15 November 2007 (and from 1966 to 1999 for additional studies on screening at less than 24 weeks' gestation), citations in the 2003 evidence report, and studies identified through consultation of experts and searches of bibliographies. STUDY SELECTION: English-language studies that used standard 1- or 2-step testing for gestational diabetes and that evaluated at least 1 of the following outcomes: neonatal mortality; brachial plexus injury; clavicular fracture; admission to a neonatal intensive care unit for hypoglycemia, hyperbilirubinemia, or the respiratory distress syndrome; maternal mortality; and preeclampsia or pregnancy-induced hypertension. DATA EXTRACTION: 2 reviewers evaluated 1607 abstracts, critically appraised 288 articles, and qualitatively synthesized 13 studies. DATA SYNTHESIS: No randomized, controlled trials that directly evaluated the risks and benefits of gestational diabetes screening were found. One good-quality randomized, controlled trial of treatment of mild gestational diabetes in a screening-detected population supported a reduction in serious neonatal complications and showed that gestational diabetes treatment also reduced the risk for gestational hypertension. Very limited evidence was found to evaluate early screening for gestational diabetes (before 24 weeks' gestation). Limited evidence suggests that serious maternal hypoglycemia is rare with treatment and that overall quality of life is not worse among women receiving gestational diabetes treatment compared with women not receiving treatment. LIMITATION: The literature is limited by lack of a consistent standard for screening or diagnosis of gestational diabetes. CONCLUSION: Limited evidence suggests that gestational diabetes treatment after 24 weeks improves some maternal and neonatal outcomes. Evidence is even more sparse for screening before 24 weeks' gestation.

Effectiveness of weight management programs in children and adolescents.

OBJECTIVES: To examine available behavioral, pharmacological, and surgical weight management interventions for overweight (defined as BMI > 85th to 94th percentile of age and sex-specific norms) and/or obese (BMI > 95th percentile) children and adolescents in clinical and nonclinical community settings. DATA SOURCES: We identified two good quality recent systematic reviews that addressed our research questions. We searched Ovid MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Education Resources Information Center from 2005 (2003 for pharmacological studies) to December 11, 2007, to identify literature that was published after the search dates of prior relevant systematic reviews; we also examined reference lists of five other good-quality systematic reviews and of included trials, and considered experts' recommendations. We identified two good quality systematic reviews and 2,355 abstracts from which we identified 45 primary studies and trials that addressed our research questions. REVIEW METHODS: After review by two investigators against pre-determined inclusion/exclusion criteria, we included existing good-quality systematic reviews, fair-to-good quality trials, and case series (for bariatric surgeries only) to evaluate the effects of treatment on weight and weight-related co-morbidities; we would have included large comparative cohort studies to evaluate longer term followup and harms of behavioral and pharmaceutical treatment and noncomparative cohort studies for surgical treatments if they had been available. Investigators abstracted data into standard evidence tables with abstraction checked by a second investigator. Studies were quality-rated by two investigators using established criteria. RESULTS: Available research primarily enrolled obese (but not overweight) children and adolescents aged 5 to 18 years and no studies targeted those less than 5 years of age. Behavioral interventions in schools or specialty health care settings can result in small to moderate short-term improvements. Absolute or relative weight change associated with behavioral interventions in these settings is generally modest and varies by treatment intensity and setting. More limited evidence suggests that these improvements can be maintained completely (or somewhat) over the 12 months following the end of treatments and that there are few harms with behavioral interventions. Two medications (sibutramine, orlistat) combined with behavioral interventions can result in small to moderate short-term weight loss in obese adolescents with potential side effects that range in severity. Among highly selected morbidly obese adolescents, very limited data from case series suggest bariatric surgical interventions can lead to moderate to substantial weight loss in the short term and to some immediate health benefits through resolution of comorbidities, such as sleep apnea or asthma. Harms vary by procedure. Short-term severe complications are reported in about 5 percent and less severe short-term complications occur in 10 to 39 percent. Very few cases provide data to determine either beneficial or harmful consequences more than 12 months after surgery. CONCLUSIONS: The research evaluating the treatment of obese children and adolescents has improved in terms of quality and quantity in the past several years. While there are still significant gaps in our understanding of obesity treatment in children and adolescents, the current body of research points the way to further improvements needed to inform robust policy development. Publication of additional research and policy activities by others, including the U.S. Preventive Services Task Force, is expected in the near future. And, in considering this important public health issue, policymakers should not ignore the importance of obesity prevention efforts as well as treatment.

Counseling about proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving: a systematic evidence review for the U.S. Preventive Services Task Force.

BACKGROUND: Motor vehicle-related injuries are the leading cause of death among children, adolescents, and young adults. PURPOSE: To systematically review evidence of the effectiveness of counseling people of any age in primary care settings about occupant restraints or alcohol-related driving to prevent injuries. DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, CINAHL, and Traffic Research Information Service; published systematic evidence reviews; experts; and bibliographies of selected trials. STUDY SELECTION: Randomized, controlled trials (RCTs); controlled clinical trials (CCTs); or comparative observational research studies that evaluated behavioral counseling interventions feasible to conduct in primary care or referral from primary care. DATA EXTRACTION: Investigators abstracted data on study design, setting, patients, interventions, outcomes, and quality-related study details. DATA SYNTHESIS: Trials report that counseling to increase the use of child safety seats leads to increased short-term restraint use (7 CCTs, 6 RCTs). Interventions that included a demonstration of correct use or distribution of a free or reduced-cost child safety seat reported larger effects. Few trials described the effect of counseling children 4 to 8 years of age to use booster seats (1 RCT); counseling older children, adolescents, or adults to use seat belts (1 CCT, 2 RCTs); or counseling unselected primary care patients to reduce alcohol-related driving behaviors (no trials). LIMITATIONS: Most of the relevant trials were published before the widespread enactment of child safety seat legislation and had methodological flaws. CONCLUSIONS: The incremental effect of primary care counseling to increase the correct use of child safety seats in the current regulatory environment is not established. The effectiveness of primary care counseling to reduce alcohol-related driving has not been tested. Studies are needed.

Screening for hereditary hemochromatosis: a systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) has not previously considered screening for hereditary hemochromatosis for a recommendation as a clinical preventive service for primary care clinicians. PURPOSE: To conduct a focused systematic review of hereditary hemochromatosis screening relating to 2 USPSTF criteria, the burden of suffering and the potential effectiveness of a preventive intervention, to determine whether evidence is sufficient for a USPSTF recommendation. DATA SOURCES: MEDLINE, CINAHL, and Cochrane Library databases from 1966 through February 2005. The authors supplemented literature searches with source materials from experts in the field and the bibliographies of key reviews and included studies. STUDY SELECTION: Studies were retrieved to answer 3 key questions: 1) What is the risk for developing clinical hemochromatosis among those with a homozygous C282Y genotype? 2) Does earlier therapeutic phlebotomy of individuals with primary iron overload due to hereditary hemochromatosis reduce morbidity and mortality compared with treatment after diagnosis in routine clinical care? 3) Are there groups at increased risk for developing hereditary hemochromatosis that can be readily identified before genetic screening? The authors critically appraised studies using quality criteria specific to their design. DATA EXTRACTION: The authors abstracted all studies into evidence tables using condition definitions and diagnostic criteria. DATA SYNTHESIS: Data were insufficient to define a very precise estimate of penetrance. Available data suggest that up to 38% to 50% of C282Y homozygotes may develop iron overload, with up to 10% to 33% eventually developing hemochromatosis-associated morbidity. Prevalence of C282Y homozygosity is higher in family members of probands and other high-risk patient groups defined by signs, symptoms, and phenotypic screening. LIMITATIONS: This review considered genetic screening for HFE-related hereditary hemochromatosis in C282Y homozygotes only. Available research is limited, is based solely on observational designs, and is plagued by poor or inconsistent reporting. CONCLUSIONS: Research addressing genetic screening for hereditary hemochromatosis remains insufficient to confidently project the impact of, or estimate the benefit from, widespread or high-risk genetic screening for hereditary hemochromatosis.

Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: While the prognosis for abdominal aortic aneurysm (AAA) rupture is poor, ultrasound imaging is an accurate and reliable test for detecting AAAs before rupture. PURPOSE: To examine the benefits and harms of population-based AAA screening. DATA SOURCES: MEDLINE (1994 to July 2004) supplemented by the Cochrane Library, a reference list of retrieved articles, and expert suggestions. STUDY SELECTION: Randomized trials of AAA population screening, population studies of AAA risk factors, and data on adverse screening and treatment events from randomized trials and cohort studies. DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined criteria. DATA SYNTHESIS: The authors identified 4 population-based randomized, controlled trials of AAA screening in men 65 years of age and older. On the basis of meta-analysis, an invitation to attend screening was associated with a significant reduction in AAA-related mortality (odds ratio, 0.57 [95% CI, 0.45 to 0.74]). A meta-analysis of 3 trials revealed no significant difference in all-cause mortality (odds ratio, 0.98 [CI, 0.95 to 1.02]). No significant reduction in AAA-related mortality was found in 1 study of AAA screening in women. Screening does not appear to be associated with significant physical or psychological harms. Major treatment harms include an operative mortality rate of 2% to 6% and significant risk for major complications. LIMITATIONS: The population screening studies focused on men and provided no information on racial or ethnic groups. No information was available on uninvited control group characteristics, so the importance of risk factors such as tobacco use or family history could not be assessed. Since all trials were conducted in countries other than the United States, generalizability to the U.S. population is uncertain. CONCLUSION: For men age 65 to 75 years, an invitation to attend AAA screening reduces AAA-related mortality.

Comparison of interface pressures with pin and suction suspension systems.

A common mode of limb suspension for transtibial amputees is the pin liner/shuttle lock system. Despite its popularity, some clinicians question its use because of observed daily and chronic changes to the residual limb. For this study, we measured limb interface pressures during ambulation with pin and suction suspension systems. No pressure differences were seen between the modes of suspension during stance phase. However, during swing phase, pin suspension maintained an average occlusive compressive pressure of 6.7 kPa on the proximal tissues, as compared to the subocclusive pressure of 1.1 kPa with suction suspension. Simultaneously, pin suspension elevated the peak magnitude of suction to -39.5 kPa at the distal residual limb, compared to -26.1 kPa with suction suspension. During swing phase, the pin liner squeezes proximally while creating a large suction distally on the residual limb and is the likely cause of daily and chronic skin changes observed in pin users.

Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets.

Interface pressures were measured during ambulation with a normal total-surface weight-bearing suction socket and a vacuum-assisted socket. The vacuum-assisted socket has been shown to eliminate daily volume loss. Urethane liners were instrumented with five force-sensing resistors to measure positive pressures and one air pressure sensor at the distal end of the liner to document negative pressures. Nine unilateral transtibial amputees participated in the study. The vacuum-assisted socket created significantly lower positive-pressure impulse (42.8, 39.6 kPa x s) and peak pressures (83.5, 80.0 kPa) during the stance phase. The pressure impulse (-10.5, -13.3 kPa x s), average (-21.2, -26.5 kPa), and peak (-28.5, -36.3 kPa) negative pressures during swing phase were significantly greater in magnitude with the vacuum-assisted socket. We believe that lower positive pressures seen during stance using the vacuum-assisted socket reduces the fluid forced out and greater negative pressures seen during swing increases the amount of fluid drawn into the limb, thereby preventing volume loss.