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1.
Circ Cardiovasc Qual Outcomes ; : CIRCOUTCOMES119006127, 2020 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-32252549

RESUMO

Background Fetal aortic valvuloplasty (FAV) may prevent progression of midgestation aortic stenosis to hypoplastic left heart syndrome. However, FAV has well-established risks, and its survival benefit remains unknown. Our primary aim was to determine whether FAV for midgestation aortic stenosis increases survival from fetal diagnosis to age 6 years. Methods and Results We performed a retrospective analysis of 143 fetuses who underwent FAV from 2000 to 2017 and a secondary analysis of the Pediatric Heart Network Single Ventricle Reconstruction trial. Using these results, we developed a decision model to estimate probability of transplant-free survival from fetal diagnosis to age 6 years and postnatal restricted mean transplant-free survival time. FAV was technically successful in 84% of 143 fetuses with fetal demise in 8%. Biventricular circulation was achieved in 50% of 111 live-born infants with successful FAV but in only 16% of the 19 patients with unsuccessful FAV. The model projected overlapping probabilities of transplant-free survival to age 6 years at 75% (95% CI, 67%-82%) with FAV versus 72% (95% CI, 61%-82%) with expectant fetal management, resulting in a restricted mean transplant-free survival time benefit of 1.2 months. When limiting analyses to the improved FAV experience since 2009 to reflect current practice, (probability of technical success [94%], fetal demise [4%], and biventricular circulation [66%]), the model projected that FAV increased the probability of survival to age 6 years to 82% (95% CI, 73%-89%). Expectant management is favored if risk of fetal demise exceeded 12% or probability of biventricular circulation fell below 26%, but FAV remained favored over plausible recent range of technical success. Conclusions Our model suggests that FAV provides a modest, medium-term survival benefit over expectant fetal management. Appropriate patient selection and low risk of fetal demise with FAV are critical factors for obtaining a survival benefit.

2.
JAMA ; 2020 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-32119076

RESUMO

Importance: Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US and a leading cause of complications from chronic liver disease. HCV is associated with more deaths than the top 60 other reportable infectious diseases combined, including HIV. Cases of acute HCV infection have increased approximately 3.8-fold over the last decade because of increasing injection drug use and improved surveillance. Objective: To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on screening for HCV infection in adolescents and adults. Population: This recommendation applies to all asymptomatic adults aged 18 to 79 years without known liver disease. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit. Recommendation: The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years. (B recommendation).

3.
JAMA ; 323(8): 757-763, 2020 02 25.
Artigo em Inglês | MEDLINE | ID: mdl-32096858

RESUMO

Importance: Dementia (also known as major neurocognitive disorder) is defined by a significant decline in 1 or more cognitive domains that interferes with a person's independence in daily activities. Dementia affects an estimated 2.4 to 5.5 million individuals in the United States, and its prevalence increases with age. Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on screening for cognitive impairment, including mild cognitive impairment and mild to moderate dementia, in community-dwelling adults, including those 65 years or older residing in independent living facilities. Population: This recommendation applies to community-dwelling older adults 65 years or older, without recognized signs or symptoms of cognitive impairment. Evidence Assessment: The USPSTF concludes that the evidence is lacking, and the balance of benefits and harms of screening for cognitive impairment cannot be determined. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults. (I statement).


Assuntos
Disfunção Cognitiva/diagnóstico , Demência/diagnóstico , Programas de Rastreamento , Idoso , Disfunção Cognitiva/terapia , Demência/terapia , Diagnóstico Precoce , Humanos , Vida Independente , Programas de Rastreamento/efeitos adversos , Testes Neuropsicológicos , Sensibilidade e Especificidade
4.
Hepatology ; 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31803945

RESUMO

Hepatitis C (HCV) and alcohol use are patient risk factors for accelerated fibrosis progression, yet few randomized controlled trials have tested clinic-based alcohol interventions. 181 patients with HCV and qualifying alcohol screener scores at three liver center settings were randomly assigned to: 1) medical provider-delivered Screening, Brief Intervention, and Referral to Treatment (SBIRT), including motivational interviewing counseling and referral out for alcohol treatment (SBIRT-only), or 2) SBIRT plus six months of integrated co-located alcohol therapy (SBIRT+Alcohol Treatment). The Timeline Followback Method assessed alcohol use at baseline, 3, 6, and 12 months. Co-primary outcomes were alcohol abstinence at 6 months and heavy drinking days between 6 and 12 months. Secondary outcomes included grams of alcohol consumed per week at 6 months. Mean therapy hours across six months were 8.8 for SBIRT-only and 10.1 for SBIRT+Alcohol Treatment participants. The proportion of participants exhibiting full alcohol abstinence increased from baseline to 3, 6, and 12 months in both treatment arms, but no significant differences were found between arms (baseline to 6 months, 7.1% to 20.5% for SBIRT-only; 4.2% to 23.3% for SBIRT+Alcohol Treatment; p=0.70). Proportions of participants with any heavy drinking days decreased in both groups at 6 months but did not significantly differ between the SBIRT-only (87.5% to 26.7%) and SBIRT+Alcohol Treatment (85.7% to 42.1%) arms (p=0.30). Although both arms reduced average grams of alcohol consumed per week from baseline to 6 and 12 months, between-treatment effects were not significant. Conclusion: Patients with current or prior HCV-infection will engage in alcohol treatment when encouraged by liver medical providers. Liver clinics should consider implementing provider-delivered SBIRT and tailored alcohol treatment referrals as part of standard of care.

5.
JAMA ; 322(22): 2211-2218, 2019 12 10.
Artigo em Inglês | MEDLINE | ID: mdl-31821437

RESUMO

Importance: An abdominal aortic aneurysm (AAA) is typically defined as aortic enlargement with a diameter of 3.0 cm or larger. The prevalence of AAA has declined over the past 2 decades among screened men 65 years or older in various European countries. The current prevalence of AAA in the United States is unclear because of the low uptake of screening. Most AAAs are asymptomatic until they rupture. Although the risk for rupture varies greatly by aneurysm size, the associated risk for death with rupture is as high as 81%. Objective: To update its 2014 recommendation, the USPSTF commissioned a review of the evidence on the effectiveness of 1-time and repeated screening for AAA, the associated harms of screening, and the benefits and harms of available treatments for small AAAs (3.0-5.4 cm in diameter) identified through screening. Population: This recommendation applies to asymptomatic adults 50 years or older. However, the randomized trial evidence focuses almost entirely on men aged 65 to 75 years. Evidence Assessment: Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have ever smoked is of moderate net benefit. The USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have never smoked is of small net benefit. The USPSTF concludes that the evidence is insufficient to determine the net benefit of screening for AAA in women aged 65 to 75 years who have ever smoked or have a family history of AAA. The USPSTF concludes with moderate certainty that the harms of screening for AAA in women aged 65 to 75 years who have never smoked and have no family history of AAA outweigh the benefits. Recommendations: The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked. (B recommendation) The USPSTF recommends that clinicians selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked rather than routinely screening all men in this group. (C recommendation) The USPSTF recommends against routine screening for AAA with ultrasonography in women who have never smoked and have no family history of AAA. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA with ultrasonography in women aged 65 to 75 years who have ever smoked or have a family history of AAA. (I statement).


Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Programas de Rastreamento , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/etiologia , Feminino , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fumar , Ultrassonografia
6.
Ann Intern Med ; 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31842205
7.
Ann Intern Med ; 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31711094

RESUMO

The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed to promote the conduct of, and provide guidance for, predictive analyses of heterogeneity of treatment effects (HTE) in clinical trials. The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risk with versus without the intervention, taking into account all relevant patient attributes simultaneously, to support more personalized clinical decision making than can be made on the basis of only an overall average treatment effect. The authors distinguished 2 categories of predictive HTE approaches (a "risk-modeling" and an "effect-modeling" approach) and developed 4 sets of guidance statements: criteria to determine when risk-modeling approaches are likely to identify clinically meaningful HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. They discuss limitations of these methods and enumerate research priorities for advancing methods designed to generate more personalized evidence. This explanation and elaboration document describes the intent and rationale of each recommendation and discusses related analytic considerations, caveats, and reservations.

8.
Ann Intern Med ; 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31711134

RESUMO

Heterogeneity of treatment effect (HTE) refers to the nonrandom variation in the magnitude or direction of a treatment effect across levels of a covariate, as measured on a selected scale, against a clinical outcome. In randomized controlled trials (RCTs), HTE is typically examined through a subgroup analysis that contrasts effects in groups of patients defined "1 variable at a time" (for example, male vs. female or old vs. young). The authors of this statement present guidance on an alternative approach to HTE analysis, "predictive HTE analysis." The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risks with versus without the intervention, taking into account all relevant patient attributes simultaneously. The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed using a multidisciplinary technical expert panel, targeted literature reviews, simulations to characterize potential problems with predictive approaches, and a deliberative process engaging the expert panel. The authors distinguish 2 categories of predictive HTE approaches: a "risk-modeling" approach, wherein a multivariable model predicts the risk for an outcome and is applied to disaggregate patients within RCTs to define risk-based variation in benefit, and an "effect-modeling" approach, wherein a model is developed on RCT data by incorporating a term for treatment assignment and interactions between treatment and baseline covariates. Both approaches can be used to predict differential absolute treatment effects, the most relevant scale for clinical decision making. The authors developed 4 sets of guidance: criteria to determine when risk-modeling approaches are likely to identify clinically important HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. The PATH Statement, together with its explanation and elaboration document, may guide future analyses and reporting of RCTs.

9.
ACR Open Rheumatol ; 1(3): 188-193, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31777794

RESUMO

Objective: Because the American College of Rheumatology (ACR) practice guidelines affect the United States' and international treatment practice, we used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to characterize the quality of the guidelines and to identify potential areas for improvement. Methods: Using the six quality domains in the AGREE II online tool, four reviewers assessed the practice guidelines available at the ACR website and the immediately previous version to summarize the domain scores for each guideline and examine trends over time. Results: As of April 2016, the ACR website listed nine guidelines, four with immediate previous versions. Based on AGREE II, the minimum and maximum for each domain (with higher being better) of the current guidelines were 78-99 for Scope and Purpose, 57-99 for Stakeholder Involvement, 87- 96 for Rigor of the Methodology, 83-99 for Clarity of Presentation, 49-78 for Applicability, 69-85 for Editorial Independence, and 71-96 overall. Over time, although the average domain quality of the guidelines improved for all, the Applicability and Editorial Independence domains had the least amount of improvement. For the four guidelines with previous versions, the mean (SD) absolute improvements for each domain were 18 (±11) for Scope and Purpose, 13 (±8) for Stakeholder Involvement, 38 (±22) for Rigor of the Methodology, 25 (±15) for Clarity of Presentation, 22 (±12) for Applicability, 24 (±17) for Editorial Independence, and 31 (±5) overall. Conclusion: Based on the AGREE II instrument, the ACR guidelines have achieved high quality over the past 16 years. The Applicability and Editorial Independence domains have the greatest potential for future improvement.

10.
Am J Prev Med ; 57(5): e143-e152, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31564600

RESUMO

INTRODUCTION: Processed meats are associated with increased risk of colorectal and stomach cancers, but health and economic impacts of policies to discourage processed meats are not well established. This paper aims to evaluate the cost effectiveness of implementing tax and warning labels on processed meats. METHODS: A probabilistic cohort-state transition model was developed in 2018, including lifetime and short-term horizons, healthcare, and societal perspectives, and 3% discount rates for costs and health outcomes. The model simulated 32 subgroups by age, gender, and race/ethnicity from the U.S. adult population and integrated nationally representative 2011-2014 data on processed meat consumption, with etiologic effects of processed meat consumption on cancer incidence, medical and indirect societal costs, and policy costs. RESULTS: Over a lifetime, the 10% excise tax would prevent 77,000 cases of colorectal cancer (95% uncertainty interval=56,800, 107,000) and 12,500 cases of stomach cancer (95% uncertainty interval=6,880, 23,900), add 593,000 quality-adjusted life years (95% uncertainty interval=419,000, 827,000), and generate net savings of $2.7 billion from a societal perspective, including $1.1 billion healthcare costs saved. The warning label policy would avert 85,400 cases of colorectal cancer (95% uncertainty interval=56,600, 141,000) and 15,000 cases of stomach cancer (95% uncertainty interval=6,860, 34,500), and add 660,000 quality-adjusted life years (95% uncertainty interval=418,000, 1,070,000), with net savings of $4.5 billion from a societal perspective, including $1.3 billion healthcare costs saved. In subgroup analyses, greater health and economic benefits accrued to (1) younger subpopulations, (2) subpopulations with greater cancer risk, and (3) those with higher baseline processed meat consumption. CONCLUSIONS: The model shows that implementing tax or warning labels on processed meats would be a cost-saving strategy with substantial health and economic benefits. The findings should encourage policy makers to consider nutrition-related policies to reduce cancer burden.

11.
JAMA ; 322(12): 1188-1194, 2019 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-31550038

RESUMO

Importance: Among the general adult population, women (across all ages) have the highest prevalence of asymptomatic bacteriuria, although rates increase with age among both men and women. Asymptomatic bacteriuria is present in an estimated 1% to 6% of premenopausal women and an estimated 2% to 10% of pregnant women and is associated with pyelonephritis, one of the most common nonobstetric reasons for hospitalization in pregnant women. Among pregnant persons, pyelonephritis is associated with perinatal complications including septicemia, respiratory distress, low birth weight, and spontaneous preterm birth. Objective: To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on potential benefits and harms of screening for and treatment of asymptomatic bacteriuria in adults, including pregnant persons. Population: This recommendation applies to community-dwelling adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection. Evidence Assessment: Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has moderate net benefit in reducing perinatal complications. There is adequate evidence that pyelonephritis in pregnancy is associated with negative maternal outcomes and that treatment of screen-detected asymptomatic bacteriuria can reduce the incidence of pyelonephritis in pregnant persons. The USPSTF found adequate evidence of harms associated with treatment of asymptomatic bacteriuria (including adverse effects of antibiotic treatment and changes in the microbiome) to be at least small in magnitude. The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in nonpregnant adults has no net benefit. The known harms associated with treatment include adverse effects of antibiotic use and changes to the microbiome. Based on these known harms, the USPSTF determined the overall harms to be at least small in this group. Recommendations: The USPSTF recommends screening pregnant persons for asymptomatic bacteriuria using urine culture. (B recommendation) The USPSTF recommends against screening for asymptomatic bacteriuria in nonpregnant adults. (D recommendation).


Assuntos
Bacteriúria/diagnóstico , Programas de Rastreamento/normas , Complicações Infecciosas na Gravidez/diagnóstico , Adulto , Antibacterianos/efeitos adversos , Antibacterianos/uso terapêutico , Bacteriúria/tratamento farmacológico , Feminino , Humanos , Masculino , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , Pielonefrite/prevenção & controle , Fatores de Risco , Infecções Urinárias/diagnóstico
12.
JAMA ; 322(9): 857-867, 2019 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-31479144

RESUMO

Importance: Breast cancer is the most common nonskin cancer among women in the United States and the second leading cause of cancer death. The median age at diagnosis is 62 years, and an estimated 1 in 8 women will develop breast cancer at some point in their lifetime. African American women are more likely to die of breast cancer compared with women of other races. Objective: To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on medications for risk reduction of primary breast cancer. Evidence Review: The USPSTF reviewed evidence on the accuracy of risk assessment methods to identify women who could benefit from risk-reducing medications for breast cancer, as well as evidence on the effectiveness, adverse effects, and subgroup variations of these medications. The USPSTF reviewed evidence from randomized trials, observational studies, and diagnostic accuracy studies of risk stratification models in women without preexisting breast cancer or ductal carcinoma in situ. Findings: The USPSTF found convincing evidence that risk assessment tools can predict the number of cases of breast cancer expected to develop in a population. However, these risk assessment tools perform modestly at best in discriminating between individual women who will or will not develop breast cancer. The USPSTF found convincing evidence that risk-reducing medications (tamoxifen, raloxifene, or aromatase inhibitors) provide at least a moderate benefit in reducing risk for invasive estrogen receptor-positive breast cancer in postmenopausal women at increased risk for breast cancer. The USPSTF found that the benefits of taking tamoxifen, raloxifene, and aromatase inhibitors to reduce risk for breast cancer are no greater than small in women not at increased risk for the disease. The USPSTF found convincing evidence that tamoxifen and raloxifene and adequate evidence that aromatase inhibitors are associated with small to moderate harms. Overall, the USPSTF determined that the net benefit of taking medications to reduce risk of breast cancer is larger in women who have a greater risk for developing breast cancer. Conclusions and Recommendation: The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. (B recommendation) The USPSTF recommends against the routine use of risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, in women who are not at increased risk for breast cancer. (D recommendation) This recommendation applies to asymptomatic women 35 years and older, including women with previous benign breast lesions on biopsy (such as atypical ductal or lobular hyperplasia and lobular carcinoma in situ). This recommendation does not apply to women who have a current or previous diagnosis of breast cancer or ductal carcinoma in situ.


Assuntos
Inibidores da Aromatase/uso terapêutico , Neoplasias da Mama/prevenção & controle , Moduladores Seletivos de Receptor Estrogênico/uso terapêutico , Tamoxifeno/uso terapêutico , Adulto , Neoplasias da Mama/genética , Feminino , Genes BRCA1 , Genes BRCA2 , Humanos , Pessoa de Meia-Idade , Mutação , Cloridrato de Raloxifeno/uso terapêutico , Medição de Risco/métodos , Fatores de Risco
13.
J Clin Transl Sci ; 3(1): 27-36, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31404154

RESUMO

Background: To enhance enrollment into randomized clinical trials (RCTs), we proposed electronic health record-based clinical decision support for patient-clinician shared decision-making about care and RCT enrollment, based on "mathematical equipoise." Objectives: As an example, we created the Knee Osteoarthritis Mathematical Equipoise Tool (KOMET) to determine the presence of patient-specific equipoise between treatments for the choice between total knee replacement (TKR) and nonsurgical treatment of advanced knee osteoarthritis. Methods: With input from patients and clinicians about important pain and physical function treatment outcomes, we created a database from non-RCT sources of knee osteoarthritis outcomes. We then developed multivariable linear regression models that predict 1-year individual-patient knee pain and physical function outcomes for TKR and for nonsurgical treatment. These predictions allowed detecting mathematical equipoise between these two options for patients eligible for TKR. Decision support software was developed to graphically illustrate, for a given patient, the degree of overlap of pain and functional outcomes between the treatments and was pilot tested for usability, responsiveness, and as support for shared decision-making. Results: The KOMET predictive regression model for knee pain had four patient-specific variables, and an r 2 value of 0.32, and the model for physical functioning included six patient-specific variables, and an r 2 of 0.34. These models were incorporated into prototype KOMET decision support software and pilot tested in clinics, and were generally well received. Conclusions: Use of predictive models and mathematical equipoise may help discern patient-specific equipoise to support shared decision-making for selecting between alternative treatments and considering enrollment into an RCT.

14.
JAMA ; 322(5): 438-444, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31386141

RESUMO

Importance: Pancreatic cancer is an uncommon cancer with an age-adjusted annual incidence of 12.9 cases per 100 000 person-years. However, the death rate is 11.0 deaths per 100 000 person-years because the prognosis of pancreatic cancer is poor. Although its incidence is low, pancreatic cancer is the third most common cause of cancer death in the United States. Because of the increasing incidence of pancreatic cancer, along with improvements in early detection and treatment of other types of cancer, it is estimated that pancreatic cancer may soon become the second-leading cause of cancer death in the United States. Objective: To update the 2004 US Preventive Services Task Force (USPSTF) recommendation on screening for pancreatic cancer. Evidence Review: The USPSTF reviewed the evidence on the benefits and harms of screening for pancreatic cancer, the diagnostic accuracy of screening tests for pancreatic cancer, and the benefits and harms of treatment of screen-detected or asymptomatic pancreatic cancer. Findings: The USPSTF found no evidence that screening for pancreatic cancer or treatment of screen-detected pancreatic cancer improves disease-specific morbidity or mortality, or all-cause mortality. The USPSTF found adequate evidence that the magnitude of the benefits of screening for pancreatic cancer in asymptomatic adults can be bounded as no greater than small. The USPSTF found adequate evidence that the magnitude of the harms of screening for pancreatic cancer and treatment of screen-detected pancreatic cancer can be bounded as at least moderate. The USPSTF reaffirms its previous conclusion that the potential benefits of screening for pancreatic cancer in asymptomatic adults do not outweigh the potential harms. Conclusions and Recommendation: The USPSTF recommends against screening for pancreatic cancer in asymptomatic adults. (D recommendation).


Assuntos
Carcinoma Ductal Pancreático/diagnóstico , Detecção Precoce de Câncer/normas , Neoplasias Pancreáticas/diagnóstico , Carcinoma Ductal Pancreático/genética , Carcinoma Ductal Pancreático/cirurgia , Efeitos Psicossociais da Doença , Detecção Precoce de Câncer/efeitos adversos , Feminino , Humanos , Masculino , Programas de Rastreamento/normas , Pâncreas/diagnóstico por imagem , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/cirurgia , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade
15.
JAMA ; 322(7): 652-665, 2019 08 20.
Artigo em Inglês | MEDLINE | ID: mdl-31429903

RESUMO

Importance: Potentially harmful mutations of the breast cancer susceptibility 1 and 2 genes (BRCA1/2) are associated with increased risk for breast, ovarian, fallopian tube, and peritoneal cancer. For women in the United States, breast cancer is the most common cancer after nonmelanoma skin cancer and the second leading cause of cancer death. In the general population, BRCA1/2 mutations occur in an estimated 1 in 300 to 500 women and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases. Objective: To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer. Evidence Review: The USPSTF reviewed the evidence on risk assessment, genetic counseling, and genetic testing for potentially harmful BRCA1/2 mutations in asymptomatic women who have never been diagnosed with BRCA-related cancer, as well as those with a previous diagnosis of breast, ovarian, tubal, or peritoneal cancer who have completed treatment and are considered cancer free. In addition, the USPSTF reviewed interventions to reduce the risk for breast, ovarian, tubal, or peritoneal cancer in women with potentially harmful BRCA1/2 mutations, including intensive cancer screening, medications, and risk-reducing surgery. Findings: For women whose family or personal history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, or who have an ancestry associated with BRCA1/2 gene mutations, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are moderate. For women whose personal or family history or ancestry is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are small to none. Regardless of family or personal history, the USPSTF found adequate evidence that the overall harms of risk assessment, genetic counseling, genetic testing, and interventions are small to moderate. Conclusions and Recommendation: The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (B recommendation) The USPSTF recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. (D recommendation).


Assuntos
Neoplasias da Mama/genética , Genes BRCA1 , Genes BRCA2 , Aconselhamento Genético , Testes Genéticos , Mutação , Neoplasias Ovarianas/genética , Neoplasias da Mama/prevenção & controle , Neoplasias das Tubas Uterinas/genética , Feminino , Predisposição Genética para Doença , Humanos , Neoplasias Ovarianas/prevenção & controle , Neoplasias Peritoneais/genética , Medição de Risco
16.
JAMA ; 322(4): 349-354, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31334800

RESUMO

Importance: Screening for hepatitis B virus (HBV) infection during pregnancy identifies women whose infants are at risk of perinatal transmission. Data from a nationally representative sample showed a prevalence of maternal HBV infection of 85.8 cases per 100 000 deliveries from 1998 to 2011 (0.09% of live-born singleton deliveries in the United States). Although there are guidelines for universal infant HBV vaccination, rates of maternal HBV infection have increased annually by 5.5% since 1998. Children infected with HBV during infancy or childhood are more likely to develop chronic infection. Chronic HBV infection increases long-term morbidity and mortality by predisposing infected persons to cirrhosis of the liver and liver cancer. Objective: To update the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for HBV infection in pregnant women. Evidence Review: The USPSTF commissioned a reaffirmation evidence update to identify substantial new evidence sufficient enough to change the prior recommendation. The USPSTF targeted its evidence review on the effectiveness and potential harms of screening and the effectiveness and harms of case management to prevent perinatal transmission. Findings: The USPSTF previously found adequate evidence that serologic testing for hepatitis B surface antigen accurately identifies HBV infection. Interventions are effective for preventing perinatal transmission, based on foundational evidence and observational studies of US case management programs. In addition, there is evidence that over time, perinatal transmission has decreased among women and infants enrolled in case management, providing an overall substantial health benefit. Therefore, the USPSTF reaffirms its previous conclusion that there is convincing evidence that screening for HBV infection in pregnant women provides substantial benefit. Conclusions and Recommendation: The USPSTF recommends screening for HBV infection in pregnant women at their first prenatal visit. (A recommendation).


Assuntos
Vírus da Hepatite B , Hepatite B , Criança , Feminino , Humanos , Lactente , Transmissão Vertical de Doença Infecciosa , Programas de Rastreamento , Gravidez , Gestantes , Estados Unidos
17.
JAMA ; 321(23): 2326-2336, 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31184701

RESUMO

Importance: Approximately 1.1 million persons in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. There were approximately 38 300 new diagnoses of HIV infection in 2017. The estimated prevalence of HIV infection among persons 13 years and older in the United States is 0.4%, and data from the Centers for Disease Control and Prevention show a significant increase in HIV diagnoses starting at age 15 years. An estimated 8700 women living with HIV give birth each year in the United States. HIV can be transmitted from mother to child during pregnancy, labor, delivery, and breastfeeding. The incidence of perinatal HIV infection in the United States peaked in 1992 and has declined significantly following the implementation of routine prenatal HIV screening and the use of effective therapies and precautions to prevent mother-to-child transmission. Objective: To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on screening for HIV infection in adolescents, adults, and pregnant women. Evidence Review: The USPSTF reviewed the evidence on the benefits and harms of screening for HIV infection in nonpregnant adolescents and adults, the yield of screening for HIV infection at different intervals, the effects of initiating antiretroviral therapy (ART) at a higher vs lower CD4 cell count, and the longer-term harms associated with currently recommended ART regimens. The USPSTF also reviewed the evidence on the benefits (specifically, reduced risk of mother-to-child transmission of HIV infection) and harms of screening for HIV infection in pregnant persons, the yield of repeat screening for HIV at different intervals during pregnancy, the effectiveness of currently recommended ART regimens for reducing mother-to-child transmission of HIV infection, and the harms of ART during pregnancy to the mother and infant. Findings: The USPSTF found convincing evidence that currently recommended HIV tests are highly accurate in diagnosing HIV infection. The USPSTF found convincing evidence that identification and early treatment of HIV infection is of substantial benefit in reducing the risk of AIDS-related events or death. The USPSTF found convincing evidence that the use of ART is of substantial benefit in decreasing the risk of HIV transmission to uninfected sex partners. The USPSTF also found convincing evidence that identification and treatment of pregnant women living with HIV infection is of substantial benefit in reducing the rate of mother-to-child transmission. The USPSTF found adequate evidence that ART is associated with some harms, including neuropsychiatric, renal, and hepatic harms, and an increased risk of preterm birth in pregnant women. The USPSTF concludes with high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial. Conclusions and Recommendation: The USPSTF recommends screening for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened. (A recommendation) The USPSTF recommends screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation).


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/diagnóstico , Programas de Rastreamento/normas , Complicações Infecciosas na Gravidez/diagnóstico , Síndrome de Imunodeficiência Adquirida/mortalidade , Síndrome de Imunodeficiência Adquirida/prevenção & controle , Adolescente , Adulto , Idoso , Contagem de Linfócito CD4 , Efeitos Psicossociais da Doença , Feminino , HIV/imunologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , Humanos , Imunoensaio , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Masculino , Pessoa de Meia-Idade , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
18.
JAMA ; 321(22): 2203-2213, 2019 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-31184747

RESUMO

Importance: An estimated 1.1 million individuals in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. In 2017, there were 38 281 new diagnoses of HIV infection reported in the United States; 81% of these new diagnoses were among males and 19% were among females. Although treatable, HIV infection has no cure and has significant health consequences. Objective: To issue a new US Preventive Services Task Force (USPSTF) recommendation on preexposure prophylaxis (PrEP) for the prevention of HIV infection. Evidence Review: The USPSTF reviewed the evidence on the benefits of PrEP for the prevention of HIV infection with oral tenofovir disoproxil fumarate monotherapy or combined tenofovir disoproxil fumarate and emtricitabine and whether the benefits vary by risk group, population subgroup, or regimen or dosing strategy; the diagnostic accuracy of risk assessment tools to identify persons at high risk of HIV acquisition; the rates of adherence to PrEP in primary care settings; the association between adherence and effectiveness of PrEP; and the harms of PrEP when used for HIV prevention. Findings: The USPSTF found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition. The USPSTF also found convincing evidence that adherence to PrEP is highly associated with its efficacy in preventing the acquisition of HIV infection; thus, adherence to PrEP is central to realizing its benefit. The USPSTF found adequate evidence that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects. The USPSTF concludes with high certainty that the magnitude of benefit of PrEP with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of acquisition of HIV infection in persons at high risk is substantial. Conclusions and Recommendation: The USPSTF recommends offering PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition. (A recommendation).


Assuntos
Antirretrovirais/uso terapêutico , Emtricitabina/uso terapêutico , Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição , Tenofovir/uso terapêutico , Síndrome de Imunodeficiência Adquirida/epidemiologia , Administração Oral , Comitês Consultivos , Antirretrovirais/efeitos adversos , Quimioterapia Combinada , Emtricitabina/efeitos adversos , Feminino , Humanos , Masculino , Adesão à Medicação , Medição de Risco , Fatores de Risco , Tenofovir/efeitos adversos , Estados Unidos/epidemiologia
19.
JAMA ; 321(15): 1502-1509, 2019 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-30990556

RESUMO

Importance: Elevated blood lead levels in children are associated with neurologic effects such as behavioral and learning problems, lower IQ, hyperactivity, hearing problems, and impaired growth. In pregnant women, lead exposure can impair organ systems such as the hematopoietic, hepatic, renal, and nervous systems, and increase the risk of preeclampsia and adverse perinatal outcomes. Many of the adverse health effects of lead exposure are irreversible. Objective: To update the 2006 US Preventive Services Task Force (USPSTF) recommendation on screening for elevated blood lead levels in children and pregnant women. Evidence Review: The USPSTF reviewed the evidence on the benefits and harms of screening for and treatment of elevated blood lead levels. In this update, an elevated blood lead level was defined according to the Centers for Disease Control and Prevention reference level of 5 µg/dL. Findings: The USPSTF found adequate evidence that questionnaires and other clinical prediction tools to identify asymptomatic children with elevated blood lead levels are inaccurate. The USPSTF found adequate evidence that capillary blood testing accurately identifies children with elevated blood lead levels. The USPSTF found inadequate evidence on the effectiveness of treatment of elevated blood lead levels in asymptomatic children 5 years and younger and in pregnant women. The USPSTF found inadequate evidence regarding the accuracy of questionnaires and other clinical prediction tools to identify asymptomatic pregnant women with elevated blood lead levels. The USPSTF found inadequate evidence on the harms of screening for or treatment of elevated blood lead levels in asymptomatic children and pregnant women. The USPSTF concluded that the current evidence is insufficient, and that the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years and younger and in pregnant women cannot be determined. Conclusions and Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic pregnant persons. (I statement).


Assuntos
Intoxicação por Chumbo/terapia , Chumbo/sangue , Programas de Rastreamento , Gestantes , Pré-Escolar , Feminino , Humanos , Lactente , Intoxicação por Chumbo/diagnóstico , Intoxicação por Chumbo/prevenção & controle , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia , Serviços Preventivos de Saúde , Inquéritos e Questionários
20.
Hosp Pediatr ; 9(3): 201-208, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30792260

RESUMO

OBJECTIVES: To target interventions to prevent readmission, we sought to develop clinical prediction models for 30-day readmission among children with complex chronic conditions (CCCs). METHODS: After extracting sociodemographic and clinical characteristics from electronic health records for children with CCCs admitted to an academic medical center, we constructed a multivariable logistic regression model to predict readmission from characteristics obtainable at admission and then a second model adding hospitalization and discharge variables to the first model. We assessed model performance using c-statistic and calibration curves and internal validation using bootstrapping. We then created readmission risk scoring systems from final model ß-coefficients. RESULTS: Of the 2296 index admissions involving children with CCCs, 188 (8.2%) had unplanned 30-day readmissions. The model with admission characteristics included previous admissions, previous emergency department visits, number of CCC categories, and medical versus surgical admission (c-statistic 0.65). The model with hospitalization and discharge factors added discharge disposition, length of stay, and weekday discharge to the admission variables (c-statistic 0.67). Bootstrap samples had similar c-statistics, and slopes did not suggest significant overfitting for either model. Readmission risk was 3.6% to 4.9% in the lowest risk quartile versus 15.9% to 17.6% in the highest risk quartile (or 3.6-4.5 times higher) for both models. CONCLUSIONS: Clinical variables related to the degree of medical complexity and illness severity can stratify children with CCCs into groups with clinically meaningful differences in the risk of readmission. Future research will explore whether these models can be used to target interventions and resources aimed at decreasing readmissions.

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