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3.
JAMA ; 325(5): 476-481, 2021 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-33528542

RESUMO

Importance: Carotid artery stenosis is atherosclerotic disease that affects extracranial carotid arteries. Asymptomatic carotid artery stenosis refers to stenosis in persons without a history of ischemic stroke, transient ischemic attack, or other neurologic symptoms referable to the carotid arteries. The prevalence of asymptomatic carotid artery stenosis is low in the general population but increases with age. Objective: To determine if its 2014 recommendation should be reaffirmed, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence review. The reaffirmation update focused on the targeted key questions on the potential benefits and harms of screening and interventions, including revascularization procedures designed to improve carotid artery blood flow, in persons with asymptomatic carotid artery stenosis. Population: This recommendation statement applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms referable to the carotid arteries. Evidence Assessment: The USPSTF found no new substantial evidence that could change its recommendation and therefore concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. Recommendation: The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (D recommendation).


Assuntos
Doenças Assintomáticas , Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Programas de Rastreamento , Acidente Vascular Cerebral/prevenção & controle , Adulto , Estenose das Carótidas/tratamento farmacológico , Estenose das Carótidas/cirurgia , Angiografia por Tomografia Computadorizada , Reações Falso-Positivas , Humanos , Angiografia por Ressonância Magnética , Programas de Rastreamento/efeitos adversos , Medição de Risco , Ultrassonografia
5.
JAMA ; 324(23): 2423-2436, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33320229

RESUMO

Importance: A 2014 review for the US Preventive Services Task Force (USPSTF) found antiviral therapy for hepatitis B virus (HBV) infection associated with improved intermediate outcomes, although evidence on clinical outcomes was limited. Objective: To update the 2014 HBV screening review in nonpregnant adolescents and adults to inform the USPSTF. Data Sources: Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Ovid MEDLINE (2014 to August 2019); with surveillance through July 24, 2020. Study Selection: Randomized clinical trials (RCTs) on screening and antiviral therapy; cohort studies on screening, antiviral therapy clinical outcomes, and the association between achieving intermediate outcomes after antiviral therapy and clinical outcomes. Data Extraction and Synthesis: One investigator abstracted data; a second investigator checked accuracy. Two investigators independently assessed study quality. Random-effects profile likelihood meta-analysis was performed. Results: Thirty trials and 20 cohort studies, with a total of 94 168 participants, were included. No study directly evaluated the effects of screening for HBV infection vs no screening on clinical outcomes such as mortality, hepatocellular carcinoma, or cirrhosis. Screening strategies that focused on risk factors such as ever having immigrated from high-prevalence countries and demographic and behavioral risk factors would identify nearly all HBV infection cases. In 1 study (n = 21 008), only screening immigrants from high-prevalence countries would miss approximately two-thirds of infected persons. Based on 18 trials (n = 2972), antiviral therapy compared with placebo or no treatment was associated with greater likelihood of achieving intermediate outcomes, such as virologic suppression and hepatitis B e-antigen (HBeAg) or hepatitis B surface antigen loss or seroconversion; the numbers needed to treat ranged from 2.6 for virologic suppression to 17 for HBeAg seroconversion. Based on 12 trials (n = 4127), first-line antiviral therapies were at least as likely as nonpreferred therapies to achieve intermediate outcomes. Based on 16 trials (n = 4809), antiviral therapy might be associated with improved clinical outcomes, but data were sparse and imprecise. Nine cohort studies (n = 3893) indicated an association between achieving an intermediate outcome following antiviral therapy and improved clinical outcomes but were heterogeneous (hazard ratios ranged from 0.07 to 0.87). Antiviral therapy was associated with higher risk of withdrawal due to adverse events vs placebo or no antiviral therapy. Conclusions and Relevance: There was no direct evidence for the clinical benefits and harms of HBV screening vs no screening. Antiviral therapy for HBV infection was associated with improved intermediate outcomes and may improve clinical outcomes.


Assuntos
Antígenos de Superfície da Hepatite B/sangue , Vírus da Hepatite B , Hepatite B Crônica/diagnóstico , Programas de Rastreamento/normas , Adolescente , Adulto , Antivirais/uso terapêutico , Emigrantes e Imigrantes , Vírus da Hepatite B/imunologia , Hepatite B Crônica/tratamento farmacológico , Humanos , Programas de Rastreamento/efeitos adversos , Guias de Prática Clínica como Assunto , Fatores de Risco
6.
JAMA ; 324(23): 2415-2422, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33320230

RESUMO

Importance: An estimated 862 000 persons in the US are living with chronic infection with hepatitis B virus (HBV). Persons born in regions with a prevalence of HBV infection of 2% or greater, such as countries in Africa and Asia, the Pacific Islands, and parts of South America, often become infected at birth and account for up to 95% of newly reported chronic infections in the US. Other high-prevalence populations include persons who inject drugs; men who have sex with men; persons with HIV infection; and sex partners, needle-sharing contacts, and household contacts of persons with chronic HBV infection. Up to 60% of HBV-infected persons are unaware of their infection, and many remain asymptomatic until onset of cirrhosis or end-stage liver disease. Objective: To update its 2014 recommendation, the USPSTF commissioned a review of new randomized clinical trials and cohort studies published from 2014 to August 2019 that evaluated the benefits and harms of screening and antiviral therapy for preventing intermediate outcomes or health outcomes and the association between improvements in intermediate outcomes and health outcomes. New key questions focused on the yield of alternative HBV screening strategies and the accuracy of tools to identify persons at increased risk. Population: This recommendation statement applies to asymptomatic, nonpregnant adolescents and adults at increased risk for HBV infection, including those who were vaccinated before being screened for HBV infection. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for HBV infection in adolescents and adults at increased risk for infection has moderate net benefit. Recommendation: The USPSTF recommends screening for HBV infection in adolescents and adults at increased risk for infection. (B recommendation).


Assuntos
Antígenos de Superfície da Hepatite B/sangue , Vírus da Hepatite B , Hepatite B Crônica/diagnóstico , Programas de Rastreamento/normas , Adolescente , Adulto , Emigrantes e Imigrantes , Vacinas contra Hepatite B , Vírus da Hepatite B/imunologia , Humanos , Programas de Rastreamento/efeitos adversos , Fatores de Risco , Estados Unidos
8.
JAMA ; 324(18): 1884-1895, 2020 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-33170247

RESUMO

Importance: Childhood hypertension can result in adverse outcomes during adulthood; identifying and treating primary and secondary childhood hypertension may reduce such risks. Objective: To update the evidence on screening and treatment of hypertension in childhood and adolescence for the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, International Pharmaceutical Abstracts, EMBASE, and trial registries through September 3, 2019; bibliographies from retrieved articles, experts, and surveillance of the literature through October 6, 2020. Study Selection: Fair- or good-quality English-language studies evaluating diagnostic accuracy of blood pressure screening; cohort studies assessing the association of hypertension in childhood and adolescence with blood pressure or other intermediate outcomes in adulthood; randomized clinical trials (RCTs) or meta-analyses of pharmacological and lifestyle interventions. Data Extraction and Synthesis: Two reviewers independently assessed titles/abstracts and full-text articles, extracted data, and assessed study quality; the evidence was synthesized qualitatively. Main Outcomes and Measures: Sensitivity, specificity, and measures of association between childhood and adulthood blood pressure; reduction of childhood blood pressure; adverse effects of treatments. Results: Forty-two studies from 43 publications were included (N>12 400). No studies evaluated the benefits or harms of screening and the effect of treating childhood hypertension on outcomes in adulthood. One study reported a sensitivity of 0.82 and a specificity of 0.70 for 2 office-based blood pressure measurements. Twenty observational studies suggested a significant association between childhood hypertension and abnormal blood pressure in adulthood (odds ratios, 1.1-4.5; risk ratios, 1.45-3.60; hazard ratios, 2.8-3.2). Thirteen placebo-controlled RCTs and 1 meta-analysis assessed reductions in systolic (SBP) and diastolic blood pressure from pharmacological treatments. Pooled reductions of SBP were -4.38 mm Hg (95% CI, -7.27 to -2.16) for angiotensin-converting enzyme inhibitors and -3.07 mm Hg (95% CI, -4.99 to -1.44) for angiotensin receptor blockers. Candesartan reduced SBP by -6.56 mm Hg (P < .001; n = 240). ß-Blockers, calcium channel blockers, and mineralocorticoid receptor antagonists did not achieve significant reductions over 2 to 4 weeks. SBP was significantly reduced by exercise over 8 months (-4.9 mm Hg, P ≤ .05; n = 69), by dietary approaches to stop hypertension over 3 months (-2.2 mm Hg, P < .01; n = 57), and by a combination of drug treatment and lifestyle interventions over 6 months (-7.6 mm Hg; P < .001; n = 95). Low-salt diet did not achieve reductions of blood pressure. Conclusions and Relevance: Observational studies indicate an association between hypertension in childhood and hypertension in adulthood. However, the evidence is inconclusive whether the diagnostic accuracy of blood pressure measurements is adequate for screening asymptomatic children and adolescents in primary care.


Assuntos
Hipertensão/diagnóstico , Programas de Rastreamento , Adolescente , Adulto , Anti-Hipertensivos/efeitos adversos , Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial/instrumentação , Doenças Cardiovasculares/prevenção & controle , Criança , Pré-Escolar , Terapia Combinada , Dieta Saudável , Exercício Físico , Feminino , Humanos , Hipertensão/terapia , Masculino , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/psicologia , Estudos Observacionais como Assunto , Guias de Prática Clínica como Assunto , Serviços Preventivos de Saúde , Sensibilidade e Especificidade
9.
JAMA ; 324(18): 1878-1883, 2020 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-33170248

RESUMO

Importance: Prevalence of hypertension (both primary and secondary) in children and adolescents in the US ranges from 3% to 4%. Primary hypertension in children and adolescents occurs primarily in children older than 13 years and has no known cause but is associated with several risk factors, including family history and higher body mass index. Secondary hypertension occurs primarily in younger children and is most commonly caused by genetic disorders, renal disease, endocrine disorders, or cardiovascular abnormalities. Objective: To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on the benefits and harms of screening, test accuracy, the effectiveness and harms of treatment, and the association between hypertension and markers of cardiovascular disease in childhood and adulthood. Population: This recommendation statement applies to children and adolescents aged 3 to 18 years not known to have hypertension or who are asymptomatic. Evidence Assessment: The USPSTF concludes that the evidence to support screening for high blood pressure in children and adolescents is insufficient and that the balance of benefits and harms cannot be determined. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. (I statement).


Assuntos
Hipertensão/diagnóstico , Programas de Rastreamento , Adolescente , Determinação da Pressão Arterial/instrumentação , Doenças Cardiovasculares/prevenção & controle , Criança , Pré-Escolar , Reações Falso-Positivas , Feminino , Humanos , Hipertensão/terapia , Masculino , Programas de Rastreamento/efeitos adversos , Serviços Preventivos de Saúde , Valores de Referência
10.
Br J Radiol ; 93(1115): 20200135, 2020 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-32816520

RESUMO

For many individuals, the term 'cancer' equates to a disease that if untreated will progress, spread from the area initially affected and ultimately cause death. 'Breast cancer', however, is a diverse of range of pathological entities, incorporating indolent to fast-growing and aggressive lesions, with varying histological patterns, clinical presentations, treatment responses and outcomes. Screening for malignancy is based on the assumption that cancer has a gradual, orderly progression and that detecting lesions earlier in their natural history, and intervening, will reduce mortality. The natural history of epithelial atypia, ductal carcinoma in situ and even invasive breast cancer is poorly understood, but widely variable. We believe that population breast screening methodology needs to change to focus on diagnosis of lesions of greatest clinical relevance.


Assuntos
Neoplasias da Mama/patologia , Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Programas de Rastreamento/métodos , Mama/diagnóstico por imagem , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/genética , Carcinoma Ductal de Mama/diagnóstico por imagem , Carcinoma Ductal de Mama/genética , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/genética , Progressão da Doença , Detecção Precoce de Câncer , Feminino , Perfilação da Expressão Gênica , Humanos , Hiperplasia/diagnóstico por imagem , Hiperplasia/patologia , Programas de Rastreamento/efeitos adversos
11.
BMC Infect Dis ; 20(1): 455, 2020 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-32600260

RESUMO

BACKGROUND: Men who have sex with men (MSM) bear a high burden of syphilis infection. Expanding syphilis testing to improve timely diagnosis and treatment is critical to improve syphilis control. However, syphilis testing rates remain low among MSM, particularly in low- and middle-income countries. We describe the protocol for a randomised controlled trial (RCT) to assess whether provision of syphilis self-testing services can increase the uptake of syphilis testing among MSM in China. METHODS: Four hundred forty-four high-risk MSM will be recruited online and randomized in a 1:1:1 ratio to (1) standard syphilis self-testing arm; (2) a self-testing arm program enhanced with crowdsourcing and a lottery-based incentive, and (3) a standard of care (control). Self-testing services include a free syphilis self-test kit through the mail at monthly intervals. Participants in the lottery incentive arm will additionally receive health promotion materials generated from an open crowdsourcing contest and be given a lottery draw with a 10% chance to win 100 RMB (approximately 15 US Dollars) upon confirmed completion of syphilis testing. Syphilis self-test kits have step-by-step instructions and an instructional video. This is a non-blinded, open-label, parallel RCT. Participants in each arm will be followed-up at three and 6 months through WeChat (a social media app like Facebook messenger). Confirmation of syphilis self-test use will be determined by requiring participants to submit a photo of the used test kit to study staff via secure data messaging. Both self-testing and facility-based testing will be ascertained by sending a secure photographic image of the completed kit through an existing digital platform. The primary outcome is the proportion of participants who tested for syphilis in the past 3 months. DISCUSSION: Findings from this study will provide much needed insight on the impact of syphilis self-testing on promoting routine syphilis screening among MSM. The findings will also contribute to our understanding of the safety, effectiveness and acceptability of syphilis self-testing. These findings will have important implications for self-testing policy, both in China and internationally. TRIAL REGISTRATION: ChiCTR1900022409 (10 April, 2019).


Assuntos
Testes Diagnósticos de Rotina/métodos , Promoção da Saúde/métodos , Homossexualidade Masculina , Imunoensaio/métodos , Programas de Rastreamento/métodos , Minorias Sexuais e de Gênero , Sorodiagnóstico da Sífilis/métodos , Sífilis/diagnóstico , Treponema pallidum/imunologia , Sorodiagnóstico da AIDS/métodos , China , Crowdsourcing/métodos , Testes Diagnósticos de Rotina/efeitos adversos , Seguimentos , Infecções por HIV/diagnóstico , Infecções por HIV/virologia , HIV-1/imunologia , HIV-2/imunologia , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Motivação , Mídias Sociais , Sífilis/microbiologia , Sorodiagnóstico da Sífilis/efeitos adversos
13.
JAMA ; 323(22): 2310-2328, 2020 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-32515820

RESUMO

Importance: Illicit drug use is among the most common causes of preventable morbidity and mortality in the US. Objective: To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019. Study Selection: Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use. Data Extraction and Synthesis: Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses. Main Outcomes and Measures: Sensitivity, specificity, drug use and other health, social, and legal outcomes. Results: Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events. Conclusions and Relevance: Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.


Assuntos
Programas de Rastreamento/normas , Antagonistas de Entorpecentes/uso terapêutico , Psicoterapia , Detecção do Abuso de Substâncias/normas , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adolescente , Adulto , Feminino , Humanos , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Naloxona/efeitos adversos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/efeitos adversos , Guias de Prática Clínica como Assunto , Gravidez , Sensibilidade e Especificidade , Detecção do Abuso de Substâncias/métodos , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Transtornos Relacionados ao Uso de Substâncias/terapia , Inquéritos e Questionários
14.
JAMA ; 323(22): 2301-2309, 2020 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-32515821

RESUMO

Importance: An estimated 12% of adults 18 years or older and 8% of adolescents aged 12 to 17 years report unhealthy use of prescription or illegal drugs in the US. Objective: To update its 2008 recommendation, the USPSTF commissioned reviews of the evidence on screening by asking questions about drug use and interventions for unhealthy drug use in adults and adolescents. Population: This recommendation statement applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment. This statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Evidence Assessment: In adults, the USPSTF concludes with moderate certainty that screening by asking questions about unhealthy drug use has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred. In adolescents, because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for unhealthy drug use are uncertain and that the balance of benefits and harms cannot be determined. Recommendation: The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. (I statement).


Assuntos
Programas de Rastreamento/normas , Antagonistas de Entorpecentes/uso terapêutico , Psicoterapia , Detecção do Abuso de Substâncias/normas , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adolescente , Adulto , Humanos , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Antagonistas de Entorpecentes/efeitos adversos , Sensibilidade e Especificidade , Detecção do Abuso de Substâncias/métodos , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/terapia , Inquéritos e Questionários
15.
JAMA ; 323(13): 1293-1309, 2020 04 07.
Artigo em Inglês | MEDLINE | ID: mdl-32259235

RESUMO

Importance: Preterm delivery results in adverse outcomes; identifying and treating bacterial vaginosis may reduce its occurrence. Objective: To update the evidence on screening and treatment of asymptomatic bacterial vaginosis in pregnancy for the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Library, and trial registries through May 29, 2019; bibliographies from retrieved articles, experts, and surveillance of the literature through December 31, 2019. Study Selection: Fair- or good-quality English-language studies evaluating diagnostic accuracy of tests feasible within primary care; randomized clinical trials (RCTs); nonrandomized controlled intervention studies (for harms only); or meta-analyses of metronidazole or clindamycin. Data Extraction and Synthesis: Two reviewers independently assessed titles/abstracts and full-text articles, extracted data, and assessed study quality; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Sensitivity, specificity, preterm delivery, maternal adverse effects, congenital birth defects, childhood cancer. Results: Forty-four studies (48 publications) were included. No studies evaluated the benefits or harms of screening. Twenty-five studies (n = 15 785) evaluated the accuracy of screening tests; across individual studies and tests, sensitivity ranged from 0.36 to 1.0 and specificity ranged from 0.49 to 1.0. Among trials reporting findings from general obstetric populations (n = 7953), no significant association was observed between treatment and spontaneous delivery before 37 weeks (pooled absolute risk difference [ARD], -1.44% [95% CI, -3.31% to 0.43%]; 8 RCTs, n = 7571) or any delivery before 37 weeks (pooled ARD, 0.20% [95% CI, -1.13% to 1.53%]; 6 RCTs, n = 6307). Among 5 trials reporting findings among women with a prior preterm delivery, findings were inconsistent; 3 showed a significant beneficial effect, while 2 did not. Maternal adverse events from treatment were infrequent and minor (eg, candidiasis) but were slightly more common with active treatment compared with placebo across 8 RCTs. Two meta-analyses of observational studies reported no significant association between metronidazole exposure and congenital malformations (odds ratio, 0.96 [95% CI, 0.75 to 1.22]; odds ratio, 1.08 [95% CI, 0.90 to 1.29]). One cohort study reported no significantly increased incidence of childhood cancer among metronidazole-exposed children (adjusted relative risk, 0.81 [95% CI, 0.41 to 1.59]). However, studies of in utero exposure had important limitations. Conclusions and Relevance: Accuracy of screening tests for bacterial vaginosis varies. The evidence suggests no difference in the incidence of preterm delivery and related outcomes from treatment for asymptomatic bacterial vaginosis in a general obstetric population but was inconclusive for women with a prior preterm delivery. Maternal adverse events from treatment appear to be infrequent and minor, but the evidence about harms from in utero exposure was inconclusive.


Assuntos
Antibacterianos/uso terapêutico , Infecções Assintomáticas , Programas de Rastreamento , Complicações Infecciosas na Gravidez/diagnóstico , Nascimento Prematuro/prevenção & controle , Vaginose Bacteriana/diagnóstico , Antibacterianos/efeitos adversos , Clindamicina/uso terapêutico , Feminino , Humanos , Programas de Rastreamento/efeitos adversos , Metronidazol/uso terapêutico , Guias de Prática Clínica como Assunto , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , Fatores de Risco , Vaginose Bacteriana/tratamento farmacológico
16.
JAMA ; 323(13): 1286-1292, 2020 04 07.
Artigo em Inglês | MEDLINE | ID: mdl-32259236

RESUMO

Importance: Bacterial vaginosis is common and is caused by a disruption of the microbiological environment in the lower genital tract. In the US, reported prevalence of bacterial vaginosis among pregnant women ranges from 5.8% to 19.3% and is higher in some races/ethnicities. Bacterial vaginosis during pregnancy has been associated with adverse obstetrical outcomes including preterm delivery, early miscarriage, postpartum endometritis, and low birth weight. Objective: To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on the accuracy of screening and the benefits and harms of screening for and treatment of bacterial vaginosis in asymptomatic pregnant persons to prevent preterm delivery. Population: This recommendation applies to pregnant persons without symptoms of bacterial vaginosis. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for asymptomatic bacterial vaginosis in pregnant persons not at increased risk for preterm delivery has no net benefit in preventing preterm delivery. The USPSTF concludes that for pregnant persons at increased risk for preterm delivery, the evidence is conflicting and insufficient, and the balance of benefits and harms cannot be determined. Conclusions and Recommendation: The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement).


Assuntos
Infecções Assintomáticas , Programas de Rastreamento , Complicações Infecciosas na Gravidez/diagnóstico , Nascimento Prematuro/prevenção & controle , Vaginose Bacteriana/diagnóstico , Antibacterianos/efeitos adversos , Antibacterianos/uso terapêutico , Feminino , Humanos , Programas de Rastreamento/efeitos adversos , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , Fatores de Risco , Vaginose Bacteriana/tratamento farmacológico
17.
Rev Med Suisse ; 16(680): 275-277, 2020 Feb 05.
Artigo em Francês | MEDLINE | ID: mdl-32022494

RESUMO

Prostate cancer screening remains controversial as the reduction in mortality is outweighed by overdiagnosis and overtreatment. Prostate specific antigen (PSA) testing remains a recurring issue for primary care physicians. Although the last guidelines recommend against the screening, everyone agreed on the importance of the shared decision-making process to inform the patient about the potential benefits and harms of screening. Existing decision support tools can help in this complex discussion. This clinical case report depicts the infectious risks of prostate biopsy that are often underestimated.


Assuntos
Programas de Rastreamento/efeitos adversos , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Tomada de Decisões , Detecção Precoce de Câncer/efeitos adversos , Humanos , Masculino
19.
JAMA ; 323(8): 764-785, 2020 02 25.
Artigo em Inglês | MEDLINE | ID: mdl-32096857

RESUMO

Importance: Early identification of cognitive impairment may improve patient and caregiver health outcomes. Objective: To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019. Study Selection: Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers. Data Extraction and Synthesis: Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis. Main Outcomes and Measures: Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being. Results: The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance. Conclusions and Relevance: Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.


Assuntos
Disfunção Cognitiva/diagnóstico , Demência/diagnóstico , Programas de Rastreamento , Idoso , Cuidadores , Disfunção Cognitiva/terapia , Demência/tratamento farmacológico , Diagnóstico Precoce , Humanos , Vida Independente , Programas de Rastreamento/efeitos adversos , Testes Neuropsicológicos , Guias de Prática Clínica como Assunto , Sensibilidade e Especificidade
20.
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
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