A commentary on interpreting the United States preventive services task force autism screening recommendation statement.

Prevalence of preeclampsia risk factors: implications for low-dose aspirin prophylaxis

ImportanceIn the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 13%, and the lifetime risk of dying of prostate cancer is 2.5%. The median age of death from prostate cancer is 80 years. Many men with prostate cancer never experience symptoms and, without screening, would never know they have the disease. African American men and men with a family history of prostate cancer have an increased risk of prostate cancer compared with other men.ObjectiveTo update the 2012 US Preventive Services Task Force (USPSTF) recommendation on prostate-specific antigen (PSA)–based screening for prostate cancer.Evidence ReviewThe USPSTF reviewed the evidence on the benefits and harms of PSA-based screening for prostate cancer and subsequent treatment of screen-detected prostate cancer. The USPSTF also commissioned a review of existing decision analysis models and the overdiagnosis rate of PSA-based screening. The reviews also examined the benefits and harms of PSA-based screening in patient subpopulations at higher risk of prostate cancer, including older men, African American men, and men with a family history of prostate cancer.FindingsAdequate evidence from randomized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened. Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened. Potential harms of screening include frequent false-positive results and psychological harms. Harms of prostate cancer treatment include erectile dysfunction, urinary incontinence, and bowel symptoms. About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence, and 2 in 3 men will experience long-term erectile dysfunction. Adequate evidence shows that the harms of screening in men older than 70 years are at least moderate and greater than in younger men because of increased risk of false-positive results, diagnostic harms from biopsies, and harms from treatment. The USPSTF concludes with moderate certainty that the net benefit of PSA-based screening for prostate cancer in men aged 55 to 69 years is small for some men. How each man weighs specific benefits and harms will determine whether the overall net benefit is small. The USPSTF concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms.Conclusions and RecommendationFor men aged 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening. (C recommendation) The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older. (D recommendation)

Colon Cancer Screening Models: Lessons and Challenges

Background: The United States Preventive Services Task Force recommends colorectal cancer (CRC) screening for all average-risk adults aged 45 years and up1. Fecal Immunochemical Tests (FIT) and FIT/DNA (Cologuard) test are the two most widely used non-invasive tests used for this screening. In the event of a positive test, a diagnostic colonoscopy is recommended within three months of the positive result. As the Covid-19 pandemic continues, hospitals have implemented policies that include strict screening guidelines before procedures such as colonoscopies. The effect of these guidelines and restrictions on elective procedures such as colonoscopy on the interval between a positive non-invasive screening test (NIST) and diagnostic colonoscopy (DC) is not clear. Study aim: to quantify the interval between a positive NIST (FIT, FIT/DNA) and DC, and to compare these findings to non-pandemic findings from the previous year. Methods: In this retrospective, time-trend analysis, we identified patients within a major hospital system in Indiana who had a positive NIST between January 1, 2019 and June 30. After our original query, we noticed FIT/DNA tests were not coded into the EMR before June 10, 2020, and had to use data from campus-based public and private hospitals to supplement for this time period. Once identified, chart review was performed to determine if/when a patient underwent DC . If a patient’s chart did not show evidence of a DC, we examined the EMR notes to discern whether, when, or why colonoscopy was / was not completed. We measured the interval between NIST result and DC by quarter, comparing results between corresponding times during 2019 and 2020 as well as the first two quarters of 2021. We also measured and compared the proportion of patients with a positive non-invasive test who had not had colonoscopy by 60, 90, and 180 days. Results: Of the 1,379 patients reviewed, 930 (68%) underwent subsequent colonoscopy in the 30-month study timeframe. Colonoscopy completion rates were 72% for the FIT/DNA group, and 47% for the FIT group over the 30-month timeframe. Of the 293 persons who did not elect to have a subsequent colonoscopy, 21 (7.2%) reported that the pandemic kept them from undergoing the procedure. Concern for acquiring COVID-19 from the colonoscopy site was the most common reason for declining colonoscopy in this group, having been mentioned by 8 of the 21 individuals. Other reasons included waiting to get a COVID vaccine before undergoing a procedure or issues with completing required COVID screening before the procedure. Only two individuals (0.7%) were found to have delayed colonoscopy due to a recent COVID infection. The proportion of patients completing a colonoscopy within 90 days of a positive NIST were 83%, 79%, and 83% for 2019, 2020, and 2021, respectively. Conclusion/Impact: Overall, the rate of DCs following a positive NIST test did not appear to be significantly affected by the COVID-19 pandemic. Concern of contracting COVID-19 was a more common reason for delay when compared to actual COVID infection. A study evaluating the rate of COVID infection following a colonoscopy procedure may be useful to address the validity of these concerns, the results of which could alleviate (or exacerbate) this issue in the setting of future outbreaks. When compared to Cologuard, patients who had a positive FIT test were more likely to wait longer for a DC. This discrepancy suggests the relationship between providers and their use of FIT vs. Cologuard should be further probed. In addition, studying patient perceptions of both screening procedures may identity reasons for delay. 1. US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977. doi:10.1001/jama.2021.6238

This is an update of the 2002 US Preventive Services Task Force recommendation on screening for child and adolescent major depressive disorder. The US Preventive Services Task Force weighed the benefits and harms of screening and treatment for major depressive disorder in children and adolescents, incorporating new evidence addressing gaps in the 2002 recommendation statement. Evidence examined included the benefits and harms of screening, the accuracy of primary care-feasible screening tests, and the benefits and risks of treating depression by using psychotherapy and/or medications in patients aged 7 to 18 years. Screen adolescents (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (B recommendation). Evidence is insufficient to warrant a recommendation to screen children (7-11 years of age) for major depressive disorder (I statement).

Response to Weinstein’s “Reply of Increased risk of vitamin D deficiency and insufficiency in Black patients with central centrifugal cicatricial alopecia.”

Clinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices

The New US Preventive Services Task Force “C” Draft Recommendation for Prostate Cancer Screening

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Clinical practice guidelines can play an important role in mitigating health inequities. The US Preventive Services Task Force (USPSTF) has prioritized addressing health equity and racism in its recommendations. To develop a framework that would allow the USPSTF to incorporate a health equity lens that spans the entirety of its recommendation-making process. Key guidance, policy, and explanatory frameworks related to health equity were identified, and their recommendations and findings were mapped to current USPSTF methods. USPSTF members as well as staff from multiple entities supporting the USPSTF portfolio were consulted. Based on all the gathered information, a draft health equity framework and checklist were developed; they were then circulated to the USPSTF's key partners for input and review. An equity framework was developed that could be applied to all phases of the recommendation process: (1) topic nomination, selection, and prioritization; (2) development of the work plan; (3) evidence review; (4) evidence deliberation; (5) development of the recommendation statement; and (6) dissemination of recommendations. For each phase, several considerations and checklist items to address are presented. These items include using health equity as a prioritization criterion and engaging a diverse group of stakeholders at the earliest phases in identifying topics for recommendations; developing necessary equity-relevant questions (eg, beyond effectiveness and harms) to address during the protocol phase; using methods in synthesizing the evidence and contextual issues in the evidence review related to specific populations experiencing a disproportionate burden of disease; and examining the magnitude and certainty of net benefit, implementation considerations, risk assessment, and evidence gaps through an equity lens when developing evidence-based recommendations. Executing this entire framework and checklist as described will be challenging and will take additional time and resources. Nonetheless, whether adopted in its entirety or in parts, this framework offers guidance to the USPSTF, as well as other evidence-based guideline entities, in its mission to develop a more transparent, consistent, and intentional approach to addressing health equity in its recommendations.

The US Preventive Services Task Force (USPSTF) is an independent body that makes evidence-based recommendations regarding preventive services to improve health for people nationwide. Here, we summarize current USPSTF methods, describe how methods are evolving to address preventive health equity, and define evidence gaps for future research. We summarize current USPSTF methods as well as ongoing methods development. The USPSTF prioritizes topics on the basis of disease burden, extent of new evidence, and whether the service can be provided in primary care and going forward will increasingly consider health equity. Analytic frameworks specify the key questions and linkages connecting the preventive service to health outcomes. Contextual questions provide information on natural history, current practice, health outcomes in high-risk groups, and health equity. The USPSTF assigns a level of certainty to the estimate of net benefit of a preventive service (high, moderate, or low). The magnitude of net benefit is also judged (substantial, moderate, small, or zero/negative). The USPSTF uses these assessments to assign a letter grade from A (recommend) to D (recommend against). I statements are issued when evidence is insufficient. The USPSTF will continue to evolve its methods for simulation modeling and to use evidence to address conditions for which there are limited data for population groups who bear a disproportionate burden of disease. Additional pilot work is underway to better understand the relations of the social constructs of race, ethnicity, and gender with health outcomes to inform the development of a USPSTF health equity framework.

Optimal gestational weight gain

Childhood and adolescent overweight and obesity are related to health risks, medical conditions, and increased risk of adult obesity, with its attendant effects on morbidity and mortality rates. The prevalence of childhood overweight and obesity has more than doubled in the past 25 years. Purpose. This evidence synthesis examines the evidence for the benefits and harms of screening and early treatment of overweight among children and adolescents in clinical settings. We developed an analytic framework and 7 key questions representing the logical evidence connecting screening and weight control interventions with changes in overweight and behavioral, physiologic, and health outcomes in childhood or adulthood. We searched the Cochrane Library from 1996 to April 2004. We searched Medline, PsycINFO, DARE, and CINAHL from 1966 to April 2004. One reviewer abstracted relevant information from each included article into standardized evidence tables, and a second reviewer checked key elements. Two reviewers quality-graded each article with US Preventive Services Task Force criteria. Although BMI is a measure of relative weight rather than adiposity, it is recommended widely for use among children and adolescents to determine overweight and is the currently preferred measure. The risk of adult overweight from childhood overweight provides the best available evidence to judge the clinical validity of BMI as an overweight criterion for children and adolescents. BMI measures in childhood track to adulthood moderately or very well, with stronger tracking seen for children with >or=1 obese parent and children who are more overweight or older. The probability of adult obesity (BMI of >30 kg/m(2)) is >or=50% among children >13 years of age whose BMI percentiles meet or exceed the 95th percentile for age and gender. BMI-based overweight categorization for individuals, particularly for racial/ethnic minorities with differences in body composition, may have limited validity because BMI measures cannot differentiate between increased weight for height attributable to relatively greater fat-free mass (muscle, bone, and fluids) and that attributable to greater fat. No trials of screening programs to identify and to treat childhood overweight have been reported. Limited research is available on effective, generalizable interventions for overweight children and adolescents that can be conducted in primary care settings or through primary care referrals. BMI measurements of overweight among older adolescents identify those at increased risk of developing adult obesity. Interventions to treat overweight adolescents in clinical settings have not been shown to have clinically significant benefits, and they are not widely available. Screening to categorize overweight among children under age 12 or 13 who are not clearly overweight may not provide reliable risk categorization for adult obesity. Screening in this age group is compromised by the fact that there is little generalizable evidence for primary care interventions. Because existing trials report modest short- to medium-term improvements (approximately 10-20% decrease in percentage of overweight or a few units of change in BMI), however, overweight improvements among children and adolescents seem possible.

Commentary on: Chou R, Croswell JM, Dana T, et al. Screening for prostate cancer: a review of the evidence for the US Preventive Services Task Force. Ann Intern Med 2011;155:762–71.[OpenUrl][1][CrossRef][2][PubMed][3][Web...

ImportanceCeliac disease is caused by an immune response in persons who are genetically susceptible to dietary gluten, a protein complex found in wheat, rye, and barley. Ingestion of gluten by persons with celiac disease causes immune-mediated inflammatory damage to the small intestine.ObjectiveTo issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for celiac disease.Evidence ReviewThe USPSTF reviewed the evidence on the accuracy of screening in asymptomatic adults, adolescents, and children; the potential benefits and harms of screening vs not screening and targeted vs universal screening; and the benefits and harms of treatment of screen-detected celiac disease. The USPSTF also reviewed contextual information on the prevalence of celiac disease among patients without obvious symptoms and the natural history of subclinical celiac disease.FindingsThe USPSTF found inadequate evidence on the accuracy of screening for celiac disease, the potential benefits and harms of screening vs not screening or targeted vs universal screening, and the potential benefits and harms of treatment of screen-detected celiac disease.Conclusions and RecommendationThe USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for celiac disease in asymptomatic persons. (I statement)