Elizabeth O’Connor

Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE Depression is a source of substantial burden for individuals and their families, including women during the pregnant and postpartum period. OBJECTIVE To systematically review the benefits and harms of depression screening and treatment, and accuracy of selected screening instruments, for pregnant and postpartum women. Evidence for depression screening in adults in general is available in the full report. DATA SOURCES MEDLINE, PubMed, PsycINFO, and the Cochrane Collaboration Registry of Controlled Trials through January 20, 2015; references; and government websites. STUDY SELECTION English-language trials of benefits and harms of depression screening, depression treatment in pregnant and postpartum women with screen-detected depression, and diagnostic accuracy studies of depression screening instruments in pregnant and postpartum women. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles and extracted data from fair- and good-quality studies. Random-effects meta-analysis was used to estimate the benefit of cognitive behavioral therapy (CBT) in pregnant and postpartum women. MAIN OUTCOMES AND MEASURES Depression remission, prevalence, symptoms, and related measures of depression recovery or response; sensitivity and specificity of selected screening measures to detect depression; and serious adverse effects of antidepressant treatment. RESULTS Among pregnant and postpartum women 18 years and older, 6 trials (n = 11,869) showed 18% to 59% relative reductions with screening programs, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3-5 months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care. Based on 23 studies (n = 5398), a cutoff of 13 on the English-language Edinburgh Postnatal Depression Scale demonstrated sensitivity ranging from 0.67 (95% CI, 0.18-0.96) to 1.00 (95% CI, 0.67-1.00) and specificity consistently 0.87 or higher. Data were sparse for Patient Health Questionnaire instruments. Pooled results for the benefit of CBT for pregnant and postpartum women with screen-detected depression showed an increase in the likelihood of remission (pooled relative risk, 1.34 [95% CI, 1.19-1.50]; No. of studies [K] = 10, I2 = 7.9%) compared with usual care, with absolute increases ranging from 6.2% to 34.6%. Observational evidence showed that second-generation antidepressant use during pregnancy may be associated with small increases in the risks of potentially serious harms. CONCLUSIONS AND RELEVANCE Direct and indirect evidence suggested that screening pregnant and postpartum women for depression may reduce depressive symptoms in women with depression and reduce the prevalence of depression in a given population. Evidence for pregnant women was sparser but was consistent with the evidence for postpartum women regarding the benefits of screening, the benefits of treatment, and screening instrument accuracy.

Screening for Obesity and Intervention for Weight Management in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Obesity is common in children and adolescents in the United States, is associated with negative health effects, and increases the likelihood of obesity in adulthood. Objective To systematically review the benefits and harms of screening and treatment for obesity and overweight in children and adolescents to inform the US Preventive Services Task Force. Data Sources MEDLINE, PubMed, PsycINFO, Cochrane Collaboration Registry of Controlled Trials, and the Education Resources Information Center through January 22, 2016; references of relevant publications; government websites. Surveillance continued through December 5, 2016. Study Selection English-language trials of benefits or harms of screening or treatment (behavior-based, orlistat, metformin) for overweight or obesity in children aged 2 through 18 years, conducted in or recruited from health care settings. Data Extraction and Synthesis Two investigators independently reviewed abstracts and full-text articles, then extracted data from fair- and good-quality trials. Random-effects meta-analysis was used to estimate the benefits of lifestyle-based programs and metformin. Main Outcomes and Measures Weight or excess weight (eg, body mass index [BMI]; BMI z score, measuring the number of standard deviations from the median BMI for age and sex), cardiometabolic outcomes, quality of life, other health outcomes, harms. Results There was no direct evidence on the benefits or harms of screening children and adolescents for excess weight. Among 42 trials of lifestyle-based interventions to reduce excess weight (N = 6956), those with an estimated 26 hours or more of contact consistently demonstrated mean reductions in excess weight compared with usual care or other control groups after 6 to 12 months, with no evidence of causing harm. Generally, intervention groups showed absolute reductions in BMI z score of 0.20 or more and maintained their baseline weight within a mean of approximately 5 lb, while control groups showed small increases or no change in BMI z score, typically gaining a mean of 5 to 17 lb. Only 3 of 26 interventions with fewer contact hours showed a benefit in weight reduction. Use of metformin (8 studies, n = 616) and orlistat (3 studies, n = 779) were associated with greater BMI reductions compared with placebo: −0.86 (95% CI, −1.44 to −0.29; 6 studies; I2 = 0%) for metformin and −0.50 to −0.94 for orlistat. Groups receiving lifestyle-based interventions offering 52 or more hours of contact showed greater improvements in blood pressure than control groups: −6.4 mm Hg (95% CI, −8.6 to −4.2; 6 studies; I2 = 51%) for systolic blood pressure and −4.0 mm Hg (95% CI, −5.6 to −2.5; 6 studies; I2 = 17%) for diastolic blood pressure. There were mixed findings for insulin or glucose measures and no benefit for lipids. Medications showed small or no benefit for cardiometabolic outcomes, including fasting glucose level. Nonserious harms were common with medication use, although discontinuation due to adverse effects was usually less than 5%. Conclusions and Relevance Lifestyle-based weight loss interventions with 26 or more hours of intervention contact are likely to help reduce excess weight in children and adolescents. The clinical significance of the small benefit of medication use is unclear.

Systematic review of the predictive effect of MSI status in colorectal cancer patients undergoing 5FU-based chemotherapy

BackgroundWe systematically reviewed the evidence for the interaction of microsatellite instability status (MSI) and treatment with 5FU in colorectal cancer to determine how well MSI status predicts health outcomes in patients undergoing 5FU-based chemotherapy.MethodsWe conducted a search of four electronic databases through June 2013. We considered studies that included both colorectal cancer patients treated with 5FU-based chemotherapy and untreated patients with survival outcomes presented by MSI status.ResultsWe identified 16 studies for qualitative analysis (9,212 patients) with 14 studies eligible for meta-analysis. The microsatellite stable (MSS) group showed an effect of 5FU treatment on disease-free survival (HR of 0.62 [95% CI: 0.54, 0.71]) and overall survival (HR of 0.65 [95% CI: 0.54, 0.79]), indicating that MSS patients who received 5FU treatment had longer survival than MSS patients who were untreated. The effect of 5FU treatment was not statistically significant for microsatellite high (MSI-H) patients for disease-free survival (HR of 0.84 [95% CI: 0.53, 1.32]) or overall survival (HR 0.66 [95% CI: 0.43, 1.03]). However, the summarized point estimates of the effects of 5FU treatment for the MSS and MSI-H groups were not different at a statistically significant level.ConclusionsOur analyses indicate that treatment with 5FU-based chemotherapy improves disease-free and overall survival in CRC patients, but that there is no difference in the effect of treatment based on MSI status. Therefore, the use of MSI status to guide treatment decisions about the use of 5FU treatment for CRC has no significant benefits for patients.

Primary care behavioral interventions to prevent or reduce illicit drug use and nonmedical pharmaceutical use in children and adolescents: a systematic evidence review for the U.S. Preventive Services Task Force.

Drug use among adolescents is a serious public health problem in the United States. The 2012 National Survey on Drug Use and Health reported that 9.5% of children aged 12 to 17 years reported illicit drug use during the past month. Marijuana and prescription psychotherapeutics (including pain relievers) are the most commonly used drugs among children and adolescents. Seven percent of children aged 12 to 17 years reported current use of marijuana, and an estimated 5% used marijuana for the first time within the past year. In 2012, 2.8% of children aged 12 to 17 years reported using a prescription drug for nonmedical reasons, and 2.2% reported nonmedical use of opioid pain relievers. Illicit drug use was approximately 15 times higher among young persons who smoked cigarettes and drank alcohol during the past month (61.1%) than among those who neither smoked cigarettes nor drank alcohol during the past month (4.0%) (1). Drug and alcohol use are the primary health risk behaviors that contribute to unintentional injuries, homicide, and suicidethe leading causes of morbidity and mortality among adolescents and young adults (2). Even infrequent drug or alcohol use increases the risk for serious adverse events by increasing risk-taking behaviors in intoxicated or impaired persons. The Substance Abuse and Mental Health Services Administration and the American Academy of Pediatrics recommend that universal screening, brief intervention, and referral to treatment (SBIRT) for substance use should be a part of routine health care as a method to reduce the health burden associated with substance use (3, 4). Although SBIRT is appropriate for all levels of risk, it is a particularly useful early intervention approach to identifying and intervening with persons with nondependent substance use before they require extensive or specialized treatment. Among children and adolescents, primary care interventions can include positive feedback for nonusers as primary prevention; brief advice for those at low risk for abuse (secondary prevention); or a motivational intervention directed at high-risk patients for reducing use, reducing associated high-risk behaviors, or accepting a referral to treatment. In 2008, the U.S. Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend for or against screening adolescents, adults, and pregnant women for illicit drug use (5). We undertook the current review to synthesize the evidence on the benefits and harms of primary carerelevant behavioral interventions designed to prevent or reduce illicit drug use or the nonmedical use of prescription drugs among children and adolescents only. The USPSTF used this review to update its recommendation for this population. Methods With input from the USPSTF, we developed an analytic framework and 3 key questions (KQs) to guide our review (Appendix Figure 1). The proposed analytic framework and KQs were posted on the USPSTFs Web site for public comment for 4 weeks. On the basis of this input, we made appropriate revisions and received final approval for publication from USPSTF liaisons. The full report provides details on our methods and results, including search strategies and all evidence tables (www.uspreventiveservicestaskforce.org/uspstf13/drugmisuse/drugmisusedraftrep.htm). Appendix Figure 1. Analytic framework and key questions. Data Sources and Searches We searched for English-language publications in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1992 through 4 June 2013 and in MEDLINE through 31 August 2013. We also assessed the 2 trials that were specific to children and adolescents and were included in the 2008 review (6). We examined the reference lists of 6 relevant published reviews and meta-analyses (712), as well as the reference lists of included studies. We considered gray literature sources and recommendations from experts. Study Selection Two investigators independently reviewed abstracts against prespecified eligibility criteria. We dually reviewed all full-text articles for potential inclusion. We included randomized, controlled trials (RCTs) or controlled clinical trials designed to prevent or reduce drug use in children and adolescents (aged <18 years [no lower age restriction]) who were not diagnosed with a substance use disorder or seeking treatment for substance misuse. We included trials conducted in primary care or those that tested interventions we judged feasible for conduct in primary care that had a link to a health care setting or system, with or without referral to specialty treatment services. This included interventions employing the full SBIRT model and other approaches to primary prevention (to prevent initiation of use) or tertiary prevention (to prevent continued use and adverse effects in those already using). We also included interventions delivered exclusively through electronic media (such as the Internet or CD-ROMs) that were not linked to health care. We excluded trials among youths diagnosed with substance abuse or dependence because they represented specialty treatment only. We also excluded studies conducted among adolescents who were mandated or directly referred to substance abuse or dependence treatment via the juvenile justice system, social services, parents, or a similar referral system. In addition, we excluded interventions conducted in substance abuse treatment centers, schools, worksites, and other institutions (for example, juvenile detention centers). Included trials had control groups that offered minimal or no treatment and reported drug use or health or social outcomes at least 6 months after baseline. Data Extraction and Quality Assessment Two independent investigators rated the quality of all included trials as good, fair, or poor according to USPSTF standards (13). We excluded poor-quality trials. One reviewer abstracted data from studies that were rated fair or good. A second reviewer checked all abstracted data for accuracy and completeness. We resolved discrepancies through discussion. Data Synthesis and Analysis We summarized all included studies in narrative form and summary tables detailing the important features of the study populations, design, intervention, and results. We used the between-group differences that were reported by authors of included studies, when available. We identified too few trials to conduct any meta-analysis, as well as too much variability in several factors (such as population or intervention). As a result, we conducted a qualitative analysis for all KQs and stratified the results into 2 groups based on the intervention: primary carebased or computer-based. Primary carebased studies recruited directly from or were conducted in primary care clinics. Computer-based interventions were judged to be feasible for primary care because they used only electronic methods of delivery, although they did not recruit from or take place in primary care. Role of the Funding Source Agency for Healthcare Research and Quality (AHRQ) staff provided technical oversight for the project. Although USPSTF liaisons helped resolve issues around the reviews scope, they were not involved in the reviews conduct. Results We reviewed 2253 abstracts and 144 full-text articles for possible inclusion (Appendix Figure 2). We identified 6 trials (reported in 7 publications) that met our inclusion criteria (1420). The most common reasons for exclusion included settings (for example, not linked to or feasible for primary care [k= 45]), out-of-scope populations (for example, aged >18 years, seeking treatment, or diagnosed with substance abuse or dependence [k= 26]), and not reporting any relevant outcomes (k= 19) (Appendix Figure 2). Table 1 provides a summary of evidence for the benefits and harms of each included study by outcome (drug use behaviors [KQ 2], health and social outcomes [KQ 1], and harms [KQ 3]). Appendix Figure 2. Summary of evidence search and selection. Table 1. Summary of Evidence for Benefits and Harms of Drug Use Interventions Effects of Interventions on Drug Use Primary CareBased Interventions Three of the 6 studies were conducted in or recruited patients from primary care (Appendix Tables 1 and 2) (16, 17, 20) and tested 4 active treatment groups. We rated all 3 studies as fair-quality according to USPSTF standards (13), with various threats to internal validity (see the full report for more detail on study quality). The smallest study had 41 participants (17), and the largest had more than 2500 (16). Ages ranged from 12 to 20 years, and girls were overrepresented60% to 68% of participants were girls. All 3 studies took place in the United States, and 1 of them (16) also included a sample of adolescents in the Czech Republic. Two of the studies were conducted among a general primary care population (16, 20), whereas the remaining study was conducted among a sample of young persons diagnosed with asthma (17). One of the studies screened adolescents for drug use before enrollment; only those who reported any marijuana use in the past year were randomly assigned (20). In this trial, marijuana use was the primary focus; the other studies targeted drug, alcohol, or tobacco use. Appendix Table 1. Study Characteristics of Included Trials Appendix Table 2. Intervention Characteristics of Included Trials All 3 studies took place during 1 office visit. Three of the interventions included brief counseling (2 to 40 minutes) by the primary care physician (16), family nurse practitioner (17), or trained research therapist (20), and all included a computer-based, self-administered educational component. The study by Walton and colleagues randomly assigned adolescents to a therapist-led brief intervention, computer-based brief intervention, or usual care control group (20). Interventions provided information and advice about substance use along with a decision-making exercise. One of the trials (16) was consis

Incidence of work-related asthma in members of a health maintenance organization.

Objective: The objective of this study was to evaluate work-related asthma among health maintenance organization (HMO) members. Recent reports suggest that the incidence of work-related asthma may be much higher than Sentinel Event Notification Systems for Occupational Risks (SENSOR) data estimate. Methods: Using the HMO’s electronic medical record, we identified 1747 persons with evidence of new or recurrent asthma. Interviews with 352 of them elicited information about workplace exposures, symptoms, and home environment. Industrial hygienists rated the potential asthmagenicity of the respondents’ work environments. Results: Based on the industrial hygienist ratings and self-reported work-relatedness of asthma symptoms, we classified 33% of those interviewed as having potentially work-related asthma, suggesting an overall work-related asthma incidence/recurrence rate of 28 cases per 10,000. Conclusions: The contribution of occupation to the occurrence of adult onset asthma may be much higher than typically suggested in the literature.

Standards of Evidence for Behavioral Counseling Recommendations.

Behavioral counseling interventions to promote healthy behaviors can significantly reduce leading causes of disease and death. Recommendations for delivery of these interventions in primary care have been and continue to be an important part of the U.S. Preventive Services Task Forces portfolio of clinical preventive services recommendations. However, primary and secondary research on the effectiveness of behavioral counseling interventions can be more complex than recommendations for screening or use of preventive medications. The nature of behavior change and interventions to promote it can lead to unique challenges. This paper summarizes and expands upon an extensive discussion held at the U.S. Preventive Services Task Forces Expert Forum on behavioral counseling interventions held in November 2013. The paper describes the foundational challenges for using behavioral outcomes as evidence to support a Task Force recommendation. The paper discusses research design and reporting characteristics needed by behavioral counseling intervention researchers in order for their research to contribute to the evidentiary basis of a Task Force recommendation. Finally, the paper identifies critical issues that need to be considered by the Task Force and other stakeholders to maintain confidence and credibility in the standards of evidence for behavioral counseling recommendations.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Overweight and obesity have been associated with adverse health effects. Objective To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force. Data Sources MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion. Study Selection Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults. Data Extraction and Synthesis Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions. Main Outcomes and Measures Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events. Results A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (−2.39 kg [95% CI, −2.86 to −1.93]; 67 studies [n = 22065]) and less weight regain (−1.59 kg [95% CI, −2.38 to −0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, −0.6 to −5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups. Conclusions and Relevance Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.

Colorectal Cancer Screening—Reply

absent data are likely missing at random. When comparing questionnaire and medical record information regarding number of IVF cycles among women with both sources (n = 9769 [51%]), 80% of women were classified into the same category. Therefore, it is unlikely that using self-reported subfertility diagnosis and number of cycles for 23% would have biased the results. Tomao and colleagues suggest that it would be interesting to investigate whether ovarian stimulation for IVF can promote the occurrence of biologically different types of breast cancer, as in the case of tamoxifen-related endometrial cancer. We agree this would be interesting; however, because IVF treatment was not associated with increased risk of breast cancer, we considered it less relevant to examine whether IVF treatment was associated with breast cancer type. To investigate whether exposure to many IVF cycles could be associated with decreased risk of specific breast cancer types, larger numbers of women with breast cancer would be needed. We agree that the decreased breast cancer risk in women treated with many IVF cycles (≥7 compared with 1-2) might also be associated with the improvement of ovarian function after repeated endocrine stimulations, or there could be other possible explanations. In the analyses, we adjusted for parity and age at first birth as clinical outcomes of IVF, which were the only confounding factors. Other clinical outcomes (ie, cancelled cycles, ovarian hyperstimulation syndrome, poor response to first IVF cycle, and duration of gestation <24 weeks) did not influence the results. However, we did not have measures of estradiol and progesterone levels to draw definitive conclusions. In our study, infertility and infertility-related nulliparity were not associated with increased risk of breast cancer. We think that anovulatory or poor ovulatory cycles should be treated to restore normal ovarian activity if women wish to have a child or are hindered by their irregular ovulatory cycles, regardless of a potential reduction of breast cancer risk.