Kimberly D. Gregory

Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.

DESCRIPTION Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for colorectal cancer. METHODS To update its recommendation, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review on 4 selected questions relating to test characteristics and benefits and harms of screening technologies, and 2) a decision analytic modeling analysis using population modeling techniques to compare the expected health outcomes and resource requirements of available screening modalities when used in a programmatic way over time. RECOMMENDATIONS The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. (A recommendation). The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. (C recommendation). The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. (D recommendation). The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. (I statement).

Aspirin for the Prevention of Cardiovascular Disease: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation about the use of aspirin for the prevention of coronary heart disease. METHODS Review of the literature since 2002, focusing on new evidence on the benefits and harms of aspirin for the primary prevention of cardiovascular disease, including myocardial infarction and stroke. The new evidence was reviewed and synthesized according to sex. RECOMMENDATIONS Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I statement) Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. (D recommendation).

Contemporary cesarean delivery practice in the United States

OBJECTIVE To describe contemporary cesarean delivery practice in the United States. STUDY DESIGN Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008. RESULTS The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. CONCLUSION To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes

OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States. METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter. RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95th percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed. CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States. LEVEL OF EVIDENCE: III

Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition. The USPSTF bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service. The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation. Summary of Recommendation and Evidence The USPSTF recommends screening for chlamydial infection for all sexually active nonpregnant young women age 24 years or younger and older nonpregnant women who are at increased risk (Figure). This is a grade A recommendation. The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 years or younger and for older pregnant women who are at increased risk (Figure). This is a grade B recommendation. The USPSTF recommends against routinely screening for chlamydial infection for women age 25 years or older, regardless of whether they are pregnant, if they are not at increased risk (Figure). This is a grade C recommendation. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men (Figure). This is an I statement. See Table 1 for a description of the USPSTF grades and Table 2 for a description of the USPSTF classification of levels of certainty regarding net benefit. Both are also available at www.annals.org. Figure. Screening for chlamydial infection. For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.preventiveservices.ahrq.gov. *Chlamydial infection results in few sequelae in men. Therefore, the major benefit of screening men would be to reduce the likelihood that infected and untreated men would pass the infection to sexual partners. There is no evidence that screening men reduces the long-term consequences of chlamydial infection in women. Because of this lack of evidence, the USPSTF could not assess the balance of benefits and harms and concluded that the evidence is insufficient to recommend for or against routinely screening men. Information from reference 1. Table 1. What the U.S. Preventive Services Task Force Grades Mean and Suggestions for Practice* Table 2. U.S. Preventive Services Task Force Levels of Certainty Regarding Net Benefit See the Clinical Considerations section for discussion of assessing risk for chlamydial infection in women and suggestions for practice regarding screening for men. Rationale Importance Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. Detection The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity. In low-prevalence populations, however, a positive test result is more likely to be false positive than true positive, even with the most accurate tests available. Benefits of Detection and Early Intervention Nonpregnant Women at Increased Risk There is good evidence that screening for chlamydial infection in nonpregnant women who are at increased risk can reduce the incidence of PID. The USPSTF concluded that the benefits of screening nonpregnant women at increased risk are substantial. Pregnant Women at Increased Risk There are no studies evaluating the effectiveness of screening for chlamydial infection in pregnant women who are at increased risk. The USPSTF, however, found that 1) screening identifies infection in asymptomatic pregnant women, 2) there is a relatively high prevalence of infection among pregnant women who are at increased risk, and 3) there is fair evidence of improved pregnancy and birth outcomes for women who are treated for chlamydial infection. The USPSTF concluded that the benefits of screening pregnant women who are at increased risk are substantial. Women Not at Increased Risk The USPSTF identified no studies documenting the benefits of screening women, including pregnant women, who are not at increased risk for chlamydial infection. While recognizing the potential benefit to women identified through screening, the USPSTF concluded that the overall benefit of screening would be small, given the low prevalence of infection among women not at increased risk. Men While concluding that the direct benefit of screening in men was likely to be small, the USPSTF noted that screening for chlamydial infection in men may be beneficial if it were to lead to a decreased incidence of chlamydial infection in women. The USPSTF did not, however, find evidence to support this outcome and therefore concluded that the benefits of screening men are unknown. The USPSTF identified this as a critical gap in the evidence. Harms of Detection and Early Treatment The USPSTF concluded that the harms of screening for chlamydial infection are small, although few studies have been published on this subject. Potential harms include anxiety and relationship problems arising from false-positive results and overtreatment. The USPSTF identified the lack of evidence related to potential harms of screening as a gap in the evidence.The USPSTF reached the following conclusions: For nonpregnant women at increased risk, the certainty is high that the benefits of screening for chlamydial infection substantially outweigh the harms. This is a grade A recommendation. For pregnant women at increased risk, the certainty is moderate that the benefits substantially outweigh the harms of screening for chlamydial infection. This is a grade B recommendation. For women not at increased risk (including pregnant women not at increased risk), the certainty is moderate that the benefits outweigh the harms of screening to only a small degree. There may be considerations that support screening an individual patient. This is a grade C recommendation. For men, the benefits of screening are not known; thus, the USPSTF could not determine the balance of benefits and harms of screening men for chlamydial infection. This is an I statement. Clinical Considerations Patient Population under Consideration These recommendations target all sexually active individuals, including adolescents and pregnant women. Assessment of Risk All sexually active women 24 years of age or younger, including adolescents, are at increased risk for chlamydial infection. In addition to sexual activity and age, other risk factors for chlamydial infection include a history of chlamydial or other sexually transmitted infection, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the same as for nonpregnant women. Prevalence of chlamydial infection varies widely among patient populations. African-American and Hispanic women have a higher prevalence of infection than the general population in many communities and settings. Among men and women, increased prevalence rates are also found in incarcerated populations, military recruits, and patients at public sexually transmitted infection clinics. Screening Tests Nucleic acid amplification tests have high specificity and sensitivity when used as screening tests for chlamydial infection. Nucleic acid amplification tests can be used with urine and vaginal swabs, enabling screening when a pelvic examination is not performed. Treatment Appropriate treatment of chlamydial infection has been outlined by the Centers for Disease Control and Prevention (CDC) (www.cdc.gov/std/treatment). In its 2006 sexually transmitted disease treatment guidelines, the CDC recommends that chlamydia infection be treated with 1 g of azithromycin in a single oral dose or with oral doxycycline, 100 mg twice daily for 7 days. Pregnant women with chlamydial infection may be treated with 1 g of azithromycin in a single oral dose or amoxicillin, 500 mg orally 3 times daily for 7 days (1). Because the CDC updates these recommendations regularly, clinicians are encouraged to access the CDC Web site (www.cdc.gov/std/treatment) to obtain the most up-to-date information. To prevent recurrent transmission, clinicians should ensure that all sexual partners of infected individuals are tested and treated if infected, or treated presumptively. Screening Intervals Screening pregnant women who are at increased risk for chlamydial infection is recommended at the first prenatal visit. For pregnant women who remain at increased risk and for those who acquire a new risk factor, such as a new sexual partner, a screening should be conducted during the third trimester. The optimal interval for screening for nonpregnant women is unknown. The CDC recommends at least annual screening for women at increased risk (1). Suggestions for Practice with regard to Insufficient Evidence on Screening in Men The USPSTF concluded that the evidence is insufficient to determine the balance of benefits and harms related to screening men for chlamydial infection. Specifically, the USPSTF did not find evidence that screening programs that target men result in a decreased incidence of infection in women. The USPSTF notes that programs that screen men as a means of reducing transmission to women are not common practice, that primary care clinicians can institute screening in men, that the costs of ad

Screening and Treatment for Major Depressive Disorder in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

DESCRIPTION. This is an update of the 2002 US Preventive Services Task Force recommendation on screening for child and adolescent major depressive disorder. METHODS. 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. RECOMMENDATIONS. 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).

Using nontraditional risk factors in coronary heart disease risk assessment: U.S. Preventive Services Task Force recommendation statement.

DESCRIPTION New recommendation from the U.S. Preventive Services Task Force (USPSTF) on the use of nontraditional, or novel, risk factors in assessing the coronary heart disease (CHD) risk of asymptomatic persons. METHODS Systematic reviews were conducted of literature since 1996 on 9 proposed nontraditional markers of CHD risk: high-sensitivity C-reactive protein, ankle-brachial index, leukocyte count, fasting blood glucose, periodontal disease, carotid intima-media thickness, coronary artery calcification score on electron-beam computed tomography, homocysteine, and lipoprotein(a). The reviews followed a hierarchical approach aimed at determining which factors could practically and definitively reassign persons assessed as intermediate-risk according to their Framingham score to either a high-risk or low-risk strata, and thereby improve outcomes by means of aggressive risk-factor modification in those newly assigned to the high-risk stratum. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors studied to screen asymptomatic men and women with no history of CHD to prevent CHD events. (I statement).

Screening for type 2 diabetes mellitus in adults: U.S. preventive services task force recommendation statement

DESCRIPTION Updated U.S. Preventive Services Task Force (USPSTF) recommendation about screening for type 2 diabetes mellitus in adults. METHODS To estimate the balance of benefits and harms of screening, the USPSTF updated its 2003 evidence review, adding evidence from new trials as well as updates on earlier studies. The review for this current recommendation focused on evidence that early treatment prevented long-term adverse outcomes of diabetes, including cardiovascular events, visual impairment, renal failure, and amputation. RECOMMENDATIONS Screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (B recommendation) Current evidence is insufficient to assess the balance of benefits and harms of routine screening in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. (I statement).

The outcome of macrosomic infants weighing at least 4500 grams: Los Angeles County + University of Southern California experience.

Objective To describe the maternal and neonatal outcome of macrosomic infants weighing at least 4500 g. Methods Maternal and neonatal records of infants with birth weights of at least 4500 g were identified during 1991. Outcome variables included the mode of delivery and incidence of maternal and perinatal complications. Results The study sample consisted of 227 infant and mother pairs. Mean (± standard deviation) birth weight was 4706 ± 219 g. A trial of labor was allowed in 192 women, and elective cesarean delivery was performed in 35 patients. The overall cesarean rate, including elective cesarean delivery and failed trial of labor, was 30.8% (70 of 227). Of those undergoing a trial of labor, 82% (157) delivered vaginally. Shoulder dystocia occurred 29 times, for an incidence of 18.5% in vaginal deliveries for macrosomia. There were seven cases each of Erb palsy and clavicular fracture, and one humeral fracture. By 2 months of age, all affected infants were without permanent sequelae. There was no birth asphyxia or perinatal mortality related to delivery for macrosomia. Maternal complications included increased risk of lacerations requiring repair (especially third- or fourth-degree lacerations) when vaginal delivery was complicated by shoulder dystocia (relative risk [RR] 5.4, 95% confidence interval [CI] 3.1–9.4). There was no statistically significant difference with respect to hemorrhage or hospital stay for women who had a vaginal delivery (with or without shoulder dystocia) compared with women who had a cesarean delivery. However, infectious morbidity increased significantly in those patients who underwent a cesarean after a trial of labor compared with women who had a vaginal delivery (RR 7.1, 95% CI 3.9–13.1) or elective cesarean birth (RR 5.4, 95% CI 3.1–9.4). Ninety-one percent of patients undergoing elective cesarean delivery had no complications. Conclusion Vaginal delivery is a reasonable alternative to elective cesarean for infants with estimated birth weights of at least 4500 g, and a trial of labor can be offered.

Maternal and infant complications in high and normal weight infants by method of delivery

Objective To estimate the population risks of maternal and infant complications with the birth of macrosomic (at least 4000 g) compared with normal weight infants. Methods Term, singleton infants were identified from the state of Washingtons birth event records database for 1990. Diagnosis codes from the Internal Classification of Diseases (9th revision) were used to identify delivery method and previously defined complications. We adjusted for maternal demographic and clinical factors using multivariable logistic regression to derive the risk of each maternal and infant complication. Results The incidence of macrosomia was 13% (8815 of 66,086). Vaginal birth of macrosomic infants was associated with low incidence of complications except for shoulder dystocia (11%) and postpartum hemorrhage (5%). Postpartum infection was the most common complication for women who had cesarean delivery after labor (5%), and complications for women who had cesarean without labor were rare (less than 3%). Neonatal complications were rare. Among infants with shoulder dystocia, the risks of asphyxia (adjusted relative risk [RR] 1.2, 95% confidence interval [CI] 0.6, 2.3), birth trauma (RR 0.6, 95% CI 0.2, 1.6), long-bone injury (RR 1.2, 95% CI 0.6, 2.4), seizures (RR 1.0, 95% CI 0.0, 25.0), and facial palsy (RR 2.2, 95% CI 0.2, 44.4) were not significantly different for macrosomic and normal weight infants; however, macrosomic infants had a significantly increased risk of Erb palsy (RR 3.5, 95% CI 1.8, 7.5). Conclusion This population-based study showed that most macrosomic infants are delivered vaginally with low rates of maternal and neonatal complications. Macrosomic infants have higher rates of Erb palsy, but similar rates of other serious complications of shoulder dystocia when compared with normal weight infants.