Search

Purpose/Aim of the study : The main purpose of the colonoscopy is screening for colorectal cancers and diagnosis of colorectal disease The cost-effectiveness of colonoscopy directly depend on the adequate bowel preparation. Inadequate colonoscopy is recommended to be re-scheduled within 1 year. Re-scheduling is an economic and patient burden. Thus instead of re-scheduling, another strategy may be attempted. The purpose of this study was to examine the usefulness and effect of the same day repeat colonoscopy after administration of an additional laxative dose. Materials and Methods: Patients with inadequate colonoscopy were enrolled in the study. The patients eligible for the enrollment were instructed to consume an additional laxative and scheduled in afternoon. The demographic data of the patient, the details of the index and repeat procedures were obtained by a questionnaire. Results: A total of 60 patients were enrolled in the study. The rate of adequate colonoscopy was 80%. Cecum intubation rate was 83.3%. There were no complications due to colonoscopy itself and additional laxatives. The polyp detection rate was 26.6%. The withdrawal time was 6.7 ± 1.34 min. Conclusion: The results of the present study showed that same day repeat colonoscopy with additional laxative dose can be a safe and effective method for repeat procedure of an inadequate colonoscopy. The patients tolerated and were satisfied with the same day protocol. Quality indicators of colonoscopy such as adenoma detection rate and cecum intubation rate were achieved. Same day bowel cleansing method may be considered as an alternative way rather than re-scheduling inadequate colonoscopy for a later time.

Introduction: Opportunistic screening for prostate cancer has been widely used, though organized programs are not recommended. We aimed to estimate the prevalence of prostate cancer screening and the perception of potential benefits and harms of screening, among the Portuguese general population., Methods: A representative sample of Portuguese-speaking inhabitants in mainland Portugal was selected, using a stratified probabilistic sampling procedure; men above 40 were considered for analysis (n = 414). Data on sociodemographic characteristics, lifetime use and usual frequency of prostate cancer screening (prostate-specific antigen test or digital rectal examination) and perception of potential benefits and adverse effects of cancer screening were assessed using face-to-face interviews, by structured questionnaire., Results: The proportion of participants who reported having been submitted to prostate cancer screening at least once in their lifetime was 44.2% (95% confidence interval: 37.5-51.0; 13.8% only digital rectal examination, 12.2% only prostate-specific antigen test, and 18.2% digital rectal examination and prostate-specific antigen test). As potential benefits of cancer screening, the options "knowledge of not having the disease", "earlier detection" and "more effective treatment" were selected by 55.8%, 12.9% and 31.3% of the participants, respectively. Regarding potential adverse effects, the most and least frequently identified were 'anxiety while waiting for the results' (55.1%) and 'false negatives' (38.0%), respectively., Conclusions: Almost half of the men between 40 and 79 years old declared that they have been screened for prostate cancer. Nearly one-third of the participants considered that reassurance of a negative result was the main potential benefit of screening, whereas most failed to identify the most frequent adverse effects.

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.

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).

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

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).

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.

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., Competing Interests: Les auteurs déclarent n’avoir aucun conflit d’intérêts en relation avec cet article.

Disease-modifying pharmacotherapies for Alzheimer's Disease (AD) are currently in late-stage clinical development; once approved, new healthcare infrastructures and services, including primary healthcare, will be necessary to accommodate a huge demand for early and large-scale detection of AD. The increasing global accessibility of digital consumer electronics has opened up new prospects for early diagnosis and management of mild cognitive impairment (MCI) with particular regard to AD. This new wave of innovation has spurred research in both academia and industry, aimed at developing and validating a new "digital generation" of tools for the assessment of the cognitive performance. In light of this paradigm shift, an international working group (the Global Advisory Group on Future MCI Care Pathways) convened to elaborate on how digital tools may be optimally integrated in screening-diagnostic pathways of AD The working group developed consensus perspectives on new algorithms for large-scale screening, detection, and diagnosis of individuals with MCI within primary medical care delivery. In addition, the expert panel addressed operational aspects concerning the implementation of unsupervised at-home testing of cognitive performance. The ultimate intent of the working group's consensus perspectives is to provide guidance to developers of cognitive tests and tools to facilitate the transition toward globally accessible cognitive screening aimed at the early detection, diagnosis, and management of MCI due to AD., Competing Interests: MB is affiliated with the Research Center and Memory Clinic, Fundació ACE, Institut Català de Neurociències Aplicades, Universitat Internacional de Catalunya, Barcelona, Spain; and with the Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Spain. Private research funding sources include Grifols SA; Caixabank S.A.; Life Molecular Imaging; Araclon Biotech; Laboratorios Echevarne; Festival Castell Paralada; Bonpreu/Esclat; and Famila Carbó. Public grants include those from Instituto de Salud Carlos III. Ministerio de Salud. Gobierno de España; Dirección General de Farmacia. Ministerio de Salud. Gobierno de España; and European Commission:H2020 program, Innovative Medicine Initiative (IMI-2); and ERA-NET NEURON program, European Marie Sklodowska Curie. Advisory work includes that for Araclon Biotech, Biogen, Bioibérica, Eisai, Grifols, Lilly, Merck, Nutricia, Roche, Oryzon, Schwabe Farma, Servier, and Kyowa Kirin. PMD has received research grants (through Duke University) from Avid, Lilly, Neuronetrix, Avanir, Bauch, Alzheimer’s Drug Discovery Foundation, Cure Alzheimer’s Fund, Wrenn Trust, DOD, ONR, and NIH. PMD has received speaking or advisory fees from Anthrotronix, Neuroptix, Genomind, Clearview, Cognicity, Nutricia, Living Media, Verily, RBC, Brain Canada, and CEOs Against Alzheimers. PMD owns shares in Muses Labs, Anthrotronix, Evidation Health, Turtle Shell Technologies and Advera Health Analytics whose products are not discussed here. He has received travel support from World Economic Forum, CCABH and Canaan Ventures. PMD served/serves on the board of Baycrest, AHEL, TLLF and TGHF. PMD is a co-inventor (through Duke) on patents relating to dementia biomarkers and therapies. BD is affiliated with the Institute of Memory and Alzheimer’s Disease (IM2A), Department of Neurology, Salpêtrière Hospital, AP-HP, Sorbonne-Université, Paris, France. JI is affiliated as an Assistant Professor-Adjunct (Group1) with the Department of Family Practice at Queen’s University. She was also a panelist for Hoffman-La Roche Limited, Ottawa, on an Alzheimer’s Disease Panel. She is involved with the Canadian Consortium on Neurodegeneration in Aging (CCNA), Extension Study as a Co- Investigator and Research Coordinator. AI received lecture fees from Eisai, Janssen, Otsuka, Eli Lilly, MSD, Chugai-Roche, Daiichi-Sankyo, Alnylam, Takeda, UCB, Ono, Integra Japan, IQVIA, Fuji Rebio, Biogen, and advisory fees from Janssen during the past three years. AP reports personal fees from Acadia Pharmaceuticals, Functional Neuromodulation, Neurim Pharmaceuticals, Grifols, Eisai, BioXcel, Tetra Discovery Partners, and Merck; grants from AstraZeneca, Avanir, Biogen, Biohaven, Eisai, Eli Lilly, Janssen, Genentech/Roche, Novartis, Merck, as well as funding from NIA, NIMH, DOD. KLP receives grant funding from the National Institute on Aging, the National Institute of Neurological Disorders and Stroke, the Global Brain Health Institute, and Quest Diagnostics. BV has consultancy and research grants from Roche, Biogen, EISAI, Nestle, Lilly, Cerecin, and Merck. HH is an employee of Eisai Inc. and serves as Senior Associate Editor for the Journal Alzheimer’s and Dementia; during the past three years he had received lecture fees from Servier, Biogen and Roche, research grants from Pfizer, Avid, and MSD Avenir (paid to the institution), travel funding from Eisai, Functional Neuromodulation, Axovant, Eli Lilly and company, Takeda and Zinfandel, GE-Healthcare and Oryzon Genomics, consultancy fees from Qynapse, Jung Diagnostics, Cytox Ltd., Axovant, Anavex, Takeda and Zinfandel, GE Healthcare, Oryzon Genomics, and Functional Neuromodulation, and participated in scientific advisory boards of Functional Neuromodulation, Axovant, Eisai, Eli Lilly and company, Cytox Ltd., GE Healthcare, Takeda and Zinfandel, Oryzon Genomics and Roche Diagnostics. He is co-inventor in the following patents as a scientific expert and has received no royalties: In Vitro Multiparameter Determination Method for the Diagnosis and Early Diagnosis of Neurodegenerative Disorders Patent Number: 8916388; In Vitro Procedure for Diagnosis and Early Diagnosis of Neurodegenerative Diseases Patent Number: 8298784; Neurodegenerative Markers for Psychiatric Conditions Publication Number: 20120196300; In Vitro Multiparameter Determination Method for The Diagnosis and Early Diagnosis of Neurodegenerative Disorders Publication Number: 20100062463; In Vitro Method for The Diagnosis and Early Diagnosis of Neurodegenerative Disorders Publication Number: 20100035286; In Vitro Procedure for Diagnosis and Early Diagnosis of Neurodegenerative Diseases Publication Number: 20090263822; In Vitro Method for The Diagnosis of Neurodegenerative Diseases Patent Number: 7547553; CSF Diagnostic in Vitro Method for Diagnosis of Dementias and Neuroinflammatory Diseases Publication Number: 20080206797; In Vitro Method for The Diagnosis of Neurodegenerative Diseases Publication Number: 20080199966; Neurodegenerative Markers for Psychiatric Conditions Publication Number: 20080131921. AV is an employee of Eisai Inc. and received lecture honoraria from Roche, MagQu LLC, and Servier.

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

Importance: Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%., Objective: To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force., Data Sources: MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019., Study Selection: Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms., Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality., Main Outcomes and Measures: AAA and all-cause mortality; AAA rupture; treatment complications., Results: Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124 926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124 929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175 085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124 929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175 085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14 424]) showed that women had higher surgical complications and postoperative mortality compared with men., Conclusions and Relevance: One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.

Background: This systematic review was conducted to inform the Canadian Task Force on Preventive Health Care recommendations on screening for thyroid dysfunction (TD). The review sought to answer key questions on the benefits and harms of screening for TD, patients' values and preferences for screening, and the benefits and harms of treating screen-detected TD., Methods: This review followed Canadian Task Force on Preventive Health Care methods, which include the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The search strategy used for benefits and harms of screening and treatment was an update to the 2014 review by the US Preventive Services Task Force and searched MEDLINE and the Cochrane Library. MEDLINE, Embase, ProQuest Public Health, and SCOPUS were searched for patients' values and preferences for screening. Outcomes of interest included all-cause mortality, deaths due to cardiovascular diseases, fatal and non-fatal cardiovascular events, atrial fibrillation, fractures, quality of life, cognitive function, and harms due to TD treatment. Two reviewers independently screened abstracts and full texts according to pre-determined inclusion criteria and assessed the risk of bias for each study included. Strength and quality of the evidence was assessed for each outcome. A narrative synthesis was conducted due to heterogeneity of the included studies., Results: No studies were found on screening for TD, treatment of subclinical hyperthyroidism, or patients' values and preferences for screening for TD. Twenty-two studies (from 24 publications) on the treatment of TD in patients with screen-detected subclinical hypothyroidism were included. Results from the included randomized controlled trials suggested no benefit of treatment for subclinical hypothyroidism for the large majority of outcomes. We found very low-quality evidence (from two cohort studies) for a small reduction in all-cause mortality among adults < 65 or 40-70 years who were treated for TD compared to those who were not., Conclusions: This review found moderate to very low-quality evidence on the benefits and harms of treatment for subclinical hypothyroidism, with most of the evidence showing no benefit of treatment.

Background: Women with Down syndrome have a lower breast cancer risk and significantly lower life expectancies than women without Down syndrome. Therefore, it is not clear whether mammography screening strategies used for women without Down syndrome would benefit women with Down syndrome in the same way., Objective: To determine the benefits and harms of various mammography screening strategies for women with Down syndrome using collaborative simulation modeling., Design: Two established Cancer Intervention and Surveillance Modeling Network (CISNET) simulation models estimated the benefits and harms of various screening strategies for women with Down syndrome over a lifetime horizon., Participants: We modeled a hypothetical cohort of US women with Down syndrome who were born in 1970., Interventions: Annual, biennial, triennial, and one-time digital mammography screenings during the ages 40-74., Main Measures: The models estimated numbers of mammograms, false-positives, benign biopsies, breast cancer deaths prevented, and life-years gained per 1000 screened women when compared with no screening., Key Results: In average-risk women 50-74, biennial screening incurred 122 mammograms, 10 false-positive mammograms, and 1.4 benign biopsies per one life-year gained compared with no screening. In women with Down syndrome, the same screening strategy incurred 2752 mammograms, 242 false-positive mammograms, and 34 benign biopsies per one life-year gained compared with no screening. The harm/benefit ratio varied for other screening strategies, and was most favorable for one-time screening at age 50, which incurred 1629 mammograms, 144 false-positive mammograms, and 20 benign biopsies per one life-year gained compared with no screening., Conclusions: The harm/benefit ratios for various mammography screening strategies in women with Down syndrome are not as favorable as those for average-risk women. The benefit of screening mammography for women with Down syndrome is less pronounced due to lower breast cancer risk and shorter life expectancy.

Background. Organized screening programs often rely on written materials to inform the public. In the United Kingdom, women invited for cervical cancer screening receive a leaflet from the National Health Service (NHS) to support screening decisions. However, information about screening may be too complex for people to understand, potentially hindering informed decision making. Objectives. We aimed to identify women's difficulties in interpreting the leaflet used in England and negative and positive responses to the leaflet. Methods. We used a sequential mixed-methods design involving 2 steps: cognitive think-aloud interviews ( n = 20), followed by an England-wide survey ( n = 602). Data were collected between June 2017 and December 2018, and participants included women aged 25 to 64 y with varying sociodemographics. Results. Interview results revealed misunderstandings concerning screening results, benefits, and additional tests and treatment, although participants tended to react positively to numerical information. Participants were often unfamiliar with the potential harms associated with screening (i.e., screening risks), key aspects of human papillomavirus, and complex terms (e.g., dyskaryosis ). Survey results indicated that interpretation difficulties were common ( M correct items = 12.5 of 23). Lower understanding was associated with lower educational level (β's >0.15, P 's <0.001), lower numeracy scores (β = 0.36, P < 0.001), and nonwhite ethnicity (β = 0.10, P = 0.007). The leaflet was evaluated positively overall. Conclusions. Despite previous user testing of the leaflet, key information may be too complex for some recipients. As a consequence, they may struggle to make informed decisions about screening participation based on the information provided. We discuss implications for the improvement of communications about screening and decision support.

Importance: Screening for asymptomatic bacteriuria can identify patients for whom treatment might be beneficial for preventing symptomatic infection and other health outcomes., Objective: To systematically review benefits and harms of asymptomatic bacteriuria screening and treatment in adults, including during pregnancy, to inform the US Preventive Services Task Force., Data Sources: MEDLINE, PubMed (publisher-supplied records), and Cochrane Collaboration Central Registry of Controlled Trials; surveillance through May 24, 2019., Study Selection: Randomized clinical trials (RCTs) and observational studies on benefits and harms of screening for asymptomatic bacteriuria; RCTs on benefits and harms of asymptomatic bacteriuria treatment. Eligible populations included unselected, asymptomatic individuals without known urinary tract conditions., Data Extraction and Synthesis: Independent critical appraisal and data abstraction by 2 reviewers. Random-effects meta-analysis was conducted to estimate benefits of the interventions., Main Outcomes and Measures: Symptomatic infection; function, morbidity, mortality; pregnancy complications and birth outcomes., Results: Nineteen studies (N = 8443) meeting inclusion criteria were identified. Two cohort studies (n = 5289) found fewer cases of pyelonephritis in the cohorts of screened pregnant women (0.5%) than within retrospective comparisons of unscreened cohorts (2.2% and 1.8%); the larger study estimated a statistically significant relative risk of 0.30 (95% CI, 0.15-0.60). No studies examined screening in nonpregnant populations. Among 12 trials of asymptomatic bacteriuria screening and treatment during pregnancy (n = 2377; 1 conducted within past 30 years), there were reduced rates of pyelonephritis (range, 0%-16.5% for the intervention group and 2.2%-36.4% for the control group; pooled risk ratio [RR], 0.24 [95% CI, 0.14-0.40]; 12 trials) and low birth weight (range, 2.5%-14.8% for the intervention group and 6.7%-21.4% for the control group; pooled RR, 0.64 [95% CI, 0.46-0.90]; 7 trials). There was no significant difference in infant mortality (pooled RR, 0.98 [95% CI, 0.29-3.26]; 6 trials). Five RCTs of asymptomatic bacteriuria treatment in nonpregnant adults (n = 777) did not report any significant differences in risk of infection, mobility, or mortality. Limited evidence on harms of screening or treatment was available, and no statistically significant differences were identified., Conclusions and Relevance: Screening and treatment for asymptomatic bacteriuria during pregnancy was associated with reduced rates of pyelonephritis and low birth weights, but the available evidence was not current, with only 1 study conducted in the past 30 years. Benefits of asymptomatic bacteriuria treatment in nonpregnant adult populations were not found. Trial evidence on harms of asymptomatic bacteriuria antibiotic treatment was limited.

This systematic review, stimulated by inconsistency in secondary evidence, reports the benefits and harms of breast cancer (BC) screening and their determinants according to systematic reviews. A systematic search, which identified 9,976 abstracts, led to the inclusion of 58 reviews. BC mortality reduction with screening mammography was 15-25% in trials and 28-56% in observational studies in all age groups, and the risk of stage III+ cancers was reduced for women older than 49 years. Overdiagnosis due to mammography was 1-60% in trials and 1-12% in studies with a low risk of bias, and cumulative false-positive rates were lower with biennial than annual screening (3-17% vs 0.01-41%). There is no consistency in the reviews' conclusions about the magnitude of BC mortality reduction among women younger than 50 years or older than 69 years, or determinants of benefits and harms of mammography, including the type of mammography (digital vs screen-film), the number of views and the screening interval. Similarly, there was no solid evidence on determinants of benefits and harms or BC mortality reduction with screening by ultrasonography or clinical breast examination (sensitivity ranges, 54-84% and 47-69%, respectively), and strong evidence of unfavourable benefit-to-harm ratio with breast self-examination. The reviews' conclusions were not dependent on the quality of the reviews or publication date. Systematic reviews on mammography screening, mainly from high-income countries, systematically disagree on the interpretation of the benefit-to-harm ratio. Future reviews are unlikely to clarify the discrepancies unless new original studies are published., (© 2019 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Importance: Pancreatic adenocarcinoma is the third most common cause of cancer death among men and women in the United States., Objective: To systematically review benefits and harms of screening for pancreatic adenocarcinoma to inform the US Preventive Services Task Force., Data Sources: MEDLINE, PubMed, and the Cochrane Collaboration Registry of Controlled Trials, from January 2002 through April 27, 2018; surveillance through March 22, 2019., Study Selection: Studies of adults with or without risk factors for pancreatic adenocarcinoma (eg, family history of pancreatic cancer, personal history of new-onset diabetes) undergoing imaging-based screening; studies of treatment for adults with screen-detected or asymptomatic pancreatic adenocarcinoma. Included study designs were randomized clinical trials, nonrandomized controlled intervention studies, diagnostic accuracy studies with a reference standard, cohort studies, and case-control studies (for evaluation of harms only). Studies consisting entirely of populations with known genetic syndromes associated with pancreatic cancer were excluded., Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and rated included studies for quality; data were quantitatively analyzed to calculate a pooled diagnostic yield and narratively synthesized., Main Outcomes and Measures: Mortality, morbidity, or quality of life; diagnostic accuracy of screening tests; any harm of screening or treatment., Results: Thirteen fair-quality prospective cohort screening studies (N = 1317) conducted predominantly in populations at high familial risk for pancreatic adenocarcinoma were included. No studies reported on the effect of screening on morbidity or mortality or on the effectiveness of treatment for screen-detected pancreatic adenocarcinoma. Although no studies evaluated the diagnostic accuracy of screening tests, all 13 studies reported the diagnostic yield. Yields ranged from 0 to 75 cases per 1000 persons in studies using endoscopic ultrasound, magnetic resonance imaging, and/or computed tomography-based screening. In total, 18 cases of pancreatic adenocarcinoma were detected in 1156 adults at increased familial risk and 0 cases were detected in 161 average-risk adults. In 8 studies (n = 675) assessing procedural harms of screening, no serious harms from initial screening were reported. Two studies (n = 271) found no evidence of psychosocial harms related to screening. Evidence of surgical harms was limited., Conclusions and Relevance: Imaging-based screening in groups at high familial risk can detect pancreatic adenocarcinoma with limited evidence of minimal harms. However, the effect of screening on morbidity and mortality in groups at high familial risk has not been studied, and no data are available in average-risk populations. There is limited evidence to assess benefits or harms of surgical intervention for screen-detected pancreatic adenocarcinoma.

Transplantation is the preferred treatment for patients with kidney failure, but the need exceeds the supply of transplantable kidneys, and patients routinely wait >5 years on dialysis for a transplant. Coronary artery disease (CAD) is common in kidney failure and can exclude patients from transplantation or result in death before or after transplantation. Screening asymptomatic patients for CAD using noninvasive tests prior to wait-listing and at regular intervals (ie, annually) after wait-listing until transplantation is the established standard of care and is justified by the need to avoid adverse patient outcomes and loss of organs. Patients with abnormal screening tests undergo coronary angiography, and those with critical stenoses are revascularized. Screening is potentially harmful because patients may be excluded or delayed from transplantation, and complications after revascularization are more frequent in this population. CARSK will test the hypothesis that eliminating screening tests for occult CAD after wait-listing is not inferior to regular screening for the prevention of major adverse cardiac events defined as the composite of cardiovascular death, nonfatal myocardial infarction, urgent revascularization, and hospitalization for unstable angina. Secondary outcomes include the transplant rate, safety measures, and the cost-effectiveness of screening. Enrolment of 3,306 patients over 3 years is required, with patients followed for up to 5 years during wait-listing and for 1 year after transplantation. By validating or refuting the use of screening tests during wait-listing, CARSK will ensure judicious use of health resources and optimal patient outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening., Objective: To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening., Design: National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey., Participants: Community-dwelling adults 55-97 years old (n = 3816)., Main Measures: Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates., Key Results: Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001)., Conclusion: Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

Objectives: Disutility allows to identify how much population values intervention-related harms contributing to knowledge on the benefits/harms ratio of cancer screening programs. This systematic review evaluates disutility related to cancer screening applying a utility theory framework., Methods: Using a predefined protocol, Embase, Medline Ovid, Web of Science, Cochrane, Google scholar and supplementary sources were systematically searched. The framework grouped disutilities associated with breast, cervical, lung, colorectal, and prostate cancer screening programs into the screening, diagnostic work up, and treatment phases. We assessed the quality of included studies according to the relevance to target population, risk of bias, appropriateness of measure and the time frame., Results: Out of 2840 hits, we included 38 studies, of which 27 measured (and others estimated) disutilities. Around 70% of studies had medium to high-level quality. Measured disutilities and Quality Adjusted Life Years loss were 0-0.03 and 0-0.0013 respectively in screening phases. Both disutilities and Quality Adjusted Life Years loss had similar ranges in diagnostic work up (0-0.26), and treatment (0.09-0.27) phases. We found no measured disutilities available for lung cancer screening and-little evidence for disutilities in treatment phase. Almost 40% of the estimated disutility values were above the range of measured ones., Conclusions: Cancer screening programs led to low disutities related to screening phase, and low to moderate disutilities related to diagnostic work up and treatment phases. These disutility values varied by the measurement instrument applied, and were higher in studies with lower quality. The estimated disutility values comparing to the measured ones tended to overestimate the harms., Competing Interests: The authors have declared that no competing interests exist.

Importance: Prenatal screening for HIV can inform use of interventions to reduce the risk of mother-to-child transmission. The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012., Objective: To update the 2012 review on prenatal HIV screening to inform the USPSTF., Data Sources: Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019., Study Selection: Pregnant persons 13 years and older; randomized clinical trials and cohort studies of screening vs no screening; risk of mother-to-child transmission or maternal or infant harms associated with antiretroviral therapy (ART) during pregnancy; screening yield at different intervals or in different risk groups., Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality., Main Outcomes and Measures: Mother-to-child transmission; harms of screening and treatment; screening yield., Results: Sixty-two studies were included in this review, including 29 new studies. There remains no direct evidence on effects of prenatal screening vs no screening on risk of mother-to-child HIV transmission, maternal or infant clinical outcomes, or the yield of repeat or alternative screening strategies. New evidence confirms that combination ART is highly effective at reducing the risk of mother-to-child transmission, with some new cohort studies reporting rates of mother-to-child transmission less than 1% when combination ART was started early in pregnancy (when begun in first trimester, 0%-0.4%; when begun after first trimester, or at any time if timing of ART initiation not reported, 0.4%-2.8%). New evidence on harms of ART was also largely consistent with the previous review. Evidence from primarily observational studies found prenatal combination ART with a boosted protease inhibitor associated with increased risk of preterm delivery (range, 14.4%-26.1%). For other birth outcomes (low birth weight, small for gestational age, stillbirth, birth defects, neonatal death), results were mixed and depended on the specific antiretroviral drug or drug regimen given and timing of prenatal therapy., Conclusions and Relevance: Combination ART was highly effective at reducing risk of mother-to-child HIV transmission. Use of certain ART regimens during pregnancy was associated with increased risk of harms that may be mitigated by selection of ART regimen. The 2012 review found that avoidance of breastfeeding and cesarean delivery in women with viremia also reduced risk of transmission and that prenatal screening accurately diagnosed HIV infection.

Importance: Untreated HIV infection can result in significant morbidity, mortality, and HIV transmission. A 2012 review for the US Preventive Services Task Force (USPSTF) found antiretroviral therapy (ART) associated with improved clinical outcomes and decreased transmission risk in persons with CD4 cell counts less than 500/mm3., Objective: To update the 2012 review on HIV screening to inform the USPSTF., Data Sources: Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019., Study Selection: Nonpregnant individuals 12 years and older; randomized clinical trials (RCTs) and controlled observational studies of screening vs no screening, alternative screening strategies, earlier vs later initiation of ART, and long-term harms of ART., Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality., Main Outcomes and Measures: Mortality, AIDS events, quality of life, function, and HIV transmission; harms of screening and long-term (≥2 years) harms of ART; screening yield., Results: Eighteen new studies (5 RCTs, 11 cohort studies, and 2 systematic reviews; N = 266 563) were included, and 11 studies (2 RCTs and 9 cohort studies; N = 218 542) were carried forward from the prior USPSTF report. No study directly evaluated effects of HIV screening vs no screening on clinical outcomes or harms, or the yield of alternative screening strategies. Two newly identified RCTs conducted completely or partially in low-resource settings found ART initiation at CD4 cell counts greater than 500/mm3 associated with lower risk of a composite outcome of mortality, AIDS-defining events, or serious non-AIDS events (relative risk [RR], 0.44 [95% CI, 0.31-0.63] and RR, 0.57 [95% CI, 0.35-0.95]); results were consistent with those from a large observational study. Early ART was not associated with increased risk of cardiovascular events. Early ART initiation was associated with sustained reduction in risk of HIV transmission at 5.5 years (RR, 0.07 [95% CI, 0.02-0.22] for linked transmission). New evidence regarding the association between abacavir use and risk of cardiovascular events was inconsistent. Certain antiretroviral regimens were associated with increased risk of long-term neuropsychiatric, renal, hepatic, and bone adverse events., Conclusions and Relevance: In nonpregnant adolescents and adults there was no direct evidence on the clinical benefits and harms of screening for HIV infections vs no screening, or the yield of repeat or alternative screening strategies. New evidence extends effectiveness of ART to asymptomatic individuals with CD4 cell counts greater than 500/mm3 and shows sustained reduction in risk of HIV transmission at longer-term follow-up, although certain ART regimens may be associated with increased risk of long-term harms.

Background: Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged., Objectives: To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population., Search Methods: We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports., Selection Criteria: RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences., Main Results: We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data., Authors' Conclusions: Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.

Description: The purpose of this guidance statement is to provide advice to clinicians on breast cancer screening in average-risk women based on a review of existing guidelines and the evidence they include., Methods: This guidance statement is derived from an appraisal of selected guidelines from around the world that address breast cancer screening, as well as their included evidence. All national guidelines published in English between 1 January 2013 and 15 November 2017 in the National Guideline Clearinghouse or Guidelines International Network library were included. In addition, the authors selected other guidelines commonly used in clinical practice. Web sites associated with all selected guidelines were checked for updates on 10 December 2018. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the quality of guidelines., Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is all asymptomatic women with average risk for breast cancer., Guidance Statement 1: In average-risk women aged 40 to 49 years, clinicians should discuss whether to screen for breast cancer with mammography before age 50 years. Discussion should include the potential benefits and harms and a woman's preferences. The potential harms outweigh the benefits in most women aged 40 to 49 years., Guidance Statement 2: In average-risk women aged 50 to 74 years, clinicians should offer screening for breast cancer with biennial mammography., Guidance Statement 3: In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer., Guidance Statement 4: In average-risk women of all ages, clinicians should not use clinical breast examination to screen for breast cancer.

Importance: Elevated blood lead level is associated with serious, often irreversible, health consequences., Objective: To synthesize evidence on the effects of screening, testing, and treatment for elevated blood lead level in pregnant women and children aged 5 years and younger in the primary care setting to inform the US Preventive Services Task Force., Data Sources: Cochrane CENTRAL and Cochrane Database of Systematic Reviews (through June 2018) and Ovid MEDLINE (1946 to June 2018); surveillance through December 5, 2018., Study Selection: English-language trials and observational studies of screening for and treating elevated lead levels in asymptomatic children and pregnant women., Data Extraction and Synthesis: Independent critical appraisal and data abstraction by 2 reviewers using predefined criteria., Main Outcomes and Measures: Elevated blood lead level, morbidity, mortality, clinical prediction tools, test accuracy, adverse events., Results: A total of 24 studies (N = 11 433) were included in this review. No studies evaluated the benefits or harms of screening vs no screening in children. More than 1 positive answer on the 5-item 1991 Centers for Disease Control and Prevention (CDC) screening questionnaire was associated with a pooled sensitivity of 48% (95% CI, 31.4% to 65.6%) and specificity of 58% (95% CI, 39.9% to 74.0%) for identifying children with a venous blood lead level greater than 10 μg/dL (5 studies [n = 2265]). Adapted versions of the CDC questionnaire did not demonstrate improved accuracy. Capillary blood lead testing demonstrated sensitivity of 87% to 91% and specificity greater than 90%, compared with venous measurement (4 studies [n = 1431]). Counseling and nutritional interventions or residential lead hazard control techniques did not reduce blood lead concentrations in asymptomatic children, but studies were few and had methodological limitations (7 studies [n = 1419]). One trial (n = 780) of dimercaptosuccinic acid (DMSA) chelation therapy found reduced blood lead levels in children at 1 week to 1 year but not at 4.5 to 6 years, while another trial (n = 39) found no effect at 1 and 6 months. Seven-year follow-up assessments showed no effect on neuropsychological development, a small deficit in linear growth (height difference, 1.17 cm [95% CI, 0.41 to 1.93]), and poorer cognitive outcomes reported as the Attention and Executive Functions subscore of the Developmental Neuropsychological Assessment (unadjusted difference, -1.8 [95% CI, -4.5 to 1.0]; adjusted P = .045) in children treated with DMSA chelation. Evidence was too limited to determine the accuracy of screening questionnaires or benefits and harms of treatment in pregnant women., Conclusions and Relevance: Screening questionnaires were not accurate for identifying children with elevated blood lead levels. Chelating agents in children were not significantly associated with sustained effects on blood level levels but were associated with harms.

Barrett's esophagus (BE) is an abnormality arising from gastroesophageal reflux disease that can progressively evolve into a sequence of dysplasia and adenocarcinoma. Progression of Barrett's esophagus into dysplasia is monitored with endoscopic surveillance. The current surveillance standard requests random biopsies plus targeted biopsies of suspicious lesions under white-light endoscopy, known as the Seattle protocol. Recently, published evidence has shown that narrow-band imaging (NBI) can guide targeted biopsies to identify dysplasia and reduce the need for random biopsies. We aimed to assess the health economic implications of adopting NBI-guided targeted biopsy vs. the Seattle protocol from a National Health Service England perspective. A decision tree model was developed to undertake a cost-consequence analysis. The model estimated total costs (i.e. staff and overheads; histopathology; adverse events; capital equipment) and clinical implications of monitoring a cohort of patients with known/suspected BE, on an annual basis. In the simulation, BE patients (N = 161,657 at Year 1; estimated annual increase: +20%) entered the model every year and underwent esophageal endoscopy. After 7 years, the adoption of NBI with targeted biopsies resulted in cost reduction of £458.0 mln vs. HD-WLE with random biopsies (overall costs: £1,966.2 mln and £2,424.2 mln, respectively). The incremental investment on capital equipment to upgrade hospitals with NBI (+£68.3 mln) was offset by savings due to the reduction of histological examinations (-£505.2 mln). Reduction of biopsies also determined savings for avoided adverse events (-£21.1 mln). In the base-case analysis, the two techniques had the same accuracy (number of correctly identified cases: 1.934 mln), but NBI was safer than HD-WLE. Budget impact analysis and cost-effectiveness analyses confirmed the findings of the cost-consequence analysis. In conclusion, NBI-guided targeted biopsies was a cost-saving strategy for NHS England, compared to current practice for detection of dysplasia in patients with BE, whilst maintaining at least comparable health outcomes for patients., Competing Interests: We have the following interests: This study was funded by Olympus. ZI and RK are employees of Olympus. Olympus is the manufacturer of NBI, a technology which is the focus of this study. GF and LH are employees of CBPartners. There are no further patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Background & Aims: Diagnosis and surveillance of Barrett's esophagus (BE) and eosinophilic esophagitis (EoE) have become emerging public health issues. Cytosponge is a novel, minimally invasive esophageal cell collection device. We aimed to assess the data on safety and acceptability of this device., Methods: We performed a patient-level review of 5 prospective trials assessing Cytosponge performance in patients with reflux disease, BE and EoE in primary and secondary care. Acceptability of Cytosponge and subsequent endoscopy were recorded with visual analogue scale (VAS), wherein 0 and 10 denoted lowest and highest acceptability. Median VAS scores were compared using a Mann-Whitney test. The number of attempts, failures in swallowing the device and occurrence of adverse events were analyzed. Risk factors for failure in swallowing were analyzed using a multivariate regression model., Results: In total, 2672 Cytosponge procedures were performed, in 2418 individuals from 2008 through 2017. There were 2 adverse events related to the device: a minor pharyngeal bleed and a case of detachment (<1:2000). The median acceptability score for the Cytosponge was 6.0 (interquartile range [IQR], 5.0-8.0), which was higher than the score for endoscopy without sedation (median 5.0; IQR, 3.0-7.0; P < .001) and lower than the score for endoscopy with sedation (median 8.0; IQR, 5.0-9.0; P < .001). Nearly all patients (91.1%) successfully swallowed the Cytosponge, most on the first attempt (90.1%). Failure to swallow the device was more likely to occur in secondary care (odds ratio, 5.13; 95% CI, 1.48-17.79; P < .01)., Conclusions: The Cytosponge test is a safe procedure with good acceptability ratings in a variety of health care settings., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Screening for Barrett's esophagus (BE) with conventional esophagogastroduodenoscopy (C-EGD) is expensive. We assessed the performance of a clinic-based, single use transnasal capsule endoscope (EG Scan II) for the detection of BE, compared to C-EGD as the reference standard., Methods: We performed a prospective multicenter cohort study of patients with and without BE recruited from 3 referral centers (1 in the United States and 2 in the United Kingdom). Of 200 consenting participants, 178 (89%) completed both procedures (11% failed EG Scan due to the inability to intubate the nasopharynx). The mean age of participants was 57.9 years and 67% were male. The prevalence of BE was 53%. All subjects underwent the 2 procedures on the same day, performed by blinded endoscopists. Patients completed preference and validated tolerability (10-point visual analogue scale [VAS]) questionnaires within 14 days of the procedures., Results: A higher proportion of patients preferred the EG Scan (54.2%) vs the C-EGD (16.7%) (P < .001) and the EG Scan had a higher VAS score (7.2) vs the C-EGD (6.4) (P = .0004). No serious adverse events occurred. The EG Scan identified any length BE with a sensitivity value of 0.90 (95% CI, 0.83-0.96) and a specificity value of 0.91 (95% CI, 0.82-0.96). The EG Scan identified long segment BE with a sensitivity value of 0.95 and short segment BE with a sensitivity values of 0.87., Conclusions: In a prospective study, we found the EG Scan to be safe and to detect BE with higher than 90% sensitivity and specificity. A higher proportion of patients preferred the EG Scan to C-EGD. This device might be used as a clinic-based tool to screen populations at risk for BE. ISRCTN registry identifier: 70595405; ClinicalTrials.gov no: NCT02066233., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: The research underpinning this analysis article was commissioned by the UK National Screening Committee (NSC). ST-P, CS, HF, JG, and AC are supported by the National Institute for Health Research CLAHRC West Midlands initiative. ST-P is supported by an NIHR Career Development Fellowship. AM is the director of the UK NSC, JM is the evidence lead and CV is an evidence review manager for the UK NSC. The views expressed in this paper are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, Public Health England, or the Department of Health. Any errors are the responsibility of the authors.

: Numerous preexposure prophylaxis (PrEP) guidelines recommend three-monthly screening for gonorrhoea and chlamydia. To quantify the risk of antimicrobial resistance this may induce, we conducted a literature review of the incidence of gonorrhoea and chlamydia in PrEP studies that conducted 3-site, 3-monthly screening. We found that screening could result in macrolide consumption rates that exceed those in high macrolide consumption populations where consumption has been strongly associated with macrolide resistance.

Fetal alcohol spectrum disorders (FASDs) are lifelong disabilities caused by prenatal alcohol exposure. Prenatal alcohol use is common in the UK, but FASD prevalence was unknown. Prevalence estimates are essential for informing FASD prevention, identification and support. We applied novel screening algorithms to existing data to estimate the screening prevalence of FASD. Data were from a population-based cohort study (ALSPAC), which recruited pregnant women with expected delivery dates between 1991 and 1992 from the Bristol area of the UK. We evaluated different missing data strategies by comparing results from complete case, single imputation (which assumed that missing data indicated no exposure and no impairment), and multiple imputation methods. 6.0% of children screened positive for FASD in the analysis that used the single imputation method (total N = 13,495), 7.2% in complete case analysis (total N = 223) and 17.0% in the analysis with multiply imputed data (total N = 13,495). A positive FASD screen was more common among children of lower socioeconomic status and children from unplanned pregnancies. Our analyses showed that the complete case and single imputation methods that are commonly used in FASD prevalence studies are likely to underestimate FASD prevalence. Although not equivalent to a formal diagnosis, these screening prevalence estimates suggest that FASD is likely to be a significant public health concern in the UK. Given current patterns of alcohol consumption and recent changes in prenatal guidance, active case ascertainment studies are urgently needed to further clarify the current epidemiology of FASD in the general population of the UK., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Colorectal cancer (CRC) screening has been found to reduce mortality from CRC but it may have adverse effects on other aspects of health. Our aim was to evaluate the effect of CRC screening on overall health status among men and women within a randomized health-services study in Finland., Material and Methods: A random sample of 10,648 men and women born in 1951 received a questionnaire on health and lifestyle. They were randomized for CRC screening or controls (1:1) in 2011 (N = 10,271). The current study population consisted of those who responded to the questionnaire both before and after screening (n = 4895). Self-rated health (SRH), perceived healthiness of diet and perceived physical fitness were used to determine health status, and assessed with logistic and ordered logistic models using calendar time (2010, 2012), screening randomization and demographic characteristics as covariates., Results: SRH, healthiness of diet and physical fitness improved over time (OR 1.32, CI 1.17-1.48, OR 1.23, CI 1.08-1.41 and OR 1.44, CI 1.28-1.60, respectively). Compared to non-invited controls, CRC screening invitation had no effect on these measures (OR 0.91, CI 0.74-1.12, OR 0.95, CI 0.75-1.20, and OR 1.09, CI 0.87-1.37, respectively). Women reported better health status than men. However, among those who attended screening, women reported weaker, and men better health status than the respective controls., Conclusions: CRC screening did not have any effect on health status measured using self-rated health, healthiness of diet, and physical fitness. Thus, screening for colorectal cancer can be recommended as a health policy.

Objectives: The objective of the study was to use the initial mean glandular dose (MGD) arising from the first screening mammogram to estimate the individual total screening lifetime effective risk., Methods: Organ doses from full-field digital mammography (FFDM) screening exposures (craniocaudal and mediolateral oblique for each breast) were measured using a simulated approach, with average breast thickness and adult ATOM phantoms, on 16 FFDM machines. Doses were measured using thermoluminescent dosimeters accommodated inside the ATOM phantom; examined breast MGD was calculated. Total effective risk during a client's lifetime was calculated for 150 screening scenarios of different screening commencement ages and frequencies. For each scenario, a set of conversion factors were obtained to convert MGD values into total effective risk., Results: For the 16 FFDM machines, MGD contributes approximately 98% of total effective risk. This contribution is approximately constant for different screening regimes of different screening commencement ages. MGD contribution remains constant, but the risk reduced because the radiosensitivity of all body tissues, including breast tissue, reduces with age. Three sets of conversion factors were obtained for three screening frequencies (annual, biennial, triennial). Three relationship graphs between screening commencement age and total effective risk, as percentages of MGD, were created., Conclusions: Graphical representation of total risk could be an easy way to illustrate the total effective risk during a client's lifetime. Screening frequency, commencement age, and MGD are good predictors for total effective risk, generating more understandable data for clients than MGD., (Copyright © 2018. Published by Elsevier Inc.)

Purpose of Review: Over 80% of children diagnosed with cancer are now cured. The burgeoning population of survivors of childhood cancer experiences high rates of morbidity and mortality due to 'late-effects' of treatment. These can be defined as any consequence of treatment that persists beyond or develops after the completion of cancer therapy. Awareness of late-effects is critically important for pediatricians and adult providers alike, as late-effects impact children in proximity to cancer treatment, as well as adults many decades removed. This review presents the importance of lifelong follow-up care for survivors, highlights existing screening guidelines, and reviews various models of survivor care., Recent Findings: National and international guidelines have been developed to standardize screening for survivors, and multiple models of survivorship care exist. The optimal model likely depends on individual factors, including the survivor's needs and preferences, as well as local resources. Key strategies for the successful care of survivors include accurate risk-stratification for specific late-effects, individualized screening plans, education of survivors and professionals, clear communication between providers, and well coordinated transition of care across services., Summary: Early identification and management of late-effects are important for survivors of childhood cancer. Providers should be familiar with the risks for specific late-effects and have access to screening guidelines. The strengths and weaknesses of care models, along with individual circumstances, should be considered in designing the optimal approach to care for each survivor.

Background and Objective: It is helpful for general practitioners (GPs) and their patients to understand the amount of health benefit expected from different preventive activities to enable a thoughtful choice of which to adopt first. The aim of this article is to illustrate how it might be possible to quantify the mortality benefit for cancer screening, quitting smoking, losing weight and treating lipids, which are preventive activities from The Royal Australian College of General Practitioners’ (RACGP’s) Guidelines for preventive activities in general practice (Red Book)., Methods: A sample of common preventive activities was taken, with an outcome for each selected for fair comparison, and benefits and harms were estimated., Results: For a man aged 50 years, the benefit in terms of reduced risk of dying is greatest for quitting smoking (at 24 fewer deaths/1000/decade), which is approximately 10 times the benefit of lowering lipids in a man with metabolic syndrome and about 50 times greater than from participating in regular colorectal cancer screening. Benefits for women are generally lower, as their baseline risk is lower., Discussion: It is feasible to quantify the benefits of some preventive activities, although estimating them is not straightforward and requires several assumptions. Nevertheless, extending estimates such as these to the items in the RACGP’s Red Book would assist GPs and their patients’ preventive activity prioritisation.

Breast cancer remains the most common nonskin cancer among women and a leading cause of morbidity and mortality. Early detection through screening and advances in treatment have contributed to a 39% mortality reduction in the United States since 1990. The NCCN Guidelines for Breast Cancer Screening and Diagnosis recommend annual mammographic screening for average-risk women beginning at age 40 years. Mammographic screening and subsequent treatment reduces breast cancer mortality based on a wide range of studies. This article highlights NCCN's position on screening mammography and the screening controversy., (Copyright © 2018 by the National Comprehensive Cancer Network.)