Management of Menopause-Related Symptoms

Although many measures have been developed to assess menopausal symptoms, few demonstrate standardization, validity, or reliability. Some measures are based on self-reports of the presence, severity, and frequency of individual symptoms, such as hot flashes. Others utilize cumulative or global scores based on lists or scales of symptoms attributed to menopause, such as mood, cognition, quality of life, sexual function, and somatic symptoms. Many studies base their measures on study-specific checklists, questionnaires, or scales. Ninety-two measures of menopausal symptoms were reported by studies included in this evidence review. This systematic evidence review focuses on five Key Questions relating to symptoms of menopause and their management, as specified by the Planning Committee for the National Institutes of Health State-of-the-Science Conference on Management of Menopause-Related Symptoms. The target population includes adult women in the United States undergoing the menopausal transition. A Technical Expert Panel was assembled to provide input from experts and clinicians in the field to ensure that the scope of the project addressed important clinical questions and issues. The panel included obstetrician/gynecologists, internists, naturopathic physicians, behavioral experts, and researchers. The panel was convened for periodic conference calls during the course of the project. Expert reviewers, including several panel members, provided comments on the draft evidence report

Preexposure Prophylaxis for the Prevention of HIV Infection Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Effective prevention strategies for HIV infection are an important public health priority. Preexposure prophylaxis (PrEP) involves use of antiretroviral therapy (ART) daily or before and after sex to decrease risk of acquiring HIV infection. Objective To synthesize the evidence on the benefits and harms of PrEP, instruments for predicting incident HIV infection, and PrEP adherence to inform the US Preventive Services Task Force. Data Sources Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and EMBASE through June 2018, with surveillance through January 2019. Study Selection English-language placebo-controlled randomized clinical trials of oral PrEP with tenofovir disoproxil fumarate/emtricitabine or tenofovir disoproxil fumarate monotherapy; studies on the diagnostic accuracy of instruments for predicting incident HIV infection; and studies on PrEP adherence. Data Extraction and Synthesis Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the Dersimonian and Laird random-effects model for effects of PrEP on HIV infection, mortality, and harms. Main Outcomes and Measures HIV acquisition, mortality, and harms; adherence to PrEP; and diagnostic test accuracy and discrimination. Results Fourteen RCTs (N = 18 837), 8 observational studies (N = 3884), and 7 studies of diagnostic accuracy (N = 32 279) were included. PrEP was associated with decreased risk of HIV infection vs placebo or no PrEP after 4 months to 4 years (11 trials; relative risk [RR], 0.46 [95% CI, 0.33-0.66]; I2 = 67%; absolute risk reduction [ARD], −2.0% [95% CI, −2.8% to −1.2%]). Greater adherence was associated with greater efficacy (RR with adherence ≥70%, 0.27 [95% CI, 0.19-0.39]; I2 = 0%) in 6 trials. PrEP was associated with an increased risk of renal adverse events (12 trials; RR, 1.43 [95% CI, 1.18-1.75]; I2 = 0%; ARD, 0.56% [95% CI, 0.09%-1.04%]) and gastrointestinal adverse events (12 trials; RR, 1.63 [95% CI, 1.26-2.11]; I2 = 43%; ARD, 1.95% [95% CI, 0.48%-3.43%]); most adverse events were mild and reversible. Instruments for predicting incident HIV infection had moderate discrimination (area under the receiver operating characteristic curve, 0.49-0.72) and require further validation. Adherence to PrEP in the United States in men who have sex with men varied widely (22%-90%). Conclusions and Relevance In adults at increased risk of HIV infection, PrEP with oral tenofovir disoproxil fumarate monotherapy or tenofovir disoproxil fumarate/emtricitabine was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP, although effectiveness decreased with suboptimal adherence

Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

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