Preventive Medicine

   

Risk Factors
Alcohol & Tobacco  risk of Colon CA
Tobacco  Osteoporosis
HTN  risk of Stroke
Increase Exercise  HDL
Quit smoking  HDL (most IMMEDIATE mortality improvement), atherosclerosis
Wt. Loss Best to BP

Screening (Overview)

Condition Screening Age
AAA > 65 yr Male, Hx of Tobacco use
DM
DM Screening of asymptomatic pt. Risk Factors:
 - BMI > 25
 - (+) FHx
 - PCOS
 - HTN
 - HL
 - high-risk ethnicity
 - Gestational DM
 - Physical Inactivity.
(+) Risk factors Screen Now
(-) Risk Factors Screen at age 45 yr
Osteoporosis Dexa:
 Women > 65
 Men > 70
Breast CA Annual Mammogram starting age 40
PAP 21-29 yr = q 3 yr
30-65 yr = PAP q 3 yr  OR PAP + HPV q 5 yr
> 65 yr = STOP unless Hx of CIN 2 or worse
STD HIV at least once regardless of risk factors for  65 yr, consider annually if high risk behavior
Women:
 < 25 yr = GC, CT annually after onset of sex.
 > 25 yr = Annual GC, CT if high risk (multi sex partner)
Heterosexual Men:
 HIV at least once, consider annual if high risk sexual behavior
Homosexual Men:
 
GC, CT, RPR & HIV

Hep B (HBsAg) at least once
Colon CA Start at 50 yr
Lung Cancer USPSTF Recommendation
  • Low-dose lung CT,
    • adults 55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years.
    • Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have lung surgery
Prostate CA Age 50 (45 in AA, of +FHx)
   

 

Immunizations

Adult Immunizations
Gardasil Girls:  11 - 26 yr
Boys: 11 - 26 yrs 
Zostavax Immunocompetent >60
Flu Annualy
Pneumovax
  • > 65 yr
  • Chronic Dz
  • Immunocompromised
Pneumovax
BOOSTER
> 65yr previously vaccinated > 5 yrs since first
Hep B
  • High Rish Adults
  • DM, > 60 yrs
Hep A  
Tdap
  • Once in all adults, can replace a Td Booster Q10yr.
  • Q5yr with wound.

 
Type Vaccine
Live, attenuated Measles, mumps, rubella (MMR combined vaccine)
Varicella (chickenpox)
Influenza (nasal spray)
Zoster (shingles)
Rotavirus
Yellow fever
Inactivated/Killed Polio (IPV)
Hepatitis A
Rabies
Toxoid (inactivated toxin) Diphtheria, tetanus (part of DTaP combined immunization
Subunit/conjugate Hepatitis B
Influenza (injection)
Haemophilus influenza type b (Hib)
Pertussis (part of DTaP combined immunization)
Pneumococcal
Meningococcal
HPV

AAA

AAA
- > 65yr
- Male
- Smoker
One time screening ultrasound

ITE 2013, Q65
In which one of the following populations does the U.S. Preventive Services Task Force support ultrasound screening for abdominal aortic aneurysm?
A) All men age 55–75
B) Males age 55–75 who currently smoke
C) Patients of both sexes age 55–75 who currently smoke
D) Men age 65–75 who have ever smoked
E) No population group
 

Breast Cancer

Breast Cancer
BSE Recommends against teaching BSE
Clinical Breast exam Annually starting age 20yr
Mammogram Women age 50-74 yr Every other year.
Women < 50 yr Individualize decision.
Women > 75 yr Insufficient evidence to assess additional benefits and harms from mammogram

[More at USPSTF website]

ITE 2013 Q#125. A 55-year-old female receives a gynecologic and breast examination from a nurse practitioner, who also orders a routine mammogram. Who is legally responsible for ensuring that the patient is notified of the results of the mammogram?

A) The nurse practitioner
B) The supervising physician
C) The facility performing the mammogram
D) The patient

ANSWER: C

  • While it is certainly appropriate for the nurse practitioner or physician who ordered the test to notify the patient of mammography results, the facility performing the test is legally responsible.
  • This is specified by the federal Mammography Quality Standards Act, first passed by Congress in 1992.

    Ref: Mammography Quality Standards Act Regulations. US Food and Drug Administration, 2009, sec 900.12(c)(2).

 

Cardiac Risk

Cardiac Risk
Aspirin Primary Prevention:
NO aspirin for primary prevention in men <45, women < 55.

Secondary Prevention:

Men 45-79 when net benefit present
Women 55-79 when net benefit present
NO recommendation for or against pt >80
BP Everybody <140/90
DM < 140/80
Cholesterol Screen all adults > 20yr Q5y
Screen all men >35yr
Screen all men 20-35yr if RF for CAD present.
Screen all women >20 if RF for CAD present.

Colorectal Cancer

Risk Factors
Alcohol & Tobacco  risk of Colon CA
- Start at 50 yr
- High-risk adults either at age 40 or 10 years before the age at which colorectal cancer was diagnosed in the youngest affected relative.
Colonoscopy Q10yr
Flexible sigmoidoscopy
Q5yr
Double-contrast barium enema
CT colonography (virtual colonoscopy)
FOBT Q1y: should be take home, Multiple screening test
Fecal Immunochemical Test (FIT)


 

Colonoscopy surveillance and screening intervals:
Baseline colonoscopy: most advanced finding(s) Recommended surveillance interval (years)
No polyps 10
Small (<10 mm) hyperplastic polyps in rectum or sigmoid 10
1 to 2 small (<10 mm) tubular adenomas 5 to 10
3 to 10 tubular adenomas 3
>10 adenomas < 3
One or more tubular adenomas ≥10 mm 3
One or more villous adenomas 3
Adenoma with HGD 3
Serrated lesions
Sessile serrated polyp(s) <10 mm with no dysplasia 5
Sessile serrated polyp(s) ≥10 mm
OR
Sessile serrated polyp with dysplasia
OR
Traditional serrated adenoma
3
Serrated polyposis syndrome* 1
The recommendations assume that the baseline colonoscopy was complete and adequate and that all visible polyps were completely removed


 
Polyp surveillance after first surveillance colonoscopy
Baseline colonoscopy First surveillance Interval for second surveillance (years)
LRA HRA 3
LRA 5
No Adenoma 10
HRA HRA 3
  LRA 5
  No Adenoma 5*
LRA: low risk adenoma;
HRA: high risk adenoma.
* If the findings on the second surveillance are negative, there is insufficient evidence to make a recommendation.



Source: uptodate.com


ITE 2012, Q206. A 56-year-old male sees you for a health maintenance visit. He inquires about the options for colon cancer screening. He has not had any screening tests performed in the past and has no personal or family history of colon cancer. You tell him that there are several alternatives, but according to the U.S. Preventive Services Task Force, recommendations regarding the optimal screening intervals vary by test. He opts for fecal occult blood testing.
You recommend he repeat this test at which one of the following intervals?
A) Yearly
B) Every 5 years
C) Every 7 years
D) Every 10 years
E) Never, if the results are negative

ANSWER: A

  • The U.S. Preventive Services Task Force recommends that all adults be screened for colon cancer beginning at age 50 and continue regular screening until age 75 (SOR A).
  • They recommend against continued routine screening in previously screened adults 75–85 years of age and against any screening in adults over 85 (SOR A).
  • Most organizations do not recommend a particular screening method, but instead list screening options, including fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy.
  • The recommended interval for fecal occult blood testing is every year. There is new evidence based on randomized, controlled trials that participation and detection rates for advanced adenomas and cancer are higher for immunochemical fecal testing than for stool guaiac testing (SOR A).
  • As long as results are normal, screening colonoscopy is recommended at 10-year intervals and screening sigmoidoscopy at 5-year intervals.

    Ref: Hewitson P, Glasziou P, Irwig L, et al: Screening for colorectal cancer using the faecal occult blood test, Hemoccult.
    Cochrane Database Syst Rev 2007;(1):CD001216. 2) US Preventive Services Task Force: Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149(9):627-637. 3) Wilkins T,
    Reynolds PL: Colorectal cancer: A summary of the evidence for screening and prevention. Am Fam Physician 2008;78(12):1385-1392, 1393-1394. 4) van Rossum LG, van Rijn AF, Laheij RJ, et al: Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population. Gastroenterology 2008;135(1):82-90.

 

ITE 2014 Q 44. One week after a complete and adequate baseline screening colonoscopy, a 51-year-old female with no history of previous health problems visits you to review the pathology report on the biopsy specimen obtained from the solitary 8-mm polyp discovered in her sigmoid colon. The report confirms that this was a hyperplastic polyp. Her family history is negative for colon cancer.
Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient?
A) 1 year
B) 2 years
C) 5 years
D) 10 years

ANSWER: D

  • There is substantial evidence that small (<10 mm) hyperplastic polyps found in the rectum or sigmoid colon are not neoplastic. Data obtained from numerous studies provides considerable evidence of moderate quality that individuals with no significant findings other than rectal or sigmoid hyperplastic polyps of this size should be included in the same low-risk cohort as those who have an unremarkable colonoscopy. For patients at low risk the recommended interval between screening colonoscopies is 10 years. Reductions in this interval are recommended for patients with one or two small tubular adenomas (5–10 years) or those with three or more tubular adenomas (3 years); the interval for more extensive disease is best individualized but can be as often as annually in unusual cases.

    Ref: Lieberman DA, Rex DK, Winawer SJ, et al: Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143(3):844–857.

DM

DM Screening of asymptomatic pt. Risk Factors:
 - BMI > 25
 - (+) FHx
 - PCOS
 - HTN
 - HL
 - high-risk ethnicity
 - Gestational DM
 - Physical Inactivity.
(+) Risk factors Screen Now
(-) Risk Factors Screen at age 45 yr

 
Cardiac Risk
Aspirin Women 55-79 when net benefit present (low risk of GI Bleed)
NO aspirin for primary prevention in men <45, women < 55.
NO recommendation for or against pt >80
Aspirin therapy is generally not recommended in patients under the age of 21 years because of an increased risk of Reye’s syndrome in this population



102. According to the American Diabetes Association, screening for diabetes mellitus in the asymptomatic patient with no risk factors should begin at which age?
A) 25 years
B) 30 years
C) 35 years
D) 40 years
E) 45 years

ANSWER: E
Testing for diabetes mellitus should be considered in all asymptomatic adults who have a BMI 25 kg/m2 and have one or more additional risk factors such as physical inactivity, a first degree relative with diabetes, a high-risk ethnicity, hypertension, hyperlipidemia, or polycystic ovary syndrome.
In asymptomatic patients with no risk factors, screening should begin at age 45.

Lung Cancer Screening

  • USPSTF draft recommendation
    • Low-dose lung CT,
      • adults 55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years.
      • Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have lung surgery
         
  • AAFP recommendation—neutral
  • Need ability to follow up and investigate nodules if found
  • Best done at experienced centers
  • Based on results of the National Lung Screening Trial 2012

A 59-year-old African-American female with diabetes comes in for follow up. You note that she has been smoking a pack a day since age 15. No cough or dyspnea. She has not had a chest x-ray in 5 years. Her mother died of colon cancer a year ago at age 83. What would you recommend for this patient?

A. Chest x-ray
B. No testing at this time
C. Low-dose lung CT
D. Low-dose abdominal CT

Prostate Cancer

Prostate Cancer
- Age 50 (45 in AA, of +FHx)
- Discuss with pt.
IF pt. wants to be tested PSA with or without rectal exam.

Obesity

Risk Factors
  • Obesity increases the risk of a variety of medical conditions, including type 2 diabetes mellitus, hypertension, hyperlipidemia, pulmonary disease, coronary artery disease, gallstones, fatty liver disease, obstructive sleep apnea, GERD, osteoarthritis, and a variety of forms of cancer.
  • A weight loss of at least 10% for greater than 1 year leads to statistically significant improvement in lipid ratios, blood glucose homeostasis, and coronary artery disease risk reduction.
  • The AAFP recommends screening for obesity and intensive counseling (> 1 session per month for > 3 months) with behavior modification for obese patients.
  • Counseling is ineffective by itself and must be combined with lifestyle modification.
  • Dietary modification, increased physical activity, and behavior modification
    • Are effective for maintaining modest weight loss for > 1 year.
    • However, there are few large, randomized, controlled trials with subjects maintaining weight reductions of 10% for over 1 year, even when combining therapy, exercise, and dietary restriction.
  • Long-term pharmacotherapy
    • Can lead to weight loss, but regaining some weight is typical.
  • Bariatric surgery
    • Leads to the most effective weight reduction and long-term maintenance in patients who are morbidly obese.
    • Gastric bypass is effective, with a mean weight loss of 71.2% at 3 years; with laparoscopic gastric banding the mean weight loss is 55.2% at 3 years.
    • In one study, 94% of gastric bypass patients maintained at least a 20% weight loss at 6 years.
    • Bariatric surgery has also been shown to significantly reduce fasting blood glucose, with resolution of diabetes mellitus in 31%–77% of lap band patients and 72%–100% of gastric bypass patients.
    • Bariatric surgery is a safe and effective means for long-term weight loss and should be considered in
      • Adults with a BMI >40,
        or
      • BMI >35 with obesity-related comorbidities.


A 39-year-old male with a BMI of 41 kg/m2 is interested in weight loss. His medical history includes adequately controlled type 2 diabetes mellitus, well-controlled hypertension, hyperlipidemia, and obstructive sleep apnea. He has no history of coronary artery disease or COPD.
Which one of the following is likely to be most effective for long-term weight loss in this patient?

A) A very low calorie diet
B) Increased physical activity
C) Frequent, long-term weight-loss counseling
D) Pharmacotherapy
E) Bariatric surgery
 

Osteoporosis

Risk Factors
Tobacco  Osteoporosis
DEXA
or
Heel ultrasound
Women >65.
Men > 70.
Postmenopausal women & men 50-65yr should be screened if they have risk factors.
Preventive Measures:
  • Adequate Ca intake = 1 - 1.5 g/day
  • Vitamin D = 600 - 1000 IU/day  OR
  • Sun exposure of 20 min/day
  • Estrogen replacement OR Raloxifene after menopause
  • Weight bearing exercise
  • Smoking cessasion
  • Limiting thyroid hormone & steroids to minimum effective doses
  • Low dose Bisphosphonate in postmenopausal women or others at risk for developing osteoporosis.


[Read More (Osteoporosis) ]


ITE 2013, Q#168.
Which one of the following effects of vitamin D is supported by the best evidence?
A) It prevents cardiovascular disease
B) It prevents colon cancer
C) It prevents dementia
D) It reduces falls in community-dwelling older adults

ANSWER: D

  • The U.S. Preventive Services Task Force recommends vitamin D supplementation to prevent falls in community-dwelling adults 65 and older who are at increased risk for falls (grade B recommendation).
  • Some studies suggest that low vitamin D levels are associated with an increased risk of cardiovascular disease, multiple sclerosis, colon cancer, dementia, and even diabetes mellitus, but these studies are epidemiologic and thus are not based on high-quality evidence (SOR C).

PAP Smear and Pelvic Exams

PAP Smear and Pelvic Exams
PAP Smear (Treat pregnant pt. the same as non-pregnant pt.)
< 21 yr NO pap smear unless HIV, SLE, Long term immunosuppression (organ transplant), to be initiated at the time of first intercourse.
21-29 Q 3 yr
30-65 - PAP = Q3yr 

 OR

- Co-testing, Pap & HPV Q5yr  ( Cytology & HPV if both initial tests are negative)
 
- Prior CIN2 or worse
- Immunosuppressed
Pap  Q 1 yr for life
> 65


STOP
unless Hx of CIN 2 or worse.
3 normal Paps in last decade (3 consecutive Neg. cytology OR 2 consecutive Neg. co-tests)
After Hysterectomy w/ NO prior CIN2 or worse

Pelvic Exam
  • Annually beginning age 21, until pt would not wish to pursue diagnostic tests or treatment of findings.
  • Even when Pap is not indicated, pelvic exam is useful for STD testing, visual screening for vaginal & vulvar lesions, & performing bimanual exam to palpate the uterus & ovaries.

STOP if

- Hysterectomy & Oopherectomy & No Hx of VIN, CIN2 or worse, VAIN, HIV or DES exposure in utero


ITE 2013, Q118.
A 31-year-old gravida 2 para 2 sees you for a routine annual visit. Her Papanicolaou (Pap) test is normal and high-risk HPV testing is negative. She has never had an abnormal Pap test. According to the guidelines of the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, this patient’s cervical cytology and HPV testing should be repeated in
A) 1 year
B) 2 years
C) 3 years
D) 4 years
E) 5 years

ANSWER: E

  • In women 30–65 years old, screening for cervical cancer with cervical cytology and HPV testing is recommended every 5 years.
  • An alternative screening recommendation is to perform cervical cytology only, at 3-year intervals.
  • A population study of 331,818 women demonstrated a 0.016% risk of cancer in the 5 years after having a negative result on both cervical cytology and an HPV test.

STD

STD
Women < 25yr GC, CT annually after onset of sex.
HIV at least once regardless of risk factors for 65 yr, consider annually if high risk behavior
 
Women >25yr Annual GC, CT if high risk (multi sex partner)
HIV at least once regardless of risk factors for 65 yr, consider annually if high risk behavior
 
Heterosexual Men HIV at least once, consider annual if high risk sexual behavior
 
Homosexual Men GC, CT, RPR & HIV
Hep B (HBsAg) at least once
 

ITE 2013, Q83
83. A 58-year-old healthy white female sees you for a routine visit. She is monogamous with her husband, is a nonsmoker, has two alcoholic drinks a week, and has mild GERD. Her BMI is normal. She takes an over-the-counter H2-blocker and a multivitamin with calcium. She had a normal mammogram 1 month ago and a negative colonoscopy at age 53. She has never had a DXA scan or screening for ovarian cancer. Her family history is noncontributory.

According to the U.S. Preventive Services Task Force, you should recommend

A) HIV screening
B) CA-125 testing for ovarian cancer screening
C) DXA for osteoporosis screening
D) colonoscopy for colorectal cancer screening
 


 

Stroke Risk

Primary Prevention:
  • Physical Activity (at least 30 min/day) = Risk of CVA
  • Aspirin:
    • Men:
      • NOT recommended for first CVA prevention
      • Recommended to prevent CAD, CVA in the presence of Risk factors.
    • Women:
      • Useful if pt has significant risk factors
      • Daily aspirin for women ages 55–79 when the benefit of stroke risk reduction outweighs the risk of gastrointestinal hemorrhage
  • Alcohol consumption:
    • Men = 2 drinks/day
    • Women = 1 drink/day
       
  • NO evidence that CRP adds any benefit
Cardiac Risk
Aspirin Primary Prevention:
-
NO aspirin for primary prevention in men <45, women < 55.
Secondary Prevention:

Women 55-79 when net benefit present (low risk of GI Bleed)

NO recommendation for or against pt >80
Aspirin therapy is generally not recommended in patients under the age of 21 years because of an increased risk of Reye’s syndrome in this population

 
Secondary Prevention:
Modifiable risk factor Therapeutic goals/recommendations
Hypertension BP < 140/90 mmHg (<130/80 for DM or CKD)
Diabetes mellitus (DM) Hemoglobin A1c ≤ 7%
Sympathomimetic abuse Abstinence
Smoking Smoking cessation
Daily alcohol use Men < 2 drinks; nonpregnant women ≤1 drink
Obesity Weight loss until waist circumference <35 inches for women and <40 inches for men
Physical inactivity ≥30 min moderate exercise most days
Symptomatic severe CAS CEA recommended for stenosis 70–99%
Symptomatic moderate CAS Consider CEA for stenosis 50–69%
Left ventricular thrombus Warfarin anticoagulation to INR 2.5 (2–3) for 3–12 months
Afib/Aflut Warfarin anticoagulation to INR 2.5 (range 2–3)
Rheumatic MV disease Warfarin anticoagulation to INR 2.5 (range 2–3)
Dilated cardiomyopathy Warfarin anticoagulation or antiplatelet therapy
HMG-CoA Reductase Inhibitors (statins) -Statins beneficial even with normal cholesterol levels and no CAD
  • Desire LDL <100 mg/dL or <70 mg/dL for very high risk patients* with multiple risk factors
Antiplatelet therapy (ASA, clopidogrel, or ASA-extended-release dipyridamole) All patients after a noncardioembolic stroke
Prosthetic heart valves Chronic anticoagulation to INR 2.5 (range 2–3)
Mitral valve prolapse/aortic stenosis Antiplatelet therapy
Sickle cell disease Exchange transfusion until Hgb S <30%
Cerebral vein thrombosis Anticoagulation to INR 2.5 (range 2–3) for 6 mo
Antiphospholipid syndrome Antiplatelet therapy or chronic anticoagulation to INR 2.5 (range 2–3) if multiple organs involved


 

ITE 2013, Q62
For the prevention of ischemic stroke in patients at low risk for gastrointestinal bleeding, the U.S. Preventive Services Task Force recommends aspirin for
A) men age 45–79
B) men age 55–79
C) women age 45–79
D) women age 55–79
E) no one, regardless of sex or age