Preventative Med in Adults

Question 1

Primary prevention

Answer 1

remove/reduce disease risk factors; e.g., immunization, giving up or not starting smoking

Question 2

Secondary prevention:

Answer 2

promote early detection of disease or precursor states e.g., routine cervical pap smear

Question 3

Tertiary prevention

Answer 3

limiting impact of established disease e. g., partial mastectomy and RT to remove and control localized breast cancer

Question 4

Requirements of an Effective Screening Test

Answer 4

• Disease is an important cause of morbidity and mortality
• Screening can detect disease in early, pre symptomatic phase
• Screening and treating patients with early disease or risk factors produces better health outcomes than treating patients when they present with symptoms
• Screening test is acceptable to patients and clinicians - safe, convenient, acceptable false-positive rate, acceptable costs
• Benefits of early detection and treatment are sufficient to justify potential harms and costs of screening

Question 5

USPSTF Grading System (prior to May 2007)

Answer 5

A: Strongly recommended
B: Recommended
C: No recommendation: fair evidence it can improve health outcomes, but balance of benefit and harm too close to make general recommendation
D: Not recommended-fair evidence of ineffectiveness, or harm outweighs benefits
I: Insufficient data to recommend for or against

Question 6

Hypertension screening

Answer 6

all persons >18 (A)

Question 7

Height/weight screening

Answer 7

all persons: If BMI> 30, offer counseling: AAFP

Screen children over the age of 6

Question 8

Lipid Disorders screening

Answer 8

screen all men >35 and women >45 (A)

                     - screen men 20-35 who are at risk (B)
                     - screen women 20-45 who are at risk (B)

Question 9

Chlamydia-

Answer 9

• all sexually active non-pregnant women ≤ 24 (A)
  - all older non-pregnant women at increased risk (A),
  - all pregnant women ≤ 24 and older pregnant women of increased risk (B)
  - No screening for men (I)

Question 10

Syphilis

Answer 10

screen all persons at increased risk for syphilis (A)

-screen all pregnant women (A)

Question 11

Bone density screening

Answer 11

women >65 at high risk for osteoporosis (B)
-Women > 65 without a previously known fracture, or secondary cause of osteoporosis
-Screen women than that of a 65 y/o white woman
without other risk factors (B)

Question 12

Colorectal cancer

Answer 12

screen all persons with fecal occult blood testing (FOBT), sigmoidoscopy or colonoscopy > 50 and up to age 75 (A)

Question 13

Prostate Cancer screening: USPSTF

Answer 13

USPSTF recommends AGAINST PSA-based screening for prostate cancer (D)
American Urologic Society, 2013 Guidelines:
-No PSA in men < 40
-No PSA in men at average risk, 40-54 years old
-In men 55-69, PSA screening based on “shared decision-making”
-In men over 70, no screening
If screening, PSA and digital rectal exam (DRE) are complimentary

Question 14

USPSTF Breast cancer screening

Answer 14

biennial screening mammogram women 50-74(B)
Cervical cancer screening: USPSTF recommendations:
Women ages 21-65 with Pap every 3 years
Women ages 30-65 who want to lengthen the screening interval-screen with
a combination of cytology and human papilloma virus (HPV) testing every 5 years (A)

Question 15

USPSTF recs for screening for Abdominal Aortic Aneurysm

Answer 15

Men 65-75 who have ever smoked (B)

Women 65-75: do not screen (D)

Question 16

Lung cancer screening: National Lung Screening Trial (NLST)

USPSTF

Answer 16

Recommending low-dose spiral (helical) CT in the following:
-high risk: > 55, smoked >30 pack years (unless has quit 15+ years)
> 50, smoked >20 pack years + one other risk factor
-No screening recommended in mod/low risk patients
Moderate risk > 50, >20 pack years or 2nd hand smoke, no other risk factors
Low risk: < 50, non-smoker
ALL patients should be asked about tobacco and tobacco product use, and counseled appropriately

Question 17

Hypertension (high blood pressure)

Answer 17

Screening every 2 yrs with BP < 120/80

Screening every year with systolic blood pressure 120-139 or diastolic blood pressure 80-90

Question 18

Type 2 diabetes (B)

Answer 18

Adults with sustained BP >135/80: perform fasting glucose, 2-hr post-load glucose,
HgA1C
ADA recommends FBS, and if FBS > 126 mg/dl, =DM; needs confirmatory testing

Question 19

HIV screening

Answer 19

Rec in all pregnant women and anyone at risk (A)

Question 20

Depression screening

Answer 20

Rec in non-pregnant adults (>18) when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up (B)

Question 21

Assess use of alcohol (B)

Answer 21

Per AAFP, screening for everyone >18 and desirable to screen in 12-17

Question 22

Chemoprophylaxis

Aspirin (ASA) use for the prevention of CV disease:

Answer 22

To reduce MI in men ages 45-79 (A)
To reduce stroke in women ages 55-79 (A)
NOT recommended in men < 45 or women < 55
NOT recommended in anyone over age 80 (l)

“Encourage use when the potential CVD benefits outweigh the potential of a GI bleed.” - no upper GI pain, no history of GI ulcer
NOT RECOMMENDED for prevention of colorectal CA in asymptomatic patients at average age risk: (D)

Question 23

Counseling

USPSTF:

Answer 23

Injury prevention = Grade l
Sexual behavior: STD prevention, contraception in adults and sexually active = Grade B
Dental health: regular visits, floss, brush, fluoride
Substance abuse: Tobacco (A), Alcohol (B), Illicit drugs (l)

-Diet and physical activity to prevent CVD- for adults at increased risk (B)
-Women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid (A)
Screening all adults for obesity (B)

Question 24

Smoking

Answer 24

single largest preventable cause of disease and premature death in the US

Black males: 20% higher risk than white men
Black women: 10% lower risk than white women
Smokers have twice the risk of fatal heart disease
Smokers have increased risk for other cancers
Smokers have higher incidence of stroke
Smokers have increased risk for bone fractures

Question 25

ATP III (Adult Treatment Panel) classifications for LDL

Answer 25

LDL < 100: Optimal 160-189: high >190: very high

Question 26

ATP III (Adult Treatment Panel) classifications for HDL

Answer 26

HDL < 40 low; > 60 high

Question 27

ATP III (Adult Treatment Panel) classifications for total cholesterol

Answer 27

Total cholesterol < 200 desirable 200-239: borderline high > 240: high

Question 28

Four Major Groups that Benefit from Statin Therapy -- Should receive MAX dose

Answer 28

1. Pt w/ history and clinical evidence of ASCVD 2. Pt 21+ with LDL > 190 mg/dl 3. Pt w/ DM, ages 40-75 with LDL 70-189 mg/dl and without clin ASCVD 4. Pt's ages 40-75, with LDL 70-189 and estimated 10 year risk of ASCVD of 7.5% or greater

Question 29

Alcoholism

Answer 29

Screening to detect problem drinking is recommended for all adults > 18 and adolescent patients CAGE test is sensitive and specific for chronic alcoholism Have you ever felt the need to Cut down on drinking? Have you ever felt Annoyed by criticism of you drinking? Have you ever felt Guilty about your drinking? Have you ever taken a morning Eye opener? Two “yes” answers indicates a problem with alcohol

Question 30

Skin Cancer USPSTF

Answer 30

- USPSTF recommends counseling patients aged 10-24 who have fair skin about minimizing their exposure to UV radiation to reduce the risk of skin CA (B) - USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of counseling adults >24 about minimizing risks to prevent skin CA (l)

Question 31

Colorectal Cancer Screening

Answer 31

Fecal occult blood testing (FOBT): Guaiac - based test of 3 consecutive bowel movements avoid NSAID’s, vitamin C, citrus juices, red meat 3 days prior to test Fecal immunochemical test (FIT): like FOBT but does not require special dietary restrictions Flexible sigmoidoscopy- direct visualization of rectum and lower portion of colon (sigmoid colon) Double contrast barium enema--an x-ray image of the entire colon. Colonoscopy-able to visualize entire rectum and colon, take tissue samples and remove polyps.

Question 32

Colorectal Cancer Screening USPSTF

Answer 32

Ages 50-75: screen with FOBT, sigmoidoscopy, colonoscopy Ages 76-85: do not screen routinely Ages 85 and over: do not screen

Question 33

Cervical cancer Tx USPSTF

Answer 33

Usually occurs in mid-life; most patients are under the age of 50 FDA approved a vaccination against HPV types 6, 11, 16 and 18 (Gardasil®) and one that protects against types 16 and 18 (Cervarix®). Recommended for girls aged 11-12, but FDA approved for females aged 9-26. Given as a series of three shots over 6 months.

Question 34

Cervical Cancer screening USPSTF

Answer 34

Women 21-65: Pap every 3 years Women 30-65: Pap plus HPV screening every 5 years No screening in women 65 if had adequate prior screening and are not high risk No screening in women who have had hysterectomy with removal of cervix and who did not have a history of high-grade precancerous lesion (CIN grade 2 or 3) or cervical CA Against screening with HPV testing alone, or in combination with cytology in women <30

Question 35

ACOG Cervical Cancer Screening Recommendations

Answer 35

Begin screening at age 21 Women 30 and older: conventional or liquid Pap test every two years Women 30 and older who have had three consecutive negative tests: can then be screened once every three years Women with HIV or weakened immune system: screen every year Stop screening around age 65-70 if woman has had three negative tests in the last ten years Women who had a hysterectomy for benign reasons do not need to be screened

Question 36

BREAST CANCER | USPSTF Recommendations:

Answer 36

- In women with a family Hx of deleterious mutations in BRCA1 or BRCA2 genes: refer for genetic counseling and evaluate for BRCA gene testing. - Biennial (every other year/ every 2 years) screening mammography for women aged 50 to 74 years (B) - Insufficient evidence to continue screening women 75 years or older (I) - Recommends against teaching breast self-examination (BSE) (D) - insufficient evidence for clinical breast examination (CBE) beyond screening mammography in women 40 years or older (I) - evidence is insufficient for using either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer (I)

Question 37

BREAST CANCER | ACOG Recommendations

Answer 37

Screening mammography every year for women aged 40 years or older Breast self-examination – for high-risk persons Clinical breast examination - every 1-3 years for women aged 20-39; annually in persons age 40 years and older

Question 38

USPSTF recs for Hepatitis B screening for people at high risk:

Answer 38

High risk individuals should be screened for Hep B-Grade B rec. High-risk people: Those born in countries and regions with high prevalence of HBV infection; US-born persons not vaccinated as infants whose parents were born in countries and regions with a high prevalence of HBV infection; HIV-positive people, injection drug uses, men who have sex with men, and those living with or having sex with someone with HBV infection; or patients with weakened immune systems or undergoing treatment for kidney failure (hemodialysis).

Question 39

USPSTF HTN screening

Answer 39

screen all adults; hypertension commonly diagnosed at 140/90. Must have 2 or more elevated readings, obtained on at least 2 visits over a period of one to several weeks. Per JNC7: If BP <120/80, screen every 2 years If systolic BP 120-139 and/or diastolic BP 80-90, screen at least yearly

Question 40

Lipid disorders

Answer 40

Screen men > 35, women > 45 who are at risk for CHD Screen men 20-35, women 20-45 who are at risk for CHD No rec for or against screening in men 20-35 and women over 20 who are at no risk

Question 41

Prostate cancer: USPSTF

Answer 41

USPSTF does not rec screening with PSA; American Urologic Association recommends screening men with average risk, >50, with PSA and DRE

Question 42

Skin cancer USPSTF:

Answer 42

counsel fair-skinned patients aged 10-24 about minimizing their exposure to UV radiation to reduce the risk of skin cancer; at-risk patients for melanoma are those who are fair-skinned men and women >65; patients with atypical moles or >50 moles.

Question 43

Chemical dependency USPSTF

Answer 43

Grade B recs for screening adults > 18 for alcohol misuse and providing individuals engaged in risky or hazardous drinking with brief behavioral counseling to reduce alcohol misuse, AND providing interventions, including education or brief counseling, to prevent the initiation of tobacco use in school-aged children and adolescents.

Question 44

Breast Cancer screening and preventions USPSTF -risk factors

Answer 44

- Grade B recs for screening women who have family members with breast, ovarian, tubal, or peritoneal cancer (by any of several methods/tools) for BRCA1 and BRCA2 genes. Those who have positive screening results should be referred for genetic counseling and if indicated after counseling, BRCA testing. - Women at increased risk for breast cancer and low risk for adverse medication effects should be offered risk-reducing medications (tamoxifen or raloxifene). Grade B

Question 45

Gestation DM

Answer 45

Screen for gestational diabetes in asymptomatic pregnant women after 24 weeks gestation. Grade B

Question 46

USPS HTN Tx

Answer 46

Hypertension treatment: in non-blacks with HTN: can use thiazide-type diuretic, CCB, ACE or ARB first-line; in blacks (including those with DM): thiazide or CCB as first-line -- In all patients, if goal is not reached within one month of treatment, increase dose of initial drug or add a 2nd; if goal cannot be reached with 2 drugs, add a 3rd. If goal cannot be reached with 3 drugs, can add a 4th from the “alternative” list; consider consulting a hypertension specialist.