ABFM Preventive Medicine – Flashcards

A, B, E, F, & G. There is currently no recommended screen for endometrial cancer, but knowing the risk factors is important for counseling patients. Endometrial cancer is associated with obesity, hyperinsulinemia, and chronic anovulation, which are all characteristics of polycystic ovary syndrome (SOR B). Obesity leads to higher estrogen levels, increasing the risk for endometrial cancer; physical activity has been shown to reduce the risk of endometrial cancer (SOR A). Estrogen levels are lower in women who are breastfeeding, and having decreased levels of estrogen for extended periods of time is associated with a lower risk of endometrial cancer (SOR B). As longer exposure to estrogen increases the risk of endometrial cancer, the combination of early menarche and nulliparity increases the risk because of uninterrupted high estrogen levels (SOR B). Oral contraceptives have been found to reduce the risk of endometrial cancer. The protective effect increases with the length of time they are used, and benefits can last years after a woman has stopped taking them (SOR A). Although raloxifene has estrogen-like effects on the uterus, it has not been shown to increase the risk of endometrial cancer (SOR A). Tamoxifen is a selective estrogen receptor modulator that has estrogen-like effects. While it has a protective effect on breast tissue, its effect on the uterus increases the risk of endometrial cancer (SOR A). Hereditary nonpolyposis colon cancer is an inherited disorder linked to certain genes. Women with this cancer have a much higher risk of developing endometrial cancer (SOR B).

A, D, & E. Although lung cancer remains the leading cause of death from cancer in American men, prostate cancer ranks as the most commonly diagnosed cancer except for skin cancer, with a lifetime risk for diagnosis of 15.9%. Over 240,000 American men received a prostate cancer diagnosis in 2011 and an estimated 33,720 men died of the disease. Prostate cancer is, however, a heterogeneous disease, as evidenced by autopsy studies which have shown that one-third of men age 40-60 have histologic evidence of prostate cancer. Such findings suggest that many cases of prostate cancer do not ever become clinically evident, raising concerns about the potential for overdiagnosis, defined as when a condition is diagnosed that would not go on to cause symptoms or death if it had not been discovered. Neither of the two major trials of PSA screening have demonstrated benefit in terms of overall or all-cause mortality. The U.S.-based Prostate, Lung, Colon, and Ovarian (PLCO) Cancer Screening Trial was a multi-center study which randomized 76,693 men and found screening was associated with a 22% increase in prostate cancer diagnoses after 7 years of follow-up. Despite this, no difference in prostate cancer mortality was demonstrated at 7 years and 10 years of follow-up. Although the European Randomized Study of Screening for Prostate Cancer (ERSPC) found that PSA-based screening reduced the rate of prostate cancer death by 21% after a median follow-up of 11 years, it failed to show a reduction in all-cause mortality. Based on their data, the ERSPC investigators estimated that to prevent one death from prostate cancer, 1055 men would need to be invited for screening and 37 cancers would need to be detected. The U.S. Preventive Services Task Force (USPSTF) has concluded that a substantial percentage of men who have asymptomatic prostate cancer detected by PSA screening have a tumor that would have remained asymptomatic for the man's lifetime. Following a review of the benefits and harms of PSA screening and the treatment of localized prostate cancer, in 2012 the USPSTF recommended against PSA-based screening for prostate cancer for all men in the general U.S. population regardless of age (USPSTF D recommendation).

A. There is fair (mixed) evidence that screening with low-dose CT, chest radiography, or sputum cytology helps detect lung cancer at an earlier stage than no screening at all. However, earlier detection has not translated into improved survival rates. Six randomized trials studying chest radiographs alone or in combination with sputum cytology found no benefit in screening for lung cancer (USPSTF I recommendation). A CBC and spirometry are not recommended for lung cancer screening. In 2011, the National Lung Screening Test (NLST) reported that screening with low-dose CT reduces mortality from lung cancer in high-risk patients. A systematic review of the evidence regarding lung cancer screening using low-dose CT was conducted in 2013 and concluded that while screening may benefit individuals at high risk for lung cancer, uncertainty still exists with regard to the potential harms of screening and the generalizability of results in the community. Based on this review, recommendations from the American College of Chest Physicians and the American Society of Clinical Oncology suggest that annual screening with low-dose CT be offered to smokers and former smokers age 55-74 who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years. This is recommended over no screening or screening with an annual chest radiograph, but should be offered only in settings that can deliver the comprehensive care provided to NLST participants (SOR A). The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults age 55-80 who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. It also recommends screening 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 curative lung surgery (B recommendation).

A, C, D, E, & F. Cervical cancer screening strategies differ based on risk. Cigarette smoking independently increases the risk of cervical cancer 2-4 times (SOR B). It is the only nonsexual behavior associated with cervical dysplasia and cancer. There is insufficient evidence to support a connection between alcohol use and cervical cancer. An early onset of sexual activity and having multiple sexual partners both increase the risk of human papillomavirus (HPV) infection, which leads to cervical dysplasia and cancer (SOR C). Infection with high-risk strains of HPV is the most important risk factor for cervical cancer. HPV DNA is detectable in 95%-100% of squamous cell cervical cancer and 75%-95% of high-grade CIN lesions (SOR B). HIV infection leads to immunosuppression, making a woman more susceptible to HPV infection and thereby leading to cervical dysplasia and cancer (SOR C).

B, C, D, & E. Breast cancer patients should be counseled that intensive surveillance using laboratory and imaging tests does not improve overall survival or quality of life. However, monthly breast self-examination, annual mammography of preserved breast tissue, and a careful history and physical examination every 6 months for 5 years are recommended (SOR C). A Cochrane review, based on two randomized, controlled trials, found that less-intensive follow-up strategies based on periodic clinical examinations and annual mammography seem as effective as more-intense surveillance schemes. Any positive findings on the history and physical examination would certainly warrant further investigation. Female Hodgkin's disease survivors treated with chest irradiation are at increased risk of developing breast cancer; surveillance should be started at 25 years of age (SOR C). The U.S. Preventive Services Task Force recommends routine screening for depression all adult patients, but only if staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up care (USPSTF B recommendation). Survivors of childhood cancers are at increased risk for depression, and should be screened and treated as appropriate (SOR C). Use of carcinoembryonic antigen testing and CT for follow-up of colorectal cancer patients yields a survival advantage of about 19% (SOR A). However, there is insufficient evidence to support any optimal combination of tests or frequency of clinical follow-up. Expert recommendations suggest that prostate cancer survivors should receive annual digital rectal examinations, plus monitoring of prostate-specific antigen levels every 6 months for 5 years, and then annually (SOR C).

B, C, D, & E. According to the U.S. Preventive Services Task Force (USPSTF), patients should generally not be referred for BRCA counseling or screening because of breast cancer in a female first degree relative unless the diagnosis was made before the age of 55 (USPSTF B recommendation). Ashkenazi Jewish women are at increased risk for BRCA mutations, and thus should be considered for testing if there is a family history of breast cancer in one first degree relative (USPSTF B recommendation). Bilateral breast cancer in a first degree relative also justifies referral for BRCA testing (USPSTF B recommendation). A history of breast cancer in any male relative justifies referral for BRCA testing (USPSTF B recommendation). BRCA mutations increase the risk for both breast and ovarian cancer before age 70 (35%-84% and 10%-50%, respectively). A family history of both types of cancer in first or second degree relatives significantly increases the risk of having a BRCA mutation, and screening is recommended (USPSTF B recommendation). For patients who may have one of these mutations, the physician should have a discussion with the patient about her risk for the mutation and its significance, and then determine her preferences before ordering screening tests.

A. The U.S. Preventive Services Task Force (USPSTF) has determined that the benefits from screening for skin cancer are unproven, even in high-risk patients (USPSTF I recommendation). Patients at increased risk for melanoma include those with atypical moles, fair-skinned individuals over the age of 65, and those with more than 50 moles. Lesions with atypical features, described as the ABCDs of melanoma (Asymmetry, Border irregularity, Color variability, Diameter >6 mm), or rapidly changing lesions, should be biopsied. Study outcomes of patients with familial syndromes have not been evaluated by the USPSTF. The most commonly advocated screening test is the full-body skin examination, although supporting data is limited and has only been collected in volunteer patients. The sensitivity and specificity of examinations performed by dermatologists are quite high. However, those done by other specialists are lower in sensitivity and considerably lower in specificity. Another possible screening tool is the risk-factor questionnaire, but its validity has not been established.

A, D, & E. Ovarian cancer is the fifth leading cause of cancer death among women in the U.S. Risk factors associated with ovarian cancer include family history and having the BRCA1 or BRCA2 gene mutation. A first or second degree relative with ovarian cancer increases the risk by about threefold. The use of oral contraceptives and pregnancy of any duration reduce the risk of ovarian cancer, but postmenopausal estrogen use may increase the risk. Screening for ovarian cancer is currently not recommended by the U.S. Preventive Services Task Force, as it is likely to have a relatively low yield (USPSTF D). Almost all women with a positive screening test for CA-125 will not have ovarian cancer. In women at average risk, the positive predictive value of an abnormal CA-125 is approximately 2% (i.e., 98% of women with positive test results will not have ovarian cancer). There are no current recommendations for ovarian cancer screening by either transvaginal ultrasonography or pelvic examination. There is a significant potential for harm associated with ovarian cancer screening, including potential distress and anxiety, unnecessary surgery, and needless follow-up testing.

A, B, & D. The American Academy of Pediatrics recommends a minimum daily intake of 400 IU of vitamin D for all infants and children, including adolescents, beginning within the first few days of life. Because breast milk has been found to contain insufficient levels of vitamin D, starting supplementation in the newborn period for infants who are solely breastfed is strongly recommended (SOR C). Cochrane reviews are under way to determine the strength of evidence behind these recommendations. Patients with chronic renal disease or those taking antiepileptic drugs are at risk for severe vitamin D deficiency and may require large maintenance doses of vitamin D (i.e., up to 50,000 IU one to three times weekly) (SOR C). Levels of 25-hydroxyvitamin D should be maintained above 32 ng/mL (80 nmol/L) to maximize bone health (SOR C). There is no evidence to suggest that supplemental vitamin D is beneficial for premenopausal women with normal 25-hydroxyvitamin D levels (SOR C). Breast cancer survivors taking bisphosphonates are at risk for developing vitamin D deficiency, and guidelines recommend routine vitamin D supplementation for all women with metastatic breast cancer (SOR C). Although the optimal dose of vitamin D for the primary prevention of fractures in noninstitutionalized postmenopausal women has not been determined, the U.S. Preventive Services Task Force recently recommended against daily supplementation with 400 IU or less of vitamin D3 and 1000 mg or less of calcium. Current dietary reference intakes recommended by the Institute of Medicine are 1200 mg/day of elemental calcium daily and 600 IU/day of vitamin D (SOR C).

C & E. In 2013, the American Heart Association (AHA) released new guidelines for the treatment of cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. These guidelines recommend statin therapy (unless contraindicated) in adults >21 years of age in four "statin benefit" groups: 1. Patients with clinical atherosclerotic cardiovascular disease (high-intensity statin if age 75 years) 2. Patients with an LDL-cholesterol (LDL-C) level >190 mg/dL (high-intensity statin) 3. Patients with type 1 or type 2 diabetes mellitus and age 40-75 years (moderate-intensity statin; high-intensity statin if 10-year ASCVD risk >7.5%) 4. Patients with an estimated ASCVD risk >7.5% and age 40-75 years (moderate- to high-intensity statin) High-intensity statin therapy is defined as a daily dosage that lowers LDL-cholesterol by >50%, and moderate-intensity statin therapy is defined as a dosage that lowers LDL-cholesterol 30%-50%. Statin therapy would thus be indicated in both the patient with a recent myocardial infarction and the patient with diabetes, regardless of LDL-C levels. Although AHA guidelines do recommend statin therapy in all adults with an LDL-C level >190 mg/dL, statins are contraindicated in pregnancy (pregnancy category X). In addition, there is no evidence that treating hyperlipidemia during pregnancy is beneficial (SOR C). Both the 40-year-old female nonsmoker with hypertension and the 55-year-old overweight female smoker have a 10-year estimated ASCVD risk <4% and thus should not be started on a statin, based on 2013 AHA guidelines.

C & D. A meta-analysis has found an increase in all-cause mortality associated with the use of vitamin E at a dosage of >400 mg/day. In addition, β-Carotene has been found in clinical trials with smokers to be related to increased rates of lung cancer and overall mortality. Furthermore, in 2003 the U.S. Preventive Services Task Force specifically recommended against the use of β-carotene for chemoprevention (USPSTF D recommendation). The evidence for vitamins A and C, and for multivitamins with folic acid, is insufficient to recommend for or against their use for chemoprevention of cancer or cardiovascular disease (USPSTF I recommendation).

A, C, D, & E. For important health benefits, the 2008 Physical Activity Guidelines for Americans recommend both aerobic activity and muscle-strengthening activity every week for adults (SOR C). The recommended minimums for weekly aerobic activity include 150 minutes of moderate-intensity aerobic activity such as brisk walking, 75 minutes of vigorous-intensity aerobic activity such as jogging or running, or an equivalent mix of moderate- and vigorous-intensity aerobic activity. In addition, muscle-strengthening activities that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) should be performed 2 or more days/week. It is best to spread the activities out over the course of the week, and patients can be reminded that even 10-minute episodes of moderate or vigorous aerobic activity can be beneficial. For those who are currently meeting minimum targets for aerobic activity, slowly increasing the amount of time spent engaging in these activities will increase the benefits. The U.S. Preventive Services Task Force (USPSTF) has concluded with moderate certainty that medium- to high-intensity counseling has a small net benefit on health behaviors and outcomes in adults without cardiovascular disease, hypertension, hyperlipidemia, or diabetes mellitus. It has recommended that clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all adults in the general population, depending on the patient, social support and community resources, and other health care and preventive service priorities (USPSTF C recommendation).

B, D, & E. Among over-the-counter pain relievers, only acetaminophen is considered safe throughout pregnancy (category B), and it is considered the analgesic of choice for pregnant patients (SOR C). Aspirin can cause premature closure of the ductus arteriosus, and while ibuprofen is considered a category B drug during the second trimester, it can also cause premature closure of the ductus arteriosus during the third trimester (SOR C). Although pseudoephedrine is a category C drug, it is the decongestant of choice during pregnancy (SOR C). Chlorpheniramine is the antihistamine of choice during pregancy (SOR C), and is rated category B. Diphenhydramine is also rated category B, but has oxytocin-like effects at high doses. Guaifenesin is associated with neural tube defects, and dextromethorphan is preferred for cough during pregnancy (SOR C).

A-D. Not only are tobacco cessation treatments effective clinically, they are also cost-effective in comparison to treatments for other medical disorders (SOR A). Several analyses have found that the cost of treatment per patient who quits ranges from several hundred to a few thousand dollars. Insurance coverage of medications and counseling to stop smoking increases quit rates (SOR A). Patients are more likely to receive treatment if their insurance pays for the medication or counseling, and insurance companies are therefore encouraged to cover tobacco cessation. Telephone quit lines are effective in tobacco cessation (SOR A). They reach a diverse population, and family physicians and other practitioners are encouraged to promote their use. Bupropion, varenicline, and five forms of nicotine replacement (gum, inhaler, lozenge, nasal spray, and patch) have all been shown to be effective in helping adults quit smoking (SOR A). However, there is insufficient evidence to recommend their use in adolescents, pregnant women, light smokers, and users of smokeless tobacco. Although medication helps individuals stop smoking, the long-term abstinence rate (12 months) is <30% (SOR A). Further research is needed to identify medications and strategies to extend the period of abstinence.

D. The USPSTF states that there is currently insufficient evidence to assess the balance of benefits and harms of broad-based screening of adolescents, adults, and pregnant women for illicit drug use (USPSTF I recommendation). They note that there are several validated and reliable instruments available, and that there is evidence that intervention in symptomatic individuals can lead to short-term decreases in drug use. However, they also note the lack of studies to show that use of these instruments in the primary care setting leads to improved social, legal, and health outcomes for patients, especially those who do not have physical, social, school, or occupational problems related to their substance use. The USPSTF review did not identify any studies examining the effectiveness of general counseling to prevent the onset of substance abuse. Experts recommend that physicians explore the possibility of substance abuse in selected patients at high risk (e.g., pregnant adolescents, individuals with changes in school/social/occupational functioning, etc.) (SOR C).

A-E. Bicycle-related crashes and related head injuries are a leading cause of nonfatal injuries in children. Both the use of approved, properly fitting bicycle helmets and educational programs designed to increase their use have been shown to reduce the risk of these injuries (SOR B). Parents should be instructed to preset the home water heater to less than 120°F in order to reduce the risk of scalding (SOR A). The most common cause of fatal injuries in children under the age of 18 is motor vehicle crashes. Placing children in age-appropriate child restraints has been shown to reduce injuries in the event of a motor vehicle crash (SOR A). Injuries secondary to fires are a leading cause of fatal injuries in children. Properly installed and maintained smoke detectors have been shown to reduce injuries associated with fires (SOR A). Clinical counseling to increase the use of smoke detectors has also been shown to reduce these injuries (SOR B). Drowning is the second most common cause of fatal injuries in children. To prevent access to swimming pools, the fencing must surround the pool, not allow direct access from the house, be made of a material that is difficult to climb, and have self-closing, self-latching gates (SOR A). In addition, personal flotation device use around water (SOR C), vigilant adult supervision (SOR B), and CPR training (SOR B) have been shown to reduce the risk of drowning in children.

A & C. USPSTF found good evidence that patients at risk for adverse outcomes from alcohol abuse can be accurately identified in the primary care setting. They also found evidence that even brief behavioral counseling (with follow-up) can produce a small to moderate sustained reduction in alcohol use, and therefore recommend screening adults for alcohol abuse and providing counseling (USPSTF B recommendation). The USPSTF found little evidence with regard to screening and counseling adolescents for alcohol use, and therefore noted that there is insufficient evidence to recommend for or against screening in this age group (USPSTF I recommendation). The CAGE and AUDIT tools are two of several validated instruments that can be used in primary care settings to screen for alcohol abuse (SOR A).

A, C, & E. As our population ages, preventing falls is of increasing importance. Approximately 35%-40% of community-dwelling persons age 65 and older fall annually, with 5% of those who fall requiring hospitalization. In addition, it is estimated that up to 40% of nursing-home admissions are fall-related. USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults age 65 or older who are at increased risk for falls (USPSTF B recommendation). It also has concluded with moderate certainty that multifactorial risk assessment with comprehensive management of identified risks had a small net benefit in preventing falls in older adults. The USPSTF found insufficient evidence for or against the use of the following interventions for preventing falls: medication discontinuation, protein supplementation, education or counseling, hip protectors, and home hazard modification. The American Geriatrics Society recommendations for fall prevention include exercise, home environmental assessment and mitigation of identified hazards, vitamin D supplementation of at least 800 IU/day, identification and appropriate treatment of foot problems, assessment and treatment of postural hypotension, advising the patient to not wear multifocal lenses while walking, minimization or withdrawal of psychoactive or other medications, and exercise therapy that targets strength, gait, and balance. There is no evidence to support recommending hip protectors (SOR A) or the use of restraints to prevent falls in the elderly.

A, B, D, & E. Meningococcal conjugate vaccine (MCV) is recommended for normal-risk children at 11-12 years of age, although children with certain medical conditions (such as sickle cell disease or asplenia) may benefit from immunization as early as 2 years of age (SOR A). HIV-infected patients who are vaccinated should receive two doses of the vaccine (SOR C). Being a new military recruit, being a first-year college student living in a dormitory, and visiting endemic areas (e.g., Mecca) are accepted indications for meningococcal vaccination. MCV is preferred for adults younger than 55, although the meningococcal polysaccharide vaccine (MPSV) can be used as an alternative. However, persons previously vaccinated with MPSV who continue to reside in endemic areas may benefit from revaccination after 3-5 years. Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection, including adults with anatomic or functional asplenia or persistent complement component deficiencies (SOR C).

B, C, & D. According to the Centers for Disease Control and Prevention, hepatitis B vaccination is recommended for all infants, all older children and adolescents who were not vaccinated previously, and all adults at risk for hepatitis B virus infection (SOR A). Persons can be at risk as a result of sexual exposure, percutaneous or mucosal exposure to blood, or travel to endemic areas. In most cases, immunization requires administration of a 3-dose series. The minimum interval between the first and second doses is 4 weeks, and there is no current evidence that it is necessary to restart the series at any point in time. Hepatitis A vaccination is recommended for all children starting at 1 year of age, travelers to endemic countries, and others at risk. It requires administration of a two-dose series, at least 6 months apart. There is no current evidence that it is necessary to restart the series at any point in time. This patient is up to date on his diphtheria, tetanus, and pertussis vaccinations, and DTaP is recommended only for young children. When meningococcal vaccine was first recommended for adolescents in 2005, it was thought that protection would last for 10 years; however, it now appears that it decreases in most adolescents within 5 years. A single dose at the recommended age of 11 or 12 years therefore may not offer protection when the risk for meningococcal infection is highest (16 though 21 years of age). For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years. Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.

A, C-E. Pneumococcal conjugate vaccine (PCV) is recommended for all children less than 5 years of age (SOR A). Although many cases of otitis media are due to pneumococcus, the vaccine is not recommended to prevent recurrent infections. However, immunization with pneumococcal polysaccharide vaccine (PPSV) is recommended prophylactically for children with certain medical conditions, such as cochlear implants, beginning at 2 years of age. Smoking is now included in the list of chronic diseases or conditions that are indications for immunization with PPSV before 65. Chronic renal failure and immunocompromised conditions are indications for one-time revaccination after 5 years, but diabetes mellitus, COPD, and most other conditions are not. All individuals should be immunized with PPSV upon turning 65, unless there is evidence that they have been vaccinated within the previous 5 years (SOR A).

A. The herpes zoster vaccine contains live attenuated varicella virus. Clinical trials show that the vaccine prevents herpes zoster in about half of those vaccinated and postherpetic neuralgia in 67%. One dose is currently recommended, with no booster (SOR A). Medicare Part D plans cover the vaccine, but co-pays vary greatly among plans. Medicare Part B does not cover the vaccine. Most private insurance plans cover the vaccine for patients age 60 or over. Some insurance plans extend coverage to patients 50-59 years of age.

B, C, D, & E. Varicella vaccine is recommended for all healthy adolescents and adults who have not received the vaccine and have no confirmed history of chickenpox (SOR A). Two doses are required, given at least 4 weeks apart. Particular attention should be given to immunizing women of reproductive age, international travelers, and close contacts of immunosuppressed patients. However, because the vaccine is a live virus, women of reproductive age should be counseled to delay conception for at least a month after receiving the second dose of the vaccine, and pregnant women should not receive the vaccine until after delivery.

A, B, & E. Pregnant women can safely receive inactivated viral or bacterial vaccines or toxoids. As a general rule, live attenuated viral vaccines should be avoided in the immediate preconception and prenatal time periods (e.g., varicella, live attenuated influenza, MMR). While there is no proven risk of adverse fetal effects, the CDC advises delaying administration of these live vaccines until after delivery due to the theoretical risk (SOR A). For the pregnant patient with no identifiable risk factors, a tetanus booster is recommended (SOR A). Women who will be pregnant during influenza season should receive the inactived vaccine. In addition, this particular patient should also receive hepatitis B vaccine because of her history of high-risk sexual behavior. Tdap would both provide the needed tetanus booster and help to minimize the risk of spreading pertussis to nursing-home residents.

A, C, & D. ACOG, the AAFP, and the CDC recommend vaccination of all women who will be pregnant during influenza season. The preferred vaccine is the trivalent inactivated influenza vaccine (SOR A). Influenza vaccine is also recommended for women who are breastfeeding, and the live attenuated virus vaccine may be given to these women (SOR A). Current CDC guidelines recommend oseltamivir for the treatment of pregnant women with suspected influenza.

B, C, & E. According to the Centers for Disease Control and Prevention guidelines, influenza vaccine should be administered as soon as it is available, and can be given throughout the entire influenza season. Emphasis should be placed on vaccinating individuals prior to the start of influenza activity in the community (SOR A). When the vaccine is closely matched to the antigenic strains circulating in the population, there are decreases in antibiotic use, hospitalization, absenteeism, and the use of health care resources in general (SOR B). A number of studies have shown that influenza vaccine significantly reduces the number of cases of acute otitis media in children, although the evidence is not conclusive (SOR B). The American Academy of Pediatrics recommends influenza vaccine as a preventive measure for otitis media. There is insufficient evidence to support use of the live attenuated influenza vaccine in children under the age of 2. Children between 6 months and 2 years of age should only receive the trivalent inactivated influenza vaccine. Children 6 months or older with evidence of, or a history of, reactive airways disease should not receive the live attenuated influenza vaccine (SOR C). Multiple studies have shown no adverse fetal effects from administration of the inactivated vaccine to the mother during pregnancy. The AAFP and ACOG both recommend immunization for influenza in pregnant women during influenza season. Pregnant women should not receive the live attenuated vaccine, however. Breastfeeding women should also be immunized, with either the trivalent inactivated or live attenuated influenza vaccine (SOR B).

C, D. USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up (USPSTF B recommendation). In the absence of staff-assisted depression care supports, the USPSTF recommends against routinely screening adults for depression (USPSTF C recommendation). In addition, the USPSTF recommends screening adolescents 12-18 years of age for major depressive disorder when systems are in place to assure accurate diagnosis, psychotherapy (cognitive, behavioral, or interpersonal) and follow-up (USPSTF B recommendation). The staff-assisted depression care support system required for adults is a multi-component system that goes beyond simple feedback of screening results. In addition to staff support for scheduling follow-up visits and facilitating referrals, other higher-intensity interventions might include elements such as intensive clinician and office support staff training, support staff or specialty mental health provider participation in ongoing depression care, and several follow-up contacts. There are several validated questionnaires that can be used in outpatient primary care settings for depression screening. A two-question screen assessing for depressed mood or loss of interest in previously pleasurable activities in the last 4 weeks (PHQ-2) is as sensitive as many longer instruments. However, the two-question screen has a low specificity, so it cannot be relied upon to make a diagnosis of depression. Confirmation of a positive screen with additional questioning is needed. Suicide rates in primary care are fortunately very low. The USPSTF found only limited evidence of the accuracy of suicide screening instruments in primary care, and no evidence that such general screening decreases suicide risk. Therefore, the USPSTF states that there is insufficient evidence for or against screening for suicide risk in the general population (USPSTF I recommendation). However, many patients with depression will express suicidal ideation, intent, or plans, and depression increases the risk of suicide. Suicidal ideation is also one of the potential diagnostic criteria for depression. Therefore, assessment of all depressed patients for suicide risk is warranted (SOR C). Several studies have shown that screening for and treating patients with depression and coronary heart disease can successfully relieve depressive symptoms and lead to improved patient quality of life. Despite the fact that depression can be successfully treated, at this time the evidence does not indicate that this translates into improved CAD morbidity and mortality.

B, D, E, & F. The USPSTF recommends screening for osteoporosis in women age 65 and older and in younger women whose fracture risk is equal to or greater than a 65-year-old white female with no additional risk factors. To determine risk in women age 50-64, the USPSTF recommends using a 10-year fracture risk threshold of 9.3% calculated using the U.S. FRAX tool (www.shef.ac.uk/FRAX) (USPSTF B recommendation). While bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture, the likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer used, and the relevance of the reference range. No studies have evaluated the optimal intervals for repeat screening. Because of limitations in the precision of testing, the USPSTF reports that a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeat screening performed to identify new cases of osteoporosis.

A, D, & E. In 2014, the USPSTF issued a recommendation that persons at high risk for infection should be screened for hepatitis B virus (HBV) infection (B recommendation). Risk groups identified by the USPSTF include the following: * Persons born in countries and regions with a high prevalence of HBV infection ( 2%) * U.S.-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection ( 8%), such as sub-Saharan Africa and central and Southeast Asia * HIV-positive persons * Injection drug users * Men who have sex with men * Household contacts or sexual partners of persons with HBV infection These groups have a prevalence rate ≥2%, which is significantly higher than the general population. In addition, the USPSTF recommends screening for patients receiving hemodialysis or cytotoxic or immunosuppressive drugs. In 2012, the CDC issued a recommendation that adults born between 1945 and 1965 receive one-time testing for HCV. This recommendation was influenced in large part by a recent CDC analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2008, which found a higher proportion of persons born during during these years were positive for HCV antibody when compared to the general population. In fact, this birth cohort accounts for 76.5% of those with HCV antibodies. Based upon estimates of the many persons in this cohort who are unaware of their infection status, the potential benefits of care and treatment, and projections of increasing morbidity and mortality in the absence of an intervention, the CDC concluded that one-time screening would be cost-effective for this group, at $35,700 per quality-adjusted life-year gained (SOR B). In addition, the CDC recommended that all persons with identified HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (SOR B). There is good evidence that early detection of hepatitis B in pregnant women can prevent infection in newborns. Administration of hepatitis B vaccine to the mother, either alone or along with hepatitis B immune globulin, is effective in preventing transmission of the infection to the newborn (SOR A). HBsAg is the only serologic test that can detect hepatitis B infection early in its course. It detects active disease, either acute or chronic, and is highly sensitive and specific (>98% for both) (SOR A).

A & D. Available screening tests for dementia, such as the Mini-Mental State Exam (MMSE), Functional Activities Questionnaire (FAQ), and others have good sensitivity but only fair specificity for diagnosing dementia; the positive and negative predictive value of these instruments will vary depending on the practice setting and prevalence of dementia in the patient population (SOR A). While pharmacologic treatment has shown a positive (but varying) effect on delays in the decline of cognitive function (equivalent to delaying the natural progression of Alzheimer's disease by 2-7 months), the evidence of a positive effect on activities of daily living is mixed, and according to the USPSTF is "small at best." There is also uncertainty as to the comparability of patients in dementia treatment trials and those in general primary care settings. Labeling patients as having dementia may cause anxiety in the patient and family members, and may also have other untoward consequences such as adverse effects on insurability. Therefore, the USPSTF has concluded that there is insufficient evidence for or against routine dementia screening, as they could not determine the balance of benefits and harms (USPSTF I recommendation). However, once patients start showing symptoms of cognitive decline, assessment for dementia is warranted.(Many would consider this a targeted diagnostic evaluation approach, not a general screening approach).

A, B, C. The USPSTF recommends screening all sexually active nonpregnant women who are at increased risk for chlamydial infection, regardless of age (USPSTF A recommendation). Screening for chlamydial infection is also recommended for all pregnant women who are at increased risk (USPSTF B recommendation). Routine screening for chlamydial infection is not recommended in women age 25 and older who have no risk factors, whether the patient is pregnant or not (USPSTF C recommendation). There is currently insufficient evidence to support screening for chlamydial infection in men (USPSTF I recommendation).

Smoking history (at least 100 cigarettes in a lifetime) and male sex are the major risk factors for abdominal aortic aneurysm (AAA). The USPSTF recommends one-time screening for AAA by ultrasonography between the ages of 65 and 75 in men who have ever smoked (USPSTF B recommendation). The USPSTF also recommends that clinicians selectively offer screening for AAA in men in this age group who have never smoked if indicated by the patient's medical history, family history, other risk factors, and personal values (USPSTF C recommendation). Important risk factors in addition to age include a first degree relative with AAA. Other risk factors to take into account include a history of other vascular aneurysms, coronary artery disease, cerebrovascular disease, atherosclerosis, hypercholesterolemia, obesity, and hypertension. The greatest likelihood of finding an AAA large enough to benefit from surgery is between the ages of 65 and 75. In patients older than 75, the likelihood of surviving surgery to repair an AAA is low enough to preclude screening. The benefit of screening for women in this age group is low due to the low number of AAA-related deaths in this population (SOR B). The USPSTF recommends against routine screening for AAA in women (USPSTF D recommendation).

C. USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up (USPSTF B recommendation). In the absence of staff-assisted depression care supports, the USPSTF recommends against routinely screening adults for depression (USPSTF C recommendation). In addition, the USPSTF recommends screening adolescents 12-18 years of age for major depressive disorder when systems are in place to assure accurate diagnosis, psychotherapy (cognitive, behavioral, or interpersonal) and follow-up (USPSTF B recommendation). The staff-assisted depression care support system required for adults is a multi-component system that goes beyond simple feedback of screening results. In addition to staff support for scheduling follow-up visits and facilitating referrals, other higher-intensity interventions might include elements such as intensive clinician and office support staff training, support staff or specialty mental health provider participation in ongoing depression care, and several follow-up contacts. There are several validated questionnaires that can be used in outpatient primary care settings for depression screening. A two-question screen assessing for depressed mood or loss of interest in previously pleasurable activities in the last 4 weeks (PHQ-2) is as sensitive as many longer instruments. However, the two-question screen has a low specificity, so it cannot be relied upon to make a diagnosis of depression. Confirmation of a positive screen with additional questioning is needed. Suicide rates in primary care are fortunately very low. The USPSTF found only limited evidence of the accuracy of suicide screening instruments in primary care, and no evidence that such general screening decreases suicide risk. Therefore, the USPSTF states that there is insufficient evidence for or against screening for suicide risk in the general population (USPSTF I recommendation). However, many patients with depression will express suicidal ideation, intent, or plans, and depression increases the risk of suicide. Suicidal ideation is also one of the potential diagnostic criteria for depression. Therefore, assessment of all depressed patients for suicide risk is warranted (SOR C). Several studies have shown that screening for and treating patients with depression and coronary heart disease can successfully relieve depressive symptoms and lead to improved patient quality of life. Despite the fact that depression can be successfully treated, at this time the evidence does not indicate that this translates into improved CAD morbidity and mortality.

B, E, & F. USPSTF recommends screening for osteoporosis in women age 65 and older and in younger women whose fracture risk is equal to or greater than a 65-year-old white female with no additional risk factors. To determine risk in women age 50-64, the USPSTF recommends using a 10-year fracture risk threshold of 9.3% calculated using the U.S. FRAX tool (www.shef.ac.uk/FRAX) (USPSTF B recommendation). While bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture, the likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer used, and the relevance of the reference range. No studies have evaluated the optimal intervals for repeat screening. Because of limitations in the precision of testing, the USPSTF reports that a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeat screening performed to identify new cases of osteoporosis.

In 2014, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation that persons at high risk for infection should be screened for hepatitis B virus (HBV) infection (B recommendation). Risk groups identified by the USPSTF include the following: •Persons born in countries and regions with a high prevalence of HBV infection ( 2%) •U.S.-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection ( 8%), such as sub-Saharan Africa and central and Southeast Asia •HIV-positive persons •Injection drug users •Men who have sex with men •Household contacts or sexual partners of persons with HBV infection These groups have a prevalence rate ≥2%, which is significantly higher than the general population. In addition, the USPSTF recommends screening for patients receiving hemodialysis or cytotoxic or immunosuppressive drugs. In 2012, the Centers for Disease Control and Prevention (CDC) issued a recommendation that adults born between 1945 and 1965 receive one-time testing for HCV. This recommendation was influenced in large part by a recent CDC analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2008, which found a higher proportion of persons born during during these years were positive for HCV antibody when compared to the general population. In fact, this birth cohort accounts for 76.5% of those with HCV antibodies. Based upon estimates of the many persons in this cohort who are unaware of their infection status, the potential benefits of care and treatment, and projections of increasing morbidity and mortality in the absence of an intervention, the CDC concluded that one-time screening would be cost-effective for this group, at $35,700 per quality-adjusted life-year gained (SOR B). In addition, the CDC recommended that all persons with identified HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (SOR B). There is good evidence that early detection of hepatitis B in pregnant women can prevent infection in newborns. Administration of hepatitis B vaccine to the mother, either alone or along with hepatitis B immune globulin, is effective in preventing transmission of the infection to the newborn (SOR A). HBsAg is the only serologic test that can detect hepatitis B infection early in its course. It detects active disease, either acute or chronic, and is highly sensitive and specific (>98% for both) (SOR A).

A, C, D, E. In 2014, USPSTF issued a recommendation that persons at high risk for infection should be screened for hepatitis B virus (HBV) infection (B recommendation). Risk groups identified by the USPSTF include the following: •Persons born in countries and regions with a high prevalence of HBV infection ( 2%) •U.S.-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection ( 8%), such as sub-Saharan Africa and central and Southeast Asia •HIV-positive persons •Injection drug users •Men who have sex with men •Household contacts or sexual partners of persons with HBV infection These groups have a prevalence rate ≥2%, which is significantly higher than the general population. In addition, the USPSTF recommends screening for patients receiving hemodialysis or cytotoxic or immunosuppressive drugs. In 2012, the CDC issued a recommendation that adults born between 1945 and 1965 receive one-time testing for HCV. This recommendation was influenced in large part by a recent CDC analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2008, which found a higher proportion of persons born during during these years were positive for HCV antibody when compared to the general population. In fact, this birth cohort accounts for 76.5% of those with HCV antibodies. Based upon estimates of the many persons in this cohort who are unaware of their infection status, the potential benefits of care and treatment, and projections of increasing morbidity and mortality in the absence of an intervention, the CDC concluded that one-time screening would be cost-effective for this group, at $35,700 per quality-adjusted life-year gained (SOR B). In addition, the CDC recommended that all persons with identified HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (SOR B). There is good evidence that early detection of hepatitis B in pregnant women can prevent infection in newborns. Administration of hepatitis B vaccine to the mother, either alone or along with hepatitis B immune globulin, is effective in preventing transmission of the infection to the newborn (SOR A). HBsAg is the only serologic test that can detect hepatitis B infection early in its course. It detects active disease, either acute or chronic, and is highly sensitive and specific (>98% for both) (SOR A).

B & D. Available screening tests for dementia, such as the Mini-Mental State Exam (MMSE), Functional Activities Questionnaire (FAQ), and others have good sensitivity but only fair specificity for diagnosing dementia; the positive and negative predictive value of these instruments will vary depending on the practice setting and prevalence of dementia in the patient population (SOR A). While pharmacologic treatment has shown a positive (but varying) effect on delays in the decline of cognitive function (equivalent to delaying the natural progression of Alzheimer's disease by 2-7 months), the evidence of a positive effect on activities of daily living is mixed, and according to the USPSTF is "small at best." There is also uncertainty as to the comparability of patients in dementia treatment trials and those in general primary care settings. Labeling patients as having dementia may cause anxiety in the patient and family members, and may also have other untoward consequences such as adverse effects on insurability. Therefore, the USPSTF has concluded that there is insufficient evidence for or against routine dementia screening, as they could not determine the balance of benefits and harms (USPSTF I recommendation). However, once patients start showing symptoms of cognitive decline, assessment for dementia is warranted.(Many would consider this a targeted diagnostic evaluation approach, not a general screening approach).

A, B, & E. The USPSTF recommends screening all sexually active nonpregnant women who are at increased risk for chlamydial infection, regardless of age (USPSTF A recommendation). Screening for chlamydial infection is also recommended for all pregnant women who are at increased risk (USPSTF B recommendation). Routine screening for chlamydial infection is not recommended in women age 25 and older who have no risk factors, whether the patient is pregnant or not (USPSTF C recommendation). There is currently insufficient evidence to support screening for chlamydial infection in men (USPSTF I recommendation).

A & D. Smoking history (at least 100 cigarettes in a lifetime) and male sex are the major risk factors for abdominal aortic aneurysm (AAA). The USPSTF recommends one-time screening for AAA by ultrasonography between the ages of 65 and 75 in men who have ever smoked (USPSTF B recommendation). The USPSTF also recommends that clinicians selectively offer screening for AAA in men in this age group who have never smoked if indicated by the patient's medical history, family history, other risk factors, and personal values (USPSTF C recommendation). Important risk factors in addition to age include a first degree relative with AAA. Other risk factors to take into account include a history of other vascular aneurysms, coronary artery disease, cerebrovascular disease, atheroslcerosis, hypercholesterolemia, obesity, and hypertension. The greatest likelihood of finding an AAA large enough to benefit from surgery is between the ages of 65 and 75. In patients older than 75, the likelihood of surviving surgery to repair an AAA is low enough to preclude screening. The benefit of screening for women in this age group is low due to the low number of AAA-related deaths in this population (SOR B). The USPSTF recommends against routine screening for AAA in women (USPSTF D recommendation).

C & D. The American Diabetes Association recommends screening all persons over the age of 45 with a fasting plasma glucose level or a 2-hour oral glucose tolerance test. Hemoglobin A1c is also an acceptable test. Screening should be performed before age 45 for any individual with a BMI >25.0 kg/m2 who has any of the following additional risk factors: •physical inactivity •low HDL-cholesterol (250 mg/dL) •a first degree relative with diabetes mellitus •polycystic ovary syndrome or other insulin-resistance conditions (e.g., acanthosis nigricans) •delivery of an infant with a birth weight >9 lb, or a history of gestational diabetes •high-risk ethnicity (African American, Hispanic, Native American, Asian American, Pacific Islander) •a previous glucose tolerance test with elevated results or a hemoglobin A1c >5.7% •a history of vascular disease •hypertension If screening results are normal, repeat testing should be done at least at 3-year intervals. An oral glucose tolerance test is required to diagnose impaired glucose tolerance (SOR B). The fasting plasma glucose level alone will miss approximately 30% of patients with isolated impaired glucose tolerance. A consensus statement issued by the American Diabetes Association recommends that if pharmacotherapy is used, both impaired fasting glucose and impaired glucose tolerance should be documented (SOR B).

C. Of the individuals described, the USPSTF recommends screening for anemia only for the pregnant female (USPSTF B recommendation). There is insufficient evidence for screening asymptomatic high-risk infants (age 6-12 months) for iron-deficiency anemia (USPSTF I recommendation). However, the USPSTF does recommend routine iron supplementation for these infants (USPSTF B recommendation). High-risk infants include those living in poverty; Native-American, Alaskan-American, or African-American infants; preterm or low birth weight infants; and immigrants from other countries. A 2-year-old is beyond the age recommended for supplementation, and the evidence is insufficient to recommend screening for asymptomatic children (USPSTF I recommendation).

D, E, & F. Although common, Intimate Partner Violence (IPV) and abuse of elderly and vulnerable adults frequently goes undetected in the United States. Nearly 31% of women and 26% of men report being subjected to some form of IPV in their lifetime, with 25% of women and 14% of men experiencing the most severe types of IPV. The USPSTF recommends that clinicians screen all women of childbearing age for intimate partner violence (IPV), and that women with a positive screen be provided with intervention services, or a referral for these services (USPSTF B recommendation). The USPSTF found insufficient evidence to recommend for or against screening all elderly or vulnerable adults for abuse (USPSTF I recommendation). Highly sensitive and specific screening instruments for identifying IPV are available and include HITS (Hurt, Insult, Threaten, Scream), OAS/OVAT (Ongoing Abuse Screen/Ongoing Violence Assessment Tool), STaT (Slapped, Threatened, and Thrown), HARK (Humiliation, Afraid, Rape, Kick), CTQ-SF (Modified Childhood Trauma Questionnaire—Short Form), and WAST (Woman Abuse Screen Tool). The HITS instrument consists of four questions and can be either self- or clinician-administered. HARK is a self-administered four-item instrument, and STaT is a three-item self-report instrument. Medical consequences stemming from IPV include not only injury and death but also sexually transmitted infections, unwanted pregnancy, chronic pain, and neurologic and gastrointestinal disorders. In addition, IPV is also associated with chronic mental health conditions, such as depression, PTSD, anxiety disorders, substance abuse, and suicidal behavior. Effective interventions to reduce IPV in women of childbearing age are available. These include counseling, home visits, information cards, referrals to community service, and mentoring support.

3%. Specificity is the proportion of people without a disease who have a negative test for the disease, or the ratio of true-negatives to (true-negatives + false-positives) on a test. The false-positive rate of a test can be calculated as 1 - specificity. Thus, a highly specific test will not overdiagnose very many patients with a particular condition. The higher the specificity of a test, the better it functions as a diagnostic tool. However, with most instruments, the higher the specificity the lower the sensitivity, and the more false-negative results. Thus, highly specific tests function well to confirm the presence of a condition (make a diagnosis), but tend not to function well for screening purposes. In this case, the MDQ has a false-positive rate of 3%, making it very useful to confirm the diagnosis of bipolar disorder in a patient you suspect has the disease. However, it has a very low sensitivity of 28%, or a false-negative rate of 72%, meaning it would miss many more bipolar patients than it would identify, limiting its usefulness as a broad, general screening tool.

A & C. An analysis of cost-effectiveness helps compare the value of two (or more) health care services or interventions. A cost-effectiveness analysis takes into account "hard" metrics such as the cost of the service and its effects, compared to a measurable benchmark, but also includes subjective judgments of effects, such as patient ratings of the effect of an intervention on their quality of life. Determining quality-adjusted life-years (QALY) is a standard way to compare the value of different interventions. While $50,000 per QALY has historically been considered the threshold for cost-effectiveness, a more proper use of cost-effectiveness is to compare the relative value of interventions, rather than stating a service is inherently cost-effective by virtue of meeting a threshold. A service does not have to save money (be cost-beneficial) in order to be cost effective. Cost-effectiveness can be assessed by observing the use of a service in controlled conditions or in actual practice, but it can also be assessed by mathematical modeling.

The rate of death attributable to breast cancer in the screened group was 595/146,284, or approximately 0.407%; in the unscreened group it was 701/122,590, or approximately 0.572%. The unadjusted relative risk of death in the screened group compared with the unscreened group is roughly 0.7 (.00407/.00572). Relative risks do not account for baseline rates of occurrence in a population, however, and therefore almost always overstate the magnitude of effect of an intervention. A more accurate way of determining the benefit of screening is to examine the absolute (or attributable) risk reduction (ARR), which is the difference between the rates of occurrence of two conditions. In this case, the ARR from screening mammography is 0.165% (or 165/100,000). The number needed to screen is the reciprocal of the ARR; in this case 1/0.00165, or approximately 606. In other words, this data would suggest that approximately 606 women over age 50 would need to be screened with mammography every 1-3 years over 13 years of follow-up in order to prevent 1 death from breast cancer.