Health Promotion & Disease Prevention
|what is "the process of enabling people to increase control over their health & its determinants & thereby improving their health"?||health promotion.|
|define "primary prevention"|| avoids the development of a disease.|
the person does NOT have the disease at all.
|define "secondary prevention"|| activities are aimed at early disease detection.|
example is mammograms for detecting breast cancer before it causes any sxs.
|what is "tertiary prevention"?|| reduces negative impact of an already established disease.|
example is HIV patient. you want to prevent them from getting diseases like TB and other opportunistic infections.
|what is "injury or damage resulting from some judgement or action in disregard for one's rights. a preconceived judgement without just grounds or before sufficient knowledge".|| PREJUDICE.|
irrational attitude of hostility directed against an individual, group, or race.
|what is racism?|| the believe that RACE is the primary determinant of human traits.|
inherent superiority of particular race.
|Since 1998, the USPSTF has been sponsored by who?||Agency for Healthcare Research and Quality (AHRQ)|
|recommendations issued by the USPSTF are intended for use in which medical setting?||PRIMARY CARE.|
|What are the different recommendations given by the USPSTF? (A, B, C, D, I)|| A = strongly recommends|
B = recommends
C = no recommendation for or against
D = recommends against
I = insufficient evidence to recommend for or against
|the recommendations from the USPSTF are published in the form of:||recommendation statements.|
|Should you routinely screen for bladder cancer?|| No.|
USPSTF recommends against routine screening for bladder cancer in adults. GRADE D
|workers in what industry may have an increased risk of bladder cancer?|| dye or rubber industries.|
Other risks: more common in men older than 50, smoking
|should you routinely refer for genetic counseling for BRCA testing in women who does not have BRCA1 or 2 associated breast cancer in her family?|| NO. GRADE D|
USPSTF recommends against routine referral for genetic counseling of BRCA test for women whose fam hx is not associated with BRCA 1 or 2.
|should you recommend genetic counseling and evaluation of BRCA for women with FHx associated with BRCA1/2 genes?|| YES. GRADE B|
|according to USPSTF, who should get a mammogram every 2 years (biennially)?|| women 50 to 74 years old.|
Grade B recommendation.
|should you screen women prior to age 50 for breast cancer according to USPSTF?|| should be an individual choice.|
take patient context into account.
Grade C. They don't recommend for or against.
|Should women > 75 get a mammogram?||There is "insufficient evidence" (GRADE I) to assess addn'l benefits/harms of screening mammograms in women older than 75.|
|when examining a woman for breast cancer, should you do more than a mammogram and clinical breast exam (CBE) in women 40 and older?||USPSTF doesn't know. Grade I for insufficient evidence.|
|According to USPSTF, should you recommend a self breast exam?|| apparently not.|
recommend against teaching BSE.
|what is the leading cancer diagnosed in women?||Breast Cancer.|
|what is the goal of breast cancer screening?||looking for cancer before onset of sxs.|
|what are some types of screening for breast cancer?|| BSE - Breast Self Exam|
CBE - Clinical Breast Exam
|T/F: BSE is less accurate then CBE or mammogram.|| true.|
this is obvious.
|when should BSE be performed?|| last day of menstruation.|
use middle 3 fingers (the pads).
press firmly enough to know how the breasts feel.
|the American College of Gynecology (ACoG) says what age group should start having mammograms?||40 to 49 years old should have mammogram Q 1 - 2 years.|
|ACOG says that women should begin annual mammograms when?||50 and older|
|ACOG opinion of BSE and CBE:|| BSE has potential to detect palpable breast cancer and can be recommended.|
ALL WOMEN should have CBE annually as part of physical exam.
|American Cancer Society (ACS) says that women should begin mammograms when?|| YEARLY at 40.|
continue as long as in good health.
get clinical breast exam too.
|What does the ACS recommend for women in their 20 and 30s?||CBE every 3 years.|
|what does the ACS recommend for women in their 20s?|| BSE is an option.|
know how your breasts normally look and feel.
report changes to health provider.
|who should have pap smear for cervical cancer screen according to USPSTF?||women who have been sexually active and have a cervix (grade A recommendation).|
|T/F: women who have had a total hysterectomy do not need pap smear according to USPSTF.||true. if the hysterectomy was for benign disease. Grade D|
|should women older than 65 get pap smears (USPSTF)?|| No. if they have had normal pap smears and are not at risk for cervical cancer, it is not recommended.|
|Should you screen for cervical cancers with methods other than pap?|| they don't know. Grade I.|
insufficient evidence to recommend for or against new technology use to screen for cervical cancer.
|Should you test for HPV as a primary screen for cervical cancer?|| they don't know. Grade I.|
insufficient to recommend for or against
|most scientific studies point to what as being responsible for > 90% of cases of cervical cancer?|| Human Papilloma Virus (HPV)|
Types 16 and 18 are MCC cancer.
|the goal of the pap smear is to sample which area of the cervix?|| TRANSFORMATION ZONE.|
where columnar endocervical epithelium changes to squamous epithelium.
|use what tool to sample the ectocervix?||extended tip spatula|
|use what tool to sample the endocervix?||cytobrush|
|when should screening for cervical cancer (pap smear) begin?|| 3 years after onset of sexual activity|
whichever comes first
|When does the USPSTF recommend that you stop testing for cervical cancer?|| appropriate to stop screening in older women, but the optimal age is not clear.|
yield of screening low in previously screened women after ate 65
|When does the ACS recommend stopping pap smears?|| AGE 70, if the following conditions are met.|
Must have 3 or more DOCUMENTED, CONSECUTIVE, SATISFACTORY normal/neg cervical cytology tests.
NO abnormal tests within last 10 years.
|Screening for cervical cancers is recommended for what older women (according to ACS)?|| older women not previously screened.|
information of previous screening unavailable.
screening unlikely to have occurred in past (such as women from countries w/ no screening programs).
|there are not better results with screening with paps more often. why are they recommended every year??|| sensitivity of the test.|
until 2 or 3 are cytologically normal.
|Your pt has hx of a hysterectomy. When is it NOT ok to stop pap smear testing?|| when reason of hysterectomy is uncertain.|
with hx of invasive cervical cancer or DES exposure due to increased risk for vaginal neoplasms.
|majority of cases of invasive cervical cancer occur in who?||women who were not adequately screened.|
|what is the new "thin prep" liquid based cytology for cervical cancer?|| allows for HPV-DNA testing.|
not cost effective unless used with screening intervals of 3 years or longer.
|when should cervical cancer screening begin according to ACOG?|| at 21 years.|
don't screen before 21 b/c it might lead to harmful and unnecessary evaluation.
|according to ACOG, cervical cancer screening from 21 to 29 years should be performed when?||21 to 29 years, every 2 years.|
|women 30 and older should be screened how often for cervical cancer (ACOG)?|| with 3 consecutive negative cervical cytology screening tests, they may extend interval between cervical cytology exams to every 3 years if...|
1. no hx of CIN 2 or 3
2. don't have HIV
3. not immunocompromised
4. not exposed to DES in utero
|T/F: according to ACOG, the liquid based and conventional methods of cervical cytology are acceptable for screening.||true.|
|according to ACOG, when can you stop cervical cancer screening?|| between ages 65 and 70.|
must have 3 or more neg cytology test results in a row and no abnormal tests in the past 10 years.
women who were previously tx for CIN2 or CIN3 or cancer, should have annual screening for 20 years post-treatment.
|T/F: annual gynecologic exams may still be appropriate even if cervical cytology is not performed at each visit.||true.|
|T/F: women who have been immunized against HPV 16 and 18 don't need screening as frequently for cervical cancer.|| FALSE.|
follow same regimen as non immunized women.
|is there routine screening for uterine cancer?||no.|
|T/F: ANY post-menopausal female with vaginal bleeding should be evaluated to rule out cancer.|| YES!|
refer to Ob-Gyn for further eval and treatment even if you get labs, U/A, and do pelvic exam.
|What does the USPSTF recommend for ovarian cancer screening?|| Recommends AGAINST routine screening. Grade D.|
(including: U/S, pelvic exam, CA-125)
|68% of women with ovarian cancer are older than:||55|
|what reduces risk of ovarian cancer?|| breast feeding.|
|what does the USPSTF recommend for colorectal cancer screening in those 50 to 75 yo?||screening for CRC using FOBT, flex sig, or colonoscopy. GRADE A|
|Once patients are 76 to 85 years old, how does the USPSTF guideline changes regarding colorectal cancer screening?|| recommends AGAINST at this age.|
consider individual patient.
(somehow grade C)
|in patients > 85 years old, the USPSTF recommends what for colorectal cancer screening?|| recommends against.|
|(USPSTF) what is the opinion on use of CT Scan and fecal DNA test for screening of colorectal cancer?|| they don't know.|
insufficient evidence. Grade I
|> 80% of colorectal cancer arises from:|| adenomatous polyps.|
most polyps don't progress to cancer.
>90% CRC occurs in those > 50 yo.
|Can the FOBT differentiate between blood from colon or stomach?||No. If FOBT is positive, a colonoscopy is needed for locate source of bleeding.|
|T/F: a FOBT done during DRE in the dr.'s office is sufficient for colorectal cancer screening.|| FALSE.|
if this test is + for blood, colonoscopy should be done to determine cause of bleeding.
|what test is similar to FOBT, but is more specific and reduces number of false positives?|| Fecal immunochemical test.|
vitamins or foods don't affect this test.
|what do you do if polyps are found on flex sig?|| pt must have colonoscopy to look for polyps or cancer in the rest of the colon.|
tests are uncomfortable, but should not be painful.
|what test for colorectal cancer allows you to see entire colon's lining?|| colonoscopy.|
safely remove polyps with electrical current.
bx can also be taken.
|what procedure produces the BEST pictures of the lining of the colon?|| Barium Enema with air contrast.|
(also called) Double Contrast Barium Enema
|what test is "more accurate than the barium enema"?|| virtual colonoscopy|
not quite as good for finding small polyps.
this test is quick, no sedation, cheaper than colonoscopy.
CURRENTLY NOT INCLUDED AMONG TESTS RECOMMENDED BY AMERICAN CANCER SOCIETY
|ACS says that beginning at age 50, men and women who are at "avg risk" for colorectal cancer should have one of what 5 screening options?|| 1. FOBT or FIT every year, or...|
2. Flex sig every 5 years, or...
3. FOBT or FIT every year + flex sig every 5 years, or...
4. double contrast barium enema every 5 years, or...
5. colonoscopy every 10 years
|what is the significance of Nonfamilial Adenomatous Polyposis?||adenocarcinoma of colon appears to start as adenomas.|
|what is the "easiest" test you can do to detect small amounts of blood in the stool?|| FOBT.|
the MOST ACCURATE method of administering this test is the "Three Day" test.
|what is the "best means" for detecting polyps of the colon/intestines?||colonoscopy|
|Once you find and remove polyps from a pt, when should you repeat "surveillance" colonoscopy?|| recommended in 3 years to look for missed polyps or new adenomas.|
neg at 3 years? increase to 5 years before next test.
|what is familial adenomatous polyposis?|| development of 100s to 1,000s of adenomas in colon as young as age 10.|
colon cancer basically inevitable by age 50 unless prophylactic colectomy is performed.
|what can you use the Amsterdam Criteria for?||to Diagnose HNPCC.|
|If someone has HNPCC, when should you start screening for cancer?|| Begin colon cancer screen at 21.|
colonoscopy every 1 to 2 years.
uterine/endometrial cancer at 25 - 35.
trans vag U/S, EMB, CA-125
send for genetic testing/counseling.
|should those at "avg risk" for colorectal cancer use ASA or NSAIDs to prevent colon cancer?|| No. USPSTF recommends against (Grade D)|
NOTE: this doesn't apply to individuals with FAP, HNPCC, or hx of CRC.
|does the USPSTF believe in screening for lung cancer detection?||Grade I. They don't know. Insufficient evidence to recommend for or against possible lung ca. screening with low dose CT or CXR, sputum cytology.|
|according to USPSTF, should patients be screened for oral cancer?||Grade I. They don't know. Insufficient evidence to recommend for or against.|
|what screening tools can be used for oral cancer?|| oral examination ONLY.|
(rating I - insufficient evidence)
downside: by the time visual changes are apparent, the cancer is quite advanced. quick spread to the lymph nodes of the neck.
|most common tumors of the pancreas are:|| EXORCINE.|
Giant Cell Carcinoma.
|what are most important environmental factors in favor of developing pancreatic cancer?|| smoking (2 to 3x more common in smokers).|
obesity (directly related to caloric intake).
|what are forms of "chronic pancreatitis"?|| cystic fibrosis.|
|So... does the USPSTF recommend screening for pancreatic cancer?|| No. GRADE D. they recommend against this.|
(possible tests include: abd palpation, U/S, serologic markers).
|Should you screen for prostate cancer in men < 75 yo?||They don't know. Grade I. insufficient evidence to assess balance of benefits and harm of prostate cancer screening in men < 75.|
|Should you screen for prostate cancer in men > 75?||NO. GRADE D. recommended against.|
|who is at higher risk for prostate ca?|| older men.|
african american men.
men with FHx of prostate cancer.
|what test is MORE sensitive than the DRE for prostate?|| PSA test.|
look at past year's doubling time.
discuss controversies with pts before offering prostate screening.
|what does the ACS recommend about prostate cancer screening?|| make an informed decision.|
research has not proven that benefits of testing > harms of testing and treatment.
men shouldn't be tested w/o learning about what we know about risks/benefits of testing.
|starting at age ____ talk to your pts about pros/cons of testing to determine whether you should do prostate ca screening.|| start at age 50.|
Consider offering screening at 45 if:
father or brother had prostate ca before 65 yo.
|should patients get screened for skin cancer with whole body skin examination?||they don't know. there is "insufficient evidence". grade I.|
|what kind of skin cancer causes more than 75% all skin cancer deaths?||malignant melanoma.|
|what is the most common form of skin cancer?|| basal cell carcinoma.|
(pearly with telangectasias).
|what kind of cancer has a greater potential to metastasize?||Squamous Cell Cancer|
|using sunscreen prevents what kind of cancer?|| SCC. (probably best to use sunscreens that protect against UV-A and UV-B. UV-B causes sunburn)|
uses for melanoma prevention are controversial. those who use sunscreen alone might increase risk for melanoma b/c they spend more time in the sun.
|T/F: studies indicate that intermittent or intense sun exposure is a greater risk factor for melanoma than chronic exposure.|| true.|
preventing sunburns in kids might reduce lifetime risk for melanoma.
avoid mid-day sun.
|what are potential harms of "counseling patients" on use of sunscreen?|| can lead to false sense of security.|
might lead to more time spent in the sun.
kids using higher SPF stayed outside longer.
|should we counsel our patients about ways to prevent skin cancer (USPSTF)?||they don't know. grade I - insufficient evidence|
|should we screen for testicular cancer (USPSTF)?||no. recommended against (grade D).|
|testicular cancer is the MC cancer in who?||men between ages 20 and 34|
|what blood tests are for tumor markers for testicular cancer?|| AFP.|
|should you biopsy suspected testicular cancer for diagnosis?|| NO. Do NOT biopsy.|
do a scrotal U/S.
|what does the ACS say about "cancer related check up"?|| people 20 years or older should receive health counseling and possible exams for:|
cancer of thyroid, oral cavity, skin, lymph notes, testes, ovaries, etc.
THE USPSTF CANNOT GO TO COURT WITH YOU!
|what kind of screening should men receive for abdominal aortic aneurysm if they have a + hx for smoking?|| Men 65 to 75 should get one time screening for AAA by U/S.|
recommended, Grade B
|What kind of screening should men receive for AAA if they do NOT have a hx of smoking?||Men 65 to 75 who have NOT smoked do not receive a recommendation for USPSTF about screening. Grade C|
|Should women receive screening for AAA?|| No. not routine and not recommended.|
|explain screening for AAA:|| U/S is 95% sensitive and nearly 100% specific.|
greater than or = to 5.5 cm is surgical candidate.
4.0 - 5.4 cm = periodic surveillance.
|what is the recommendation from the USPSTF on taking ASA for prevention of CV disease in men 45 to 79 yo?|| RECOMMENDS. GRADE A.|
benefit due to a reduction in myocardial infarctions.
outweighs the potential harm of increase in gastrointestinal hemorrhage.
|what is the recommendation from the USPSTF on taking ASA for prevention of CV disease in women age 55 to 79?|| RECOMMENDS. GRADE A.|
potential benefit of reduction in ischemic stroke.
outweighs potential harm of increase in GI hemorrhage.
|should men and women older than 80 use ASA for prevention of CVD?||not enough info to balance risks and benefits. Class I.|
|should women younger than 55 and men younger than 45 use ASA for stroke and MI prevention (USPSTF)?||recommends against. GRADE D.|
|what is important to remember about the ASA recommendations?|| they apply ONLY to patients without a hx of coronary heard dz or CVA.|
decisions for ASA therapy should consider overall risk for stroke and GI bleeds.
|what is the optimum dose of ASA for preventing CAD?|| optimum dose unknown.|
75 mg/d is reasonable.
|should patients get screened for carotid artery stenosis (USPSTF)?|| NO. CLASS D recommends against.|
Note: recommendation is for screening only; not applicable to those who are having neuro sxs of a stroke or TIA!!
|screening methods for carotid artery stenosis include:|| Duplex U/S.|
Digital Subtraction Angiography.
screening could lead to non-indicated surgeries resulting in harm.
|should patients be screened with spirometry for COPD? (USPSTF)|| No. Not recommended. Class D.|
Note: this does NOT apply to people w/ respiratory sxs.
|should adults with low risk for coronary heart disease (CHD) be screened?||No. Grade D. recommended AGAINST by USPSTF.|
|should adults with increased risk for CHD be screened (USPSTF)?||they don't know. grade I insufficient evidence.|
|who are the "low risk" pts for CHD?|| men < 50 and women < 60 with no risk factors for CHD.|
adults or young adults with 1 or more risk factors are considered HIGH risk patients.
|what are some screening tests used for CHD?|| EKG.|
EET (exercise treadmill test).
EBCT (electron-beam CT).
|how could screening for CHD potentially reduce risks in 2 ways?|| 1. detect people at HIGH risk for CHD events who could benefit from more risk factor modification.|
2. detecting people w/ existing coronary artery stenosis whose life could be prolonged by CABG.
evidence for this stuff is inadequate to determine actual benefit.
|USPSTF recommends screening for HTN in what patients?|| in adults 18 and older.|
GRADE A. Strongly recommends.
|when can HTN offically be diagnosed?|| 2 or more elevated readings.|
at least 2 visits.
period of 1 to several weeks.
|what is the most common primary dx in america?||HTN|
|when does the JNC recommend screening for HTN?|| no optimal interval to screen.|
screen every 2 years for those with SPB and DBP below 130/85 mmHg
more frequent screens for those with BP at higher levels.
|most pts with HTN need 2 or more antiHTN agents to achieve goal bp. what is the goal?||< 140/90|
|what is the screening recommendation for lipid disorders in women > 45 who are at increased risk for CHD?||USPSTF STRONGLY recommends screening. GRADE A.|
|what is the screening recommendation for lipid disorders in women 20 to 35 yo if they are at increased risk for CHD? (same for men)|| USPSTF recommends.|
|what is the recommendation for screening of lipid d/o in young men and all women who are not at risk for lipid d/o?||no recommendation.|
|what is the recommendation for screening men for lipid d/o aged 35 and older if they are not at risk?|| screen 35 and older.|
|what are some screening tests for lipid disorders?|| total cholesterol.|
Calculated LDL (Total chol - HDL - TG/5)
|what does the USPSTF recommend for screening for peripheral artery disease (PAD)?|| recommends against.|
|what is a screening test is used for PAD?|| ankle brachial index.|
ABI < 0.90 is 95% sensitive & specific for PAD.
|who should receive screening for asymptomatic bactiuria (USPSTF)?|| Pregnant Women with urine culture at 12 to 16 weeks gestation GRADE A.|
Never in men or nonpregnant women. GRADE D. recommends against.
|when should non-pregnant women be screened for chlamydia? (USPSTF)|| GRADE A strongly recommended screening for ALL sexually active non-pregnant women aged 24 and younger.|
plus in older women at increased risk.
|when should pregnant women be screened for chlamydia? (USPSTF).|| GRADE B. recommends screening for ALL pregnant women age 24 and younger.|
plus in older women who are at increased risk.
|should women older than 25 be screened for chlamydia?|| probably not. Class B.|
USPSTF recommends against routine screening in women 25 or older (even if pregnant) if there is not an increased risk.
|should men be screened for chlamydia? (USPSTF).|| they don't know. GRADE I.|
|what is the most common reportable disease in the U.S.?|| chlamydia.|
may be asx.
Tx: azithromycin 1g PO 1 time, or Doxy 100 mg po BID x 7 days
|should pregnant women be screened for genital herpes? (USPSTF)||no. GRADE D for asymptomatic women.|
|should asymptomatic adolescents and adults be screened for genital herpes? (USPSTF).||no. GRADE D. recommended against.|
|what are some reasons we don't test for herpes?|| crossover from HSV1 and 2.|
pt may be serologically positive and never express dz.
by adulthood, up to 90% of US population has abs to HSV1.
|should you screen for gonorrhea in sexually active women (USPSTF)?|| Yes. CLASS B.|
screen all sexually active women, AND those who are pregnant for gonorrhea if they are at increased risk for infection
|screen for gonorrhea in men? (USPSTF)|| not sure. Class I|
insufficient evidence to recommend for or against routine screening.
|screen for gonorrhea in pregnant women who are NOT at an increased risk for infection? (USPSTF)|| insufficient evidence to recommend.|
|The USPSTF strongly recommends prophylactic topical meds for all newborns against:|| gonococcal opthalmia neonatorum.|
|when are pregnant women screened for gonorrhea?|| FIRST PRENATAL VISIT.|
vaginal culture is accurate.
Tx: Rocephin or FQ.
tx for chlamydia too.
|should pregnant women be screened for Hep B (USPSTF)?|| YES.|
strongly recommended at first prenatal visit.
|should "regular" (non pregnant) women be screened for Hep B?||NO. Class D. no routine screening for the general asx population for chronic HBV infection.|
|screen for Hep C in adults? (USPSTF)|| No. Grade D.|
recommends against in those who are asx and are not at increased risk.
|what does the USPSTF recommend for HIV screening for those "at risk"?||GRADE A strongly recommends screening for HIV all adolescents and adults at risk.|
|screen low risk people for HIV (USPSTF)?|| no recommendation for or against.|
|T/F: USPSTF recommends that all pregnant women should be screened for HIV.||YES. Grade A.|
|what does the USPSTF recommend for STI prevention?|| GRADE B recommendation of high intensity behavioral counseling to prevent STIs for ALL sexually active adolescents.|
and for adults at increased risk for STIs.
|should non sexually active adolescents and adults not at increased risk receive counseling for STI prevention? (USPSTF).|| GRADE I.|
insufficient evidence to support either way.
|USPSTF recommends what regarding syphilis screening for those at increased risk?||STRONGLY recommends screening. GRADE A.|
|USPSTF recommends what regarding syphilis screening in those who are asx and NOT at risk?|| recommends against.|
|Should pregnant women be tested for syphilis? (USPSTF)|| YES. Grade A|
screen all pregnant women for syphilis infection.
|USPSTF recommendation for screening of parents/guardians for physical abuse/neglect of children, of women for intimate partner violence, older adults/caregivers for elder abuse.|| Grade I.|
|T/F: though several instruments to screen parents have been studied, ability to predict child abuse or neglect is limited.|| true.|
but, home visit programs have shown good outcomes.
|what are some screening tools used to intimate partner violence?|| HITS (Hurt, Insulted, Threatened, Screamed at instrument).|
Partner Abuse Interview/
WEB Scale (Women's Experience with Battering Scale).
good internal consistency, but no validation in outcomes.
|what are screening tools used to evaluate older adult abuse?|| CASE (Caregiver Abuse Screen)|
HSEAST (Hwalek-Sengstock Elder Abuse Screening Test)
(haven't been tested in clinical setting)
|All 50 states have passed some form of a mandatory child abuse/neglect reporting under the:||Child Abuse Prevention and Treatment Act (CAPTA)|
|USPSTF recommendation of seat belts:|| GRADE I|
found that it was insufficient to assess incremental benefit (beyond legislation and community based intervention) counseling in primary care regarding motor vehicle occupant restraints (aka seat belts, child safety belts, lap/shoulder belts)
|USPSTF recommendation of driving under the influence of alcohol or riding with others who are alcohol impaired?|| Grade I.|
|what does FL's law say about child restraints?||All children under the age of 18 must be buckled up while riding in any car, pickup truck, or van on Florida's roads, no matter where they are sitting in the vehicle.|
|children through age of 3 must sit in:||federally approved child restraint seat|
|children who are 4 or 5:||secured by federally approved child restraint seat or safety belt.|
|define "alcohol misuse"||risky, hazardous and harmful drinking that places individuals at risk for future problems.|
|define "risky & hazardous drinking"|| 7+ drinks/week or 3+ drinks/occasion for women.|
14+ drinks/week or 4+ drinks/occasion for men.
|what is "harmful drinking"?||when one experiences physical, social, psychological harm from alcohol but does NOT meet criteria for dependence.|
|what is considered "moderate drinking"?|| less than or equal to 2 drinks/day for men.|
less than or equal to 1 drink/day for women.
may decrease coronary heart disease in middle aged to older adults.
|should you tell a pregnant woman and adults not to "misuse" alcohol in the primary care setting (USPSTF)?|| GRADE B recommends.|
YES, do screening and behavior counseling interventions.
|should you advise adolescents not to misuse alcohol in the primary care setting?||apparently there is insufficient evidence GRADE I to support use of screening and behavioral interventions.|
|what is the MOST STUDIED screening tool used to detect alcohol related problems?|| Alcohol Use Disorders Identification Test (AUDIT).|
detects alcohol misuse, abuse, dependence.
can be used alone or in combo w/ broader health risk or lifestyle assessments.
score of 20 or more suggests dependence.
|what is the MOST POPULAR screening tool used for alcohol consumption?|| CAGE questionnaire.|
C = cut down
A = annoyed by criticism
G = guilty
E = eye opener in the morning
|what questionnaire is used to screen adolescents for misuse of alcohol?|| CRAFFT questionnaire.|
C = car with someone impaired.
R = used alcohol to relax
A = use when ALONE
F = forget things you did
F = family or friends tell you to stop
T = ever gotten into TROUBLE.
|what screening test for alcohol misuse is used for pregnant women?|| TWEAK and T-ACE|
both detect lower levels of alcohol consumption that may cause risks in pregnancy.
|what are the "5 As" of behavioral counseling framework?|| 1. Assess|
3. agree on goals
4. assist with support/skills/tools
5. arrange for follow up, tx, etc.
|what are the "5 Rs" for behavioral counseling?|| Relevance|
(can use for tobacco use)
|screen adults for depression if you are equipped to help them?|| YES. Grade B|
make sure you can assure accurate dx, effective tx, follow up
|screen adults for depression if you are NOT equipped to help them?|| Grade C. Not really recommended.|
there may be considerations that support screening for depression in an individual patient.
|should you screen adolescents, pregnant women, adults for illicit drug use? (USPSTF)||they don't know. GRADE I|
|what is the most commonly used illicit drug in the US?|| marijuana.|
(cocaine is the 2nd MC used)
|T/F: standardized questionnaires have been shown to be valid and reliable in screening adolescent and adult patients for drug use/misuse.|| TRUE.|
But this is too much trouble to incorporate these into our busy schedules.
|should primary care providers screen for suicide risk in the general population routinely?|| USPSTF says there is insufficient evidence.|
|T/F: most depressed patients (99.9%) do not commit suicide.||true.|
|T/F: Deliberate Self Harm (DSH) is synonymous with attempted suicide.|| FALSE.|
those with borderline personality disorder (BPD) are at increased risk.
|what does the american academy of peds recommend about talking to kids about depression, substance abuse, suicidial thoughts?||recommends asking about these things.|
|should you ask patients about tobacco use (USPSTF)?|| YES. GRADE A|
recommended that clinicians ask ALL adults about tobacco use.
provide tobacco cessation interventions.
|should you ask pregnant women about tobacco use?|| YES. GRADE A|
ask pregnant women about tobacco use.
provide augmented, pregnancy-tailored counseling for those who smoke.
|T/F: brief tobacco cessation interventions have proven to increase abstinence rates.|| true.|
counseling (< 3 minutes).
|what are the 5As of Tobacco?|| ASK about tobacco use.|
ADVISE to quit.
|what pharmacotherapy can be used to stop smoking?|| nicotine replacement: gum, patches, inhaler, nasal spray.|
|should you promote a healthy diet to unselected patients in the primary care setting?|| USPSTF doesn't know.|
Grade I for insufficient evidence to recommend for or against routine behavioral counseling re: healthy diet.
|who SHOULD you counsel for behavioral dietary counseling? (USPSTF)|| GRADE B recommended.|
adult patients with HYPERLIPIDEMIA.
other known risks for CV disease & diet related chronic disease.
|effective dietary interventions combine what two things?||nutrition education + behaviorally oriented counseling.|
|what are the "5 As" of behavioral counseling framework?|| ASSESS dietary practices.|
ADVISE to change diet practices.
AGREE on individual goals.
ASSIST to change.
ARRANGE follow up, nutritional counseling.
|what is "medium intensity" dietary counseling?|| 2-3 to a group or individual sessions.|
Delivered by a dietician, nutritionist or specially trained primary care physician or nurse practitioner.
|what is "lower intensity" dietary counseling?|| 5 minutes or less of primary care provider counseling.|
patient SELF HELP materials.
|the largest effect of dietary counseling was observed with who?|| MORE INTENSIVE INTERVENTIONS.|
last 30 minutes or longer in asx patients, pts with HTN or hyperlipidemia.
prompts, reminders, counseling algorithms SIGNIFICANTLY improve counseling.
|how can you calculate the number of calories you need daily?|| multiply body weight (lbs) by 15 (if active) or 12 (if inactive).|
if overweight or obese, multiply ideal body weight.
Example: weight 150 lbs and are inactive.
150 lbs x 12 = 1800 calories/day
|should you do routine genetic screening for hereditary hemochromatosis in the asx general population?||NO. GRADE D according to USPSTF.|
|when can one expect the onset of sxs for hemochromatosis?|| occurs earlier in males.|
rarely recognized before 5th decade.
eventually pt develops hepatic, pancreatic, cardiac insufficiency & hypogonadism.
appears in women 10 to 20 years postmenopausal.
|what iron-loving organisms are patients with hemochromatosis at risk for?|| vibrio.|
|hemochromatosis lab findings:|| abnormal LFTs like AST and alk phos.|
elevated plasma iron.
greater than 50% saturation of transferrin.
elevated serum ferritin.
|what is the tx for hemochromatosis?|| weekly phlebotomies of 500 mL blood (about 250 mg iron) x 2 to 3 years to achieve depletion of iron stores.|
monitor by hematocrit & serum iron determinations.
when iron store depletion is achieved, maintenance phlebotomies every 2 to 4 mos are continued.
diet low in iron rich foods also beneficial.
|T/F: with proper tx, you can prevent cirrhosis in pts with hemochromatosis.||yes.|
|should you combine estrogen & progestin for chronic condition prevention in post menopausal women? (USPSTF)||NO. GRADE D. recommends against.|
|Should you use unopposed estrogen for prevention of chronic conditions in postmenopausal women who have had a hysterectomy? (USPSTF)||NO. GRADE D. recommends against.|
|menopause leads to decreased levels of estrogen and progestin. what are the effects of this?||decreased hormone levels increase bone loss.|
|hormone therapy is used for tx of:|| menopausal sxs.|
decreased risk of colon cancer.
prevention of memory or thinking problems.
|"combination therapy" with estrogen & progestin for hormone replacement:|| for use in women with their uterus.|
estrogen only leads to an increased chance of uterine cancer.
|estrogen only therapy uses.|| can be used in women who have had a hysterectomy.|
(no risk for uterine cancer.)
|what "good things" are associated with hormone replacement?|| decreased risk of osteoporosis related fractures.|
combination HT decreases colorectal cancer risk.
symptom control for improved quality of life.
|what "bad things" are associated with hormone replacement?|| no decrease in risk for heart disease.|
combination HT INCREASES risk for heart disease.
increased risk for blood clots & stroke.
combination increases risk for gallbladder probs.
(uncertain effects on breast cancer, ovarian cancer, and overall survival)
|In 2002, the USPSTF recommended against hormone replacement therapy...||there was insufficient info to make a recommendation for estrogen replacement alone.|
|should you screen babies 6 to 12 mos old for iron deficiency anemia? (USPSTF_||probably don't screen. GRADE I insufficient data to recommend for or against.|
|should pregnant women be screened for iron deficiency anemia?|| GRADE B.|
USPSTF recommends routine screening for iron deficiency anemia in asx pregnant women.
|should asx children age 6 to 12 mos who are at increased risk for iron deficiency take iron supplements?|| USPSTF says YES. they do recommend supplementation. GRADE B.|
NOTE: No recommendation for babies who aren't at risk (Grade I).
No recommendation for pregnant women who are not anemic for iron supplementation (grade I).
|should you screen patients for obesity? (USPSTF).|| YES. GRADE B.|
you should screen ALL pts for obesity & offer intensive counseling & behavioral interventions to promote sustained weight loss for obese adults.
|should you use moderate to low intensity counseling w/ behavioral interventions to promote sustained weight loss in obese adults?||GRADE I USPSTF says insufficient evidence to recommend for or against the counseling and behavioral interventions.|
|should you use counseling and behavioral interventions to promote sustained weight loss in overweight adults?|| GRADE I.|
insufficient evidence to recommend for or against the use of couseling of any intensity.
|what are pharmacology interventions for obesity?|| Orlistat & Phentermine.|
Gastric Bypass for Class III obesity or Class II with other obesity related illness.
|should you recommend behavioral counseling in the primary care setting to promote physical activity?||GRADE I. no sufficient evidence to recommend for or against.|
|what are some interventions to promote physical activity in primary care?|| patient goal setting.|
written exercise prescription.
tailored physical activity regimens.
mail/telephone/email follow up.
|what are potential harms of physical activity counseling?|| not well studied.|
muscle & fall related injuries.
|should adults receive routine thyroid screening?||USPSTF says there is insufficient evidence to decide. GRADE I|
|high risk patients for thyroid disease:|| elderly.|
|the USPSTF recommends screening for Type 2 Diabetes in what patients?|| GRADE B|
asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mmHg
benefits and harms of screening are unknown. those with lower BP than 135/70 have "insufficient evidence" to support screening. GRADE I.
|75% of T2DM present with...|| polyuria/nocturia.|
unexplained weight loss.
|when should you screen for T2DM?|| every pt is different.|
depends if pt is at risk.
depends if pt will benefit for routine screening.
USE CLINICAL JUDGMENT TO DETERMINE IF SCREENING IS NECESSARY FOR INDIVIDUAL PATIENTS.
|what "risk factors" in a pt might suggest a screen for T2DM?|| BP > 135/80 (USPSTF recommendation).|
History of Gestational Diabetes (GDM) .
Family History of Type II Diabetes Mellitus.
Age over 40 years.
if the pt is at risk for heart disease, screen for diabetes.
|what are the cholesterol goals for pt with T2DM or Cardiovascular Disease?|| LDL < 100 (< 70 with CVD or metabolic syndrome)|
TGs < 150
HDL > 40
|what three tests are used for Type 2 DM?|| fasting plasma glucose (FPG).|
2 hour post load plasma glucose (2-hour PG-GTT)
|the American Diabetes Associated (ADA) recommends HbgA1C test for screening. What is the diagnostic level?|| > 6.5% is diagnostic of diabetes.|
optimal screening interval is not known.
ADA recommends screening every 3 years. Those at high risk should have shorter screening intervals
|should you use interventions to prevent low back pain in adults in the primary care setting?|| GRADE I|
insufficient evidence to recommend for or against.
|T/F: exercise does not prevent low back pain.|| true.|
exercise has other benefits, though.
|T/F: lumbar supports and back belts reduce the incidence of low back pain.||FALSE.|
|T/F: educational interventions at jobsites have long term benefits in reducing low back pain.|| FALSE.|
they have short term benefits.
|T/F: back schools may prevent further injuries for those with current or chronic low back pain.|| true.|
what is a back school?
|when should women be screened routinely for osteoporosis?|| women aged 65 and older.|
(begin screening at age 60 for those with increased risk for osteoporotic fx). GRADE B
|what is the osteoporosis screening recommendation for women who are postmenopausal but younger than 60, or those who are 60 to 64 w/o risk of osteoporosis?|| Grade C.|
no recommendation for or against...
|T/F: osteoporosis is a part of "normal" aging.||true.|
|what is the single best predictor of low bone mineral density in osteoporosis?||lower body weight, less than 70 kg.|
|how much bone loss do women lose in the first 5 to 7 years post menopause?||can lose up to 20% bone mass|
|what is the best predictor of hip fx?|| DEXA scan.|
(comparable to forearm measurements for predicting fractures at other sites).
|what does "peripheral bone density" measure?||identifies post menopausal women who have higher risk for fx over 1 year|
|how does hormone therapy relate to osteoporosis?|| estrogen + progestin is shown to reduce incidence of fractures.|
estrogen alone in those who have had a hysterectomy reduces fracture risk.
|what is tx for osteoporosis?|| bisphosphonates. decrease bone loss.|
Didrocal (combination therapy).
SERM - Evista. reduces the risk of vertebral fractures and works like estrogen agonist at some sites and antagonist at other sites.
|should you screen pregnant women for bacterial vaginosis if they are at low risk for pre term delivery?||NO. GRADE D recommended against to screen if they are NOT at risk for pre term delivery.|
|should you screen women for bacterial vaginosis if they are high risk for preterm delivery?|| Grade I|
USPSTF says that it is insufficient to assess the balance of benefits and harms of screening in women at high risk.
|who is at risk for preterm delivery?|| african american race or ethnicity.|
BMI < 20
previous preterm delivery.
short (< 2.5 cm) cervix.
|how do you diagnose bacterial vaginosis?|| Amsel Clinical Criteria:|
vaginal pH > 4.7
thin homogenous discharge
amine "fishy odor" with KOH.
or gram stain.
|should you encourage breast feeding?|| YES. GRADE B by USPSTF.|
before and after birth, support and promote breast feeding.
(remember "B for Breast")
|what is a contraindication to breastfeeding?||HIV!|
|should you test for gestational diabetes?|| evidence is insufficient (GRADE I) to recommend for or against routine screening for gestational diabetes.|
(discuss w/ pregnant patients and make decision on a case by case basis).
|what test is most commonly used to diagnose gestational diabetes?|| an initial 50-gram 1 hour glucose challenge test.|
abnormal? pt undergoes 100 gram 3 hour oral GTT.
two or more abnormal values on OGTT are diagnostic of GDM
|what is tx of gestational diabetes?|| diet and exercise.|
DIET & INSULIN.
NO ORAL AGENTS!!
Somtimes meds (insulin).
nearly ALL pregnant patients should be encouraged to achieve moderate weight gain based on their pre pregnancy BMI
|should you screen for Rh(D) incompatibility?|| YES. GRADE A.|
USPSTF recommends blood typing and ab testing for all pregnant women during their FIRST VISIT for pregnancy care.
|should you test a second time during pregnancy for Rh (D) antibody?|| Recommended GRADE B|
The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation.
(unless the biological father is known to be Rh (D)-negative)
|what do you give to all unsensitized Rh negative women after repeated antibody testing at 24 to 28 weeks gestation?|| administration of a full (300 ug) dose Rh immunoglobulin is recommended.|
given after amniocentesis and after induce, spontaneous, or threatened abortion.
|if an Rh positive infant is delivered, what should be repeated within 72 hrs post partum?||Rh immunoglobulin|
|should you screen adults for glaucoma?|| GRADE I|
insufficient evidence to recommend for or against screening adults for glaucoma.
|T/F: Recent evidence overwhelmingly rejects a causal relation between the measles-mumps-rubella vaccine and autism.|| TRUE.|
TELL YOUR FRIENDS!
|can males receive gardasil?|| YES.|
now approved for males aged 9 to 26 to prevent condyloma acuminata.
|the rest of this lecture 7 is the immunization schedule.|| Butler didn't seem to care about it.|