pREVENTIVE MEDICINE

LEARNING OBJECTIVES :

KNOWLEDGE - Students should be able to define or describe

1. The concepts of primary, secondary, and tertiary prevention.
2. The major criteria for determining whether or not a particular maneuver should be incorporated       into the periodic health assessment of adults.
3. Major areas of controversy in screening (i.e. PSA, mammography in 40's).  
4. The concepts of sensitivity, specificity, negative and positive predictive value
5. Common adult vaccines with their indications, efficacy, and intervals of administration - (Influenza, Pneumococcus, Rubella, Tetanus and Diphtheria, Varicella, Hepatitis B).
6. Cancer screening strategies by physical examination and lab testing - (Breast, Colon, Cervix, and Oral Exam in smokers).
7. The current recommendations for cholesterol, hypertension, and diabetes screening.
8. The major preventive services as they apply to large age groups - (16-40 years old, 40-65 years old, 65 years and over).
9. The balance of benefit and harm of aspirin prophylaxis for the primary prevention of MI in men ages 50-80.

SKILLS - Students should be able to:

1. Take an accurate history and provide counseling for common adult problems - (alcohol and drug use, injury and violence prevention, nutrition, physical activity, STD's and unintended pregnancy, and smoking/tobacco use).
2. Locate recently published recommendations concerning preventive services.
3. Identify patients with risk factors for coronary artery disease and cancer.

ATTITUDES AND PROFESSIONAL BEHAVIORS - Students should:

1. Appreciate the role of primary care physicians in the longitudinal role of health promotion and disease prevention.
2. Address preventive health care issues as a routine part of patient assessment.
3. Encourage and council patients to participate fully in disease prevention.       

RECOMMENDED READINGS :

1. Report of the U.S. Preventive Services Task Force.   Guide to Clinical Preventive Services ,  
   Updated 2000 –2004 (3 rd edition) version can be viewed online at http://www.ahrq.gov/clinic/prevnew.htm
   
2. Lauer M. S., Aspirin for Prevention of Coronary Events.   N Engl J Med 2002; 346:1468-1474, May 9, 2002.

ADULT VACCINATION RECOMMENDATIONS

1. INFLUENZA
   
   Influenza has caused in excess of twenty thousand deaths in each of 10 different epidemics from 1972 to 1991.   Inactivated influenza vaccine contains antigens for influenza A and B viruses.   The vaccine has been shown to prevent or reduce severity of influenza in 70-80% of healthy children and adults under age 65.   In one case control study, influenza vaccine prevented 31-45% of hospitalizations for pneumonia and influenza and 43-45% of deaths due to all respiratory conditions.
   
   RECOMMENDATION: Influenza vaccine should be given annually to all persons aged 50 or older; residents of chronic care facilities; and persons with cardiopulmonary disease, diabetes, renal failure, immunosuppression, or hemoglobinopathies.   Additionally, the AAP recommends that children between the age of 2 months and 6 years of age receive the vaccine.   Lastly, the CDC has recommended that the vaccine be given to anyone who asks for it.
   
   
2. PNEUMOCOCCAL DISEASE
   
   Pneumococcal disease accounts for 15% of severe community acquired pneumonia and a case fatality rate of 9-26%.   Elderly carry a 30-43% case fatality rates.   The current vaccine is a 23 valent polysaccharide injection.  
   
   RECOMMENDATION: Pneumococcal vaccine should be given every 5-6 years in persons 65 and over; residents of chronic care facilities; and persons with cardiopulmonary disease, diabetes, renal failure, asplenia, alcoholism, cirrhosis, cancer, immunosuppression, multiple myeloma, or sickle cell disease.
   
   
3. TETANUS AND DIPHTHERIA
   
   As a result of routine immunization, tetanus an diphtheria are uncommon now in the U.S.   Adults over age 50 account for the majority of cases of tetanus.   Persons over 70 have a case fatality rate of 26%.   Diphtheria is a potentially severe illness with a 5-10% case fatality rate.
   
   RECOMMENDATION: A Td booster should be given every 10 years.   Td should also be administered after a dirty would if a booster has not been given within 5 years
   
   
4. RUBELLA
   
   Rubella is a mild adult illness that can cause miscarriage, stillbirth, and congenital rubella syndrome when contracted by pregnant women.   The vaccine is 95% effective at conferring lifetime immunity.   It is a live vaccine that should not be given to pregnant women.   Women should be advised not to become pregnant prior to 3 months after the vaccine is administered.
   
   RECOMMENDATION: All women of childbearing age should be revaccinated OR have serology confirming immunity in adulthood.   Childhood vaccination alone is not an acceptable strategy for adult women of childbearing age.
   
   
5. HEPATITIS B
   
   An estimated 200,000 - 300,000 persons contract hepatitis B Virus (HBV) each year with 10,000 hospitalizations.   The risk of chronic HPV is 6-10% after acute infection.   Cirrhosis and hepatocellular cancer from HPV causes 5,000 deaths each year.   The completed hepatitis B vaccination series is 85-95% protective in immunocompetent individuals.
   
   RECOMMENDATION: All infants and previously unvaccinated children/ adolescents are actively being vaccination before adulthood.   All high risk adults (IV drug use, male homosexuals, multiple sex partners, health care workers) should be vaccinated.   All other adults who have not been vaccinated should be individually assessed and counseled about the potential benefits of this vaccine.   In adults HiB vaccine is given at 0, 1, and 6 months.
   
   
6. VARICELLA
   
   Varicella is a common childhood disease which carries a higher morbidity in adults and pregnant women.   Studies with children and adolescents have shown an 86-98% efficacy.   All children and previously unvaccinated adolescents are now actively being vaccinated before adulthood.   Adults have a poorer immune response and 2 doses are required for optimal seroconversion.
   
   RECOMMENDATION: Two doses of varicella vaccine given 4-8 weeks apart are recommended for healthy adults with no history of varicella or vaccination.  

**Recommendations taken primarily from the U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 1996.

Updated 2002 version can be viewed online at http://www.ahrq.gov/clinic/prevnew.htm and                                                          http://odphp.osophs.dhhs.gov/pubs/guidecps

CANCER SCREENING RECOMMENDATIONS

1. CERVICAL CANCER
   
   Roughly 16,000 new cases are diagnosed each year, and about 4,800 patients die annually from cervical cancer.   The 5 year survival of advanced cervical cancer (Stage IV) is 14%, making early detection and treatment essential.   In one major report of over 1.8 million women, the cumulative incidence of invasive cervical cancer was reduced 91% by performing regular Pap tests on 3 year intervals.   The use of an endocervical brush and “Thin Prep” smears increase the utility of the screening maneuver.
   
   RECOMMENDATION: Regular Pap tests are recommended for all women who are or have been sexually active and have a cervix.   Testing should begin when the woman first engages in sexual activity.   Low risk women should receive testing every 3 years after 2 negative exams.
   
   High risk women (early onset of intercourse, multiple partners, history of STD's, unprotected intercourse) with no previous abnormal tests should be tested annually.   Regular testing after age 65 may not be necessary for low risk women with previous normal smears.
   
   
2. COLON CANCER
   
   Colorectal cancer is the second most common form of cancer.   It accounts for approximately 140,000 new cases and 55,000 deaths each year.   Five year survival is 60% with regional spread and 6% with distant metastases.   A digital rectal exam (DRE) is of limited value because only 10% of colorectal cancer can be felt by an examining finger.   Fecal occult blood testing (FOBT) is best done with 3 separate stool specimens.   FOBT can reduce mortality by 31-57%.  
   
   RECOMMENDATION: Colon Cancer screening is recommended for all adults over age 50.   FOBT can be done on an annual basis.   Sigmoidoscopy can be done as an alternative to FOBT on a 3-5 year basis.   Many experts consider colonoscopy at 5-10 year intervals a superior screening test (vs. sigmoidoscopy & FOBT) with increased sensitivity, specificity, and cost effectiveness.   Nevertheless, colonoscopy has increased complication rates
   
   
3. BREAST CANCER
   
   In 1995 there were 182,000 new cases and 46,000 deaths from breast cancer.   Breast cancer is the leading cause of cancer death in women aged 15-54.   The sensitivity of mammography exceeds 75% for breast cancer and is generally 10-15% lower for women in the 40's.   For women over age 50, mammography lowers mortality 20-30%.
   
   RECOMMENDATION: Screening for breast cancer is recommended every year with mammography (+/- clinical breast exam) for women aged 50-69.   For women 40-49 there is disagreement between the various screening organizations as to when to offer mammography for women under 50.
   
   
4. SKIN CANCER
   
   Insufficient evidence to recommend for or against routine exam by physicians or patients.   Referral of high risk individuals (dysplastic nevi, family history of melanoma, severe childhood sunburns) may be made on other clinical grounds.
   
   
5. ORAL CANCER
   
   Insufficient evidence to recommend for or against.   Persons who use alcohol or tobacco are at increased risk.   Clinicians may wish to perform regular oral exams on high risk patients with lack if direct evidence.
   
   
6. TESTICULAR CANCER
   
   There is insufficient evidence to recommend for or against physician exam or patient self examination.   Patients with increased risk (cryptorchidism, atrophic testes) should be informed of their risk and screening options.  
   
   
7. PROSTATE CANCER
   
   Routine screening for prostate cancer with DRE, PSA, or transrectal ultrasound is not recommended by the U.S. Preventive Task Force.   If screening is to be performed, it should be limited to men with a life expectancy of 10 years or greater.   PSA screening of high risk individuals (family history, African-Americans) may be made on clinical grounds.

*Recommendations taken primarily from the Report of the U.S. Preventive Services Task   Force, Guide to Clinical Preventive Services,   1996

Updated 2002 version can be viewed online at http://www.ahrq.gov/clinic/prevnew.htm                                                  http://odphp.osophs.dhhs.gov/pubs/guidecps

DIABETES MELLITUS SCREENING