MedU 2: 55-year-old male annual exam - Mr. Reynolds

The most frequent causes of death for a 55-year-old male in the US:

1 Heart disease: 611,105 2 Cancer: 584,881 3 Chronic lower respiratory diseases: 149,205 4 Accidents (unintentional injuries): 130,557 5 Stroke (cerebrovascular diseases): 128,978 6 Alzheimer's disease: 84,767 7 Diabetes: 75,578 8 Influenza and Pneumonia: 56,979 9 Nephritis, nephrotic syndrome, and nephrosis: 47,112 10 Intentional self-harm (suicide): 41,149 malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis

Based on what you know so far, Mr. Reynolds dietary habits appear poor. What are three ways to gather a more complete nutrition history?

Gathering a Complete Nutrition History Dietary choices can affect a patient's risk for coronary heart disease, diabetes, some cancers, and stroke. Thus, nutrition assessment is a critical aspect of the preventive routine exam. There are many ways to gather a nutrition history. A brief history should include the number of meals and snacks eaten in a 24-hour period; dining-out habits; as well as frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy products, and desserts. Nutrients missing in the diet are equally important as those eaten in excess. When this initial history indicates a poor diet or there are medical indications for a more complete diet history, use of one or more of the following methods is indicated. 24-hour Dietary Recalls: Ask about each meal separately. Be sure to include snacks and beverages as well as portion sizes. WAVE is a pocket card tool designed to encourage dialogue about the patient's "Weight, Activity, Variety and Excess". Based on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of servings from the Food Guide Pyramid (Variety) and whether he or she is eating too much fat, salt, sugar, and calories (Excess) recommended in the Dietary Guidelines for Americans. The card also lists counseling tips to aid the practitioner in setting dietary goals with the patient. Food Frequency Questionnaire: Usually covers food intake over the period of a month. Often used in combination with the 24-hour recall, it is the quickest way to determine nutritional deficiencies and excesses. Rapid Eating and Activity assessment for Patients (REAP) is a brief validated questionnaire that assesses diet related to the Food Guide Pyramid and the 2000 U.S. Dietary Guidelines. REAP includes questions to assess intake of whole grains, calcium-rich foods, fruits and vegetables, fat, saturated fat and cholesterol, sugary beverages and foods, sodium, alcoholic beverages and physical activity. REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and how willing the patient is to make changes to eat healthier. Patients can either fill out the instrument in the waiting room or have it sent home to complete before their appointment. The REAP Physician Key includes sections on patients at risk, further evaluation and treatment as well as counseling points/further information for each major dietary area. Daily Dietary Intake Records (or Food Diaries): Ask the patient to bring in a complete record of everything consumed over a 3-4 day period. Have the patient include Saturday and Sunday, since many people eat differently on the weekend. Usual Diet History: Ask the patient to describe a typical day's diet. In addition, ask how often and under what circumstances the patient varies from this typical intake. This method is often combined with a 24-hour dietary recall. Observed Intake: Patients are directly observed eating known food quantities. Performed primarily in research settings. Weighed Intakes: This is the most accurate method of assessing dietary intake. All food and drink are weighed before intake. It requires a highly motivated patient. Referral to a nutritionist or dietician may also be indicated, especially if covered by medical insurance. Patients may complete a sample nutrition history form in the waiting room prior to the visit.

Management of CHD Risk

An ASCVD risk of 17.4% places Mr. Reynolds at high risk for an ASCVD event in the next ten years. 1. Appropriate steps are to start Mr. Reynolds on aspirin (A) and 2. begin a moderate-to high-intensity statin (B). 3. An exercise stress test can be considered to further evaluate for the presence of coronary atherosclerosis in a high risk man, particularly if he were planning to begin a vigorous exercise program. If he had symptoms of coronary artery disease, further evaluation with stress testing would be indicated. HS CRP (C) is a minor risk factor for ASCVD, which might be helpful if there was clinical uncertainty after assessing risk using the Pooled Cohort Equations. - Similarly, EBCT (D) may help stratify those at intermediate risk. Mr. Reynolds is already at high risk and warrants aggressive therapy to lower his lipids, so HS CRP or EBCT results would not change his management. USPSTF review in 2007 gave a D recommendation for carotid ultrasound in asymptomatic individuals (E). USPSTF review in 2005 gave a B recommendation for one-time abdominal ultrasound of the aorta (F) in males aged 65-75 who have smoked. Mr. Reynolds is only in his 50s, so it is not recommended now for Mr. Reynolds.

United States Preventive Services Task Force Screening Recommendations for a 55-year-old asymptomatic man who smokes "A" or "B" screening recommendations include: The USPSTF grades each recommendation according to one of five classifications: A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is substantial. B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is fair or fair certainty that the net benefit is moderate - substantial. C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved - net benefit is small. However there may be occasions that warrant provision of this service in a patient. D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits or harms outweigh benefits. I: There is insufficient evidence to recommend for or against the service.

Colorectal cancer Obesity Diabetes mellitus Lipid disorders Tobacco use Lung cancer screening (A) Lung cancer screening is only recommended under certain circumstances... annual screening for lung cancer with low-dose computed tomography is recommended in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. In this case, Mr. Reynolds has a <30 pack-year smoking history, so lung cancer screening is not recommended at this time. Hypertension (B) Alcohol misuse (E) Hepatitis C (F) Screen for hepatitis C virus (HCV) infection in persons at high risk for infection. Offer one-time screening for HCV infection to adults born between 1945 and 1965. Depression (G) Note: One of the USPSTF depression screening recommendations is Grade B, another is Grade C. Grade B: Screen adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Grade C: Do not routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. Screen for depression with two questions: Over the past 2 weeks, have you ever felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? "D" (not recommended) screening recommendations include: Bacteriuria, bladder cancer, pancreatic cancer (C), testicular cancer (D), spirometry for COPD, genital herpes, gonorrhea, hemochromatosis, and hepatitis B. Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important to consider other factors, including family history, travel history, sexual history, etc. Men at increased risk for sexually transmitted infections should be screened for HIV, syphilis, chlamydia, and gonorrhea. Consider hepatitis B and C screening as well. Genital herpes testing should only be performed on symptomatic individuals. The CDC now recommends routine HIV testing for all adults after the patient is notified the testing will be performed, unless the patient declines. Some states still require informed consent before HIV testing. Those at high risk for HIV infection should be screened annually, at least. "I" screening recommendations include: Prevention of motor vehicle injuries with seatbelt use and avoiding driving under the influence of alcohol; family and intimate partner violence screening; illicit drug use; and skin cancer screening. Depending upon the patient population, additional screening receiving an "I" recommendation are: screening for glaucoma; lung cancer screening (A); oral cancer screening; and thyroid disease screening.

Approach to ECG Interpretation and Exercise Stress Test

Examine rate, PR interval, QRS, duration, and QT interval. Look for abnormalities in P waves. Assess axis, R wave progression, presence of Q waves, and level of voltage. Look for ST depression or elevation and inverted T waves. Mr. Reynolds' ECG: Normal rate, PR interval, QRS duration, and QT interval. Normal sinus rhythm. No P wave abnormalities. Axis is +30. Good R wave progression in the precordial leads. No Q waves. Voltage is not abnormally high. No ST depression or elevation, and no inverted T waves. A resting ECG can provide useful information in Mr. Reynolds because of his risk factors for coronary artery disease. We also do not know how long he may have had an elevated blood pressure. Evidence of left ventricular hypertrophy (LVH) may appear, although the ECG is not a very sensitive test for LVH. In addition, if he shows up in our emergency department with chest pain, they can call up this ECG on the electronic medical record for a baseline comparison." Because of his age and cardiac risk factors, an exercise treadmill test should be considered Asymptomatic male patients over 45 years of age with one or more risk factors (hypercholesterolemia, hypertension, smoking, or family history of premature coronary artery disease) may obtain useful prognostic information from exercise testing.

Domestic Violence

Incidence: The reported frequency of domestic violence varies. It is particularly common among women and the elderly, but occurs at all ages and men can be victims too. Screening: Routinely asking about domestic violence significantly increases its detection. It is essential to address this topic when alone with the patient and to assure the patient of confidentiality. A valuable screening tool is the SAFE series of questions: Stress/safety: "Do you feel safe in your relationship?" Afraid/Abused: "Have you ever been in a relationship where you were threatened, hurt, or afraid?" Friends/Family: "Are your friends or family aware that you have been hurt? Could you tell them and would they be able to give you support?" Emergency Plan: "Do you have a safe place to go and the resources you need in an emergency?"

Family History

Reasons to gather a family history: Identify disease risks for conditions that occur more frequently within a particular family. Identify relationships among individuals within the family. http://www.jfponline.com/Pages.asp?AID=2462 Method for gathering a family history - genogram: Constructing a genogram is a simple method for gathering relevant family history. The CDC has a section on their web site with programs enabling individuals to generate a genogram depicting disease risk in their family.

RISE mnemonic for preventive visits 55 year old man; general physical exam

Risk factors - Identify risk factors for serious medical conditions during history and physical exam. Immunizations - Provide recommended immunizations / chemoprophylaxis. Screening tests - Order appropriate screening tests. Education - Educate patients on ways to live healthier while reducing risks for disease.

Colon Cancer Screening Options

Screening colonoscopy every 10 years Annual testing of three stools for blood and a flexible sigmoidoscopy test every 5 years Double-contrast enemas every five years CT colography (virtual colonoscopy) is still considered experimental A rectal exam and test for occult blood are not adequate screening.

A 55-year-old white male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? Single Choice Answer: A Symmetry B Borders C Color D Diameter E Location

Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is >6mm which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma.

Risk Factors for CVD and ASCVD Many risk factors have been independently associated with cardiovascular disease (CVD) including:

sedentary lifestyle (A) stress (C) premature family history (E) excess alcohol use (H) and many more (e.g. obesity, poor diet, low selenium levels, high homocysteine levels, etc.).

ECG changes suggesting coronary artery disease:

1. Horizontal ST segment depression or downsloping ST segment (A) - Suggests cardiac ischemia 2. Convex ST segment elevation (D) - Suggests acute myocardial injury 3. Q waves (B) that are greater than 25% of succeeding R wave and greater than 0.04 seconds - Indicate infarction Other ECG changes: 1. U waves (C) abnormal when greater than 1.5 mm in any lead, and are associated with: - bradycardia, electrolyte imbalance such as 1. hypokalemia 2. hypercalcemia 3. hypomagnesemia 4. drug effect (digitalis, quinidine, procainamide), 5. CNS disease 6. hyperthyroidism 7. LVH/MVP 2. A short PR interval (E) is seen in arrhythmias such as: 1. Wolff-Parkinson-White 2. AV junctional rhythm with retrograde P wave conduction, or 3. Lown-Ganong-Levine

Risk Factors for CVD and ASCVD

Most of a person's risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a patient's risk category from that determined by the major risk factors. Of those listed above, only current smoking (B) is considered a major risk factor. But except for family history, they are all modifiable risk factors. American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD. For more required information about risk factors for ASCVD, read the MedU Cholesterol Guidelines Module. Travel history (D) is not a major risk factor for developing cardiac disease. Although a complete review of systems should always be asked, symptoms related to cardiovascular disease should definitely be included. Leg pain with activity (F) may indicate claudication, a manifestation of peripheral atherosclerotic disease. Chest pain with activity (G) may indicate angina pectoris, a manifestation of coronary artery atherosclerosis.

How effective are oral medications, such as bupropion (Wellbutrin, Zyban, Budeprion) or varenicline (Chantix), in helping smokers quit? Choose the one best answer. Multiple Choice Answer: Please select your answers. Please note that you will receive peer response results in addition to the Expert answers on this question. A Not effective (quit rate at 12 months no higher than placebo quit rate) B Somewhat effective (quit rate at 12 months 1.5-3 times the placebo quit rate) C Moderately effective (quit rate at 12 months 3-5 times the placebo quit rate) D Very effective (quit rate at 12 months 5-10 times the placebo quit rate)

Most smokers quit multiple times before being truly successful. It is helpful to view tobacco abuse as a chronic disease and continue to work with smokers who relapse. The annual quit rate for smokers without any medical interventions is about 2-3% per year. Interventions which improve quit rates: Quit rates are highest when patients are engaged in a group setting. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 - 3 times the placebo quit rate (B). When combined with medication, a series of one-on-one counseling sessions (as in a physician's office), enhances quit rates. Providing practical problem-solving skills, assistance with social supports, and use of relaxation/breathing techniques can increase quit rates. Choosing medication to assist with smoking cessation: Many physicians prefer prescribing bupropion to help smokers quit. Due to side effects, varenicline is often reserved for those that have failed bupropion or if a patient specifically requests it.

"Do you wear a seat belt when you are in a car?" "I wear it on long drives. Why do you ask?"

You respond: "Motor vehicle crashes are one of the common causes of death at your age. I don't want to preach to you, but restraints can save your life. Remember, you can be the best driver in the world and still get hit by a bad driver. Most accidents occur within 25 miles of home, so I recommend that you wear your seatbelt whenever you are in a car."

A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? Single Choice Answer: A Underweight B Ideal C Overweight D Obese E Morbidly (very severely) obese

Based on BMI measurements, Underweight is considered <18.5; Ideal: 18.5-25; Overweight 25 - 30; Obese 30 - 40; Morbidly (very severely) obese > 40.

A 55-year-old male with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35 pack year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" Which stage of change best describes this patient at this time? Single Choice Answer: A Precontemplation B Contemplation C Preparation D Action E Maintenance

Based on this man's response, it appears he has not actively considered quitting smoking despite his family's concern. All stems refer to a different stage in the Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses.

A 55-year-old male with a past medical history that includes hypertension, Chronic Obstructive Pulmonary Disease (COPD), and hyperlipidemia presents to clinic as a new patient for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently noncompliant with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient? Multiple Choice Answer: A Influenza , Meningococcal, and Zoster B Influenza, Pneumococcal, and Tda C Influenza and, Zoster, and Tda D Meningococcal, Pneumococcal, and Tda E Meningococcal, Pneumococcal, and Zoster

Because this man has a diagnosis of COPD and smokes cigarettes, both annual Influenza and Pneumococcal vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time TdaP is recommended. - At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. - Zoster vaccine is recommended to all adults at age 60 or older.

Billing for prevention visits

Billing for prevention visits is different from billing for problem-based visits. There is a separate set of codes that are based on patient age and whether the patient is new to the practice or not. Note that since Mr. Reynolds has not been seen for four years (>36 months), he is considered a new patient. A preventive visit should include: • a comprehensive history and physical examination • anticipatory guidance, and risk factor reduction interventions or counseling • ordering of appropriate immunizations or laboratory / diagnostic procedures • management of any insignificant problems Specific procedures or immunizations performed during the office visit should be billed separately. Minor problems or simple medication refills, not requiring significant additional work, are included in the preventive medicine codes. If a specific significant problem is additionally addressed during the preventive visit, requiring additional time and effort, then an additional office visit code may be added, with a -25 modifier. Adequate distinct (usually separate) documentation of the problem addressed, is required. However, some private insurances do not recognize -25 modifiers and do not pay for the extra care rendered. Some insurances, including Medicare, do not generally pay for adult preventive visits. If the patient has no diagnosis or symptom to use for coding the visit, it will be denied for payment. Medicare does pays for one initial "welcome exam" when a patient turns age 65. If preventive counseling and/or risk factor reduction is provided during an office visit for a specific problem, there are separate billing codes available if a significant portion of the visit is used for this counseling. But again, not all insurances reimburse for these codes. You examine the billing form that Dr. Nayar completes for this visit. CPT Code: 99386 (new patient age 40-64) Additional codes: Digital rectal exam (G0102 or V76.44); Tdap immunization (90715); ECG with interpretation (93000) Diagnoses: routine general medical exam (V70.0); elevated blood pressure (796.2); obesity (278.00)

Physical exam findings:

Blood pressure - 164/96 in both arms. Eyes; fundi; ears; oral cavity; neck, including thyroid nodes, listening for a carotid bruit; heart and lungs; abdomen; back; and extremities, including pulses. Skin searched for suspicious-looking lesions. No abnormalities found. After completing the physical exam, you step out of the room and present Mr. Reynolds' history to Dr. Nayar, including the fact that you provided some smoking cessation counseling. You note Mr. Reynolds' significant family history of hypertension and stroke. And you inform Dr. Nayer that you did not notice any abnormalities on physical exam other than obesity and elevated blood pressure.

Medications available to help patients quit smoking Small, short-term studies comparing varenicline with bupropion show varenicline at least as effective and probably slightly more effective.

Bupropion (Wellbutrin, Zyban, Budeprion) Mechanism: Norepinephrine and dopamine reuptake inhibitor. Use: It is started a week before the quit smoking date. The dose is titrated up and maintained for 2-3 months. It may be used in conjunction with nicotine replacement methods, especially those that can be titrated during the day. Adverse effects: Bupropion has been associated with an increase in suicide in adolescents and young adults. Contraindications: It should not be used in patients with seizures and with caution in those with significant renal or hepatic impairment. Varenicline (Chantix) Mechanism: Nicotine receptor blocker. Use: Started a week before the quit date, titrated up, and maintained for 2-3 months. Should NOT be used with nicotine replacement. Adverse effects: Associated with an increase in suicide. The dose should be lowered for those with renal insufficiency. Nausea, the most common side effect, may be lessened by taking it with food. Nicotine replacement Comes in multiple delivery forms. Available without prescription: Gum, patch, and lozenge Require prescription: transdermal patch, inhaler, nasal spray, and sublingual tablet These treatments are generally indicated for tobacco users who require daily use and have some nicotine addiction. All are to be started after the last use of tobacco on the quit date. The patch comes in different strengths, which are gradually decreased over weeks. The other methods require the user to self-titrate the dose, gradually decreasing their use until they are able to stop. Although not FDA approved for heavier smokers (>1 pack per day), the patch may be combined with a short acting form of nicotine replacement for additional relief of urges and cravings.

What is his BMI (body mass index) and what does this mean? Your answer: its your height over your weight, allows you to know if youre in proportion/if youre weight is appropriate for your height. Expert answer: 31.6 kg/m2 (height 1.78 m; weight 100kg) A BMI over 30 categorizes Mr. Reynolds as obese.

Calculating the BMI and Understanding Its Importance BMI = weight in kg / height in m2 Category BMI (kg/m2) Underweight below 18.5 Normal 18.5 - 24.9 Overweight 25.0 - 29.9 Obese 30.0 and above Some subcategorize obesity into obese 30-35; very obese 35-40; and extremely or morbidly obese 40+. Incidence: The population of overweight and obese patients has increased steadily over the past 20 years. In the United States, the lifetime risk of becoming obese is 25%. Use: BMI is used clinically because actual measurement of percent body fat is difficult. Importance: BMI is important because high total body fat is a risk factor for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. Other measurements: Body fat distribution may provide additional risk stratification for coronary artery disease beyond BMI. Waist circumference and waist-hip ratio, as indicators of abdominal adiposity, are independent risk factors for coronary artery disease. Consider measuring these in overweight patients to further determine risk and need for weight loss. Mr. Reynolds is at risk for metabolic syndrome, characterized by abdominal obesity, dyslipidemia, hypertension, and insulin resistance with or without impaired glucose tolerance.

You know that smoking is a serious health risk requiring further discussion. Addressing Tobacco Use: Three Cs of Addiction: The Five A's of Counseling for Behavior Change: Stages of Behavior Change:

Compulsion to use lack of Control Continued use despite adverse consequences Ask or Address the behavior needing change. Assess for interest in behavior change. Advise on methods to change behavior. Assist with motivation to change behavior. Arrange for follow-up. Pre-contemplative - Not aware of need to change or not interested in changing behavior. Contemplative - Currently interested in changing behavior. Active - Currently making a behavior change. Relapse - Attempted behavior change but no longer making the change.

Characteristics of a Good Screening Test 1. disease that's amendable to screening is: - prevalent - morbid and mortal - detectable preclinical phase of the right length detecting something for which there is some form of treatment * leading us to to be able to demonstrate that screening plus treatment is effective at reducing mortality from the disease 2. applied to populations of asymptomatic patients in order to identify those with a RF for a disease or an early case of the disease - they are best applied to important common disease with a detectable preclinical phase of the right length. 3. while it is a muddy process best way to show a screen test is beneficial is to conduct a large randomized controlled trial

Medical screening should be considered for conditions that are important health problems which: 1. can be treated (A) and 2. have a latent phase of a disease (B) enabling early detection and more timely treatment, impacting the outcome of the disease. 3. The screening test should be acceptable to patients (D) 4. at reasonable cost (E). 5. prevalent 6. high morbidity and mortality - randomized control + follow up - loss of f/u (attrition) + crossover - harder to show a difference in disease specific mortality btwn two study arms. Since patients without symptoms are being screened, the overall prevalence of the condition in the population will be low. The goal is to identify cases at an early stage; thus, an effective screening test should have: 1. very good sensitivity (identify most or all potential cases) and 2. high specificity (label incorrectly as few as possible as potential cases). Remember that even a test with a specificity of 95% will lead to many false positives when the prevalence of the condition is very low. Sensitivity is the proportion of patients with disease who test positive. False Negative rate among those with disease = (1-Sensitivity). Specificity is the proportion of patients without disease who test negative. False Positive rate among those without disease = (1-Specificity). Sample 2X2 table. Test sensitivity is 98%. Test specificity is 95%. Prevalence of disease is 1 in 100. 10,000 people are screened with the test. Disease No disease Test + 98 492 Test - 2 9408 The positive predictive value (PPV) is 98/(98+492) = 16.6%. Even though the screening test has a sensitivity of 98%, a patient with a positive test result in this low prevalence population has only a 16.6% chance of having the disease. Some commonly used screening tests have poorer test characteristics than this example. For example, PSA for prostate cancer screening has the following test characteristics, depending upon the cutoff for a positive test: Cut-off 3.1 ng/mL; sensitivity 32.2% and specificity 86.7% Cut-off 1.1 ng/mL; sensitivity 83.4% and specificity 38.9%

Guidelines on Diabetes Screening

Guideline recommendations vary even for a topic such as screening for diabetes mellitus in adults. No study is perfect. In the area of prevention, large randomized trials, which provide the best evidence are often not available. Two organizations with evidence-based recommendations on this topic are the USPSTF and the American Diabetes Association (ADA). USPSTF Re-review of diabetes mellitus screening in 2008 1. concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. 2. They gave a B recommendation to screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. ADA Guidelines for screening 2014 in recommend: 1. that asymptomatic adults without risk factors should begin screening at age 45. 2. Testing should be considered in younger adults who are overweight or obese (BMI > 25 kg/m2) and have one or more of the following risk factors for diabetes: 1. Physical inactivity 2. First-degree relative with diabetes 3. Members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, and Pacific Islander) 4. Women who delivered a baby weighing 9 lb or were diagnosed with gestational diabetes mellitus 5. Hypertension (140/90 mmHg or on therapy for hypertension) 6. HDL cholesterol level 35 mg/dl (0.90 mmol/l) and/or a triglyceride level 250 mg/dl (2.82 mmol/l) 7. Women with polycystic ovarian syndrome (PCOS) 8. Hemoglobin A1C ≥ 5.7%, Impaired glucose tolerance or impaired fasting glucose on previous testing 9. Other clinical conditions associated with insulin resistance (e.g., severe obesity or acanthosis nigricans) 10. History of cardiovascular disease For Mr. Reynolds, who is above age 45 and has an elevated blood pressure, following either guideline would leads to a recommendation for screening for diabetes mellitus. But there are clearly other patients where these guidelines lead to divergent recommendations. In those cases, use patient preference along with an overall assessment of individual risk to decide whether screening is warranted.

Managing "door handle" issues

Here is how Dr. Nayar handles it: Dr. Nayar responds to Mr. Reynolds' Viagra request matter of factly, "Are you having problems attaining erections?" Mr. Reynolds answers, "Sometimes they are not as hard as they used to be." Dr. Nayar replies, "I am glad you mentioned this and very sorry we do not have any time right now to talk about it more. I will make a note of your concern, and we will be sure to address it when you come back for follow-up." Answer comment: Patients often bring up a question or issue at the end of a visit that can take more than a minute to discuss. There are conflicting priorities: service to this patient versus keeping on schedule as much as possible for the remaining patients on the schedule. Sometimes the "door handle" issue is more important than the original reason for visit. A quick assessment of whether the issue is life-threatening or requires an early return visit should be made. Usually the patient will understand if the issue is not completely dealt with at that visit but can be discussed at a future visit. It is not always possible to avoid this situation, but allowing the patient to state an agenda at the start of the interview has been shown to correlate with fewer late concerns. Studies of clinicians show that the average patient is allowed to talk uninterrupted by the physician for only 18-23 seconds.

Other vaccine recommendations

Medical indications for pneumococcal vaccine in adults younger than age 65 years include: 1. Lungs: chronic pulmonary disease (including COPD, emphysema and asthma); 2. Heart: chronic cardiovascular disease; 3. diabetes mellitus; 4. Liver: chronic liver disease, including liver cirrhosis; alcoholism; 5. Kidney: chronic renal failure, nephrotic syndrome; 6. Spleen: functional or anatomic asplenia (including sickle cell disease, and other hemoglobinopathies, congenital or acquired asplenia, splenectomy or splenic dysfunction); immunosuppressive conditions (e.g. congenital immunodefiency, HIV - vaccinate as close to dx as possible); cerebrospinal fluid (CSF) leak; or cochlear implants. Other indications include: All adults aged 65 years and older, all smokers; and residents of nursing homes and other long-term care facilities. The pneumonia vaccine may also be recommended by public health authorities to American Indian/Alaskan Natives who live in areas where there is a high risk for invasive pneumococcal disease. High-risk indications for Hepatitis A vaccine: chronic liver disease; persons receiving clotting-factor concentrates; men who have sex with men, persons who use injection or non-injection illicit drugs;; and travel to a country with endemic hepatitis A. High-risk indications for Hepatitis B vaccine: end-stage renal disease, including dialysis patients; persons seeking evaluation or treatment for a STD; HIV; chronic liver disease; persons receiving clotting-factor concentrates; workers with potential exposure to blood or body fluids; staff of institutions for the developmentally disabled; men who have sex with men; persons who use illegal drugs; and travel to a country with endemic hepatitis B. Hepatitis B vaccine is also now recommended for all diabetics aged 60 years and younger with recommendations to vaccinate as soon as possible after diagnosis. Diabetics who are aged 60 years and older may be given the hepatitis B vaccine at the discretion of the treating physician based factors such as the frequency of glucose monitoring in long term care facilities, and likelihood of acquiring hepatitis B infection. High-risk indications for MMR vaccine: recently exposed to measles or in outbreak setting; previously vaccinated with a killed measles vaccine; work in a health care facility; student in post-secondary school; or those who plan international travel. For international travelers, the CDC website for travel immunizations can provide a wealth of information: http://wwwn.cdc.gov/travel/contentVaccinations.aspx

Weight Loss

Obese individuals often are insensitive to the degree of their obesity and ideal body weight. Obese individuals also tend to have poorer ability to recognize normal portion sizes and underestimate the amount of food they are eating. Referral to a dietician for individual, family, or group counseling can be very helpful for obese patients to get additional help for weight loss and healthier eating patterns. - Bariatric surgery programs are an option for those who are unable to lose weight, - especially if they have other significant co-morbid conditions such as diabetes or heart disease. Some of the most popular lay diets are: 1. low-carbohydrate, high-protein, high-fat diet (Atkins) 2. high-carbohydrate, low-fat diet (Pritikin) 3. high in fruits, vegetables, whole grains, nuts, beans, seeds, and monosaturated fats (Mediterranean diet) 4. high-protein, low-carbohydrate, fat-controlled diet (South Beach, Zone, ...) 5. high-fiber, low-fat, vegetarian diet (Ornish) 6. grapefruit or raw food diet (single food or food group) 7. pre-packaged diet (Jenny Craig, NurtriSystems, Weight Watchers, ...) 8. very low calorie or fasting diet - Trials examining low-carbohydrate, low-fat, and Mediterranean diets have shown benefits from each. - Low carb diets can lower lipids significantly and Mediterranean diets can have favorable glycemic control. Individual patient preferences and metabolic considerations should be taken into account when providing diet advice. Vegetarian or vegan diets may work, but the majority of Americans cannot or will not stay on these diets. The other diets have little to no good scientific evidence of their safety or efficacy, but they enjoy considerable popularity. Single food or food group diets should be discouraged because essential nutrients may be omitted. Pre-packaged diets may be helpful for some for weight loss, but the extra cost for the foods endorsed by the plan may be significant. Extreme low calorie diets may be dangerous if the patient has underlying medical problems. A problem with most fad diets is that they are used for acute weight loss and long-term eating patterns are not changed. Orlistat (Xenical, Alli) is relatively safe, but has limited efficacy. The weight lost is often regained after stopping the medication. It is now available without prescription.

Pros and Cons of the "Annual Exam"

The "annual physical exam" is a tradition for many adults. National surveys show about 21% of the adult population get a preventive exam annually. Several studies have shown that patients are more likely to get recommended preventive services if the visit was designated for prevention rather than for another reason. A survey of over 700 primary care physicians showed that 65% agreed that an annual physical exam is necessary. While this is true, more than half of preventive services (e.g. ordering screening mammography or colonoscopy) are done at non-preventive care visits. No evidence-based guidelines recommend routine annual exams for all adults. Many patients expect auscultation of the heart and other components of physical exam as part of the periodic exam, even if not recommended by scientific evidence of benefit. Patients also expect "routine" laboratory tests. Physicians often meet these expectations, despite no evidence that they improve patient outcomes. For example, a screening urinalysis is done at 25% of preventive visits. In the absence of randomized trials demonstrating benefit of a yearly physical exam, many physicians recommend for younger healthy adults to have periodic exams, not necessarily yearly. People with multiple chronic medical conditions should schedule periodic visits specifically focused on prevention, rather than on the chronic conditions, especially when over age 50.

More About the Controversy Over Prostate Cancer Screening Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA based screening in average risk males results in little or no reduction in prostate cancer related deaths and is associated with harms related to tests, procedures and treatment of the condition, some of which may be unnecessary. Other organizations, such as the American Cancer Society (ACS) recommended that physicians should have a discussion of the potential benefits and harms of screening with a PSA test. The USPSTF recommends against PSA-based screening for prostate cancer. This recommendation applies to men in the general U.S. population, regardless of age. This recommendation does not include the use of the prostate-specific antigen (PSA) test for surveillance after diagnosis or treatment of prostate cancer; the use of the PSA test for this indication is outside the scope of the USPSTF. Other organizations recommend discussion about the risks and benefits of PSA screening, but it often does not occur. Many clinicians do not take the time to provide extensive individual counseling regarding PSA screening and decide for the patient whether to get the test or not. Until final results from on-going large randomized trials in the U.S. and Europe are available, it may be prudent to inform men that PSA screening may lead to unnecessary anxiety or unnecessary procedures from an elevated result. It is also possible that it may prevent a few men from dying from prostate cancer. Preliminary results from a European study suggest that to prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected and treated (many incurring significant side effects).

A 55-year-old male with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. Based on current US Preventive Services Task Force guidelines, which of the following is the most appropriate recommendation to give this man concerning screening for prostate cancer? Single Choice Answer: A PSA testing is recommended B Referral for prostate biopsy under ultrasound is an option C The benefits and risks of screening for prostate cancer are uncertain D Recommend against PSA screening E First, check a digital rectal examination

The US Preventive Services Task Force - at the time of printing, April 2014 - recommends against screening using PSA testing because the risks of harm of detecting and treating asymptomatic prostate cancer outweigh the known benefits. Digital rectal exam, prostate biopsy, and transrectal ultrasound are not recommended as screening tests either.

Benefit and Harm of PSA screening

The potential benefit of PSA screening is that it may lead to prolonged life from early detection and treatment of prostate cancer. In addition to the potential benefit of early detection of malignant prostate cancer, some men may receive psychological reassurance that they probably do not have prostate cancer or they have probably caught it early so it can be treated. A potential harm of PSA screening is serious complication (such as erectile dysfunction, urinary incontinence, bowel dysfunction) or even death from treatment of a prostate cancer that would not have caused symptoms if left undetected during his lifetime. Another potential harm is pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.

Effects of Alcohol

The effect of alcohol on health is complex. For some people, even mild alcohol use carries major risks. For others, moderate alcohol use may offer a degree of protection. At this time, there is no consensus about whether one form of alcohol is better or worse than another. Regardless of type of alcohol, drinkers should drink in moderation: up to 1 drink per day for women, up to 2 drinks per day for men. Effects of moderate alcohol intake: It is not clear at this point whether moderate alcohol drinking is beneficial to the heart. Recent research suggests moderate alcohol consumption (wine or beer) does offer some protection against heart disease. Alcohol can cause small increases in HDL cholesterol. Alcoholic beverages may contain other chemicals that act as anti-oxidants or inhibit platelet aggregation. These population studies are suggestive of a benefit, but there are no good intervention studies documenting clear benefit from drinking alcohol. Effects of red wine: Red wine contains more anti-oxidant polyphenols, in particular flavonoids and resveratrol, than white wine or other alcoholic beverages. These anti-oxidants have been associated with less heart disease and cancer in animal models. Effects with certain chronic diseases: Patients with heart failure, cardiomyopathy, diabetes, hypertension, arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol ingestion. It is not always possible to identify those who will develop alcoholism. The American Heart Association cautions people to NOT start drinking if they do not already drink alcohol.

Exercise Prescriptions: The American Academy of Family Physicians has a program called Americans in Motion-Healthy Interventions (AIM-HI)

Their website includes excellent links for resources to provide patients to encourage exercise and healthy eating. Generally, exercise prescriptions include the following specific recommendations: 1. Type of exercise or activity: Patient preference should guide the choice of type of exercise. - Swimming or water jogging is beneficial for those with musculoskeletal problems, such as arthritis. -Varying the activity can increase compliance by providing variety. - Precautions: Issues such as orthopedic concerns should be regarded. Specific workloads: E.g. watts, walking speed, etc. 2. Duration and frequency: Depends on the activity or exercise session. - For cardiovascular fitness, sessions should be 40 minutes three times a week. - For weight loss, patients should try to do 20-40 minutes every day. 3. Intensity guidelines: Target heart rate (THR) range and estimated rate of perceived exertion (RPE). - If you can talk and walk at the same time, you aren't working too hard. - Target heart rate calculation: THR = (220 - age) * 0.7-0.8 3. Perceived exertion: - There is a fairly good correlation between THR and perceived exertion, so after measuring for THR with exercise several times, patients can rely on perceived exertion to gauge their level of exercise. 4. Using the Borg perceived level of exertion scale, patients should exercise to a level of 12-14. 5. The U.S. Department of Health and Human Services Recommends - men participate in at least 150 minutes of moderate-intensity aerobic exercise per week, as well as muscle strengthening at least twice per week. Borg Scale 6 No exertion at all 7 Extremely light 8 9 Very light Easy walking slowly at a comfortable pace 10 11 Light 12 13 Somewhat hard It is quite an effort; you feel tired but can continue 14 15 Hard Heavy 16 17 Very hard Very strenuous, and you are fatigued 18 19 Extremely hard You cannot continue for long at this pace 20 Maximum exertion