Preventive Care - MFBA

At what age does the American Heart Association recommend initiation of screening for hyperlipidemia to assess atherosclerotic cardiovascular disease risk? 20 25 30 35 45

Critique:

A 53-year-old male asks your advice about the use of supplements to prevent cancer and cardiovascular disease. Which of the following would you specifically recommend that he avoid? (Mark all that are true.) Vitamin A Vitamin C Vitamin E β-Carotene Multivitamins with folic acid

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

Risk factors for lung cancer other than tobacco use include which of the following? (Mark all that are true.) Exposure to secondhand smoke Radon exposure Asbestos exposure Elevated vitamin B6 levels Idiopathic pulmonary fibrosis

Critique: A personal smoking history is the most significant risk factor for the development of lung cancer. Established risk factors include secondhand smoke/passive smoke, a family history of lung cancer, COPD, radon exposure, asbestosis, and idiopathic pulmonary fibrosis. The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults age 55-80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. It also recommends screening be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (B recommendation). The European Prospective Investigation into Cancer and Nutrition (EPIC) trial found an inverse relationship between lung cancer risk and vitamin B6 levels, as well as serum methionine levels.

A 24-year-old pregnant female in her second trimester is concerned that she may contract influenza and endanger her baby's health. Her due date is in October and she plans to breastfeed.Which of the following would be an appropriate recommendation? (Mark all that are true.) She can safely receive trivalent inactivated influenza (TIV) vaccine prior to the upcoming influenza season She can safely receive live attenuated influenza vaccine (LAIV) prior to the upcoming influenza season If vaccine is not available prior to her delivery, she can safely receive LAIV vaccine while breastfeeding She can safely take oseltamivir (Tamiflu) for prophylaxis if she is exposed to influenza prior to delivery

Critique: ACOG, the AAFP, and the CDC recommend that all women who will be pregnant during influenza season receive influenza vaccine. The CDC recommends use of injectable influenza vaccines (including inactivated influenza vaccines and recombinant influenza vaccines). The nasal spray flu vaccine (live attenuated influenza vaccine or LAIV) is no longer used. Influenza vaccine is also recommended for women who are breastfeeding (SOR A). Current CDC guidelines recommend oseltamivir as the preferred treatment of pregnant women with suspected influenza.

Which one of the following has the least effect on reducing systolic blood pressure in an individual with hypertension? Reducing dietary sodium intake to 2400 mg/day or less Following the DASH diet, which is rich in fruits, vegetables, and low-fat dairy products Moderation of alcohol consumption to 2 drinks or less per day for men or 1 drink or less per day for women Losing 10 kg of body weight in an overweight patient Engaging in 30 minutes of aerobic physical activity on most days of the week

Critique: According to the 2017 hypertension guidelines from the American Heart Association and the American College of Cardiology, limiting daily alcohol intake to 1-2 drinks in men and 1 drink in women has the least impact on lowering systolic blood pressure (SBP) among nonpharmacologic interventions in hypertensive individuals, with an anticipated reduction of 4 mm Hg in SBP. Adoption of a DASH eating plan (a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat) represents the most effective dietary intervention for reducing SBP, with an approximate impact of -11 mg Hg. Weight loss is a core recommendation in overweight individuals, with an expected drop in SBP of about 1 mm Hg per kilogram of weight loss. Engaging in regular aerobic exercise 90-150 minutes per week is also an effective intervention, leading to expected reductions of 5-8 mm Hg in SBP. Reduction of dietary sodium intake by at least 1000 mg/day (with an optimal goal of <1500 mg/day) would be expected to reduce SBP by 5-6 mm Hg.

A 24-year-old female presents for a routine annual evaluation. She reports being in a monogamous relationship and having a total of two sexual partners, with first intercourse at age 19. She denies any previous personal history of sexually transmitted diseases. She has been with her current partner for 5 years. To her knowledge he has had a total of three sexual partners and no sexually transmitted diseases. She has had annual Papanicolaou (Pap) tests since age 20, and all have been normal. She currently uses only condoms intermittently for birth control, but expresses an interest in starting oral contraceptive pills. Which one of the following would be the most appropriate advice regarding HPV vaccine? It is not necessary because she is in a monogamous relationship It should be delayed because it is not currently recommended for women under age 26 She should receive the vaccine at this visit, with no additional doses She should receive the vaccine at this visit, a second dose in 1 week, and a third dose in 2 weeks She should receive the vaccine at this visit, a second dose in 1-2 months, and a third dose in 6 months

Critique: According to the CDC's Advisory Committee on Immunization Practices, HPV vaccination is recommended for all women <26 years of age, regardless of risk (SOR A). Ideally, the full vaccination series should be administered before potential exposure to HPV through sexual activity; however, women who are sexually active should still be vaccinated, including those with a history of genital warts, abnormal Papanicolaou (Pap) smears, or positive HPV DNA tests. If the first dose of vaccine is given before the patient's 15th birthday a two-dose schedule should be followed, with the second dose given 6-12 months after the first dose. A series of three doses is recommended if the vaccine is initiated on or after the patient's 15th birthday. The second dose should be administered 1-2 months after the first dose, and the third dose should be administered 6 months after the first dose. Compared with placebo, vaccination against HPV is more effective at reducing the incidence of persistent HPV infections at 6-30 months and is more effective for increasing HPV antibodies at 7-48 months.

True statements regarding seasonal influenza vaccine include which of the following? (Mark all that are true.) Providers should wait until October to begin immunizing Administration of the vaccine to healthy adults has been shown to decrease both work absenteeism and the use of health care resources Influenza vaccine has been shown to reduce the incidence of acute otitis media in some studies Healthy children age 6 months or over may be given any of the currently available influenza vaccines Inactivated influenza vaccine is considered safe for use in pregnancy

Critique: According to the Centers for Disease Control and Prevention guidelines, influenza vaccine should be administered as soon as it is available, and can be given throughout the entire influenza season. Emphasis should be placed on vaccinating individuals prior to the start of influenza activity in the community (SOR A). When the vaccine is closely matched to the antigenic strains circulating in the population, there are decreases in antibiotic use, hospitalization, absenteeism, and the use of health care resources in general (SOR B). A number of studies have shown that influenza vaccine significantly reduces the number of cases of acute otitis media in children, although the evidence is not conclusive (SOR B). The American Academy of Pediatrics recommends influenza vaccine as a preventive measure for otitis media. Injectable trivalent and quadrivalent vaccines have varying age indications, with some types not recommended for children below a certain age and some recommended only for those age 65 or older. Multiple studies have shown no adverse fetal effects from administration of the inactivated vaccine to the mother during pregnancy. The AAFP and ACOG both recommend immunization for influenza in pregnant women during influenza season. Pregnant women should not receive the live attenuated vaccine, however. Breastfeeding women should also be immunized, with either the trivalent inactivated or live attenuated influenza vaccine (SOR B).

A 17-year-old male comes to your office in August for a physical examination required for entering college. He reports smoking 1-2 cigarettes per day, and drinking 1-2 bottles of beer per week. He denies any history of illicit drug use. He says he has been sexually active with both men and women since age 16. His only international travel has been to Mexico last year, and he plans to go again for spring break next year. He has no history of medical or surgical problems, and does not take any routine medications. He completed the primary series of DTaP, polio, MMR, and varicella vaccines at the recommended ages. In addition, he received one dose each of Tdap, meningococcal vaccine, hepatitis B vaccine, and hepatitis A vaccine at age 13. His physical examination is normal. What immunizations should this patient receive today? (Mark all that are true.) DTaP Hepatitis A vaccine Hepatitis B vaccine Meningococcal vaccine HPV vaccine

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

The National Cholesterol Education Program's Adult Treatment Panel III (ATP III) identified which of the following as major coronary heart disease risk factors? (Mark all that are true.) Hypertension Cigarette smoking A family history of premature CHD Age >45 in men or >55 in women An HDL-cholesterol level <40 mg/dL An HDL-cholesterol level >60 mg/dL

Critique: According to the National Cholesterol Education Program's Adult Treatment Panel III (ATP III), the major coronary heart disease (CHD) risk factors that warrant modification of LDL-cholesterol goals include cigarette smoking, hypertension (blood pressure >140/90 mm Hg or on antihypertensive medication), low HDL-cholesterol (<40 mg/dL), a family history of premature CHD (CHD in a male first degree relative <55 years of age or female first degree relative <65 years of age), and age (men >45 years; women >55 years). HDL-cholesterol >60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count. ATP III also considers diabetes mellitus as a CHD risk equivalent. ATP III recommendations are based on expert consensus (SOR C).

According to the U.S. Preventive Services Task Force, which of the following women should be offered BRCA mutation genetic counseling, based on the information provided? (Mark all that are true.) An African-American female whose mother was diagnosed with breast cancer at age 70 and whose sister who was diagnosed with breast cancer at age 60, but with no other known family history of cancer A Native American female whose grandfather was diagnosed with breast cancer at age 56 An Ashkenazi Jewish female whose sister was diagnosed with breast cancer 2 years ago An Asian female whose mother had breast cancer and whose grandmother had ovarian cancer A Hispanic female whose sister was recently diagnosed with bilateral breast cancer

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

The recombinant herpes zoster vaccine (Shingrix) would be recommended for which of the following patients, based on the information provided? (Mark all that are true.) A 52-year-old female with diabetes mellitus, hypertension, and hyperlipidemia An 82-year-old male who received the attenuated live vaccine (Zostavax) 1 year ago A 69-year-old male with a previous episode of herpes zoster A 61-year-old male who had a negative test for immunity to varicella zoster virus An 83-year-old male who takes no regular medications and has no history of chickenpox

Critique: Advancing age and chronic illness are risk factors for herpes zoster and associated postherpetic neuralgia. Approximately 99.5% of the U.S. population age 40 and older has serologic evidence of previous varicella infection. Thus, all older adults are at risk for zoster, although many cannot recall any previous history of chickenpox. The CDC currently recommends that healthy adults age 50 and older get two doses of the recombinant herpes zoster vaccine, separated by 2-6 months, to prevent shingles and the complications from the disease. Although the CDC does not recommend serologic testing when vaccinating adults age 50 and older, if serologic evidence of varicella susceptibility is available to the health care provider, the CDC recommends that providers follow the guidelines for varicella vaccination recommended by the Advisory Committee on Immunization Practices (ACIP). Since the recombinant vaccine has not been evaluated in persons who are seronegative for varicella, it is not indicated for the prevention of varicella and thus should not be administered to patients who test negative for immunity to varicella zoster virus. Other contraindications to the recombinant vaccine include a severe allergic reaction to any component of the vaccine or after a dose of of the vaccine, a current diagnosis of shingles, and currently being pregnant or breastfeeding. A reported history of zoster does not preclude vaccination, as repeat episodes of zoster have been confirmed in immunocompetent persons (SOR C). The exact risk for and severity of zoster after a previous episode are unknown, but some experts believe it may be similar to those with no history of zoster. There is no laboratory test to confirm previous zoster infection, and reports of previous episodes may be erroneous. Although the safety and efficacy of zoster vaccine have not been assessed in persons with a history of zoster, additional safety concerns are not expected in this group. Since recombinant vaccine is not a live vaccine, it is not contraindicated in immunocompromised persons. However, it is not recommended by the ACIP at this time. The ACIP is expected to review the evidence for its use in immunocompromised persons and will modify vaccine policy as necessary. The CDC does express the opinion that the recombinant vaccine can be given to someone who is taking low-dose immunosuppressive medication, is anticipating immunosuppression, or has recovered from an immunocompromising illness.

True statements regarding screening for intimate partner (domestic) violence (IPV) include which of the following? (Mark all that are true.) Up to 3% of women and 2% of men report having experienced some form of IPV in their lifetime To be reliable, IPV screening instruments used in primary care settings should be administered by a clinician and consist of 10-15 questions The U.S. Preventive Services Task Force (USPSTF) recommends screening for IPV in all women of childbearing age The USPSTF recommends screening all elderly or vulnerable adults for abuse and neglect Risk factors for IPV include young age, substance abuse, marital difficulties, and economic hardship Patients of both sexes who have experienced IPV are at increased risk for depression

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

True statements regarding prostate cancer in the United States include which of the following? (Mark all that are true.) With the exception of skin cancer, it is the most commonly diagnosed cancer in men It is the leading cause of cancer deaths in men Autopsy studies have shown that one-third of men 40-60 years of age have histologic evidence of prostate cancer U.S. Preventive Services Task Force guidelines state that there is insufficient evidence to determine whether PSA screening tests improve health outcomes in men 50-75 years of age There is no evidence that PSA screening reduces prostate cancer mortality

Critique: Although lung cancer remains the leading cause of death from cancer in American men, prostate cancer ranks as the most commonly diagnosed cancer except for skin cancer, with a lifetime risk for diagnosis of 15.9%. Over 240,000 American men received a prostate cancer diagnosis in 2011 and an estimated 33,720 men died of the disease. Prostate cancer is, however, a heterogeneous disease, as evidenced by autopsy studies that have shown that one-third of men age 40-60 have histologic evidence of prostate cancer. Such findings suggest that many cases of prostate cancer do not ever become clinically evident, raising concerns about the potential for overdiagnosis, defined as when a condition is diagnosed that would not go on to cause symptoms or death if it had not been discovered. The Prostate, Lung, Colon, and Ovarian (PLCO) Cancer Screening Trial was a multi-center study based in the United States that randomized 76,693 men and found screening was associated with a 22% increase in prostate cancer diagnoses after 7 years of follow-up. No difference in prostate cancer mortality was demonstrated at 7 years and 10 years of follow-up but there was significant cross-contamination in the control group. On the other hand, the European Randomized Study of Screening for Prostate Cancer (ERSPC) found that PSA screening reduced the rate of prostate cancer death by 21% after a median follow-up of 11 years. Such a reduction translates into an absolute risk reduction of 1.1 deaths per 10,000 person-years. Although active treatment for prostate cancer detected by screening has been shown to reduce the risk for metastatic disease, both radical prostatectomy and radiation therapy are associated with a higher risk for erectile dysfunction and radical prostatectomy has been linked to a higher risk for urinary incontinence as well. In 2012 the USPSTF recommended against PSA screening for prostate cancer for all men in the general population regardless of age. In 2018 the USPSTF revised its position and now recommends that for men aged 55-69 the decision to undergo periodic PSA screening should be an individual one (USPSTF C recommendation). For men 70 years and older, the USPSTF continues to recommend against PSA screening for prostate cancer.

Over-the-counter medications considered safe during the entire course of pregnancy include which of the following? (Mark all that are true.) Aspirin Acetaminophen Ibuprofen Pseudoephedrine Chlorpheniramine Guaifenesin

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

A 70-year-old female comes to your office after a minor fall in her home and asks you for advice to prevent falls in the future. Interventions that have been shown to prevent falls in the elderly population include which of the following? (Mark all that are true.) Vitamin D supplementation Protein supplementation Supervised exercise Hip protectors Physical therapy

Critique: As our population ages, preventing falls is of increasing importance. Approximately 35%-40% of community-dwelling persons age 65 and older fall annually, with 5% of those who fall requiring hospitalization. In addition, it is estimated that up to 40% of nursing-home admissions are fall-related. In 2018 the U.S. Preventive Services Task Force (USPSTF) found sufficient evidence to recommend exercise interventions (supervised individual and group classes and physical therapy) to prevent falls in community-dwelling adults age 65 or older who are at increased risk for falls (USPSTF B recommendation). It also found evidence to recommend that clinicians selectively offer this population customized multifactorial interventions based on a comprehensive individualized fall risk assessment (USPSTF C recommendation). In its 2012 report the USPSTF found insufficient evidence for or against the use of the following interventions for preventing falls: medication discontinuation, protein supplementation, education or counseling, hip protectors, and home hazard modification. Although vitamin D supplementation was recommended in the past to prevent falls, in 2018 the USPSTF concluded that vitamin D supplementation not only offers no benefit in preventing falls in older adults but actually may result in a higher risk at very high dosages. As a result, the USPSTF now recommends against vitamin D supplementation to prevent falls in community-dwelling adults age 65 or older (USPSTF D recommendation). There is no evidence to support recommending hip protectors (SOR A) or the use of restraints to prevent falls in the elderly

True statements regarding dementia screening in patients over age 65 include which of the following? (Mark all that are true.) There is good evidence to support general screening of older primary care patients for dementia Dementia screening instruments have good sensitivity Dementia screening instruments have good specificity Pharmacologic treatment of dementia may decrease the rate of cognitive decline Pharmacologic treatment of dementia improves performance of instrumental activities of daily living (IADLs)

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

Prostate-specific antigen (PSA) testing has been shown to increase detection of early-stage prostate cancer. At this time, however, it is unclear whether earlier detection leads to a decrease in deaths from prostate cancer. This means that screened patients know they have the diagnosis for longer periods of time than they would if they were not screened, but may not actually live longer. This phenomenon is called confounding diagnosis bias lead-time bias length-time bias selection bias

Critique: Bias is a systematic error in study design or data analysis that threatens the validity of the results. Lead-time bias is the term for situations where a disease is diagnosed at an earlier stage, but the ultimate outcome is not affected (thus patients live longer with knowledge of the disease but do not actually attain a real survival benefit). Length-time bias results when screening tends to detect more slowly progressive disease, and to miss rapidly progressing disease that becomes detectable and symptomatic in the interval between screenings. This is also a concern in PSA screening, where the test may "overdiagnose" low-grade slow-growing cancers (ones that patients die with, not from) but may not be very helpful in detecting rapidly growing cancers at a stage where treatment would be effective. Selection bias is a systematic error in sampling a population for a study or analysis, where the included subjects are not representative of the broader population to which the conclusions are intended to apply. This might occur, for example, in studies of PSA done in urology departments of academic medical centers, thereby excluding patients in community primary care settings. Confounding occurs when there are factors (often not measured or accounted for in analyses) that are associated with both a proposed cause and a proposed effect, leading to the possibility that the proposed cause and effect might be incorrectly assumed to be related. Diagnosis bias is not a term that is currently utilized in epidemiology.

When counseling patients about sleeping habits, appropriate advice would include which of the following? (Mark all that are true.) Most adults need 7-8 hours of sleep a night Persons over the age of 65 need less sleep than younger adults No association has been found between exercise and sleep Inadequate sleep is associated with the development of several chronic conditions (e.g., hypertension, diabetes mellitus, and obesity) A sleep-deprived individual's judgment and psychomotor performance is similar to that of someone who has drunk a significant amount of alcohol

Critique: On average, most adults need 7-8 hours of sleep each night, although the normal range is from 5 to 10 hours. Teenagers need an average of 9 hours of sleep each night, and infants need about 16 hours a day (SOR B). Like their younger counterparts, the elderly need 7-8 hours of sleep each night. However, sleep disorders increase with age, and the elderly are much more likely to have sleep problems, including insomnia and a lack of deep sleep (SOR C). Daily exercise is important for sleeping well. However, patients should be advised to exercise about 5-6 hours before going to bed to avoid the stimulating effect of exercise. Other recommendations include maintaining a regular sleep schedule; avoiding nicotine, caffeine, and alcohol; and performing relaxing activities before bed (SOR C). An association has been found between primary sleep disorders and insufficient sleep and multiple chronic conditions, including obesity, hypertension, and other cardiovascular disease, diabetes mellitus, and cerebrovascular disease. Studies have shown that somnolent individuals are more likely to make errors in judgment and performance, sleep-deprived drivers are more likely to be in collisions (SOR C), and sleep-deprived health care workers are more likely to make errors that affect their patient's health. Major industrial accidents (Three Mile Island, Chernobyl, Exxon Valdez) have been associated with sleep-deprived night-shift workers.

Which of the following would be recommended for the patient described? (Mark all that are true.) Carcinoembryonic antigen testing for a 65-year-old breast cancer survivor 6 months after her breast cancer diagnosis and treatment Breast cancer screening for a 25-year-old female Hodgkin's disease survivor who was treated with chest irradiation Depression screening for a 25-year-old survivor of leukemia Follow-up carcinoembryonic antigen testing for a 65-year-old male colon cancer survivor Digital rectal examination and monitoring of prostate-specific antigen levels every 6 months for a 72-year-old prostate cancer survivor

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

A 58-year-old postmenopausal female sees you for a routine annual evaluation and asks about measures to prevent osteoporosis. She has no current medical problems, takes no regular medications, and has a negative history for previous surgery or bone fractures. She has no current or prior history of smoking, alcohol consumption, or illicit drug use. She reports moderate caffeine intake, and says she eats a low-fat diet and exercises daily. She has no family history of cancer, heart disease, diabetes mellitus, or osteoporosis. Her blood pressure is 118/72 mm Hg, pulse rate 72 beats/min, and respiratory rate 16/min. She is 173 cm (68 in) tall and weighs 75 kg (165 lb). Which one of the following would be an appropriate recommendation for this patient? Combination hormone therapy Raloxifene (Evista) Regular calcium supplementation to reach a total daily intake of 1000 mg A total daily calcium intake of at least 1200 mg, obtained primarily from dietary sources Regular vitamin D supplementation to reach a total daily intake of 200 IU

Critique: Calcium supplementation has been shown to have a beneficial effect on bone density in postmenopausal women. Although the U.S. Preventive Services Task Force (USPSTF) recently stated that current evidence was insufficient to assess the balance of the benefits and harms of daily supplementation with >400 IU of vitamin D3 and >1000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women (USPSTF I recommendation), it was able to conclude that daily supplementation with 400 IU of vitamin D3 combined with 1000 mg of calcium had no effect on the incidence of fractures (USPSTF D recommendation). The Institute of Medicine currently recommends 1200 mg/day of elemental calcium and 600 IU/day of vitamin D. Although many patients choose to obtain this from supplements, recent studies suggest that excessive intake of supplemental calcium has an adverse effect on cardiovascular morbidity. Until this issue is resolved, it would seem prudent to advise patients to rely more heavily on dietary sources of calcium, such as low-fat dairy foods, beans, and green, leafy vegetables. The USPSTF recommends against the use of hormone therapy for osteoporosis prevention (USPSTF D recommendation). Raloxifene is not used for osteoporosis prevention in postmenopausal women.

Risk factors for cervical cancer include which of the following? (Mark all that are true.) Cigarette smoking Alcohol use Early onset of sexual activity Having multiple sexual partners HPV infection HIV infection

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

True statements regarding screening for hepatitis include which of the following? (Mark all that are true.) The U.S. Preventive Services Task Force (USPSTF) recommends routine screening for hepatitis B infection in adults at high risk of infection The Centers for Disease Control and Prevention recommends one-time testing for hepatitis C virus for persons born between 1985 and 2005 The USPSTF recommends against routine screening for hepatitis C in asymptomatic adults who are not at high risk for infection All pregnant women should be screened for active hepatitis B infection at their first prenatal visit The principal screening test for hepatitis B infection is HBsAg

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

The U.S. Preventive Services Task Force recommends discontinuation of routine colorectal cancer screening after what age 75 years

Critique: In 2016 the U.S. Preventive Services Task Force (USPSTF) recommended screening for colorectal cancer (CRC) starting at age 50 and continuing until age 75 (USPSTF A recommendation). For individuals 76-85 the USPSTF recommended that the decision to screen for colorectal cancer should be an individual one, taking into account the patient's overall health and prior screening history, with adults in this age group who have never recommendations.been screened for colorectal cancer more likely to benefit (USPSTF C recommendation). American Cancer Society (ASC) guidelines in 2018 recommend regular screening for colorectal cancer at age 45 as a qualified recommendation, regular screening in adults aged 50 years and older as a strong recommendation, and screening average risk adults in good health with a life expectancy of greater than 10 years through the age of 75 years as a qualified recommendation. In addition, ASC guidelines recommend that clinicians individualize CRC screening decisions for individuals age 76-85 based on patient preferences, life expectancy, health status, and prior screening, and recommend discouraging individuals over age 85 from continuing CRC screening. Both of these are qualified recommendations.

Based on the findings and recommendations of the U.S. Preventive Services Task Force, the use of daily low-dose aspirin is recommended for primary prevention of cardiovascular disease (CVD) in men age 50-59 with a 10-year CVD risk ≥10% is recommended for primary prevention of CVD in women age 50-59 with a 10-year CVD risk ≥10% is associated with a reduced risk for colon cancer is associated with an increased risk for ischemic stroke is associated with a reduced risk for hemorrhagic stroke

Critique: In 2016, the U.S. Preventive Services Task Force (USPSTF) concluded that in adults age 50-69 years at increased cardiovascular disease (CVD) risk, the benefits of aspirin use include prevention of myocardial infarction and ischemic stroke, and, with long-term use, a reduced incidence of colorectal cancer. Aspirin use may also result in small to moderate harms, including gastrointestinal bleeding and hemorrhagic stroke. Decisions about the use of low-dose aspirin therapy in primary prevention should take into account the patient's overall risk for cardiovascular disease, colorectal cancer, and gastrointestinal bleeding. The USPSTF recommends initiating low-dose aspirin use for the primary prevention of CVD and colorectal cancer in adults age 50-59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years (USPSTF B recommendation). For adults age 60-69 years with a 10% or greater 10-year CVD risk, the USPSTF felt the decision to initiate low-dose aspirin use should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin (USPSTF C recommendation). The USPSTF deemed the current evidence to be insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and colorectal cancer in adults younger than 50 or ≥70 (USPSTF I recommendation).

In which of the following patients would a statin be indicated for prevention of coronary events? (Mark all that are true.) A 40-year-old African-American female nonsmoker with well controlled stage 1 hypertension, no family history of coronary artery disease, and no diabetes mellitus, with a blood pressure of 132/82 mm Hg, a total cholesterol level of 230 mg/dL, an LDL-cholesterol level of 150 mg/dL, and an HDL-cholesterol level of 44 mg/dL A 40-year-old pregnant white female with familial hypercholesterolemia, a total cholesterol level of 330 mg/dL, and an LDL-cholesterol level of 200 mg/dL A 50-year-old Hispanic male with type 2 diabetes mellitus, a total cholesterol level of 160 mg/dL, and an LDL-cholesterol level of 105 mg/dL A 55-year-old overweight white female who is a former smoker and has a family history of coronary artery disease, no diabetes mellitus or hypertension, a blood pressure of 90/68 mm Hg, a total cholesterol level of 220 mg/dL, an LDL-cholesterol level of 120 mg/dL, and an HDL-cholesterol level of 38 mg/dL A 72-year-old white female with a recent inferior wall myocardial infarction, a total cholesterol level of 175 mg/dL, and an LDL-cholesterol level of 115 mg/dL

Critique: In 2018, the American Heart Association (AHA) released new guidelines for the management of cholesterol levels to reduce atherosclerotic cardiovascular disease (ASCVD) risk. These guidelines identified four groups who were most likely to benefit from moderate- to high-intensity statin therapy: * For patients with clinical ASCVD, high-intensity statin therapy is recommended for those <75 years of age, and moderate- or high-intensity statin therapy for those >75 years of age * For patients 20-75 years of age with severe hypercholesterolemia and an LDL-cholesterol (LDL-C) level >190 mg/dL, maximally tolerated statin therapy is recommended * For patients 40-75 years of age with type 1 or type 2 diabetes mellitus, moderate-intensity statin therapy is recommended, or high-intensity therapy if the patient has multiple ASCVD risk factors or a 10-year ASCVD risk >20% * For adults age 40-75 years of age with an estimated ASCVD risk >7.5%, moderate-intensity statin therapy is recommended following a clinician-patient risk discussion and shared decision making High-intensity statin therapy is defined as a daily dosage that lowers LDL-cholesterol by >50%, and moderate-intensity statin therapy is defined as a dosage that lowers LDL-C by 30%-50%. Statin therapy would therefore be indicated in both the patient with a recent myocardial infarction and the patient with diabetes, regardless of LDL-C levels. Although AHA guidelines do recommend statin therapy in all adults with an LDL-C level >190 mg/dL, statins are contraindicated in pregnancy (pregnancy. In addition, there is no evidence that treating hyperlipidemia during pregnancy is beneficial (SOR C). Both the 40-year-old female nonsmoker with hypertension and the 55-year-old overweight female smoker have a 10-year estimated ASCVD risk <4% and and thus would not be started on a statin, based on 2018 AHA guidelines.

True statements regarding meningococcal vaccine include which of the following? (Mark all that are true.) It is indicated for normal-risk children 11-12 years of age It is indicated for first-year college students living in dormitories The preferred form for persons less than 55 years of age is meningococcal polysaccharide vaccine (MPSV4) Revaccination every 5 years is recommended for persons with functional or anatomic asplenia Vaccination is recommended for travelers to Mecca

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

You are counseling a 62-year-old African-American male about colon cancer screening. He asks you about fecal DNA testing as an option. You find an article that notes the first-generation fecal DNA test has a sensitivity of 20% and a specificity of 96% for "screen-relevant" neoplasms. You also find a recent study that found that African-Americans have a higher prevalence of polyps compared with whites.True statements regarding this situation include which of the following? (Mark all that are true.) The negative predictive value of a test depends on its sensitivity The negative predictive value of a test is roughly equal to its sensitivity The negative predictive value of a test depends on its specificity The negative predictive value of a test is roughly equal to its specificity The negative predictive value of fecal DNA testing is higher in African-American patients than in white patients

Critique: Negative predictive value (NPV) is the proportion of patients with a negative result on a given test (or screen) who do not have the condition being tested (or screened) for. Like the positive predictive value, the NPV of a test depends on the characteristics of the test (sensitivity and specificity), but also on the pretest probability of disease in the individual being tested/screened. The pretest probability of disease can be estimated by the prevalence of the disease in the population most representative of the patient being tested/screened. The lower the pretest probability of disease, the higher the NPV of a test or screen. In this example, since the pretest probability of polyps is higher in African-American patients, one would expect the NPV of his fecal DNA test to be lower than it would be for a white patient of a similar age.

True statements regarding tobacco cessation counseling include which of the following? (Mark all that are true.) Tobacco cessation treatment is cost-effective Telephone quit line counseling has been shown to be effective Insurance coverage of tobacco cessation strategies has an effect on tobacco quit rates Multiple first-line pharmacologic agents have been shown to be more effective than placebo in promoting tobacco cessation Use of pharmacologic agents for tobacco cessation will result in long-term abstinence in approximately 50% of patients

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

A 42-year-old female sees you for a routine annual visit. Her neighbor was just diagnosed with ovarian cancer and has encouraged her to have her CA-125 level checked. The patient is concerned about the possibility that she could develop this cancer, and asks your advice about prevention and screening. Which of the following would be appropriate advice? (Mark all that are true.) Although ovarian cancer is rare, it is the fifth leading cause of cancer deaths in women Oral contraceptives increase the risk of ovarian cancer Transvaginal ultrasonography is the preferred screening test for ovarian cancer There is significant potential harm associated with ovarian cancer screening CA-125 has a false-positive rate of 98% when used to screen for ovarian cancer

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

Which of the following should receive pneumococcal vaccine? (Mark all that are true.) A healthy 2-month-old infant An 8-year-old child who has had frequent episodes of otitis media A 45-year-old female who smokes cigarettes and has not previously received pneumococcal vaccine A 56-year-old male with chronic renal failure who received pneumococcal vaccine at age 50 A 65-year-old male who is uncertain of his immunization status

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

A 32-year-old pregnant female in her second trimester presents to your office to establish care. She is uncertain when she became pregnant or who the child's father is, but based on dates you calculate that her expected delivery date is in March. She has not seen a physician in over 10 years and is uncertain about her history of prior immunizations and childhood illnesses. She works in a local nursing home. Which of the following immunizations should she receive at this time? (Mark all that are true.) Tdap Inactivated influenza vaccine MMR Varicella vaccine Hepatitis B vaccine

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

Which of the following patients should be offered abdominal ultrasonography to screen for an abdominal aortic aneurysm, based on the information provided? (Mark all that are true.) A 70-year-old nonsmoking male with hypertension and hypercholesteolemia A 60-year-old female with new-onset renal failure A 65-year-old female with hypertension and a 20-pack-year smoking history A 68-year-old male with a 5-pack-year smoking history A 74-year-old male who had abdominal ultrasonography at age 65 A 75-year-old female with a recent history of hemorrhagic stroke

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

For which of the following patients would you consider recommending vitamin D supplementation? (Mark all that are true.) A 4-week-old male who has been exclusively breastfed since birth A 24-year old female beginning phenytoin therapy A 35-year-old female with depression and fatigue whose 25-hydroxyvitamin D level was 52 ng/mL when checked at a recent health fair A 45-year-old female with metastatic breast cancer who is taking a bisphosphonate A 63-year-old female with no known risk factors for osteoporosis other than her postmenopausal status

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

The American Diabetes Association would recommend screening for prediabetes and diabetes mellitus for which of the following, based on the information provided? (Mark all that are true.) An obese 21-year-old female who delivered a 10-lb infant 2 years ago An obese 27-year-old female with polycystic ovary disease A 30-year-old Hispanic female with a BMI of 30.2 kg/m2 A 40-year-old white male with a BMI of 27.1 kg/m2 and no additional risk factors for diabetes mellitus A 60-year-old male who had a normal fasting glucose level 3 years ago

Critique: The American Diabetes Association recommends screening all persons over the age of 45 with a fasting plasma glucose level or a 2-hour oral glucose tolerance test. Hemoglobin A1c is also an acceptable test. Screening should be performed before age 45 for any individual with a BMI >25.0 kg/m2 who has any of the following additional risk factors: * physical inactivity * low HDL-cholesterol (<35 mg/dL) or high triglycerides (>250 mg/dL) * a first degree relative with diabetes mellitus * polycystic ovary syndrome or other insulin-resistance conditions (e.g., acanthosis nigricans) * delivery of an infant with a birth weight >9 lb, or a history of gestational diabetes * high-risk ethnicity (African American, Hispanic, Native American, Asian American, Pacific Islander) * a previous glucose tolerance test with elevated results or a hemoglobin A1c >5.7% * a history of vascular disease * hypertension If screening results are normal, repeat testing should be done at least at 3-year intervals.

True statements regarding screening for diabetes mellitus include which of the following? (Mark all that are true.) All adults with hypertension should be screened for diabetes All adults over the age of 45 should have a fasting blood glucose measurement every 2 years A fasting glucose assessment can miss up to 30% of patients with impaired glucose tolerance If a high-risk patient has a normal screening result, testing should be repeated within 3 years

Critique: The American Diabetes Association recommends screening all persons over the age of 45 with a fasting plasma glucose level or a 2-hour oral glucose tolerance test. Hemoglobin A1c is also an acceptable test. Screening should be performed before age 45 for any individual with a BMI >25.0 kg/m2 who has any of the following additional risk factors: * physical inactivitylow * HDL-cholesterol (<35 mg/dL) or high triglycerides (>250 mg/dL) * a first degree relative with diabetes mellitus * polycystic ovary syndrome or other insulin-resistance conditions (e.g., acanthosis nigricans) * delivery of an infant with a birth weight >9 lb, or a history of gestational diabetes * high-risk ethnicity (African American, Hispanic, Native American, Asian American, Pacific Islander) * a previous glucose tolerance test with elevated results or a hemoglobin A1c >5.7% * a history of vascular disease * hypertension. If screening results are normal, repeat testing should be done at least at 3-year intervals. An oral glucose tolerance test is required to diagnose impaired glucose tolerance (SOR B). The fasting plasma glucose level alone will miss approximately 30% of patients with isolated impaired glucose tolerance. A consensus statement issued by the American Diabetes Association recommends that if pharmacotherapy is used, both impaired fasting glucose and impaired glucose tolerance should be documented (SOR B).

True statements regarding alcohol abuse counseling include which of the following? (Mark all that are true.) The CAGE and AUDIT tools have been validated as screening instruments for adult alcohol abuse The U.S. Preventive Services Task Force (USPSTF) recommends screening and counseling adolescents on the risks of alcohol misuse The USPSTF recommends screening and counseling adults on the risks of alcohol misuse While the USPSTF found that screening can accurately identify adults at risk for alcohol misuse, there was insufficient evidence of effectiveness for brief multicontact behavioral counseling

Critique: The U.S. Preventive Services Task Force (USPSTF) found good evidence that patients at risk for adverse outcomes from alcohol abuse can be accurately identified in the primary care setting. They also found evidence that counseling interventions in the primary care setting can positively affect unhealthy drinking behaviors in adults engaging in risky or hazardous drinking, with brief multicontact behavioral counseling demonstrating the best evidence of effectiveness. In 2013 the USPSTF therefore recommended that clinicians screen adults age 18 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse (USPSTF B recommendation). The USPSTF also found little evidence with regard to screening and counseling adolescents for alcohol use, and noted that there is insufficient evidence to recommend for or against screening in this age group (USPSTF I recommendation). The CAGE and AUDIT tools are two of several validated instruments that can be used in primary care settings to screen for alcohol abuse (SOR A).

The U.S. Preventive Services Task Force has found sufficient evidence to recommend which one of the following for skin cancer screening? No currently available method A periodic questionnaire to identify high-risk patients for referral for total-body skin examinations An annual full-body skin examination by a primary care physician for high-risk patients only An annual full-body skin examination by a dermatologist for all patients after age 65

Critique: The U.S. Preventive Services Task Force (USPSTF) has determined that the benefits from screening for skin cancer are unproven, even in high-risk patients (USPSTF I recommendation). Patients at increased risk for melanoma include those with atypical moles, fair-skinned individuals over the age of 65, and those with more than 50 moles. Lesions with atypical features, described as the ABCDs of melanoma (Asymmetry, Border irregularity, Color variability, Diameter >6 mm), or rapidly changing lesions, should be biopsied. Study outcomes of patients with familial syndromes have not been evaluated by the USPSTF.

A 45-year-old male executive makes an appointment to see you for a "complete physical." He has been working out twice a week at a local health club, and his personal trainer has suggested he be evaluated for heart disease. He brings in a copy of laboratory work from a local health fair he attended last year, which includes a total fasting cholesterol of 220 mg/dL, with an HDL-cholesterol level of 38 mg/dL and an LDL-cholesterol level of 138 mg/dL. His fasting glucose level was 105 mg/dL. On examination his body mass index is 26.4 kg/m2 and his blood pressure is 132/84 mm Hg. He does not smoke. His grandparents developed coronary artery disease (CAD) in their early 70s, but there is no family history of diabetes mellitus. Which of the following would you recommend at this time? (Mark all that are true.) A 10-year American Heart Association atherosclerotic cardiovascular disease risk assessment A repeat fasting lipid level A repeat fasting glucose level A high-sensitivity C-reactive protein (hs-CRP) level An EKG An apolipoprotein B level A serum homocysteine level Electron-beam computed tomography

Critique: The U.S. Preventive Services Task Force (USPSTF) recommends against routine use of resting EKGs, exercise treadmill testing, or electron-beam computed tomography to screen for coronary heart disease in adults at low risk (SOR A, USPSTF D recommendation). There is little evidence that these tests greatly increase the accuracy of coronary artery disease (CAD) prediction on a population level when compared with standard risk factors. In addition, these tests add significant expense and carry a risk of misdiagnosis due to false-positive results. The potential added benefit of apolipoprotein B and high-sensitivity C-reactive protein compared with traditional risk factor assessment is still unclear at this time. Lowering serum levels of homocysteine using folic acid has not been proven useful in primary or secondary prevention of CAD. The 2013 American College of Cardiology/American Heart Association guidelines on assessment of cardiovascular risk recommend assessment of traditional atherosclerotic cardiovascular disease (ASCVD) risk factors every 4-6 years in adults 20-79 years of age without ASCVD, and estimation of 10-year ASCVD risk every 4-6 years using Pooled Cohort Equations in adults 40-79 years of age without ASCVD. This patient's 10-year ASCVD risk is ≤4%, which places him at low risk. Reassessment of fasting glucose and fasting lipids is indicated in this patient, as both of these results were mildly elevated on his previous assessment (SOR A).

You have observed an increase in the number of patients seeking your help for stressful life situations, and have decided to implement strategies in your practice to screen for depression. True statements regarding screening measures for this problem include which of the following? (Mark all that are true.) There is good evidence to support screening of adult patients for depression There is good evidence to support screening of adolescents for depression A two-question screening instrument can be an effective screen for major depression The U.S. Preventive Services Task Force recommends practice-level screening for suicide risk Treating depression in patients following acute coronary syndrome may improve long-term cardiac outcomes

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

According to the U.S. Preventive Services Task Force, screening for Chlamydia infection would be recommended for which of the following? (Mark all that are true.) A sexually active 20-year-old nonpregnant female with a past history of sexually transmitted disease (STD) and several sexual partners A sexually active 24-year-old pregnant female with multiple sexual partners A sexually active 25-year-old bisexual male A sexually active 30-year-old pregnant female who has had only one lifetime partner and no STDs A sexually active 30-year-old nonpregnant female with STD risk factors

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

You provide care for an extended family that includes a 23-year-old female who has recently scheduled her first visit for a refill of her oral contraceptives. She is unmarried and has a 15-month-old son. The family receives housing assistance and participates in the Supplemental Nutrition Assistance Program (SNAP). The woman's 69-year-old grandmother, 44-year-old mother, and 14-year-old stepsister live in the community and are also patients of yours. All of these family members are asymptomatic. The grandmother is a former smoker with a 30-pack-year smoking history. Which of the following would be recommended by the U.S. Preventive Services Task Force? (Mark all that are true.) Screening the 15-month-old for autism Screening the 14-year-old for scoliosis Screening the 23-year-old for gonorrhea Screening the 44-year-old for thyroid disease Screening the 69-year-old for abdominal aortic aneurysm

Critique: The U.S. Preventive Services Task Force (USPSTF) recommends screening for both gonorrhea and Chlamydia in sexually active women 24 years of age and younger (USPSTF B recommendation). The USPSTF has found insufficient evidence for screening children 18-30 months of age for autism, children and adolescents 10-18 years of age for scoliosis, and nonpregnant asymptomatic adults for thyroid dysfunction (USPSTF I recommendations). Although the USPSTF recommends abdominal aortic aneurysm (AAA) screening by ultrasonography in men ages 65-75 years who have ever smoked, it found current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women ages 65-75 years who have ever smoked (USPSTF I recommendation).

For which of the following women is a Papanicolaou (Pap) test indicated? (Mark all that are true.) A 20-year-old who has been sexually active since the age of 16 A 25-year-old who has never been sexually active A 32-year-old whose last Pap test 3 years ago was normal A 36-year-old who had a normal Pap smear and a negative HPV test 4 years ago A 54-year-old who had a hysterectomy at age 50 for uterine fibroids and has a history of normal Pap tests in the past, with the exception of a test at age 47 reported as ASCUS A 67-year-old who has had three normal Pap tests within the past 10 years, with the most recent at age 64

Critique: The U.S. Preventive Services Task Force (USPSTF) recommends screening for cervical cancer every 3 years with cervical cytology alone in women 21-29 years of age. For women 30-65 years of age, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (USPSTF A recommendation). Screening for cervical cancer is not recommended for women younger than 21 years of age regardless of sexual history (USPSTF D recommendation). The USPSTF recommends discontinuation of screening at age 65 for women who have had adequate prior screening and who are not otherwise at high risk for cervical cancer (USPSTF D recommendation). For women in this category, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology define adequate prior screening as three consecutive negative cytology results or two consecutive negative HPV results within the past 10 years, with the most recent test occurring within the past 5 years. Screening beyond this age is still recommended in older women who have not been previously screened or in women with at least one abnormal Pap smear in the past 10 years. If documentation is available to confirm that a woman has had a total hysterectomy for benign disease and has no history of a high-grade precancerous lesion (CIN grade 2 or 3) or cervical cancer, the USPSTF recommends against further screening for cervical cancer (USPSTF D recommendation).

True statements regarding screening for osteoporosis include which of the following? (Mark all that are true.) The U.S. Preventive Services Task Force (USPSTF) recommends that routine screening begin at age 60 for women with a risk factor for osteoporotic fractures The USPSTF recommends that all women age 65 and older be screened routinely for osteoporosis The optimal interval for osteoporosis screening in a woman with a history of normal DXA scans is every year Patients should continue receiving routine recommended osteoporosis screening after being diagnosed with osteoporosis The likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test Bone density measured at the femoral neck by DXA is the best predictor of hip fracture

Critique: The U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women age 65 and older (USPSTF B recommendation). In postmenopausal women younger than 65 the USPSTF recommends screening with bone measurement testing in those at increased risk for osteoporosis as determined by a use of a formal clinical risk assessment tool (USPSTF B recommendation). Formal clinical risk assessment tools include the Simple Calculated Osteoporosis Risk Estimation (SCORE), the Osteoporosis Risk Assessment Instrument (ORAI), the Osteoporosis Index of Risk (OSIRIS), and the Osteoporosis Self-Assessment Tool (OST). The commonly used threshold to identify an increased risk for osteoporosis or osteoporotic fractures is ≥6 for SCORE, ≥9 for ORAI, <1 for OSIRIS, and <2 for OST. The FRAX tool, developed at the University of Sheffield, is a country-specific, computerized algorithm that calculates the 10-year probability of hip fracture and major osteoporotic fracture. In women younger than 65 the the USPSTF threshold for screening with bone measurement testing is a 10-year major osteoporotic fracture risk which exceeds that of a 65-year-old white woman without major risk factors. This threshold was calculated as a 9.3% risk in 2011, but in 2018 the FRAX the threshold is an 8.4% risk. While bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture, the likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer used, and the relevance of the reference range. No studies have evaluated the optimal intervals for repeat screening. Because of limitations in the precision of testing, the USPSTF reports that a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals such as 4-8 years may be adequate for repeat screening performed to identify new cases of osteoporosis.

Which one of the following is true regarding screening for drug abuse? All adolescents should be screened for drug abuse Counseling adolescents and young adults about drug abuse has been shown to prevent them from abusing drugs Because of the risks to both mother and fetus, all pregnant women should be screened for drug abuse and counseled about this issue The U.S. Preventive Services Task Force has found insufficient evidence for or against screening and counseling for drug abuse

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

A 20-year-old female smoker sees you for a routine health maintenance visit. She has been sexually active since age 16 and has had a total of three partners. She is not currently using any form of contraception, and states that she would welcome a pregnancy. She has never had a Papanicolaou (Pap) test. She was diagnosed with chlamydial urethritis last year and was treated with azithromycin (Zithromax). She has received one HPV immunization, 2 months ago. A physical examination is normal. Which of the following would be recommended at this visit by either the U.S. Preventive Services Task Force or the CDC's Advisory Committee on Immunization Practices? (Mark all that are true.) Tobacco cessation counseling Screening for Chlamydia Counseling about preventing sexually transmitted diseases A Pap test A second dose of HPV vaccine

Critique: The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products (USPSTF A recommendation). While the patient described may not currently be pregnant, the USPSTF strongly recommends that clinicians provide augmented pregnancy-tailored counseling to pregnant women who smoke. There is good evidence that extended or augmented smoking cessation counseling (5-15 minutes) using messages and self-help materials tailored for pregnant smokers is useful. Compared with brief generic counseling interventions alone, a pregnancy-tailored approach can substantially increase abstinence rates during pregnancy and leads to increased birth weights (USPSTF A recommendation).The USPSTF recommends screening for chlamydial infection for all sexually active nonpregnant women age 24 and younger, and for older nonpregnant women who are at increased risk (USPSTF A recommendation). The Centers for Disease Control and Prevention (CDC) recommends annual screening for patients at increased risk. The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs (USPSTF B recommendation). The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in adolescents who are not sexually active, or in adults not at increased risk for STIs (USPSTF I recommendation). The USPSTF recommends cervical cancer screening every 3 years for women between the ages of 21 and 65, regardless of their sexual history (USPSTF A recommendation). According to the CDC's Advisory Committee on Immunization Practices, HPV vaccination is recommended for all women age 26 or under, regardless of risk (SOR C). Ideally, the full vaccination series should be administered before potential exposure to HPV through sexual activity; however, women who are sexually active should still be vaccinated, including women with a history of genital warts, abnormal Papanicolaou smears, or positive HPV DNA tests. A complete series consists of 3 doses for all women. The second dose should be administered 2 months after the first dose, and the third dose 6 months after the first dose (SOR C).

The Cochrane Library periodically reviews the evidence of the effectiveness of mammography screening for detection of breast cancer. One analysis from their 2006 review looked at deaths ascribed to breast cancer for women at least 50 years of age who had screening mammography, generally every 1-3 years, compared with women who did not. After 13 years of follow-up, 595 out of 146,284 women in the screened group died of breast cancer, compared with 701 of 122,590 unscreened women. According to this data, the number needed to screen with mammography to prevent 1 death from breast cancer over 13 years of follow-up is approximately 606 women.

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

Which of the following women would be at increased risk for endometrial cancer, based on the information provided? (Mark all that are true.) A 35-year-old with a BMI of 32.4 kg/m2 A 39-year-old with polycystic ovary syndrome A 43-year-old who has taken combined oral contraceptive pills for over 25 years A 46-year-old who has had 6 children and breastfed all of them A 47-year-old who experienced menarche at age 10 and has never been pregnant A 59-year-old with hereditary nonpolyposis colon cancer A postmenopausal female with a strong family history of breast cancer who is taking tamoxifen (Soltamox) to prevent breast cancer A postmenopausal female who is taking raloxifene (Evista) to prevent osteoporosis

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

A 40-year-old asymptomatic male patient sees you for a routine annual visit. He mentions that his father recently died from complications related to COPD, and is concerned about his own risk for this condition. The most appropriate screening tool to help direct this patient's management is spirometry peak-flow testing a chest radiograph chest CT no screening for COPD

Critique: There is no data to support the use of tests to screen asymptomatic patients for COPD. High-quality spirometry remains the gold standard for diagnosing COPD in patients suspected of having the disease. When spirometry is not available, peak flow meters may be used to assist in the diagnosis (with an understanding of the limited positive and negative predictive values). Hyperinflation and hyperlucency of lung fields are radiologic changes associated with COPD, but an abnormal chest radiograph is rarely diagnostic of COPD. CT is rarely used for making the diagnosis of COPD. None of these tests is indicated to detect COPD in asymptomatic patients. In 2009, the U.S. Preventive Services Task Force reviewed the evidence and specifically recommended against the use of spirometry to screen adults for COPD (USPSTF D recommendation).

A 62-year-old female sees you for the first time for a health maintenance visit. She asks for information about the new herpes zoster vaccine that she has read about recently that the article said was better than the previous vaccine. Accurate advice about the recombinant herpes zoster vaccine (Shingrix) would include which of the following? (Mark all that are true.) It contains live attenuated varicella virus A second dose is required 2-6 months after the initial dose It is more than 90% effective for preventing herpes zoster and postherpetic neuralgia It should not be administered to a patient who received the older vaccine (Zostavax) within the previous 12 months Since the introduction of Shingrix, the older vaccine is no longer recommended by the CDC

Critique: Unlike the older herpes zoster vaccine that contains a live attenuated varicella virus, Shingrix is a non-live, recombinant subunit vaccine that combines a lyophilized varicella zoster virus glycoprotein E (gE) antigen and an adjuvant system. It is administered in two doses of 0.5 mL each, with the second dose given 2-6 months after the initial dose. It has been shown to be more than 90% effective in preventing herpes zoster and postherpetic neuralgia. Its protective effect remains at 85% for at least 4 years after administration. As a result, it is the preferred shingles vaccine over the live attenuated virus vaccine, which reduces the risk of herpes zoster by 51% and the risk of postherpetic neuralgia by 67%. Whereas the live attenuated vaccine was recommended by the CDC for persons over age 60, the recombinant vaccine is recommended for healthy adults 50 years of age and older. Recombinant vaccine is recommended for patients who have had shingles in the past, as well as those who received the live attenuated vaccine in the past. The CDC recommends that patients wait at least 8 weeks after receiving the live attenuated vaccine before getting the recombinant vaccine. Although it is not the preferred shingles vaccine, the CDC still recommends the live attenuated vaccine for healthy adults 60 years and older to prevent shingles. It still has a role in certain cases, such as when a person prefers the older vaccine, is allergic to the recombinant vaccine, or requests immediate vaccination and the recombinant vaccine is unavailable.

In the absence of proven immunity, varicella vaccine would be recommended for which of the following? (Mark all that are true.) A 19-year-old female in the second trimester of her first pregnancy A 24-year-old graduate student who will be doing field work in Guatemala starting in 2 months A 27-year-old female who says she would like to discontinue her oral contraceptives in 6-12 months so that she and her husband can start a family A 32-year-old male who received a single dose of the vaccine 5 weeks ago The 43-year-old mother of a bone marrow transplant patient who lives in the same household

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

A 50-year-old Asian female visits your office for a routine annual visit. She is asymptomatic and has no known family history of cancer.According to the U.S. Preventive Services Task Force, which of the following would be recommended to screen for breast cancer in this patient? (Mark all that are true.) Teaching the patient how to perform monthly breast self-examinations MRI Genetic testing for BRCA mutations Mammography

Critique: With the exception of mammography, the U.S. Preventive Services Task Force (USPSTF) has found insufficient evidence to recommend screening for breast cancer in women with no risk factors. The USPSTF recommends mammography screening every 1-2 years beginning at age 50 for all women (USPSTF B recommendation). The USPSTF recommends against teaching breast self-examination (USPSTF D recommendation) and has found insufficient evidence to recommend for or against clinical breast examinations to screen asymptomatic women (USPSTF I recommendation). Clinical trials have not found that mortality is improved in women screened with a clinical breast examination in addition to mammography. However, the patient should be provided with this information, and the physician should ask about her preferences. The USPSTF has concluded that the evidence is insufficient to assess the benefits and norms of MRI screening for breast cancer (USPSTF I recommendation). The American Cancer Society has recommended annual MRI screening in addition to mammography for women with a 20% lifetime risk or higher for breast cancer, and has recommended against MRI screening for women with a 15% lifetime risk or lower (SOR C).

You see a 76-year-old African-American male in your office for the first time. He has not seen a physician for many years and would like to have a complete evaluation. This patient's risk for prostate cancer is increased by which of the following? (Mark all that are true.) His age His ethnicity His high dietary fat intake His family history of prostate cancer

In 2018, the USPSTF revised its position and recommended that for men age 55-69 the decision to undergo periodic PSA screening for prostate cancer be an individual one (USPSTF C recommendation) and recommended against PSA screening for men age 70 and older (USPSTF D recommendation). The USPSTF concluded that PSA screening may reduce prostate cancer mortality risk but is associated with false-positive results, biopsy complications, and overdiagnosis. In addition, compared with conservative approaches, the USPSTF concluded that active treatments for screen-detected prostate cancer have unclear effects on long-term survival but are associated with sexual and urinary difficulties.

The father of one of your patients recently died of lung cancer, and she requests screening for the disease. She is a 45-year-old asymptomatic female with a 20-pack-year smoking history. Which one of the following would be recommended by the U.S. Preventive Services Task Force to screen for lung cancer? No screening A CBC Spirometry Sputum cytology A chest radiograph Chest CT

The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults age 55-80 who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. It also recommends screening be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (B recommendation).

IMMUNIZATION (vaccination)

administration of a weakened or killed pathogen, or a protein of a pathogen, to cause the immune system to create antibodies for future protection

CANCER Screening

tests used to detect cancer cells at an early stage of disease so that it can be treated more effectively

CHEMOPREVENTION

the use of natural or synthetic substances such as drugs or vitamins to reduce the risk of developing cancer, or to reduce the chance that cancer will recur

Medical Screening

used to suggest or detect disease among individuals in a population without signs or symptoms of the health problem