Preventive Health Maintenance

1. Preventive Health Maintenance Common Ambulatory Topics July 2007 Lisa L. Willett MD J. R. Hartig MD

2. Roadmap Breast Cancer Screening Colorectal Cancer Screening Cervical Cancer Screening Adult Vaccinations Osteoporosis Screening �Recreational Activities� Lipid Screening Abdominal Aortic Aneurysm Screening

3. Breast Cancer Projected 211,000 new cases in US and 40,400 deaths in women in 2005 Second cause of cancer related death in women More common in older women Risk 1 in 25 for ages 40-59 Risk 1 in 15 for ages 60-79

4. Question: Breast cancer screening 34 yoF presents for routine follow up. After spending the visit discussing her HTN and DM care, you turn to her health maintenance. She has a family history of breast cancer in her great aunt. You recommend which of the following? Clinical breast exam Screening mammography beginning at age 35 Screening mammography beginning at age 40 Screening mammography beginning at age 50 Screening breast ultrasound beginning at age 35

5. Methods of screening Clinical Breast Exam (CBE) Breast Self Exam (BSE) Mammography

6. Recommendations US Preventive Services Task Force (USPSTF) Canadian Task Force of Preventive Health Care (CTFPHC) Both evidence based, explicit methodology Others: AMA, ACS, ACOG, AAFP Literature review and expert opinion

7. Summary of Recommendations

8. USPSTF Grades and Recs

9. USPSTF Evidence is strongest for 50-69 Weaker for 40-49, but most studies show mortality benefit (but less than 50-69) Difficult to account for delay in observed benefit Insufficient evidence for optimal screening interval Insufficient data for CBE, BSE (I)

10. Question: Breast cancer screening 34 yoF presents for routine follow up. After spending the visit discussing her HTN and DM care, you turn to her health maintenance. She has a family history of breast cancer in her great aunt. You recommend which of the following? Clinical breast exam Screening mammography beginning at age 35 Screening mammography beginning at age 40 Screening mammography beginning at age 50 Screening breast ultrasound beginning at age 35

11. Question: Breast cancer screening 34 yoF presents for routine follow up. After spending the visit discussing her HTN and DM care, you turn to her health maintenance. She has a family history of breast cancer in her great aunt. You recommend which of the following? Clinical breast exam Screening mammography beginning at age 35 Screening mammography beginning at age 40 Screening mammography beginning at age 50 Screening breast ultrasound beginning at age 35

12. FAQs When can I stop screening? Evidence is strongest for 50-69 Can generalize to >70 without co-morbidities higher absolute risk of breast cancer What about high risk women (family history, previous abnormal breast biopsy, first childbirth >30)? Start sooner, perhaps annually

13. Colorectal Cancer Epidemiology 3rd most common cancer in the U. S. 3rd leading cause of cancer death At age 50 a person has 5% lifetime chance Pathology 80% arise from adenomatous polyps Screening Rates ~25% report FOBT in last 12 months ~38% report any form of endoscopy in 5 years 5% lifetime chance of being diagnosed with CR Ca 1 in 3 people who are diagnosed die from the disease Average person dying with colorectal cancer loses 13 years of expected life More than 80% of colorectal cancers arise from adenomatous polyps. Although fewer than 1% of adenomatous polyps less than 1 cm will eventually develop into cancer, 10% of adenomatous polyps greater than 1 cm become malignant within 10 years, and about 25% become malignant after 20 years.6 The prevalence of adenomatous polyps increases from 20% to 25% at age 50 to 50% by age 75-80.5% lifetime chance of being diagnosed with CR Ca 1 in 3 people who are diagnosed die from the disease Average person dying with colorectal cancer loses 13 years of expected life More than 80% of colorectal cancers arise from adenomatous polyps. Although fewer than 1% of adenomatous polyps less than 1 cm will eventually develop into cancer, 10% of adenomatous polyps greater than 1 cm become malignant within 10 years, and about 25% become malignant after 20 years.6 The prevalence of adenomatous polyps increases from 20% to 25% at age 50 to 50% by age 75-80.

14. Question: Colorectal Cancer According to USPSTF, which of the following strategies for colorectal cancer screening is acceptable? Colonoscopy every 5-7 years after 50yo for low-risk individuals Annual in-office DRE and FOBT after 50yo Flex sig and DCBE every 5 years after 50yo Annual home FOBT beginning age 50 Virtual colonoscopy every 10 years after 50yo

15. Methods of Screening FOBT should be used on three consecutive stool samples obtained at home by the patient and returned to the physician. Rehydration of samples increases sensitivity but also increases the false positive rates. Sensitivity and specificity of a single test have been estimated at 40% and 96% to 98%, respectively. Hydration of specimen increases sensitivity (60%) but reduces specificity (90%). Annual screening with hydrated specimens detected 49% of all incident cancers, but 38% of all subjects had at least 1 colonoscopy due to positive results. Programs using unrehydrated specimens and/or biennial testing detect a smaller proportion of cancers (27% to 39%) but require fewer colonoscopies (5% to 28%). In 3 recent randomized trials, performing flexible sigmoidoscopy in addition to FOBT yielded approximately 7 additional cancers or large polyps per 1,000 patients compared to FOBT alone. Adding FOBT did not improve the yield over sigmoidoscopy alone at the initial screening in these studies, which used flexible sigmoidoscopy, but did in an earlier study that used rigid sigmoidoscopy. Previous studies have reported high sensitivity (86% to 90%) of DCBE for colorectal cancer and polyps, and high specificity (95%). In the National Polyp Study, however, DCBE detected only 48% of polyps greater than 1 cm.15 Sensitivity might be higher in a typical screening population where the proportion of large polyps is higher. Specificity of DCBE in this study was 85%. Neither DRE nor single office occult testing is recommended in colorectal cancer screening. FOBT should be used on three consecutive stool samples obtained at home by the patient and returned to the physician. Rehydration of samples increases sensitivity but also increases the false positive rates. Sensitivity and specificity of a single test have been estimated at 40% and 96% to 98%, respectively. Hydration of specimen increases sensitivity (60%) but reduces specificity (90%). Annual screening with hydrated specimens detected 49% of all incident cancers, but 38% of all subjects had at least 1 colonoscopy due to positive results. Programs using unrehydrated specimens and/or biennial testing detect a smaller proportion of cancers (27% to 39%) but require fewer colonoscopies (5% to 28%). In 3 recent randomized trials, performing flexible sigmoidoscopy in addition to FOBT yielded approximately 7 additional cancers or large polyps per 1,000 patients compared to FOBT alone. Adding FOBT did not improve the yield over sigmoidoscopy alone at the initial screening in these studies, which used flexible sigmoidoscopy, but did in an earlier study that used rigid sigmoidoscopy. Previous studies have reported high sensitivity (86% to 90%) of DCBE for colorectal cancer and polyps, and high specificity (95%). In the National Polyp Study, however, DCBE detected only 48% of polyps greater than 1 cm.15 Sensitivity might be higher in a typical screening population where the proportion of large polyps is higher. Specificity of DCBE in this study was 85%. Neither DRE nor single office occult testing is recommended in colorectal cancer screening.

17. Screening Methods and Trials FOBT should be used on three consecutive stool samples obtained at home by the patient and returned to the physician. Rehydration of samples increases sensitivity but also increases the false positive rates. Sensitivity and specificity of a single test have been estimated at 40% and 96% to 98%, respectively. Hydration of specimen increases sensitivity (60%) but reduces specificity (90%). Annual screening with hydrated specimens detected 49% of all incident cancers, but 38% of all subjects had at least 1 colonoscopy due to positive results. Programs using unrehydrated specimens and/or biennial testing detect a smaller proportion of cancers (27% to 39%) but require fewer colonoscopies (5% to 28%). In 3 recent randomized trials, performing flexible sigmoidoscopy in addition to FOBT yielded approximately 7 additional cancers or large polyps per 1,000 patients compared to FOBT alone. Adding FOBT did not improve the yield over sigmoidoscopy alone at the initial screening in these studies, which used flexible sigmoidoscopy, but did in an earlier study that used rigid sigmoidoscopy. Previous studies have reported high sensitivity (86% to 90%) of DCBE for colorectal cancer and polyps, and high specificity (95%). In the National Polyp Study, however, DCBE detected only 48% of polyps greater than 1 cm.15 Sensitivity might be higher in a typical screening population where the proportion of large polyps is higher. Specificity of DCBE in this study was 85%. Neither DRE nor single office occult testing is recommended in colorectal cancer screening. FOBT should be used on three consecutive stool samples obtained at home by the patient and returned to the physician. Rehydration of samples increases sensitivity but also increases the false positive rates. Sensitivity and specificity of a single test have been estimated at 40% and 96% to 98%, respectively. Hydration of specimen increases sensitivity (60%) but reduces specificity (90%). Annual screening with hydrated specimens detected 49% of all incident cancers, but 38% of all subjects had at least 1 colonoscopy due to positive results. Programs using unrehydrated specimens and/or biennial testing detect a smaller proportion of cancers (27% to 39%) but require fewer colonoscopies (5% to 28%). In 3 recent randomized trials, performing flexible sigmoidoscopy in addition to FOBT yielded approximately 7 additional cancers or large polyps per 1,000 patients compared to FOBT alone. Adding FOBT did not improve the yield over sigmoidoscopy alone at the initial screening in these studies, which used flexible sigmoidoscopy, but did in an earlier study that used rigid sigmoidoscopy. Previous studies have reported high sensitivity (86% to 90%) of DCBE for colorectal cancer and polyps, and high specificity (95%). In the National Polyp Study, however, DCBE detected only 48% of polyps greater than 1 cm.15 Sensitivity might be higher in a typical screening population where the proportion of large polyps is higher. Specificity of DCBE in this study was 85%. Neither DRE nor single office occult testing is recommended in colorectal cancer screening.

18. Summary of Recommendations 1 http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.pdf

19. USPSTF Clinical factors influencing recommendations: Cost effectiveness � likely any strategy ok Choice of strategy individualized based on patient and availability of services Cost effective for prevention is generally defined as = $30,000 per additional year of life gained. Cost effective for prevention is generally defined as = $30,000 per additional year of life gained.



22. Colorectal Cancer FAQs Screening for colon cancer should begin�? Screen all adults beginning at age 50 Earlier if family history or personal risks exist When can I stop screening? FOBT has been proven effective 50-80yo How should I screen for colorectal cancer? Depends on patient and situation. Insurance!!! At what interval should I screen for this method? Depends on method used. FOBT q1, Flex sig q5, ACBE q5-10, Colon q10. There are few data to determine optimal age for starting or stopping screening. FOBT has been proven effective for persons aged 50-80 and sigmoidoscopy is associated with reduced mortality in persons older than 45. One cost-effectiveness model suggests that beginning screening at age 40 rather than at age 50 would offer less than a 1-day average improvement in life expectancy. Randomized trials suggest that a life expectancy of at least 5 years may be required to realize the benefits of screening. There are few data to determine optimal age for starting or stopping screening. FOBT has been proven effective for persons aged 50-80 and sigmoidoscopy is associated with reduced mortality in persons older than 45. One cost-effectiveness model suggests that beginning screening at age 40 rather than at age 50 would offer less than a 1-day average improvement in life expectancy. Randomized trials suggest that a life expectancy of at least 5 years may be required to realize the benefits of screening.

24. Cervical Cancer 13,000 new cases and 4,100 deaths in the US in 2002 Mean age of diagnosis: 47 yrs Risks: early onset of sexual activity, greater number of lifetime partners, HIV, cigarette smoking

25. HPV infection Human papilloma virus (HPV) necessary precursor plus host factors High risk types 16,18 Peak incidence and prevalence in women <25, but most are transient Less prevalent in older women

26. Question: Cervical cancer screening 22 yoF presents for primary care. She has been sexually active since 19, with 2-4 partners per year and uses oral contraception. Her college medical records show a normal pap 1 year ago. You recommend which of the following? Cervical smear for HPV testing Cervical smear for HSV testing Colonoscopy Pap smear now Pap smear in three years

27. Summary of Recommendations

28. Cervical cytology: Pap Smear Sensitivity for single test is 60-80% Most organizations recommend annual screening until 2-3 normal

29. Human papillomavirus (HPV) Human papillomavirus (HPV) testing Limited evidence to determine risk/benefits Trials underway will clarify Useful in decision making for ASCUS If HPV negative with ASCUS, annual screening If HPV positive with ASCUS, refer for colposcopy



32. Cervical Cancer FAQs Do I screen women with a total hysterectomy? NO, if done for benign purposes Do I screen women never sexually active? Although unlikely, most recommend screen >21 At what age can I stop doing pap smears? If adequate prior screening, normal paps and not otherwise high risk: >65 USPSTF or >70 ACS

34. Adult Vaccinations Rates of immunization are improving? 1989 to 2003 in adults >65 years of age Pneumococcal vaccine 15% to 64% Influenza vaccine 33% to 70% 1995 data on younger adults 18-49 years old 12% with indications had received pneumococcal 20% with indications had received influenza Tetanus/diphtheria Only 47% adults had protective antibody levels Overall immunization rates are improving in older adults (age 65) However rates in younger adults at risk for disease / with indications for vaccination are still poor Adult rates lag behind pediatrics rates which are overall >80% and for many diseases well into the 90% range Less than 500 children a year die from vaccine preventable illnesses. In contrast it is estimated that between 50000 to 70000 adults die annually from these two vaccine preventable diseases. Only 47% of adults >20 years old had protective antibody levels to both tetanus and diphtheria in a large serologic survey published in Annals in 2002. This is compared to 91% of children age 6-11yo. Overall immunization rates are improving in older adults (age 65) However rates in younger adults at risk for disease / with indications for vaccination are still poor Adult rates lag behind pediatrics rates which are overall >80% and for many diseases well into the 90% range Less than 500 children a year die from vaccine preventable illnesses. In contrast it is estimated that between 50000 to 70000 adults die annually from these two vaccine preventable diseases. Only 47% of adults >20 years old had protective antibody levels to both tetanus and diphtheria in a large serologic survey published in Annals in 2002. This is compared to 91% of children age 6-11yo.

35. Advisory Committee on Immunization Practices (ACIP) Group of physicians/scientists at CDC Responsible for vaccine recommendations Schedules Notification of changes / shortages Reports published in MMWR www.cdc.gov/mmwr Generally in concert with other medical societies (ACP, AAP, ACOG, AAFP) Part of the CDC that produces the guidelines and recommends immunization schedules and practices in the US. Morbidity and Mortality Weekly ReportPart of the CDC that produces the guidelines and recommends immunization schedules and practices in the US. Morbidity and Mortality Weekly Report

36. The National Childhood Vaccine Injury Act of 1986 Requires healthcare providers to follow directives, record and maintain records and report adverse events Provide appropriate Vaccine Information Statements (VIS) Vaccine Adverse Event Reporting System (VAERS) www.vaers.org (800) 822-7967 Vaccine Injury Compensation Program www.hrsa.gov/osp/vicp (800) 338-2382 Requires health providers to provide VIS for all shots given during childhood. And Td. Influenza and Pneumococcal VIS are available but not required by law. VAERS requires certain reactions to be reported to CDC. Other less serious reactions are optional to report. VICP is a �no-fault� system intended to compensate individuals that have had adverse reactions to vaccines. It was created to avoid civil litigations.Requires health providers to provide VIS for all shots given during childhood. And Td. Influenza and Pneumococcal VIS are available but not required by law. VAERS requires certain reactions to be reported to CDC. Other less serious reactions are optional to report. VICP is a �no-fault� system intended to compensate individuals that have had adverse reactions to vaccines. It was created to avoid civil litigations.

37. Vaccine Information Sheets (VIS) Produced by the CDC and freely available over the internet in pdf format. Use has been required since 1994Produced by the CDC and freely available over the internet in pdf format. Use has been required since 1994

38. VIS � available in many languages The same Td VIS in Arabic Reference for the other languages is provided at the end of this section and freely available on the internet in pdf formatting.The same Td VIS in Arabic Reference for the other languages is provided at the end of this section and freely available on the internet in pdf formatting.

39. Question: Immunizations A 66yo M with a 7 year history of diet controlled-DM comes to your office for a routine visit. After providing appropriate care for his DM, you review his immunization record: Last Pneumococcal vaccine: 7 years ago. Last tetanus: he cannot recall, none documented Your best plan today is: Obtain old records and update shots at next visit Td today, IM Flu if season, and Pneum. in 3 years Td today, IM Flu if season, Pneum. today Td today, Intranasal Flu if season, Pneum. today Td later, Intranasal Flu if season, Pneum. in 3 years

40. Adult Immunization Schedule Only going to discuss the top three vaccines on the chart. Other vaccines may be appropriate for individual patients but� that�s another noon conference in itself In fact Dr. Stamm gave an excellent Update on Vaccines in May 2003 available at our website. Only going to discuss the top three vaccines on the chart. Other vaccines may be appropriate for individual patients but� that�s another noon conference in itself In fact Dr. Stamm gave an excellent Update on Vaccines in May 2003 available at our website.

41. Pneumococcal Vaccines Capsular polysaccharide vaccine First used in 1945 Currently use 23 valent vaccine (1983) Pneumococcal Polysaccharide Vaccine (PPV23) Nonrandomized studies � significant benefit Cochrane Review1 not effective in preventing death or pneumonia Does reduce invasive pneumococcal disease 1 Dear KB G, Andrews RR, Holden J, Tatham DP. Vaccines for preventing pneumococcal infection in adults. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000422. DOI: 10.1002/14651858.CD000422. First vaccine derived from a capsular polysaccharide. First used in 1945 � which was around the same time as penicillin was discovered. Originally not very popular because the prevailing thought was �Why give a vaccine when we have adequate antibiotics to treat the problem?� Dr. Robert Austin in the 1970s promoted a 14 valent vaccine, which later evolved into the 23 valent vaccine that we now use since 1983 Pneumococcal Polysaccharide Vaccine 23 valent (PPV23) More people die from pneumococal disease than any other vaccine preventable disease. Estimated to be 40,000 per year. Thought that as many as half of these deaths could be prevented with increased use of the PPV23. Efficacy of 57% Effects ages <2yo or >65yo primarily Vaccination rates are improving 1989 15% to 2003 64% 2 available preparations Merck: Pneumovax. Lederle: Pnu-Immune 23 with phenol or thimerosal as a preservative Efficacy Nonrandomized studies have demonstrated significant benefit: Cochrane Review mention also Efficacy of 50% then corresponds to a number-needed-to-treat (NNT) of 20,000 vaccinations per infection avoided, and perhaps 50,000 per death avoided. First vaccine derived from a capsular polysaccharide. First used in 1945 � which was around the same time as penicillin was discovered. Originally not very popular because the prevailing thought was �Why give a vaccine when we have adequate antibiotics to treat the problem?� Dr. Robert Austin in the 1970s promoted a 14 valent vaccine, which later evolved into the 23 valent vaccine that we now use since 1983 Pneumococcal Polysaccharide Vaccine 23 valent (PPV23) More people die from pneumococal disease than any other vaccine preventable disease. Estimated to be 40,000 per year. Thought that as many as half of these deaths could be prevented with increased use of the PPV23. Efficacy of 57% Effects ages <2yo or >65yo primarily Vaccination rates are improving 1989 15% to 2003 64% 2 available preparations Merck: Pneumovax. Lederle: Pnu-Immune 23 with phenol or thimerosal as a preservative Efficacy Nonrandomized studies have demonstrated significant benefit: Cochrane Review mention also Efficacy of 50% then corresponds to a number-needed-to-treat (NNT) of 20,000 vaccinations per infection avoided, and perhaps 50,000 per death avoided.

42. Indications for Pneumococcal Vaccine Adapted from MMWR 2003; 52:739-40 Asthma � Yes for flu. No for Pneumococcal Functional or anatomic asplenia (i.e. patients with sickle cell disease) No one should receive more than 2 doses of the vaccine unless they started as a child <10 years old Contraindications include: Previous anaphylactic reaction to vaccine or component Relative contraindication during pregnancyAsthma � Yes for flu. No for Pneumococcal Functional or anatomic asplenia (i.e. patients with sickle cell disease) No one should receive more than 2 doses of the vaccine unless they started as a child <10 years old Contraindications include: Previous anaphylactic reaction to vaccine or component Relative contraindication during pregnancy

43. Influenza Vaccines Epidemiology Annually 36,000 deaths/year in 1990-1999 Complications highest in = 2yo, = 65yo and individuals with certain diseases (DM, asthma) School absenteeism >25%, Lost work productivity, increased medical burden Vaccine products Whole virus vs Split product - intramuscular Live attenuated influenza vaccine (LAIV) In the US accounts for approx. 36,000 deaths/year during the 1990s. 90% of those deaths occurred in people older than 65years However during the last pandemics of flu, those 18-65 accounted for nearly half of deaths (1972) 30 million seek medical care for the flu each year 300K hospitalizations for flu related illnesses. Tremendous cost to the US each year. Children have the highest rates of infection overall for any age groups but complications such as hospitalization, pneumonia and death occur primarily in individuals less than 2 or older than 65. Both whole virus and split product vaccines are appropriate for use in adults and children over the age of 12. Whole virus vaccines tend to cause a greater reaction in children under 12 though. But for us, it is little concern as only split product vaccines are available currently in the US. LAIV is approved for use in healthy individuals 5-49 years of age. Inactivated intramuscular vaccine is for 6 months and older. In 2005 there will be a thimerosal-free vaccine for influenza available. When the vaccine and circulating viruses are antigenically similar, influenza vaccine prevents influenza illness among approximately 70%�90% of healthy adults aged <65 years. Vaccination of healthy adults also has resulted in decreased work absenteeism and decreased use of health-care resources, including use of antibiotics, when the vaccine and circulating viruses are well-matched. In a randomized study among children aged 1�15 years, inactivated influenza vaccine was 77%� 91% effective against influenza respiratory illness and was 44%�49%, 74%�76%, and 70%�81% effective against influenza seroconversion among children aged 1�5, 6�10, and 11�15 years, respectively. In the US accounts for approx. 36,000 deaths/year during the 1990s. 90% of those deaths occurred in people older than 65years However during the last pandemics of flu, those 18-65 accounted for nearly half of deaths (1972) 30 million seek medical care for the flu each year 300K hospitalizations for flu related illnesses. Tremendous cost to the US each year. Children have the highest rates of infection overall for any age groups but complications such as hospitalization, pneumonia and death occur primarily in individuals less than 2 or older than 65. Both whole virus and split product vaccines are appropriate for use in adults and children over the age of 12. Whole virus vaccines tend to cause a greater reaction in children under 12 though. But for us, it is little concern as only split product vaccines are available currently in the US. LAIV is approved for use in healthy individuals 5-49 years of age. Inactivated intramuscular vaccine is for 6 months and older. In 2005 there will be a thimerosal-free vaccine for influenza available. When the vaccine and circulating viruses are antigenically similar, influenza vaccine prevents influenza illness among approximately 70%�90% of healthy adults aged <65 years. Vaccination of healthy adults also has resulted in decreased work absenteeism and decreased use of health-care resources, including use of antibiotics, when the vaccine and circulating viruses are well-matched. In a randomized study among children aged 1�15 years, inactivated influenza vaccine was 77%� 91% effective against influenza respiratory illness and was 44%�49%, 74%�76%, and 70%�81% effective against influenza seroconversion among children aged 1�5, 6�10, and 11�15 years, respectively.

44. Indications for Influenza Vaccine * If 6mo=x<9yo and first-ever dose, repeat in 1 month. <36 mo use 0.25ml dose. If LAIV 2nd dose 6-10wks later Adapted from MMWR June 29, 2007 internet release These recommendations are from the MMWR just released the week of July 13th for the upcoming 2005-06 flu season. Vaccination is associated with reductions in influenza-related respiratory illness and physician visits among all age groups, hospitalization and death among persons at high risk, otitis media among children, and work absenteeism among adults. Added this year are individuals with spinal cord injuries, neuromuscular diseases, aspiration syndromes, seizure disorder or any condition that can impair respiratory function or clearance of secretions. TABLE 4. Inactivated influenza vaccine* dosage, by age group � United States, 2005�06 season Age group� Dose No. of doses Route� 6�35 mos 0.25 mL 1 or 2� Intramuscular 3�8 yrs 0.50 mL 1 or 2� Intramuscular >9 yrs 0.50 mL 1 IntramuscularThese recommendations are from the MMWR just released the week of July 13th for the upcoming 2005-06 flu season. Vaccination is associated with reductions in influenza-related respiratory illness and physician visits among all age groups, hospitalization and death among persons at high risk, otitis media among children, and work absenteeism among adults. Added this year are individuals with spinal cord injuries, neuromuscular diseases, aspiration syndromes, seizure disorder or any condition that can impair respiratory function or clearance of secretions. TABLE 4. Inactivated influenza vaccine* dosage, by age group � United States, 2005�06 season Age group� Dose No. of doses Route� 6�35 mos 0.25 mL 1 or 2� Intramuscular 3�8 yrs 0.50 mL 1 or 2� Intramuscular >9 yrs 0.50 mL 1 Intramuscular

45. Contraindications to Influenza Vaccine Anaphylactic hypersensitivity to eggs Anaphylactic history to vaccine or component Acute febrile illness (relative) Guillain-Barr� syndrome 1976 swine influenza vaccine High risk � probably vaccinate; low risk � probably not No LAIV � if age <5 or >50, or essentially any true indication to receive influenza vaccine 1976 vaccine had increased association with GBS. Annual rate of GBS is 10-20cases/1million Subsequent studies have failed to demonstrate an association except one study of the 1992-93, 1993-94 seasons with the overall RR of 1.7 (95% CI 1.0 to 2.8 p=0.04) representing approx 1 additional case per 1 million vaccinated. Recent data from VAER system have documented decreased occurences with increasing immunization rates.1976 vaccine had increased association with GBS. Annual rate of GBS is 10-20cases/1million Subsequent studies have failed to demonstrate an association except one study of the 1992-93, 1993-94 seasons with the overall RR of 1.7 (95% CI 1.0 to 2.8 p=0.04) representing approx 1 additional case per 1 million vaccinated. Recent data from VAER system have documented decreased occurences with increasing immunization rates.

46. Indications for Tetanus Vaccine Described by Esdall in 1976 as �The inexcusable disease� Incidence in the US 0.16 per million (43/year) Wonderful case review and comments by Drs. Smallheiser and Deb Levine in the Annals not too long ago. Annual incidence of 0.16/million or about 43 cases per year. But very poor levels of immunity in the elderly � who are also at great risk of disease. Contraindications are primarily related to sever hypersensitivity to vaccine or its components in pastWonderful case review and comments by Drs. Smallheiser and Deb Levine in the Annals not too long ago. Annual incidence of 0.16/million or about 43 cases per year. But very poor levels of immunity in the elderly � who are also at great risk of disease. Contraindications are primarily related to sever hypersensitivity to vaccine or its components in past

47. Stop sign insertStop sign insert

48. Tdap Don�t forget� Everyone should receive one Tdap in place of the usual Td booster vaccine�

49. Question: Immunizations A 66yo M with a 7 year history of diet controlled-DM comes to your office for a routine visit. After providing appropriate care for his DM, you review his immunization record: Last Pneumococcal vaccine: 7 years ago. Last tetanus: he cannot recall, none documented Your best plan today is: Obtain old records and update shots at next visit Td today, IM Flu if season, and Pneum. in 3 years Td today, IM Flu if season, Pneum. today Td today, Intranasal Flu if season, Pneum. today Td later, Intranasal Flu if season, Pneum. in 3 years

50. Question: Immunizations A 66yo M with a 7 year history of diet controlled-DM comes to your office for a routine visit. After providing appropriate care for his DM, you review his immunization record: Last Pneumococcal vaccine: 7 years ago. Last tetanus: he cannot recall, none documented Your best plan today is: Obtain old records and update shots at next visit Td today, IM Flu if season, and Pneum. in 3 years Tdap today, IM Flu if season, Pneum. today Td today, Intranasal Flu if season, Pneum. today Td later, Intranasal Flu if season, Pneum. in 3 years

51. Common Resources Internet www.immunize.org www.cdc.gov Palm OS Based and PC versions Shots 2007

52. Question: Osteoporosis screening 58 yo AAF postmenopausal for 3 years, presents for routine visit without complaint. In regards to osteoporosis screening, which of the following are true? She needs a DEXA now She needs 1200 mg of Calcium daily She needs a DEXA at age 60 She needs a DEXA at age 65

53. Osteoporosis Screening Women aged 65 and older (B) Begin at age 60 if increased risk (B) Weight <70kg (154 lbs)- single best predictor Smoking, family history, alcohol, caffeine, low calcium/vitamin D DEXA minimum of 2 years No data on when to stop



56. �Recreational Activities� Sexually Transmitted Diseases Tobacco Alcohol Seat Belts

57. Question: STDs A 24 yoF presents to your clinic asking for a refill of birth control pills. She is monogamous with one partner. She denies h/o STDs, vaginal discharge, or other symptoms and has no PMH. You recommend which of the following? Mammogram Clinical breast exam Chlamydia screening Gonorrhea screening HIV screening

58. STDs Chlamydia ALL sexually active women aged 24 or less regardless of symptoms (A) ALL ages women at increased risk (A) Insufficient evidence for asymptomatic men (I) Gonorrhea All sexually active women if increased risk (B) Insufficient evidence for men at risk (I) HIV & syphilis at increased risk & pregnant (A)

59. Universal HIV screening? September 2006, CDC published All individuals age 13-64 be screened for HIV regardless of risk* USPSTF reviewed the quality and strength of the evidence and maintains C (no recommendation) for those not at increased risk

60. Question: STDs A 24 yoF presents to your clinic asking for a refill of birth control pills. She is monogamous with one partner. She denies h/o STDs, vaginal discharge, or other symptoms and has no PMH. You recommend which of the following? Mammogram Clinical breast exam Chlamydia screening Gonorrhea screening HIV screening

61. Question: STDs A 24 yoF presents to clinic asking for a refill of birth control pills. She is monogamous with one partner. She denies h/o STDs, vaginal discharge, or other symptoms and has no PMH. You recommend which of the following? Mammogram Clinical breast exam Chlamydia screening Gonorrhea screening HIV screening

62. Tobacco, alcohol, seat belts Tobacco Screen all adult patients, including pregnant women, and provide cessation interventions (A) Alcohol Screen all adult patients, including pregnant women, and provide cessation interventions (A) Seat belts (B)

64. Lipid Background Why screen? Primary and secondary prevention trials for CHD Epidemiology Prevalence estimated at 17.5% of men, 20% of women had total cholesterol (TC) = 240 According to National Center for Health Statistics data from 1988 to 1994, 17.5% of men and 20% of women aged 20 to 74 years had high levels of TC (240 mg/dL or greater) According to National Center for Health Statistics data from 1988 to 1994, 17.5% of men and 20% of women aged 20 to 74 years had high levels of TC (240 mg/dL or greater)

65. Summary of RecommendationsWho to screen 1 http://www.ahrq.gov/clinic/ajpmsuppl/lipidrr.pdf 2 JAMA, May 16, 2001�Vol 285, No. 19 2487 3 http://pediatrics.aappublications.org/cgi/reprint/101/1/141.pdf The USPSTF makes no recommendation for or against routine screening for lipid disorders in younger adults (men aged 20 to 35 or women aged 20 to 45) in the absence of known risk factors for coronary heart disease. (C) Screening is recommended for men aged 20 to 35 and women aged 20 to 45 in the presence of any of the following: �- Diabetes � A family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives � A family history suggestive of familial hyperlipidemia � Multiple coronary heart disease risk factors (eg, tobacco use, hypertension) Much controversy regarding the AAP statement as there is little evidence to suggest that any child with elevated cholesterol actually gains any benefit from interventions/treatments. Diets often prove ineffective in lowering total cholesterol or LDL in these children.The USPSTF makes no recommendation for or against routine screening for lipid disorders in younger adults (men aged 20 to 35 or women aged 20 to 45) in the absence of known risk factors for coronary heart disease. (C) Screening is recommended for men aged 20 to 35 and women aged 20 to 45 in the presence of any of the following: �- Diabetes � A family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives � A family history suggestive of familial hyperlipidemia � Multiple coronary heart disease risk factors (eg, tobacco use, hypertension) Much controversy regarding the AAP statement as there is little evidence to suggest that any child with elevated cholesterol actually gains any benefit from interventions/treatments. Diets often prove ineffective in lowering total cholesterol or LDL in these children.

66. Summary of RecommendationsWhat to screen 1 http://www.ahrq.gov/clinic/ajpmsuppl/lipidrr.pdf 2 JAMA, May 16, 2001�Vol 285, No. 19 2487 3 http://pediatrics.aappublications.org/cgi/reprint/101/1/141.pdf The USPSTF concludes that the evidence is insufficient to recommend for or against triglyceride measurement as a part of routine screening for lipid disorders. I recommendation. At least two values are necessary to ensure that the true value is within 10% of the mean of the measurements AAP recommendations vary depending upon other risk factors and indications for screeningThe USPSTF concludes that the evidence is insufficient to recommend for or against triglyceride measurement as a part of routine screening for lipid disorders. I recommendation. At least two values are necessary to ensure that the true value is within 10% of the mean of the measurements AAP recommendations vary depending upon other risk factors and indications for screening

67. USPSTF Optimal intervals to screen are uncertain 5 years perhaps (NCEP/ATP III q5 years) Age to stop screening is unclear Levels are unlikely to rise after age 65 ACP concludes no evidence to screen = 75yo Clinical factors influencing recommendations: TC and HDL can measured non-fasting LDL measurement requires fasting; costly

68. Lipids FAQs At what age should I begin screening adults for lipid abnormalities? Men = 35yo and women = 45yo. (= 20?) At what age should I stop screening? After 65 to 75 years of age What tests should be ordered for screening? Either TC/HDL or fasting lipoprotein analysis How often should I screen if initial values are normal? Every 5 years (?)

70. Question: AAA According to the USPSTF which of the following scenarios is best supported by data in screening for abdominal aortic aneurysms? (Which one should you screen and how?) 77yo W with HTN, DM, CAD +tob; by ultrasound 60yo M with CAD, ? lipids, + tob; by exam 66yo M with CVAs, HTN past tob; by ultrasound 70yo M with HTN, CABG, - tob; by ultrasound 68yo W with CABG, +tob; by exam

71. AAA Background Epidemiology 9,000 annual deaths associated with AAAs Prevalence Men: 4-9% Women: 1% Deaths tend to occur in men >65 and women >80 Risk Factors Age >65, male sex, history of >100 cigarettes, and ? Family History Major risk factors for AAA are smoking (ever in one�s lifetime of >100 cigarettes), age >65 years, and male sex. First degree family history of surgical repair of a AAA elevates a male�s risk not necessarily a female�s risk Majority of deaths related to AAA in women occur after age 80 Report 9000 annual deaths associated with large AAAs Prevalence of AAA in men is estimated to be 4-9% and in women 1%. Almost all deaths from AAA rupture occur in men >65 years and in women >80 years of age. Prevalence of a AAA >5cm in men 65-79 is 0.5%. Strongest risk factor for rupture is maximal diameter. Major risk factors for AAA are smoking (ever in one�s lifetime of >100 cigarettes), age >65 years, and male sex. First degree family history of surgical repair of a AAA elevates a male�s risk not necessarily a female�s risk Majority of deaths related to AAA in women occur after age 80 Report 9000 annual deaths associated with large AAAs Prevalence of AAA in men is estimated to be 4-9% and in women 1%. Almost all deaths from AAA rupture occur in men >65 years and in women >80 years of age. Prevalence of a AAA >5cm in men 65-79 is 0.5%. Strongest risk factor for rupture is maximal diameter.

72. Abdominal Aortic Aneurysm Screening Methods of Screening Exam Ultrasonography CT scan MRI Interventions Observation and repeat study Surgical Repair Ultrasonography has a sensitivity of 95% and specificity of nearly 100% when performed in a setting with adequate quality assurance. Open Surgical Repair remains the only proven method of decreased AAA mortality in the long term, Endovascular Aneurysm Repair is now frequently used. EVAR has lower short-term mortality rate 1%. Conversion to open procedure is about 2%. If converted to open mortality is 24%. Operative mortality for open surgical repair of an AAA is 4% to 5%, and nearly one-third of patients undergoing this surgery have other important complications (e.g., cardiac and pulmonary). Additionally, men having this surgery are at increased risk for impotence. Open Repair in-hospital mortality to be 4.2%. Complication rate of elective surgery approx. 32% (including graft infection, MI, renal failure, and other forms of ischemia) Ultrasonography has a sensitivity of 95% and specificity of nearly 100% when performed in a setting with adequate quality assurance. Open Surgical Repair remains the only proven method of decreased AAA mortality in the long term, Endovascular Aneurysm Repair is now frequently used. EVAR has lower short-term mortality rate 1%. Conversion to open procedure is about 2%. If converted to open mortality is 24%. Operative mortality for open surgical repair of an AAA is 4% to 5%, and nearly one-third of patients undergoing this surgery have other important complications (e.g., cardiac and pulmonary). Additionally, men having this surgery are at increased risk for impotence. Open Repair in-hospital mortality to be 4.2%. Complication rate of elective surgery approx. 32% (including graft infection, MI, renal failure, and other forms of ischemia)

73. Summary of Recommendations 1 http://www.ahrq.gov/clinic/uspstf05/aaascr/aaars.pdf 2 Kent KC, et al. Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg. 2004;39:267�269. The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. C recommendation. The USPSTF recommends against routine screening for AAA in women. D recommendation. These groups further recommend the following courses of action after screening: no further testing if aortic diameter is less than 3.0 cm; yearly ultrasonographic screening if aortic diameter is between 3.0 to 4.0 cm; ultrasonography every 6 months if aortic diameter is between 4.0 to 4.5 cm; and referral to a vascular specialist if aortic diameter is greater than 4.5 cm. The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. C recommendation. The USPSTF recommends against routine screening for AAA in women. D recommendation. These groups further recommend the following courses of action after screening: no further testing if aortic diameter is less than 3.0 cm; yearly ultrasonographic screening if aortic diameter is between 3.0 to 4.0 cm; ultrasonography every 6 months if aortic diameter is between 4.0 to 4.5 cm; and referral to a vascular specialist if aortic diameter is greater than 4.5 cm.

74. USPSTF Clinical factors influencing recommendations: Effect of screening Harm of screening Cost effectiveness similar to other measures NNS Male smokers: 500 Male nonsmokers: 1783 Effect of screening women under age 80 had little impact on mortality given other confounding illnesses. In men 65-74 Number needed to screen to prevent one AAA related death in the next 5 years: Nonsmokers: 1783 Smokers: 500 Abnormal screening had significant impact on other quality of life measures scoring lower for the next 12 months before returning to baseline. Cost effectiveness similar to other preventive measures. Effect of screening women under age 80 had little impact on mortality given other confounding illnesses. In men 65-74 Number needed to screen to prevent one AAA related death in the next 5 years: Nonsmokers: 1783 Smokers: 500 Abnormal screening had significant impact on other quality of life measures scoring lower for the next 12 months before returning to baseline. Cost effectiveness similar to other preventive measures.



78. WWWD(What Would We Do?) Breast cancer Colon cancer Cervical Cancer Women age 40-69 every 1-2 years Screen all age = 50 with annual FOBT min., other screening based on situation Women 21-70 annually for 2-3 years, then every 3 years, but continue annually if high risk

79. WWWD? Vaccinations Osteoporosis STDs Tobacco/Alcohol/Seat Belts Review status annually Women over 65 Women <25 annually for chlamydia HIV for high risk +/- all All patients

80. WWWD? Lipids AAAs M 20-35 W 20-45 once M =35 W =45 q 5year Stop after age 75 Males 65-75 who have ever smoked

82. Plenty of other topics not discussed� Screening for DM Screening for HTN Routine labs Prostate cancer screening Vaccines HPV Hep B Mening.

Preventive Health Maintenance

Preventive Health Maintenance

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Preventive Maintenance

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