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Preventive medicine
1. PREVENTIVE MEDICINE
Vaccines
Smoking cessation
AAA screening
Lipids
DM Screening
Osteoporosis
Cancer screening - Oncology
Seat belts
Safety issues in children
Jet Lag
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4. MMR
Absolute contraindications
– Anaphylactic reaction to eggs is no longer a
contraindication to MMR.
– Pregnancy
– Immunodeficiency ( in HIV, MMR is recommended if CD4
> 200 as benefits outweigh risks )
Conditions that are not a contraindication to
vaccine
–
–
–
–
–
Tuberculosis or positive PPD
Lactation
Pregnancy in household contact or mother
Household contact with Immunodeficiency (e.g. HIV)
Anaphylactic reaction to egg or neomycin is no longer a
contraindication to MMR
5. Note:
Pregnant women should wait to get
MMR vaccine until after they have
given birth. Women should avoid
getting pregnant for 4 weeks after
getting MMR vaccine.
6. Influenza
Inactivated vaccine
Indications
Age 65 years and older
Children aged 6 months to 18 years
Nursing Home residents
Patients with Chronic cardiopulmonary disease (e.g. Asthma):
any age
Long term Aspirin use under age 18 years - Prevents Reye's
Syndrome
People who can serve as vectors
–
Health care workers , Nursing home personnel , Family members of
high risk patients, Families and child care workers caring for children
under age 5 years
Students in Institutional settings
Pregnancy – 2nd or 3rd tromester
Human Immunodeficiency Virus
Breast Feeding
–
–
–
Contraindications
Age under 6 months
Anaphylaxis to eggs or other vaccine components
Acute febrile illness ( Temp > 104 F)
7. Meningococcal Vaccine
A routine vaccination ( Meningococcal
conjugate vaccine, MCV4) is recommended at
age 11-12 years or at high school entry if not
previously vaccinated ( age 15 years)
MPSV4 should be used for children 2 to 10
years old, and adults over 55, who are at risk
In other age groups, recommended for
patients who are at increased risk of
meningococcal disease
8. Meningococcal vaccine
The populations at increased risk for
meningococcal disease:
college freshmen living in dormitories
microbiologists who are routinely exposed to isolates
of N. meningitdis
military recruits
persons who travel to or reside in countries in which
N. meningitdis is hyperendemic or epidemic,
particularly if contact with the local population will be
prolonged
persons who have terminal complement component
deficiencies
persons who have anatomic or functional asplenia or
in HIV patients
9. Chemoprophylaxis
The primary mode of prevention of sporadic
meningococcal disease involves antimicrobial
chemoprophylaxis of close contacts of a patient
with invasive meningococcal disease). (YOU SHOULD
KNOW WHO IS A CLOSE CONTACT!!)
Who needs it? – all close contacts of a patient with
meningococcal disease. Oropharyngeal or
nasopharyngeal cultures of contact are not useful in
determining the need for chemoprophylaxis ( don’t do
them)
When ? Chemoprophylaxis should be given ASAP
(ideally <24 hours after identification of the index
patient) because the rate of secondary disease for
close contacts is highest immediately after onset of
disease in the index patient, chemoprophylaxis given
after 14 days of onset of illness in the index patient is
of no value.
10. Chemoprophylaxis
One of the following chemo-prophylactic agents can
be used
Rifampin : can be used in children and adults.
Not recommended in pregnancy due to teratogenecity in
animals.
Also, remember contraceptive failure can occur from Rifampin
interaction with OCPills so, if a reproductive age group
women is taking Rifampin counsel her regarding the use of
alternative contraceptive measures while taking Rifampin
Ciprofloxacin : can be used in adults.
Not recommended for people < age of 18 years and in
Pregnancy or lactation because it was known to cause
cartilage damage inimmature experimental animals.
However, literature review indicates no reports of irreversible
cartilage damage in children or adolescents so, if no other
alternative is available, it can be used for chemoprophylaxis in
this age groups.
Ceftriaxone : single IM dose – 250mg in adults and 125mg in
children
11. Who are defined Close contacts for patients with
Menigococcal disease?
Close contacts of a patient who has meningococcal
disease include
household members
child-care center contacts
persons directly exposed to the patient’s oral
secretions (e.g., by kissing, mouth-to-mouth
resuscitation, endotracheal intubation,or
endotracheal tube management).
(REMEMBER People in the same household or
day-care center, or anyone with direct contact
with a patient's oral secretions (such as a
boyfriend or girlfriend) is at increased risk of
acquiring the infection )
12. Quiz
A 24 y/o college freshman who lives in a dormitory brought
to the ER with complaints of fever, headache and neck
stiffness. Lumbar puncture revealed gram negative
diplococci. He was started on ceftriaxone and vancomycin.
However, over the next two hours he develops complicated
disease with renal failure and purpura. He becomes
comatose and was intubated by the anesthetist for airway
protection. After knowing that the patient likely has a
meningococcal disease, the ER staff, the anesthetist and
the residents who initially cared for the patient are very
concerned and requests chemoprophylaxis. What is the
most appropriate course of action?
Give Rifampin to the resident who collected blood from the
patient
Give Rifampin to the anesthetist
Give Ceftriaxone to the RN who took care of the patient
Give Rifampin to the ER physician who initially evaluated
the patient
13. Pneumococcal Vaccine
Two types
Pneumococcal Conjugate vaccine ( 7 valent – PCV7)
– pediatric vaccine, given to infants and toddlers < 2
yrs of age)
Pneumococcal Polysaccharide vaccine ( 23 valent
vaccine - PPV) Adult vaccine, given to adult
children > 2yrs of age and adults with certain chronic
illnesses)
Pneumococcal vaccine is indicated because
it can reduce common Streptococcus
Pneumoniae infections (age <6)
Community acquired Pneumonia
Otitis media
Bacterial Meningitis
Prevents Streptococcus bacteremia
14. Pneumococcal Conjugate Vaccine
Infants and Children Under 2 Years of Age
PCV is given as a series of 4 doses, one dose at each of these ages: 2
months, 6 months, 4 months and 12-15 months
Children who miss their vaccines at these ages should still get the
vaccine. The number of doses and the intervals between doses will
depend on the child’s age.
Children 2 through 4 Years of Age
Healthy children between their 2 through 4 years of age who have not
completed the PCV series should get 1 dose.
Children with medical conditions such as:
– -sickle cell disease
– Asplenia,
– Cochlear implants,
– HIV/AIDS or other diseases that affect the immune system (such as
diabetes, cancer, or liver disease)
– chronic heart or lung disease
– children on immunosuprressive medications medications such as
chemotherapy or steroids
IN THESE CHILDREN, GIVE 2 DOSES 2 MONTHS APART IF THEY HAVE NOT
COMPLETED THE FOUR DOSE SERIES.
Age 5 years or older this vaccination not recommended
15. Pneumococcal Polysaccharide Vaccine
Children under < 2yrs of age may not respond to this vaccine
– so, not used.
Indications:
All adults 65 years of age or older.
Anyone over 2 years of age who have chronic illness : heart disease,
lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis
Anyone over 2 years of age with immunosuppressive disease/
condition: Hodgkin’s disease, lymphoma, leukemia, kidney failure,
multiple myeloma, nephrotic syndrome, HIV infection or AIDS,
damaged spleen, or no spleen, organ transplant
Anyone over 2 years of age taking immunosuppressive therapy
long-term steroids, certain cancer drug, radiation therapy
Alaskan Natives and certain Native American populations.
One dose of PPV is sufficient. However, in some classes two
doses recommended – next slide
Pregnancy ? the safety of pneumococcal vaccine in
pregnancy not established. Women who are at risk for this
infection should get vaccinated prior to their pregnancy.
16. PPV – Repeat Dose
One dose of PPV is sufficient. In some conditions,
a second dose is indicated :
For those people aged 65 and older who got their
first dose when they were under 65, if 5 or more
years have passed since that dose.
A second dose is also recommended for people
who:
- have a damaged spleen or no spleen
- have sickle-cell disease
- have HIV infection or AIDS
- have cancer, leukemia, lymphoma, multiple myeloma
- have kidney failure
- have nephrotic syndrome
- have had an organ or bone marrow transplant
- are taking medication that lowers immunity (such as
chemotherapy or long-term steroids)
In Children 10 years old and younger, give this
second dose 3 years after the first dose. If older
than 10, give it 5 years after the first dose.
17. Hepatitis A vaccine
Indications
– Persons traveling to or working in countries endemic with infection
(Start vaccine at least 4 weeks before departure )
– Men who have sex with men
– Drug use
– Persons who work with HAV-infected primates or with HAV in a
research laboratory setting
– Persons with chronic liver disease
– Persons with clotting factor disorders
– Food handlers where health authorities or private employers determine
vaccination to be cost-effective
– All children as Primary Series at age 1 year (New recommendation in
U.S. as of 2006 ) – children may act as reservoirs/vaccination may
eradicate infection from population
NOTE : HAV vaccine is safe in HIV patients – but having HIV itself is
not an absolute indication. HAV vaccine should be given to all HIV
pts that are at risk or those who have HCV to avoid
fulminant hepatitis
Contraindications: A history of hypersensitivity to alum or
the preservative 2-phenoxyethanol
18. Hepatitis B Vaccine
Children and Adolescents
All children should get their first dose of hepatitis B vaccine at
birth and should have completed the vaccine series by 6-18
months of age.
Children and adolescents through 18 years of age who did not get
the vaccine when they were younger should also be vaccinated.
Adults : All unvaccinated adults at risk for HBV infection
should be vaccinated. This includes:
sex partners of people infected with HBV,
men who have sex with men,
IV Drug users
people with more than one sex partner,
chronic liver or kidney disease,
Health care/ lab workers handling human blood
household contacts of people infected with HBV,
residents and staff in institutions for the developmentally disabled
Hemodialysis Patients
HIV Patients
Contraindications Anaphylactic reaction to baker's yeast
19. Polio
Indications
Health care workers in close contact with
patients excreting wild poliovirus or who
handle lab specimens from such patients.
Travelers to developing countries
In immunocompromised patients ( hiv), if
polio vaccine is indicated – give IPV.
Household members and nursing
personnel in close contact with
immunocompromised patients should not
receive OPV ( They should be given IPV)
20. Polio Vaccine
Contraindications
IPV:
Pregnancy
Anaphylactic allergy to streptomycin or
neomycin.
OPV:
If the Vaccine recipient or if prospective vaccine
recepient;’s household contact is immunodeficient
or immunosuppressed (including HIV infection)
Pregnancy - only a relative contraindication. If
immediate protection is needed, use OPV.
• Anaphylactic allergy to neomycin or streptomycin
22. –
–
–
–
–
–
–
–
–
–
–
Live Vaccines that are contraindicated in HIV
Varicella Vaccine
Oral Polio Vaccine ( IPV is safe)
Oral typhoid vaccine ( parenteral inactivated typhoid vaccine is safe
alternative)
Yellow fever vaccine (Yellow fever vaccine virus poses a theoretical
risk of encephalitis to those with severe immunosuppression or
known HIV infection such patients should not receive the vaccine.
If travel to an endemic area unavoidable, patients should be advised
of the risk, instructed in methods for avoiding vector mosquitos, and
supplied with vaccination waiver letters by their physicians .
Live Vaccines in HIV that are indicated because Benefit exceeds
Risk
Measles Mumps Rubella Vaccine (MMR Vaccine)
Non-Live Vaccines indicated in HIV
Immunogenecity will be better if the CD4 count is higher. If you are
starting HAART, Consider delaying the vaccination until CD4
Count>200. Vaccination is optional in patients with low CD4 despite
therapy.
Pneumovax Vaccine
Given after diagnosis and then every 6 years
Conjugated H Influenza type b capsular vaccine
Influenza Vaccine ( Inactivated vaccine)
Hepatitis A Vaccine (it’s a killed vaccine) in at risk patients and
those with HCV
Hepatitis B Vaccine if anti-hbs is negative.
24. Varicella Vaccine
Popular brand – Varivax
Live virus vaccine
Indications ( CDC 1999)
Children > 1 year of age without prior infection
In adults who never have been vaccinated or never had chicken pox for Post
chicken pox -exposure vaccination within 3-5 days can reduce the incidence
of chickenpox
Non Pregnant women of childbearing age who are not immune (Pregnant
women should wait until after they give birth to receive the vaccine. Women
should not get pregnant until four weeks after the vaccine)
Susceptible family members and other contacts of HIV-infected or
immunodeficient persons should receive the chickenpox vaccine, because
of the risk that natural chickenpox and its complications present for these
patients.
persons who live or work in environments in which transmission of VZV is
likely (e.g., teachers of young children,
day care employees, and residents and staff members in institutional
settings)
persons who live and work in environments in which transmissioncan
occur (e.g., college students, inmates and staff members of correctional
institutions, and military personnel)
international travelers
adolescents and adults living in households with children.
CDC (2007) RECOMMENDS VACCINATION FOR ALL ADULTS AND
ADOLESCENTS WITHOUT EVIDENCE OF IMMUNITY ( Check antibody, if
not present just immunize)
Many states have mandatory requirement of chicken pox
immunization prior to attending child care centers, students in all
grade levels, persons attending college or other postsecondary
educational institutions evidence of immunization needs to be
submitted before entering the institution eg: evidence of immunity
includes – see next slide
25. Varicella Vaccine – Evidence of immunity
Evidence of immunity includes
– Documentation of two doses of varicella vaccine
– Blood tests that show you are immune to varicella
or laboratory confirmation of prior disease
– Born in the United States before 1980, excluding
health-care workers, pregnant women, and
immunocompromised persons. These individuals
need to meet one of the other criteria for evidence
of immunity.
– Receipt from a healthcare provider of a) a
diagnosis of chickenpox or b) verification of a
history of chickenpox
– Receipt from a healthcare provider of a) a
diagnosis of herpes zoster (shingles) or b)
verification of a history of herpes zoster
(shingles).
No need the chickenpox vaccine, if any of the
above criteria for evidence of immunity is met
26. Varicella Vaccine
Contraindications
– in pregnancy ( to prevent congenital varicella). Also, women should
not get pregnant for four weeks following vaccination
– Anaphylactic reaction to neomycin
– Active Tuberculosis.
– Should not be given for 5 months following the receipt of antibodycontaining (e.g., blood transfusion) products ( as it can inactivate
vaccine virus)
– Hx of congenital immune deficiency in a first degree relative
– Immunosuppressed patients eg: AIDS (remember mild HIV is not a
contraindication. Should be considered for HIVinfected children
with age specific CD4+ T-lymphocyte lymphocyte percentages
>15% and may also be considered in adults with CD4 > 200 ),
high dose steroids
– May be safe in Lactation
– Realize that low grade fever, pregnant family member are not a
contraindication
Vaccine protocol ( CDC – 2007 recommendations require 2 doses
for all age groups listed)
Age under 13 years – Administer 2 doses recommended
- 1st dose at age 12–15 months
- 2nd dose at age 4–6 years
If giving after age over 13 years – give 2 doses 2 doses,
4–8 weeks apart
If giving in early HIV – give 2 doses 3 months apart
27. VZIG
Varicella zoster immune globulin (VZIG) used to prevent
disease after exposure to chickenpox But it is costly
and only provides temporary protection hence, VZIG is
recommended only for those at high risk of developing
severe disease who are not eligible to receive chickenpox
vaccine. (All other patients should get varivax in 3-5 days
post exposure) The groups that cannot get Varivax and
hence, the need for VZIG :
Newborns whose mothers have developed chickenpox 5 days
prior to 2 days after delivery ( un vaccinated newborns of these
mothers may develop fatal varicella)
Premature babies exposed to varicella in the first month of life
Children with leukemia or lymphoma who have not been
vaccinated
Persons with cellular immunodeficiencies or other immune system
problems eg: Advanced HIV
Persons receiving immunosuppressive medications – high dose
steroids, immunosuppressants etc
Pregnant women
VZIG best effective only if given within 96 hrs of
exposure to Varicella (chickenpox) or to Zoster. Rx after 96
hrs is of uncertain value.
Varicella vaccine and VZIG never given together ( varicella
is a live vaccine and will be ineffective)
Contraindications : hx of prior serious reaction to human
immunoglobulin or severe thrombocytopenia
28. Quiz
A 8 years old boy brought to you by his
mom for office visit. He is healthy and
attends school. One of his friends at school
became sick with chickenpox. Boy didn't
get any chickenpox vaccine before. Mom
asks you what to do?
1. Give Ig.
2.give vaccine
3. Give Ig and vaccine.
4 do nothing
5. Give acyclovir
29. Varicella Zoster Vaccine
Popular brand – Zostavax
A live attenuated vaccine of VZV
Indicated in elderly patients age equal to or greater than 60
to prevent herpes zoster and to reduce its sequelae such as
post herpetic neuralgia.
Dose : given 0.65 ml sub cutaneous in deltoid
Contraindications : ( Realize that the virus load injected
here is 14 times greater than in Varivax)
– Hx of anaphylactic reaction to Gelatin, Neomycin or any other vaccine
components.
– Hx of immunodeficiency eg: leukemia, lymphoma, advanced HIV
– Persons with active, untreated tuberculosis
– Persons receiving immunosuppressive therapy, including high dose
steroids.
– Concomitant acute febrile illness with fever > 102
Side effects : Rash similar to chicken pox or Shingles can
commonly occur after vaccine.
Immunity lasts for 4 years
30. VZV vaccine – Why important?
Vaccine reduces incidence of herpes
zoster by 50% ( Number needed to treat
= 60 i.e; 60 patients need to be treated to
prevent one case. NNT = 1/incidence so
realize that higher incidence can mean
lower NNT, making the successful
intervention more cost effective.) so,
since shingles is more common in age >
60, vaccine is most cost effective in this
age group.
Post herpetic neuralgia is the most
debilitating complication of Herpes Zoster
VZV vaccine reduces PHN by 66%
32. A. These vaccines only have a very Small risk in controlled animal studies
– Td (Tetanus and Diphtheria Toxoid) - Give after first trimester if the last dose
was more than 10 years
– Hepatitis A Vaccine -Give if patient is travelling to endemic area or hx of IVDA
in pregnancy
– Hepatitis B Vaccine - Recommended in pregnancy if they have Hepatitis B risk
factor (having more than one sex partner during the previous 6 months, been
evaluated or treated for an STD, recent or current injection drug use, or having
had an HBsAg-positive sex partner
– Influenza Vaccine - Indicated in all pregnan woman in Influenza season, Give
after first trimester ( inactivated vaccine should be used. Not live attenuated
influenza vaccine)
– Polyvalent pneumococcal Vaccine - preferably, avoid during pregnancy
– Polio Vaccine (live and inactivated) - Avoid during pregnancy. But if high risk
polio exposure may give IPV
– Rabies Vaccine for post exposure prophylaxis
B. These vaccines have strong evidence of risk to the human fetus
– Yellow Fever Vaccine (Live vaccine) – AVOID! ( should be given only if travel to
endemic area is unavoidable and if risk of exposure determined as high)
C. These have Very high risk to the human fetus : CONTRAINDICATED!
– Measles Vaccine
– Mumps Vaccine
– Rubella Vaccine
– BCG vaccine
– Small Pox Vaccine ( but pregnant women with defibitive evidence of small pox
exposure should be vaccinated as benefit outweighs risk )
– Varicella Vaccine (Varivax) – theoretic risk of congenital varicella. So, avoid! If
pregnant woman is exposed to chicken pox, use VZIG
D. Quadrivalent HPV vaccine is not recommended for use in pregnancy. ( Data
33. MMR - Pregnancy
Measles-mumps-rubella (MMR) vaccine and its component
vaccines should not be administered to pregnant women.
A risk to the fetus from administration of these live virus vaccines
cannot be excluded for theoretical reasons So, women should
be counseled to avoid becoming pregnant for 28 days after
vaccination with MMR or its components.
If vaccination of an unknowingly pregnant woman occurs or if she
becomes pregnant within 4 weeks after MMR vaccination, she
should be counseled about the theoretical basis of concern for the
fetus Remember, however, MMR vaccination during pregnancy
should not be regarded as a reason to terminate pregnancy
Rubella-susceptible women who are not vaccinated because they
state they are or may be pregnant should be counseled about the
potential risk for CRS and the importance of being
vaccinated as soon as they are no longer pregnant. but,
never give vaccine during pregnancy.
Women who inadvertently received Rubella vaccine should be
counseled about theoretical risk of CRS but its not an indication to
terminate pregnancy A registry of susceptible women
vaccinated with rubella vaccine between 3 months before and 3
months after conception – the "Vaccine in Pregnancy (VIP)
Registry" – was kept between 1971 and 1989. No evidence of CRS
occurred in the offspring of the 226 women who received the
current RA 27/3 rubella vaccine and continued their pregnancy to
term.
34. Quiz
A 35 y/o woman comes for an antenatal visit. Her
LMP was 8 weeks ago. She tells you that she 2
weeks after she missed her menstrual period she
checked herself with home pregnancy kit and
tested positive. She is concerned now because
she received Rubella vaccination 4 weeks ago
after an exposure without knowing that she was
pregnant. She read about the dangers to fetus on
the internet and is very worried now. The next
step in management :
A. Refer her to medical termination of pregnancy
B. Tell her that there is a high established risk to
fetus and she should strongly consider
termination of pregnancy
C. Counsel her about theoretical risk to fetus and
continue pregnancy care
D. Administer Rubella immunoglobulin
E. Reassure her that there is no risk to fetus.
35. Yellow fever Vaccine
Live attenuated vaccine
Indications: Travel to Yellow Fever
endemic areas
Sub-Saharan Africa
Amazon basin of South America
Contraindications
Immunocompromised Patient : HIV Infection and
those on Immunosuppressive medications
Pregnancy (relative contraindication, if the travel is
unavoidable while pregnant, you can use it!)
Infant under age 6 months
Hypersensitivity to egg products
Effectiveness lasts for 10 years
36. Human Papilloma Virus Vaccine ( Gardasil)
Indications
Prevention of Cervical Dysplasia – use in
women routinely at age 12 . If not
vaccinated at age 12, you can give for age
below 26 yrs of age. After that, no benefiit
This vaccine is a mixture of primary
capsid proteins of 4 HPV types that
cause genital warts ( 6 & 11) and
that cause cervical cancer ( 16 & 18)
Given IM in 3 doses Schedule: 0,
2, and 6 months
38. Smoking Cessation
At first visit, ask patient for tobacco use.
(The USPSTF strongly recommends that clinicians screen all adults for
tobacco use and provide tobacco cessation interventions for those
who use tobacco products; and that clinicians screen all pregnant
women for tobacco use and provide augmented pregnancy-tailored
counseling to those who smoke )
Counsel all patients about smoking cessation at
least during first visit and then, at each follow-up
visit.
Repeated encouragement is important
Some Important Benefits of Smoking cessation :
In COPD patients , After 5 years, smoking cessation
produced a reduced decline in FEV1
Reductions in fatal and nonfatal cardiovascular disease and
coronary heart disease.
Reduces the overall mortality
Reduces the incidence of lung cancer
Smoking cessation during 1st trimester pregnancy can
substantially reduce the number of pre-term births.
39. Smoking Cessation
Drug interventions : These interventions
are aimed to reduce the withdrawl
symptoms in a patient who has strong
intention to quit smoking
Bupropion for 8 to 12 weeks. Ask the patient set a
smoking cessation date for about 1 week after
starting therapy
Nicotine replacement therapy : Several preparations
available eg: transdermal patch, nicotine gum,
nicotine nasal spray, and nicotine inhalers. There is
no difference between these preparations in their
effectiveness. Started on highest dose and then
tapered off over several weeks.
Varenecline : New drug that’s been shown to be
effective in smoking cessation by reducing craving
and curbing the desire to smoke.
40. USPTF Recommendation Grades
A—Strongly Recommended: The USPSTF
strongly recommends that clinicians provide
[the service] to eligible patients. The USPSTF
found good evidence that [the service]
improves important health outcomes and
concludes that benefits substantially
outweigh harms.
B—Recommended: The USPSTF
recommends that clinicians provide [the
service] to eligible patients. The USPSTF
found at least fair evidence that [the service]
improves important health outcomes and
concludes that benefits outweigh harms.
C—No Recommendation: The USPSTF
makes no recommendation for or against
routine provision of [the service]. The
USPSTF found at least fair evidence that [the
service] can improve health outcomes but
concludes that the balance of benefits and
harms is too close to justify a general
recommendation.
D—Not Recommended: The USPSTF
recommends against routinely providing [the
service] to asymptomatic patients. The
USPSTF found at least fair evidence that [the
service] is ineffective or that harms outweigh
benefits.
I—Insufficient Evidence to Make a
Recommendation: The USPSTF concludes
that the evidence is insufficient to
recommend for or against routinely providing
[the service]. Evidence that the [service] is
effective is lacking, of poor quality, or
conflicting and the balance of benefits and
harms cannot be determined.
Quality of Evidence
The USPSTF grades the quality of the overall
evidence for a service on a 3-point scale
(good, fair, poor):
Good: Evidence includes consistent results
from well-designed, well-conducted studies in
representative populations that directly
assess effects on health outcomes.
Fair: Evidence is sufficient to determine
effects on health outcomes, but the strength
of the evidence is limited by the number,
quality, or consistency of the individual
studies, generalizability to routine practice,
or indirect nature of the evidence on health
outcomes.
Poor: Evidence is insufficient to assess the
effects on health outcomes because of
limited number or power of studies,
important flaws in their design or conduct,
gaps in the chain of evidence, or lack of
information on important health outcomes.
42. USPTF Recommendations
Screening Men
Screen all men aged 35 and older for lipid disorders (Grade A)
Screening men aged 20 to 35 for lipid disorders if they
are at increased risk for coronary heart disease. (GradeB).
Screening Women at Increased Risk
Strongly recommends screening women aged 45 and
older for lipid disorders if they are at increased risk for
CAD.
(Grade: A).
Screen women aged 20 to 45 for lipid disorders if they
are at increased risk for CAD.
(Grade: B).
Screening Young Men and All Women Not at
Increased Risk
The USPSTF makes no recommendation for or against
routine screening for lipid disorders in men aged 20 to
35, or in women aged 20 and older who are not at
increased risk for coronary heart disease.
(Grade: C).
A repeat level should be obtained every 5 years if the
first test was normal
43. Lipid Screening
All these patients should get a
fasting lipid panel as a screening test
: In general, screen people with
increased risk for CAD
Diabetes ( or any other CAD equivalent),
A positive family history of premature CVD
A family history of dyslipidemia
evidence of hyperlipidemia on physical
examination ( Xanthomas, xanthelesmas
etc)
increased risk of CAD with two or more
other cardiovascular risk factors ( Male sex,
Hypertension, smoking etc).
44. When to stop?
There are no data on at what age
screening should be stopped.
However, available data suggest that
lipid-lowering treatment is effective
in elderly patients up to age 80
Patients over age 80 have not been
well studied.
45. Type 2 DM
Screening
Screening is with Fasting blood sugar –
fasting blood sugar greater than or equal to
126 mg% , on two separate occasions
confirms DM ( Also, Random blood glucose
> 200 with symptoms indicate DM but it
needs confirmation with a fasting blood
sugar on another day)
46. USPTF Recommendations
Screen all asymptomatic patients with
sustained blood pressure ( either treated
or untreated) > 135/80 mm hg ( that
means all patients with “Hypertension”
must be screened )
USPSTF says that there is insufficient
evidence to recommend screening for type
2 diabetes in asymptomatic adults with
blood pressure of 135/80 mm Hg or lower
( “I” recommendation)
Eventhough, its not USPTF
recommendation, screen all patients with
hyperlipidemia also for diabetes ( ADA
recommendation)
47. OSTEOPOROSIS
Screen with DEXA scan
Start Calcium + vitamin D in post
menopausal Women
Rx with Bisphosphonates
Prevent Steroid Induced Osteoporosis
Screening test : DEXA scan
(T score)
To monitor treatment efficacy or to rescreen, repeat DEXA scan every 2 years
48. USPTF Recommendations
All women aged 65 and older be screened
routinely for osteoporosis. (Grade B)
For women with risk factors, screening should
begin at age 60 ( RISK FACTORS : Low Body
mass index ( < 127lbs), short women, smokers,
Family hx of osteoporotic fracture, personal
history of osteoporotic fracture as an adult), use
of steroids for more than 3 months and
consumption of alcohol > 2 drinks per day)
( Grade B)
The USPSTF makes no recommendation for or
against routine osteoporosis screening in
postmenopausal women who are younger than 60
or in women aged 60-64 who are not at increased
risk for osteoporotic fractures. ( Grade C)
49. Steroid Induced Osteoporosis
In patients requiring prolonged
steroid therapy ( > 3 months) :
Use calcium and vitamin D to prevent
osteoporosis.
Obtain baseline Dexa scan.
If baseline Dexa scan reveals osteopenia or
osteoporosis, start Bisphosphonates also.
Repeat Dexa scan in one year.
Stress induced amenorrhea +
osteoporosis/ stress fractures/ anorexia
nervosa – these entities discussed under
Gyn section
51. Probable Risk Factors
Risk Factors for Abdominal Aortic
Aneurysm
OR or RR
Importanc
e
Age >60 years
OR, 1.93
High
Male sex
5.6-12.21
High
Smoking
1.8-5.57
High
First-degree relative with history of
AAA
4.3
High
Hypertension
1.4 (diastolic)
Low
Possible Risk Factors
Peripheral vascular disease
Low
Coronary artery disease
Low
Height
Low
53. Key Points because it is
Use ultrasound to screen for AAA,
more sensitive and specific than abdominal
palpation.
Recommend one-time screening for AAA
with ultrasound to asymptomatic men aged
65 to 79 years, especially those who are or
have ever been smokers.
Do not screen women for AAA, because no
benefit has been shown in this group.
Do not repeat screening for persons whose initial
screening test is normal.
Refer patients with an AAA 5.5 cm in diameter to
a vascular surgeon for consideration of elective
repair
Recognize that data from randomized clinical
trials indicate that ultrasound screening for AAA
54. AAA
Be aware that physical exam is only moderately
sensitive for detecting an AAA >5.0 cm in diameter
and is even less sensitive for smaller diameters or in
obese patients; it does not rule out an aneurysm if
normal; and if a pulsatile mass 3 cm is palpated, it is
highly suggestive of AAA and should be confirmed
by ultrasonography.
Consider ultrasound as the preferred test for AAA
screening, with a sensitivity for large AAAs and a
specificity of nearly 100%; note that minor
measurement variations (usually <0.5 cm) may
result in misclassification of some borderline cases.
Repeat measurements of AAAs <5.5 cm periodically
with ultrasound to determine when elective repair
should be performed (every 6 months for AAAs 4.0
cm and every 2 to 3 years for AAAs <4.0 cm).
In case of suspected AAA rupture , CT is the test of
choice if the pt is hemodynamically stable. If pt is
unstable, send directly to OR ( look for peritoneal
55. Spectrum of presentation - AAA
Recognize that AAA can be:
Asymptomatic
Incidentally noted on abdominal
examination or an imaging study
A cause of: ( suspect rupture and consult
vascular surgeon if pt develops these
symps)
– Abdominal, flank, or back pain ( get a CT r/o
rupture)
– Hypotension ( direct to OR)
– Syncope
– Sudden collapse and shock
Advise the pt with hx of known AAA that
he should promptly report sudden
56. CASE STUDY
A 68-year-old asymptomatic man comes to the office for
his health maintenance examination. He has a 5-year
history of treated hypertension and hyperlipidemia. His
medications include lisinopril, 20 mg daily,
hydrochlorothiazide, 25 mg daily, and atorvastatin, 10 mg
daily. He smokes one-half pack of cigarettes per day. On
physical examination, his heart rate is 88/min and blood
pressure is 152/88 mm Hg. The remainder of the physical
examination is unremarkable. Electrocardiography shows
sinus rhythm and left ventricular hypertrophy by voltage.
An abdominal ultrasound shows a 4.6-cm infrarenal
abdominal aortic aneurysm. In addition to counseling
the patient to discontinue smoking, which of the
following is the best management plan?
( A ) Follow-up abdominal ultrasound in 12 months
( B ) Atenolol, 100 mg daily, and follow-up abdominal
ultrasound in 6 months
( C ) Increase lisinopril to 40 mg daily, and follow-up
abdominal ultrasound in 6 months
( D ) Initiation of roxithromycin and follow-up abdominal
ultrasound in 6 months
( E ) Surgical repair of abdominal aortic aneurysm
57. Ans. B
Surgery for abdominal aortic
aneurysm is indicated if the
aneurysm is symptomatic, exceeds
5.0 to 5.5 cm in diameter,or expands
>0.5 cm within 6 months.
ß-blockers should be considered for
patients with abdominal aortic
aneurysm if there are other
indications for their use, such as
coronary artery disease or
hypertension.
59. Safety issues in children
Crib safety
Avoiding thermal injuries
60. Crib safety
crib bars should not be more than 2 inches apart.
Use bumpers to avoid suffocation from mattresses
and to prevent injury from head banging.
Prone position is associated with increased risk of
SIDS. So, position the infant on their side or back
while sleeping.
Thermal injury – Set the water heater
temperature below 120F to prevent
accidental scalding by sitting in the
water( Most heaters are set at 150F and
can cause scalds in infants)
Use child seat in the cars and place the
child seat in the rear.
62. Jet Lag
General Advise :
Avoid Alcohol and Caffeine
Maintain adequate hydration
Coordinate extended sleep during flight to
destination
– Try to Match sleep to destination time zone
Equilibration requires 12-24 hour per time zone
crossed
Management for flights >8 hours
Melatonin
Sleep medication may be given on day of travel
and for 2-3 days after
– Short acting Benzodiazepine (e.g. Halcion)
– Zolpidem
