PREVENTION
PREVENTIVE
HEALTH CARE
DANA BARTLETT, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.
ABSTRACT
Screening is an effective method for detecting and preventing acute and chronic diseases. In the United States healthcare tends to be provided after someone has become unwell and medical attention is sought. Poor health habits play a large part in the pathogenesis and progression of many common, chronic diseases. Conversely, healthy habits are very effective at preventing many diseases. The common causes of chronic disease and prevention are discussed with a primary focus on the role of health professionals to provide preventive healthcare and to educate patients to recognize risk factors and to avoid a chronic disease.
Policy Statement
This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
Health professionals need to know the recommended screening tests that may lead to early detection or prevention of medical problems that cause morbidity and mortality if left undiagnosed and untreated.
Course Purpose
To provide health clinicians with up-to-date knowledge of the current recommendations for preventive health screening tests and techniques, as well as recommendations in lifestyle changes that will promote preventive healthcare.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
1. One of the limitations of screening tests is:
a. Guidelines are often changed and updated.
b. They rarely provide a high degree of specificity or sensitivity.
c. They can only be used for adolescents and adults.
d. The benefits seldom outweigh the risks.
2. Screening tests must be used with the understanding that
a. they are seldom able to detect diseases.
b. most of them are associated with harmful side effects.
c. they are not diagnostic.
d. they cannot be used for children.
3. Adults should be screened for alcohol misuse if they
a. are males over age 35.
b. drink hard liquor.
c. use illicit drugs.
d. engage in risky drinking behavior.
4. Breast cancer is
a. only found in post-menopausal women.
b. the second most common cancer in women.
c. primarily caused by cigarette smoking.
d. not detectable without a biopsy.
5. Breast cancer screening may include
a. an x-ray.
b. a CT scan.
c. a biopsy.
d. mammography and genetic testing.
Introduction
Screening is an effective method for detecting and preventing acute and chronic diseases. Instead, healthcare in the United States is typically provided after someone has become unwell. People generally seek a physician or medical attention when sick and not before. Additionally, poor health habits play a large part in the pathogenesis and progression of many common, chronic diseases. Often people view illnesses, such as atherosclerosis, diabetes, hypertension, or obesity, as acute and unexpected rather than conditions that can be prevented through screening and follow-up with their health clinician.
Collaboration In Preventative Medicine
In many cases, the signs and symptoms of chronic medical problems that cause morbidity and mortality in most Americans are just confirmation of an illness that has been present for many years. For example, approximately 34% of the adults in the U.S., are obese. Obesity is a major risk factor for the development of type 2 diabetes. The primary cause of obesity is harmful patterns of food intake and energy expenditure; too many calories and not enough exercise. Studies have clearly shown that type 2 diabetes can be prevented by weight loss, dietary changes, and exercise. Healthy habits are very effective at preventing many other diseases, as well.
Preventative medicine involves a collaborative effort by the healthcare community and individual patients. These include the following local healthcare and individual efforts to promote health prevention.
• The healthcare community identifies the diseases that affect, or are likely to affect a specific population.
• The healthcare community screens for acute and chronic health problems and identifies people at risk.
• The healthcare community delivers specific interventions and therapies that will prevent disease, i.e., vaccinations.
• The healthcare community provides consumers with information about behaviors and interventions that can help prevent chronic illness.
• The healthcare community supports consumers in a life-long commitment to healthy life style choices
• The individual makes the changes in diet, exercise, and other life style factors that influence his/her health.
Screening For Disease Detection And Prevention
Screening is an effective method for detecting and preventing acute and chronic diseases. However, it is important to remember the following points when broad screening guidelines are used for a heterogeneous population.
• Not all cases of disease can or will be detected.
• Screening guidelines are always being changed and updated.
• Screening should be done on a case-by-case basis and when appropriate, screening should be accompanied by an examination and interview with a healthcare professional.
• A screening test is not a diagnostic test.
In addition, screening is most effective when a disease or disorder 1) is an important public health problem, 2) has an early, asymptomatic phase, 3) has an effective screening test that can accurately identify people who will benefit from treatment, 4) has an available treatment, and 5) involves screening tests with benefits that outweigh the risks. Screening tests should be simple to perform, cost-effective, and easy to interpret and they must be sensitive and specific.
The primary source of information used in this learning module is the U.S. Preventive Services Task Force’s (USPSTF) Guide to Clinical Preventive Services 2014. The USPSTF Guide discusses many diseases and disorders. This module will for the most part only discuss ones for which the Guide provides screening recommendations but some exceptions have been made. The Guide to Clinical Preventive Services 2014 is available online.1
Alcohol Use Disorder And Addiction
The unhealthy use of alcohol by Americans is endemic. The 2014 National Survey on Drug Use and Health noted that 60.9 million Americans reported binge alcohol use in the past month and 16.3 million reported heavy drinking in the past month.2 Over 17 million American adults have an alcohol use disorder, and the twelve-month and lifetime prevalence of alcohol use disorder has been estimated to be 13.9% and 29.1%, respectively.3
The unhealthy use of alcohol is often unrecognized in the primary care setting and studies support screening of the population for unhealthy alcohol use.4 Who should be screened for alcohol use, when people should be screened, and how often screening should be done depends on factors such as age and an individual’s experience with alcohol and/or drugs; and, different screening guidelines are available. The USPSTF recommendations are shown below.5
USPSTF Recommendations for Screening for Alcohol Misuse
| |
|Screen for alcohol misuse and provide brief behavioral counseling interventions to persons engaged in risky or hazardous |
|drinking. |
| |
|There is a moderate net benefit to alcohol misuse screening and brief behavioral counseling interventions in the primary care |
|setting for adults aged 18 years or older. |
| |
|Counseling interventions in the primary care setting can improve unhealthy alcohol consumption behaviors in adults engaging in |
|risky or hazardous drinking. |
| |
|Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of |
|interactions. Brief multi-contact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral |
|counseling has limited effect. |
| |
|Numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. The USPSTF |
|prefers the following tools for alcohol misuse screening in the primary care setting: AUDIT, the abbreviated AUDIT-C, and |
|single-question screening such as asking, “How many times in the past year have you had 5 (for men) or 4 (for women and all |
|adults older than 65 years) or more drinks in a day?” |
The AUDIT and the Audit-C screening tools are accurate and well validated, widely accepted and used in primary care settings for alcohol misuse. These screening tools have been shown to be useful in identifying hazardous drinking and to help initiate behavioral changes in patients who engage in harmful or hazardous drinking.6-8
The Alcohol Use Disorders Identification Test – AUDIT
In the AUDIT, the answers are scored as: 0 for never and 1-4 for ascending frequency of use. Questions 9 and 10 are scored as 0, 2, and 4 for ascending frequency. A score of ≥8 is associated with harmful or hazardous drinking; and, a score of ≥13 in women and ≥ 15 or more in men is likely to indicate alcohol dependence. The healthcare professional will ask the following questions when using the AUDIT screening tool.9
|1. How often do you have a drink containing alcohol? |
|a. Never |
|b. Monthly or less |
|c. 2-4 times a month |
|d. 2-3 times a week |
|e. 4 or more times a week |
| |
|2. How many alcoholic drinks do you have on a typical day drinking? |
|a. 1 or 2 |
|b. 3 or 4 |
|c. 5 or 6 |
|d. 7 to 9 |
|e. 10 or more |
| |
|3. How often do you have six or more drinks on one occasion? |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
|4. During the past year, how often have you found that you were unable |
|to stop drinking? |
| |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
| |
|5. During the past year, how often have you failed to do what was |
|normally expected of you because of drinking? |
| |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
|During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? |
| |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
|During the past year, how often have you had a feeling of guilt or remorse after drinking? |
| |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
|During the past year, have you been unable to remember what happened the night before because you had been drinking? |
| |
|a. Never |
|b. Less than monthly |
|c. Monthly |
|d. Weekly |
|e. Daily or almost daily |
| |
|Have you or someone else been injured as a result of your drinking? |
| |
|a. No |
|b. Yes, but not in the past year |
|c. Yes, during the past year |
| |
|Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? |
| |
|a. No |
|b. Yes, but not in the past year |
|c. Yes, during the past year |
Alcohol Use Disorders Identification Test-Consumption - AUDIT-C
For men a score of ≥ 4 is considered positive. In women, a score of ≥ 3 or more is considered positive. Generally, the higher the AUDIT-C score the more likely drinking is affecting health and safety. The questions are listed in the table below.10
|How often did you have a drink containing alcohol in the past year? If the answer is never, score questions 2 and 3 as zero. |
| |
|a. Never - 0 points |
|b. Monthly or less - 1 point |
|c. 2 to 4 times a month - 2 points |
|d. 3 or 4 times per week - 3 points |
|e. 4 or more times a week - 4 points |
| |
| |
|How many drinks did you have on a typical day when you were drinking in the past year? |
| |
|a. 1 or 2 - 0 points |
|b. 3 or 4 - 1 point |
|c. 5 or 6 - 2 points |
|d. 7 to 9 - 3 points |
|e. 10 or more - 4 points |
| |
| |
|How often did you have 6 or more drinks on one occasion in the past year? |
| |
|a. Never - 0 points |
|b. Less than monthly - 1 point |
|c. Monthly - 2 points |
|d. Weekly - 3 points |
|e. Daily or almost daily - 4 points |
| |
The four question CAGE screening test for alcohol use is familiar to many healthcare professionals. This test asks the following:
• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever taken a drink first thing in the morning (Eye-
opener) to steady your nerves or get rid of a hangover?
The CAGE test is not recommended as a screening tool for alcohol use as it is not highly sensitive or specific.4
Tobacco Or Nicotine Use And Addiction
Tobacco use and its correlating problems are enormous public health concerns. Tobacco use is the leading cause of preventable death in the United States. The number of Americans who smoke has decreased by more than one-half in the past 50 years, but tobacco and cigarette smoking are still the primary causes of, or contributors to certain cancers, heart disease, common respiratory diseases, and many other acute and chronic pathology. A 2014 report from the Surgeon General noted that tobacco and smoking have “... killed ten times the number of Americans who died in all of our nation’s wars combined.”125
It has also been proven that second-hand smoke is a significant cause of serious acute and chronic heath problems in children and adults. Second-hand smoke (also called side stream smoke) is very dangerous. Second-hand smoke is smoke that is produced from burning tobacco or smoke that has been exhaled by someone using a cigarette and there is no safe level of second-hand smoke.
Smoking and tobacco use are still common in the United States. Statistics from the Centers of Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Association (SAMHSA) are listed in the tables below.126-128
Smoking and Tobacco Use in the United States
|In 2014, almost 17 of every 100 U.S., adults aged 18 years or older (16.8%) currently smoked cigarettes. This means an |
|estimated 40 million adults in the United States currently smoke cigarettes. There are also millions of people who use |
|smokeless tobacco and e-cigarettes. |
| |
|Cigarette smoking is the leading cause of preventable disease and death in the United States, accounting for more than |
|480,000 deaths every year, or 1 of every 5 deaths. |
| |
|More than 16 million Americans live with a smoking-related disease. |
| |
|Current smoking has declined from nearly 21 of every 100 adults (20.9%) in 2005 to nearly 17 of every 100 adults (16.8%) in |
|2014. |
| |
|In 2014, an estimated 66.9 million Americans aged 12 or older were current users of a tobacco product (25.2%). Young adults |
|aged 18 to 25 had the highest rate of current use of a tobacco product (35%), followed by adults aged 26 or older (25.8%), |
|and by youths aged 12 to 17 (7%). |
| |
|In 2014, the prevalence of current use of a tobacco product was 37.8% for American Indians or Alaska Natives, 27.6% for |
|whites, 26.6% for blacks, 30.6% for Native Hawaiians or other Pacific Islanders, 18.8% for Hispanics, and 10.2% for Asians. |
The CDC as well as several other sources have published the health effects of second-hand smoke, as well as recommendations to recognize the potential and ways to avoid it.129-130
Health Effects of Second-Hand Smoke
| |
|Asthma attacks |
|Bronchitis |
|COPD |
|Ear infections |
|Heart disease |
|Lung cancer |
|Pneumonia |
|Stroke |
|Sudden infant death syndrome (SIDS) |
Second-hand smoke has been estimated to increase the relative risk of developing chronic obstructive pulmonary disease (COPD), stroke, and ischemic heart disease by 1.66, 1.35, and 1.22, respectively.131 Children are especially vulnerable to the harmful effects of second-hand smoke and prenatal exposure to second-hand smoke has been identified as a risk factor for developing asthma.132 Also, close proximity is not necessary for exposure to second-hand smoke; many studies have shown that living in a multi-residential building can expose non-smokers to second-hand smoke.133
Smoking Cessation Interventions
There are interventions that can prevent people from smoking and there are behavioral counseling techniques and medications that have been shown to be effective at helping smokers quit. But nicotine, the primary active component of cigarette smoke, is strongly addictive and since tobacco is legal the prevention of smoking and smoking cessation are considerable challenges. Behavioral-based interventions that can be helpful as aids to smoking cessation include direct provider to patient interaction, group therapy, specialized clinics, self-help intervention using educational resources like printed material or videos, web-based and text-based resources, and telephone applications and telephone contact counseling have all been successfully used. The specific intervention chosen will depend on availability, cost, and patient preference. Important aspects of medication and behavioral interventions as aids to smoking cessation that can increase the chance of success are discussed below.134-138
Pharmacotherapy
Pharmacotherapy (with or without behavioral interventions) can significantly influence smoking cessation rates in adults. There are three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation: bupropion, nicotine replacement therapy (NRT), and varenicline. Alternative approaches to support patients during their course of care in a smoking cessation program have been reported to provide value and good results of quitting smoking, such as acupuncture, hypnosis and e-cigarettes.
Each year approximately two out of every three smokers will try and quit but the majority will be unsuccessful.139,140 There are many reasons why smokers find it difficult to quit and difficult to maintain abstinence, including but not limited to: side effects of cessation such as cravings and withdrawal, weight gain, mood changes, poor social support, access problems for smoking cessation programs, poor preparation for quitting, and incorrect use of medications. These issues, along with the addictive properties of nicotine, clearly present smokers with a considerable challenge when they try to quit and to cease the smoking habit long-term.
Screening and Prevention Through the Electronic Health Record
Improving tobacco use screening and exposure to second-hand smoke has become an area of focus for many electronic health records (EHRs) with smoking prevention and cessation patient teaching tools built into the admission process. Most clinic and hospital providers will screen for tobacco use, such as asking patients how many years or how much they smoke each day. A patient who reports a smoking history may be offered educational handouts that promote health prevention and resources for smoking cessation; several examples are listed below.
• Freedom from Smoking® is a program offered by the American Lung Association. Use this link: and scroll down the page to the section title Get Help.
• The American Lung Association also has a help line, 1- 800 LUNG USA.
• is a website of the United States Department of Health and Human Services. It includes information on healthy habits, how smoking affects one's health, and tips on preparing to quit. It also includes resources specifically for women, teens, and Spanish-speaking patients.
• 1-800-QUIT Now (1-800-784-0669) is a toll free number that connects smokers to the Quit For Life® program, sponsored by the American Cancer Society.
Lung Cancer
Lung cancer is the most common cause of death from cancer in American adults.73 The National Cancer Institute estimates that in 2016 there will 224,390 new cases of lung cancer and that lung cancer will account for more than one-fourth of all cancer deaths.74 Cigarette smoking is the primary cause of lung cancer. Most lung cancers are discovered when they are in the late stage. Targeted screening is advised.
The USPSTF and the American Cancer Society recommends that asymptomatic adults aged 55 to 80 years who have a 30 pack-year history of smoking and currently smoke or have quit smoking within the past 15 years should have annual screening with low dose computed tomography.5,75 The 2014 Clinical Guidelines state: “Annual screening for lung cancer with low-dose computed tomography is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking.”5
Breast Cancer
Breast cancer is the most common cancer in women, excluding skin cancer. In 2013, 230,815 women and 2109 men were diagnosed as having breast cancer. That same year, 40,860 women and 464 men died from breast cancer in the United States.11
Risk factors for breast cancer include age, age at first live childbirth, age at menarche, alcohol use, body mass index, breast density, diet, estrogen and progesterone use, menopause status or age, number of first-degree relatives with breast cancer, personal history of ductal or lobular carcinoma in situ, personal history of breast biopsy, physical activity, and race/ethnicity.5
Screening for breast cancer includes screening for neoplasms and screening for genetic susceptibility to breast cancer.
American Cancer Society Screening Recommendations
The American Cancer Society’s breast cancer screening recommendations are outlined below.12
• Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (X-rays of the breast) if they wish to do so.
• Women age 45 to 54 should get mammograms every year.
• Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening.
• Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
• All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. They also should know how their breasts normally look and feel and report any breast changes to a healthcare provider right away.
USPSTF Screening Recommendations
The USPSTF recommendations for breast cancer screening are reviewed in this section.5 Women aged 40-49 should be considered for a biennial mammogram. The decision to do a mammogram should be made on an individual basis, depending on the woman’s circumstances and values. Women aged 50-74 should have a mammogram every two years. The USPSTF does not include a recommendation for the use of mammograms in women age 75 or older.
The USPSTF recommendations apply to women aged ≥40 years that are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women.
There is convincing evidence that using mammography to screen for breast cancer reduces overall mortality from breast cancer. This reduction in risk becomes increased for women aged 50 to 74 years. Harms of screening include psychological effect, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. The level of harm appears to be moderate for each age group.
USPSTF Recommendations for Genetic Testing
The population for screening is asymptomatic women who have not been diagnosed with BRCA-related cancer. Genetic testing for breast cancer is recommended for women whose family history may be associated with an increased risk for potentially harmful breast cancer mutations.5
Genetic risk assessment and breast cancer mutation testing involves identification of women who may be at increased risk for potentially harmful mutations, genetic counseling, and genetic testing of selected high-risk women when indicated. If the screening tests are positive women should receive genetic counseling and, if indicated after counseling, breast cancer mutation testing.
Tests for breast cancer mutations are highly sensitive and specific for known mutations, but interpretation of results is complex and generally requires post-test counseling. In women whose family history is associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention is moderate. Interventions in women who are BRCA mutation carriers include earlier, more frequent, or intensive cancer screening, use of risk-reducing medications such as tamoxifen or raloxifene, and risk-reducing surgery such as mastectomy or salpingo-oophorectomy. Genetic counseling and testing for breast cancer mutations is not recommended for women whose family history is not associated with an increased risk for potentially harmful breast cancer mutations.
Cervical Cancer
In 2013, 11,955 women in the United States were diagnosed with cervical cancer and 4,217 women died from the disease.13 Risk factors for cervical cancer include cigarette smoking, early onset of sexual activity, infection with high-risk strains of human papilloma virus (HPV), immunosuppression, multiple sex partners, oral contraceptive use, and persistent HPV infections.14
Cervical cancer screening decreases the incidence and mortality of cervical cancer. In the U.S., it has been estimated that screening has decreased mortality from this disease by 70%,15 and “… reviews and meta-analyses of observational studies provide consistent and compelling evidence that screening leads to a decrease in incidence and mortality from cervical cancer.”14
The harmful effects of cervical cancer screening include cost, psychosocial consequences, and discomfort. In addition, screening may lead to unneeded diagnostic and/or treatment procedures (which have risks), particularly in women 6 mm
Colorectal Cancer
In 2013, 136,119 people in the U.S., were diagnosed with colorectal cancer and 51,813 people in the U.S., died from colorectal cancer.17 Colorectal cancer is the second leading cause of death from cancer in the U.S., and approximately one of three people diagnosed with the disease will die five years after it is discovered.18
Risk factors for colorectal cancer include a family history for colorectal cancer, African American ethnic status, alcohol use, cigarette smoking, Crohn’s disease, diabetes mellitus and insulin resistance, diet, inflammatory bowel disease, obesity, and radiation therapy for abdominal cancer.
There is unequivocal evidence that colorectal cancer screening and removal of pre-malignant adenomas can decrease the incidence and mortality of colorectal cancer.5,18,19 The specific risks of the invasive screening procedures, of colonoscopy and sigmoidoscopy, include infection, adverse effects from sedating drugs used during the
procedures, perforation and bleeding. Major adverse effects after flexible sigmoidoscopy and colonoscopy examinations are very unusual, occurring is less than 1% of all patients.20-22 The risk of contrast enemas and CT colonography is exposure to radiation.
Several methods are used to detect colorectal cancer. An individual’s risk profile will determine which one is appropriate.
USPSTF Screening Recommendations
The USPSTF recommendations for colorectal cancer screening are highlighted below.
• Age 50-75: Screen with high sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy.
• Age 76-85: Do not automatically screen.
• Age > 85: Do not screen.
• Screening intervals: Annual screening with high-sensitivity fecal occult blood testing; sigmoidoscopy every 5 years, with high-sensitivity fecal occult blood testing every 3 years; or screening colonoscopy every 10 years.
• For all populations, evidence is insufficient to assess the benefits and harms of screening with computerized tomography colonography (CTC) and fecal DNA testing.
Dental And Periodontal Disease And Oral Cancer
Regular examinations and periodic cleanings by a dental hygienist clearly help prevent dental caries and periodontal disease. In addition, there is evidence that dental caries and periodontal disease are associated with systemic illnesses. The American Dental Association recommends that the frequency of dental visits and professional cleanings be determined on a case-by-case basis. People who have risk factors that increase the chances of developing dental caries and periodontal disease.
Oral cavity and oropharyngeal cancers are a serious pathology. The American Cancer Society estimates that in 2016 approximately 48,000 Americans will develop oral cavity or oropharyngeal cancer and approximately 9,500 will die from one of these cancers.24
Most of these cancers are not detected in the early stages and the five-year survival rate is 80% if they are detected when still in Stage I or Stage II.25 The primary risk factors for these cancers are alcohol use, tobacco use, and HPV infection.
Although screening is recommended by many dental associations and dental professionals, unfortunately there is a lack of evidence to support the effectiveness of screening for oral cancer.25 By example, “The USPSTF found inadequate evidence on the diagnostic accuracy, benefits, and harms of screening for oral cancer. Therefore, the USPSTF cannot determine the balance of benefits and harms of screening for oral cancer in asymptomatic adults.”5
The American Dental Association in 2010 published guidelines about oral cancer screening. In brief, these guidelines noted that oral inspection and tactile palpation were the recommended screening tools. These guidelines also noted that the use of devices that rely on auto-fluorescence or tissue reflectance to detect oral cancers do not appear to be superior for this purpose when compared to conventional visual inspection and tactile palpation.26
Coronary Heart Disease
Coronary heart disease and its associated conditions are the leading cause of death in the U.S. Risk factors for the development of coronary heart disease includes those that are modifiable and non-modifiable. Modifiable risk factors include cigarette smoking, diabetes, diet, elevated serum lipids and cholesterol, hypertension, obesity, and sedentary life style. Non-modifiable risk factors are age, gender, and family history of coronary heart disease.
The USPSTF does not recommend specific screening for coronary heart disease for asymptomatic adults who do not have coronary heart disease or diabetes.5 The USPSTF does recommend that people be screened for the presence of the risk factors for coronary heart disease and counseled on smoking cessation, diet, exercise and management of diabetes and hypertension.
The American Heart Association’s specific guidelines for coronary heart disease risk factor screening are outlined below.
• Blood pressure:
Starting at age 20, blood pressure measurement at each regular healthcare visit or at least once every two years if blood pressure is < 120/80 mm Hg.
• Blood glucose:
Starting at age 45, measure blood glucose every three years.
• Cholesterol:
Starting at age 20, measure total cholesterol, HDL and LDL cholesterol, and triglycerides every four to six years for normal people, more often if someone has an elevated risk for heart attack or stroke.
• Starting at age 20, discuss smoking and physical activity at every regular healthcare visit.
• Starting at age 20, measure waist circumference as needed. This is a supplemental measure that should be used if the BMI is ≥ 25/kg/m2.
The American Heart Association’s specific guidelines for coronary heart disease risk factor screening may be found on its website.23
Hypertension
Hypertension is one of the most important preventable causes of cardiovascular disease, diabetes, stroke, and renal failure.59, 60
Approximately 72 million Americans have hypertension, more than half are undiagnosed, and of those that are diagnosed, control of the disease has been described as suboptimal.60,61 Risk factors for the development of primary hypertension (the most common form of the disease) include but are not limited to the factors are listed in the table below.60
Risk Factors for Hypertension
| |
|Age |
|Cigarette smoking |
|Obesity |
|Family history |
|Race – African American |
|Excess sodium intake |
|Excessive alcohol consumption |
|Physical inactivity |
|Diabetes and dyslipidemia |
|Personality traits and depression |
Hypertension is defined as a blood pressure of 140/90 mm Hg or higher.59 The USPSTF screening recommendations, derived from the
the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - JNC 7 Report, include the following.5
All adults be screened for hypertension
Screening every two years if the blood pressure is > 120/80 mmHg
Screening every year for systolic blood pressure of 120-139 mmHg
Adults with hypertension should be screened for diabetes
The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present on several occasions. Blood pressure can be measured in a physician’s office, by using ambulatory blood pressure monitoring, or using home blood pressure monitoring.60
Diabetes
Approximately 21 million Americans have diabetes and 37% percent of the population 20 years of age or older have pre-diabetes.35 Approximately 27.8% of people who have diabetes are undiagnosed, and almost half of Asian Americans and Hispanic Americans who have diabetes are undiagnosed.35,36 The prevalence of diabetes is increasing,37 and diabetes is the primary cause of, or a major contributing factor in, the development of many serious diseases such as blindness, heart disease, and kidney failure.
There is evidence that suggests screening for and early treatment of diabetes can be beneficial.38-41 The American Diabetes Association (ADA) has recommendations for testing for diabetes or pre-diabetes in asymptomatic adults as set forth in the following table.
Testing for Diabetes/Pre-diabetes in Asymptomatic Adults
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk factors, as outlined below.42
• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (i.e., African American, Latino, Native American, Asian American, Pacific Islander)
• Women who have delivered a baby weighing >9 lb. or were diagnosed with gestational diabetes mellitus
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level 250 mg/dL (2.82 mmol/L)
• Women with polycystic ovary syndrome
• HbA1c ≥5.7% (39 mmol/mol), IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (i.e., severe obesity, acanthosis nigricans)
• History of CVD
– For all patients, testing should begin at age 45 years
– If results are normal, testing should be repeated at three year
– More frequent testing should be done, depending on initial results and risk status
– Diabetes may be diagnosed based on plasma glucose criteria – either fasting plasma glucose or the 2-hour plasma glucose value after a 75-gram oral glucose tolerance test - or HbA1c
USPSTF Screening Recommendations
The USPSTF screening recommendations for symptomatic adults with sustained blood pressure greater than 135/80 mmHg are recommended to screen for type 2 diabetes mellitus. These recommendations apply to adults with no symptoms of type 2 diabetes mellitus or evidence of possible complications of diabetes.5
Blood pressure measurement is an important predictor of cardiovascular complications in people with type 2 diabetes mellitus. The first step in applying this recommendation should be measurement of blood pressure (BP). Adults with treated or untreated BP >135/80 mm Hg should be screened for diabetes.
The American Diabetes Association recommends screening with fasting plasma glucose (FPG), and defines diabetes as FPG ≥ 126 mg/dL; and, recommends confirmation with a repeated screening test on a separate day. The optimal screening interval is not known. The ADA, on the basis of expert opinion, recommends an interval of every 3 years.
To determine whether screening would be helpful on an individual basis, information about 10-year coronary heart disease (CHD) risk must be considered. For example, if CHD risk without diabetes was 17% and risk with diabetes was >20%, screening for diabetes would be helpful because diabetes status would determine lipid treatment. In contrast, if risk without diabetes was 10% and risk with diabetes was 15%, screening would not affect the decision to use lipid-lowering treatment. The diagnostic criteria for diabetes are outlined below.42
• Fasting plasma glucose of 126 mg/dL or higher. The fasting plasma glucose test is a measurement of plasma glucose that is performed after the patient has been fasting for at least eight hours. The test should be repeated twice to confirm the presence of diabetes. The normal fasting plasma glucose is considered to be < 100 mg dL.
• A 2-hour plasma glucose level ≥ 200 mg/dL during an oral glucose challenge test. The patient should be fasting for eight hours prior to the test. A plasma glucose level is obtained and if it is < 140 mg/dL, the patient is given 75 grams of an oral glucose solution. Two hours after administration of the glucose solution the plasma glucose is measured, and the result should be < 140 mg/dL. (It should be noted that the level considered to be normal varies somewhat with age).
• A hemoglobin A1c (HbA1c) level of > 6.5%. The HbA1c, aka the glycosated hemoglobin level, measures glucose that is attached to hemoglobin and it provides an indication of what the average blood glucose has been for several months prior to the test.
• In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL.
Screening for medical complications that are caused by or associated with diabetes is very important. The following recommendations are from the ADA, Standards of Medical Care in Diabetes - 2016.43
• Hypertension:
Patients who are at risk for, or who have diabetes, should be screened for hypertension and blood pressure should be measured at every routine visit. A systolic blood pressure of ≤ 140 mm Hg or a blood pressure of < 140/90 m Hg is desirable. These levels have been associated with a reduction in CVD, nephropathy, and stroke in patients who have diabetes.
• Lipid Profile:
The Standards recommend that “... it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter, or more frequently if indicated.”43
• Diabetic Nephropathy:
Measure urinary albumin level and eGFR at least once a year in patients who have had type 1 diabetes ≥ 5 years, in all patients who have type 2 diabetes, and in all patients who have diabetes and hypertension.
• Diabetic Retinopathy:
Adults who have type 1 diabetes should have a dilated and comprehensive eye examination within five years of the time of diagnosis. Patients who have type 2 diabetes should have a dilated and comprehensive eye examination at the time of diagnosis. If the patient does not have retinopathy after one or more yearly examinations, then biennial examinations may be considered. If any level of retinopathy is discovered then dilated retinal examination should be done at least every year and if the retinopathy is progressing, more frequent examinations may be needed.
For pregnant women who have diabetes, an eye examination should be done before pregnancy or in the first trimester. Subsequently, patients should be monitored each trimester and for one year, post-partum, as indicated by the degree of retinopathy.
• Diabetic Peripheral Neuropathy:
Patients who have type 1 diabetes should be assessed for the presence of diabetic five years after the diagnosis is made. For patients who have type 2 diabetes, this assessment should be done at the time the diagnosis is made. The assessment should include a patient history, 10-g monofilament testing, and at least one of the following tests: pinprick, temperature, or vibration sensation.
• Diabetic Foot Ulcers:
A comprehensive foot evaluation should be done every year. The examination should include inspection of the skin, assessment of foot deformities, and a neurological assessment including 10-g monofilament testing and pinprick or vibration testing or assessment of ankle reflexes. The pulses in the feet and legs should be checked, as well.
• Cardiovascular Disease:
Asymptomatic patients should not be screened for cardiovascular disease but cardiovascular risk factors should be assessed annually, at least. These risk factors include dyslipidemia, hypertension, family history of premature cardiovascular disease, presence of albuminuria, and smoking.
Lipid Disorders
The lipid disorders of elevated cholesterol and elevated triglycerides are an important factor in the development of atherosclerosis. Atherosclerosis contributes to the development of coronary heart disease, it is a risk factor for stroke, and it is considered to be the major cause of premature death in developed countries.72 Libby (2015) writes: “Abnormalities in plasma lipoproteins and derangements in lipid metabolism rank among the most firmly established and best understood risk factors for atherosclerosis.”72
The USPSTF advises that the benefits of lipid screening definitely outweigh the risks and that these populations should be screened for lipid disorders:5
• Men age 35 years and older
• Women age 45 years and older who are at increased risk for coronary heart disease
• Men ages 20 to 35 years who are at increased risk for coronary heart disease
• Women ages 20 to 45 years who are at increased risk for coronary heart disease
Increased risk would be the presence of atherosclerosis or coronary heart disease, diabetes, family history of coronary heart disease, hypertension, obesity and smoking.
Fasting total serum cholesterol, high-density and low-density cholesterol should be measured. The optimal interval for screening is not certain, but lipid measurement every five years in patients who are below the treatment threshold, and measurement at shorter intervals for people who have lipid levels that are close to those requiring therapy is recommended as a reasonable approach.5 Screening can be done at longer intervals if someone has no risk factors and repeated lipid measurements are normal.
Obesity
Obesity is a significant public health problem worldwide and in the United States. The prevalence of obesity in the U.S., has been estimated to be 35% for men and 40.4% for women.76 Obesity is a contributing factor for the development of many diseases, and people who are obese have an increased risk for cancer, coronary heart disease, depression, type 2 diabetes, gallbladder disease, osteoarthritis, respiratory problems, sleep apnea, and stroke.77
Screening for obesity is recommended5,78 and the USPSTF advises that adults age 18 and older be screened by using body mass index (BMI) and anyone with a BMI ≥ 30 kg/m2 “… should be offered or referred to intensive, multi-component behavioral interventions.”5 Additionally, “Screening combined with interventions can improve glucose tolerance and decrease risk factors for cardiovascular disease and the harms of this approach are considered to be small.”5
It should be noted that body mass index (BMI) is calculated by dividing weight in kilograms divided by the square of height in meters. Body mass index may not always be the most accurate way to determine whether or not someone is obese and in some circumstances measuring weight circumference is preferable.
Osteoporosis
Osteoporosis is a skeletal disorder that is characterized by decreased bone mass. Osteoporosis is very common, especially in the elderly. It is more common in women than in men, although with advancing age, many men develop osteoporosis as well. The National Osteoporosis Foundation estimates that 54 million Americans have osteoporosis/low bone mass,79 and the health consequences of this disease are significant. Osteoporosis does not produce symptoms, but there are estimated 1.5 million fragility fractures that happen in the United States every year, and one out of every two women and one out of every four men 50 years old or more will have a fracture caused by osteoporosis.79,80
Risk factors for osteoporosis are outlined below as:80
• Asian or white race
• Current tobacco use
• Estrogen deficiency and < 45 years of age
• Excessive use of alcohol
• Family history of osteoporosis
• Female > 65 years of age
• History of fragility fracture or fragility fracture in a first-degree relative
• Long-term use of glucocorticoids
• Low calcium intake
• Male > 70 years of age
• Low body weight: < 127 pounds or BMI < 20
• Sedentary life style
• Testosterone deficiency
• Vitamin D deficiency
The USPSTF recommendations for osteoporosis screening5 state that dual-energy x-ray absorptiometry of the hip and lumbar spine should be done for the following groups of women.
• Women age ≥ 65 years without previous known fractures or secondary causes of osteoporosis.
• Women age < 65 years whose 10-year fracture risk is equal to or greater than that of a 65-year-old white woman without additional risk factors.
Hepatitis B And Hepatitis C
Hepatitis B is a viral infection of the liver. Hepatitis B is transmitted primarily by contact with infected blood, and it can also be transmitted through other body fluids, by sexual contact, and from mother to child. The risk of developing a chronic infection after an exposure is approximately 2%-6%, and the Centers for Disease Control and Prevention (CDC) estimates that there are between 850,000 to 2.2 million Americans who are chronically infected with the Hepatitis B virus.52 Factors that increase the risk of being infected with Hepatitis B include intravenous drug use, hemodialysis, a healthcare occupation, men who have sex with men, unprotected sex with multiple partners, or travel to an area where there is a high infection rate of Hepatitis B. The signs and symptoms of a Hepatitis B infection are temporary and for the most part, non-specific.
The CDC recommends screening the following groups for Hepatitis B by testing for the presence of Hepatitis B surface antigen (HBsAg):53
• Persons born in geographic regions with HBsAg prevalence of ≥2%
• U.S., born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of ≥8%
• Injection-drug users
• Men who have sex with men
• Persons with elevated ALT/AST of unknown etiology
• Persons with selected medical conditions who require immunosuppressive therapy
• Pregnant women
• Infants born to HBsAg-positive mothers
• Household contacts and sex partners of HBV-infected persons
• Persons who have had blood or body fluid exposures that might warrant post-exposure prophylaxis (i.e., needle-stick injury to a healthcare worker)
• Persons infected with HIV
The USPSTF recommends that at the first prenatal visit, all pregnant women should be screened for Hepatitis B by checking for HBsAg.5 The USPSTF also recommends rescreening women with unknown HBsAg status or new or continuing risk factors at admission to hospital, birth center, or other delivery setting.
Hepatitis C is a viral infection of the liver. Hepatitis C is primarily transmitted by contact with infected blood, and infection after contact with other body fluids and from sexual contact is also possible. Approximately 85% of people who have an acute infection with Hepatitis C will develop a chronic Hepatitis C infection,54 and the CDC estimates that 2.7-3.9 million people in the U.S., have chronic Hepatitis C.55 Hepatitis C is one of the most common indications in the U.S., for liver transplantation.54
Factors that increase the risk of being infected with Hepatitis C include the following: 1) current or former IV drug users, 2) hemodialysis patients, 3) healthcare workers who are exposed to blood or body fluids, 4) anyone who was given clotting factors before 1987, 5) anyone who received a blood transfusion or a sold organ transplant prior to July of 1992, 6) persons infected with HIV, and 7) children born to mothers who are infected with Hepatitis C. The signs and symptoms of a Hepatitis C infection are temporary, for the most part non-specific, and the patient often has no signs or symptoms.
Hepatitis C Screening
The USPSTF recommendations for hepatitis screening are highlighted here.5
• Persons at high risk for infection and adults born between 1945 and 1965 should be screened.
• Persons with continued risk for HCV infection should be screened periodically.
• Anti-HCV antibody testing should be used for screening. This can be followed with confirmatory polymerase chain reaction testing, as needed.
The CDC’s recommendations for Hepatitis C screening are essentially the same as the USPSTF but are more specific about who should be screened.52
CDC Recommendations for Hepatitis C Screening
• Persons born from 1945 through 1965
• Persons who have ever injected illegal drugs, including those who
injected only once many years ago
• Recipients of clotting factor concentrates made before 1987
• Recipients of blood transfusions or solid organ transplants before
July 1992
• Patients who have ever received long-term hemodialysis treatment
• Persons with known exposures to HCV, such as healthcare workers
after needle sticks involving HCV-positive blood or recipients of
blood or organs from a donor who later tested HCV-positive
• All persons with HIV infection
• Patients with signs or symptoms of liver disease, i.e., abnormal liver
enzyme tests
• Children born to HCV-positive mothers (to avoid detecting maternal
antibody; these children should not be tested before age 18
months)
Human Immunodeficiency Virus
Infection with the human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome (AIDS). An acute infection with HIV after exposure may produce mild, non-specific signs and symptoms or the infected person may feel fine. The acute infection period lasts approximately two weeks and then the virus enters the dormant phase. During this time HIV is reproducing at a slow rate and the infected person is asymptomatic.
The dormant phase of the virus lasts approximately 10 years and at that point viral replication increases rapidly and HIV begins to cause serious, irreversible damage to the immune system. At that point the infected person has AIDS. The average survival time after development of AIDS is three years and death is typically caused by an opportunistic infection.
The CDC estimates that there are 1.2 million Americans infected with HIV, and that the number of new infections has been decreasing each year since 2005.56 People who are infected with HIV are asymptomatic for approximately 10 years while the virus is in the dormant stage but during that time the virus can be transmitted so screening for HIV is an important public health concern.
The human immunodeficiency virus is primarily transmitted by sexual contact and contact with infected blood and the USPSTF recommends HIV screening for the following individuals.5
1. Adolescents and adults aged 15 to 65 years
2. Younger adolescents and older adults at increased risk for infection
3. Pregnant women
Younger adolescents and adults considered to be at increased risk include:5
• Men who have sex with men
• Active injection drug users
• People who have a sexually transmitted disease
• Anyone having unprotected vaginal or anal intercourse
• Being a sex partner of someone who is HIV-infected, bisexual or an injection drug user
• Anyone exchanging sex for drugs or money
• People exposed to HIV contaminated blood as an occupational hazard, i.e., a needle-stick injury in healthcare workers
• Anyone who has multiple sex partners
A one-time screening test is sufficient unless risk factors are present and then screening should be done once a year, or in some cases, every three to six months.55 Screening for HIV is done by testing blood for HIV antibodies and HIV antigen. Rapid HIV testing can be done (results within 5-40 minutes) and over-the-counter HIV testing products are available, but when these methods are used formal laboratory testing is required to confirm the results.5,58
Illicit Drug And Prescription Drug Use
Illicit drug use is a significant public health problem. The USPSTF advises that clinicians should be aware of, and alert to the signs and symptoms of illicit drug use but that “… the evidence is insufficient to determine the benefits and harms of screening for illicit drug use.”5
An area of increased concern is the rise of prescription drugs as sources of illicit drug use and addiction. This has become a serious health and social concern within all age groups where the use of prescribed controlled substances have led to heightened monitoring requirements by providers when reviewing patient history of use and exposure to controlled substances in the home. The American College of Preventive Medicine defines the term abuse of a controlled substance as “the self-administration of substances to alter one’s state of consciousness and an intentional and maladaptive pattern of using a medication leading to significant impairment or distress.”141 An individual noted to be abusing controlled substances is using a drug in a detrimental way to one’s health and wellbeing. Health providers as well as many employer policies for workers may receive special training on how to recognize impaired individuals in a health agency or workplace, and are guided on steps to report impairment as a public safety concern.
Prescription drug abuse has been identified as a very real threat to society and the numbers of patients abusing these types of drugs has increased dramatically in recent decades. In 2011, the CDC declared that prescription drug abuse is a nationwide epidemic.142 Without keeping restraints on controlled substances, including those that are prescribed for medical use, the potential for misuse and abuse of these drugs continues to increase.
The risk factors for developing addiction to controlled substances may vary depending on the age of the patient, life circumstances, medical history, and physical health. While prescription drug abuse and the numbers of overdoses that occur every year is not necessarily consistent with one particular age group, there are differences between social, physical, and environmental factors that can increase the risks of abuse and addiction more for some age groups. According to the National Council on Drug Abuse, risk factors can affect people at different stages of their lives; however, with each risk, there are preventive measures that can change the gravity of the risk through intervention.143
Health providers can identify a potential problem relative to an individual’s level of exposure and risk to develop a substance use and addiction disorder, and can educate about the risk factors involved to abuse prescription medication. For instance, an adolescent who witnesses misuse of prescription sedatives by a parent to aid in sleep may be more likely to develop a substance use disorder with a similar type of controlled substance as well. Not enough has been said about the effect of prescription drug abuse on children and adolescents however a recent retrospective nationwide study focused on admissions to emergency departments from 2006 to 2012 found that “poisonings by prescription opioids largely impact both young children and adolescents,” and that future screening and preventive strategies need to focus on this age group.144
Glaucoma
More than 2 million Americans 40 years and older have glaucoma. It is estimated that more than one-half of these people have not been diagnosed or are not being treated.44,45 Common risk factors for the development of glaucoma include:45,46 1) African-American or Hispanic heritage, 2) age > 40, 3) Asian heritage, 4) circulatory problems, 5) corneal thinness, 6) diabetes, 7) family history of glaucoma, 8) myopia, 9) history of an eye injury, 10) hypertension or hypotension, 11) migraine headache, 12) obstructive sleep apnea, and 13) smoking.
The USPSTF has no recommendation for glaucoma screening, and the 2014 Guidelines state: “Evidence on the accuracy of screening tests, especially in primary care settings, and the benefits of screening or treatment to delay or prevent visual impairment or improve quality of life is inadequate. Therefore, the overall certainty of the evidence is low, and the USPSTF is unable to determine the balance of benefits and harms of screening for glaucoma in asymptomatic adults.”5
Jacobs (2016) writes that: “It remains controversial which (if any) populations should be screened, what screening tests should be performed, and with what frequency.”47 On the other hand, the American Academy of Ophthalmology provides these guidelines for screening.46
• People of any age with glaucoma symptoms or glaucoma risk factors should have an ophthalmologic examination.
• By the age of 40 all adults should have a complete eye disease screening.
Hearing Impairment
Hearing loss or hearing impairment is common in older adults, and advancing age is one of the primary risk factors for decreased hearing ability.5 Other risk factors for hearing loss are diabetes, genetic susceptibility, exposure to loud noise, exposure to ototoxic drugs, and recurrent ear infections.5
The USPSTF does not recommend routine screening for hearing loss in asymptomatic adults 50 years and older, noting that there is no convincing evidence to determine the benefits and harms of screening in this population.5 The USPSTF does recommend universal hearing screening for all infants before one month of age, and infants who do not pass the screening test should have audiologic and medical evaluation before 3 months of age.5
Hearing loss is the most common congenital condition in the U.S. Each year approximately three in every 1,000 infants born in the United States will have moderate, severe, or profound hearing loss48 and half of these children have no identifiable risk factors.49 Common causes or risk factors for childhood hearing loss include (but are not limited to) congenital anomalies, infection, trauma, and the use of ototoxic drugs like aminoglycosides and platinum antineoplastics.50 Hearing loss in the first few years of life can cause delays in cognitive, language, and speech development, but early identification of hearing impairment can prevent these.50
Hearing testing for newborns is mandatory in all 50 states. For the specific regulations of each state the American Academy of Pediatrics web link may be used,51 or the website of the American Academy of Pediatrics may be accessed to search for State Early Hearing Detection and Intervention (EHDI) Laws and Regulations, 2016.
Genitourinary Infections And Sexually Transmitted Diseases
Bacteriuria
Asymptomatic bacteriuria is defined as the presence of at least 105 colony forming units of bacteria per 1 mL of urine.90 Asymptomatic bacteriuria has been reported to occur in 2%-10% of pregnant women and can result in pyelonephritis, low birth weight, and pre-term birth.90,91
The USPSTF recommends that all pregnant women be screened for asymptomatic bacteriuria.5 This should be done by obtaining a mid-stream, clean catch urine sample at 12-14 weeks of the pregnancy or if later than that, at the first prenatal visit. The USPSTF 2014 Guidelines note that there are adverse effects from antibiotics and the possibility of developing antibiotic resistance but “… detection and treatment of asymptomatic bacteriuria with antibiotics significantly reduces the incidence of symptomatic maternal urinary tract infections and low birthweight.”5
Chlamydial Infection
Chlamydia trachomatis is bacteria that can cause many types of infections, but it is most often a sexually transmitted disease.92 Chlamydia is the most common sexually transmitted disease in the United States93 and it can be transmitted by anal, oral and vaginal sex. Signs and symptoms of a sexually transmitted chlamydial infection may include vaginal discharge and pain when urinating.
Sexually transmitted chlamydial infections are much more common in women than men93 and a genital infection with C trachomatis can cause pelvic inflammatory disease (PID) and PID can result in chronic pain and/or infertility and pre-term birth. Transmission of the C trachomatis infection to an infant can cause conjunctivitis and/or pneumonia.94
Genital chlamydial infections in women are very common. The infections may not produce symptoms and the consequences of an untreated genital chlamydial infection can be quite serious. For these reason and because screening is simple (either a urine sample or a cervical swab is used) and essentially has no risks, the USPSTF recommends screening women for chlamydial infections.5
USPSTF Screening Recommendations
The USPSTF screening recommendation for women 24 years and younger, including adolescents, and for women 25 years and older and at increased risk, is to be screened for chlamydial infection. This recommendation also applies to women who are pregnant. Increased risk is considered to exist for women who have had a previous chlamydial infection or other sexually transmitted infections, had new or multiple sexual partners, do not consistently use condoms, or are in sex work.
In non-pregnant women the optimal interval for screening is not known, but the CDC recommends that women at increased risk be screened at least annually. In pregnant women ages 24 years and younger and older women at increased risk, screening should be provided at the first prenatal visit. For patients at continuing risk, or who are newly at risk, screening should be offered in the 3rd trimester.
Gonorrhea
Gonorrhea is a common sexually transmitted disease caused by infection with the Neisseria gonorrhoeae bacterium. Gonorrhea infections can occur after anal, oral, or vaginal intercourse, and the infection can be transmitted from a pregnant woman to her child. There were 350,062 reported cases of gonorrhea in the United States in 2104, but this number is considered to be far less than the actual incidence of the disease.95
High rates of gonorrhea infection are especially common in adolescents and young adults aged 15-24 and in non-Hispanic blacks.94 In women the signs and symptoms of gonorrhea are non-specific, they are often mild, and a large majority of women with a gonorrhea infection are asymptomatic.95 Untreated gonorrhea can have serious consequences for women.96,97 Between 10%-20% will develop PID95 and fallopian tube infection and scarring and infertility are relatively common sequelae of PID.95
The USPSTF recommendations for gonorrhea screening women are outlined below.5 Testing is done by obtaining a cervical swab or a urine sample.
USPSTF Screening Recommendations
Sexually active women, including pregnant women, should be screened when at risk for gonorrhea infection. Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use.
Screening is recommended at the first prenatal visit for pregnant women who are in a high-risk group for gonorrhea infection. For pregnant women who are at continued risk, and for those who acquire a new risk factor, a second screening should be conducted during the third trimester.
The optimal interval for screening in the non-pregnant population is not known. The USPSTF concluded that the benefits of screening women at increased risk for gonorrhea infection outweigh the potential harms.
Syphilis
Syphilis is a sexually transmitted disease caused by the Treponema pallidum bacterium. Syphilis can be transmitted by anal, oral, or vaginal intercourse. In its early stages a syphilis infection does not
cause dramatic or highly specific signs or symptoms but a late stage syphilis infection may cause severe cardiovascular, dermal, and neurological complications.
Syphilis can be transmitted from an infected mother to an unborn child: this is called congenital syphilis. Congenital syphilis that is untreated can cause early infant death, miscarriage, spontaneous abortion, still birth, late complications in the infant, and other serious sequelae.107-109
Syphilis can be effectively treated and prevented with antibiotics and public education and behavioral modification and in some areas of the world congenital syphilis has been eradicated. However, in the United States the incidences of syphilis and congenital syphilis have been increasing.109,110 The USPSTRF recommends that all pregnant women be screened for syphilis at the first prenatal visit; the venereal disease research laboratory (VDRL) or rapid plasma regain (RPR) test can be used.5 If needed, positive VDRL or RPR test results can be confirmed using fluorescent treponemal antibody absorbed (FTA-ABS) or Treponema pallidum particle agglutination (TPPA) tests.5
Iron Deficiency Anemia
Iron deficiency anemia is relatively common in pregnant women. Older data indicated that the prevalence of anemia in pregnant women was 18.6%99 and pregnant women are much more likely to be anemic than non-pregnant women.100 Anemia during pregnancy can cause, or has been associated with increased maternal mortality, premature birth, spontaneous abortion, fetal death, low birth weight, and in utero abnormalities.101-104
Causes of iron deficiency anemia during pregnancy include poor intake, poor nutrition, gastrointestinal disease, vegetarian diet, medications that interfere with iron absorption, and multiple pregnancies.99,105,106
The USPSTF recommends that all asymptomatic pregnant women be screened for iron deficiency anemia by measuring hematocrit and hemoglobin levels.5
Depression
Depression is a significant public health problem in the U.S. and the most common psychiatric disorder.27 The National Institute of Mental Health estimated that in 2014, 15.7 million American adults had one episode of major depression28 and the lifetime prevalence of depression of Americans is estimated to be 7% to 16.6%.29,30
Depression is a major cause of disability, mental and physical impairment from mild to major, and lost productivity, and it is one of the most important causes of suicide.31 Risk factors for depression include (but are not limited to) childbirth, family history, female gender, serious medical illness, stressful life occurrences, and substance use.5,27,31
The USPSTF recommends screening for depression in non-pregnant adults 18 years and older “… when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.”5
In 2009, the USPSTF recommended screening all adults when staff-assisted depression care supports are in place and selective screening based on professional judgment and patient preferences when such support is not available. In recognition that such support is now much more widely available and accepted as part of mental health care, the current recommendation statement has omitted the recommendation regarding selective screening, as it no longer represents current clinical practice. The current statement also specifically recommends screening for depression in pregnant and postpartum women, subpopulations that were not specifically reviewed for the 2009 recommendation.5
Staff-assisted depression care support “refers to clinical staff that assists the primary care clinician by providing some direct depression care and/or coordination, case management, or mental health treatment.”5 The optimal interval for screening is not known.5 The USPSTF guidelines do not comment on the benefits of screening for depression.
Narayana and Wong (2015) write in their review of office-based screening for mental disorders that screening for depression “… is most likely cost-effective in the setting of high prevalence and the availability of treatment using a collaborative care model. Despite the availability of screening tools, the overall cost-effectiveness of general screening for anxiety or depression is uncertain.”33
Major Depressive Disorder
The criteria for major depressive disorder are listed in the section below.113
Diagnostic Criteria
The diagnostic criteria for major or depressive disorder include that five or more of the following symptoms have been present during a two-week period, are a significant change from the patient’s previous mood and functioning, at least one of the symptoms is depressed mood or loss of pleasure or interest, and the symptoms are not caused by a medical condition. The criteria include:
• Depressed mood most of the day, nearly every day. The depressed mood can be subjective (i.e., the patient reports feeling sad, hopeless) or can be observed by others. In children or adolescents, irritation is often present.
• Markedly diminished interest or pleasure in daily activities. This happens nearly every day and is reported by the patient or by others.
• Significant weight loss (> 5% of body weight) when not dieting or a decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day: this should be observable by others and not just the patient’s feelings of restlessness or feeling lethargic.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
• Diminished ability to think or concentrate, or indecisiveness, nearly every day, reported by the patient or observed by others.
• Recurrent thoughts of death; recurrent suicidal ideation without a specific plan; a suicide attempt or a specific plan for committing suicide.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The episode is not attributable to a substance or another medical condition.
• The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
• There has never been a manic episode or a hypomanic episode.
The incidence of major depressive disorder in children and adolescents has been estimated as between 3.9% to 12.8%, depending on the age group that was surveyed and how the data was collected.114
Depression in children is often undertreated and it can cause serious impairment of psycho-social functioning.115 Risk factors for depression in children and adolescents include:5,115
• Abuse, neglect
• ADHD
• Anxiety disorder
• Bullying
• Chronic illness
• Family conflict
• Family history of depression
• Gender dysphoria
• Learning disabilities
• Oppositional defiance disorder
• Substance use disorder
• Traumatic brain injury
The USPSTF advises that adolescents age 12-18 should be screened for depression when there are resources in place for diagnosis, treatment, and follow-up.5 The Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory Primary Care Version (BDI-PC) have been shown to useful for assessment of adolescents for depression.5
There are many well-validated screening tools that can be used for detecting depression; for example, the Beck Depression Inventory, Hamilton Depression Scale, and the Patient Health Questionnaire-9 (PHQ-9) screening tool. A 2014 review showed that the commonly used ones are essentially equal in sensitivity and specificity.34 The PHQ-9 is often used because it is free and easy to use.
PHQ-9 Screening Tool
|Over the last 2 weeks, how often have you been bothered by any of the following problems? |
| |
|Little interest or pleasure in doing things. |
| |
|Feeling down, depressed, or hopeless. |
| |
|Trouble falling or staying asleep, or sleeping too much. |
| |
|Feeling tired or having little energy. |
| |
|Poor appetite or overeating. |
| |
|Feeling bad about yourself, or that you are a failure, or have let yourself or your family down. |
| |
|Trouble concentrating on things, such as reading the newspaper or watching television. |
| |
|Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have |
|been moving around a lot more than usual. |
| |
|Thoughts that you would be better off dead or of hurting yourself in some way. |
| |
| |
|The possible answers and their respective scores are: |
|0 = Not at all |
|1 = Several days |
|2 = More than half the days |
|3 = Nearly every day |
| |
| |
|Depression score ranges: |
|5 to 9: Mild |
|10 to 14: Moderate |
|15 to 19: Moderately severe |
|20 to 27: Severe |
| |
Screening For Newborns, Children And Adolescents
Congenital Hypothyroidism
The thyroid hormone tri-iodothyronine (T3) is essential for normal childhood growth and development, especially in the first few years of life.111 During the first trimester the fetus is dependent on maternal thyroid hormones and maternal thyroid hormone requirements are increased at this time, as well.111,112 An increased maternal need, dependency of the fetus on maternal thyroid function, and hypothyroidism in a pregnant woman can cause serious consequences: impaired cognitive functioning in the child and complications of pregnancy such as low birth weight, miscarriage, preterm birth, and preeclampsia.112
Screening newborns for congenital hypothyroidism is mandatory in all 50 states and in the District of Columbia. The USPSTF recommends that T4 and TSH be measured when the infant is between two to four days old. If the tests are abnormal confirmatory testing should be done.5
Obesity
The prevalence of obesity in children and adolescents in the United States is approximately 17% and it is expected to increase.116,117
The USPSTF recommends that children and adolescents age 6 to 18 be screened for obesity.5 Obesity is defined as an age and gender specific BMI ≥ 95th percentile.5
Phenylketonuria
Phenylketonuria (PKU) is a relatively common inborn error of metabolism. People who have PKU do not have normal activity of the liver enzyme phenylalanine hydroxylase. Phenylalanine is an amino acid, a breakdown product of many proteins. Accumulations of phenylalanine can cause mental retardation, seizures, and other serious neurological problemns.111
Screening for PKU is mandated in all 50 states, and infants should be screened at or near seven days of age.5 The Guthrie Bacterial Inhibition Assay (BIA), automated fluorometric assay, or tandem mass spectrometry can be used.5
Sickle Cell Disease
Sickle cell disease is an inherited hematologic disorder. People who have sickle cell disease have hemoglobin S and when oxygen binds to hemoglobin S, red blood cells form an abnormal shape (the sickle shape) and they hemolyze, causing an anemia that deprives the tissues of oxygen and blocking blood vessels. Sickle cell disease primarily affects African Americans, and approximately 1 in every 365 African Americans has the disease.118
The USPSTF recommends that all newborn infants be screened for sickle cell disease using either thin-layer isoelectric focusing (IEF) or high performance liquid chromatography (HPLC).5
Visual Impairment in Children Ages 3 to 5
Children ages 3 to 5 years should be screened for ambylopia. Ambylopia, often called lazy eye, is defined as decreased vision in one eye. The term lazy eye is used because the affected eye often is fixed to the lateral or medial side. Ambylopia can result from an imbalance in the muscles that move and position the eyes or from neurological abnormalities and if it is untreated it can cause permanent vision loss. Effective treatments for ambylopia are available so early detection is critical. The USPSTF recommends that children three to five years of age have vision scrrening.5
Amblyopia is defined as a functional reduction in visual acuity that is caused by abnormal visual development during childhood. Amblyopia is the most common cause of visual impairment in children116,117 with a reported prevalence of 1%-4%.116-119 Ambylopia develops during a critical period of three months to eight years when the vision is maturing. Risk factors for ambylopia include having a first-degree relative with amblyopia; neurodevelopmental delay; premature birth; and, small size in relation to gestational age.116 Amblyopia affects boys and girls equally.
The USPSTF recommends that children age three to five have vision screening4 and screening for, and early detection of amblyopia can improve the prognosis for normal visual development.116,120,121 Screening is also important because amblyopia is an asymptomatic condition; certain types of amblyopia are characterized by an obvious lateral deviation of one eye (commonly called lazy eye) but some are not; and, the treatments for amblyopia are most effective when they are used early.121
Children who are pre-verbal are screened by using the fixation reflex test or the objection to occlusion test.116 Children who are three years of age or older can have their visual acuity checked by using the Snellen chart (the classic eye chart with letters and number, viewed from 20 feet away) or by using Allen figure cards.116
In the fixation reflex test one eye is occluded, the examiner moves an object back and forth across the child’s visual space, and the child’s ability to maintain contact - to fixate - is assessed. During the occlusion test the examiner watches the child’s response as each eye is alternately occluded. Children who have amblyopia will usually become upset when the good eye is occluded.
Intimate Partner Violence And Elderly Abuse
Intimate partner violence is defined by the CDC as physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner.62 Breiding, et al., (2014, 2008) noted that a substantial number of American women and men have suffered from one or more types of intimate partner violence (as many as one in four women and one in seven men)63,64 and intimate partner violence is often unreported and undiagnosed.63
Risk factors for suffering intimate partner violence include (but are not limited to 1) female gender, 2) prior history of intimate partner violence, 3) experiencing or witnessing violence as a child, and 4) chronic mental illness. Risk factors for perpetrating intimate partner violence include (but are not limited to) exposure to violence during childhood, marital difficulties, post-traumatic stress disorder (PTSD), substance use, and job loss.
The USPSTF recommends that asymptomatic women of childbearing age be screened for intimate partner violence and that screening and interventions provide a moderate benefit.5 There are many screening tools that can be used to detect intimate partner violence but there is no agreement as to which one is best.63,64 A recent (2016) survey65 of intimate partner violence screening tools found that the Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK) are particularly useful.66,67 The WAST screen is provided below as an example.
Women Abuse Screen Tool
|1. In general, how would you describe your relationship? |
|A lot of tension; some tension; no tension |
|2. Do you and your partner work out arguments with: |
|Great difficulty; some difficulty; no difficulty? |
|3. Do arguments ever result in you feeling down or bad about yourself? |
|Often; sometimes; never |
|4. Do arguments ever result in hitting, kicking or pushing? |
|Often; sometimes; never |
|5. Do you ever feel frightened by what your partner says or does? |
|Often; sometimes; never |
|6. Has your partner ever abused you physically? |
|Often; sometimes; never |
|7. Has your partner ever abused you emotionally? |
|Often; sometimes; never |
|8. Has your partner ever abused you sexually? |
|Often; sometimes; never |
Elder abuse is a common problem in the United States and elsewhere. As with intimate partner violence, elder abuse is underreported but several studies have found a prevalence of 7.6% to 10%.68 Elder abuse has been defined and classified into five categories.68
• Physical abuse or acts carried out with the intention to cause physical pain or injury
• Psychological or verbal abuse
• Sexual abuse, i.e., non-consensual sexual contact
• Financial exploitation
• Neglect
Risk factors for elder abuse include dementia, isolation, low income, poor social support, a shared living situation with a large number of relatives, and perpetrator characteristics such as alcohol use, mental illness, and exposure to violence as a child.69-71
The USPSTF does not have recommendations for elder abuse screening, noting that “… there were no studies on the accuracy, effectiveness, or harms of screening in this population.”5 However,
screening for or inquiry about elder abuse is recommended by organizations such as the National Center on Elder Abuse, the National Academy of Sciences, and the American Academy of Neurology and the American Medical Association recommend routine screening.71
Prevention and Personal Health Counseling
Counseling is a vital component of preventive medicine. Screening tests detect health problems and identify people at risk. But screening tests should be followed by counseling and patient education if the patient has, or is at risk for a specific disease or disorder. The USPSTF recommends that when appropriate, adult patients should be counseled about the following.5
• Alcohol misuse
• Breastfeeding
• Falls
• Healthful diet and physical activity
• Motor vehicle occupant restraints
• Obesity
• Sexually transmitted infections
• Skin cancer
• Tobacco use
Children and adolescents should be counseled, when appropriate, about:5
• Alcohol misuse
• Illicit drug use
• Motor vehicle occupant restraints
• Obesity
• Sexually transmitted infections
• Skin cancer
Vaccinations
Vaccinations are a critically important part of preventive medicine. The vaccination schedules presented here are the recommendations of the CDC.
CDC Vaccination Schedules
|Vaccine [pic] |Age Group [pic] |
|Tetanus, diphtheria, pertussis |Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs |
|(Td/Tdap) 3, | |
|Varicella 4, |←2 doses→ |
|Human papillomavirus (HPV) Female 5, |←3 doses→ | | | | |
|Human papillomavirus (HPV) Male 5, |←3 |doses→ | | |
|Pneumococcal 13-valent conjugate |←1 dose→ |
|(PCV13)8, | |
|Pneumococcal polysaccharide |←1 or 2 doses→ |←1 dose→ |
|(PPSV23)9,10 | | |
|Meningococcal 11, |←1 or more doses→ |
|Hepatitis A 12, |←2 doses→ |
|Hepatitis B 13, |←3 doses→ |
|Haemophilus influenzae type b (Hib)14,|←1 or 3 doses→ |
Pediatrics: 0 – 15 Months Vaccination Schedule
|Vaccine |Birth |1 mo |2 mos |4 mos |
|Rotavirus2(RV) | | |←1st dose→ |
|RV1 (2-dose series); RV5 (3-dose series) | | | |
Pediatrics: 15 Months to 18 Years Vaccination Schedule
|Vaccines |18 mos |19-23 mos |
|Rotavirus2(RV) | | |
|RV1 (2-dose series); RV5 (3-dose series) | | |
|Pneumococcal conjugate6 (PCV13) | | |
|Pneumococcal polysaccharide6(PPSV23) | | | |
|Inactivated poliovirus7 (IPV)( age 50.
b. IV drug users and men who have sex with men.
c. pregnant women and adolescents.
d. anyone born between 1945 and 1965.
10. Screening for Hepatitis C is recommended for
a. people who misuse alcohol and people > age 50.
b. all persons who have diabetes.
c. pregnant women and adolescents.
d. anyone born between 1945 and 1965.
11. Screening for HIV is recommended for
a. anyone having unprotected anal or vaginal intercourse.
b. anyone born between 1945 and 1965.
c. anyone who misuse alcohol.
d. anyone who has hypertension and diabetes.
12. True or False: The USPSTF recommends that all adults should be screened for hypertension.
a. True
b. False
13. Intimate partner violence
a. involves physical harm to the victim.
b. includes physical, sexual, psychological harm.
c. is limited to violence done by men to women.
d. is a very rare occurrence.
14. Screening for obesity is done by measuring
a. body weight.
b. body weight and height.
c. waist and upper arm circumference.
d. body mass index.
15. Osteoporosis is very common in
a. young African American males
b. all men under the age of 50.
c. elderly white females.
d. people who have hypertension.
16. All pregnant women should be screened for
a. depression and illicit drug use.
b. bacteriuria.
c. alcohol misuse and coronary heart disease.
d. osteoporosis and syphilis.
17. True or False: The benefits of prostate cancer screening far outweigh the risks.
a. True
b. False
18. All newborns should be screened for
a. lipid disorders.
b. iron deficiency anemia.
c. phenylketonuria.
d. hypertension.
19. All pregnant women should be screened for
a. gonorrhea.
b. syphilis.
c. sickle cell disease.
d. skin cancer and lipid disorders.
20. All newborns should be screened for
a. sickle cell disease.
b. elevate cholesterol.
c. autism.
d. Hepatitis C.
21. True or False: Screening infants for hearing impairment is mandatory.
a. True
b. False
22. All newborns should be screened for
a. HIV.
b. diabetes.
c. Hepatitis B.
d. congenital hypothyroidism.
23. Which of the following is the leading cause of preventable deaths in the United States?
a. Diabetes
b. Alcohol
c. Tobacco
d. HIV
24. Which of the following is NOT true regarding cigarette smoking in the United State?
a. An estimated 40 million adults currently smoke cigarettes.
b. It accounts for more than 480,000 deaths every year.
c. Less than one million adults live with a smoking-related disease.
d. Smoking has declined from 20.9% adults in 2005 to nearly 16.8% in 2014.
25. Heath effects of second-hand smoke include
a. sudden infant death syndrome (SIDS).
b. ear infections.
c. pneumonia.
d. All of the above
26. Which of the following is one of the three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation?
a. Tamoxifen
b. Prescription opioids
c. Varenicline
d. Raloxifene
27. The USPSTF and the American Cancer Society recommends asymptomatic adults, aged 55 to 80 years, have annual screening with low dose computed tomography if they have a 30 pack-year history of smoking and currently smoke or have quit smoking
a. within the past 15 years.
b. within the past 5 years.
c. but started smoking again.
d. within the past year.
28. True or False: Second-hand smoke is smoke that is produced from burning tobacco or smoke that has been exhaled by someone using a cigarette and although second-hand smoke may be dangerous, there are safe levels of second-hand smoke.
a. True
b. False
29. The USPSTF advises or states that
a. clinicians should be aware of, and alert to the signs and symptoms of illicit drug use.
b. the evidence supports the benefits and harms of screening for illicit drug use.
c. drug use disorders and overdoses are consistent with one particular age group.
d. All of the above
30. Risk factors for non-melanoma and melanoma skin cancer include
a. indoor tanning.
b. a family history of melanoma.
c. the use of psoralen.
d. All of the above
31. The American Dental Association in 2010 published guidelines about oral cancer screening stated or recommended
a. auto-fluorescence screening as the only proven tool.
b. tissue reflectance as the primary screening tool.
c. auto-fluorescence and tissue reflectance as the most effective screening tools.
d. oral inspection and tactile palpation as screening tools.
32. Congenital syphilis that is untreated can cause
a. spontaneous sequelae.
b. phenylketonuria.
c. early infant death.
d. neonatal phenylketonuria.
33. Which of the following is a modifiable risk factor for coronary heart disease?
a. diabetes.
b. family history of coronary heart disease.
c. gender.
d. age.
34. True or False: The four question CAGE screening test for alcohol use, which is familiar to many healthcare professionals, is NOT recommended as a screening tool for alcohol use as it is not highly sensitive or specific.
a. True
b. False
35. The USPSTF recommendations for cervical cancer screening for women aged 30-65 is
a. to screen with cytology more often than every 3 years.
b. screen three years with a Pap smear and HPV testing.
c. to not screen.
d. screen three years with a Pap smear.
36. The USPSTF recommendations for cervical cancer screening for women over the age of 65 who have had adequate prior screening and are not high risk is
a. to screen every 5 years.
b. screen three years with a Pap smear and HPV testing.
c. to not screen.
d. screen three years with a Pap smear.
37. The USPSTF states that screening for cervical cancer earlier than age 21 years
a. leads to more harms than benefits.
b. depends on the patient’s sexual history.
c. provides a modest decrease in cervical cancer.
d. should be done on a case-by-case basis.
38. True or False: The USPSTF recommends routine screening for skin cancer.
a. True
b. False
39. The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present
a. and there is no causal event.
b. on one or more occasions.
c. using ambulatory blood pressure monitoring.
d. on several occasions.
40. Blood pressure measurement is an important predictor of cardiovascular complications in people with
a. type 2 diabetes mellitus.
b. colorectal cancer.
c. iron deficiency anemia.
d. lipid disorders.
41. People who have sickle cell disease have hemoglobin S and when oxygen binds to _______________, red blood cells form an abnormal shape (the sickle shape).
a. hemoglobin C.
b. hemoglobin A.
c. hemoglobin A2.
d. hemoglobin S
42. Basal cell carcinoma and squamous cell carcinoma are the two
a. melanoma skin cancers.
b. non-melanoma skin cancers.
c. cancers reported in the cancer registries.
d. malignant melanomas.
43. True or False: Because of the increased use of sunscreens, incidences of malignant melanoma, and deaths from this cancer, have been decreasing for years.
a. True
b. False
44. The USPSTF recommends that __________ asymptomatic pregnant women be screened for iron deficiency anemia by measuring hematocrit and hemoglobin levels.
a. diabetic
b. vegetarian
c. all
d. first-time
45. Which of the following causes iron deficiency anemia during pregnancy?
a. A high protein, meat diet
b. A vegetarian diet
c. Iron deficiencies are limited to first-time pregnancies
d. Consuming a single beer each day
46. Anemia during pregnancy can cause, or has been associated with
a. spontaneous abortion.
b. high birth weight.
c. overdue births.
d. breast cancer.
47. Malignant melanoma can metastasize to
a. the lymph nodes only.
b. the skin but not other organs.
c. any organ.
d. the skin and lymph nodes only.
CORRECT ANSWERS:
1. One of the limitations of screening tests is
a. guidelines are often changed and updated.
“However, it is important to remember the following points when broad screening guidelines are used for a heterogeneous population… Screening guidelines are always being changed and updated.”
2. Screening tests must be used with the understanding that
c. they are not diagnostic.
“However, it is important to remember the following points when broad screening guidelines are used for a heterogeneous population… A screening test is not a diagnostic test.”
3. Adults should be screened for alcohol misuse if they
d. engage in risky drinking behavior.
“Screen for alcohol misuse and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking.”
4. Breast cancer is
b. the second most common cancer in women.
“Breast cancer is the most common cancer in women, excluding skin cancer."
5. Breast cancer screening may include
d. mammography and genetic testing.
“There is convincing evidence that using mammography to screen for breast cancer reduces overall mortality from breast cancer… Genetic testing for breast cancer is recommended for women whose family history may be associated with an increased risk for potentially harmful breast cancer mutations.”
6. Screening for cervical cancer
a. significantly decreases mortality from the disease.
“Cervical cancer screening decreases the incidence and mortality of cervical cancer.”
7. Colorectal cancer screening can be done using
b. fecal occult blood testing and colonoscopy.
“The USPSTF recommendations for colorectal cancer screening are highlighted below. Age 50-75: Screen with high sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy…. Screening intervals: Annual screening with high-sensitivity fecal occult blood testing;…”
8. Screening adolescents age 12-18 for depression is recommended if
c. follow-up care and support is available.
“The USPSTF advises that adolescents age 12-18 should be screened for depression when there are resources in place for diagnosis, treatment, and follow-up.”
9. True or False: Almost 30 percent of people who have diabetes go undiagnosed.
a. True
“Approximately 27.8% of people who have diabetes are undiagnosed,…”
10. The American Diabetes Association recommends screening for diabetes using
b. fasting plasma glucose.
“The American Diabetes Association recommends screening with fasting plasma glucose (FPG),…”
11. People who have diabetes should periodically be screened for
c. cardiovascular disease.
“Asymptomatic patients should not be screened for cardiovascular disease but cardiovascular risk factors should be assessed annually, at least. These risk factors include dyslipidemia, hypertension, family history of premature cardiovascular disease, presence of albuminuria, and smoking.”
12. Screening for Hepatitis B is recommended for
b. IV drug users and men who have sex with men.
“The CDC recommends screening the following groups for Hepatitis B … Injection-drug users… Men who have sex with men.”
13. Screening for Hepatitis C is recommended for
d. anyone born between 1945 and 1965.
“The USPSTF recommendations for hepatitis screening are highlighted here… Persons at high risk for infection and adults born between 1945 and 1965 should be screened.”
14. Screening for HIV is recommended for
a. anyone having unprotected anal or vaginal intercourse.
“Younger adolescents and adults considered to be at increased risk include:… Anyone having unprotected vaginal or anal intercourse.”
15. True or False: The USPSTF recommends that all adults should be screened for hypertension.
a. True
“The USPSTF screening recommendations,… include the following… All adults be screened for hypertension.”
16. Intimate partner violence
b. includes physical, sexual, psychological harm.
“Intimate partner violence is defined by the CDC as physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner.”
17. Screening for obesity is done by measuring
d. body mass index.
“Screening for obesity is recommended and the USPSTF advises that adults age 18 and older be screened by using body mass index (BMI)…”
18. Osteoporosis is very common in
c. elderly white females.
“Risk factors for osteoporosis are outlined below as:… Asian or white race… Female > 65 years of age.”
19. All pregnant women should be screened for
b. bacteriuria.
“The USPSTF recommends that all pregnant women be screened for asymptomatic bacteriuria.”
20. True or False: The benefits of prostate cancer screening far outweigh the risks.
b. False
“Screening for prostate cancer by measuring prostate-specific antigen (PSA) and digital rectal examination can reduce the mortality rate prostate cancer but this reduction is very small and does not outweigh the risks.”
21. All newborns should be screened for
c. phenylketonuria.
“Screening for PKU is mandated in all 50 states, and infants should be screened at or near seven days of age.”
22. All pregnant women should be screened for
a. gonorrhea.
“The USPSTRF recommends that all pregnant women be screened for syphilis at the first prenatal visit…”
23. All newborns should be screened for
a. sickle cell disease.
“The USPSTF recommends that all newborn infants be screened for sickle cell disease…”
24. True or False: Screening infants for hearing impairment is mandatory.
a. True
“Hearing testing for newborns is mandatory in all 50 states.”
25. All newborns should be screened for
d. congenital hypothyroidism.
“Screening newborns for congenital hypothyroidism is mandatory in all 50 states and in the District of Columbia.”
26. Which of the following is the leading cause of preventable deaths in the United States?
c. Tobacco
“Tobacco use is the leading cause of preventable death in the United States.”
27. Which of the following is NOT true regarding cigarette smoking in the United State?
c. Less than one million adults live with a smoking-related disease.
“More than 16 million Americans live with a smoking-related disease.”
28. Heath effects of second-hand smoke include
a. sudden infant death syndrome (SIDS).
b. ear infections.
c. pneumonia.
d. All of the above [Correct Answer]
“Heath effects of second-hand smoke: ear infections, pneumonia, sudden infant death syndrome (SIDS).”
29. Which of the following is one of the three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation?
c. Varenicline
“There are three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation:… and varenicline.”
30. The USPSTF and the American Cancer Society recommends asymptomatic adults, aged 55 to 80 years, have annual screening with low dose computed tomography if they have a 30 pack-year history of smoking and currently smoke or have quit smoking
a. within the past 15 years.
“The USPSTF and the American Cancer Society recommends that asymptomatic adults aged 55 to 80 years who have a 30 pack-year history of smoking and currently smoke or have quit smoking within the past 15 years should have annual screening with low dose computed tomography.”
31. True or False: Second-hand smoke is smoke that is produced from burning tobacco or smoke that has been exhaled by someone using a cigarette and although second-hand smoke may be dangerous, there are safe levels of second-hand smoke.
b. False
“Second-hand smoke is smoke that is produced from burning tobacco or smoke that has been exhaled by someone using a cigarette and there is no safe level of second-hand smoke.”
32. The USPSTF advises or states that
a. clinicians should be aware of, and alert to the signs and symptoms of illicit drug use.
“’The USPSTF advises that clinicians should be aware of, and alert to the signs and symptoms of illicit drug use but that’… the evidence is insufficient to determine the benefits and harms of screening for illicit drug use.”
33. Risk factors for non-melanoma and melanoma skin cancer include
a. indoor tanning.
b. a family history of melanoma.
c. the use of psoralen.
d. All of the above [Correct Answer]
“Risk factors for non-melanoma and melanoma skin cancer include (but are not limited to: 1) Caucasian ethnicity, 2) exposure to sunlight, 3) indoor tanning, 4) immunosuppression, 5) fair skin, 6) family history of melanoma, 7) atypical nevi, 8) advanced age, 9) psoralen, and 10) UVA light therapy.”
34. The American Dental Association in 2010 published guidelines about oral cancer screening stated or recommended
d. oral inspection and tactile palpation as screening tools.
“The American Dental Association in 2010 published guidelines… noted that oral inspection and tactile palpation were the recommended screening tools. These guidelines also noted that the use of devices that rely on auto-fluorescence or tissue reflectance to detect oral cancers do not appear to be superior for this purpose when compared to conventional visual inspection and tactile palpation.”
35. Congenital syphilis that is untreated can cause
c. early infant death.
“Syphilis can be transmitted from an infected mother to an unborn child: this is called congenital syphilis. Congenital syphilis that is untreated can cause early infant death, miscarriage, spontaneous abortion, still birth, late complications in the infant, and other serious sequelae.”
36. Which of the following is a modifiable risk factor for coronary heart disease?
a. diabetes.
“Modifiable risk factors include cigarette smoking, diabetes, diet, elevated serum lipids and cholesterol, hypertension, obesity, and sedentary life style. Non-modifiable risk factors are age, gender, and family history of coronary heart disease.”
37. True or False: The four question CAGE screening test for alcohol use, which is familiar to many healthcare professionals, is NOT recommended as a screening tool for alcohol use as it is not highly sensitive or specific.
a. True
“The CAGE test is not recommended as a screening tool for alcohol use as it is not highly sensitive or specific.”
38. The USPSTF recommendations for cervical cancer screening for women aged 30-65 is
b. screen three years with a Pap smear and HPV testing.
“The USPSTF recommendations for cervical cancer screening are highlighted below… Women aged 30-65: screen every three years with a Pap smear or a Pap smear and HPV testing.”
39. The USPSTF recommendations for cervical cancer screening for women over the age of 65 is
c. to not screen.
“The USPSTF recommendations for cervical cancer screening are highlighted below... Women older than age 65 who have had adequate prior screening and are not high risk: Do not screen.”
40. The USPSTF states that screening for cervical cancer earlier than age 21 years
a. leads to more harms than benefits.
“The USPSTF recommendations for cervical cancer screening are highlighted below... Screening earlier than age 21 years, regardless of sexual history, leads to more harms than benefits.”
41. True or False: The USPSTF recommends routine screening for skin cancer.
b. False
“The USPSTF does not recommend routine screening for skin cancer…”
42. The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present
d. on several occasions.
“The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present on several occasions. Blood pressure can be measured in a physician’s office, by using ambulatory blood pressure monitoring, or using home blood pressure monitoring.”
43. Blood pressure measurement is an important predictor of cardiovascular complications in people with
a. type 2 diabetes mellitus.
“Patients who are at risk for, or who have diabetes, should be screened for hypertension and blood pressure should be measured at every routine visit. A systolic blood pressure of ≤ 140 mm Hg or a blood pressure of < 140/90 m Hg is desirable. These levels have been associated with a reduction in CVD, nephropathy, and stroke in patients who have diabetes.”
44. People who have sickle cell disease have hemoglobin S and when oxygen binds to _______________, red blood cells form an abnormal shape (the sickle shape).
d. hemoglobin S
“People who have sickle cell disease have hemoglobin S and when oxygen binds to hemoglobin S…”
45. Basal cell carcinoma and squamous cell carcinoma are the two
b. non-melanoma skin cancers.
“Basal cell carcinoma and squamous cell carcinoma are the two non-melanoma skin cancers.”
46. True or False: Because of the increased use of sunscreens, incidences of malignant melanoma, and deaths from this cancer, have been decreasing for years.
b. False
“Malignant melanoma can metastasize to any organ (most often the skin and lymph nodes) and the incidence of malignant melanoma and deaths from this cancer have been increasing for years.”
47. The USPSTF recommends that __________ asymptomatic pregnant women be screened for iron deficiency anemia by measuring hematocrit and hemoglobin levels.
c. all
“The USPSTF recommends that all asymptomatic pregnant women be screened for iron deficiency anemia by measuring hematocrit and hemoglobin levels.”
48. Which of the following causes iron deficiency anemia during pregnancy?
b. A vegetarian diet
“Causes of iron deficiency anemia during pregnancy include poor intake, poor nutrition, gastrointestinal disease, vegetarian diet, medications that interfere with iron absorption, and multiple pregnancies.”
49. Anemia during pregnancy can cause, or has been associated with
a. spontaneous abortion.
“Anemia during pregnancy can cause, or has been associated with increased maternal mortality, premature birth, spontaneous abortion, fetal death, low birth weight, and in utero abnormalities.”
50. Malignant melanoma can metastasize to
c. any organ.
“Malignant melanoma can metastasize to any organ (most often the skin and lymph nodes) and the incidence of malignant melanoma and deaths from this cancer have been increasing for years.”
References Section
The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.
1. . This link is to the USPSTF main page. [Keyword searches, i.e., “Alcohol Misuse,” will link you to the relevant discussion and screening recommendations].
2. Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 154927, NSDUH Series H-50). . Accessed July 30, 2016.
3. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015; 72(8):757-766.
4. Saltz R, Screening for unhealthy use of alcohol and other drugs in primary care. UpToDate. August 7, 2015. . Accessed August 14, 2016.
5. Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services 2014. . Accessed August 14, 2016. [This link is to the USPSTF main page. Keyword searches, i.e., “Alcohol Misuse,” will link you to the relevant discussion and screening recommendations].
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