1. Preventive Medicine




“Treatment without prevention is simply unsustainable.”


—Bill Gates


1.1 Types of Prevention



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1.2 General Screening Recommendations in Adults











































































































Start screening at the following age


Patient group


Screen for


Testing modality


Frequency





  • All patients who have risk factors for sexually transmitted disease (STD)a



  • All females aged < 25 years who are sexually active


Chlamydia trachomatis and gonorrhea


Nucleic acid detection method (urine or genital swabs)


Depends on presence of risk factorsa


15


All patients


Human immunodeficiency virus (HIV)


Combination HIV-1/2 immuoassay (this detects both HIV antigen and antibody)


20


Only in patients with risk factors for dyslipidemia (see the “Dyslipidemia” section below)


Dyslipidemia


Lipid profile


At regular intervals


21


All females


Cervical cancer


Pap smear test


See Ob/Gyn chapter for further details


35


All males


Dyslipidemia


Lipid profile


At regular intervals


45


All females


Dyslipidemia


Lipid profile


At regular intervals


All patients


Diabetes




  • Start screening earlier if there are additional risk factors


Fasting blood glucose or HbA1C


At regular intervals


50


All females


Breast cancerb


Mammography


Every 1-2 years


All patients


Colon cancerc


Colonoscopy (test of choice for screening)


Every 10 years


Only in patients with family history of prostate cancer


Prostate cancer


Digital rectal examination and prostate-specific antigen (PSA)


At regular intervals


55


All patients with ≥ 30 pack-year smoking historyd


Lung cancer


Low dose chest CT scan


Every 1 year




  • Stop screening at 80, or 15 years after smoking cessation


60


Female patients with risk factors for osteoporosise


Osteoporosis


DEXA scan (dual-energy X-ray absorptiometry scan)


At regular intervals


65


All female patients


Osteoporosis


At regular intervals


Male patients with significant smoking history


Abdominal aortic aneurysm


Abdominal ultrasound (!)


Once


a Risk factors for STD: men who have sex with men, contact with sex workers, illicit drug use, a new partner in the last 3 months, incarceration, and previous history of STD. Also, consider screening for other STDs -HIV, HBV, HCV, and syphilis.


b At age 40, all women can be offered screening mammography. At age 50, all women should begin screening.


c Patients with family history of colon cancer in any first-degree relative before age 60, or in two or more first-degree relatives at any age should begin screening at age 40, or 10 years before the youngest case in the family, whichever comes earlier. See Chapter 9, Gastroenterology, colon cancer section for further details.


d How to calculate pack-years? Multiply the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, smoking 1 packet per day for 30 years is equal to 1 x 30 = 30 pack-year smoking history.


e Risk factors for osteoporosis: family history, smoking, alcohol abuse, chronic steroid use, chronic anticonvulsant use, low body weight, and previous history of pathological fractures.



Caution

(!) Do not choose CT scan.



In a nutshell



  • Patient’s age is very important for screening purposes.




    • Is chlamydia screening recommended for a 27-year-old sexually active female patient with no risk factors? The answer is no.



    • What if the patient’s age was 24? The answer is yes.



  • Generally, preventive screening is stopped at the age of 70 to 80 years, or if life expectancy is less than 10 years.



  • Do not screen a patient just because he/she requests it. Know the indications above.



Additional screening


All adults should be screened for depression, alcohol misuse, hypertension, obesity, and smoking at regular intervals.


Smoking cessation: patients who want to quit smoking, nicotine replacement therapy is recommended; use combination of nicotine patch plus gum, inhaler, or lozenges. Bupropion or varenicline (which decreases the urge to smoke) can also be considered.



1 Varenicline is associated with higher rates of cardiovascular events. Avoid this in patients with cardiac conditions. Also, both varenicline and bupropion comes with black-box warning of increased risk of suicide. Consider this risk in patients with psychiatric conditions.




1.3 Preventive Management of Dyslipidemia


Start screening for dyslipidemia from 20 years of age, if patient has any of the following risk factor:




  • Diabetes mellitus.



  • Family history of dyslipidemia.



  • Multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) (e.g., smoking and hypertension).



  • Family history of coronary artery disease (CAD) in a male relative < 50 years or female relative < 60 years—termed as premature CAD.



  • Obese patient.


If none of the above is present, begin screening for dyslipidemia at the age of 35 years in male and 45 years in females.



When to initiate statin therapy ?



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a If patient has any of following medical history, it is defined as Clinical ASCVD




Cerebrovascular disease—history of ischemic stroke or transient ischemic attack.



Peripheral vascular disease—history of claudication or vascular procedure.



CAD—history of stable angina, acute coronary syndrome, or cardiovascular procedures.


b The boards will not ask you what is high- or moderate-intensity dose for each statin (Just FYI- high intensity dose of atorvastatin is 40–80 mg).


c Benefits of statin therapy may be less clear in the following patients: age < 45 or > 75, or with low-density lipoprotein (LDL) levels of <70 mg/dL.


d ASCVD score is a composite number calculated using following risk factors: age, gender, hypertension (controlled or uncontrolled), diabetes mellitus, race, cigarette smoking, and high-density lipoprotein. A 10-year risk score is used for dyslipidemia management. (The boards will not ask you to calculate ASCVD score, or what conditions are factored in 10-year ASCVD risk-score will be provided in the question itself).



MRS

The magic number is 75. Age cutoff is 75 and ASCVD score cutoff is 7.5.

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Dec 11, 2021 | Posted by in GENERAL SURGERY | Comments Off on 1. Preventive Medicine
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