الرحمن ا بسمالرحیم

Preventive Medicine

Homayouni MD

10/Oct/2011

18/1390مهر/

Live sensibly - among a thousand people , only one die a natural death the rest succumb to irrational modes

of living

Maimonides AD 1135-1204ابو عمران موس بن میمون بن عبدال القراطبی

A small number of modifiable factors underlies a large number of death and disabilities

Criteria of a good screening test 1)High sensitivity & specificity

2)High positive predictive Value

3)Simplicity & Cost

4)Safety

5)Acceptable to patient & physician

6)Labeling

Tier Definition

Universal preventionaddresses the entire population (national, local community, school, district) and aim to prevent or delay the abuse of alcohol, tobacco, and other drugs. All individuals, without screening, are provided with information and skills necessary to prevent the problem.

Selective prevention

focuses on groups whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings.

Indicated prevention

involves a screening process, and aims to identify individuals who exhibit early signs of substance abuse and other problem behaviors. Identifiers may include falling grades among students, known problem consumption or conduct disorders, alienation from parents, school, and positive peer groups etc.

Aspirin

Aspirin for primary prevention of cardiovascular events Men ages 45 to 79, women ages 55 to 79, when benefits outweigh harms: A

Diabetes mellitus

There are no randomized trials examining the ffectiveness of screening for diabetes. Models suggest that creening for diabetes in people with elevated blood pressure may be cost-effective because of effects of blood pressure management on cardiovascular outcomes [34,35]. owever, these models are based on evidence that people with diabetes benefit from tighter blood pressure control than people without diabetes. Recent trials (eg, ACCORD-BP) cast some doubt on this assumption [36].

Dyslipidemia

Screening for dyslipidemia Average risk- men >35: A Increased risk: men 20-35, women >20: B

Screen with TC and HDL: B

Abdominal aortic aneurysm

Ruptured abdominal aortic aneurysm (AAA) is a catastrophic but uncommon event. The great majority of the 9000 annual US deaths from AAA rupture are in men between the ages of 65 and 75 years who are current or former smokers. Open surgical repair of AAA ≥5.5 cm reduces deaths associated with AAA rupture, at a cost of increased surgical procedures.

Colorectal cancer

Patients should be asked about first and second degree relatives who have

had colorectal cancer. Screening and prevention recommendations for

patients with a family history of colorectal cancer, as well as genetic

screening, are discussed in detail elsewhere

Hypertension

Hypertension in the US accounts for 35 percent of myocardial infarctions

and strokes, 49 percent of episodes of heart failure, and 24 percent of

premature deaths [9]. High blood pressure is diagnosed when systolic blood

pressure (SBP) is ≥140 mmHg, or diastolic blood pressure (DBP) is

≥90mmHg , on two or more visits over a period of several weeks

Lung cancer

Reducing the risk of lung cancer should focus on those people who smoke tobacco and on targeted populations (i.e, adolescents) who are at risk of initiating tobacco use. Avoidance and cessation of tobacco use could potentially reduce the incidence and mortality from lung cancer by about 90 percent.

Smoking

Screen for tobacco use and provide tobacco cessation interventions Adults: A

Pregnant women: A

Osteoporosis

Screening for osteoporosis Women ages 65+ and women 60-64 with risk factors: B

Prostate cancer

Screening for prostate cancer is controversial. The benefits of screening (ie, reducing prostate cancer mortality) are small, in that they accrue to only a small number of men (no more than one in 1,400) and only after nine years [24]. Benefits may be outweighed by the significant harms of screening that affect many more men (need for biopsy, and impotence or incontinence occurring in at least 50 percent of men who undergo treatment for a disease that may be indolent).

What not to doAdult screening and prevention recommendations of USPSTF (December

2009) D recommendations (discourage testing)

Service Population

Screening for abdominal aortic aneurysm Women

Aspirin and NSAIDs to prevent colorectal cancer Men under age 45; women under age 55

Aspirin to prevent CHD Men under age 45

Aspirin to prevent ischemic stroke Women under age 55

Screening for bacterial vaginosis Average risk

Screening for breast cancer by teaching BSE All women

Screening for asymptomatic bacteriuria Men and non-pregnant women

Beta carotene supplements Adults

Screening for bladder cancer Adults

Screening for hepatitis C Not at increased risk Chemoprevention of breast cancer Women not at increased risk of breast cancer BRCA mutation testing for breast and ovarian cancer Women whose family history is not associated with an increased risk for deleterious mutations in BRCA 1 or BRCA 2 Cervical cancer screening with Pap smear Women over age 65 who have had previous negative screens; women who have had total hysterectomy for benign disease Screening for coronary heart disease Adults not at increased risk (ECG,

ETT, or EBCT) Screening for hepatitis B infection General population Serologic screening for genital herpes simplex Asymptomatic pregnant women; asymptomatic adolescents and adults Postmenopausal hormone therapy for primary prevention of chronic problems Postmenopausal women with or without a hysterectomy: estrogen plus progestin or estrogen alone

Screening for idiopathic scoliosis Adolescents Screening for ovarian cancer Women Screening for pancreatic cancer Adults Screening for peripheral arterial disease Adults Screening for syphilis Not at increased risk Screening for testicular cancer Men Screening for asymptomatic carotid artery stenosis Adult men and women Screening for chronic obstructive pulmonary disease with spirometry Adult men and women Screening for prostate cancer Men ages 75 and older Screening for colorectal cancer Men and women ages 86 years and older

Rec’s U.S.P.S.T.F.

AAbdominal Aortic Aneurysm: Screening Never smoked 65 y__________________________________________________________

BBacterial Vaginosis in Pregnancy: Screening (2001)Bacteriuria: Screening (2004)Bladder Cancer: Screening (2004) Blood Pressure: Screening (2003) 19 YBreast Cancer: Screening (2002) / Preventive Medication (2002) Breastfeeding: Counseling (2003)

CCarotid Artery Stenosis: Screening (1996)

Cervical Cancer: Screening (2003)

Chlamydial Infection: Screening (2001)

Colorectal Cancer: Screening (2002)

Coronary Heart Disease: Screening (2004)___________________________________________

DDementia: Screening (2003)

Dental Caries in Preschool Children: Screening (2004)

Depression: Screening (2002)

Diabetes Mellitus: Screening (2003)

Diet: Counseling(2003)

Down Syndrome: Screening (1996)

Drug Abuse: Screening (1996)____________________________________________F

Family Violence: Screening (2004)

GGestational Diabetes: Screening (2003)

Glaucoma: Screening (2005)

Gonorrhea: Screening (2005)

Gynecologic Cancers: Counseling(1996)___________________________________________

HHearing Impairment: Screening (1996)

Hearing, Newborn: Screening (2001)

Hemoglobinopathies: Screening (1996)

Hepatitis B Virus Infection: Screening (2004)

Hepatitis C Virus Infection: Screening (2004)

Herpes Simplex, Genital: Screening (2005)

Home Uterine Activity Monitoring: Screening (1996)

Hormone Replacement Therapy: Preventive Medication (2005)

Household and Recreational Injuries: Counseling (1996)

Human Immunodeficiency Virus (HIV) Infection: Screening (2005) / Counseling (1996)

Hypothyroidism, Congenital: Screening (1996)

IIdiopathic Scoliosis in Adolescents: Screening (2004)

Immunizations, Adult: Immunizations (1996)

Immunizations, Childhood: Immunizations (1996)

Intrapartum Electronic Fetal Monitoring: Screening (1996)____________________________________________

LLead Levels in Childhood and Pregnancy: Screening (1996)

Lipid Disorders: Screening (2001)

Lung Cancer: Screening (2004) ___________________________________________

MMotor Vehicle Injuries: Counseling(1996) ____________________________________________

NNeural Tube Defects: Screening (1996)____________________________________________

OObesity in Adults: Screening (2003) / Counseling (1996)

Oral Cancer: Screening (2004)

Osteoporosis: Screening (2002)

Overweight in Children and Adolescents: Screening (2005)

Ovarian Cancer: Screening (2004)

PPancreatic Cancer: Screening (2004)

Peripheral Arterial Disease: Screening (2005)

Phenylketonuria: Screening (1996)

Physical Activity: Counseling (2002)

Postexposure Prophylaxis for Selected Infectious Diseases: Preventive Medication (1996)

Preeclampsia: Screening (1996)

Prostate Cancer: Screening (2002)_______________________________________

RRh Incompatibility: Screening (2004)

Rubella: Screening (1996)_______________________________________

SSkin Cancer: Screening (2001) / Counseling (2003)

Suicide Risk: Screening (2004) / Counseling (1996)

Syphilis: Screening (2004)

TTesticular Cancer: Screening (2004)

Thyroid Disease: Screening (2004)

Thyroid Cancer: Screening (1996)

Tobacco Use: Screening (2003)

Tuberculous Infection: Screening (1996) _________________________________________________

UUltrasonography in Pregnancy: Screening (1996)

Unintended Pregnancy: Counseling (1996)_________________________________________________

VVisual Impairment: Screening (1996)

Visual Impairment in Children Ages 0-5: Screening (2004)

Vitamin Supplementation to Prevent Cancer and Coronary Heart Disease: Counseling (2003)_________________________________________________

YYouth Violence: Counseling (1996)

What not to doAdult screening and prevention recommendations of USPSTF (December

2009) D recommendations (discourage testing)

Service Population

Screening for abdominal aortic aneurysm Women

Aspirin and NSAIDs to prevent colorectal cancer Men under age 45; women under age 55

Aspirin to prevent CHD Men under age 45

Aspirin to prevent ischemic stroke Women under age 55

Screening for bacterial vaginosis Average risk

Screening for breast cancer by teaching BSE All women

Screening for asymptomatic bacteriuria Men and non-pregnant women

Beta carotene supplements Adults

Screening for bladder cancer Adults

Screening for hepatitis C Not at increased risk Chemoprevention of breast cancer Women not at increased risk of breast cancer BRCA mutation testing for breast and ovarian cancer Women whose family history is not associated with an increased risk for deleterious mutations in BRCA 1 or BRCA 2 Cervical cancer screening with Pap smear Women over age 65 who have had previous negative screens; women who have had total hysterectomy for benign disease Screening for coronary heart disease Adults not at increased risk (ECG,

ETT, or EBCT) Screening for hepatitis B infection General population Serologic screening for genital herpes simplex Asymptomatic pregnant women; asymptomatic adolescents and adults Postmenopausal hormone therapy for primary prevention of chronic problems Postmenopausal women with or without a hysterectomy: estrogen plus progestin or estrogen alone

Screening CVD HTN AAAObesity & eating disorder Hyperlipemia TB if at riskPhysical , sexual and emotional abuse Learning and school problemsSubstance use

Behavior and emotion for depression & suicideSexual behaviorSTDHIVCancerDM Vision and hearing problems

Recommended tests

داستان نقش ویتامینها در جلوگیری از بیماریها

Folic acid pregnancy

Cancer → Colorectal

CVD → Homocictein

HTN

Hearing loss

Vitamin D

Osteoporosis

Falls

Cancer(±)

Vitamin E

Cancer(−)

CVD(−)

Dement ion(−)

Infection(−)

DVT(+)

Antioxidant

Vitamin A (Retinol)

Cancer (±)

CVD(−)

Immunity (+) in children

Fraction (+) Retic factor

Cataract (−)

Vitamin C

Cancer (−)

CVD (−)

Cataract , Maculadegeration (−)

Vitamin B2

Riboflavin(−)

Vitamin B5Pyridoxine(±)

Vitamin B12Cobalamin

Poor intake

Summery* Folia acid supplementation may prevent neural tube defects in

many women, especially as these defects occur before pregnancy is detected in most cases. ( See “Folic acid” above).

* Vitamin D supplementation with calcium many reduce fracture rates and falls. ( See “Vitamin D” above).

* Vitamin B12 supplementation, particularly those at high risk for deficiency, many prevent neurologic disease (eg, dementia, poor balance). (See “Vitamin B12 (cobalamin)” above).