SCREENING GUIDELINES AND
PREVENTIVE HEALTHCARE PROGRAMS
NOAH CARPENTER, MD
Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his
Bachelor of Science in Chemistry and medical school and training at the University of
Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University
of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult
Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh,
Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser
and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia,
Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary
Doctorate of Law from the University of Calgary, and was appointed a Citizen
Ambassador to China, and has served as a member of the Indigenous Physicians
Association of Canada (IPAC), the Canadian College of Health Service Executives, the
Science Institute of the Northwest Territories, Canada Science Council, and the
International Society of Endovascular Surgeons, among others. He has been an
inspiration to youth, motivating them to understand the importance of achieving
higher education.
DANA BARTLETT, RN, 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 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 Elsevier, Lippincott, and Thieme. He has written widely about
toxicology and was a contributing editor, toxicology section, for Critical Care Nurse
journal. He is currently employed at the Connecticut Poison Control Center.
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ABSTRACT
Health prevention programs that involve annual physical evaluations and
screening is an accepted method to effectively reduce the incidence and
negative impact of common diseases. In the United States, research has
focused on initiatives to improve community-based programs to increase
healthy lifestyles throughout all age groups. New strategies to promote
healthier populations must consider prior barriers to preventive healthcare
and environmental influences that impact the risk and outcome of a disease
state. By developing a solid understanding of health prevention, enhanced
strategies to improve health outcomes may be reached by health teams that
support healthier populations in U.S. regions and worldwide. A search of the
literature provided examples of health prevention approaches to improve
healthcare in various world regions, which included case trials and program
development aimed at new ways to improve the utilization of accepted
standards of care as well as to incorporate individual approaches based on
lessons learned relative to disease prevention, treatment and outcomes. There
are multifactorial risks and environmental influences that impact how
prevention strategies evolve and these constitute an ongoing challenge to the
health profession and to medical researchers.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies
of
NurseCe4Less.com
and
the
continuing
nursing
education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses.
Continuing Education Credit Designation
This educational activity is credited for 8 hours at completion of the activity.
Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
Health professionals need to know the recommended screening tests that
support early detection and prevention of diseases associated with morbidity
and mortality when left undiagnosed and untreated. Health strategies across
geographic and national boundaries are continuously developing with a high
focus on social, economic, environmental and other factors linked to patterns
of disease. Healthy populations require that health prevention research and
policies move beyond a sole standardized model and that interdisciplinary
health teams participate in the implementation of screening guidelines
throughout the lifespan.
Course Purpose
To provide members of the interdisciplinary health team with knowledge of
recommended preventive health screening tests and techniques to promote a
healthy population.
Target Audience
Advanced
Practice
Registered
Nurses,
Registered
Nurses,
and
other
Interdisciplinary Health Team Members.
Disclosures
Noah Carpenter, MD, Dana Bartlett, RN, BSN, MSN, MA, CSPI, Kellie Wilson,
PharmD, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN,
FPMHNP-BC – all have no disclosures. There is no commercial support.
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Self-Assessment of Knowledge Pre-Test:
1. One of the limitations of screening tests is
a.
b.
c.
d.
screening guidelines are often changed and updated.
these tests rarely provide a high degree of specificity or sensitivity.
the guidelines differ for children and adults.
the benefits seldom outweigh the risks.
2. Screening tests must be used with the understanding that
a.
b.
c.
d.
they are seldom able to detect diseases.
most of them are associated with harmful side effects.
they are not diagnostic.
they cannot be used for children.
3. Adults should be screened for alcohol misuse
a.
b.
c.
d.
unless the patient is pregnant.
only if they use illicit drugs.
only if they engage in risky drinking behavior.
in all cases.
4. Breast cancer is
a.
b.
c.
d.
more common in women < 50 years of age.
the most common cancer in women.
primarily caused by cigarette smoking.
not detectable without a biopsy.
5. What is the recommendation of the U.S. Preventive Services Task
Force (USPSTF) regarding the use of mammograms to screen for
breast cancer in women age 75 or older?
a.
b.
c.
d.
They should have a mammogram annually.
The USPSTF recommends against a mammogram in all cases.
They should have a biennial mammogram.
There is no recommendation.
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Introduction
Preventative healthcare involves disease identification in specific at-risk
populations,
and
preventive
health
programs
typically
include
an
interdisciplinary health team that is knowledgeable of screening guidelines for
acute and chronic health conditions. Health prevention strategies should aim
at the delivery of specific interventions and therapies to reduce the chance of
developing a chronic disease, and the promotion of successful health
outcomes through strong patient engagement. A primary role of all health
professionals is to educate patients about health prevention and screening
practices, and to raise awareness of how poor health habits can lead to the
development of many common, chronic diseases. Good health prevention
education promotes awareness in individuals and communities about needed
changes to health behaviors to help avoid disease through a lifelong
commitment to healthy lifestyle choices.
Screening for Disease Detection and Prevention
Screening tests are done to detect potential health disorders or diseases
in a patient who does not have symptoms of a health condition. Screening
tests are not considered diagnostic but they are used to identify a group of
the population who should be tested to determine the presence or absence of
disease. Through early detection, a patient may be made aware of the
potential disorder or disease and make lifestyle changes to address it. The
patient may also receive regular monitoring and treatment to reduce the risk
of disease.1
The goal with screening for disease is to prevent chronic medical
problems that often result in increased morbidity and mortality. Poor dietary
choices, lack of exercise and obesity has been identified as a major risk factor
for the development of multiple health problems, including metabolic disease,
heart disease and cancer.1,2 Harmful patterns of food intake, such as those
dense in sugar, saturated fat, and poor portion control, and not enough
exercise have been studied and reported to have a direct correlation with the
incidence of chronic disease.1,2
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Annual health screening is an effective method for detecting and
preventing poor health habits that cause acute and chronic diseases. Although
broad screening guidelines are often a helpful start to discussing personal
health choices, in a heterogeneous population the use of screening guidelines
are not likely to detect all cases of disease. Screening guidelines are
continuously evolving and being updated, so screening on a case-by-case
basis is recommended. When appropriate, screening should be accompanied
by a physical examination and patient interview with a health professional.
Health screening is most beneficial when a disease is known to be an
important public health problem. A screening examination has the best
outcome when completed during an early, asymptomatic phase of a disease
and after identifying people who may benefit from treatment.1,2 Also,
treatment that is readily available and where the benefits of treatment
outweigh health risks generally yield improved outcomes. In general,
screening tests should be simple to perform, cost-effective, easy to interpret
and they must be sensitive and specific to the disease being screened.
Alcohol Use Disorder
The unhealthy use of alcohol by Americans is endemic. The 2015
National Survey on Drug Use and Health noted that 24.9% of Americans
reported binge alcohol use in the past month and 6.9% reported heavy
drinking in the past month.3 Almost three of every 10 Americans uses alcohol
in an unhealthy way, and 14% met the criteria for alcohol use disorder.3 The
unhealthy use of alcohol may go unrecognized in the primary care setting and
studies have supported screening of the population for unhealthy alcohol use.4
How often and who should be screened for alcohol use depends on several
factors, such as age and an individual’s experience with alcohol and/or drug
use. Different screening guidelines are available, and the U.S. Preventive
Services Task Force (USPSTF) recommendations are to screen for unhealthy
alcohol use in primary care settings in adults 18 years or older, including
pregnant women.4
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The AUDIT and the Audit-C screening tools are accurate and widely
accepted and have been used in primary care settings for assessment of
alcohol use disorder.5 These screening tools have been shown to be useful in
identifying hazardous drinking and if they are used in conjunction with
interventions, they can be used to help initiate behavioral changes in patients
who engage in harmful or hazardous drinking.5,6
Alcohol Use Disorders Identification Test – AUDIT
In the AUDIT, the answers are scored as follows: 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. Health clinicians are guided to ask the following
questions when using the AUDIT screening tool.5
AUDIT
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 five 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
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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
6.
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
7.
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
8.
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
9.
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
10. 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
A score of ≥8 is associated with harmful or hazardous drinking with use
of the AUDIT screening tool. A score of ≥13 in women and ≥15 or more in
men is likely to indicate an alcohol use disorder.5
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Alcohol Use Disorders Identification Test-Consumption - AUDIT-C
The Audit-C asks three questions and 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.5
AUDIT-C
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
Research: Alcohol Use Prevention and Road Safety
The following case studies were obtained from a PubMed search. The
authors focused on a public program that was presented at the World Health
Organization global conference aimed at reducing the incidence of driving
while under the influence of alcohol.7 The World Health Organization reported
that approximately 85% of deaths caused by a noncommunicable disease
(NCD) occur either in poor or in developing countries. High risk factors of NCDs
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involve excessive alcohol consumption, smoking, unbalanced diets and lack of
exercise, and a main cause of traffic accidents is due to drinking and driving.7
A descriptive study (2015 to 2018) was done of two Brazilian programs:
1) São Paulo Traffic Safety Movement, and 2) Safe Life Program of Brasília.
The goal of these programs was to reduce road accident deaths by 8.3 deaths
per 100,000 inhabitants by 2020 in São Paulo and by 2016 in Brasília. The
main foci were to improve traffic safety and lower the incidence rate of harmful
use of alcohol by 10% by 2020.7
Traffic Safety Movement
The authors reported that the Traffic Safety Movement involved 122
actions that were divided into three types: 1) engineering, 2) education and
communication, and 3) control.7 Under engineering, improvements were
made to the local infrastructure, such as the use of footbridges, traffic lights,
bicycle paths, and lowering of the speed limit. Education and communication
involved “supporting the mobility of bicycles and pedestrians.”7 Control was
accomplished by surveilling critical spots.7 Initial results from the program
showed that goals were met. In 2016, an estimated 460 lives were saved,
representing 6.5% fewer deaths than in 2015. In 2017, a sharp increase of
7,600 casualties were avoided. Projecting toward 2020, without such a
prevention program, there would be an estimated doubling of 7,760
accidents.7 A review of study outcomes helped to reassess processes and to
further develop an improved system to prevent traffic-related death or
irreversible damage as a result of drinking and driving.7
Safe Life Program
The Safe Life Program undertook a comprehensive survey and review,
which found that 34% of the fatalities in 2016 were related to alcohol
consumption, and the highest percentage of deaths involved individuals
between the ages of 30 and 39 (34%), followed by the age ranges of 20 to 29
years and 40 to 49 years, with each age group showing a fatality rate of 21
percent.7
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The Safe Life Program focused on three factors: road safety, health, and
education. Road safety and health showed results, indicating that the model
was appropriate. The education factor involved a school and community-based
preventive program (implemented in 2019).7
The Safe Life Program implemented a tool that was recommended by
the World Health Organization for treating and managing cases. It was called
“brief intervention.”7 Brief intervention was preceded by an AUDIT screening
test to identify alcohol use disorders. This test efficiently identified individuals
who were at greater risk. Professionals worked to identify and quantify the
hospitalizations caused by harmful use of alcohol. Based on the assessment
done, men aged 40 to 49 years were defined as the critical profile for the
project, and solutions for the problem were considered. A total of 1,645 people
underwent screening and 77 of them were referred for treatment in the
geographic areas identified for this study.
In order to get ahead of the problem, the Safe Life Program also included
the development of a prevention program targeting underage alcohol
consumption.7 This was essential based on the randomized survey that was
conducted in schools from April to May 2018. This survey will help reveal the
extent of alcohol use among underage students, from 13 to 17 years old, in
public and private schools.7 Once the extent of the problem is revealed,
“specific actions aimed at reducing alcohol use among school students” may
be developed.7
Thereafter, interventions may be implemented in public schools.7 Within
a brief time, consistent progress was identified through education aimed at
lowering alcohol use while driving.7
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Alcohol Use Prevention Quiz:
I.
Which of the following screening tests was used by the Safe Life
Program to identify at-risk persons?
a.
b.
c.
d.
II.
Deaths from noncommunicable diseases (NCDs) are mainly caused by
a.
b.
c.
d.
III.
PHQ-9
AUDIT
Kessler 6
NIAAA
excessive alcohol consumption.
smoking.
unbalanced diets and lack of exercise.
All of the above
The Traffic Safety Movement involved actions that were divided into
three types. One type, education and communication, involved
a.
b.
c.
d.
the use of footbridges.
lowering speed limits.
adding more traffic lights.
supporting the mobility of bicycles and pedestrians.
Discussion:7
The authors stated that “all the effort to save lives was worthwhile. In
2017 alone, 133 lives were saved in traffic. This meant 34% fewer deaths
(down to 255), compared with the total of 392 people who had lost their lives
in traffic accidents in the Federal District in 2016. In other words, in just one
year, the program had almost reached the target set for 2020.”7 Prevention
of traffic related deaths reportedly correlated with changes in people’s habits
and actions, notably alcohol use.7 The number of hospitalizations related to
the harmful use of alcohol were found to be reduced.7 The application of the
model yielded surprising results that went beyond reduction of deaths and
injuries in traffic accidents. Educational actions that were developed in schools
and public spaces made the programs more sustainable.
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Answers to Alcohol Use Prevention Quiz:
I.
Which of the following screening tests was used by the Safe Life
Program to identify at-risk persons?
b. AUDIT
“Brief intervention was preceded by an AUDIT screening test to identify alcohol use
disorders. This test efficiently identified individuals who were at greater risk.”
II.
Deaths from noncommunicable diseases (NCDs) are mainly caused by
a. excessive alcohol consumption.
b. smoking.
c. unbalanced diets and lack of exercise.
d. All of the above [correct answer]
“High risk factors of a NCD involve excessive alcohol consumption, smoking, unbalanced
diets and lack of exercise, and a main cause of traffic accidents is due to drinking and
driving.”
III.
Which of the following screening tests was used by the Safe Life
Program to identify at-risk persons?
d. supporting the mobility of bicycles and pedestrians.
“The authors reported that the Traffic Safety Movement involved 122 actions that were
divided into three types: 1) engineering, 2) education and communication, and 3) control.
Under engineering, improvements were made to the local infrastructure, such as the use
of footbridges, traffic lights, bicycle paths, and lowering of the speed limit. Education and
communication involved ‘supporting the mobility of bicycles and pedestrians.’ Control was
accomplished by surveilling critical spots.”
Tobacco Use Disorder
Tobacco use is an enormous public health concern. It is the leading
cause of preventable death in the United States.8 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 certain cancers,
heart disease, common respiratory diseases, and many other acute and
chronic pathologies.
It has also been proven that second-hand smoke is a significant cause
of serious acute and chronic health problems in children and adults.
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Secondhand smoke is smoke that is produced from burning tobacco or smoke
that is exhaled by someone smoking tobacco.
There is no safe level of second-hand smoke. Sidestream smoke is the
smoke that emits from the burning end of a cigarette or cigar. It contains
higher levels of toxic chemicals and smaller particles that may more easily
enter a person’s lungs.
Smoking and tobacco use are still common in the United States.
Statistics about smoking and tobacco use are listed in the table below.
SMOKING AND TOBACCO USE IN THE UNITED STATES8-10
●
In the US 15.8% of males and 12.2% of females aged 18 years or older
currently smoke cigarettes every day or some days.
●
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
one of every five deaths.
●
E-cigarette use is less common than cigarette smoking, but approximately
10.8 million Americans use e-cigarettes, and e-cigarettes are the most
commonly used nicotine product among American youth.
●
Approximately 24% of American Indians/Alaska Natives, 15.2% of White
Americans, and 14.9% of Black Americans/non-Hispanics are current
smokers.
The adverse effects of smoking are not limited to cigarette smokers.
Secondhand smoke is a significant cause of heart disease, lung cancer, and
stroke, it can cause exacerbations of asthma, ear infections and respiratory
infections in children.11 It is a contributory factor to the development of many
other illnesses like diabetes.12 There is no safe level of secondhand smoke and
close proximity to secondhand smoke is not necessary for a significant
exposure to occur.11 Studies have shown that living in a multi-residential
building can expose non-smokers to second-hand smoke.12 The health effects
of secondhand smoke include asthma attacks, bronchitis, chronic obstructive
pulmonary disease (COPD), ear infections, heart disease, lung cancer,
pneumonia, stroke, and sudden infant death syndrome (SIDS).
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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. Nonetheless, nicotine, the primary
active component of cigarette smoke, can lead to strong cravings in a person
and develop into a tobacco use disorder.13 Since tobacco is legal the
prevention of smoking and smoking cessation pose considerable challenges.
Behavioral-based interventions alone or performed in combination with
pharmacotherapy can be effective for helping people quit smoking.13 These
interventions may include self-help interventions using educational resources
like printed material or videos, web-based and text-based resources, and
telephone applications and telephone contact counseling, which have all been
used with success.13 Acupuncture and hypnosis have obtained mixed reviews
in the literature relative to the level of success for smoking cessation that each
technique provides.14 The specific intervention chosen will depend on
availability, cost, and patient preference.
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. These drugs have been proven to be very effective for smoking
cessation.15 Electronic cigarettes have been reported to be an effective
smoking cessation intervention, but at this time there is no conclusive
evidence that they are effective or safe for this purpose.16
Most adult smokers want to quit and many make the effort, but most
fail and at any given time only 1 of every 10 people who try and stop smoking
are successful.17 There are many reasons why smokers find it difficult to quit
and to maintain abstinence, including 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 properties of
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nicotine that lead to tobacco use disorder, clearly present smokers with a
considerable challenge when they try to quit and to cease the smoking habit
long-term.
EHR: Screening and Prevention
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 clinicians will screen for tobacco
use during patient admission, 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 of smoking cessation programs include:
●
Freedom from Smoking: a program offered by the American Lung
Association with an available website that provides a “Get Help” portal:
http://www.lung.org/stop-smoking/i-wantto-quit/how-to-quitsmoking.htmlv.
●
The American Lung Association: offers a helpline at 1-800-LUNGUSA.
●
Smokefree.gov: 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): a toll-free number that connects
smokers to Quit For Life program, sponsored by the American Cancer
Society.
Research: Smoking Cessation Program
The following case report was obtained through a PubMed search. The
authors looked specifically at women who smoked during pregnancy and their
motivation to quit or remain abstinent. The smoking cessation approach that
was evaluated was the Motivation and Problem Solving (MAPS) plan. The
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MAPS plan was designed to consider general life stressors and substance use
together, and involves a wellness plan utilizing counselling sessions relative
to motivation enhancement and skill training strategies.18
Motivation and Problem Solving (MAPS)
A specific MAPS wellness plan is developed with the client during initial
sessions and the plan is adjusted during the course of the patient’s treatment.
The goal of MAPS is to keep the patient engaged in treatment and to enhance
the patient’s sense of wellbeing, thereby improving the patient’s chance of
success at maintaining abstinence from tobacco use. Smoking behavior is
evaluated in the context of life stressors that may include lifestyle changes, a
mood disorder (anxiety, depression) and interpersonal conflict. The MAPS
approach includes motivational interviewing (MI) to improve the patient’s level
of motivation and commitment to smoking cessation.
MAPS and Smoking Cessation in Pregnant Women
The authors discussed smoking and relapse during pregnancy and at 8
weeks postpartum in the U.S., comparing MAPS with conventional smoking
abstinence techniques (42% MAPS versus 28% conventional abstinence
methods). MAPS is currently being tried for alcohol use, diet and physical
activity. MAPS for smoking cessation includes techniques of “motivation, selfefficacy, coping behaviors, perceived stress and negative effect.”18 These are
factors that may influence smoking cessation success.
The authors stated that additional data was obtained “through
questionnaires from 143 smoker and ex-smoker pregnant women seeking
prenatal care.”18 They also set out to identify differences between smokers
and ex-smokers relative to “education, home smoking rules, number of
previous pregnancies and living children, heaviness of smoking, age of
smoking
onset,
number
of
quit
attempts,
importance
assigned
to
quitting/staying quit, confidence in quitting/staying quit, partner’s smoking
status, dyadic efficacy for smoking cessation, dyadic coping, partner
interactions, and relationship quality.”18 The term dyadic refers to the dyad or
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significant relationship in the woman’s life, such as a husband or partner. In
this context, the reference is to the impact this dyad has on smoking
cessation.
Quit Together Utilized in Study
The study sought to enroll 120 pregnant women during the first 28
weeks of pregnancy who were self-reported smokers in a smoking cessation
program called Quit Together. Women selected were “18 years or older,
married or living with a partner,” they owned a phone, were willing to provide
phone contact for their partner, and had a willingness and cognitive ability to
understand and sign an informed consent form to participate in the trial.18
Partners were contacted and invited to enroll and participate in the study.
Women participating in the study were asked to complete a self-administered
Quit Together questionnaire, which involved questions on a woman’s
sociodemographics, reproductive and medical history, tobacco and alcohol
use, partner relationship and support for smoking cessation, and on a
woman’s emotional health.18
Counselors involved in the program had received special training in MI
and practiced interventions through role-playing. A program research team
was formed to supervise counselors’ activity, and supervisors were trained in
clinical psychology with expertise in MI and a MAPS role focused on
supervising counseling sessions. Supervisors provided feedback to MAPS
counselors either in person or via telecommunications, such as Skype. The
supervisor also reported to the research team on interventions and progress
of study participants. Monthly meetings were held to review outcomes and the
commitment of study participants to quit smoking.
Counselling sessions were telephone-based, led by the counselors, and
typically lasted 20–30 minutes. Telephone counseling sessions were offered
during pregnancy and 2 months postpartum. Up to 8 sessions were included
in a counseling session and were offered by female counselors to pregnant
smokers; 6 sessions during pregnancy and 2 after birth. Also, up to 4 sessions
were offered by a male counselor to the woman’s partners; 3 during
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pregnancy and 1 after birth. Counseling sessions were individually determined
based upon the preferences and needs of study participants. Dyadic efficacy
enhancing techniques during counseling sessions focused on couple activities
or prior successes in the area of behavior change.
Quit Together utilized MAPS to increase maternal smoking cessation
during pregnancy and smoking abstinence after birth. The focus was on
smoking abstinence for both women and their partners. The couple approach
emphasized the “dyadic efficacy for smoking cessation, the anticipated
contribution to the field of research on smoking cessation during and around
pregnancy, and the high potential to be adopted in the universal health
system…”18
MAPS-trained
18
counseling.”
counselors
delivered
“proactive
phone
Intervention strategies involved the patient’s sociocultural background.
Within the broad context of smoking behaviors, the researchers considered 1)
high-risk situations, such as partner smoking behavior and social norms, 2)
outcome expectancies related to smoking cessation, 3) prior smoking
cessation trials, 4) and patient attitudes, knowledge and beliefs about
smoking. A patient’s motivation to quit or remain abstinent was studied by
looking at the patient’s coping mechanisms, identity, transition to motherhood
in the context of smoking, and interactions with a healthcare system.
Documentation of the study results focused on these socio-cultural variations.
Smoking Cessation Quiz:
I.
In this study, the authors evaluated the importance of
_____________ on a woman’s ability to quit smoking.
a.
b.
c.
d.
II.
comorbidities
a spouse or partner
alcohol use
motherhood
One of the goals of MAPS is to
a.
b.
c.
d.
make the patient accountable when abstinence fails.
show how a dyad is the primary cause of smoking.
keep the patient engaged in treatment.
highlight prior smoking cessation trials.
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III.
Which of the following topical areas is covered by the Quit Together
questionnaire?
a.
b.
c.
d.
A woman’s emotional health
Nutrition and physical activity
Family planning
All of the above
Discussion:
The authors sought to determine the positive effect of MAPS on prenatal
and postnatal family smoking, considering the short- and long-term health
benefits for the mother, partner and their child. They noted that while the
study focused on pregnancy and couple-smoking cessation, the MAPS
approach could be a useful intervention for health prevention involving
nutrition, physical activity and family health during a woman’s reproductive
years. They discussed the types of protocol used during counseling sessions
and comparisons of intervention outcomes with control groups, and they
outlined data quality control that was implemented, including accuracy
checks,
outlier
examination,
missing
data
patterns,
distributional
assumptions, and the intervention or control balance on a variety of
characteristics at baseline. Separate analyses were done on women and their
partners. The study appeared robust and considered pregnant woman,
including 2 months postpartum, considering a variety of health and
environmental factors, including the participation and support of partners.
Limitations of the authors approach was identified as: 1) possible
conflicted relationships between women and their partners, 2) potential low
compliance and study participant retention, 3) difficulty verifying smoking
status during phone meetings, and 4) missed data values for the assessment
of intervention efficacy were some of the difficulties identified. Quit Together
maternal smoking abstinence considered the “number of quit attempts,
cigarettes/day among those who continued smoking, maternal motivation,
self-efficacy, dyadic efficacy for smoking cessation, paternal smoking
abstinence, and cigarettes per day among those who smoke.”18
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Answer to Smoking Cessation Quiz:
I.
In this study, the authors evaluated the importance of
_____________ on a woman’s ability to quit smoking.
b. spouse or partner
“Women selected were ‘18 years or older, married or living with a partner,...”
II.
One of the goals of MAPS is to
c. keep the patient engaged in treatment.
“The goal of MAPS is to keep the patient engaged in treatment ...”
III.
Which of the following topical areas is covered by the Quit Together
questionnaire?
a. A woman’s emotional health
“... a woman’s emotional health.”
Lung Cancer
Lung cancer is the most common cause of death from cancer in
American adults.19 After skin cancer, it is the second most common cancer.20
The American Cancer Society estimates that in 2019 there will 228,150 new
cases of lung cancer and 142,670 deaths from lung cancer.20 Cigarette
smoking is believed to cause 85% to 90% of all lung cancer.19
Targeted screening in high-risk populations has been shown to increase
the incidence of detection of lung cancer and to reduce the mortality rate.19
The USPSTF and professional organizations like the American Cancer Society
and the American Society of Clinical Oncology recommend 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.19,20 The 2014 USPSTF
Clinical Guidelines stated: “Annual screening for lung cancer with low-dose
computed tomography is of moderate net benefit in asymptomatic persons
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who are at high risk for lung cancer based on age, total cumulative exposure
to tobacco smoke, and years since quitting smoking.”21
Research: National Lung Screening Trials
The following study reported on lung cancer screening. The authors
reported on the National Lung Screening Trials (NLST), which focused on the
effectiveness of low dose chest computed tomography (LDCT) to detect lung
cancer in the early stages and to prevent disease mortality.22 The authors
noted that the utilization of LDCT continues to be low.
The primary purpose of the study was to understand the attitudes and
beliefs among primary care clinicians regarding LDCT lung cancer screening.22
The authors reported that “nearly 82% of survey respondents in this study
noted that recommendations from the USPSTF were relevant to their medical
practice. The USPSTF also reinforced that LDCT screening recommendations
should be used in addition to, rather than as a replacement for, smoking
cessation interventions. A grade B recommendation means that the USPSTF
recommends the service based on a high certainty that the net benefit is
moderate, or a moderate certainty that the net benefit is moderate to
substantial; clinicians should offer this service.”22 Further, electronic medical
systems had potential to assure that guideline eligible patients (age 55–79,
30+ pack-year history, current smokers or quit <15 years) would be referred
for LDCT screening.22
Additionally, the study, conducted at a Veteran’s Administration (VA)
health facility assessed clinician knowledge gaps to identify existing
opportunities to reinforce accessible and evidence-based lung cancer
screening. Half of clinicians considered LDCT “very effective,” and 47.4% of
clinicians reported recommending LDCT often as a lung cancer screening
tool.22 Most clinicians referred patients for LDCT based on their smoking
history. Other factors included patient health status, sex, family history, past
medical history, and occupational exposures. Clinician knowledge about the
use of LDCT as a lung screening tool was generally good; however, the
effectiveness of LDCT for lung cancer early detection was not as well
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understood. Some patient referrals for LDCT was not founded on evidencebased guidelines.22
The authors reported that in 2013, the USPSTF had issued a Grade B
recommendation for annual lung cancer screening among asymptomatic
adults (55 to 80 years of age) with a 30 pack-year smoking history, who
currently smoked, or had quit smoking for 15 years. Lung cancer mortality
among participants screened with LDCT was compared to those screened with
chest radiographs (CXR), and there was 20.0% decreased mortality from lung
cancer in those screened with LDCT as compared with those screened with
CXR.22 Other studies exploring physician attitudes and experiences with LDCT
screening have been previously done; however, the authors suggested that
their study (conducted at a single VA facility) highlighted that nearly 60% of
study participants were aware of USPSTF guidelines, yet unable to recall
eligibility criteria. Their study also highlighted that clinicians held variable
interest in completing lung cancer screening.22
The topic of lung cancer screening in VA and other community hospitals
raised in prior studies showed that barriers impacting effective lung cancer
screening included “time constraints, competing demands, lack of access to
decision aids and patient characteristics.”22 In some studies, not all clinicians
were aware of the USPSTF lung cancer screening guidelines, and few felt
knowledgeable enough to recommend lung cancer screening to patients. Also,
many were reportedly skeptical about the efficacy of that screening test and
viewed cost (uninsured patients) and geographic locations (rural) as barriers
for considering lung cancer screening.22
Pulmonologists in the VA system have reported being familiar with
national lung cancer screening guidelines; however, they held varied
perceptions, which led to both over-screening and under-screening of patients
at risk for lung cancer.22 One study (2016) reported that although family
physicians discussed LDCT with high-risk patients, they did so inconsistently
and patient referrals for LDCT were low.
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Another study (2016) comparing patient-provider discussions about
lung cancer screening between 2012 and 2014, on or about the time of the
USPSTF guidelines, showed that discussions between the provider and patient
on lung cancer screening had been more prevalent prior to release of the lung
cancer screening guidelines (17% in 2012 and 10% in 2014). Of significance,
patient-provider discussions on lung cancer screening had been low during
both periods.22
Identifying Patients for LDCT Screening
Smoking status is understood to be a key factor for referring a patient
to be screened for lung cancer. Secondary factors for making patient referrals
for lung cancer screening include family history, prior history of cancer, and
occupational exposures. Additional factors identified by some clinicians for
making referrals for lung cancer screening include sex and a patient’s overall
health status.22
Public Health Significance of Lung Cancer Screening
The authors referred to the report of the National Lung Screening trial,
which suggested that “the use of low-dose chest CT scans, among high-risk
smokers resulted in a 15–20% reduction in lung cancer deaths relative to
screening with chest x-rays. This reduction in the lung cancer death rate is
equivalent to three fewer deaths per thousand people screened over the 6.5
years of follow-up (17.6 lung cancer deaths/1000 versus 20.7 lung cancer
deaths/1000).”22 Physicians were asked to comment on the clinical and public
health significance of these findings. Many respondents believed the public
health significance of the current national reports had important implications
for their practice. There were contrasting views on how many lives could be
saved through the use of LDCT screening, and some felt the evidence
supporting LDCT did not outweigh the cost risk. There were questions about
third party payer coverage and the identity of national organizations
supporting the current screening guidelines. Also, some respondents
suggested that the rates of the long term effectiveness of LDCT were needed.
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Lung Cancer Screening Quiz:
I.
Most clinicians referred patients for low dose chest computed
tomography (LDCT) based on
a.
b.
c.
d.
II.
their smoking history.
gender.
occupational exposures.
family history.
True or False: Lung cancer mortality among participants screened with
LDCT were 20% lower than those screened with chest radiographs
(CXR).
a. True
b. False
III.
Clinicians expressed barriers that caused them NOT to consider lung
cancer screening for patients, such as
a. cost for uninsured patients.
b. time constraints.
c. competing demands.
d. All of the above
Discussion:22
The authors raised that the USPSTF guidelines for lung cancer screening
(grade B) allowed for approximately 10.5 million people in the United States
to be eligible for lung cancer screening “with the potential to prevent 18,000
lung cancer deaths.”22 They found that while primary care providers endorse
the effectiveness of LDCT for lung cancer early detection, they are
recommending LDCT to their patients less frequently.22
The American Academy of Family Physicians found the data did not
support recommending for or against LDCT screening for lung cancer. The
Centers for Medicare and Medicaid Services and private insurers (2015) began
to offer coverage for LDCT lung cancer screening as a health preventive
service based on patient eligibility criteria in keeping with the USPSTF and
other organizations. They raised a need for the ongoing promotion of
education on LDCT lung cancer screening, specifically for primary care
clinicians who reported being left with unanswered questions. This could help
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address the skepticism about the efficacy of the LDCT screening test, its cost,
and geographic barriers.
Finally, the effectiveness of lung cancer screening cannot improve
unless facilities address the barriers listed by primary care providers: “time
constraints, competing demands, lack of access to decision aids and patient
characteristics.”22
Answer to Lung Cancer Screening Quiz:
I.
Most clinicians referred patients for low dose chest computed
tomography (LDCT) based on
a. their smoking history.
“Most clinicians referred patients for LDCT based on their smoking history.”
II.
True or False: Lung cancer mortality among participants screened
with LDCT were 20% lower than those screened with chest
radiographs (CXR).
a. True
“ … there was 20.0% decreased mortality from lung cancer in those screened with LDCT
as compared with those screened with CXR.”
III.
Clinicians expressed barriers that caused them NOT to consider lung
cancer screening for patients, such as
a.
b.
c.
d.
cost for uninsured patients.
time constraints.
competing demands.
All of the above [correct answer]
"... barriers impacting effective lung cancer screening included ‘time constraints,
competing demands, lack of access to decision aids and patient characteristics.’”
Breast Cancer
Breast cancer is the most common cancer in women.23 Every year in the
United States approximately 245,000 women are diagnosed with breast
cancer and approximately 41,000 will die from the disease.23 Breast cancer
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also occurs in men but it is much less common; approximately 2200 men are
diagnosed and approximately 460 die each year from breast cancer.23
Risk factors for breast cancer may include age >50 years, early
menarche, late menopause, hormone replacement therapy, family history of
breast cancer, obesity, and excessive alcohol use.24,25 Screening for breast
cancer
includes
screening
for
neoplasms
and
screening
for
genetic
susceptibility to breast cancer. Breast cancer screening has been shown to
increase the rate of detection and to significantly reduce mortality. There is
no evidence for a benefit of breast self-examination or physical examination
of the breasts by a practitioner.21-26
American Cancer Society Screening Recommendations
Recommendations by the American Cancer Society breast cancer
screening program for women who are at average risk for breast cancer
include those highlighted here.27
●
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 if a woman is in good health and is expected to
live 10 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 suggest that
women aged 40-49 should be considered for a biennial mammogram.28 The
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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 recommend 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.28
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.28 The level of harm
appears to be moderate for each age group.
Breast Cancer Genetic Testing Recommendations
The American Society of Breast Surgeons recommendations for genetic
testing for breast cancer suggest that all patients who have a personal history
of breast cancer should be offered genetic testing.29 Genetic testing for breast
cancer should be available to patients who do not have a personal history of
breast cancer if they met testing guidelines of the National Comprehensive
Cancer Network.
The USPSTF position on genetic screening for breast cancer suggests
that primary care clinicians should assess women with a personal or family
history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry
associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene
mutations.30 If the patient has a positive result on the risk assessment, she
should receive genetic counseling and if needed, genetic testing. Genetic
assessment, counseling, and testing should not be done unless the risk factors
are present.30
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Research: Nutrition and Breast Cancer Prevention
The following case report was obtained from a PubMed search that
focused on nutrition in the prevention of breast cancer. The authors stated
that as early as the 1990s, a diet of cruciferous vegetables (e.g., cabbage,
broccoli) was reported to protect against various types of cancer.31 Their study
specifically looked at how consumption of cruciferous vegetables impacted
breast cancer risk, which included “a hospital-based case-control study in
1491 patients with breast cancer and 1482 controls.”31 The study was
conducted between 1982 and 1998 and study participants were mostly
Caucasian (99%) women between the ages of 21 to 97 years. The study
reportedly adjusted for age, year of admission, family income, body mass
index, cigarette smoking, age at menarche, parity, age at first birth, family
history of breast cancer, hormone replacement therapy, and total meat intake.
Study participants self-reported on menopausal status.31
Cruciferous vegetables were identified as having cancer preventive
properties that may prevent or inhibit breast cancer development through
“modulating activity of phase I and phase II enzymes, inhibiting cell
proliferation, regulating the expression of estrogen receptor, altering the
metabolism of estrogen, or suppressing cyclooxygenase 2 (COX-2).”31 While
there is strong evidence from cell and animal studies supporting the
preventive effect of cruciferous vegetable consumption against breast cancer,
studies within the general population typically show differing outcomes: e.g.,
one case-control study may show a correlation between cruciferous vegetable
intake among premenopausal women only, yet another report may indicate
reduced risk only among postmenopausal women.31
Worldwide studies also generate mixed reports, such as those focused
in Asian populations. The authors suggested that part of the reason for study
outcome inconsistencies may include the fact that cruciferous vegetables may
not have been studied comprehensively and that there have been changing
dietary patterns in worldwide populations relative to fruit and vegetable
consumption,
altering
risk-association
over
time
in
such
studies.31
Nonetheless, cruciferous vegetable consumption in breast cancer cases and
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controls were studied by the authors on a large scale with the goal to validate
existing studies examining the effects of cruciferous vegetable intake on
breast cancer risk. Raw versus cooked vegetable consumption were also
compared in commonly consumed cruciferous vegetables such as broccoli,
cabbage, cauliflower, brussels sprouts, kale, turnip, collard, and mustard
greens, and were documented separately. Total meat intake was used as a
potential confounding factor in overall diet composition (pork chops, hotdogs,
canned ham, ham, salami, liver, pork sausage, beef, bacon, chicken, and
hamburger).31
The
consumption
of
cruciferous
vegetables
were
studied
with
consumption pattern changes that, over time relative to pre- and postmenopausal women, were found to be influenced by the aforementioned
factors. The authors stated that “when individual cruciferous vegetables were
examined, only broccoli and cauliflower intakes showed a significant inverse
association with breast cancer risk; and consistently, the associations were
observed only in premenopausal women and appeared to be stronger with raw
vegetable consumption than with their cooked vegetable counterparts.”31 The
consumption of cruciferous vegetables increased over time in both cases and
controls, although the increase in cases was slower and smaller than in
controls.31
Breast Cancer Screening Quiz:
I.
A diet of cruciferous vegetables, e.g., ___________, was reported to
protect against various types of cancer.
a.
b.
c.
d.
II.
celery
cabbage
carrots
All of the above
True or False: The benefits of a cruciferous vegetable diet is limited
since there is a reduced cancer risk only among premenopausal
women on a cruciferous vegetable diet.
a. True
b. False
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III.
The authors stated that a reduced the risk of breast was strongest
among women
a.
b.
c.
d.
with diets that included celery.
who were postmenopausal.
with diets that included asparagus.
who consumed raw cruciferous vegetables.
Discussion:31
The study suggested that cruciferous vegetable intake, especially
broccoli and cauliflower, was associated with a reduced breast cancer risk. The
authors also raised the fact that few previous studies investigated raw
compared with cooked cruciferous vegetable intake in relation to breast cancer
risk. They noted that eating or cooking styles vary across different
populations, and studied the three most commonly consumed cruciferous
vegetables in the United States — broccoli, cauliflower, and cabbage — in raw
and cooked forms. Both broccoli and cauliflower “showed stronger inverse
associations with breast cancer risk when consumed raw than when consumed
cooked.”31 Further, it was reported that “the inverse association of cruciferous
vegetable consumption with breast cancer risk seems to be more apparent in
premenopausal women.”31
There is an association between cruciferous vegetables and changes in
estrogen metabolism, which the authors suggested influences cancer risk in
pre- and postmenopausal women, albeit, other preventive factors could apply.
The encouragement of vegetable consumption and anticipated positive
outcomes from changes in dietary patterns is anticipated to correspond with
positive health benefits and the reduction of disease risk in the general public.
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Answers to Breast Cancer Screening Quiz:
I.
A diet of cruciferous vegetables, e.g., ___________, was reported to
protect against various types of cancer.
b. cabbage
“The authors stated that as early as the 1990s, a diet of cruciferous vegetables (e.g.,
cabbage, broccoli) was reported to protect against various types of cancer…. Cruciferous
vegetables were identified as having cancer preventive properties that may prevent or
inhibit breast cancer development ….”
II.
True or False: The benefits of a cruciferous vegetable diet is limited
since there is a reduced cancer risk only among premenopausal
women on a cruciferous vegetable diet.
b. False
“While there is strong evidence from cell and animal studies supporting the preventive
effect of cruciferous vegetable consumption against breast cancer, studies within the
general population typically show differing outcomes: e.g., one case-control study may
show a correlation between cruciferous vegetable intake among premenopausal women
only, yet another report may indicate reduced risk only among postmenopausal women.”
III.
The authors stated that a reduced the risk of breast was strongest
among women
d. who consumed raw cruciferous vegetables.
“The authors stated that ‘when individual cruciferous vegetables were examined, only
broccoli and cauliflower intakes showed a significant inverse association with breast
cancer risk; and consistently, the associations were observed only in premenopausal
women and appeared to be stronger with raw vegetable consumption than with their
cooked vegetable counterparts.’”
Cervical Cancer
The American Cancer Society has estimated there will be 13,170 new
cases of cervical cancer detected and 4250 women who will die of cervical
cancer in the United States in 2019.32 Risk factors for cervical cancer may
include HPV infection, smoking, a high number of sex partners, early age at
first intercourse, having three or more children, and long-term use of oral
contraceptives.32,33 Cervical cancer screening decreases the incidence and
mortality of cervical cancer.34,35
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The recommendations for cervical cancer screening are essentially
universal, although there are some variations. A Pap test should be done every
three years for women 21 and older.35,36 Women should be screened even if
they are sexually abstinent, and screening at a younger age is not
recommended; however, screening should be considered if the patient is less
than 21 and is immunocompromised or had an abnormal Pap test.35,36 The
decision about when, how, and how often to screen for cervical cancer should
be made on a case by case basis.
Starting at age 30, women should be offered Pap testing and testing for
HPV infection. If this approach is used and the tests are normal, the screening
interval can be extended to every five years.37 It is not known when screening
should be stopped but women who are 65 and older and who have had normal
tests in the previous 10 years should be offered the choice to stop screening.
The USPSTF recommends screening for cervical cancer according to
the following criteria:37
●
“Women aged 21 to 65 years: Screen every 3 years with cervical cytology
alone in women aged 21 to 29 years. For women aged 30 to 65 years, the
USPSTF recommends screening every 3 years with cervical cytology alone,
every 5 years with high-risk human papillomavirus (hrHPV) testing alone,
or every 5 years with hrHPV testing in combination with cytology
(cotesting).
●
Women older than 65 years: The USPSTF recommends against screening
for cervical cancer in women older than 65 years who have had adequate
prior screening and are not otherwise at high risk for cervical cancer.
●
Women younger than 21 years: The USPSTF recommends against
screening for cervical cancer in women younger than 21 years.
●
Women who have had a hysterectomy: The USPSTF recommends against
screening for cervical cancer in women who have had a hysterectomy with
removal of the cervix and do not have a history of a high-grade
precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2
or 3) or cervical cancer.”
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Research: Cervical Cancer Screening and HPV Vaccination
The following study was obtained from a PubMed search and the authors
reported that a majority of cervical cancer cases occur in low-and lowermiddle-income countries (LLMICs) due to multiple factors, including a lack of
cervical cancer screening programs, lack of treatment of cervical lesions
identified by screening, human papillomavirus (HPV) vaccine not being
provided due to vaccine cost, barriers of healthcare to administer the HPV
vaccine, and perceptions of the HPV vaccine as a low priority.38
The HPV-16 and 18 are reportedly the cause of 70% of cervical cancer;
and, along with the HPV types 31/33/45/52/58, these viruses are the cause
of approximately 90% of cervical cancers worldwide. Although the prevalence
of HPV types varies geographically, the authors reported a higher prevalence
of HPV52 and 58 in East Asia and North America and HPV31, 33 and 45 tend
to be more common in Europe.
First Generation Vaccines
The authors reported the following facts relative to first generation
vaccines, 4vHPV and 2vHPV.38
●
2vHPV activates innate immunity through Toll-like receptor 4.
●
The 4vHPV and 2vHPV have greater than 90% efficacy against cervical
intraepithelial neoplasia grade 1–3, adenocarcinoma in situ, and invasive
cervical carcinoma due to HPV16/18 in women aged 15–26 years.
●
Both vaccines might provide protection against other HPV-related cancers
such as vulvar, vaginal, and anal cancer.
●
Only 4vHPV is licensed against HPV-related cancers and against HPV6- and
HPV11-related genital warts.
●
Neutralizing antibodies are believed to be the primary mediator of
protection for HPV vaccines, however the actual level required for
protection remains unknown.
●
Seroconversion occurs in 99–100% vaccinated persons in randomized
double-blind placebo-controlled trials.
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●
Antibody responses (following vaccination peak at 7 months, one month
following dose 3) at titers between 10- and 100-fold higher than the levels
found following natural infection, and may persist > 10 years several-fold
higher than natural infection.
The high vaccine efficacy has led to the use of HPV vaccine in young
adolescents prior to becoming sexually active. Studies evaluating 4vHPV or
2vHPV in adolescent girls/boys and in women following a three-dose schedule
resulted in “at least one- to two-fold higher type-specific antibodies in the
younger age group.”38 Two doses given to adolescents six months apart
reportedly showed antibody responses non-inferior to women who were given
the standard three-dose schedule.
In 2014, the WHO revised its recommendation to include a two-dose
HPV vaccine schedule for girls aged < 15 years, provided the interval between
each dose is at least six months.
HPV Vaccine 9vHPV
The use of 9vHPV reportedly protects against the nine most common
cancer-causing HPV types and against a majority of genital warts. This vaccine
was licensed in the last five years therefore study outcomes based on
worldwide population use is pending.38 However, during the trial that was used
to license 9vHPV, vaccine efficacy was reported to be greater than 96%
against “high-grade cervical, vulvar, or vaginal disease as well as six-month
persistent infection caused by HPV31, 33, 45, 52, and 58 in women not
previously infected with HPV following three doses of 9vHPV.”38
The authors reported that there is current evidence that the 9vHPV is
safe and is “highly efficacious against HPV infection and anogenital precancer
lesions in both men and women.”38 In addition, 9vHPV was “shown to be safe
and generally well tolerated in participants aged 9–26 years, with a similar
adverse event profile to that of 4vHPV (which is used in many countries
globally as part of national immunization programs).”38
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Adverse Effects
Common adverse events were reported as injection-site pain, swelling,
and redness, and were more common for 9vHPV than 4vHPV with increasing
doses. Most adverse events were identified as mild to moderate. Vaccinerelated serious adverse events were reported as rare and possibly due to
preexisting medical conditions.38
Future Directions of 9vHPV Vaccination
Future directions of HPV vaccination was identified by the authors. The
9vHPV has been licensed in a number of world regions including the United
States and is being used in national immunization programs either schoolbased or through primary care. In Australia, one of the first countries to
Australia was one of the first countries to introduce a government-funded,
school-based HPV vaccine program is expected to be the first country that will
eliminate cervical cancer (projected to occur in 2028).38 For these purposes,
the elimination of cervical cancer is defined as “four new cases per 100,000
women each year.”38
One of the outcomes of the Australian program was the use of HPV
nucleic acid testing to replace Pap screening. This was due largely to the
effects vaccinations had on Pap screening.38
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Cervical Cancer Screening Quiz:
I.
A group of human papillomaviruses (HPVs) are the cause of
approximately ______ of cervical cancers worldwide.
a.
b.
c.
d.
II.
First generation vaccines, 4vHPV and 2vHPV, may provide protection
against other HPV-related cancers such as
a.
b.
c.
d.
III.
90%
50%
25%
70%
anal cancer.
breast cancer.
lung cancer.
melanoma.
Common adverse events from human papillomavirus (HPV) vaccines
were reported as
a.
b.
c.
d.
injection-site pain.
swelling.
redness.
All of the above
Discussion:38
The HPV vaccines are considered safe and have similar safety profiles
between the mixed vaccine schedule and the standard schedule worldwide.
The clinical significance remains unknown and long-term follow up is needed
relative to the prevalence of genital warts and other HPV-related diseases.
The use of 9vHPV in LLMICs is not expected due to its high cost as
compared to 2vHPV or 4vHPV vaccines. The efficacy and immunogenicity of a
single-dose HPV vaccine (9vHPV and 2vHPV) is being studied and may change
how vaccines are made available in LLMICs. Single-dose schedules or mixed
HPV vaccine schedules will be important considerations in how the HPV vaccine
is implemented worldwide.
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Answers to Cervical Cancer Screening Quiz:
I.
A group of human papillomaviruses (HPVs) are the cause of
approximately ______ of cervical cancers worldwide.
a. 90%
“The HPV-16 and 18 are reportedly the cause of 70% of cervical cancer; and, along with
the HPV types 31/33/45/52/58, these viruses are the cause of approximately 90% of
cervical cancers worldwide.”
II.
First generation vaccines, 4vHPV and 2vHPV, may provide protection
against other HPV-related cancers such as
a. anal cancer.
“First generation vaccines, 4vHPV and 2vHPV, may provide protection against other HPVrelated cancers such as vulvar, vaginal, and anal cancer.”
III.
Common adverse events from human papillomavirus (HPV) vaccines
were reported as
a. injection-site pain.
b. swelling.
c. redness.
d. All of the above [correct answer]
“Common adverse events were reported as injection-site pain, swelling, and redness, and
were more common for 9vHPV than 4vHPV with increasing doses.”
Prostate Cancer
Prostate cancer is the most commonly diagnosed cancer in men.39 One
in nine men will develop prostate cancer during his lifetime, and the American
Cancer Society estimates that in the United States in 2019, 174,560 new cases
of prostate cancer will be diagnosed and there will 31,260 deaths from
prostate cancer.32 Risk factors for prostate cancer may include having a firstdegree relative who had prostate cancer, African American ethnicity, and age
> 65 years.40,41
The need for and the usefulness of screening for prostate cancer is a
complex and controversial topic so that a full discussion of the issue is beyond
the scope of this section. Prostate cancer is common but death from this
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disease is relatively uncommon. The five-year survival rate for localized and
regional prostate cancer is 100%.42 The life-time risk of dying of prostate
cancer is 2.5 percent.43
Screening for prostate cancer does not have a large positive effect on
reducing mortality from the disease.44 Many of the cancers detected by
prostate cancer screening do not require treatment and aggressive treatment
that may be initiated based on a prostate screening result can have many
adverse effects.45,46 Although there is no standard approach to screening for
prostate cancer, there are recommendations from authoritative sources and
the USPSTF recently (2018) published guidelines.45 Screening for prostate
cancer is not recommended for men < age 50 unless they have risk factors
for prostate cancer. Those at higher risk of prostate cancer include African
American ethnicity, men who have specific BRCA genetic mutation, and men
who have a family history of prostate cancer.44 The preferred screening test
is PSA measurement done every two years.44 Digital rectal examination is not
recommended.44 The USPSTF recommends that men 55 to 69 should be
screened for prostate cancer only after carefully considering the risks and
benefits.45,46
Research: Prostate Cancer Risk and Dairy Intake
The following study was obtained through a PubMed search.47 The
authors investigated whether there is an association between dairy product
consumption and prostate cancer. This study used the prospective Prostate,
Lung, Colorectal and Ovarian (PLCO) Cancer Screening trial cohort.47 This
study is relevant because dairy products are generally known to contain many
essential nutrients but some dairy are also potentially high in saturated fatty
acid that has been associated with chronic diseases, including cancer.47 This
dichotomy has led to differing conclusions or guidelines: e.g., the Dietary
Guidelines for Americans 2015–2020 recommends lower fat options of dairy
products; however, studies have reported a positive association between
prostate cancer risk with low-fat milk intake and an inverse association with
whole milk consumption.47 Total dairy product, total milk, and total cheese
intakes were significantly positively associated with prostate cancer risk but
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yogurt, skim milk, ice cream, and butter had no significant associations with
prostate cancer risk.47
The authors suggested that in order to investigate this apparent conflict
further, “it is important to investigate dairy products separately by fat content
and fermentation method.”47 These categories are important because food
products high in saturated fatty acid has been associated with cancer but
fermented dairy products may prevent cancer by enhancing intestinal
microbiota growth.47 Therefore, the study divided dairy products into specific
categories: “total” for products that contained all dairy products; regular-fat
or low-fat products; by fermented or non-fermented products; and, milk
consumption as total or by fat content (nonfat to whole).47 “Animal fat is
hypothesized to promote prostate carcinogenesis by increasing testosterone
levels, consequently activating pro-oncogenes and deactivating tumor
suppressor genes.”47 The proliferation of cancer cells through milk intake is
believed to be a result of elevated insulin-like growth factor-I (IGF-1) that is
linked to an increased risk of prostate cancer. One meta-analysis of 12
prospective studies showed there was a 38% increase in prostate cancer risk
with high concentrations of IGF-1.47
Lactose-free dairy products were also considered since these may allow
for the intake of minerals and vitamins from dairy products for lactoseintolerant individuals: “lactose enhances calcium absorption, which affects
calcium and vitamin D levels, both of which may affect prostate cancer risk.”47
The authors divided the study participants “by non-advanced (clinical stages
I/II and Gleason scores of <7) or advanced status (clinical stages III/IV and/or
Gleason scores of ≥7) and also by each of the characteristics alone (clinical
stage, early stages I/II vs. late stages III/IV; and Gleason score, low-grade:
<7 vs. high-grade: ≥7).”47 A statistically significant positive association with
regular-fat dairy intake and late stage prostate cancer was observed, but there
was not a positive association with regular-fat dairy intake and a high-Gleason
score.47 The authors concluded that “dairy product consumption was not
associated with prostate cancer overall.”47 This conclusion differed from the
findings of previous studies.47 This study found a modest positive association
between 2%-fat milk intake and the risk of advanced prostate cancer. There
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was also a modest positive association between regular-fat dairy product
intake and a risk for late-stage prostate cancer. However, there was no
difference in the risk for prostate cancer based on advanced status or clinical
stage.47
Prostate Cancer Screening Quiz:
I.
The authors suggested that in order to investigate whether there is an
association between dairy product consumption and prostate cancer, it
is important to study dairy products separately according to their
a.
b.
c.
d.
II.
The proliferation of cancer cells through milk intake is believed to be a
result of elevated
a.
b.
c.
d.
III.
mineral and vitamin content.
concentrations of IGF-1.
fat content and fermentation method.
calcium and vitamin D levels.
calcium levels.
insulin-like growth factor-I (IGF-1).
growth levels of intestinal microbiota.
presence of tumor suppressor genes.
Animal fat is hypothesized to promote prostate carcinogenesis by
increasing ________________ levels, consequently activating prooncogenes and deactivating tumor suppressor genes.
a.
b.
c.
d.
Gleason score
intestinal microbiota
calcium
testosterone
Discussion47
The authors observed a statistically significant positive association with
regular-fat dairy intake and late stage prostate cancer but there was not a
positive association with regular-fat dairy intake and a high-Gleason score.47
This result raises new questions since late stage prostate cancer and a highGleason score are both considered advanced prostate cancer. Since the
authors authors did not find an association between dairy product
consumption and prostate cancer overall, further studies are needed,
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especially since this conclusion differed from the findings of previous studies.47
The authors also reported that there was no difference in the risk for prostate
cancer based on advanced status or clinical stage. Further studies need to be
done to look into this latter point.
Answers to Prostate Cancer Screening Quiz:
I.
The authors suggested that in order to investigate whether there is an
association between dairy product consumption and prostate cancer, it
is important to study dairy products separately according to their
c. fat content and fermentation method.
“The authors suggested that in order to investigate this apparent conflict further, ‘it is
important to investigate dairy products separately by fat content and fermentation
method.’”
II.
The proliferation of cancer cells through milk intake is believed to be a
result of elevated
b. insulin-like growth factor-I (IGF-1).
“The proliferation of cancer cells through milk intake is believed to be a result of elevated
insulin-like growth factor-I (IGF-1) that is linked to an increased risk of prostate cancer.
One meta-analysis of 12 prospective studies showed there was a 38% increase in
prostate cancer risk with high concentrations of IGF-1.”
III.
Animal fat is hypothesized to promote prostate carcinogenesis by
increasing ________________ levels, consequently activating prooncogenes and deactivating tumor suppressor genes.
d. testosterone
“‘Animal fat is hypothesized to promote prostate carcinogenesis by increasing
testosterone levels, consequently activating pro-oncogenes and deactivating tumor
suppressor genes.’”
Skin Cancer
Skin cancer is divided into two categories: non-melanoma and
melanoma. Basal cell carcinoma and squamous cell carcinoma are the two
non-melanoma skin cancers. These cancers are not usually reported to cancer
registries, so their true incidence and prevalence are not known:48,49 They
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account for approximately 97% of all skin cancers but the incidences of
morbidity and mortality from these neoplasms are very small.50
Malignant melanoma is much less common than non-melanoma skin
cancers but it is much more serious. The incidence of malignant melanoma
has been increasing for years. Malignant melanoma can metastasize to any
organ but in most cases it will metastasize to the skin and lymph nodes.51,52
The five-year survival rate for melanoma skin cancer, localized, regional, and
distant (metastasized) is 98%, 64%, and 23%, respectively.53
Risk factors for nonmelanoma and melanoma skin cancer include
Caucasian ethnicity, fair skin, the presence of multiple nevi, and family history
of melanoma.51,52 There does not seem to be any benefit from universal
screening for skin cancer: the USPSTF concluded that “... the current evidence
is insufficient to assess the balance of benefits and harms of visual skin
examination by a clinician to screen for skin cancer in adults.”49,50
Clinicians and patients should remember that skin lesions should be
considered potentially malignant if they are rapidly changing, and if there are
changes in the size of a skin lesion or if its border is asymmetric, if it is > 6m,
or it is multi-colored, these features may indicate that the lesion is malignant;
these are called the ABCDE criteria, asymmetry, border, color, diameter,
evolution.51
Research: The USPSTF’s Skin Cancer Screening Recommendations
Reviewed
Melanoma is a deadly form of skin cancer, causing the death of
approximately 10,000 people in the U.S., annually.54 The author’s report that
the incidence of melanoma is increasing dramatically, requiring more
aggressive screening for this form of cancer; however, skin cancer screening
rates are not increasing- they remain low in the USA- rendering high-risk
populations vulnerable to a delay in melanoma diagnosis.54 In spite of this
risk, the USPSTF concluded that “the current evidence is insufficient to assess
the balance of benefits and harms of visual skin examination by a clinician to
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screen for skin cancer in adults.”49 This raises the question: Why is skin cancer
screening through total body skin examination (TBSE) not more broadly
recommended, especially for high-risk age groups?
Population groups who are at high risk of skin cancer need to be
identified. Screening recommendations for high risk groups should be
outlined. Review of the relevant data by the authors lead to the conclusion
that “it seems reasonable to propose a screening age of 35–75 years for
melanoma.”54 Primary care providers could then incorporate TBSE into routine
examinations for high risk patients in this age group.54 This approach could be
applied efficiently since the skin is accessible for clinical examination by visual
inspection and high risk groups could be simultaneously screened for skin
cancer during examination for other systemic diseases.54 This is important
because melanomas are usually curable if caught early.54
Johnson, et al. (2017) propose that the USPSTF’s position falls short
when compared to its screening recommendations for other cancers and
diseases.54 They propose guidelines for skin cancer screening that are riskbased and data-driven and that are more in line with USPSTF’s guidelines for
other cancers and diseases.54 The authors reviewed the USPSTF’s position and
raised the following questions, which are italicized here:54
●
“The USPSTF warns, ‘an important consideration for the 2.1 million
Medicare enrollees diagnosed with nonmelanoma skin cancer annually is
the increase in the detection and treatment of basal cell carcinoma in
adults that likely has limited impact on life expectancy.’ Is it appropriate
to consider the detection of basal cell carcinoma a harm of screening rather
than a benefit?”54 This question is important since it would not be
appropriate to recommend screening guidelines that caused more harm
than good; however, say the authors, this “harm” may be overstated.
Undiagnosed keratinocyte carcinomas can lead to meaningful levels of
morbidity and mortality. Basal cell carcinomas may be less aggressive than
cutaneous squamous cell carcinomas but these two skin cancers “often
appear clinically similar and must be biopsied to confirm the diagnosis.”54
The American Cancer Society estimates that around 2,000 people die each
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year in the U.S., from keratinocyte carcinomas (usually cutaneous
squamous cell carcinoma) and this figure may be underreported.54 This
being the case, early detection of basal cell carcinomas and cutaneous
squamous cell carcinomas should be viewed as a potential benefit of TBSE
rather than a potential harm, especially for high risk patients.54
●
One aim of the USPSTF's literature review was to investigate, “the
association between earlier detection of skin cancer and skin cancer
morbidity,” as well as the effects on quality of life. Why was the morbidity
associated with a delayed diagnosis of basal and squamous cell carcinoma,
and melanoma omitted in the USPSTF risk estimates? As mentioned above,
basal and squamous cell carcinomas are not trivial with respect to
morbidity and mortality. The authors added here that a delay in diagnosis
of basal and squamous cell carcinoma can result in the need for wider local
excision, the need for sentinel lymph node biopsy, and lymph node
dissection and/or systemic therapy. These events are associated with
increased morbidity.54
●
The USPSTF draft cited two German articles in review of the risks of skin
cancer screening and concluded that the numbers of excisions needed to
treat skin cancer were too high. Is the estimated number of excisions
needed to treat BCC (one out of nine excisions) and melanoma (one out
of 28 excisions) too high, particularly given the morbidity associated with
delayed diagnosis?54
●
The USPSTF assumed that the standards of care for skin biopsy techniques
are the same in the USA and Germany. The term ‘excision’ implies a fullthickness fusiform-type excision with closure. The USPSTF based their
assessment of risk for complications and cosmetic outcome on the
assumption that all potential skin cancers are biopsied in an excisional
fashion. In the USA, are the majority of biopsies for KC excisional, and are
the majority of excisional biopsies for melanoma the same type reported
in the German article? The authors argue that there is an important
difference between “excisional biopsy” as practiced in Germany and an
“excision" in the USA.54 By failing to consider this distinction, the USPSTF
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effectively overestimated the harm due to negative biopsies, which
resulted in an incorrect view on the safety and utility of skin cancer
screening.54
●
The USPSTF concluded that excisions for skin cancer result in risk of
cosmetically displeasing scars, based on a German study examining
removal of benign nevi for cosmetic purposes. Is it valid to extrapolate
satisfaction of results from a cosmetic procedure to results from a
diagnostic procedure for cancer?54
●
The USPSTF applied rigorous criteria to the articles that were included in
the analysis. How were the inclusion and exclusion criteria applied to the
worldwide publications that ultimately formed the rationale for the decision
statement?54
Following their critique of the USPSTF’s recommendations on screening
for skin cancer, the authors proposed the following skin cancer screening
guidelines.54
●
Adults aged 35–75 years with one or more of the following risk factors
should be screened at least annually with a total body skin examination:
Personal History:
History of melanoma, actinic keratosis or keratinocyte carcinomas;
CDKN2A
(or
other
high-penetrance
gene)
mutation
carrier;
immunocompromised.
Family history:
Melanoma in one or more family members; family history suggestive of
a hereditary predisposition to melanoma.
Physical features:
Light skin (Fitzpatrick I-III); blonde or red hair; >40 total nevi; two or
more atypical nevi; many freckles; severely sun-damaged skin. UVR
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overexposure: History of blistering or peeling sunburns; history of
indoor tanning.
The total body skin examination referred to above includes evaluation
of entire skin surface (scalp, face, ears, neck, chest, abdomen, back, buttocks,
genitals, upper and lower extremities, hands, feet), eyes (iris and sclera), oral
mucosa, hair and nails. Immunocompromised patients would be those with a
suppressed immune system due to a disease such as HIV/AIDS or due to
medications such as anti-rejection medications for organ transplants,
chemotherapies or immunosuppressants for autoimmune disorders.54
Skin Cancer Screening Quiz:
I.
The authors propose that a total body skin examination (TBSE) should
be used to screen
a.
b.
c.
d.
II.
all adults annually.
adults 35 and over every three years.
high risk patients age 35–75 annually.
patients with at least three risk factors for skin cancer.
True or False: Unlike melanoma Keratinocyte carcinomas (e.g.,
cutaneous squamous cell carcinoma) are not fatal.
a. True
b. False
III.
Basal cell carcinomas __________________ cutaneous squamous cell
carcinomas.
a.
b.
c.
d.
more aggressive than
often appear clinically similar to
are clinically distinctive from
are the same as
Discussion:54
The authors reviewed the USPSTF recommendations regarding skin
cancer screening, which included the statement that “the current evidence is
insufficient to assess the balance of benefits and harms of visual skin
examination by a clinician to screen for skin cancer in adults.”54 They found
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that this recommendation fell short. The authors proposed guidelines using
risk-based skin cancer screening.54 Risk-based skin cancer screening could
potentially “impact early detection of melanoma, resulting in a reduction of
morbidity, mortality and cost of treatment.”54
The authors acknowledged that the “guidelines are not absolute, and
more
or
less
stringent
screening
can
be
appropriate
in
individual
circumstances. These guidelines are meant to serve as a starting point for
further discussion and may be refined as additional data become available.”54
Answers to Skin Cancer Screening Quiz:
I.
The authors propose that a total body skin examination (TBSE) should
be used to screen
c. high risk patients age 35–75 annually.
“Adults aged 35–75 years with one or more of the following risk factors should be
screened at least annually with a total body skin examination…”
II.
True or False: Unlike melanoma Keratinocyte carcinomas (e.g.,
cutaneous squamous cell carcinoma) are not fatal.
b. False
“The American Cancer Society estimates that around 2,000 people die each year in the
U.S., from keratinocyte carcinomas (usually cutaneous squamous cell carcinoma) and this
figure may be underreported.”
III.
Basal cell carcinomas __________________ cutaneous squamous cell
carcinomas.
b. often appear clinically similar to
“Basal cell carcinomas may be less aggressive than cutaneous squamous cell carcinomas
but these two skin cancers ‘often appear clinically similar and must be biopsied to confirm
the diagnosis.’”
Colorectal Cancer
Colorectal cancer is the third-most common cancer in the United
States.55 The lifetime risk for colorectal cancer is 4.49% for men and 4.15%
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for women and the American Cancer Society estimates that in 2019 there will
be 101,420 new cases of colon cancer and 44,180 new cases of rectal
cancer.55
Risk factors for colorectal cancer include alcohol use, obesity, smoking,
a diet that is high in red meat, sedentary lifestyle, a family or personal history
of the disease, inflammatory bowel disease, age > 50, type 2 diabetes, and
African American ethnicity.56
There is unequivocal evidence that colorectal cancer screening and
removal of pre-malignant adenomas can decrease mortality from colorectal
cancer.57 The specific risks of the invasive screening procedures, colonoscopy
and sigmoidoscopy, include infection, adverse effects from sedating drugs
used during the procedures, perforation and bleeding. Major adverse effects
like perforation after invasive screening procedures like colonoscopy or
sigmoidoscopy are very uncommon, occurring in 0.03% of patients.58 The risk
of contrast enemas and CT colonography is exposure to radiation.
There are many different tests that can be used for colorectal screening
tests, each with benefits, risks, and considerations of cost, safety, patient
acceptability, and availability. Doubeni (2019) stated that the best screening
test for colorectal cancer is the one that is acceptable to the patient and the
one that the patient will complete.58
The American Cancer Society’s recommendation for screening for
colorectal cancer in patients who have an average risk for the disease state
that screening should be started at age 45. A patient is at average risk for
colorectal cancer if any of the following are present.
●
A personal history of colorectal cancer or certain types of polyps
●
A family history of colorectal cancer
●
A personal history of inflammatory bowel disease (ulcerative colitis or
Crohn’s disease)
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●
A confirmed or suspected hereditary colorectal cancer syndrome, such as
familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colon cancer or HNPCC)
●
A personal history of getting radiation to the abdomen (belly) or pelvic
area to treat a prior cancer
Screening can be done by colonoscopy, sigmoidoscopy, test for occult
blood in the stool (FOBT), a blood test known as a fecal immunochemical test
or FIT, testing the stool for DNA, or a Computed Tomography (CT)
colonoscopy.58 Screening should continue until age 75. From age 76 to 85,
screening should be done on a case by case basis. There is no
recommendation to screen for colorectal cancer after age 85.58
USPSTF Screening Recommendations
Screening for colorectal cancer should start at age 50 years and
continuing until age 75 years. The decision to screen adults aged 76 to 85
years should be done on a case by case basis, considering the patient’s overall
health and prior screening history.59 Stool-based tests should be done every
year, colonoscopy should be done every 10 years, and CT colonoscopy should
be done every five years. Flexible sigmoidoscopy should be done every five
years or if used with a yearly FIT, every 10 years.59
Research: Colorectal Cancer Screening
The authors of this research study reported on colorectal cancer (CRC)
and the decline of incidence and mortality worldwide due to colorectal
screening programs.60 They identified that screening tools commonly used
have been the fecal occult blood testing (FOBT), flexible sigmoidoscopy, and
colonoscopy. Computed tomography (CT) colonography has been most
recently included in CRC screening.60
Although there has been a decline of incidence and mortality worldwide
due to colorectal screening programs, the effectiveness of CRC screening has
been limited by poor testing availability and by suboptimal screening
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compliance, resulting in advanced or metastatic disease.60 These limitations
have opened up a need and an opportunity for improvements to the current
CRC screening programs.60
One newly developed screening program is the use of molecular
markers.60 Molecular markers are highly accurate and non-invasive CRC
screening tests. They include DNA, proteins, messenger RNA (mRNA), and
microRNA (miRNA), which have all shown potential.60 Aside from fecal
hemoglobin, only DNA-based markers have been developed for clinical testing.
Stool DNA testing has been approved in the United States (2014) for
population-wide screening of average risk, asymptomatic individuals.60 The
authors focused on the “development and validation of a multi-target stool
DNA test for CRC screening that has recently been approved by the US Food
and Drug Administration (FDA) for CRC screening.”60 Additional studies to
determine optimal screening, patient compliance with screening, rates of false
positive results, the use of DNA testing in high-risk populations is needed.60
Adenomatous Polyp and CRC
Colorectal cancer is caused by the growth of a colonic adenomatous
polyp. An adenoma can progress to become an advanced adenoma (> 1 cm
in size, villous histology), and becomes a CRC. While this may usually take
10–15 years to develop there may be some physiological factors that could
cause the cancer to grow much faster. Colorectal cancer screening becomes
important to find the polyp, to remove it and to kill the cancer.60
There is growing knowledge regarding the meaning of molecular
changes in polyps and CRCs. Molecular changes are viewed as the primary
drivers of tumor behavior and the development of cancer. As such, “CRCs
have been classified into at least four subgroups based on their molecular
features:
1)
Hypermutable-Microsatellite
unstable,
2)
Hypermutable-
Microsatellite Stable, 3) Microsatellite Stable (chromosome Unstable), and 4)
CpG Island Methylator Phenotype (CIMP) cancers.”60
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Each subclass has its own set of driver genes in the differing CRC
molecular subgroups; however, there are some mutant genes (APC and
TGFBR2/SMAD4) that have been identified as common among all the
molecular subgroups. They have a key role in the signaling pathways in CRC
overall, but there are some that are restricted to one subclass of CRC. The
authors stated that the most common alterations identified in CRC include:
APC,CTNNB1, KRAS, BRAF, SMAD4, TGFBR2, TP53, PIK3CA, ARID1A, SOX9,
FAM123B, and ERBB2, which appear to promote colorectal tumorigenesis.
Neoplastic cells develop due to the deregulation of other signaling pathways.60
The tumor microenvironment (gut microbiome, inflammatory state of adjacent
tissue, etc.) is also key, as it “modulates the way these mutations affect CRC
formation.”60 Alterations in genes drive the formation of CRC in the context of
tumor promoting factors obtained from adjacent tissue.60
Use of the newer molecular markers for CRC screening was described
by the authors as a well-established, non-invasive detection method for CRC.
Guaiac-based methods for fecal occult blood testing (gFOBT) beginning in the
mid-1960s has been shown in randomized controlled clinical trials (RCT) to
reduce mortality by 11–33% (20 year follow up). However, the gFOBT as a
CRC screening test involves modest specificity for CRC, which can generate
many false positive test results when used in population-based screening
programs, and it also has modest sensitivity for colon polyps.60
Limitations
of
gFOBT
have
led
to
the
development
of
fecal
immunochemical tests (FIT), which detect blood by a human hemoglobin
specific immunoassay. The authors stated that prior studies have shown FIT
assays have numerous benefits over the gFOBT by:60
●
detecting both the presence and quantity of fecal hemoglobin, modifying
the sensitivity and specificity of the assays to detect polyps and CRC
●
showing superior sensitivity and specificity for CRC and advanced
adenomas
●
only one sample is required for analysis, as opposed to three
●
a more acceptable sample collection to the general public, increasing
compliance with screening
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The more sensitive fecal immunochemical test for CRC screening leads
to only 20-30% detection rate of adenomas > 1 cm in diameter. Also, occult
blood testing detection of right colon lesions is less than those that occur in
the left colon, which the authors identify as a significant issue given the
increased incidence of right-sided CRCs reported over the last two decades.60
The discovery of left-sided lesions, however, is not unique to fecal hemoglobin
testing and has been reported in RCTs studying the use of invasive flexible
sigmoidoscopy, and currently more RCTs are in progress with a focus on the
use of colonoscopy to diagnose right-sided colonic adenomatous polyps early
enough to avoid morbidity and mortality.60
Colorectal Cancer Screening Quiz:
I.
The authors report that with colorectal cancer (CRC)
a.
b.
c.
d.
II.
As a screening test for colorectal cancer (CRC), molecular markers
a.
b.
c.
d.
III.
the incidence of the disease is on the rise.
the mortality rates for the disease have been increasing.
poor testing availability has limited the effectiveness of CRC screening.
All of the above
are highly accurate and non-invasive.
are modestly effective in screening for CRC.
can generate many false positive test results.
are effective but are currently limited in use because the testing is highly
invasive.
Colorectal cancers (CRCs) have been classified into at least four
subgroups based on their molecular features because
a. none of the subgroups have common genes.
b. some genes are restricted to one subclass of CRC.
c. mutated genes are always specific to one subclass of CRC.
d. as with cancer staging, an adenoma may or may not progress.
Discussion:60
The focus of the authors’ study was on the utility of non-invasive testing
for CRC screening and the development of tests based on the detection of
specific molecular alterations (e.g. abnormal protein or mRNA expression,
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gene mutations, abnormally methylated genes, etc.) found to exist in body
fluids, such as blood, urine, stool so that individuals with asymptomatic colon
polyps or CRC can be identified. The feasibility of this approach continues to
be studied and more research is needed to determine its effectiveness to
identify a colonic lesion before it becomes a deadly cancer.60
The authors concluded that the “development of molecular marker
assays for CRC screening have demonstrated the feasibility of these assays
and the discovery of a myriad of promising markers. The ultimate generation
of a clinically robust and accurate molecular marker assay has been a slow
and iterative process, which has now resulted in an FDA approved assay that
is being implemented clinically. MT-sDNA can now be added to our CRC
screening armamentarium.”60 As the research on the molecular detection of
colorectal and other gastrointestinal cancers continues to develop there will
likely be more screening tools of higher performance to prevent colorectal and
other GI cancers in the future.60
Answers to Colorectal Cancer Screening Quiz:
I.
The authors report that with colorectal cancer (CRC)
c. poor testing availability has limited the effectiveness of CRC screening.
“Although there has been a decline of incidence and mortality worldwide due to colorectal
screening programs, the effectiveness of CRC screening has been limited by poor testing
availability and by suboptimal screening compliance, resulting in advanced or metastatic
disease. These limitations have opened up a need and an opportunity for improvements to
the current CRC screening programs.”
II.
As a screening test for colorectal cancer (CRC), molecular markers
a. are highly accurate and non-invasive.
“Molecular markers are highly accurate and non-invasive CRC screening tests…. Use of the
newer molecular markers for CRC screening was described by the authors as a wellestablished, non-invasive detection method for CRC.”
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III.
Colorectal cancers (CRCs) have been classified into at least four
subgroups based on their molecular features because
b. some genes are restricted to one subclass of CRC.
“As such, “CRCs have been classified into at least four subgroups based on their molecular
features: … Each subclass has its own set of driver genes in the differing CRC molecular
subgroups; however, there are some mutant genes (APC and TGFBR2/SMAD4) that have
been identified as common among all the molecular subgroups. They have a key role in
the signaling pathways in CRC overall, but there are some that are restricted to one
subclass of CRC.”
Oral Cancer
Oral cancer may develop on the tongue, the mouth and gums and the
area of the throat at the back of the mouth.61 Oral cancers account for 2-4%
of all cancers in the United States, and the American Cancer Society estimates
that in 2019, 53,000 people will develop oral or oropharyngeal cancer and
10,860 people will die from the disease.62
These cancers are almost always squamous cell carcinomas, and they
can occur in the gums, the lining of the cheeks, lips, tongue, and the floor and
the roof of the mouth. Risk factors for developing oral cancer are smoking and
tobacco use, alcohol use, and infection with the human papillomavirus HPV16.61,63
The National Cancer Institute and the USPSTF have concluded that there
is inadequate evidence to determine if screening would result in a decrease in
mortality from head and neck squamous cell cancers.64
Research: Oral Leukoplakia and Oral Cancer Prevention
This study focused on the prevention of oral cancer due to oral
leukoplakia.65 Specifically, this study evaluated if people affected by
leukoplakia can benefit from (local or systemic) surgical, medical or
complementary treatments.65 Preventing oral cancer is critical because rates
of oral cancer survival longer than five years after diagnosis are low.65
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Leukoplakia is a fairly common oral lesion. It forms as a white patch in
the lining of the mouth that cannot be rubbed off.65 Leukoplakia is diagnosed
when other oral mucosal conditions have been excluded, e.g., frictional
keratosis, lichen planus, white sponge nevus, or hairy leukoplakia.65
In a small percentage of people, leukoplakia is a precursor to oral
cancer.65 In addition, there is evidence that people with oral leukoplakia have
a higher risk of oral cancer than do people with normal oral mucosa.65
The authors explained that leukoplakia is not generally noticeable by the
patient. They stated that: “It often does not hurt and may go unnoticed for
years.”65
There were 14 randomized controlled trials (RCTs) of medical and
complementary treatments that the authors reviewed, which involved 909
total participants. The treatments they considered included “herbal extracts,
anti-inflammatory drugs, vitamin A, beta carotene supplements and others.
Surgical treatment has not been compared with placebo or no treatment in an
RCT.”65 They reported on cancer development in studies where three
treatments were measured: systemic vitamin A, systemic beta carotene and
topical bleomycin.
For the prevention of cancer, none of the treatments raised proved
effective after two years of data compilation for vitamin A and beta carotene,
and seven years for bleomycin. While some studies of vitamin A and beta
carotene showed a possibility of effectiveness for improving or healing oral
lesions, a high rate of relapse was noted in participants where treatment had
resolved the lesions. The side effects of treatment were addressed, which
occurred in a high number of subjects and varied in severity. The authors
determined there was good treatment acceptance by study participants based
on drop-out rates.
Prior studies were evaluated as having limitations in their design and
results with low quality relative to their evidence for the outcome of oral
cancer development. In this area of cancer prevention research, larger,
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improved studies of longer duration are needed that included the benefit of
drug treatment and alternative treatments (vitamins), the effectiveness and
safety of surgery, and of the elimination of other risk factors, such as smoking.
Leukoplakia Groups, Conditions and Causes
A helpful delineation of 'leukoplakia' and its current treatment was
described by the authors. They explained that conditions involving leukoplakia
may include frictional keratosis, lichen planus, white sponge nevus, and hairy
leukoplakia, which all require biopsy and histopathological studies to rule out
epithelial dysplasia or carcinoma.65
Tobacco smoking or chewing can lead to leukoplakia. Use of alcohol, and
a systemic infection or virus need further investigation.65
Leukoplakia is generally described in two groups: 1) homogeneous
leukoplakia (uniform flat appearance with possible superficial irregularities),
and consistent texture, and 2) non-homogeneous leukoplakia, which is a
predominantly white or white and red lesion (erythroleukoplakia) showing an
irregular texture, possible ulceration, speckled, nodular or wart-like in
appearance. The histological features of both leukoplakia types are variable
and “may include ortho-keratosis or para-keratosis of various degrees,
acanthosis or atrophy of the squamous epithelium, mild inflammation in the
corium, dysplastic changes of various grades (i.e., mild, moderate or severe),
carcinoma in situ or carcinoma. Some cases of predominantly white lesions
that are difficult to diagnose, in spite of the availability of a biopsy.”65
Disease Prevalence65
The prevalence of leukoplakia varies according to geographical areas
and demographic groups, however is an estimated < 1% to > 5% within the
general population. More than 1000 individuals had been studied and the
authors reported that the pooled prevalence was estimated to be between
1.49% and 4.27%. In another Japan study an age-adjusted incidence rate per
100,000 person-years of 409.2 among males and 70 among females was
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reported, and in an Indian study, distinctive risk factors for oral cancer in a
population found there to be lower figures (240 for males and 3 for females).
As a potentially malignant disorder, leukoplakia transforms into
squamous cell carcinoma with a rate that has been reported to vary between
0% to 36.4%. One study investigating malignant transformation on the basis
of European epidemiological data determined that the “upper limit of the
annual transformation rate of oral leukoplakia is unlikely to exceed 1%.”65 The
authors also noted that non-homogeneous leukoplakias have a higher risk of
transformation compared to the homogeneous variants.65
Oral Leukoplakia Quiz:
I.
Leukoplakia may manifest as an oral lesion that
a.
b.
c.
d.
II.
becomes cancerous in most cases.
is usually accompanied by moderate pain.
forms as a white patch in the mucosal lining of the mouth.
is also known as frictional keratosis.
True or False: Preventing oral cancer is critical because survival rates
longer than 5 years after diagnosis are low.
a. True
b. False
III.
For the prevention of cancer developing from leukoplakia, which of the
following treatments proved effective?
a.
b.
c.
d.
Vitamin A
Beta carotene
Bleomycin
None of the above
Discussion:65
This research study focused on the many approaches to leukoplakia
treatment for the prevention of cancer development. The authors described
approaches that included surgical excision with different techniques (scalpel,
cryosurgery, photodynamic therapy, laser surgery and vaporisation), medical
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treatment (topical or systemic), cessation of risk activities (smoking and
alcohol) and no intervention but strict surveillance.
Many of the treatments for leukoplakia to prevent cancer have
potentially serious adverse effects. Therefore, the authors suggested a “wait
and see” approach based on specific standardized clinical and histological
surveillance to catch cancer early and to begin cancer treatment.
Answers to Oral Leukoplakia Quiz:
I.
Leukoplakia may manifest as an oral lesion that
c. forms as a white patch in the mucosal lining of the mouth.
“Leukoplakia is a fairly common oral lesion. It forms as a white patch in the lining of the
mouth that cannot be rubbed off. Leukoplakia is diagnosed when other oral mucosal
conditions have been excluded, e.g., frictional keratosis,.... In a small percentage of
people, leukoplakia is a precursor to oral cancer…. ‘It often does not hurt and may go
unnoticed for years.’”
II.
True or False: Preventing oral cancer is critical because survival rates
longer than 5 years after diagnosis are low.
a. True
“Preventing oral cancer is critical because rates of oral cancer survival longer than five
years after diagnosis are low.”
III.
For the prevention of cancer developing from leukoplakia, which of the
following treatments proved effective?
a. Vitamin A
b. Beta carotene
c. Bleomycin
d. None of the above [correct answer]
“For the prevention of cancer, none of the treatments raised proved effective after two
years of data compilation for vitamin A and beta carotene, and seven years for
bleomycin. While some studies of vitamin A and beta carotene showed a possibility of
effectiveness for improving or healing oral lesions, a high rate of relapse was noted in
participants where treatment had resolved the lesions.”
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Coronary Heart Disease and Hypertension
Coronary heart disease and its associated conditions are the leading
cause of death in the United States. 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 lifestyle.
Non-modifiable risk factors are age, gender, and family history of coronary
heart disease.66
People
who
have
coronary
heart
disease
(CHD)
are
typically
asymptomatic until they have advanced disease. The first sign of CHD is often
a major event like angina, arrhythmia, or myocardial infarction.66 The USPSTF
does not recommend specific screening tests for coronary heart disease for
asymptomatic adults who do not have coronary heart disease or diabetes.21
The USPSTF and authoritative sources do 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.66
Hypertension
Hypertension is defined as a systolic blood pressure of 130 to 139 mmHg
and higher or diastolic blood pressure of 80 to 89 mmHg and higher.67
Hypertension
is
one
of
the
most
important
preventable
causes
of
cardiovascular disease, diabetes, stroke, and renal failure.68 More than 100
million Americans have hypertension, but only about 75% are being treated
and approximately 52.5% who are treated have their blood pressure under
control.68
There is a direct relationship between blood pressure and adverse
effects; the higher the blood pressure the greater the risk for complications
and morbidities and the risk of developing cardiovascular disease doubles with
each 20 mmHg increase in systolic blood pressure and each 10 mmHg increase
in diastolic blood pressure.68 Risk factors for the development of primary
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hypertension (the most common form of the disease) may include age,
smoking, obesity, family history, African American race, excessive sodium
intake,
excessive
alcohol
intake,
physical
inactivity,
diabetes
and
dyslipidemia.
67,69
The USPSTF screening recommendations, derived from the Seventh
Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure - JNC 7 Report include those listed
below.70 These recommendations are basically the same as those from
authoritative sources and other professional organizations like the American
College of Cardiology/American Heart Association:67
Adults 18 years of age and older be screened for hypertension.
● Adults 18-39 who have normal blood pressure and who do not have risk
●
factors should be screened every three to five years.
●
Adults 40 years of age and older and people who have risk factors for
hypertension should be screened every year.
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 a home blood pressure monitoring to confirm the
presence of hypertension after an initial diagnosis has been made.70
Research: Benefits of Exercise for the Heart
As mentioned above, risk factors for the development of primary
hypertension includes physical inactivity. Exercise interventions were the
focus of the study discussed in this section. The authors reviewed selected
articles and classified them into 7 categories. One of the categories was
cardio-cerebral vascular system disease.71 Exercise protocols and their
duration, frequency, and intensity level were discussed relative to cardiocerebral vascular system disease. The protocols were primarily identified as
aerobic exercise, resistance training, home-based exercise, multimodal
exercise, and other exercises including a combination of exercises.
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Classification of Exercise Types
Aerobic exercise involves high repetition and low resistance demands
and the authors described it as a well-established approach to improving
aerobic capacity and health. Walking and running, yoga, Tai Chi, Pilates, and
cycling are examples of aerobic exercise.
During periods of postoperative rehabilitation or severe disease, aerobic
exercise can be performed at low, moderate, or high intensity. Cycling,
treadmill, or stationary bicycle can be paced at high-intensity interval training
(HIIT) for individuals who have acceptable cardiorespiratory function. Highintensity interval training can improve blood pressure and aerobic capacity in
obese youths.
Resistance exercise can improve an athlete’s performance and is
currently part of the recommended activities to maintain overall health. It can
lower the risk of cardiovascular disease and other comorbid conditions, such
as elevated lipid panels, low energy and depression, and metabolic syndrome.
At home, people can incorporate resistance exercise through the use of elastic
exercise bands, body weights, and exercise machines. The upper body and
lower muscles can be conditioned with the use of resistance exercises.
Combinations of aerobic exercise and resistance training enhance
cardiorespiratory function and they improve muscle strength. Before patients
are prescribed a combination program of aerobic and resistance training they
should receive a complete physical assessment and they should be cleared by
a medical provider to start such a program. The most common combination
exercise regimes include walking and riding a bicycle. Depending on the
patient’s strength and physical health, a combination exercise regime of < 6
weeks is considered short-term, and > 6 weeks is classified as long-term.71
Home exercise is a concept that enhances a person’s ability to continue
long-term exercise training in the comfort of home. Being at home is believed
to allow for an exercise program that can be part of a person’s daily routine,
and that is “simple and easy.”71 The authors stated that home exercise may
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only improve aerobic exercise and not as much endurance. Although intended
to be simple and doable, the home exercise is still a prescribed training, which
may include high-intensity leg-strengthening exercises.71
Other training exercises varying in intensity were reviewed by the
authors however not all will be covered here. The main concept conveyed in
their study was that exercise regimes prescribed for recovery and long-term
endurance were available for providers to design with their patients and
treatment team committed to heart health and cardiovascular disease
prevention.71
With regard to heart and lung function, proper exercise can improve
blood circulation, increase the body’s oxygen supply, and improve blood vessel
condition. It is well known that exercise typically lowers blood lipids and
prevents the development of arteriosclerosis and thrombosis. The effects of
exercise effectively prevent cardiovascular diseases, including coronary artery
disease, congestive heart failure and stroke.71
The authors reported that exercise interventions for coronary artery
disease included home-based exercises and aerobic exercises. They listed the
most common forms of exercise in this category as walking, cycling, jogging,
and Tai Chi. Specifically, they reported that the long-term, moderate-intensity
walking exercise “decreased the severity of sleep apnea in coronary artery
disease patients.”71 Also, HIIT reduced the morbidity and mortality of coronary
artery disease and prevented atherosclerosis. A patient’s heart function and
quality of life reportedly improved and the risk of heart disease decreased.71
In earlier smaller trials, advanced individual training was reportedly
more effective for the rehabilitation of patients with coronary artery disease
(CAD) as compared to aerobic continuous training. Other studies showed that
long-term home exercise was superior to traditional hospital-based cardiac
rehabilitation in terms of cardiopulmonary function measures, improving
postoperative recovery. Exercise interventions in general usually improved
coronary artery disease-related risk factors, such as body composition and
blood pressure. The authors concluded that compared with moderate
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continuous training, long-term aerobic and home exercise regimes in patients
with coronary artery disease proved more effective to improve physical
condition.71
For patients diagnosed with congestive heart failure (CHF), poor venous
system condition and insufficient arterial perfusion typically led to cardiac
dysfunction. Some people with poor heart function believe they should avoid
exercise and heart stimulation but the authors reported that recent research
has shown that moderate exercise benefited CHF patients. Aerobic exercise,
resistance exercise, and HIIT were recommended routines that included longterm walking with breathing exercise to improve blood oxygen saturation as
well as a person’s mood and quality of life.71
For CHF patients, the authors identified that long-term, moderateintensity “stretching combined with cycling improved and enhanced muscle
metabolic reflex control. HIIT protocols improved the patients’ quality of life
by changing their levels of health.” Although easy to implement and welltolerated, HIIT was not found to be more effective compared to continuous
aerobic exercise. The focus of the exercise program was to improve aortic
dilatation ability, increase systolic blood pressure, and vascular response.
Exercise interventions usually improve cardiopulmonary function in CHF
patients. The authors concluded that compared with continuous aerobic
exercise training or no exercise, “HIIT improved the cardiac contraction
function and quality of life.”71 HIIT has been often used in the long-term
treatment of CHF patients.
Benefits of Exercise for the Heart Quiz:
I.
Cycling, treadmill, or stationary bicycle can be paced at high-intensity
interval training (HIIT) for
a.
b.
c.
d.
individuals who have acceptable cardiorespiratory function.
all individuals.
preoperative individuals only.
patients with normal blood pressure levels only.
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II.
Before patients are prescribed a combination program of aerobic and
resistance training they should
a. begin with a low-intensity program for 6 weeks.
b. begin with upper body muscles exercises only.
c. receive a complete physical assessment and they should be cleared by a
medical provider.
d. begin with lower body muscles exercises only.
III.
Exercise is effective in preventing
a.
b.
c.
d.
coronary artery disease.
congestive heart failure.
stroke.
All of the above
Discussion:71
Clinicians need to educate patients that the lack of exercise leads to the
risk of heart disease, rising medical costs and economic burden for patients,
their families, and community health systems. The authors aptly proposed
that “Guiding people to take part in exercise properly to enhance physical
fitness is more urgent and more important than ever.”71 Exercise prescription
and the prevention of heart disease had other corresponding health benefits,
such as improved mental health, musculoskeletal strength and balance, and
pain control. While health providers can help to develop an effective exercise
program for patients based on randomized controlled trials, the authors also
emphasized the importance of adopting an individualized approach when
promoting rehabilitation and heart disease prevention. The exercise program
developed should be individualized, based upon the patient’s heart health
condition and physical tolerance.
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Answers to Benefits of Exercise for the Heart Quiz:
I.
Cycling, treadmill, or stationary bicycle can be paced at high-intensity
interval training (HIIT) for
a. individuals who have acceptable cardiorespiratory function.
“During periods of postoperative rehabilitation or severe disease, aerobic exercise can be
performed at low, moderate, or high intensity. Cycling, treadmill, or stationary bicycle
can be paced at high-intensity interval training (HIIT) for individuals who have
acceptable cardiorespiratory function.”
II.
Before patients are prescribed a combination program of aerobic and
resistance training they should
c. receive a complete physical assessment and they should be cleared by a
medical provider.
“Before patients are prescribed a combination program of aerobic and resistance training
they should receive a complete physical assessment and they should be cleared by a
medical provider to start such a program.”
III.
Exercise is effective in preventing
a. coronary artery disease.
b. congestive heart failure.
c. stroke.
d. All of the above [correct answer]
“The effects of exercise effectively prevent cardiovascular diseases, including coronary
artery disease, congestive heart failure and stroke.”
Diabetes and Lipid Disorders
Approximately 9.4% of Americans have diabetes, 34% percent of the
population 20 years of age or older have prediabetes, and approximately 25%
of the people who have diabetes are undiagnosed.72 Almost half of Asian
Americans and Hispanic Americans who have diabetes are undiagnosed. The
prevalence of diabetes is increasing, 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.72
Screening for and early treatment of diabetes can be beneficial.72 The
American Diabetes Association (ADA) has recommendations for testing for
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diabetes or pre-diabetes in asymptomatic adults, and for people with medical
conditions associated with diabetes.73,74
Diabetes/Prediabetes Testing in Asymptomatic Adults
Screening for prediabetes and type 2 diabetes by using an assessment
of risk factors or validated tools should be considered in asymptomatic adults.
Testing for prediabetes and/or type 2 diabetes in asymptomatic people should
be considered in all adults of any age who are overweight or obese (BMI ≥25
kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more other risk
factors for diabetes.73
For people age 45 years and older, testing should begin regardless of
risk. The following criteria for diabetes testing are recommended:73
●
If tests are normal, it is reasonable to repeat testing at a minimum of 3year intervals.
●
A fasting plasma glucose, 2-hour plasma glucose during a75-g oral glucose
tolerance test, and A1C measurement are equally appropriate to test for
prediabetes and type 2 diabetes.
●
Women who have had gestational diabetes should have lifelong testing
done.
●
If the patient has prediabetes or type 2 diabetes, identify and treat other
cardiovascular disease risk factors.
●
Risk-based screening for prediabetes and/or type 2 diabetes should be
considered after the onset of puberty or after 10 years of age, whichever
occurs earlier, in if the patient is overweight (BMI ≥85th percentile) or
obese (BMI ≥95th percentile) and has other risk factors for diabetes.
For people of any age who have risk factors for diabetes or prediabetes,
screening may be indicated.73 Screening for Risk factors for diabetes screening
include obesity, risk of insulin resistance, a first-degree relative with diabetes,
ethnicity (African American, Native American, Pacific Islander, Latino, Asian
American), history of CVD, hypertension, polycystic ovary disease in women,
sedentary lifestyle,
and HDL cholesterol level <35 mg/dL (0.90 mmol/L)
and/or a triglyceride level >250 mg/dL (2.82 mmol/L).73
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Screening for Medical Complications Associated with Diabetes
The ADA recommends that cardiovascular risk factors should be
systematically assessed at least annually in all patients with diabetes. This
assessment is directed at the prevention and management of atherosclerotic
cardiovascular disease and heart failure.74 “These risk factors include
obesity/overweight, hypertension, dyslipidemia, smoking, a family history of
premature coronary disease, chronic kidney disease, and the presence of
albuminuria.”74 Some of these are discussed here.
Hypertension:
Identification and treatment of hypertension in patients who have
diabetes can reduce the risk of cardiovascular events and microvascular
complications.74 The American Diabetes Association recommends that blood
pressure should be measured at every visit with a healthcare provider. If the
blood pressure is ≥ 140/90 mmHg, multiple reading should be done, on
separate days, to confirm. If the patient has hypertension, a home blood
pressure monitoring device should be used.74
Dyslipidemia:
The
American
Diabetes
Association’s
recommendations
for
lipid
screening state that in diabetic patients who are not taking a statin or other
lipid-lowering drug, consider measuring a lipid profile when the patient is first
diagnosed.74 For patients under 40, this can be repeated every five years or
as needed.74
A lipid profile should be obtained when lipid lowering therapy is started,
4-12 weeks after initiation or after a dose change, and every year thereafter.74
Lowering lipid levels can decrease the risk of developing atherosclerosis
and heart disease. Deciding who to screen, when, and how often are decisions
that are usually made by considering the cardiovascular disease risk profile of
the patient. Vijan (2019) recommended that young adults who have never
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been screened for elevated lipids should have baseline testing done.
Additionally, people who have a high risk for cardiovascular disease should be
screened starting at age 25-30 for men, and age 30-35 for women.76
High risk for cardiovascular disease would be someone who has
diabetes, hypertension, obesity, sedentary lifestyle, smoking, and/or a family
history of premature heart disease. People who have a low risk for
cardiovascular disease should have a screening at age 35 for men, and age
45 for women. Total cholesterol, high-density lipoprotein and low-density
lipoprotein should be measured.76 The American Academy of Pediatrics
recommends that children be screened for dyslipidemia by assessing risk
factors and if needed, measuring lipid levels, starting at age four, several more
times during childhood, and yearly from age 11 to 16.77 The USPSTF concluded
that the “... current evidence is insufficient to assess the balance of benefits
and harms of screening for lipid disorders in children and adolescents 20 years
or younger.”78
Cardiovascular Disease:
The American Diabetes Association does not recommend screening for
patients who are asymptomatic for coronary artery disease so long as risk
factors for atherosclerotic cardiovascular disease are treated.75
Chronic Kidney Disease:
Urinary albumin and estimated glomerular filtration rate (GFR) should
be measured once a year for patients who have had type 1 diabetes for ≥ five
years, in all patients who have type 2 diabetes, and in patients who have
comorbid conditions. At least once a year, urinary albumin (e.g., spot urinary
albumin-to-creatinine ratio) and the estimated glomerular filtration rate in
patients with type 1 diabetes with duration of ≥5 years, should be tested. All
patients with type 2 diabetes and with comorbid hypertension should be tested
at least annually.75
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Components of Diabetes Care
Diabetic patients with proliferative diabetic retinopathy (PDR) or
macular edema may be asymptomatic. This may be due to treatment. For
these reasons, screening to detect diabetic retinopathy is recommended.
Other conditions that should be screened include diabetic peripheral
neuropathy, and diabetic foot ulcers.75
Diabetic Retinopathy:
Patients who have type 1 diabetes should have a comprehensive dilated
eye examination within five years of the time of diagnosis. Patients who have
type 2 diabetes should have a comprehensive dilated eye examination at the
time of diagnosis.
If there is no evidence of retinopathy after one-two examinations and
blood sugar is well controlled, doing an examination every one or two years
can be considered. When examinations show signs of retinopathy, annual
examinations should be done and if retinopathy is present and progressing,
more frequent examinations are required. Examinations, e.g., retinal camera
images, can be evaluated remotely by an ophthalmologist or optometrist.75
Women who have type 1 or type 2 diabetes who are planning a
pregnancy or who are pregnant should be counseled on the risk of
development and/or progression of diabetic retinopathy. Women who have
type 1 or type 2 diabetes should have an eye examination done before
pregnancy or in the first trimester and the patient should be monitored every
trimester and for 1-year postpartum.75
Diabetic Neuropathy:
Patients who have type 1 diabetes should be screened for diabetic
peripheral neuropathy five years after the time of diagnosis and then annually.
Patients who have type 2 diabetes should be screened at the time of
diagnosis.75
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Assessment for distal symmetric polyneuropathy should include a
history, and an assessment of temperature or pinprick sensation and vibration
sensation using a 128-Hz tuning fork. Every patient should have annual 10-g
monofilament testing to identify feet at risk for ulceration and amputation. If
the patient has microvascular complications, autonomic neuropathy should be
ruled out.75
Diabetic Foot Ulcer:
A comprehensive foot evaluation should be done at least once a year. If
the patient has signs and symptoms of sensory loss or of a previous ulcer, the
feet should be evaluated at every visit. It should be determined if the patient
has had an amputation, ulceration, Charcot foot, angioplasty or vascular
surgery, renal disease, a history of smoking, retinopathy, or vascular
disease.75
The examination should include pinprick, vibration, and temperature
assessment, and 10-g monofilament testing, and assessment of the pulses in
the feet and legs. Assess for signs and symptoms of neuropathy. If there are
abnormalities on the vascular examination or the patient has signs/symptoms
of claudication, an ankle-brachial index test should be done, and the patient
should be referred for further assessment of vascular function. Patients who
have structural abnormalities or complications of the lower extremities,
smokes, peripheral arterial disease, or loss of protective sensation, should be
referred to a foot care specialist.
Research: Exercise and Metabolic Disorders
Metabolic disorders have serious deleterious effects on the health and
quality of life of those who are affected. The authors of this research study
reported on lifestyle strategies to prevent and treat metabolic diseases.71 They
focused on exercise in addition to diet and weight control as a combined
recommended treatment to avoid the risk of a metabolic disorder and to
promote recovery. The following are conditions they highlighted as targets for
an effective treatment strategy.71
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Obesity:
While obesity can occur as a result of a person’s genetics and lifestyle,
secondary obesity is caused by multiple endocrine and metabolic diseases.
Exercise prescriptions for obesity include aerobic exercise and resistance
exercise combined with HIIT. Long-term and moderate to high intensity
aerobic exercise, including treadmill and stationary bicycle training, helps to
improve body composition in obese individuals. Aerobic interval training (AIT)
helps improve the microvascular endothelial dysfunction in obese patients.
Resistance exercise combined with HIIT in sedentary, overweight,
middle-aged individuals leads to weight loss, and resistance exercise
combined with HIIT has been shown to be superior to resistance training
alone. Exercise methods typically have positive results and aerobic exercise is
the common for treating or preventing obesity.
Type 2 Diabetes:
Type 2 diabetes carries high morbidity and mortality, and is a significant
health problem worldwide. There is a global increase in the prevalence and
incidence of type 2 diabetes over the past several decades. The authors report
a worldwide estimate of 371 million people with diabetes with an anticipated
total of 552 million diabetics by 2030. They stated that “Diet therapy, drug
therapy, psychotherapy, and self-care monitoring are commonly used
intervention methods. Exercise therapy is also a key treatment for patients
with T2D and is considered a cornerstone of treatment for T2D, alongside diet
and drug treatments.”71
Some of the exercise forms for diabetes type 2 include aerobic exercise,
resistance exercise, and HIIT. The treadmill and stationary bicycle were
recommended exercise routines. The benefit of long-term exercise training for
people with diabetic complications primarily involves resistance exercise at
moderate and high intensity because in type 2 diabetics (notably older people)
this approach can “significantly decrease glucose, insulin, and homeostatic
model assessment-insulin resistance levels.”71
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Low-volume HIIT on a cycle ergometer was tried in type 2 diabetics and
was found to have immunomodulatory and potential anti-inflammatory
effects. The authors reported that the most common exercises to treat type 2
diabetes included aerobic exercise and resistance exercise, and that longterm, moderate intensity exercise had positive health effects in type 2 diabetic
patients.
Type 1 Diabetes
Type 1 diabetes involves a complex relationship between genetic and
environmental
factors.
Research
is
ongoing
to
determine
its
exact
pathogenesis. The authors identified that insulin therapy, psychotherapy, and
exercise therapy are effective treatments for type 1 diabetes.
With regard to exercise, “HIIT and speed endurance training were the
exercise methods used to treat T1D. Cycle sprint training was used as a
common speed endurance training method. In the HIIT protocol, cycle sprints
with acute interval training carried out on cycle ergometers with high intensity
showed a positive effect in that the intervention rapidly decreased patients’
perception
of
subsequent
hypoglycemia
and
reduced
their
cognitive
dysfunction caused by hypoglycemia.”71 The authors concluded that long-term
speed endurance training at high intensity is able to improve type 1 diabetes
outcomes.
Nonalcoholic fatty liver disease (NAFLD)
Nonalcoholic fatty liver disease is reportedly “the most common chronic
liver disease in the world.”71 The authors reported that NAFLD is predicted to
be the primary reason for liver transplantation by 2030 with a diverse range
of liver conditions, such as simple steatosis (nonalcoholic fatty liver),
nonalcoholic steatohepatitis, and liver cirrhosis, which place a person at risk
of developing hepatocellular carcinoma.
The American Association for the Study of Liver Diseases reportedly had
proposed that hepatic steatosis can be reduced in patients with NAFLD through
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a routine of exercise. Exercise prescriptions included aerobic exercise as a
main intervention for NAFLD at moderate to high intensity, both long-term
and short-term programs. Aerobic exercise has also been found to reduce the
overall risk of developing NAFLD with some benefit of intrahepatic triglyceride.
A one-year program of moderate aerobic exercise for obese individuals
with NAFLD was found to significantly lower intrahepatic triglyceride levels and
decreased abdominal obesity and blood pressure. The authors reported that
positive effects could be obtained through moderate intensity aerobic exercise
to prevent and to treat NAFLD.
Metabolic Disorders Quiz:
I.
The benefit of long-term exercise training for elderly patients with
diabetic complications primarily involves
a.
b.
c.
d.
II.
resistance exercise at moderate and high intensity.
dead-weight lifts to build strength.
low intensity exercises such as walking.
abdominal exercises, such as sit ups.
True or False: Effective treatment plans for type 1 diabetes do NOT
include exercise therapy because this disease is caused by genetic
factors.
a. True
b. False
III.
A one-year program of moderate aerobic exercise for obese individuals
with nonalcoholic fatty liver disease (NAFLD) was found to
a.
b.
c.
d.
significantly lower intrahepatic triglyceride levels.
decrease abdominal obesity.
decrease blood pressure.
All of the above
Discussion:71
The use of exercise to prevent and to treat many diseases is a common
medical wisdom based upon numerous prior studies. The authors of this case
study encouraged clinicians to validate the benefit of exercise interventions to
their patients. They stated that “Compared with the huge cost of drugs,
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exercise intervention is an economic and safe way to prevent and treat
diseases, and has few side effects, which reduces the economic burden on
families and society.”71 Exercise therapy cannot improve all diseases and
sometimes it can only be used as an adjuvant treatment for major illness. At
present, the types of exercise interventions used as treatments are mainly
aerobic exercise, resistance exercise, and HIIT. Different types of training
methods have their own characteristics. For instance, resistance exercise
primarily enhances muscle strength and increases basal metabolic rate. The
authors of this research study focused on combined recommended treatment
of varied exercise regimes in addition to diet and weight control lower
metabolic risk and as treatment.
Answers to Metabolic Disorders Quiz:
I.
The benefit of long-term exercise training for elderly patients with
diabetic complications primarily involves
a. resistance exercise at moderate and high intensity.
“The benefit of long-term exercise training for people with diabetic complications primarily
involves resistance exercise at moderate and high intensity ...’”
II.
True or False: Effective treatment plans for type 1 diabetes do NOT
include exercise therapy because this disease is caused by genetic
factors.
b. False
“Type 1 diabetes involves a complex relationship between genetic and environmental
factors.”
III.
A one-year program of moderate aerobic exercise for obese individuals
with nonalcoholic fatty liver disease (NAFLD) was found to
a. significantly lower intrahepatic triglyceride levels.
b. decrease abdominal obesity.
c. decrease blood pressure.
d. All of the above [correct answer]
“A one-year program of moderate aerobic exercise for obese individuals with NAFLD was
found to significantly lower intrahepatic triglyceride levels and decreased abdominal
obesity and blood pressure.”
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Obesity
Obesity and being overweight can have serious health consequences like
the development of cardiovascular disease, diabetes, bone and joint disorders,
and morbidities associated with essentially every organ system. Being
overweight in adults is defined as a body mass index (BMI) of 25 to 29.9
kg/m2. For children, being overweight is having a BMI between the 85th and
95th percentile for the child’s age and sex.79
Specifically, obesity is defined as a BMI ≥30 kg/m2. For children, obesity
is defined as a BMI ≥95th percentile for age and sex. Severe obesity is defined
as a BMI ≥40 kg/m2 (or ≥35 kg/m2 if the patient has comorbidities).79
Obesity and being overweight are common in American adults, children
and adolescents. More than 20% of American adults are obese, and
approximately one-third of children and adolescents are overweight or
obese.80 In certain ethnic groups, e.g., non-Hispanic blacks, the prevalence of
obesity is >39%.79 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, multicomponent behavioral
interventions.”21 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.”21
For
some
adults,
particularly
those
of
Asian
descent,
waist
circumference should also be measured if the patient has a BMI of 25 kg/m2
to 30 kg/m2 as failing to do so may not detect patients at risk for weightassociated morbidities.81 The USPSTF recommends obesity screening for all
children and adolescents > age six.82
Research: Obesity Risk in Youth
The following study was conducted in Canada and focused on healthy
young people in British Columbia. The aim of the study was to determine if
there is a relationship between stressful life events and obesity in young
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people, and whether there is a different outcome based on gender.83 The study
found that “the frequency of major life events may be an important social
stressor associated with obesity in adolescents, particularly for young men.”83
Study findings added to previous work supporting the need to consider
addressing young people's experiences of stressful life events in future obesity
prevention strategies. The authors suggested that additional gender-sensitive
health research should investigate the behavioral and biological mechanisms
linking stressful life events with obesity risk.83
By considering stressful life events relative to levels of obesity in a group
of ethnically diverse youth in a specific geographic region, both static and
dynamic risk factors were identified, such as gender and history of trauma or
current environmental triggers to stress.83 These become an important part
of clinical assessment for a clinician who consults with parents and a child who
are concerned about obesity.83
In this study, 905 British Columbian adolescents (13–17 years of age)
self-reported on stressful life events.83 The authors reported that young men
reporting one stressful life event had an estimated 50% more chance of having
obesity at 6-month follow-up and those reporting multiple stressful life events
had twice the chance of developing obesity at 6-month follow-up than young
men who reported no stressful life events over the prior year.83 Young women
reporting multiple events demonstrated a higher chance of developing obesity
than young women reporting no life events at the end of the study.83
The authors concluded that the “frequency of major life events may be
an important social stressor associated with obesity in adolescents,
particularly for young men. However, findings should be replicated in larger
samples using measured anthropometry to inform future obesity prevention
strategies.”83
Because adolescent obesity has grown into a worldwide concern, the
authors wanted to investigate how stress-related weight gain could impact a
youth’s overall development. They opined that it was important to understand
social stressors, specifically adverse life events, in youth and the role of stress
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in adolescent obesity so that preventive health interventions could be
developed to improve health outcomes. The authors highlighted the following
considerations:83
●
Young people experience a unique period of developmental vulnerability
relative to major life events.
●
Social stressors can permanently impact a young person’s brain
development and metabolic systems, thereby negatively impacting
physical functioning and emotional regulation later on in life.
●
Young people are more vulnerable to the health impact of stress and have
less control over stressful life events.
●
Independent stressors in youth reportedly vary: more common everyday
life events (25%), i.e., parental divorce, peer conflict; more extreme but
less common life events (6.2%), i.e., death of a parent or being a victim
of violence.
●
An estimated quarter of young people by the age of 16 encounter at least
one high-magnitude stressor.
●
Young people are more emotionally vulnerable to social stressors because
they have higher hypothalamic–pituitary–adrenal (HPA) activity and
heightened biological stress reactivity, which impacts cortisol levels effects
on central adiposity.
When social stressors impact the brain of a youth it could lead to
negative metabolic consequences. The youth could turn to food as a means of
calming by consuming highly desirable foods (such as those rich in sugar and
fat). The authors stated that “energy-dense foods triggers the brain's reward
pathway and becomes a reinforcing behavior in the same way as that of drug
use in young people, underpinned by the principles of reward and
reinforcement.”83 Also, sex hormones differ in HPA activation and stress
reactivity so it is important to understand how stressful life events can affect
weight-related outcomes for both young women and young men.83
During times of social stress, young people may not only have poor
quality diets but may appear sedentary, not exercising and sleeping less, and
consuming illegal substances, e.g., tobacco and alcohol.83 These behaviors
have all been associated with obesity. Other factors could add to the risk of
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obesity such as sleep deprivation related to changes in sleep–wake cycles and
effects on leptin (satiety hormone) regulation and emotional regulation. These
combined factors lead to behavioral changes in youth, as well as the formation
of lifestyle habits contributing to obesity.83
Sex chromosomes reportedly regulate habit formation and the sleep
deprivation impacting metabolic processes is said to be greater in young
women than in young men.83 Few studies exist that include a gender-based
analysis focused on the differences between male and female exposures to
stressful life events and the varied vulnerability of male and female youth to
the metabolic effects of stressful life events.
The authors hypothesized that “greater levels of stressful life events
would be associated with higher obesity at follow-up and that the associations
would show gender-specific patterning.”83
Adolescent Obesity Quiz:
I.
This study asks if there is a relationship between ______________
and obesity in young people.
a.
b.
c.
d.
II.
Young people are more emotionally vulnerable to social stressors
because adolescents have
a.
b.
c.
d.
III.
school performance
ethnicity
stressful life events
sleep patterns
lower biological stress reactivity.
higher hypothalamic–pituitary–adrenal (HPA) activity.
a decreased glucose level when stressors are present.
a blunted, stress-induced HPA axis response.
True or False: Sleep deprivation impacting metabolic processes is said
to be greater in young women than in young men.
a. True
b. False
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Discussion83
The authors concluded there was longitudinal data that showed how
stressful life events in young and adult populations were positively associated
with obesity.83 They also reported on potential gender differences, as young
women reporting two or more events showed higher obesity rates. In children
a greater exposure to stressful life events were found to correlate with a 12%
greater likelihood of overweight status with some gender differences in young
children. They stated, “It is difficult to directly compare our results with those
of previous works, as the literature uses heterogeneous nomenclature and
operationalization of both stressful life events and obesity status, lacks a focus
on this vulnerable age group of mid-to late-puberty and is silent on potential
gender differences.”83
Factors highlighted by the authors that explained how stressful life
events corresponded with obesity rates included:83
●
Chronic stress increases overall activation of the HPA axis, negatively
affecting hormonal regulation of metabolic activities.
●
Elevated cortisol levels are associated with increased leptin levels and
central adiposity. Disrupted leptin levels may result in inhibited satiety,
and increase food consumption.
●
Stressful life events correspond with unhealthy behavioral responses, poor
coping mechanisms, which further contribute to obesity risk through
psychosocial effects and sedentary behavior.
Metabolic dysregulation and unhealthy behaviors combined have known
sex- and gender-based differences that underlie stressful life events and
obesity among adolescent males.83 During exposure to a stressful event,
young males reportedly have higher cortisol and autonomic nervous system
reactivity than young females. The sex-based difference in HPA response
patterns in mid-adolescence has been found to be similar to those in adults.
Female sex hormone cycles involving post-ovulation luteal phase and circadian
rhythms can effect HPA responsiveness to perceived stress.83
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Canadian studies have shown that the social roles and norms of young
females suggest they have a wider social network and support system to help
them cope with stressful life events thereby avoiding negative metabolic
outcomes due to stressful life events. It was also suggested that young women
carry thin body ideals that explain why stressful life events tend to not be
correlated with obesity.83
The authors stated that a key strength of the study pertained to its
representation of a regions broader adolescent population, including youth
ethnicity, pubertal stage and socioeconomic status. They were able to observe
that independent stressful life events (versus perceived psychological stress)
incorporated identified risk factors for future interventions to target during
treatment. Also, this study focused on youth aged 13–17 years during a
“unique developmental period putting them at particularly high risk of
negative metabolic consequences from major life events.”83 Gender played a
critical role relative to the relationship between stressful life events and
obesity in the teen group that was monitored in this Canadian study.83
Answers to Adolescent Obesity Quiz:
I.
This study asks if there is a relationship between ______________
and obesity in young people.
c. stressful life events
“The aim of the study was to determine if there is a relationship between stressful life
events and obesity in young people, and whether there is a different outcome based on
gender.”
II.
Young people are more emotionally vulnerable to social stressors
because adolescents have
b. higher hypothalamic–pituitary–adrenal (HPA) activity.
“Young people are more emotionally vulnerable to social stressors because they have
higher hypothalamic–pituitary–adrenal (HPA) activity and heightened biological stress
reactivity, which impacts cortisol levels effects on central adiposity.”
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III.
True or False: Sleep deprivation impacting metabolic processes is said
to be greater in young women than in young men.
a. True
“Sex chromosomes reportedly regulate habit formation and the sleep deprivation
impacting metabolic processes is said to be greater in young women than in young
men.”
Osteoporosis
Osteoporosis is defined as reduced bone strength that increases the risk
for fractures, and it is a very common disease.84 Approximately 10 million
American have osteoporosis, and osteoporosis is the cause of about 2 million
fractures each year in the United States.84
Osteoarthritis is also a degenerative bone disease affecting the elderly.
After age 50 the number of people who have osteoarthritis increases and in
the United States, at least 20% of men and women over the age of 50 have
had one or more osteoporotic fractures. Women suffer disproportionately from
osteoarthritis.84-86
Risk factors for osteoporosis include advanced age, caucasian race,
excessive alcohol use, family history, female gender, long-term treatment
with a glucocorticoid, low body weight, and smoking.87 The USPSTF
recommends that all women 65 years of age and older be screened for
osteoporosis; post-menopausal women < age 65 years who have an increased
risk for osteoporotic fracture should be screened.88 There is not enough
evidence to determine if screening men for osteoporosis is beneficial.
Wu (2018) noted that some professional organizations, the National
Osteoporosis Foundation (NOF), the International Society for Clinical
Densitometry (ISCD), the Endocrine Society, the American College of
Preventive
Medicine,
and
the
American
College
of
Physicians
(ACP)
recommends that men 65 years of age and older be screened for
osteoporosis.87 The USPSTF has determined that osteoporosis screening may
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reduce hip fractures in women; however, the review by Wu (2018) concluded
that the evidence for the effectiveness of osteoporosis screening was
mixed.87,88 Dual-energy x-ray absorptiometry (DXA) is the most commonly
used method of osteoporosis screening.87
Research: Vitamin D Deficiency and Osteoporosis
The authors of this case study focused on Vitamin D deficiency as the
most common nutritional deficiency for all age groups worldwide. They
reported on a 51-year-old woman who dressed routinely in a religious garment
with almost no exposure to sunlight for years, and she developed slowly
progressing weakness over a two year period involving the proximal limb
muscles, extreme fatigue, chest and lower spine pain, paresthesia,
depression, difficulties in walking and waddling gait.89
The patient had a health history that was negative for metabolic
syndrome. She was hospitalized and treated for fibromyalgia with the use of
NSAIDs, but without improvement of her clinical symptoms. Her social history
included married status with two healthy children and one child deceased from
leukemia.89
The physical examination of the patient in this case study revealed
demineralization of teeth and an unstable gait.89 Laboratory testing reports
showed her serum vitamin D3 level was extremely low at 3 ng/mL and
parathyroid hormone level was found to be very high at 423 pg/mL. The
patient was diagnosed with severe Vitamin D deficiency.89
Other diagnostic testing included inflammation markers and thyroid
hormones, which were normal. Antibodies for celiac disease returned
negative, and the patient’s renal and hepatic functions were normal.
electrocardiography (ECG) was normal. A whole-body bone scintigraphy
showed diffuse metabolic changes (chest ribs and knees bones), and a dualenergy X-ray absorptiometry scan (DXA) showed low body mass density and
severe osteoporosis in both femur region and L-spine. A lumbosacral
radiograph revealed biconcave vertebral bodies, characteristically called “fish
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vertebrae,” indicating osteomalacia, and upper anterior fracture of the 5th
lumbar vertebra. A gastroesophagoscopy was done and biopsies were done
that showed the patient had chronic gastroduodenitis. Thyroid and parathyroid
disease was ruled out by ultrasound, and the patient reported no signs or
symptoms of cardiovascular disease.89
In summary, the patient was diagnosed with a severe deficiency of
25(OH) vitamin D, high PTH, low calcium and high alkaline phosphatase.
Follow up of treatment was over a six month period. The treatment plan
addressed the patient’s “malabsorption of vitamin D due to gastrointestinal
lymphoplasmacytic inflammatory infiltrates.”89 The authors reported that
cholecalciferol (vitamin D3) 300,000 IU intramuscularly was administered
followed by vitamin D3 50,000 IU orally every week, along with calcium 1000
mg daily. She was provided dairy products for one month and this was
followed with 25,000 IU orally every week for another two months.
Appropriate sun exposure in daily bases was recommended and other
necessary treatment. Last three months, appropriate doses of Vitamin D were
ordered in oral tablets.89
The patient gained 3 kg and significant improvement in her walking, and
she denied pain and paresthesia, and depression. A DXA revealed normal
values on follow up. Treatment with the use of high doses of vitamin D and
calcium replacement led to improvement of osteomalacia and the patient’s
overall muscle/bone performance and gait improved with reduced pain level
continued following vitamin D treatment.89
The authors stated that cases for osteomalacia in individuals wearing a
religious garment and with insufficient exposure to sunlight have been
reported. In such cases, laboratory studies should include 25 (OH) vitamin D,
parathyroid hormone (PTH) level, calcium and alkaline phosphatase levels,
and DXA performance should be done, however, frequently these measures
are not done and vitamin D deficiency and corresponding complications go
undiagnosed. Women who wear concealing clothing are likely at increased risk
of vitamin D deficiency, poor bone status and muscle function.89
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Vitamin D Deficiency and Osteoporosis Quiz:
I.
The patient in this case study suffered from ____________ due to a
lack of exposure to the sun.
a.
b.
c.
d.
II.
metabolic syndrome
fibromyalgia
Vitamin D deficiency
All of the above
Diagnostic testing of this Vitamin D-deficient patient revealed
a.
b.
c.
d.
III.
abnormal renal hepatic function.
biconcave vertebral bodies (fish vertebrae) indicating osteomalacia.
the presence of antibodies for celiac disease.
abnormal hepatic function.
The patient in this study was diagnosed with
a.
b.
c.
d.
high levels of calcium.
low PTH.
a severe deficiency of 25(OH) vitamin D.
low alkaline phosphatase.
Discussion89
Malabsorption, inadequate exposure to sunlight, environmental factors
such as institutionalization can lead to vitamin D deficiency. Osteomalacia,
decreased mineralisation of newly formed osteoid (areas of bone turnover),
can be associated with symptoms of diffuse body aches and pain. The authors
raised the following health concerns related to vitamin D deficiency:89
●
Nearly 30-50% of all age groups are Vitamin D deficient worldwide.
●
Secondary hyperparathyroidism and osteomalacia can occur due to
severe, long-standing vitamin D deficiency.
●
Muscles weakness with difficulty in walking, and proximal myopathy.
The Institute of Medicine (IOM) has defined vitamin D deficiency as
25(OH)
vitamin
D
less
than
20
ng/mL.
As
mentioned,
secondary
hyperparathyroidism and osteomalacia can develop due to prolonged, severe
vitamin D deficiency. Clinicians should be aware of factors causing vitamin D
deficiency,
such
as
poor
sunlight
exposure,
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and
prolonged
use
of
85
anticonvulsants
and
corticoids,
and
nutritional
deficiency.
Intestinal
inflammation, celiac disease or gastric surgery can lead to malabsorption of
dietary nutrients.
The authors stated that vitamin D is important to immune system
function, cardiovascular health, oncogenesis, and cognitive functioning. They
referred to earlier studies that had reported a connection between
hypovitaminosis and poor muscle function in people, emphasizing the
importance of vitamin D to proper blood levels of calcium, phosphorus and
bone metabolism. When there is a chronically low 25(OH) or vitamin D status,
intestinal calcium and phosphorus absorption becomes reduced and the body
starts to increase secretion of parathyroid hormone. In secondary
hyperparathyroidism bone tissue becomes depleted of calcium, and also there
is increased phosphorus wasting affecting the kidneys. High increases of
parathyroid hormone and osteoclastic activity resulting from inadequate
calcium-phosphorus levels can lead to decreased bone mineral density (BMD),
osteopenia and osteoporosis. Other abnormal laboratory test findings can
include elevation of alkaline phosphatase (ALP) levels in the setting of
secondary hyperparathyroidism due to osteomalacia.
In children, vitamin D deficiency and an increased serum PTH level can
lead to soft bones (rickets), whereas in in adults bone turnover and bone loss
results in osteomalacia. Muscles weakness corresponds with difficulty walking,
increased falling and bone fracture risk. Generally, a vitamin D level below 30
nmol/l is associated with decreased muscle strength.
In the case of this female patient diagnosed with osteomalacia the
authors reported that vitamin D has an important role in muscle growth,
strength and gait, and low vitamin D “is always associated with a decrease in
muscle function and performance and an increase in disability. Progressive
difficulties in changing the body position, or rising from a chair followed with
diffuse muscle pain are all symptoms of myopathy from osteomalacia.”89 The
active form of vitamin D, calcitriol or 1, 25-dihydroxy vitamin D3 reportedly
has an effect on the muscle tissue that involves rapid influx of calcium into
the cell.
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Osteomalacia should be considered in a population of people wearing
religious garments, and in those with poor sunlight exposure. Laboratory
evaluations should involve 25(OH) vitamin D, PTH, calcium, alkaline
phosphatase and DXA testing to diagnose a potential vitamin D deficiency.
Vitamin D supplementation is needed for women who wear concealing clothes
to maintain a healthy vitamin D status and to avoid osteomalacia. In these
cases, treatment with high doses of vitamin D and calcium supplements is
recommended to avoid osteomalacia and myopathy.
Answers to Vitamin D Deficiency and Osteoporosis Quiz:
I.
The patient in this case study suffered from ____________ due to a
lack of exposure to the sun.
c. Vitamin D deficiency
“The patient had a health history that was negative for metabolic syndrome. She was
hospitalized and treated for fibromyalgia with the use of NSAIDs, but without improvement
of her clinical symptoms…. The patient was diagnosed with severe Vitamin D deficiency.”
II.
Diagnostic testing of this Vitamin D-deficient patient revealed
b. biconcave vertebral bodies (fish vertebrae) indicating osteomalacia.
“A whole-body bone scintigraphy showed diffuse metabolic changes (chest ribs and
knees bones), and a dual-energy X-ray absorptiometry scan (DXA) showed low body
mass density and severe osteoporosis in both femur region and L-spine. Lumbosacral
radiograph revealed biconcave vertebral bodies (fish vertebrae) indicating osteomalacia,
and upper anterior fracture of the 5th lumbar vertebra.”
III.
The patient in this study was diagnosed with
c. a severe deficiency of 25(OH) vitamin D
“In summary, the patient was diagnosed with a severe deficiency of 25(OH) vitamin D,
high PTH, low calcium and high alkaline phosphatase.”
Hepatitis B and Hepatitis C
This section addresses viral hepatitis, which affects people worldwide
and leads to a short-term condition or may develop into a chronic infection,
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which may be life-threatening. Common features of hepatitis B and hepatitis
C are discussed.
Hepatitis B
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 Centers
for
Disease
Control
and
Prevention
(CDC)
estimated
that
in
2016
approximately 862,000 Americans were chronically infected with the hepatitis
B virus.90 Factors that increase the risk of being infected with hepatitis B are
close, household contact with an infected person, healthcare workers who are
exposed to blood or blood-contaminated fluids, hemodialysis, infants of
mothers infected with hepatitis B, injection drug use, men who have sex with
men, and sexual contact with an infected person.90
People who have a chronic hepatitis B infection are typically
asymptomatic.91 A study (2019) found that 33.9% of Americans infected with
hepatitis B were unaware they had the virus.90
Early identification of hepatitis B can reduce the risk for virus
transmission and liver damage, and the CDC recommends screening the
following groups for hepatitis B by testing for the presence of hepatitis B
surface antigen (HBsAg), antibody to HBsAg [anti-HBs], and antibody to
hepatitis B core antigen:90
●
Persons born in countries with 2% or higher HBV prevalence
●
Men who have sex with men
●
Persons who inject drugs
●
HIV-positive persons
●
Household and sexual contacts of HBV-infected persons
●
Persons requiring immunosuppressive therapy
●
Persons with end-stage renal disease (including hemodialysis patients)
●
Blood and tissue donors
●
Persons with elevated alanine aminotransferase levels (>19 IU/L for
women and >30 IU/L for men)
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●
Pregnant women (HBsAg only is recommended)
●
Infants born to HBV-infected mothers (HBsAg and anti-HBs are only
recommended)
Hepatitis B screening accurately identifies pregnant women who are
infected and can prevent mother-to-child transmission.91 The USPSTF
recommends that at the first prenatal visit all pregnant women be screened
for hepatitis B.92 The vaccine for hepatitis is very effective, and the CDC
recommends hepatitis B vaccination in these groups/stuations.90
●
All infants
●
Unvaccinated children aged <19 years
●
People at risk for infection by sexual exposure
o Sex partners of hepatitis B surface antigen (HBsAg)–positive
persons
o
Sexually active people who are not in a long-term, mutually
monogamous relationship (e.g., persons with more than one sex
partner during the previous 6 months)
o
People seeking evaluation or treatment for a sexually transmitted
infection
o
●
Men who have sex with men
People at risk for infection by percutaneous or mucosal exposure to blood
o
Current or recent injection-drug users
o
Household contacts of people who are HBsAg-positive
o
Residents and staff of facilities for developmentally disabled
people
o
Health
care
and
public
safety
personnel
with
reasonably
anticipated risk for exposure to blood or blood-contaminated body
fluids
o
Hemodialysis patients and predialysis, peritoneal dialysis, and
home dialysis patients
o
People with diabetes aged 19–59 years; persons with diabetes
aged ≥60 years at the discretion of the treating clinician
●
International travelers to countries with high or intermediate levels of
endemic hepatitis B virus (HBV) infection (HBsAg prevalence of ≥2%)
●
People with hepatitis C virus infection
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●
People with chronic liver disease (including, but not limited to, persons
with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune
hepatitis,
and
an
alanine
aminotransferase
[ALT]
or
aspartate
aminotransferase [AST] level greater than twice the upper limit of normal)
●
People with HIV infection
●
People who are incarcerated
●
All other people seeking protection from HBV infection
Hepatitis C
Hepatitis C is a viral disease of the liver. Hepatitis C is transmitted by
contact with infected blood or body fluids, and there is a small risk of
transmission by sexual contact.93 As with hepatitis B, patients who have
chronic hepatitis C infection are almost always asymptmatic.93
The CDC estimated that in 2017 there were 44,300 new cases of
hepatitis C and that there are approximately 2.4 million Americans who are
chronically infected with hepatitis C.91 Risk factors for hepatitis C include:93
Blood transfusion or organ transplantation before 1992, hemodialysis, HIV
infection, infants born to infected mothers, injection drug use (current and
former), transfusion of clotting factors made prior to 1987, needle stick that
was contaminated with hepatitis C.
Some people exposed to hepatitis C will spontaneously clear the virus
but in 75-85% of acute infections, the hepatitis C infection becomes chronic.93
The CDC recommendations for hepatitis C screening include those listed
here:93
●
Anyone born from 1945 to 1965
●
Anyone who was transfused with clotting factors made before 1987
●
Anyone who received a blood transfusion or organ transplantation before
1992
●
Anyone
●
Chronic hemodialysis patients
●
Current and former IV drug users
●
Exposure to hepatitis C, e.g., a needle stick injury
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Hepatitis screening consists of blood tests for hepatitis C antibodies,
hepatitis C RNA, and hepatitis C viral load.93 Pregnant women should be
screened for hepatitis C during the first prenatal visit.94 Screening and early
detection of hepatitis C reduces the risk of liver damage and complications.95
There is no hepatitis C vaccine.
Research: Hepatitis C and mCGN
In the following PubMed study the authors discussed the case of a 47year-old Caucasian male with a history of HCV infection (genotype 3A),
hypertension and renal failure.96 Hepatitis C virus infection-associated
cryoglobulinemia is reportedly a common disease, and affects the kidney by
causing polyclonal cryoglobulinemic glomerulonephritis (pCGN); however, the
renal biopsy in this case revealed “cryoglobulinemic glomerulonephritis (CGN)
with monoclonal light chain restriction.”96 The authors highlighted the
importance of looking for monoclonal cryoglobulinemic glomerulonephritis
(mCGN) in the renal biopsies obtained from HCV-infected patients.96
The incidence of monoclonal cryoglobulinemic glomerulonephritis
(mCGN) was reviewed in this research study, which also highlighted the
importance of detecting monoclonality in the renal biopsies obtained from
HCV-infected patients. Monoclonal (type I) cryoglobulinemia accounts for
about 10-15% of total cryoglobulinemia cases. Also, mCGN is a very rare
diagnosis, and there are fewer than 50 cases reported so far in the literature.96
In this case, the patient was reportedly admitted with symptoms of
shortness of breath, dyspnea on exertion, lower extremity edema, abdominal
distention, and decreased urine output over a period of two months. His
physical examination revealed an elevated jugular venous pulse to 8-10 cm of
water, bibasilar crackles, an S3 gallop, bilateral lower extremity edema, and
hepatosplenomegaly. He was hypertensive and had a blood pressure of
183/111 mmHg. Laboratory tests revealed pancytopenia, hypoalbuminemia,
hypocomplementemia, cryoglobulinemia, elevated HCV PCR levels, an
elevated creatinine level, and an elevated rheumatoid factor level. Urine
microscopy revealed dysmorphic red blood cells (RBC) in addition to white
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blood cell (WBC) and RBC casts. He was also found to have nephrotic range
proteinuria (9.5 g in 24 hours).
Retroperitoneal ultrasound only showed a small volume of ascites, 14 cm
and
12 cm
sized
kidneys
with
no
hydronephrosis.
HCV-induced
cryoglobulinemia was suspected and a kidney biopsy was performed. The
renal biopsy revealed cryoglobulinemic glomerulonephritis with monoclonal
light chain (mCGN). Hepatosplenomegaly associated with retroperitoneal
para-aortic lymph node enlargement was detected by computed tomography
(CT) and a bone survey did not show lytic or blastic lesions. The patient’s bone
marrow however was biopsied and the results were consistent with low-grade
lymphoma (marginal zone lymphoma). Immunohistochemistry studies were
conducted and identified lymphoid cells as mostly PAX-5 and CD20 positive B
cells.
A diagnosis of marginal zone lymphoma was made, and the patient
started on a rituximab/dexamethasone-based regimen with improvement of
his renal function. The patient was diagnosed with mCGN (with type III MPGN
pattern) based on the following findings: “features of MPGN (type III),
intracapillary coagula of cryoglobulin (by LM), glomerular deposits of IgM with
Kappa restriction (by IF), and organized deposits of cryoglobulins (by EM).”96
During the course of his hospitalization, hematology and infectious disease
were consulted and planned a trial of direct acting antivirals at a later stage.
At the most recent follow-up, patient reportedly was continued on the
abovementioned therapy and was monitored by oncology closely.
HCV and mCGN Quiz:
I.
This case study highlights the importance of looking for
______________________ in an HCV-infected patient’s renal biopsy.
a.
b.
c.
d.
mCGN
blastic lesions
pCGN
PAX-5 and CD20 positive B cells
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II.
True or False: Monoclonal (type I) cryoglobulinemia accounts for most
of the total cryoglobulinemia cases.
a. True
b. False
III.
Which of the following findings was included as one of the reasons
this patient was diagnosed with mCGN?
a.
b.
c.
d.
Intracapillary coagula of cryoglobulin (by LM)
A high volume of ascites in the kidneys
The presence of hydronephrosis
The presence of lytic or blastic lesions
Discussion:96
The HCV-infected patient in this case was diagnosed with renal failure.
The patient underwent a renal biopsy that revealed cryoglobulinemic
glomerulonephritis with monoclonal light chain restriction (mCGN).96 The
importance of this case is that it raises awareness regarding the “possibility
of monoclonality in the biopsy of HCV-infected patients.”96
This case report also suggests that the incidence of mCGN among HCV
patients may be higher than previously thought since monoclonality can be
overlooked in biopsies.96 The importance of looking for mCGN on a renal
biopsy will help clinicians make an early diagnosis so that more effective
treatment and management of the disease may be implemented. This will help
contribute to a better patient outcome.
Answers to HCV and mCGN Quiz:
I.
This case study highlights the importance of looking for
______________________ in an HCV-infected patient’s renal biopsy.
a. mCGN
“The authors highlighted the importance of looking for monoclonality in the renal biopsies
obtained from HCV-infected patients.”
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II.
True or False: Monoclonal (type I) cryoglobulinemia accounts for most
of the total cryoglobulinemia cases.
b. False
“Monoclonal (type I) cryoglobulinemia accounts for about 10-15% of total cryoglobulinemia
cases.”
III.
Which of the following findings was included as one of the reasons this
patient was diagnosed with mCGN?
a. Intracapillary coagula of cryoglobulin (by LM)
“The patient was diagnosed with mCGN (with type III MPGN pattern) based on the
following findings: ‘features of MPGN (type III), intracapillary coagula of cryoglobulin (by
LM), glomerular deposits of IgM with Kappa restriction (by IF), and organized deposits of
cryoglobulins (by EM).’”
Human Immunodeficiency Virus
The human immunodeficiency virus (HIV) is primarily transmitted by
sexual contact and contact with contaminated blood. After the initial HIV
infection, approximately 5-6% of untreated patients each year progress to
autoimmune deficiency syndrome (AIDs) and for patients who do not, there
is a dormant period of up to 15 years.97 At that point viral replication increases
rapidly, HIV begins to cause serious, irreversible damage to the immune
system, and patients succumb to a wide variety of opportunistic infections
and/or cancer.
The CDC estimates that at the end of 2016 (The last time that accurate
statistics were available) 1.1 million Americans were infected with HIV and
approximately 14% did not know they were infected.98 Screening for HIV is
recommended for everyone between the ages of 13 and 65.99 Anyone who
has had contact with blood contaminated with HIV, e.g., a healthcare worker
who has a needle stick injury, should be tested for HIV.100 Also, anyone who
has recently had exposure - or a possible exposure – to HIV, e.g., unprotected
sex with someone who is infected with HIV should be tested. People who are
at high risk for HIV infection should be screened annually.99 High risk would
include IV drug users, anyone who has had unprotected sex with someone
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who is infected with HIV, men who have sex with men, anyone who has had
sex with more than one person since the last HIV test, anyone who has sex in
exchange for drugs or money, people who are infected with hepatitis or
tuberculosis or were treated for these diseases, and anyone who has been
diagnosed with or treated for a sexually transmitted disease.99,101
Screening for HIV is critically important. It decreases the risk for
transmission, especially given that many people are unaware they are
infected, and it allows for early treatment of HIV infection. Testing for HIV
after an acute exposure like a needle stick injury is critical because prompt
use of post-exposure prophylaxis (PEP) can significantly decrease the risk of
developing an HIV infection after an acute exposure.102 Screening for HIV is
typically done using a combination antibody-antigen test.101 There is no HIV
vaccine.
Research: A “Status Neutral” Approach to HIV
Major progress has been made in confronting the HIV epidemic but
these advances have been tempered by the reality that HIV continues to
spread.103 New models for prevention and treatment are urgently needed.103
In order to address this continuing spread of HIV, the authors proposed a
“status-neutral” strategy that engages people living with HIV and those at risk
of HIV in treatment and prevention, without regard to a person’s HIV status.
The authors stated that the paths end at a “common final state,” where
patients are engaged in clinical care, with either sustained viral load
suppression (VLS) or daily PrEP.103 The difference in the response to the risk
of HIV transmission or acquisition is negligible in this state.103
The program starts with HIV testing and “two divergent paths depending
on the results.”103 The authors of this research study introduced a new
approach they called “status neutral,” because it incorporated people living
with HIV and people at risk of HIV. This approach begins with an HIV test and
proposes two different paths of care depending on the patient’s test results:
a patient testing negative is placed in the group for “HIV Primary Prevention
Engagement;” and, a patient testing positive is placed in the group for “HIV
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Treatment Engagement.”103
Both paths end at a common final state, as
described above.
103
HIV Quiz:
I.
In a “status-neutral” approach for prevention and treatment of HIV,
the focus is on
a.
b.
c.
d.
II.
The “status-neutral” strategy tests patients for HIV and places patients
a.
b.
c.
d.
III.
people who are HIV positive only.
the focus is on those at risk so the spread of HIV may be controlled.
HIV status.
people living with HIV and those at risk of HIV infection are treated.
in “HIV Primary Prevention Engagement” regardless of test outcome.
in a “common final state” of HIV Treatment Engagement.
in “HIV Treatment Engagement” regardless of test outcome.
who test negative in “HIV Primary Prevention Engagement.”
The concept of “common final state” refers to the fact that, regardless
of their HIV status, patients are
a.
b.
c.
d.
treated with sustained viral load suppression (VLS).
engaged in clinical care.
treated with daily PrEP.
placed in HIV Primary Prevention Engagement.
Discussion:103
Healthcare is provided regardless of the patient’s HIV status, and
continuous care services is ongoing as the patient and provider remain
engaged in preventive care or treatment.
Key outcomes of this approach are that HIV testing is the ultimate
gateway to prevention and treatment. The same approaches used for
achieving viral load suppression for treatment are necessary and useful for
HIV prevention. People receiving prophylactic care are not distinguishable
from people receiving treatment for HIV, according to how the authors
explained this program approach. The authors stated that “Normalizing both
treatment and prevention serves to destigmatize both.”103 They also
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maintained that using a “status-neutral continuum” will help accomplish the
ultimate goal of eliminating new HIV infections.103
Answers to HIV Quiz:
I.
In a “status-neutral” approach for prevention and treatment of HIV,
the focus is on
d. people living with HIV and those at risk of HIV infection are treated.
“The authors considered a “status-neutral” strategy for both people living with HIV and
those at risk with a high priority on engagement regardless of a person’s HIV status.”
II.
The “status-neutral” strategy tests patients for HIV and places
patients
d. who test negative in “HIV Primary Prevention Engagement.”
“This approach begins with an HIV test and proposes two different paths of care
depending on the patient’s test results: a patient testing negative is placed in the group
for “HIV Primary Prevention Engagement;” and, a patient testing positive is placed in the
group for “HIV Treatment Engagement.”
III.
The concept of “common final state” refers to the fact that, regardless
of their HIV status, patients are
b. engaged in clinical care.
“... the authors proposed a “status-neutral” strategy that engages people … that the
paths end at a “common final state,” where patients are engaged in clinical care, with
either sustained viral load suppression (VLS) or daily PrEP.”
Illicit Drug and Prescription Drug Use
Use of illicit drugs, prescription medications, and alcohol is a growing
problem in the United States. The Substance Abuse and Mental Health
Services Administration estimated that in 2018 7.8% of all Americans, 19.3
million, had a substance use disorder.104 In 2016 almost 63,000 Americans
died from a drug overdose.105 The number of deaths in the United States from
acute overdose of opioids increased by 345% from 2001 to 2017.106
The USPSTF states that “... the current evidence is insufficient to assess
the balance of benefits and harms of primary care–based behavioral
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interventions to prevent or reduce illicit drug or non-medical pharmaceutical
use in children and adolescents.”21 Saitz (2018) recommends the use of a
single questioning screening to detect drug use, stating that single question
screening is as well validated for use in primary care as longer, more involved
questionnaires, and the author advised clinicians ask patients: “How many
times in the past year have you used an illegal drug or used a prescription
medication for non-medical reasons?”107
Research: Opioid Use in an Era of Medical Marijuana Dispensaries
The authors of this research reported on 2004 to 2014 U.S. National
Survey data, which focused on nonmedical prescription opioid use and the
change in prescription opioid use disorder (POUD) among users after medical
marijuana law enactment.108 They raised an interesting question: Could the
introduction of medicinal marijuana as a treatment for chronic pain reduce the
need for opioid use and prescriptions? If the answer to this question is yes,
medicinal marijuana could be a partial solution to the opioid crisis in the United
States.
The dates of enactment of medical marijuana laws vary from state to
state. In 1996, California was the first state to enact a medical marijuana law.
Rates of opioid use disorder (OUD) have increased and in 2016, 2 million
Americans met the criteria for OUD. There has also been an alarming increase
in opioid overdose deaths between 1999 and 2017 in the United States, as
reported by the authors: “An estimated 25 million US individuals aged 12
years and older initiated nonmedical use of prescription opioids (NMUPO)
between 2002 and 2011.”108
Research has partially attributed increases in POUD and opioid-related
deaths to increases in prescription opioids dispensed for chronic, noncancer
pain. Opioid prescribing increased from 1999 to 2010 and then decreased each
year through 2015. However, opioid prescriptions remain approximately 3
times higher than in 1999. This spike in prescription opioids has contributed
to 400,000 opioid overdose deaths in the United States between 1999 and
2017.”108
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Marijuana provides possible pain relief, which is viewed as an alternative
to prescription opioids, possibly lowering opioid use, nonmedical use, and
serious outcomes of opioid use disorder and mortality. The authors reported
that there is some evidence that medical marijuana laws (MMLs) may reduce
certain opioid-related outcomes. The MML status and prevalence of NMUPO at
a state-wide level was shown in some studies to correspond with a decreasing
trend in POUD treatment following the opening of state-wide medical
marijuana dispensaries. There was a significant limitation with these statistics
since individual data was not included. Without individualized data, the
authors stated, there was no direct proof that an individual’s reduction in
opioid use was due to marijuana use. There could be other factors leading to
the decline in POUD treatment. This study found that there was not adequate
support for the hypothesis that individual NMUPO and POUD are lower in states
with MMLs.108
Opioid Use and Medical Marijuana Quiz:
I.
Research has partially attributed increases in prescription opioid use
disorder (POUD) and opioid-related deaths to increases in
a.
b.
c.
d.
II.
Marijuana provides possible pain relief, which is viewed as an
alternative to prescription opioids, possibly lowering
a.
b.
c.
d.
III.
the number of states legalizing medicinal marijuana.
primary care–based behavioral interventions.
prescription opioids dispensed for chronic, noncancer pain.
illicit drug use in children and adolescents.
opioid use.
nonmedical use.
opioid use disorder and mortality.
All of the above
True or False: The authors stated that individual opioid use went down
as a result of marijuana use.
a. True
b. False
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Discussion108
The authors acknowledged that further studies were needed to answer
the important question of how medical marijuana laws and rise of dispensaries
influenced opioid use for pain control. If their results were confirmed, this
could suggest that medical marijuana laws may not be sufficient to reduce
“individual-level opioid outcomes.”108
The better approach may be opioid-specific interventions. There was
also no discussion regarding whether marijuana users may be more likely than
nonusers to misuse prescription opioids and to develop prescription opioid use
disorder.
Answers to Opioid Use and Medical Marijuana Quiz:
I.
Research has partially attributed increases in prescription opioid use
disorder (POUD) and opioid-related deaths to increases in
c. prescription opioids dispensed for chronic, noncancer pain.
“Research has partially attributed increases in POUD and opioid-related deaths to
increases in prescription opioids dispensed for chronic, noncancer pain.”
II.
Marijuana provides possible pain relief, which is viewed as an
alternative to prescription opioids, possibly lowering
a. opioid use.
b. nonmedical use.
c. opioid use disorder and mortality.
d. All of the above [correct answer]
“Marijuana provides possible pain relief, which is viewed as an alternative to prescription
opioids, possibly lowering opioid use, nonmedical use, and serious outcomes of opioid use
disorder and mortality.”
III.
True or False: The authors stated that individual opioid use went down
as a result of marijuana use.
b. False
“Without individualized data, the authors stated, there was no direct proof that an
individual’s reduction in opioid use was due to marijuana use.”
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Glaucoma
Glaucoma is the second leading causes of blindness.109 Approximately 3
million Americans have glaucoma110 and about 50% have not been
diagnosed.110 There several types of glaucoma and the most common, open
angle glaucoma, is a progressive disease. Patients typically have no symptoms
until the disease is quite advanced and glaucoma is discovered during an eye
examination. Risk factors for developing glaucoma include age, African
American ethnicity, diabetes, elevated intraocular pressure, family history,
hypertension, and lipid disorders.109,110
Vision loss from glaucoma can be prevented with early detection and
treatment.111 Periodic eye examinations can help slow vision loss, but there is
no universal agreement on who should be screened and how often.109,112 The
2014 USPSTF guidelines concluded that there was no conclusive evidence for
or against routine glaucoma screening.21 However, Zhao, et al. (2018)
concluded that that the USPSTF guidelines were based in part on studies with
insufficient patient follow up.111
Jacobs (2019) and the American Academy of Ophthalmology provided
recommendations for individuals with and without risk factors. For individuals
without risk factors, a comprehensive eye examination should be done every
5-10 years for patients < 40, every two to four years for patients 40-54 years
of age, every one to three years for patients 55 to 64 years of age, and every
one to two years for patients ≥ 65 years of age.109,112
Where risk factors exist, a comprehensive eye examination should be
done every 1 to 2 years in patients < 40 and ≥ 55 years of age, and every 1
to 3 years in patients aged 40 to 54 years.109 The American Academy of
Ophthalmology (2016) has stated that a comprehensive eye examination
should be done every one to two years in patients < 40 and ≥ 55 years of
age, every one to three years in patients aged 40 to 54 years, every one to
two years in patients aged 55-64, and every one to two years in patients ≥
65 years of age.112
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Diabetes:
For individuals diagnosed with type 1 diabetes, a comprehensive eye
examination should be done at five years from the time of diagnosis and then
annually. For type 2 diabetes, a comprehensive eye examination at the time
of diabetes should be done, and then annually.111
Research: Open-angle Glaucoma Case Study
The authors in this case study presented a 65-year-old phakic patient
with open-angle glaucoma and no previous filtration surgery.113 They reported
that patients with an intraocular lens (phakic) treated with high-intensity
focused ultrasound (HIFU) might be at risk of pupil ovalization with
accommodation loss.113
The authors reported that the complications observed in their patient
were unique and had not been previously reported, as far as they knew.113
They believed that the accommodation loss and pupillary ovalization were best
explained by the fact that the patient was phakic.113 The authors noted that
“the root of the iris, the ciliary body, and the zonula are functionally and
anatomically related structures.”113 Pupillary ovalization was observed as
“oblique in both eyes, with a major axis in the superior temporal-inferior nasal
direction.”113 In these two positions, 2 out of the 6 piezoelectric transducers
were activated in the treatment. This patient was the only phakic patient
treated with HIFU by the authors. The authors commented on the fact that
“most publications do not distinguish between phakic and pseudophakic
patients” and this distinction should be considered.113
After intervention, the patient presented with mild uveitis for 10 days,
which remitted with the application of topical cycloplegic and corticosteroid
treatment. After that, he reported a loss of near vision and examination
showed pupil ovalization. It persisted 6 months later, with an accommodation
loss of one diopter.113
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High-intensity focused ultrasound treatment applied in this study
consisted in the sequential activation of 6 miniaturized piezoelectric
transducers, activated for 8 seconds. The complications following the
procedure were accommodation loss and pupillary ovalization.113
Open-angle Glaucoma Quiz:
I.
The authors reported that patients with an intraocular lens (phakic)
treated with high-intensity focused ultrasound (HIFU)
a.
b.
c.
d.
II.
After the patient was treated in both eyes with high-intensity focused
ultrasound (HIFU), the patient presented with _______________
which remitted after treatment.
a.
b.
c.
d.
III.
may experience pupil ovalization with accommodation loss.
will have fully restored peripheral vision.
may experience pupil ovalization but with no optical loss.
may experience pupillary reflex but with no accommodation loss.
ovalization
mild uveitis
hypertension
presbyopia
The authors believed that the accommodation loss and pupillary
ovalization were best explained by the fact that the patient
a.
b.
c.
d.
was hypertensive.
was presbyopic.
was phakic.
had pupillary ovalization in one eye.
Discussion:113
The authors stated that the complications observed in this patient had
not been previously described in any literature. They concluded that the key
factor that explained the accommodation loss and pupillary ovalization was
the characteristic as a phakic patient. Mention was made of the fact that
clinicians do not distinguish between phakic and pseudophakic patients and
this distinction should be considered.113
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Because of the risk that phakic patients treated with HIFU might be at
risk of pupil ovalization with accommodation loss, the authors recommended
that this complication be included in the informed consent for patients with
glaucoma who are offered HIFU as a treatment optiions.113
Answers to Open-angle Glaucoma Quiz:
I.
The authors reported that patients with an intraocular lens (phakic)
treated with high-intensity focused ultrasound (HIFU)
a. may experience pupil ovalization with accommodation loss.
“They reported that patients with an intraocular lens (phakic) treated with high-intensity
focused ultrasound (HIFU) might be at risk of pupil ovalization with accommodation loss.”
II.
After the patient was treated in both eyes with high-intensity focused
ultrasound (HIFU), the patient presented with _______________
which remitted after treatment.
b. mild uveitis
“The patient was treated in both eyes with HIFU. After intervention, the patient presented
with mild uveitis for 10 days, which remitted with the application of topical cycloplegic and
corticosteroid treatment.”
III.
The authors believed that the accommodation loss and pupillary
ovalization were best explained by the fact that the patient
c. was phakic.
“They believed that the accommodation loss and pupillary ovalization were best explained
by the fact that the patient was phakic. The authors noted that ‘the root of the iris, ciliary
body, and the zonula are functionally and anatomically related structures.” Pupillary
ovalization was observed as ‘oblique in both eyes, with a major axis in the superior
temporal-inferior nasal direction.’”
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.114
Other
risk
factors
for
hearing
loss
are
diabetes,
genetic
susceptibility, exposure to loud noise, exposure to ototoxic drugs, and
recurrent ear infections.114,115
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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.21
Hearing loss in newborns and children is relatively common; 1-2 per
1000 newborns and 2 of 1000 children have some form of hearing loss.116
Common causes or risk factors for childhood hearing loss may include
congenital anomalies, infection, trauma, and the use of ototoxic drugs like
aminoglycosides and platinum antineoplastics.116 Hearing loss in the first few
years of life can cause delays in cognitive, language, and speech development,
so early identification of hearing impairment is critical.117
Hearing testing for newborns is mandatory in all 50 states.118 Specific
guidelines for newborn hearing screening for each state can be viewed on
link from the American Academy of Pediatrics.118
Research: Hearing Impairment
The authors presented a case study of a 26-year-old man who was
referred to an ear, nose and throat (ENT) clinic for hearing loss pain in the
right ear.119
The patient stated that his hearing normal prior to a wasp sting to his
ear. Hearing loss followed about 8 to 10 hours later. The patient had been
taken to an emergency department about 29 days earlier because of the
incident. At that time, the patient complained that he sensed the presence of
a foreign object in his right ear. After inspection by the emergency department
personnel, a foreign body was removed from the right ear that turned out to
be a wasp, Vespula vulgaris.
Inspection of the ear canal at the time of the patient’s evaluation at the
ENT clinic revealed “erythema above the right tympanic membrane and what
initially appeared to be a small perforation in the left upper quadrant of the
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right tympanic membrane.”119 Testing was performed confirming sudden
sensorineural hearing loss (SSNHL). The reaction to the wasp’s Hymenoptera
venom is believed to be an immunoglobulin E (IgE)-mediated allergy, or IgEmediated mechanism. The patient was prescribed oral steroids.
The patient was asked to schedule a follow-up evaluation within 14 days
but did not return for an evaluation until 42 days later. The patient advised
the ENT team that his condition had not improved. Testing revealed moderate
hearing loss with a slight improvement in the higher frequencies when
compared with the previous tests. An “intratympanic dexamethasone injection
was tried. Topical phenol was applied to the right tympanic membrane and
0.5 mL dexamethasone (4 mg/mL) was injected through the anesthetized
area.”119
At the patient’s follow-up visit 7 days later, the patient reported that his
hearing had returned. Upon evaluation, the ENT team observed “a pinhole
perforation to the right ear in the location of the intratympanic injection, but
the previously described perforation/monomeric/dimeric area in the left upper
quadrant had resolved.”119
Hearing Impairment Quiz:
I.
The patient in this case was diagnosed with a reaction to a possible
wasp sting to his inner ear and he was prescribed
a.
b.
c.
d.
II.
rest and observation.
pain medication.
oral steroids.
aspirin to reduce the inflammation.
When the oral steroids did not resolve the patient’s hearing loss, his
hearing returned after
a.
b.
c.
d.
an intratympanic dexamethasone injection.
oral steroids were readministered.
further rest and observation.
antihistamines were administered.
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III.
At the patient’s final, follow-up visit the medical team observed a
pinhole perforation to the right ear which was caused by
a.
b.
c.
d.
wasp sting.
the oral steroids.
the intratympanic injection procedure.
the patient’s use of a swab.
Discussion119
The exact mechanism for the patient’s SSNHL following the wasp sting
was not determined. The authors surmised it was possible that there was a
connection between the IgE levels (associated with the allergic reaction
induced by the Hymenoptera venom) and the development of SSNHL but
further studies are needed to confirm this association. Sudden sensorineural
hearing loss can have a number of causes. The most common cause is an
idiopathic (an unknown) mechanism.
Regardless of the mechanism, treatment involves the use of oral and
intratympanic steroid injections. One possible cause is an insect sting, as in
this case but a thorough history should be taken to rule out other causes.
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Answers to Hearing Impairment Quiz:
I.
The patient in this case was diagnosed with a reaction to a possible
wasp sting to his inner ear and he was prescribed
c. oral steroids.
“The reaction to the wasp’s Hymenoptera venom is believed to be an immunoglobulin E
(IgE)-mediated allergy, or IgE-mediated mechanism. The patient was prescribed oral
steroids.”
II.
When the oral steroids did not resolve the patient’s hearing loss, his
hearing returned after
a. an intratympanic dexamethasone injection.
“Testing revealed moderate hearing loss with a slight improvement in the higher
frequencies when compared with the previous tests. An ‘intratympanic dexamethasone
injection was tried. Topical phenol was applied to the right tympanic membrane and
0.5 mL dexamethasone (4 mg/mL) was injected through the anesthetized area.’”
III.
At the patient’s final, follow-up visit the medical team observed a
pinhole perforation to the right ear which was caused by
c. the intratympanic injection procedure.
“At the patient’s follow-up visit 7 days later, the patient reported that his hearing had
returned. Upon evaluation, the ENT team observed ‘a pinhole perforation to the right ear
in the location of the intratympanic injection, but the previously described
perforation/monomeric/dimeric area in the left upper quadrant had resolved.’”
Genitourinary Infections and Sexually Transmitted Diseases
Genitourinary infections and sexually transmitted diseases discussed in
this section are asymptomatic bacteriuria, chlamydial infection, gonorrhea,
and syphilis.
Asymptomatic Bacteriuria
Asymptomatic bacteriuria is defined as the presence of at least 105
colony forming units of bacteria per 1 mL of urine.120 Asymptomatic bacteriuria
has been reported to occur in 2%-7% of pregnant women.121 It can cause
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pyelonephritis, low birth weight, preterm birth, and increased infant
mortality.121,122
The USPSTF has published a draft statement about screening for
asymptomatic bacteriuria, and it recommends that all pregnant women should
be screened for asymptomatic bacteriuria with the use of a urine culture.123
Chlamydial Infection
Chlamydia trachomatis is bacteria that can cause many types of
infections, but it is most often a sexually transmitted disease.124 Chlamydia is
the most common sexually transmitted disease in the United States,and it can
be transmitted by anal, oral and vaginal sex. Most cases of sexually
transmitted chlamydia infections occur in adults aged 18-24.124,125 Twice as
many women as men develop chlamydia infections, and these infections can
cause chronic pelvic pain and infertility.125 Men infected with chlamydia can
develop urethritis, epididymitis, prostatitis.124 Chlamydia can also be
transmitted from mother child, and C. trachomatis infection in an infant can
cause conjunctivitis and/or pneumonia.126
Signs and symptoms of a sexually transmitted chlamydial infection may
include vaginal discharge and pain when urinating. However, chlamydial
infections may not cause signs and symptoms and given the consequences of
chlamydial infection, screening is recommended.21 Screening is done by
testing a urine sample or testing fluid obtained by swabbing an infected area.
The CDC recommendations for chlamydia screening include:127
●
Sexually active women < 25 years of age. Sexually active women 25 years
of age and older if there is increased risk: women who have a new sex
partner, more than one sex partner, a sex partner who has concurrent
partners, or a sex partner who has a sexually transmitted infection. Retest patients at three months post-treatment.
●
Pregnant women < 25 years of age. Pregnant women who are sexually
active, 25 years of age and older, and who have an increased risk. Retest
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during the 3rd trimester for women under 25 years of age or who have
increased risk.
●
Consider screening young men if there is high prevalence of infection or if
they are in a risk group, e.g., men who have sex with men. Men who have
sex with men should be tested at least once a year, and all possible
infection sites should be tested. If the patient has increased risk, test every
three to six months.
●
People who have HIV infection should be tested at the time of diagnosis
and at least once a year after that. More frequent testing should be done
if the patient has increased risk.
The USPSTF recommendations for chlamydia screening state that
sexually active women who are < 24 years and younger and older women who
are risk for chlamydial infection should be screened.21
Gonorrhea
Gonorrhea is a common sexually transmitted disease caused by
infection with 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. In 2017 there were 555,608
reported cases of gonorrhea in the United States.128 Gonorrhea is more
common in men than in women, most cases occur in adolescents and young
adults.128 Gonorrhea is more likely to occur in people who have multiple sex
partners, ethnic minorities, people who are substance abusers, and in people
who have had a gonococcal infection.129
Gonorrhea can cause chronic pelvic pain, ectopic pregnancy, pelvic
inflammatory disease, and tubal infertility.128 In men, gonorrhea can cause
epididymitis and urethritis.129 In addition, a gonococcal infection may increase
the risk of HIV transmission.128
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Many people who have gonorrhea are asymptomatic and given that
transmission of the bacterium is very effective, screening is essential.
Screening is done by testing a urine sample or testing fluid obtained by
swabbing an infected area. The CDC recommendations for gonorrhea
screening include the following groups of people.127
●
Sexually active women under 25 years of age. Re-test patients at three
months post-treatment.
●
Sexually active women 25 years of age and older if they are at increased
risk. Increased risk is: A new sex partner, more than one sex partner, a
sex partner with concurrent partners, or a sex partner who has an STI.
Additional risk factors for gonorrhea include inconsistent condom use
among persons who are not in mutually monogamous relationships,
previous or coexisting sexually transmitted infections, and exchanging sex
for money or drugs.
●
All pregnant women < 25 years of age, and older pregnant women if they
are at increased risk.
●
Men who have sex with men should be screened at least once a year, and
testing should be done at all body sites of sexual activity. Men who have
sex with men and have an increased risk should be tested every three to
six months.
●
People who have HIV infection should be tested at the time of diagnosis
and at least once a year after that. More frequent screening should be
considered based on the patient’s risk factors and the burden of HIV
infection in the area.
The USPSTF recommendations for gonorrhea screening in women state
that sexually active women who are < 24 years and younger and older women
who are risk for gonococcal infection should be screened.21
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Syphilis
Syphilis is a sexually transmitted disease caused by the Treponema
pallidum bacterium. Syphilis can be transmitted by anal, oral, or vaginal
intercourse, and less often by blood transfusion and organ transplantation,
nonsexual personal contact, and in utero transmission.130
In its early stages a syphilis infection does not cause dramatic or highly
specific signs or symptoms – primarily genital lesions and non-specific signs
and symptoms - but a late stage syphilis infection may cause severe
neurological complications.130 Vertical transmission can cause congenital
syphilis, and this has been associated with severe developmental,
musculoskeletal, and neurological morbidities and fetal death.131,132
There were 30,644 cases of syphilis in 2017, and most cases occurred
in men and in men who have sex with men. The CDC recommendations for
screening for syphilis state that the following groups should be screened:133
●
All pregnant women should be screened for syphilis at the first prenatal
visit.
●
If the patient has a high risk for syphilis, re-test early in the third trimester
and again at delivery.
●
Men who have sex with men should be screened at least once a year and
screened every three to six months if they are high risk.
●
People who have HIV infection should be tested at the time of diagnosis
and at least once a year after that. More frequent screening should be
considered based on the patient’s risk factors and the burden of HIV
infection in the area.
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Research: Antimicrobial-Resistant Neisseria Gonorrhoeae
In this article, the author reports that gonorrhea is extremely difficult to
control because the microbe, Neisseria gonorrhoeae, which causes gonorrhea,
“has developed resistance to all antimicrobials introduced for treatment of
gonorrhea
since
the
mid-1930s.”134
These
drugs
include
penicillins,
cephalosporins, tetracyclines and macrolides. What is striking is the decrease
in the susceptibility of the gonococcal cell to such a wide range of
antimicrobials, which have different modes of action.134
This is a global problem: Neisseria gonorrhoeae’s resistance to most
antimicrobials is high internationally.134 This can have serious consequences
since gonorrhea is a worldwide health issue that can result in severe
complications and disease. Gonorrhea also increases the spread of HIV. As a
result,
gonorrhea
causes
significant
morbidity
and
socioeconomic
consequences globally.134
The author notes that without an effective gonococcal vaccine,
gonorrhea can only be controlled using antimicrobial treatment after
infection.134 In most countries, “the only options for first-line empirical
antimicrobial
monotherapy
are
currently
the
extended-spectrum
cephalosporins (ESCs) cefixime (oral) and particularly the more potent
ceftriaxone (injectable).”134 Moreover, the last drug, ceftriaxone plus
azithromycin, is the recommended first-line treatment for gonorrhea in every
country, with the exception of Canada.134 While this treatment option is
relatively uniform, the dosing is not: the recommended doses of ceftriaxone
vary “from 250 mg × 1 (USA and Canada) to 1 g × 1 (Germany), and the doses
of azithromycin range from 1 g × 1 (USA, Canada, UK and Australia) to 2 g × 1
(Europe).”134
These first-line therapies have recently experienced failures.134 Most
alarming is the “sporadic treatment failures” of ceftriaxone reported in
Japan, Australia, Sweden, and Slovenia.134 This failure is critical because
ceftriaxone is the only option for “first-line monotherapy in many
countries.”134
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The reports of ceftriaxone treatment failures and the emergence of
“superbugs with high-level ceftriaxone resistance,” has led to a fear that
gonorrhea may become untreatable.134 This has prompted world health
organizations such as the U.S. Centers for Disease Control and Prevention to
publish response plans to address this threat.134 These international responses
to antibacterial-resistant strains of gonorrhea provide a more holistic action
plan: i.e., these plans attempt in varying degrees to improve prevention,
diagnosis, and treatment, and epidemiological surveillance of gonorrhea
cases.134
National and international monitoring of antibacterial- resistant strains
of gonorrhea is also crucial. This includes the need for better reporting of
treatment failures and local use or misuse of antimicrobial agents, which is
lacking in some regions.134
In light of the development of antibacterial-resistant strains of
gonorrhea, the author proposed the following:134
●
The reintroduction of “old” antimicrobials for future empirical monotherapy
of gonorrhea.
●
Novel affordable antimicrobials for monotherapy or at least inclusion in
new dual treatment regimens for gonorrhea are essential and several of
the recently developed antimicrobials deserve increased attention.
●
Now is certainly the right time to readdress the challenges of developing a
gonococcal vaccine.
Antimicrobial-Resistant Neisseria Gonorrhoeae Quiz:
I.
Currently, the most effective way to control gonorrhea is the use of
a.
b.
c.
d.
antimicrobial treatment after infection.
a gonococcal vaccine as a preventative measure.
penicillins.
macrolides.
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II.
The drug ceftriaxone is important in the treatment of gonorrhea
because it
a.
b.
c.
d.
III.
is the only drug that has not failed therapeutically.
remains effective against all gonococcal superbugs.
is the only option for first-line monotherapy in many countries.
is administered orally, making it readily accessible.
In light of the development of antibacterial-resistant strains of
gonorrhea, the author stated that
a.
b.
c.
d.
dual treatment regimens should be used in lieu of monotherapies.
it is time to work at developing a gonococcal vaccine.
“old” antimicrobials should be discarded.
a holistic approach to therapy is needed.
Discussion:134
The current antimicrobial therapy for the treatment of gonorrhea
(ceftriaxone 250 mg-1 g plus azithromycin 1–2 g remains effective but there
are reported failures. These outcomes make monitoring the use of
antimicrobial therapy crucial. More importantly, antimicrobial stewardship is
essential: the overuse or misuse of antimicrobial therapy will accelerate and
exacerbate antimicrobial-resistant Neisseria gonorrhoeae. Novel, affordable
antimicrobials for monotherapy or dual treatment regimens for gonorrhea are
essential.
Answers to Antimicrobial-Resistant Neisseria Gonorrhoeae Quiz:
I.
Currently, the most effective way to control gonorrhea is the use of
a. antimicrobial treatment after infection.
“The author notes that without an effective gonococcal vaccine, gonorrhea can only be
controlled using antimicrobial treatment after infection.”
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II.
The drug ceftriaxone is important in the treatment of gonorrhea
because it
c. is the only option for first-line monotherapy in many countries.
“These first-line therapies have recently experienced failures. Most alarming is the
‘poradic treatment failures’ of ceftriaxone reported in Japan, Australia, Sweden, and
Slovenia. This failure is critical because ceftriaxone is the only option for ‘first-line
monotherapy in many countries.’”
III.
In light of the development of antibacterial-resistant strains of
gonorrhea, the author stated that
b. it is time to work at developing a gonococcal vaccine.
“In light of the development of antibacterial-resistant strains of gonorrhea, the author
proposed the following: ... Now is certainly the right time to readdress the challenges of
developing a gonococcal vaccine.”
Iron Deficiency Anemia and Pregnancy
Anemia during pregnancy is defined as a hemoglobin level < 11 g/dL in
the first and third trimester and < 10.5 g/dL in the second trimester.135
Anemia during pregnancy is very common; the prevalence depends on the
population that has been studied and in economically distressed areas up to
90% of pregnant women have been found to be anemic.136 Iron deficiency
anemia accounts for 95% of all cases of anemia during pregnancy.137 When
undetected and uncorrected, iron deficiency anemia has been associated with
low
birth
weight,
premature
labor,
developmental
issues
and
other
morbidities.
138,139
Iron deficiency anemia during pregnancy is caused by increased
maternal iron requirements for red blood cell production, inadequate intake,
and growth of the fetus and placenta.139 Iron deficiency anemia during
pregnancy is easily treated, but it often goes undetected.139 However,
screening is a somewhat controversial topic.140,-142
The USPSTF and the International Federation of Gynecology and
Obstetrics (FIGO) state that the current evidence is insufficient to determine
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whether the benefits of screening for iron deficiency in pregnant women
outweigh the harm associated with screening.140,141 The USPSTF specifically
stated that “... the current evidence is insufficient to assess the balance of
benefits and harms of screening for iron deficiency anemia in pregnant women
to prevent adverse maternal health and birth outcomes.”141 The International
Federation of Gynecology and Obstetrics also noted: “Although iron deficiency
in pregnancy is, in principle, identifiable, treatable, and possibly preventable,
there is uncertainty about its significance as a clinical and public health
problem, and whether systematic screening and treatment for iron deficiency
and iron deficiency anemia in pregnancy would improve maternal and infant
outcomes.”140 Some practitioners recommend screening but even supporters
of screening for iron deficiency anemia admit that “... the data do not
definitively demonstrate a cause-and-effect relationship between iron
deficiency and adverse outcomes or between iron supplementation and
improved outcomes.”142
Research: Intravenous Iron for Iron Deficiency Anemia
The authors of this study were located through a PubMed search and
focus on the use of intravenous infusions of iron to treat iron deficiency anemia
during pregnancy.143 Neonatal iron deficiency is common and occurs at an
estimated rate as high as 45% despite oral iron supplementation. Anemia
during pregnancy varies between 8% and 20%, depending on the economic
status of a worldwide region. The authors stated that in India and Pakistan
there were some regions reporting up to 90% incidence rate.143 The authors
stated that the Centers for Disease Control and Prevention (CDC), American
College of Obstetricians and Gynecologists (ACOG) and the United States
Preventive Service Task Force (USPSTF) all recommend routine screening for
anemia during pregnancy; additionally, the CDC and ACOG has recommended
low-dose iron supplementation for all pregnant women. A recent USPSTF
publication supported these guidelines; however, this publication also noted
that “there is insufficient evidence that routine prenatal screening and
supplementation for iron deficiency anemia improves maternal or infant
clinical health outcomes.”143 The publication added that supplementation may
improve maternal hematologic indices.143
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Although there is a lack of published outcome data, published evidence
suggests more work needs to be done on the existing recommendations.
Moreover, screening for anemia alone is insufficient to diagnose iron
deficiency.143 Current guidelines do not recommend routine screening for iron
deficiency in newborns or routine prenatal screening and supplementation for
iron deficiency in the absence of anemia.143 The incidence of iron deficiency
anemia is associated with adverse maternal and fetal health. Maternal
mortality, preterm labor and low birth weight are amongst the health risks
associated with iron deficiency anemia during pregnancy: during pregnancy
there is a reported two-fold increase incidence of preterm labor and a threefold increase in the incidence of low birth weight in pregnancy cases involving
iron deficiency. In addition, iron deficiency in neonates “is associated with a
statistically significant increment in cognitive and behavioral abnormalities
which persist after iron repletion.”143
Oral iron supplementation is the frontline standard. It is inexpensive and
readily available but oral ingestion is associated with poor absorption and
efficacy. It is also associated with an unacceptably high incidence of
gastrointestinal adverse events leading to poor adherence.143 Intravenous iron
has been reported as safe and effective during the second and third trimesters
of pregnancy, and is the preferred route for an intolerance of oral iron or in
situations where oral iron is ineffective or harmful.143 For severe anemia (< 8
g/dL) in the second or third trimester, intravenous iron is preferred when iron
quantities delivered to the fetus is believed to suffer, as iron requirements
increase during every trimester of a woman’s pregnancy.143
Iron Deficiency Anemia Quiz:
I.
According to the authors, neonatal iron deficiency treated with oral
iron supplementation is
a.
b.
c.
d.
safe and effective in 90% of cases.
more effective than intravenous iron supplementation.
associated with poor absorption and efficacy.
not utilized during the second and third trimesters.
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II.
True or False: The USPSTF found that there is insufficient evidence that
routine prenatal screening and supplementation for iron deficiency
anemia improves maternal or infant clinical health outcomes.
a. True
b. False
III.
Intravenous iron is the preferred route for administration of an iron
supplement
a.
b.
c.
d.
because it is less expensive than oral supplements.
for patients who cannot tolerate oral iron supplements.
during the first trimester only.
because oral supplements do not reach the fetus.
Discussion:143
The authors stated that the guidelines for maternal and neonatal
screening and treatment lack consistency and differ between the United States
and Europe. Intravenous iron is “underutilized in pregnancy and guidelines
suggesting there is insufficient evidence to recommend the routine screening
and treatment of iron deficiency in gravidas should be revisited.”143 The
authors suggested that in low-income countries there could be a trial to test
the “efficacy, safety, cost and feasibility of the administration of intravenous
iron to anemic and/or iron-deficient women.”143
The authors concluded that clinicians are slow to include intravenous
iron into the screening and prevention treatment for iron deficiency during
pregnancy. A reason for this clinical gap in clinical practice may be due to the
fact that “no intravenous iron formulation has been assigned the highest
safety rating from FDA…”143 They suggest the lack of FDA endorsement may
actually be a discouragement to obstetricians who possibly struggle in a
litigious environment. Minor infusion reactions in the case studies may also
further delay the use of parenteral iron formulations despite the fact most are
very safe.
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The
authors
recommended
that
clinicians
revisit
the
current
international guidelines for the screening and treatment of anemia during
pregnancy, and provided the following suggested steps:143
●
All newly diagnosed gravidas, irrespective of hemoglobin level at
presentation to their obstetricians, midwives or other providers, be
screened for iron deficiency to include serum iron, total iron binding
capacity, percent transferrin saturation and serum ferritin.
●
If iron deficiency is present in the first trimester one ferrous sulfate tablet
every other day should be taken. These recommendations may not be
practical for much of the world’s pregnant woman with limited health care
budgets, however the potential improved outcomes may prove cost
effective.
●
If iron deficiency is diagnosed in the second trimester, the hemoglobin is
greater than 8 g/dL and the mother’s serum ferritin is greater than 15
ng/ml, one ferrous sulfate tablet every other day should be taken with a
rapid switch to intravenous iron if the therapy proves ineffective or is
poorly tolerated. If the hemoglobin level is less than 8 g/dL or the mother’s
serum ferritin is less than 15 ng/ml, the intravenous route is preferable.
●
Neonates at risk for iron deficiency should be screened at birth. These
include preterm infants, infants of diabetic mothers, infants born to anemic
or iron deficient mothers, those with parasitic infestation or malaria, HIV,
and those who had chronic hypoxia in utero (infants of smokers).
●
In low income countries, a trial or demonstration project to test efficacy,
safety, cost and feasibility of the routine administration of intravenous iron
appears prudent.
●
Intravenous iron is the preferred route of replacement if required, in the
third trimester.
●
A prospective comparison of oral to intravenous iron with screening of
neonates appears prudent.
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Answers to Iron Deficiency Anemia Quiz:
I.
According to the authors, neonatal iron deficiency treated with oral
iron supplementation is
c. associated with poor absorption and efficacy.
“Oral iron supplementation is the frontline standard. It is inexpensive and readily
available but oral ingestion is associated with poor absorption and efficacy…. Intravenous
iron has been reported as safe and effective during the second and third trimesters of
pregnancy, and is the preferred route for an intolerance of oral iron or in situations
where oral iron is ineffective or harmful.”
II.
True or False: The USPSTF found that there is insufficient evidence
that routine prenatal screening and supplementation for iron
deficiency anemia improves maternal or infant clinical health
outcomes.
a. True
“A recent USPSTF publication supported these guidelines; however, this publication also
noted that ‘there is insufficient evidence that routine prenatal screening and
supplementation for iron deficiency anemia improves maternal or infant clinical health
outcomes.’”
III.
Intravenous iron is the preferred route for administration of an iron
supplement
b. for patients who cannot tolerate oral iron supplements.
“Intravenous iron has been reported as safe and effective during the second and third
trimesters of pregnancy, and is the preferred route for an intolerance of oral iron or in
situations where oral iron is ineffective or harmful. For severe anemia (< 8 g/dL) in the
second or third trimester, intravenous iron is preferred when iron quantities delivered to
the fetus is believed to suffer, as iron requirements increase during every trimester of a
woman’s pregnancy.”
Major Depression
Major depression is the most common psychiatric disorder.144 The
lifetime prevalence of depression has been estimated to be between 6.8 to
8.7%.145 In 2017, an estimated 17.3 million American adults and 3.2 million
adolescents reportedly had a major depressive disorder.146 Risk factors for
depression may include adverse life experiences, family history of depression,
female gender, major illness, certain medications, and substance abuse.147,148
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Depression is the most important risk factor for suicide.149 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
those outlined here.148
●
Depressed mood most of the day, nearly every day. The depressed mood
can be subjective (for example, 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. (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 are generally known to cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning. Further, major depression is suspected when 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
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other specified and unspecified schizophrenia spectrum and other psychotic
disorders and there has never been a manic episode or a hypomanic episode.
Many people who have major depression are not identified.144 Screening can
identify people who are depressed, and screening and there is evidence that
early treatment can improve the response rate to treatment and improve
outcomes.144,150 The USPSTF recommendations for depression screening state
that depression screening should be done in the general population, including
pregnant and postpartum women. Depression screening should be done with
adequate systems in place “... to ensure accurate diagnosis, effective
treatment, and appropriate follow-up.”150
There is evidence that screening improves identification of people who
are depressed, and identification and use of therapies for depression improves
clinical outcomes and decreases clinical morbidity. The optimal timing and
optimal interval for screening for depression is not known. Short depression
screening questionnaires that have been validated and have good sensitivity
and specificity are available, such as the:144,150
●
Beck Depression Inventory for Primary Care (BDI-PC)
●
Patient Health Questionnaires (PHQ-2 and PHQ-9)
●
World Health Organization Well-Being Index (WHO-5) There is no
significant
difference
between
these
questionnaires
in
terms
of
performance.
144
The prevalence of depression in children ages 3 to 5 has been estimated
to be 0.5%; in children aged 6 to 11 1.4%, and in adolescents aged 12 to 17,
3.5%.151 The USPSTF recommends screening for major depressive disorder in
adolescents aged 12 to 18 years.151 Screening should be implemented with
adequate systems in place to ensure accurate diagnosis, effective treatment,
and appropriate follow-up.152
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PHQ-9 SCREENING TOOL
Over the last 2 weeks, how often have you been bothered by any of the
following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself, or that you are a failure, or have let yourself
or your family down.
7. Trouble concentrating on things, such as reading the newspaper or
watching television.
8. 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.
9. 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
Research: Comorbid Major Depression and PTSD
The authors of this case study reported on an unusual case of a 36year-old female with major depression and a history of post-traumatic stress
disorder (PTSD) who had a remission of symptoms following treatment.153 The
patient also had co-occurring adrenal insufficiency diagnosed by an insulin
tolerance test (ITT). The authors reported that the patient experienced
remission PTSD symptoms following a hypoglycemic episode with intravenous
short-acting insulin.153
The patient’s social status was married, with no children. She had
completed university and worked as a lawyer. Her primary psychiatric
symptoms included depression, low motivation, insomnia, and feelings of
worthlessness. She was diagnosed with major depressive disorder (MDD) and
was started on escitalopram 20 mg daily.153
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After 5 weeks of treatment the patient showed no signs of improvement.
Paroxetine 60 mg daily was started for depressed mood and trazodone 150 mg
at bedtime for insomnia, which led to a marked improvement of the patient’s
symptoms after 6 weeks; however, the patient continued to have difficulty
starting activities.153 Later, the patient was diagnosed with Hashimoto
autoimmune thyroiditis. Levothyroxine 75 mg daily was believed to help with
remission of depressive symptoms and the patient was diagnosed with mood
disorder secondary to hypothyroidism with a major depressive-like episode.153
In the following year the patient became pregnant. Multiple birth defects
of the fetus were diagnosed by ultrasound, and fetal demise transpired in week
16 of the pregnancy. The patient developed psychiatric symptoms of intense
fear and helplessness, and eventually sought help for unremitting depression,
poor motivation, insomnia, and feelings of worthlessness. The patient began
to have dreams of the trauma related to losing her child and the perception
that the event was recurring; however, she had poor memory of details related
to the trauma. When efforts were made to discuss the loss of her child, the
patient became withdrawn and defiant. She had symptoms of irritability, angry
outbursts, difficulty concentrating, and hypervigilance. She was unable to
function socially at home or work. Major depression in the context of acute
PTSD was diagnosed.153
Paroxetine 20 mg daily and trazodone 75 mg at bedtime were prescribed
since they had worked for depression in the past and were also indicated for
PTSD. After 5 weeks of treatment there was not much improvement.
Paroxetine was increased up to 60 mg/day and trazodone increased up to
150 mg daily at bedtime. Sleep dysfunction was described as delayed onset of
sleep at nighttime, frequent waking periods during the night, and the patient
reportedly showed high irritability, as well as multiple outbursts of anger and
anxiety. Trazodone was increased to 200 mg at bedtime and diazepam 5 mg
twice daily was added.153
Medically, the patient lost 10% of her initial body weight over a month,
and had a body mass index (BMI) 19 kg/m2. Physical symptoms were
described
as
general
weakness,
dizziness
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fainting,
episodes
of
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hyperventilation and paresthesia. She experienced dehydration and
hypotension of 100/60 mmHg at rest with orthostatic hypotension. Serum
adrenocorticotropin (ACTH) and cortisol levels drawn in the morning as an
outpatient showed slightly decreased levels (ACTH = 6.00 pg/ml; cortisol =
4.90 ng/ml), and the patient was diagnosed with suspected adrenal
insufficiency.
The authors stated that “In order to assess the ACTH/cortisol axis for
detecting secondary adrenal insufficiency, a standard ITT was performed….
Symptomatic hypoglycemia, with blood glucose values below 40 mg/dl, was
required to evoke a reliable central stress response with the activation of the
hypothalamic–pituitary–adrenal (HPA) axis. Intravenous insulin was
administered (0.1 units/kg; 6j aspart insulin). Symptomatic hypoglycemia,
with blood glucose values of 29 mg/dl within 30 min of the test, was achieved.
The patient experienced mild palpitations, massive hot flushes, and sweating,
which disappeared within several minutes of the procedure. The results of the
test excluded any abnormalities of the ACTH/cortisol and growth hormone
secretion.”153
The induction of a “hypoglycemic episode with intravenous short-acting
insulin was temporarily connected to improvement of PTSD symptoms in PTSD
and MDD comorbidity.”153 This result demonstrated “the mutual dependencies
between the endocrine and nervous systems, covered extensively by
psychoneuroendocrinology.”153
Psychiatry consultation followed the patient’s treatment, and the
psychiatrist reported a marked improvement of the patient’s mental status.
The patient showed less PTSD symptoms, “arousal diminished, sleep was
normalized, and bouts of anxiety became much less frequent and less
severe.”153 Memory improved for the patient and she was able to recall
traumatic events, and recurrent distressing dreams since the trauma event
reportedly
disappeared.
The
symptoms
of
MDD
continued,
including
depressed mood, decreased interest, and feelings of worthlessness. Diazepam
was tapered over 10 days and stopped.153
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The patient’s MDD symptoms continued to gradually lessen. Trazodone
was lowered to 100 mg at bedtime (from 200 mg at bedtime), and paroxetine
reduced to 40 mg daily from 60 mg daily. Within 14 months following the
insulin tolerance test, the patient remained in remission from depressive
symptoms and was planning a pregnancy.153
The authors postulated that the patient’s symptoms of depression were
a result of metabolic issues that improved with intravenous insulin-induced
hypoglycemia. The patient was able to experience excitation due to the “effect
of insulin on the central nervous system, the impact of hypoglycemia on the
release of aspartate and glutamate, and transiently GABA.”153 Lower GABA
levels seen in PTSD has typically been treated with benzodiazepines.153
Major Depression and PTSD Quiz:
I.
In this study, the patient’s improved PTSD symptoms and MDD
comorbidity were attributed to
a.
b.
c.
d.
II.
cessation of the drug trazodone.
the administration of paroxetine and trazodone.
treatment for insulin resistance syndrome.
the induction of a hypoglycemic episode with intravenous short-acting
insulin.
The authors postulated that the patient’s symptoms of depression were
a result of ____________ that improved with intravenous insulininduced hypoglycemia.
a.
b.
c.
d.
insulin resistance syndrome
metabolic issues
hyperglycemia
hypertension
Discussion:153
A review of the literature included statistics showing that an estimated
52% of patients diagnosed with PTSD develop a co-occurring condition of
major
depressive
disorder
(MDD).
Symptoms
can
include
cognitive
impairment, resistance to antidepressant medications, and increased risk of
suicide in comparison to individuals diagnosed with PTSD alone.
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Differences between people with PTSD and MDD and those with PTSD
alone have been determined through the use of neuroimaging studies:153
●
Medial prefrontal cortex and amygdala activation by threatening stimuli
are lower in the PTSD/MDD group than in those diagnosed with PTSD
alone.
●
People with PTSD/MDD exhibit a lower functional connectivity between the
insula and hippocampus when compared to those with PTSD alone.
●
It may be hypothesized that PTSD and MDD comorbidity can represent a
subtype of PTSD.
●
There is an approximate 60% response rate of PTSD symptoms to FDA
approved pharmacological treatment.
●
Prognosis PTSD and MDD co-occurrence in people is less than for those
diagnosed with MDD or PTSD alone.
●
Treatment dropout rates for people diagnosed with PTSD/MDD are more
common. Therefore, optimal drug therapy is necessary to ensure patient
retention and treatment success.
The authors reported on a case of insulin tolerance testing that resulted
in hypoglycemia, and consequently resolution of the patient’s PTSD
symptoms. Mention was made of Manfred Sakel, an Austrian psychiatrist, who
used insulin to help decrease anxiety and agitation in patients during opioid
withdrawal. Insulin shock therapy was originally used to treat schizophrenia
and later it was used for depressive disorders. This procedure had not been
scientifically determined.153
The HPA response axis in patients with PTSD/MDD are similar to those
with PTSD alone. Patients with PTSD/MDD typically have lower peripheral
cortisol levels with enhanced glucocorticoid receptor (GR) sensitivity, whereas
patients with PTSD “have an exaggerated cortisol suppression response to
dexamethasone (DEX), which indicates that the negative-feedback system of
the HPA axis is overly sensitive.”153 Intranasal insulin prior to a psychosocial
stressor reportedly can diminish saliva and plasma cortisol in healthy people
without affecting heart rate or blood pressure stress, which indicates that
insulin blunts the stress-induced HPA axis response. In this case report, an
induced
hypoglycemic
episode
with
intravenous
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insulin
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corresponded with improvement of PTSD symptoms in a female with PTSD
and MDD comorbidity.
The authors highlighted the mutual dependencies between the
endocrine and nervous systems that is an ongoing area of research by
neuroendocrinologists.153
Answers to Major Depression and PTSD Quiz:
I.
In this study, the patient’s improved PTSD symptoms and MDD
comorbidity were attributed to
d. the induction of a hypoglycemic episode with intravenous short-acting
insulin.
“The induction of a ‘hypoglycemic episode with intravenous short-acting insulin was
temporarily connected to improvement of PTSD symptoms in PTSD and MDD
comorbidity.’ This result demonstrated “the mutual dependencies between the endocrine
and nervous systems, covered extensively by psychoneuroendocrinology.”
II.
The authors in this case study postulated that the patient’s symptoms
of depression were a result of ______________ that improved with
intravenous insulin-induced hypoglycemia.
b. metabolic issues
“The authors postulated that the patient’s symptoms of depression were a result of
metabolic issues that improved with intravenous insulin-induced hypoglycemia.”
Screening for Newborns, Children and Adolescents
This section focuses on key areas of screening and treatment of youth
in the prevention literature, including congenital hypothyroidism, obesity,
phenylketonuria, sickle cell disease and visual impairment.
Congenital Hypothyroidism
Normal functioning of the thyroid gland is essential for cognitive,
neurological, and physical development.154 Congenital hypothyroidism occurs
in
1:2000
to
1:4000
births, and
undetected,
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hypothyroidism can lead to growth deficiency as well as severe mental
retardation.154-156 It is one of the most common preventable causes of
intellectual disability, and there is an inverse level between time of initiation
of treatment and intelligence quotient.156
Congenital hypothyroidism is primarily caused by a disruption in the
development of the thyroid gland, and it is easily detected and treated.154-156
Screening for congenital hypothyroidism is mandatory in the United States.
The infant’s blood is tested one to two days after birth.156 The blood is tested
for T3, T4, thyroid stimulating hormone (TSH) levels. Different approaches to
the use of these tests have recommended and the decision as to which to use
should be done on a case by case basis.156 False negative and positive results
can occur, and clinicians should be aware of any situation that can affect the
accuracy and sensitivity of screening.156
Obesity
The prevalence of obesity in children and adolescents in the United
States
has
been
adolescents.
157
estimated
to
be
18.5%/13.7
million
children
and
More than one-third of children and adolescents are
overweight.158
The adverse health effects of obesity in adults are well known, and obese
children have a high risk and an increased risk of developing dyslipidemia,
hypertension, non-alcoholic fatty liver disease, obstructive sleep apnea, type
2 diabetes, and other diseases.159,160
The USPSTF recommendations are obesity screening in children and
adolescents state that children 6 years of age and older should be screened
for obesity using measurement of BMI. The USPSTF concluded that screening
and interventions can improve weight status.158
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Phenylketonuria
Phenylketonuria is a rare genetic disease that causes an inability, in
varying degrees, to metabolize the amino acid phenylalanine.161,162 Elevated
phenylalanine
levels
can
cause
serious
neurological
and
psychiatric
morbidities like attention deficits, anxiety, irreversible intellectual disability,
mood disorders, and seizures.161,162 The incidence of phenylketonuria has
been estimated to be 1 in 10,000 live births.161
All infants should be screened for PKU.161 In all 50 states, PKU screening
is mandatory and is done by measuring serum phenylalanine level, usually by
tandem mass spectrometry.162
Sickle Cell Disease
Sickle cell disease is an inherited hematologic disorder. People who have
sickle cell disease have an abnormal, inherited hemoglobin called hemoglobin
S. When hemoglobin S binds to oxygen, red blood cells form an abnormal
shape (the sickle shape) and result in hemolysis. Hemolysis causes an anemia
that deprives the tissues of oxygen and blocks blood vessels.163,164 Sickle cell
disease primarily affects African Americans, and approximately 1 in every 365
African Americans has the disease.164
All newborns should be screened for sickle cell disease.163 Screening
provides early recognition of the disease and early intervention, and the latter
can reduce morbidities and decrease mortality rate.166.167
Visual Impairment in Children Ages 3 to 5: Amblyopia
Amblyopia is defined as a functional reduction in visual acuity that is
caused by abnormal visual development during childhood.168,169 Amblyopia is
the most common cause of monocular visual impairment in children,168 with a
reported prevalence of 1%-4%.169,170 Amblyopia develops during a critical
period of three months to eight years when the vision is maturing. Risk factors
for amblyopia include having a first-degree relative with amblyopia,
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neurodevelopmental delay, premature birth, and small size in relation to
gestational age, strabismus, and anisometropia.169-171 Amblyopia affects boys
and girls equally.169
Screening for amblyopia is recommended by the American Academy of
Pediatrics, the American Academy of Family Physicians, and the USPSTF.169,171
Early detection of amblyopia and early treatment improves the chances of
normal visual development and can reduce the severity of amblyopia.169,171
Untreated amblyopia is not likely to resolve spontaneously,
149
and amblyopia
can increase the risk of vision abnormalities and/or vision loss in the
unaffected eye.171
The USPSTF recommendations for amblyopia screening state that
children from 3 to 5 years old should be screened for amblyopia and amblyopia
risk factors at least once.171
Children who are preverbal are screened by using the fixation reflex test
or the objection to occlusion test.171 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 numbers, viewed from 20 feet away) or by
using Allen figure cards.171
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.
Research: Amblyopia in Children
The authors of this study reported that amblyopia (blunted sight) is a
common condition affecting 2-3% of the population, and involves a unilateral
or bilateral decrease in vision where no cause exists.172
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People affected by amblyopia experience reduced visual acuity, the
phenomenon of crowding, presence of a central suppression scotoma, and
impairment of binocular vision. The authors stated that first-line treatment
involves “correction of any existing significant refractive error for at least
18 weeks (refractive adaptation) but full resolution only occurs in about 30%.”
If amblyopia persists, treatment will include patching, or more recently,
penalisation. Wearing patches can be uncomfortable and compliance tends to
vary. There have been reports of bullying against children who wear patches.
With patching, the normal eye is covered up to help improve the vision
in the amblyopic eye; however, it can also lead to reduced vision in the
patched eye. The authors reported on an alternative treatment using a
strategy based on dichoptic stimulation. They defined dichoptic stimulation as
“the ability to present different images to each eye independently. For
example, one could present the sprite (a sprite is a computer graphic which
may be moved on-screen and otherwise manipulated as a single entity and
here refers to a gaming object of interest) to one eye and objects to collect to
the other eye thereby forcing both eyes to work together in order to
successfully play the game.”172
A number of early devices had been developed to treat amblyopia:
1) Priestly-Smith’s fusion tubes, 2) Worth’s amblyoscope, and 3) Maddox
developed the major amblyoscope, or synoptophore (in the 1930s). The
synoptophore was developed with the notion of dichoptic stimulation for
therapeutic benefit. However, the interest of participants typically did not last
more than a few minutes and little therapeutic effect was realized.
Currently, rapid advances in stereo-viewing technology has led to easily
adapted dichoptic stimulation. This new technology involves a virtual realitybased system to treat amblyopia using dichoptic stimulation, either playing
special video games or watching DVDs (Interactive Binocular Treatment or IBIT). The authors stated that the I-BiT™ system “can improve the visual acuity
in amblyopic patients. The most recent of these pilot studies using shutterglasses technology showed that all patients who completed their planned
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treatment (nine of the 10 patients) showed a mean improvement in visual
acuity of 0.18 LogMAR.”172
The I-BiT™ system was originally designed for treating patients under
supervision in a hospital-based setting. The authors reported on an I-BiT
system for home use combined with an eye-tracker. This method allows for
dichoptic stimulation and harmonious retinal presentation with the use of
visual material that engages a child long enough for treatment. Their target
study participants included children ages 3.5 to 12 years with anisometropic,
mixed and strabismic amblyopia. They aimed to report on dichoptic
stimulation as an effective treatment for amblyopia, building upon previous
studies. They introduced the I-BiT system with the following improvements:172
●
Home-based system: simple use and safe. The system switches off if it is
left idle for 15 minutes and can be used without supervision
●
Range of games and videos (not just one game and one video)
●
●
Allow image off-setting for strabismic and mixed amblyopia
Simple psychophysical tests incorporated
●
Monitor activities undertaken and treatment time. A treatment session
longer than 1 hour or more than 2 hour in a day is not permitted.
●
A face verification system to ensure the person using the system is the
intended participant
Mention was made that a major cause of treatment failure with patching
is poor compliance; however, engaging video games also has unique
compliance issues. This revised I-BiT included eight programmed games for
reasonable choice and around 40 hours of videos aimed to appeal to the 3.5–
6 years of age group.
In strabismic and mixed amblyopia, “only the fovea can support normal
visual acuity and so it seems an important requirement that the dichoptic
images are presented harmoniously. The revised I-BiT has this capability to
off-set images by a required amount and it can measure the distance of the
participant from the screen in real time to ensure that the angle of off-set can
change with distance such that the degree of off-set as measured in prism
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dioptres is kept constant.”172 Study participants included those whose only
treatment was prescription glasses, not patching. All participants must have
undergone at least 12 weeks of refractive adaptation, which can occur over
30 weeks and standard practice is to allow 18 weeks of refractive adaptation
prior to initiating patching or penalisation.
The tests described are standard; however, variation exists in practice,
especially with children. Practice variation involved clinicians’ perceived
failures in concentration by the child. Other variations centered on patient
diagnosis, for example, “patients with anisometropic amblyopia are required
not to have had previous patching or penalisation whereas this is permissible
for those with strabismic amblyopia.”172 Age of presentation was described as
a determining factor; most patients with strabismic amblyopia were less than
3.5 years of age and considered too young to engage in the use of I-BiT. On
the other hand, patients with anisometropic amblyopia usually presented at
3.5 years of age, making I-BiT more feasible.
Data was collected for cost-utility analysis in the pediatric population,
which posed a problem of accuracy. No instrument existed for children under
the age of six. There were two questionnaires used to calculate Qualityadjusted Life Years (QALYs): 1) the CHU-9D22 and 2) the EQ-5D-Y23. The
CHU-9D22 was validated for ages 7–11 years and the EQ-5D-Y23 for age
8 years. For ages 6–7 years the CHU-9D performed better than the EQ-5D-Y
and so the authors chose it. It also had a proxy form whereby a guardian could
respond on behalf of the child. The authors also used a modified CAT-QoL
“which is a treatment-specific tool as a disease-specific measure.”172 The
authors stated that the “revised I-BiT does have the ability to perform simple
psychophysical testing. The participants in this study will be monitored
clinically but the efficacy of this automated testing will be separately assessed
as it may be possible, in the future, to monitor progress remotely and without
the need for hospital visits.”172 The I-BiT approach was described as having
the ability to transform how patients with amblyopia are treated.
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Amblyopia in Children Quiz:
I.
A child with amblyopia may be treated by placing a patch over
a.
b.
c.
d.
II.
_________________ involves presenting different images to each eye
independently.
a.
b.
c.
d.
III.
the amblyopic eye.
the normal eye.
one eye and using dichoptic stimulation.
either eye.
Refractive adaptation
Penalisation
Monocular stimulation
Dichoptic stimulation
In strabismic and mixed amblyopia, only the ________ can support
normal visual acuity and so it seems an important requirement that the
dichoptic images are presented harmoniously.
a.
b.
c.
d.
fovea
sclera
choroid
ciliary body
Discussion:172
Amblyopia or lazy eye affects a significant percentage of children in the
U.S., and worldwide. The condition has been studied in numerous worldwide
studies. The authors of this case study reported on the traditional eye patch
treatment as it compared to the I-BiT system - stereo technology. The eye
patch treatment involves having the child wear a patch over his or her good
eye for a number of hours daily, over several months. The I-BiT system stereo technology uses shutter glasses designed to treat amblyopia with
dichoptic stimulation. It is designed with home use application and eyetracking capability.
This study was sponsored by the Department of Research and
Innovation at Nottingham University Hospital Trust. In 2018, research
subjects were being recruited and the study is currently underway to
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determine how the I-BiT system will help in the treatment of amblyopia, as
well as patient engagement and compliance of all age groups recruited.
Answers to Amblyopia in Children Quiz:
I.
A child with amblyopia may be treated by placing a patch over
b. the normal eye.
“With patching, the normal eye is covered up to help improve the vision in the amblyopic
eye; ….”
II.
_________________ involves presenting different images to each eye
independently.
d. Dichoptic stimulation
“The authors reported on an alternative treatment using a strategy based on dichoptic
stimulation. They defined dichoptic stimulation as ‘the ability to present different images
to each eye independently.’”
III.
In strabismic and mixed amblyopia, only the ________ can support
normal visual acuity and so it seems an important requirement that
the dichoptic images are presented harmoniously.
a. fovea
“In strabismic and mixed amblyopia, ‘only the fovea can support normal visual acuity and
so it seems an important requirement that the dichoptic images are presented
harmoniously.’”
Interpersonal Violence: Intimate Partner & Elder
The CDC defines intimate partner violence (IPV) as “... physical, sexual,
or psychological harm by a current or former partner or spouse. This type of
violence can occur among heterosexual or same-sex couples and does not
require sexual intimacy.”173 The CDC lists four behaviors as being part of
IPV:173
●
Physical violence: Someone hurts or tries to hurt a partner by hitting,
kicking, or using another type of physical force.
●
Sexual violence: Forcing or attempting to force a partner to take part in a
sex act, sexual touching, or a non-physical sexual event (e.g., sexting)
when the partner does not or cannot consent.
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●
Stalking: Repeated, unwanted attention and contact by a partner that
causes fear or concern for one’s safety or the safety of someone close to
the victim.
●
Psychological aggression: Verbal and non-verbal communication with the
intent to harm another person mentally or emotionally and/or exert control
over another person.
Approximately 1 in 4 women and 1 in 10 men have experienced IPV,
and psychological aggression is particularly common. More than 43 million
women and 38 million men have experienced psychological aggression by an
intimate partner at least once in their lives.173 Risk factors for IPV are
community, personal, relationship, and societal, e.g., poverty, poor
community support, low self-esteem, alcohol and drug use, jealousy and
possessiveness in the intimate relationship, and economic inequality.173 The
consequences of IPV may include physical harm and death, psychological
conditions like depression, post-traumatic stress disorder (PTSD), sexually
transmitted disease, substance use disorder, suicide, unwanted pregnancy,
and pre-term birth.174
Screening can detect IPV inflicted on women but there is no conclusive
evidence that screening decreases the incidence of IPV. There is no data on
screening men for IPV.174 The USPSTF recommendations for screening for IPV
state that women of reproductive age should be screened for IPV and if
appropriate, provide support services or refer to support services.174 There is
no evidence about the appropriate intervals for IPV screening. These screening
instruments have been shown to accurately IPV in adult women that has
occurred in the past year: Humiliation, Afraid, Rape, Kick (HARK), Hurt, Insult,
Threaten, Scream (HITS), Extended–Hurt, Insult, Threaten, Scream (E-HITS),
Partner Violence Screen (PVS), and Woman Abuse Screening Tool (WAST).
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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
The CDC defines elder abuse “... as an intentional act, or failure to act,
by a caregiver or another person in a relationship involving an expectation of
trust that causes or creates a risk of harm to an older adult.”175 Elder abuse
includes emotional/psychological abuse, financial exploitation, neglect, and
sexual abuse, and the perpetrators can be family members and healthcare
workers.176 The consequences of elder abuse may include emotional and
psychological distress, physical harm, and death.174
Risk factors for elder abuse are community, personal, relationship, and
societal, e.g., alcohol and drug use, inadequate support services, and
poverty.175 The National Council on Aging notes that approximately 1 in 10
million Americans 60 years of age or older has suffered some type of elder
abuse, and that only 1 out of 14 cases are reported.176
The American Medical Association, the American Academy of Neurology,
and the US Medicare program recommend screening for elder abuse.177 The
USPSTF concluded that there is insufficient evidence to determine the balance
of benefits and harms of screening for elder abuse.174 The Brief Abuse Screen
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for the Elderly (BASE) and the Elder Assessment Instrument (EAI) have been
validated and are simple and fast to use.177
Research: Interdisciplinary Team and Elder Care
The authors of this case study reported on an 85-year-old widowed,
Caucasian male who received healthcare through the Department of Veterans
Affairs. He carried diagnoses of left-sided cerebrovascular accident with
hemiparesis but without significant language impairment.178
The patient was in need of extended care; he had no in-home assistance
since his wife died and he had no other family support. His health history
included hypertension, arteriosclerotic heart disease, sleep apnea (treated
with a continuous positive airway pressure [CPAP] device), age-related
macular degeneration (early stage), and chronic back pain (adequately
controlled).
Laboratory
testing
was
unremarkable.
A
brain
magnetic
resonance imaging (MRI) prior to his stroke had revealed mild to moderate
chronic small vessel disease. His mental health history included a diagnosis of
posttraumatic stress disorder related to his military service (asymptomatic at
the time of his long-term care placement) and bereavement related to the loss
of his spouse.
Prior to his stroke the patient had lived independently at home with his
spouse at the time of her unexpected death. He developed difficulty managing
his independent needs, and reportedly becoming less organized and
increasingly depressed living alone at home. Following the stroke, he
underwent a period of rehabilitation and was diagnosed with Alzheimer’s
disease. It was determined the patient was in need of a legal guardian;
however, the patient strongly opposed having one appointed. His personal
lawyer reportedly felt concern for his protection, and petitioned the county
court for joint guardianship and conservatorship. The patient’s diagnosis of
Alzheimer’s disease was highlighted as a reason for the need of “a permanent
plenary guardian and conservator.”178 A cousin who was familiar with the
patient was appointed guardian and conservator by the court.
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The patient did not progress much with rehabilitation efforts and was
transitioned into long-term care. The guardian proceeded to sell the patient’s
house; however, the sale of his property and home items were not the
patient’s wishes. The authors identified relevant statutes pertaining to this
case. In this case, state statute allowed for:178
●
Any person to petition the court for the appointment of a conservator for
a proposed ward, with specific reasons why one is believed to be needed.
●
A court may then appoint a conservator upon finding that it is in “the best
interest of the proposed ward.”
●
The court could classify the adult as an “incompetent person” defined as
“an individual who, for reasons other than being a minor, is unable
unassisted to properly manage and take care of himself or his property as
a result of the medical conditions of advanced age, physical disability,
disease, the use of alcohol or controlled substances, mental illness, mental
deficiency or intellectual disability.”
●
Many states have moved away from relying on global determinations of
incapacity in favor of more limited and specific determinations making for
guardians or conservators with limited authorities.
●
Decisional abilities are not specifically addressed as part of the
guardianship and conservatorship statutes, but may be found in statutes
related to health care decisions.
●
“Capacity” (in this case) is defined as “the ability to understand the
significant benefits, risks, and alternatives to proposed health care and to
make and communicate a health care decision.”
The authors reported that the patient remained in the long-term care
facility and continued as an active participant in his healthcare, in the facility
where he stayed, and in community activities. An interdisciplinary health team
were part of his treatment planning and consisted of an advanced nurse
practitioner, nurse manager, registered nurse, social worker, psychologist,
chaplain, physical therapist, occupational therapist, recreational therapist,
dentist, and dietician.
Members of the interdisciplinary team met weekly to discuss the
patient’s treatment plan. A formal treatment team session, which included the
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patient, met on a quarterly basis to discuss his long-term care status. The
patient was actively engaged with his social worker and nurse practitioner and
made several requests related to his medical decisions and finances. His major
concern related to regaining control over his finances. The patient made his
own low risk medical decisions such as agreeing to start or discontinue
medications, and consenting to special procedures such as laboratory blood
draws, the seasonal flu shot, and other treatments.
Veteran benefits were included in the patient’s finances. He received a
monthly check from the federal government (disability from his wartime
service). The guardianship was considered a related evaluation, and was done
to “capture diagnostic impressions and to evaluate the patient’s capacity to
manage his own finances.”178 Interdisciplinary health team members generally
agreed the patient did not appear to have a major neurocognitive disorder;
however, the patient was evaluated as perseverative, making repetitive
requests and showing a defect of memory. The patient also was observed to
have a decline in his decisional capacity, i.e., donating large sums of money
to a suspicious charity. The health team noticed a male visitor taking the
patient out for meals but always made the patient pay the cost. After some of
these meal outings, the patient suddenly wanted to donate approximately
$50,000 to a children’s charity run by this same person. Although the patient
had fired his lawyer the lawyer had investigated previous court cases involving
this male visitor and discovered a history of financial exploitation of vulnerable
people. The lawyer’s discovery aligned with the treatment team’s observations
that the patient lacked decisional capacity.
The patient was provided information regarding his evaluation and the
recommendation for continuance of the conservatorship. He was informed that
the evaluation would focus on his financial abilities, and that evaluation of
medical decision-making capacity would require another evaluation. The
patient appeared to understand and provided informed consent. The guardian
provided consent for the evaluation.
The patient’s general physical functioning, cognitive abilities, and
perceptions of impressionability were considered. The guardian was consulted
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for specific information related to the patient’s health history, financial
management skills, and with regard to his finances, and legal counsel was
consulted for the financial portion.
The authors noted that an interview was completed and based on the
American Psychological Association (APA)/American Bar Association (ABA)
Assessment of Capacity in Older Adults handbook). Brief neurocognitive
testing was administered to determine the patient’s specific cognitive
strengths and weaknesses, and his cognitive performance was found to be in
the average range, although this may have declined from a prior baseline.
The patient’s hemiparesis was considered the main concern of the
interdisciplinary health team. Tasks that were challenging due to his
hemiparesis included writing a check, balancing a checkbook, and using a
calculator, however basic financial knowledge of his own resources remained
intact.
The treatment team believed that the patient was susceptible to
potential elder abuse, such as the influence of the representative from the
children’s
charity.
The
guardian
opined
that
the
patient
was
“very
impressionable” and required protection; his large donation to the children’s
charity was concerning to the team. Ultimately, the patient was found
incapable of managing his day-to-day financial affairs, and the team proposed
limited conservatorship “to balance the patient’s autonomy and need for
assistance.”178 Recommendations made included providing assistance with the
physical demands of financial management (writing checks, paperwork, etc.),
and with the management of stocks, investments, and more difficult financial
operations.
The patient needed both physical assistance following his stroke and
oversight for his limitations with problem-solving. Specific recommendations
were made for the team to provide effective communication when working
with an older person, such as speaking at a slower pace, facing the person
directly, and being mindful of professional jargon.
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The patient’s lawyer and guardian had access to the patient’s report.
The patient shared the report with his lawyer who provided it to the court. The
authors stated that “the impact of medical and mental health conditions, and
the prognosis of both must be weighed in determinations of capacity. In a
related vein, the presence of neurocognitive impairments or disorders are
essential to consider as they may affect decision-making abilities in various
ways.”178
The treatment team had concerns about the patient’s safety and
vulnerability to elder abuse; however, they were also careful to discuss all of
their concerns and findings with him. Mention was made that “legal
clarification on the state statutes relevant to the case provided further
education to team members when patient autonomy could be curtailed by
safety concerns.”178
Elder Care Quiz:
I.
An ‘incompetent person” is defined as an individual who, for reasons
other than being a minor, is unable unassisted to properly manage and
take care of himself or his property as a result of
a.
b.
c.
d.
II.
Mental capacity includes the ability of the patient
a.
b.
c.
d.
III.
advanced age, physical disability, or disease.
the use of alcohol or controlled substances.
mental illness, mental deficiency or intellectual disability.
All of the above
to understand the significant benefits and risks of proposed health care.
to make the right health care choices.
to administer care.
All of the above
True or False: Formal treatment team sessions should not include the
patient because long-term care status should be discussed by
professionals only.
a. True
b. False
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Discussion:178
This case study showed how interdisciplinary team members engaged
an older person with physical and cognitive disabilities, and the effort made
to assist the patient with his needs and keep him safe. The authors
recommended that interdisciplinary health team members make an effort to
“elicit input up front from relevant stakeholders (e.g., the physician if the
question pertains to medical decision-making, occupational therapy if there
are
questions
about
independent
living).”178
These
interprofessional
interactions were described as “a prime opportunity to provide informal
education about capacity evaluations.”178
Each health team member may have a different perspective regarding
how to balance a patient’s safety over the patient’s autonomy. These different
perspectives may conflict. To resolve this conflict, each team member should
attempt to understand where the other member is coming as the team seeks
to balance the patient’s safety and his need for autonomy.178 Providers should
be interacting with a local or regional counsel or hospital attorney regarding
local laws and practices that might be relevant to an assessment.178
Hospital policies and procedures are important to know. If necessary, a
provider should step back and evaluate a situation. In this case, the patient
had experienced delirium therefore no immediate decision was made until the
patient could stabilize before evaluating for competency and a fitness to
proceed with an evaluation. Conducting capacity assessments are often
challenging and may feel intimidating. Working as a team of health
professionals will support all members of the health team as well as the patient
and family members to consult and progress to act as advocates for the
patient.
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Answers to Elder Care Quiz:
I.
An ‘incompetent person” is defined as an individual who, for reasons
other than being a minor, is unable unassisted to properly manage and
take care of himself or his property as a result of
a. advanced age, physical disability, or disease.
b. the use of alcohol or controlled substances.
c. mental illness, mental deficiency or intellectual disability.
d. All of the above [correct answer]
“The court could classify the adult as an ‘incompetent person’ defined as ‘an individual
who, for reasons other than being a minor, is unable unassisted to properly manage and
take care of himself or his property as a result of the medical conditions of advanced age,
physical disability, disease, the use of alcohol or controlled substances, mental illness,
mental deficiency or intellectual disability.’”
II.
Mental capacity includes the ability of the patient
a. to understand the significant benefits and risks of proposed health care.
“‘Capacity” (in this case) is defined as ‘the ability to understand the significant benefits,
risks, and alternatives to proposed health care and to make and communicate a health
care decision.’”
III.
True or False: Formal treatment team sessions should not include the
patient because long-term care status should be discussed by
professionals only.
b. False
“A formal treatment team session, which included the patient, met on a quarterly basis to
discuss his long-term care status.”
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.
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The USPSTF recommends that when appropriate, adult patients should
be counseled about the following health concerns.21
●
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
the following health concerns.21
●
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
Centers for Disease Control and Prevention has published recommendations
for vaccination schedules, and these are available to the general public online
at https://www.cdc.gov/vaccines/schedules/index.html.179
Summary
Screening is an effective method for detecting and preventing acute and
chronic diseases. Health clinicians need to know the recommended screening
tests or practice tools that may lead to early detection or prevention of medical
problems that cause morbidity and mortality if left undiagnosed and
untreated.
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Screening tests include the recommendations contained in the U.S.
Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services
2014, and recommendations on screening by applicable organizations such as
the National Center on Elder Abuse, the National Academy of Sciences, the
American Academy of Neurology and the American Medical Association.
Other public health concerns that have been raised in the above sections
are currently being developed within interdisciplinary health teams that carry
an interest in the development for improved standardized screening tools to
help identify high risk health issues and guide patient education, such as those
related to smoking cessation and exposure to second-hand smoke and varied
other health and public safety hazards related to disease recognition and
prevention.
Health clinicians who are informed on the evolving area of preventive
health medicine, and of the many resources available to educate patients and
their families, are pivotal in guiding patients to make better health choices
that help them to avoid illness. In addition to finding ways to reduce morbidity
and mortality rates, such as through earlier disease detection, the above
sections highlighted the many research trials validating the importance of
screening for disease prevention and the role of health clinicians to
continuously promote prevention education and the best available evidence
on health prevention, and on the treatment and recovery of common diseases.
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Self-Assessment of Knowledge Post-Test:
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation. Completing the study
questions is optional and is NOT a course requirement.
1. One of the limitations of screening tests is
a.
b.
c.
d.
screening guidelines are often changed and updated.
these tests rarely provide a high degree of specificity or sensitivity.
the guidelines differ for children and adults.
the benefits seldom outweigh the risks.
2. Screening tests must be used with the understanding that
a.
b.
c.
d.
they are seldom able to detect diseases.
most of them are associated with harmful side effects.
they are not diagnostic.
they cannot be used for children.
3. Adults should be screened for alcohol misuse
a.
b.
c.
d.
unless the patient is pregnant.
only if they use illicit drugs.
only if they engage in risky drinking behavior.
in all cases.
4. Breast cancer is
a.
b.
c.
d.
more common in women < 50 years of age.
the most common cancer in women.
primarily caused by cigarette smoking.
not detectable without a biopsy.
5. What is the recommendation of the U.S. Preventive Services Task
Force (USPSTF) regarding the use of mammograms to screen for
breast cancer in women age 75 or older?
a.
b.
c.
d.
They should have a mammogram annually.
The USPSTF recommends against a mammogram in all cases.
They should have a biennial mammogram.
There is no recommendation.
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6. Screening for cervical cancer
a.
b.
c.
d.
decreases mortality from the disease.
should begin during adolescence.
has no effect on mortality in women.
is only recommended for women with a genetic disposition for
cervical cancer.
7. Risk factors for colorectal cancer include
a.
b.
c.
d.
lower levels of low-density lipoprotein.
a sedentary lifestyle.
Leriches syndrome.
perforation and bleeding.
8. Screening adolescents ages 12 to 18 for major depressive
disorder should be implemented
a.
b.
c.
d.
on a case-by-case basis.
if the clinician is comfortable talking about depression.
with follow-up care.
if depression symptoms have lasted 12 months or longer.
9. True or False: Diabetes is a major contributing factor to
blindness, heart disease and kidney failure.
a. True
b. False
10. Testing for prediabetes and/or type 2 diabetes in asymptomatic
people should be considered in
a.
b.
c.
d.
11.
all adults of any age.
adults with a risk factor for diabetes and who are overweight.
women who were pregnant.
adults who are overweight or obese.
Screening for Hepatitis B is recommended for
a.
b.
c.
d.
people who misuse alcohol and people > age 50.
infants born to HBV-infected mothers.
patients with renal disease.
anyone born between 1945 and 1965.
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12.
Screening for Hepatitis C is recommended for
a.
b.
c.
d.
13.
Screening for HIV is recommended for people
a.
b.
c.
d.
14.
people who misuse alcohol and people > age 50.
all persons who have diabetes.
pregnant women and adolescents.
anyone born from 1945 to 1965.
who are infected with hepatitis or tuberculosis.
as part of routine screening for all patients.
who misuse alcohol.
with hypertension and diabetes.
True or False: The USPSTF recommends that all adults should
be screened for hypertension.
a. True
b. False
15.
The Centers for Disease Control and Prevention (CDC) includes
_____________ as one of the behaviors constituting intimate
partner violence.
a.
b.
c.
d.
16.
A patient who has comorbidities is considered severely obese if
the patient has a body mass index (BMI)
a.
b.
c.
d.
17.
anger
sexting
theft
All of the above
of 25 to 29.9 kg/m2.
≥30 kg/m2
≥25 kg/m2
≥35 kg/m2
Osteoporosis is most common in
a.
b.
c.
d.
African American males.
men age 50 or older.
elderly white females.
people of average or above average weight.
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18.
The Centers for Disease Control and Prevention (CDC)
recommendations for chlamydia screening include
a.
b.
c.
d.
19.
all pregnant women.
pregnant women < 25 years of age.
all women of childbearing age.
men who are sexually active.
True or False: The benefits of prostate cancer screening far
outweigh the risks.
a. True
b. False
20.
All newborns should be screened for
a. lipid disorders.
b. iron deficiency anemia.
c. phenylketonuria.
d. liver disease.
21.
All pregnant women under the age of 25, regardless of risk,
should be screened for
a.
b.
c.
d.
gonorrhea.
trichomonas.
HSV infection.
Hepatitis C.
22. All newborns should be screened for
a.
b.
c.
d.
23.
sickle cell disease.
elevated cholesterol.
Hepatitis C.
All of the above
True or False: Screening infants for hearing impairment is
mandatory.
a. True
b. False
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24.
All newborns should be screened for
a. HIV.
b. diabetes.
c. Hepatitis B.
d. congenital hypothyroidism.
25.
Which of the following is the leading cause of preventable
deaths in the United States?
a.
b.
c.
d.
26.
Diabetes
Alcohol
Tobacco
HIV
Which of the following is NOT true regarding cigarette smoking
in the United State?
a. Sidestream smoke is more toxic than second-hand smoke.
b. Multi-residential living arrangements can expose non-smokers to
second-hand smoke.
c. There is a safe level of second-hand smoke.
d. Sidestream smoke enters a person’s lungs more easily than secondhand smoke.
27. Health effects of secondhand smoke include
a.
b.
c.
d.
28.
sudden infant death syndrome (SIDS).
ear infections.
pneumonia.
All of the above.
Which of the following is a drug approved by the Food and
Administration (FDA) for assisting patients with smoking
cessation?
a.
b.
c.
d.
Tamoxifen
Disulfiram
Varenicline
Raloxifene
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29.
Sidestream smoke is smoke that is
a.
b.
c.
d.
30.
produced when a person exhales cigarette smoke.
emitted from the burning end of a cigarette or cigar.
produced by inhaling tobacco smoke.
less toxic than second-hand smoke.
True or False: Intimate partner violence may include stalking.
a. True
b. False
31.
Risk factors for non-melanoma and melanoma skin cancer
include
a.
b.
c.
d.
32.
Risk factors for developing oral cancer include
a.
b.
c.
d.
33.
a tuberculosis infection.
infection with hepatitis C.
contracting syphilis.
infection with the human papillomavirus HPV-16.
Congenital syphilis that is untreated can cause
______________ in or to a mother’s unborn baby.
a.
b.
c.
d.
34.
smoking tobacco.
absence of ephelides on the skin.
alcohol consumption.
the presence of multiple nevi.
spontaneous sequelae
phenylketonuria
death
All of the above
Which of the following is a modifiable risk factor for coronary
heart disease?
a.
b.
c.
d.
diabetes.
family history of coronary heart disease.
gender.
age.
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35.
True or False: The AUDIT and the Audit-C screening tools are
accurate and widely accepted and have been used in primary
care settings for assessment of an alcohol use disorder.
a. True
b. False
36.
The USPSTF recommends that women aged 21-29 be screened
for cervical cancer
a.
b.
c.
d.
37.
The USPSTF recommends that women
____________________ do not need to be screened for
cervical cancer.
a.
b.
c.
d.
38.
basal cell
non-melanoma
malignant melanoma
melanoma
In its early stages, a syphilis infection will cause
a.
b.
c.
d.
40.
with a prior, negative screening
aged 21-29
younger than 21
All of the above
Squamous cell carcinoma is a form of _________________
skin cancer.
a.
b.
c.
d.
39.
if they are in a high risk category.
every three years.
only if they have a history of cervical cancer.
once a year.
dramatic symptoms.
severe neurological complications
primarily genital lesions and non-specific signs and symptoms.
HIV infection.
True or False: The USPSTF recommends routine screening for
skin cancer.
a. True
b. False
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41.
The diagnosis of hypertension cannot be confirmed until an
elevated blood pressure is present
a.
b.
c.
d.
42.
with no causal event.
on one or more occasions.
using ambulatory blood pressure monitoring.
on several occasions.
Blood pressure measurement is an important predictor of
cardiovascular complications in people with
a.
b.
c.
d.
diabetes.
colorectal cancer.
iron deficiency anemia.
lipid disorders.
43. People who have sickle cell disease have an abnormal, inherited
hemoglobin called
a. hemoglobin
b. hemoglobin
c. hemoglobin
d. hemoglobin
44.
C.
A.
A2.
S.
Screening for _______________ should continue until age 75.
a. skin cancer.
b. prostate cancer
c. colorectal cancer
d. sickle cell anemia
45.
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
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46.
The USPSTF stated that the evidence related to screening for
iron deficiency anemia in pregnant women leads to the
following position:
a.
b.
c.
d.
47.
Iron deficiency anemia during pregnancy is caused by
a.
b.
c.
d.
48.
premature labor.
high birth weight.
delayed labor and late birth.
breast cancer.
Malignant melanoma can metastasize to any organ but in most
cases it will metastasize to the skin and the
a.
b.
c.
d.
50.
a mother’s increased iron needs for red blood cell production.
inadequate iron intake.
the growth of the fetus and placenta.
All of the above
Anemia during pregnancy can cause, or has been associated
with
a.
b.
c.
d.
49.
all women should be screened for iron deficiency anemia.
it is unclear whether the benefits of screening outweigh the harm.
the benefits of screening outweigh the harm.
maternal health and birth outcomes are greatly improved by
screening.
lymph nodes.
lungs.
pancreas.
liver.
Amblyopia is defined as a functional reduction in
a.
b.
c.
d.
hearing ability.
mental development.
visual acuity.
a sense of smell.
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Reference Section
The References below include published works and in-text citations of
published works that are intended as helpful material for further reading.
1.
2.
3.
4.
5.
6.
7.
8.
9.
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