Based on the chapter ‘Disease prevention & health maintenance’ of the very good medical book of Fauci A.S. et al., ‘Harrison’s Manual of Medicine, McGraw – Hill, 17th edition, 2009 mcgraw-hillmedical.com

• Accidents are a major cause of death or disability in any age (and 1st cause of mortality on people younger than 44 years). Routine seat belt use & helmet use (bicycles, motorcycle, skateboard) has to be encouraged (especially from pregnant – proper use has to be ensured).

• Everyone must realize that drinking and driving can be fatal.

• Also alcohol while swimming or boating is dangerous as well.

• Counselling about diet and regular exercise for all ages.

• Immunization status for adults.

a) For tetanus (end diphtheria as Td adult) for > 18 years old, every 10 years booster shot.

b) Meningococcal vaccination is needed for high risk adults (1 or more doses).

c) Vaccination for hepatitis B (HBV) and hepatitis A (HAV) is offered for high risk groups (on 3 doses for HBV and 2 doses on HAV).

d) MMR (measles, mumps & rubella) vaccination for women in childbearing age (for rubella) – 1 dose. 1 dose has also to be considered in people with (clinical or lab) lack of immunity on MMR (that didn’t have these diseases) and are 19-49 years old (1 – 2 doses). MMR (1 dose) may be also considered in high risk patients older than 50 years. Don’t give MMR in HIV positive patients! Also MMR is contraindicated in cancer patients receiving chemo, pts with Hodgkin’s and hematopoietic stem cell transplant recipients.

e) Also, for susceptible people > 18 years old, VZV Varicella immunization (2 doses) has to be considered (if not immune to the disease, namely that haven’t passed the disease). On people aged 19 – 49 years old 2 doses are needed. This vaccine is also used in high risk specific groups aged 50 – 60 years old. Don’t give it to pregnant women or women who may become pregnant within 1 month after the vaccination. Also VZV is contraindicated in cancer patients receiving chemo, pts with Hodgkin’s and hematopoietic stem cell transplant recipients.

f) For sexual active women HPV immunization is recommended. HPV virus is related with cervical cancer. HPV (human papilloma virus) is suggested for females (3 doses) aged 19 – 26 years old.
g) Vaccination against influenza may also be needed annually on special risk patients/groups 19 – 49 years old and in all people older than 50. Special risk groups are patients with chronic disorders due to cardiovascular or pulmonary problems (including asthma), chronic metabolic diseases (including diabetes mellitus), chronic renal problems, hemoglobinopathies, immunosupression (including immunosupression caused by HIV or drugs), pregnancy during influenza period, patients with asplenia (spleen removed), conditions that compromise respiratory function and/or respiratory secretions handling and/or that increase the risk for aspiration (e.g. stroke, seizures, other neuromuscular problems, spinal cord injury and cognitive impairment), healthcare workers and employees in long term health care facilities (e.g. nursing homes), nursing home residents, etc.

h) Also 1 – 2 doses vaccination against pneumoniococcus may be needed in high risk groups aged 19- 64 years old. For people older than 65 years old give 1 dose, once.

• Accidents are 1st cause of death on people aged 15 – 44 years old.

• Homicides are 2nd cause of mortality in age < 24. Gun (or any other weapon such as knife) possession and use has to be investigated. On people 15 – 24 years old suicide, malignancy and heart disease (from more frequent to less) follow accident and homicide as reasons of mortality.

• Screening for domestic violence (women, elderly, pregnant, children) in all ages.

• Substance use history, illicit - recreation drug misuse and alcohol abuse screening in all ages (especially in younger).

• Screening for depression and suicide attention in all (especially in people aged 15 –24 years where suicide is 3rd cause of death).

• Assess medication, concordance, abuse, side effects, contraindications, interactions with other drugs. Assessment includes over the counter drugs (OTC), ‘vitamins’, herbs, self medications & the ‘Pill’.

• Every 1 – 3 years females 18 – 65 years old have to undertake Pap test (cervical smear for cytology) for cervical cancer prevention starting from the beginning of sexual life, until 65 years old.

• Pelvic examination is recommended by ACS for all females 18 – 40 years old and recommends to be performed every 1 – 3 years with Pap test. For women older than 40 it is recommended annually.

• Breast examination is recommended monthly for all women >_ 20.

• On women is recommended every 1 – 2 years mammography for breast cancer screening, beginning at age 40. Earlier & more frequent screening if strong family history of breast cancer.

• Skin, breast and testicular self exam and physical examination.

• Avoidance of UV sunlight and solarium and regular sunscreen use for prevention of skin cancer and especially malignant melanoma.

• Periodic complete skin examination recommended from ACS (especially skin cancer screening).

• Screening for depression and suicidal or homicidal ideation especially in people aged 15 –24 years.

• Recommend diet low in saturated & trans fat, 2- 3servings of fish weekly (especially fat fish for omega – 3), fruits & vegetables & moderate alcohol intake (no more than 1 – 2 drinks daily).

• Recommend regular exercise more than 30 min moderate intensity physical (aerobic) activity daily (e.g. jogging, cycling, brittle walking, rowing, etc).

• In all ages periodically measurement of Blood Pressure (BP), height, weight & Body Mass Index.

• Also blood glucose & lipids cholesterol – HDL – LDL frequent (e.g. annually) check up. Check blood cholesterol every 5 years for men older than 35 and every 5 years for women older than 45.

• Specific risk factors for CHD (coronary heart disease) are dyslipidemia (increased LDL ‘bad cholesterol’ and decreased HDL ‘good cholesterol’), high serum homocysteine, (folic acid and B6 & B12 vitamin lower it), high sensitivity CRP, lipoprotein (a), high fibrinogen, DM (diabetes), insulin resistance and metabolic syndrome, male gender, male >_45 years old, postmenopausal women (>_55), cigarette smokers, hypertensive, obese, patients with family history or premature CHD and patients with sedentary life style.

• Diabetes (DM) check up every 3 years for people older than 45 (earlier if additional risk factors e.g. obesity, family history, gestational diabetes etc).

• Body weight control, if overweight or obese, should be encouraged. Low BMI on young women may indicate anorexia neurosa.

• Hypertension, hyperlipidemia and diabetes should be treated maliciously. BP is normal < 140/90 (namely maximum normal levels are 139/49). It should be kept < 130/80 in diabetics. Cholesterol should be < 200mg/dL (<5.17 mmol/L). Optimal LDL should be < 2.59 mmol/L (< 100 mg/dL) and < 70 mg/dL (<1.81 mmol/L) on very high risk patents. Normal maximum fasting glucose levels should not exceed 110 mg/Dl (6.1 mmol/L).

• Information about health risks of smoking in all ages. Smoke cessation should be encouraged (information about ways such as nicotine gums or pads, acupuncture etc).

• STDs (Sexual Transmitted Diseases e.g. Chlamydia) screening and contraceptive counselling for sexual active females. Every 1– 2 years screening for Chlamydia in women 18 – 25 years old.

• Safe sex counselling for everyone (condom use & contraception, but mention the side effects and contraindications e.g. migraine, DVT etc) and complications (e.g. liver problems, breast and endometrial cancer, PE etc.).

• Chlamydia, gonorrhoea, HIV, hepatitis B (and C), HSV and syphilis testing for high risk sexual behaviour or history of STDs.

• On people older than 25 years take family history for malignancy and other diseases. Genetic counselling on high risk patients with strong family history. Screening/ preventing program in high risk groups.

• On people older than 25 years assess cardiac risk factors:

a) Non – modifiable: male gender, increasing age (men >_45 women >_ 55), ethnic origin (e.g. India), personal or family history, socio – economic status, IUGR (and small birth weight) and premature CHD (coronary heart disease).

b) Modifiable: smoking, hyperlipidaemia, hypertension, diabetes mellitus (DM), diet, obesity, physical activity, heart failure, behaviour (competitiveness, aggression, feeling under time pressure), increased plasma fibrinogen, increased Lipoprotein a, increased blood homocysteine and decreased blood folate , vitamin B12 and B6 (folate and Vit B12 deficiency increase homocysteine levels), sedentary life style and depression. Alcohol in low doses is cardio protective; however in high doses it induces hypertension and numerous of physical problems.

• On people older than 25 – 44 years prevent cardiovascular disease with aspirin 75 mg once daily (od) with food (if not contraindicated) for pts at > 3% 5 year risk of a vascular event (for men with >_ 10% 10 year risk ore women with > _20% 10 year risk). If not tolerated then use clopidogrel 75 –160 mg od. Perhaps use PPI or H2RAs for gastric protection.

• On people older than 25 years assess chronic alcohol abuse & risk factor for hepatitis B&C to assess the risk of chronic liver disease.

• Main causes of mortality on people aged 25 – 44 years are (lined from most important to less) accident, malignancy, heart disease, suicide, homicide and HIV.

• Cardiac functional status assessment e.g. ECG (any age), exercise test (after age of 50) and perhaps, if indicated, scintigraphy test, Holter and Echo.

• Assess CVA (stroke) risk factors: increasing age, hypertension, diabetes, atrial fibrillation, previous stroke or TIA, MI, artificial heart valves, hyper viscosity, smoking, obesity, alcohol, and low physical activity. Patients with sustained/chronic atrial fibrillation should take anticoagulation.

• Pulmonary function test (spirometry) is recommended for chronic smokers to assess the development of chronic obstructive pulmonary disease (COPD).

• Chronic alcohol abuse assessment.

• Causes of mortality on people aged 45 – 64 years (from more frequent to less) are malignancy, heart disease, accident, DM (diabetes), CVA (stroke), chronic lower respiratory disease (e.g. COPD), chronic liver disease & cirrhosis and suicide.

• Prostate cancer screening with annual PSA and digital rectal examination (and perhaps transrectal ultrasound TRUS, but it’s expensive) starting at the age of 50 years (earlier if family history or Africans). PSA is used to detect early state prostate cancer, however evidence is inconclusive that improves the outcomes! An intermediate PSA doesn’t mean always cancer.

• Colorectal cancer screening for people >_ 50 years old with annual fecal occult blood test and/or colonoscopy (every 10 years), or flexible sigmoidoscopy (every 5 years). Also (not officially indicated & less preferred because of radiation) barium enema. Earlier & more frequent screening if strong family history of colorectal cancer. Colonoscopy or sigmoidoscopy have similar or greater efficacy to occult blood test.

• Reassessment of vaccination status at 50 years old and again at 65 years old people. Think special indications for specific risk groups. Vaccinate all smokers against influenza and S.pneumonia at age of 50 years. Vaccinate against influenza and S.pneumonia also people aged older than 65 (for pneumoniococcus) or 50 (for influenza) or on high risk groups.

• Screening for CHD (coronary heart disease) in high risk patients (see previously) older than 45 years.

• Causes of death on people aged older than 65 years are (from more frequent to less) are heart disease, malignancy, CVA (stroke), chronic lower respiratory disease (e.g. COPD), Alzheimer’s, Influenza, Pneumonia, DM (diabetes mellitus), kidney disease, accidents, septicaemia.

• Ovarian ultrasound and CA125 cancer index and genetic screening in high risk women for ovary cancer.

• Reassessment of smoking status, encourage cessation in every visit!

• Screening for osteoporosis for all postmenopausal women older than 65 (or 60 if risk factors) and men older than 65 years with risk factors. Home safety counselling to avoid falls (e.g. avoid climbing a ladder or a short chair). Visual and balance (e.g. ataxia) problems also contribute to falls.

• Screening for dementia and depression for people older than 65 years old.

• Screening for hearing and visual problems (they also contribute to accidents), home safety and abuse for people older than 65years old. Unilateral hearing loss often contributed to age (presbyacusia), but sometimes may caused from brain (e.g. optic neurinoma) tumour!

• Screening in domestic violence/ abuse to children, women, pregnant and elderly.

• Statin therapy in all patients with Coronary Heart Disease (CHD) (regardless the cholesterol levels!) and type 2 diabetics.

• One time ultrasound for AAA (abdominal aortic aneurysm) screening in men 65 – 75 years old who have ever smoked.

• Periodically visual & hearing check up on people older than 65.

• Periodically alcohol abuse screening in all people aged older than 18.

• Mouth wash (rinse) with oral fluids containing high alcohol (and other metabolites such as acetaldehyde) are connected with oral cancer, according to an Australian research of 2009. Alcohol and cigarette smoking is also connected with mouth and larynx cancer.

SCREENING PROGRAMMES UNDER EVALUATION IN THE UK

• Abdominal aortic aneurysm (ultrasound on people older than 65).

• Lung Cancer (periodically Chest X’ ray, CT?) screening.

• Bladder Cancer (for high risk patients e.g.in colour industries) screening.

• Glaucoma (increased eye pressure) screening by eye doctors.

• Oral Cancer screening.

• Cystic fibrosis (newborn or antenatal screening).

• Thyroid disease (especially if family history and also if symptoms such as arrhythmias, insomnia, AF etc) with TSH, fT3, fT4 (also newborn screening for prevention of cretinism).

REFERENCE

1. Disease prevention & health maintenance, p. 1103 – 1130, Harrison’s Manual of Medicine, Fauci A.S., Braunwald E.B., Kasper D.L., Hauser S.L., Longo D.L., Jameson J.L., Loscalzo J., 17th edition, Mc Graw Hill Medical, 2009.
mcgraw-hillmedical.com

2. Screening in the future, p. 160 – 161, Oxford Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick, 2nd edition, Oxford University Press,2005.
www.oup.com