Neha Mehra is a 58 year old female in good health. She has no significant past medical history. Her father died 3 years ago at age 83 of natural causes. Her mother is still alive at age 85 and suffers from diabetes. This patient denies any history of recreational drug, tobacco, or alcohol use. She is sexually active only with her husband. The patient comes to your office today to get her immunizations up to date. She is not planning any travel this year out of the United States. She had her last set of vaccines over ten years ago and she does not recall what she received.
According to the Advisory Committee on Immunization Practices (ACIP) recommendations, which one of the following vaccinations is recommended for this patient?
A) Td (Tetanus and diphtheria)
B) PPV (Pneumococcal polysaccharide vaccine)
C) Zoster vaccine
D) Influenza (Flu) vaccine
E) Human papillomavirus (HPV) vaccine
The correct answer is D.
Neha Mehra is 58 years old and should have the influenza vaccine. The flu vaccine should be administered annually to people of all ages without a contraindication.
Option A is incorrect.
This patient should receive the Tdap, not the Td vaccine. The ACIP recommends a one-time dose of Tdap to adults aged less than 65 years who have not received Tdap previously or for whom vaccine status is unknown to replace one of the 10-year Td boosters. Adult vaccination against pertussis is an important component of community prevention, although in 2012 only 10% of adults had received their recommended pertussis booster. More than half of infants younger than 1 year old who get pertussis are hospitalized, and 1 or 2 in 100 hospitalized infants die.
Option B is incorrect.
PPV is administered once at age 65 or older. It is also recommended for younger patients:
Option C is incorrect.
A single dose of Zoster vaccine is recommended for adults age 60 or older regardless if they report a previous episode of herpes zoster.
Option E is incorrect.
The HPV vaccine series is recommended for males and females at ages 11-12. HPV vaccination is recommended for all females aged <26 years and males <21 years who have not completed the vaccine series. Males may receive it up to age 26 (Source: Advisory Committee on Immunization Practices (ACIP) recommendations 2012).
Hae-won Kim is a 40 year old Korean woman who presents to your office today for a routine physical examination. She is in good health. Her father suffers from gout, her mother has hypertension, and her sister is healthy. You schedule the patient for her first mammography. Ms. Kim asks you to teach her to perform a routine breast self examination to screen for breast cancer.
According to the United States Preventive Services Task Force (USPSTF), which one of the following statements about routine breast self examination as a screen for breast cancer is most accurate? The USPSTF:
A) found good evidence that breast self examination reduces breast cancer mortality
B) recommends teaching breast self examination (Category B)
C) recommends against teaching breast self-examination (Category D)
D) recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient (Category C)
E) concludes that the current evidence is insufficient to recommend teaching breast self-examinations (Category I)
The correct answer is C.
The USPSTF recommends against teaching breast self-examination (BSE) [Category D]. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. (Source: United States Preventive Services Task Force, Breast Cancer, Screening, 2009)
Sharon Hall is a 42 year old female patient who comes today for a routine health care maintenance visit. She has smoked 1 pack of cigarettes a week since she was 17. When asked if she ever thought about quitting, she rolls her eyes and says: "Ay, I've been waiting for 2 hours to see you and now you want to give me a lecture? Listen, you doctors are always trying to get me to quit smoking. I've told you over and over again - I'm not interested!" Write down what you feel would be the most helpful response that you could make at this point.
Answer: To be discussed in MCY-F session
Jeff Altbaum is a 70 year old white male who presents for a health maintenance visit. He has no present complaints. His only past medical history is mild arthritis for which he takes acetaminophen occasionally. He has no allergies. He does not drink alcohol or use recreational drugs. He smoked a half pack of cigarettes from age 22 until he successfully quit at age 30. The patient is sexually active only with his wife.
According to the United States Preventive Services Task Force (USPSTF), which one of the following routine clinical preventive services is recommended (Grade A or B) for this patient?
A) Duplex ultrasonography screening for asymptomatic carotid artery stenosis
B) Spirometry screening for chronic obstructive pulmonary disease
C) Ultrasonography screening for abdominal aortic aneurysm
D) Ankle brachial index screening for asymptomatic peripheral arterial disease
E) Oral examination to screen for oral cancer
The correct answer is C.
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked (Category B). The major risk factors for abdominal aortic aneurysm (AAA) include age (being 65 or older), male sex, and a history of ever smoking (at least 100 cigarettes in a person's lifetime). A first-degree family history of AAA requiring surgical repair also elevates a man's risk for AAA.
This may also be true for women but the evidence is less certain. There is only a modest association between risk factors for atherosclerotic disease and AAA. Because of the low prevalence of large AAAs in women, the number of AAA-related deaths that can be prevented by screening this population is small. There is "good" evidence that screening and early treatment result in important harms, including an increased number of surgeries with associated morbidity and mortality, and psychological harms. The USPSTF concluded that the harms of screening women for AAA outweigh the benefits (Source: United States Preventive Services Task Force Recommendations, 2005).
Option A is incorrect.
The USPSTF recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population (Category D). The most feasible screening test for severe CAS (for example, 60% to 99% stenosis) is duplex ultrasonography. "Good" evidence indicates that this test has moderate sensitivity and specificity and yields many false-positive results. A positive result on duplex ultrasonography is often confirmed by digital subtraction angiography, which is more accurate but can cause serious adverse events. Noninvasive confirmatory tests, such as magnetic resonance angiography, involve some inaccuracy. Given these facts, some people with false-positive test results may receive unnecessary invasive carotid endarterectomy surgery. "Good" evidence indicates that in selected, high-risk trial participants with asymptomatic severe CAS, carotid endarterectomy by selected surgeons reduces the 5-year absolute incidence of all strokes or perioperative death by approximately 5%. These benefits would be less among asymptomatic people in the general population. For the general primary care population, the benefits are judged to be no greater than small. "Good" evidence indicates that both the testing strategy and the treatment with carotid endarterectomy can cause harms. A testing strategy that includes angiography will itself cause some strokes (Source: United States Preventive Services Task Force Recommendations, 2007)
Option B is incorrect.
The USPSTF recommends against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry (Category D) and has no net benefit. Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible, is usually progressive, and is associated with an abnormal inflammatory response of the lung to noxious particles or gases. The diagnosis is based on objective airflow limitation, defined as an FEV1-FVC ratio less than 0.70 with less than 12% reversibility, in association with risk factors (such as smoking history) and/or symptoms (such as chronic sputum production, wheezing, or dyspnea). There is "good" evidence that history and clinical examination are not accurate predictors of airflow limitation. There is "fair" evidence indicates that most individuals with airflow obstruction do not recognize or report symptoms. There is also "fair" evidence to indicate that fewer than 10% of those identified by screening spirometry have severe or very severe COPD, using current diagnostic criteria. The opportunity costs (time and effort required by both patients and the health care system) associated with screening for COPD using spirometry are large even in populations at higher risk. The physical performance of spirometry has not been associated with adverse effects. "Fair" evidence indicates that spirometry can lead to substantial overdiagnosis of COPD in "never smokers" older than age 70 years, and that it produces fewer false-positive results in other healthy adults (Source: United States Preventive Services Task Force Recommendations, 2008).
Option D is incorrect.
The USPSTF found "fair" evidence that screening with ankle brachial index can detect adults with asymptomatic PAD. There is also "fair" evidence that screening for PAD among asymptomatic adults in the general population would have few or no benefits; the prevalence of PAD in this group is low and there is little evidence that treatment of PAD improves health outcomes at this asymptomatic stage of disease, beyond treatment based on standard cardiovascular risk assessment. The USPSTF found "fair" evidence that screening asymptomatic adults with the ankle brachial index could lead to some small degree of harm, including false-positive results and unnecessary work-ups. Thus, the USPSTF concludes that, for asymptomatic adults, harms of routine screening for PAD exceed benefits. The USPSTF recommends against routine screening for peripheral arterial disease (Category D) (Source: United States Preventive Services Task Force Recommendations, 2005).
Option E is incorrect.
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer (Category I). The USPSTF found no new "good"-quality evidence that screening for oral cancer leads to improved health outcomes for either high-risk adults (i.e., those over the age of 50 who use tobacco) or for average-risk adults in the general population. It is unlikely that controlled trials of screening for oral cancer will ever be conducted in the general population because of the very low incidence of oral cancer in the United States. There is also no new evidence for the harms of screening. As a result, the USPSTF could not determine the balance between benefits and harms of screening for oral cancer (Source: United States Preventive Services Task Force Recommendations, 2004).
A local hospital conducted a community oriented primary care (COPC) initiative in Central Harlem. They identified the target population by collecting relevant demographic, historical, political, cultural, and economic data from the "10027" zip code. The hospital next identified the health needs of the target population by reviewing local and national databases for socioeconomic, demographic, and morbidity and mortality rates. Several health issues in the target population that were out of proportion to the rest of the city or national distribution were benchmarked. This was followed by "door to door" neighborhood surveys and focus groups that allowed the community to decide which one of the "benchmarked" health issues needed prioritizing. The majority of the participants in the survey believed the most pressing issue was tobacco smoking. Central Harlem residents were more likely to be current smokers (26%) than those in Manhattan (17%) and New York City overall (18%). 7 in 10 smokers in Central Harlem (73%) were trying to kick the habit.
As part of a two-year intervention, twenty hospital employees were sent to hand out leaflets on the streets of Central Harlem with telephone numbers of free smoking cessation resources. After the intervention, an assessment of the outcomes of the program showed no change in the percentage of current smokers or in those trying to quit. The hospital wanted to modify future interventions based upon these outcomes.
Which one of the following is an example of an essential step omitted in this COPC initiative?
A) Cultural competency training of the twenty hospital employees before distributing the smoking cessation leaflets
B) Formation of a partnership with a local community agency to train community members as health educators in smoking cessation
C) The New York City Department of Health decides which health issues need prioritizing in the target population
D) Distribution of free nicotine patches in the hospital lobby by a nurse
The correct answer is B.
Although the community was allowed to participate in prioritizing their health issues through surveys and focus groups, implementation of the intervention did not involve the community. There are six essential steps to develop a COPC initiative:
Define the community – Identify the targeted population by collecting relevant demographic, historical, political, cultural, and economic data.
Identify the health problem – Identify the health needs of the target population. This is done by reviewing local and national databases for socioeconomic, demographic, and morbidity and mortality rates. Health issues in the target population that are out of proportion to the national distribution should be benchmarked.
Prioritize health needs - Conduct neighborhood surveys and focus groups to allow the community to participate in the "community diagnosis" and which health issues need prioritizing. The New York City Department of Health may generate the morbidity and mortality data for Central Harlem and implement health initiatives, but in COPC initiatives – the community has a voice in deciding priority.
Implement appropriate interventions to address the health needs – Involve community members in implementing the intervention. This may involve training community members in specific skills such as health educators or the formation of partnerships with existing community agencies and resources. This was omitted in the initiative.
Evaluate the impact of intervention(s) – Maintain ongoing surveillance, evaluation, and assessment of the outcomes of the COPC program.
Modify future intervention(s) based upon evaluation and reassess outcomes.
Although cultural competency training of the twenty hospital employees before distribution of the smoking cessation leaflets may have helped with the original initiative, cultural competency training is not an essential step in the COPC approach. Distribution of free nicotine patches in the hospital lobby by a nurse is a hospital-based initiative, but in the COPC approach, community involvement and participation in the initiative is essential (Source: Iliffe, S., Lenihan, P. "Integrating Primary Care and Public Health: Learning for the Community-oriented Primary Care Model." International J Health Services. 2003; 33 (1); 85 – 98