PREVENTIVEMEDICINE:

Tdvaccineboostershouldbegivenevery10yearsafterage18.Asingletetanus,diphtheria,and acellularpertussis(DTaP)boosterisrecommendedbetweenages19and64years? Papsmear:itshouldstartonayearlybasisstartingatage21or3yearsaftertheirfirstsexual encounter,whichevercomesfirst.Thescreeningintervalcanincreasetoevery3yearsifthepatienthas 2or3consecutivepapsmearsthatarenormalandhasonemonogamouspartner.Thiscyclemustbe restartedwitheverynewsexualpartner. Womenwhohavehadtheircervixremovedfornonmalignancyrelatedreasonsandareoverthe ageof65or70donotneedcervicalpapsmears. TheHPVvaccinemaybegiventofemalesaged926yrsandismosteffectiveifgivenbefore coitarche. Theinfluenzavaccineisforadultswhoareinclosecontactwithchildrenaged059months(<5 years) shouldbegiventoalladultsaged50andolder.Itshouldalsobegiventoalladultswithchronic heart,lungs,liver,kidney,ormetabolic,immunosuppressedorpregnant.Healthcareworkersandthose innursinghomesshouldbevaccinated.Healthy,nonpregnantpersonsaged549yearsmayreceivethe intranasalinfluenzavaccine. ChildrenwithCFshouldreceiveannualinfluenzavaccinationsthroughouttheirlivesanda pneumococcalboosterbetweentheagesof4and6(PCV2doses+PPVformaximaleffect) ScreeningforbladdercancerisNOTrecommended,eveninpatientswhoareatriskfordeveloping thedisease. Tscore:1.5to2.5isOSTEOPENIA.PatientswithaTscoreoflessthan1.5plusriskfactorsfor osteoporosisoraTscoreoflessthan2.0shouldreceivepreventativemedications.Thepreferredmed Iseitheroralbisphosphonateorraloxifene. Patientswithcirrhosisshouldreceiveanassemblyofpreventativecare.Theyshouldbeimmunized againsthepatitisAandB,pneumococcaldisease,andyearlyinfluenzavaccination.Alladultsshould haveaTdboosteratleastevery10years. TheriskfactorsforCADaremen>=45years,women>=55years,HTN,cigarettesmoking,HDL<40 mg/dLandfamilyhistoryofprematureCAD(male<55yearsandfemale<65years).HavinganHDL level>=60negatesoneriskfactor. CADriskequivalentsincludeDM,PAD,symptomaticcarotidarterydisease,abdominalaortic aneurysm,ora10yearriskofCADof>=20% Screeningforanabdominalaorticaneurysmsisrecommendedforsmokermenaged6575. Ultrasoundistherecommendedscreeningtest.ONCE

 SomevaccinesinduceapredominantlyIgAresponse.Thebestexampleistheoralpoliovaccine, whichpromotesthedevelopmentofantipoliovirusIgAantibodiesintheGItract. PatientswhohaveCINII/IIIshouldreceiveapapsmearwithorwithoutcolostomyandendcervical curettageevery6monthsuntil3negativesamplesareobtained.Once3negativesamplesareobtained thepatientmayresumeageandbehaviorappropriatecervicalcancerscreening. Recommendationsforwhoshouldreceivethemeningococcalvaccine:individualswhoareof collegeageorlivinginbarracksordormitories,patientswhoareasplenic,andthosewithtravel exposures.(SaudiArabia) HIVrecommendedvaccines:influenza,hepatitisB,andpneumococcal.ThehepatitisAvaccine shouldbegiventomenwhoengageinsexualactiviteswithmen. Ingeneral,HIVpatientsshouldnotreceivelivevaccines.TheseincludeBCG,varicella(chickenpox), varicellazoster(shingles),anthrax,oraltyphoid,intranasalinfluenza,oralpolio,andyellowfever. TheoneexceptionistheMMRvaccinewhichmaybeusedinpatientswithoutevidenceof immunodeficiencyiftheirCD4countis>200/mm3andtheyhavenohistoryorevidenceofanAIDS definingillness. Osteoporosisshouldbescreenedinallwomenwhoare65yearsandolderwithaDEXAscan. Additionallywomenshouldbescreenediftheyareatleast60yearsoldandiftheyhaveotherrisk factors(i.ecigarettessmoking,steroiduse,lackofweightbearingexercises,lowbodymass,alcohol, poorcalcium/vitaminDintake) Colonoscopyisrecommendedforcoloncancerscreening.Itshouldstartattheageof50forpeople ofnormalriskandberepeatedevery10yearsunlessthereisevidenceofpolyps.Peoplewithhighrisk polypsshouldreceivefollowupcolonoscopiesevery35years. Coloncancerscreeningisrecommendedinallpatientsaged50andolder.Therearemanyteststhat canbeusedforscreening,i.e.FOBT(annual),flexiblesigmoidoscopy(every5yrs)colonoscopy(every10 yrs),ordoublecontrastbariumenema. Thestandardrecommendationforpatientswithanaffectedfirstdegreerelativeistostartscreening at10yearsbeforetheageattherelativewasdiagnosed.Thusifapatientsfatherwasdiagnosedwith coloncanceratage50,screeningforthepatientshouldbeginatage40. IfapatientisimmunetohepatitisBandtheyareexposedtoit,reassuranceisallyouneedtodo. Patientswithunknownvaccinationhistory,whoareexposedtohepatitisB,shouldreceiveboth passiveandactiveimmunity.PassiveimmunityisprovidedviahepatitisBimmunoglobulinshortlyafter exposure(iewithin24hours).ActiveimmunityisviathehepatitisBvaccine. VaccinationsforpreterminfantsaregivenaccordingtotheirCHRONOLOGICage,nottheir gestationalage.Thisisbecauseprematuritydoesnotmarkedlychangetheimmuneresponseto vaccinesandtheriskofinfectionandcomplicationsinpreterminfantsisgreaterthantermbabies.A preterminfantshouldthusreceiveahepatitisBvaccineatbirth(unlesstheinfantweighslessthan2 kg),andhepatitisB,rotavirus,DTaP,HiB,pneumococcal,andinactivatedpolio(SALK)at2monthsof age.

 Pancreaticcancerisafatalcancer.Itisoftendiagnosedatalocallyadvancedormetastaticage. RightnowthereisNOserologicorradiographictestthathasproveneffectiveinscreeningfor pancreaticcancerinasymptomaticadults. Decubitusulcersareasignificantsourceofmorbidityinhospitalizedpatients.Frequent repositioningevery2hoursisasimpleandeffectivewaytoreduceulcer(2hoursistheintervalchosen becausethisisthepointatwhichuninterruptedpressureonasurfacebeginstoinducetissuedamage). Pressurereducingdevices(air/foammattresses)arealsoimportantmethodsofprevention. RememberthatsmokingduringpregnancycarriesariskofIUGRbutmicrocephalyisNOTa feature. TheTORCHinfections(toxoplasmosis,rubella,CMV,HSV,andsyphilis)causeasyndrome characterizedbymicrocephaly,hepatosplenomgaly,deafness,chorioretinitis,andthrombocytopenia. Womenataverageriskforbreastcancershouldbeginhavingyearlymammogramsatage40. Clinicalbreastexamsalsomaybeappropriateevery3yrsforwomenlessthan40andyearlyforolder women.Thereisnotaclearlydefinedstoptimeformammogramscreening,butmanyexpertsagree thatscreeningthroughatleastage70isappropriate. Routinecholesterolscreening:inmenataverageriskforCADshouldbeginatage35andinwomen atage45.Expertsadvocatecheckinglipidsnomorethanevery5yearsinpatientswithnormalriskfor CADandnormallipidsinthepast.Butinthepresenceofriskfactorsorafamilyhistoryofcardiovascular diseasebeforeage50inamalerelativeorbeforeage60inafemalerelative,screeningshouldbegin betweenages20and35formalesandbetweenages20and45forfemales. Itisreasonabletoscreenindividualsevery5years,withshorterintervalsforpeoplewhohavelipid levelsclosetothosewarrantingtherapy. Chlamydiatrachomatis(frequency?)screeningisrecommendedroutinelyinallsexuallyactive womenage24andyounger,andinotherasymptomaticwomen(>24yrs)atincreasedriskforSTDs. PatientsatincreasedriskincludethosewithotherSTDandthosewithnewornumerouspartners. InpatientswhohaveHDLlessthan40mg/dl,itisrecommendedthatyoushouldincreasetheHDL above40mg/dLoncenonHDLcholesterolgoalshavebeenmet. The2m.cmedstoincreaseHDLlevelsarefibratesandnicotinicacid.BothofthemincreaseHDL anddecreaseLDLandtriglycerides.ButfibratesdecreasetriglyceridesaLOTandniacinincreasesHDLa lot.Rhabdomyolysisisapotentiallyserioussideeffectthatcanoccurwhenfibratesareusedin conjunctionwithstatins. Pneumococcalvaccineisrecommendedforpeopleoverage65,peoplebelowage65withco morbiditieslikeheart,renal,liver,lungfailure,etc,andinfantsandyoungchildren.Itcontains polysaccharides.WhereaspeptidesgetpresentedtoTcellsbymacrophagesandBcells, polysaccharidescannotbepresentedtoTcells.ThustheyyieldaBcellonly,Tcellindependent response.Personsvaccinatedbeforeage65needaboosterin5years. Childrenaged05yearsshouldbegivenvisionscreeningtoidentifythosewithstrabismus, amblyopic,andrefractiveerrors.

 OvarianCAscreening: PtswithlowriskfamilyHx(isolatedrelativeswithOvarianCA)AnnualtransvaginalUSG+CA 125 PtswithhighrishfamilyHx(MultiplerelativeswithovarianandbreastCAORsinglerelativewith ovarianCA<40yrsold)BRCA1&2+CA125TWICEeveryyear Ptswhotest+BRCA1and2Prophylacticoophorectomyaftercompletingfamily. Venousinsufficiency: Pneumaticdecompressiondevicestopreventvenousulcers. MMR: bornafter1957andnotvaccinated1doseMMR MMRboostergivenwhohadMMRasachild.