disclosures the adult periodic health exam: screening … · 17-11-09 1 the adult periodic health...
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17-11-09
1
THEADULTPERIODICHEALTHEXAM:
ScreeningandPreven@on
Dr.SusanR.GoldsteinAssistantProfessor
DepartmentofFamily&CommunityMedicineUniversityofToronto
FMFNovember9,2017
Susan.goldstein@utoronto.ca
DISCLOSURES
• Norelevantdisclosures• Allrecommenda@onsareCTFPHCunlessotherwisespecified
• Allrecommenda@onsrefertolowriskADULTS
Objec@ves
• Provideaevidence-basedPHEtoouradultpa@ents
• Orderappropriatescreeningtestsbasedonrelevantpa@entdemographics
• Useresourcesefficientlytopromotepa@enthealth
Awordaboutguidelines
• Clinicalprac*ceguidelines(CPGs)– "systema@callydevelopedstatementstoassistprac@@onersandpa@entdecisionsaboutappropriatehealthcareforspecificcircumstances.“ Field&Lohr(1990)
• Informedbysystema@creviewofevidence• Op@mizecare,improvehealthoutcomes• Minimizeharm• Costeffec@ve
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GuidelinesCanadianTaskForceonPreven*veHealthCare(CTFPHC)• Recommenda@ons
– “strong”:benefitsoutweighharms– “weak”:benefit“probably“outweighsharms
• Opportunityforcollabora@vediscussion• Levelsofevidence:GRADEprocess
– “extenttowhichourconfidenceinanes@mateoftheeffectisadequatetosupportapar@cularrecommenda@on”• high,moderate,low,noevidence
hbps://canadiantaskforce.ca/
ThePeriodicHealthExamAPeriodicHealthVisit- topreventdiseaseand
promotehealth- Ptpresentswithnoapparent
physicalormentalillness- Mustincludeintermediateor
par@alassessmentfocusingonageandgenderappropriate- history- physicalexamina@on- healthscreening- relevantcounselling.
hbp://www.health.gov.on.ca/en/pro/programs/ohip/bulle@ns/4000/bul4585.pdf
!Screening!
“Examina@onofagroupofusuallyasymptoma@cpeopletodetectthosewithahighprobabilityofhavingagivendisease,typicallybymeansofaninexpensivediagnos@ctest.”
REMEMBER!
• Screening,
Whathappenedtotheannualphysical?”
Okenanotherwisehealthypa@entreques@ngayearly“completereview”“Ageneralassessment(A003)isafamilyprac9ceserviceprovidedsomewhereotherthanthepa9ent’shomeandincludesafullhistory(includingmedical,familyandsocialhistoryandfunc/onalenquiry)andexceptforbreast,genitalorrectalexamina9onwherenotwheremedicallyindicatedorrefused,anexamina/onofallbodyparts”
hbp://www.health.gov.on.ca/english/providers/pub/ohip/physmanual/
download/sec@on_2.pdf
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TheAnnualPhysicalisNOTrecommended.
• November1979:TaskForceonthePeriodicHealthExamrecommendednoannualphysical
• Thosewhoseekitdon’tneedit• Toowideanet,riskofharm
AnnualCPX
CochraneReviewGeneralhealthchecksinadultsforreducingmorbidity
andmortalityfromdisease2012• IncludedRCTsforhealthchecksvsnoneforspecificdiseasesorriskfactors
– 182,880par@cipants• Outcomesweremorbidityandmortality• 16trials(datafor14):
– 9Totalmortality– 8CVSmortality– 8CAmortality
• Nodecreasein– morbidity,– hospitaliza@on,– disability,– worry,– addi@onalphysicianvisits,or– absencefromwork
• Nooverallreduc@onindiseasespecificoroverallmortality• Conclusion:generalhealthchecksareunlikelytobebeneficial
hbp://www.bmj.com/content/345/bmj.e7191
ChoosingWiselyPeriodicPxexamhasbenefitsReplaceAnnualPxwithintermibent“preven@vehealthchecks”
hbps://choosingwiselycanada.org/family-medicine/
Periodicpreven*vehealthvisits:amoreappropriateapproachtodeliveringpreven*veservices
FromtheCanadianTaskForceonPreven9veHealthCare
Publica9onpending:Nov.14,2017
“Annualphysicalexamina9onsmightincreasethelikelihoodoffindingcondi9onsofuncertainclinicalimportance.Althoughinves9ga9onandtreatmentofincidentallydiscoveredabnormali9escanbebeneficial,thismustbeweighedagainstthepoten9alharmsoflabeling,false-posi9veendings,andcomplica9onsfromfollow-uptes9ngandunnecessarytreatment.”
CanadianFamilyPhysician,Vol63:November2017
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PeriodicHealthExam/VisitPreven@veHealthCheck
PHE- history- physicalexamina@on- healthscreening- relevantcounselling.
Howfrequentisperiodic?Annual?Q3y?5y?...1. Demographics2. Healthhistory3. Presenceofchronicmedicalcondi@ons
(monitoringvsscreening)
ThePHE---HISTORY
1. Pa*entconcerns2. UpdateCPPinclMedreview3. Habits/Lifestyle
1. Smoking,ETOH2. Diet,vitamins3. Exercise,weight4. Safety
1. Seatbelt2. BikeHelmet3. Sunprotec@on4. Noiseprotec@on
5. Other4. Screening:
1. Cancerscreening2. Cardiovascular:
1. DM2. Lipids3. AAA?
3. Osteoporosis4. STIScreening?
5. Immuniza@ons
History:Lifestyle• Lifestyle
– Smoke:quit!• aids,nico@nereplacement,
Buproprion– ETOH:
• Women10/week(max2/day)• Men15/wk(max3/day)• Specialoccasionsmaxis+1• Don’tdrinkeveryday
– Exercise• 150min/weekmoderateac@vity• Minimum10minbursts(CCS)• +2daysweekmuscle/bone
strengthening
hbp://www.ccsa.ca/Resource%20Library/2012-Canada-Low-Risk-Alcohol-Drinking-Guidelines-Brochure-en.pdf
Diet,vitamins
• HealthyDiet– Canada’sfoodguide– Counselifdietaryrestric@ons
• AssessCalciumintake– Under50:1000mg– Age50+:1200mg– Dietaryispreferable!!!– Useonlinecalculatortodetermineintake
• E.g.OCwww.osteoporosis.ca• IOFhbps://www.iosonehealth.org/calcium-calculator
• AssessVitaminD3supplementa@on:– LowriskofVitDdeficiency:400-1000IU/day– Mod.RiskofVitDdeficiencyorover50yrs:800-1000IU/day– max2000IU
hbp://www.cmaj.ca/content/182/17/1864.full
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Obesity&Overweight(2015)• AssessBMIandWC
• Target5-10%loss0.5-1kg/week• Obese(BMI30-40)andhighriskof
DM:offerorrefertostructuredbehavioralprogramsaimedatweightloss(strong/mod)
• Overweight/obese:offerorrefertostructuredprogramsasabove(weak/mod)
• Overweight/obese:donotofferwtlossmedica@ons(eg.orlistat/metormin)(weak/mod)
Safety:
1. Seatbelt2. BikeHelmet3. Sunprotec@on4. Noiseprotec@on
hbp://www.cfpc.ca/projectassets/templates/resource.aspx?id=1184&langType=4105
History-Eyes,Dental• Dental-oralhygeine
– ReltoCVSdx,oralCa
• Vision/Eyeeval(Consensus)• Highriskincludes
– DM– Cataract– Macdegen– Glaucoma– FHxoftheabove
Age Normalscreen
AgeifHighrisk
Highriskscreen
<40 Q10years
Over40 Q3years
41-55 Q5years
Over50 Q2years
56-64 Q3years
Over60 Annual
65+ Q2years
CanadianOpthalmologicalSocietyCanJOpthalmolvol42Nov1,2007
COSVisionScreeningCPGEng_Feb07.odfn
History:SpecificScreening
1.Cancer– Colorectalcancer– Lungcancer– BreastCancer– CervicalCancer– ProstateCancer
2.CardiovascularRisk:– AAA– DM– Lipids
3.Bonehealth/Osteoporosis4.STIs&Communicabledisease
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ColorectalCancer(2016)
• NOcolonoscopyforscreening(weak/low)• AbnormalFOBT;Cscopewithin8weeks(CCO)
Age FOBT/FIT
Flexsig Evidence
50-59 Q2Y Q10Y Weak/mod
60-74 Q2Y Q10Y Strong/mod
75+ NO NO Weak/low
hbps://canadiantaskforce.ca/
LungCancer(2016)ScreeningwithLowDoseCT
Forhigh-riskpopula@onsdefinedas:(weak/low)- persons55to74yearsofage- ≥30pack-years- currentlysmokeorhavequit
withinthepast15years- arediseasefreeatthe@meof
screening.- ANNUALx3- Onlyscreenwheretreatmentis
availableCXR+/-sputumcytologyNOTrecommended(strong/low)
hbps://canadiantaskforce.ca/
BreastCancerScreening
TenyearriskofBreastCancerforwomenintheir:
40s 13/100050s 23/100060s 29/100070s 31/1000
Breastcancer(2011):anopportunityfordiscussion?
Age Mammo Evidence NNS FPs BxRate Mortalitybenefit
40-49 NO Weak/mod
2100 1/3 1/28 15%
50-69 Q2-3yr Weak/mod
720 1/4 1/28 21%
70-74 Q2-3y Weak/low
450 1/5 1/38 32%
75+ Individualchoice
BSE NO Weak/mod
CBE NO Weak/low
MRI NO Weak/noevidencehbps://canadiantaskforce.ca/
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MammographyAdverseOutcomes:
Basedonmedian11yearsscreeningatq2yrs40-49 50-69 70-74
Topreventonedeath:
NNS 2100 720 450
MammoFalsePos 1/3 1/4 1/5
UnnecessaryBiopsy 1/28 1/28 1/38
UnnecessarySurgery 1/200 1/200 1/200
Riskofdyingbaseline
1/313(0.32%) 1/155(0.64%) 1/146(0.68%)
Riskofdyingifscreened
1/370(0.27%) 1/196(0.51%) 1/217(0.46%)
Screeningbenefit 15% 21% 32%
CervicalCancer(2013)Screeningsexuallyac9vewomen
Annualvs.q3yscreen:+3/100,000cervicalCA*CCO:startage21ifsexac@ve,asdefined
Age Screen Evidence
25-29 Q3years Weak/mod
30-69 Q3years Strong/high
70+ Stopif3successivein60s
Weak/low
LowImmunity Annual
Rxfordysplasia* Annual
hbps://canadiantaskforce.ca/
Prostatecancer:PSAscreening? Prostatecancer(2014)PSAscreening?
• NOPSA• <55:(strong/low)• 55-69:(weak/mod)• 70+(strong/low)• USTFPH2012:NO(D)
BUT• Melbourneconsensusstatement
– 50-69:PSAreducesincidenceandCa-specificmortalityrates
– BaselinePSAin40sispredic@veoffuturedisease– Don’tdenyoldermenwith>10yrlifeexpectancy– Consideraspartofmul@variateapproach
• ProstateCancerCanada– “knowyournumber” hbps://canadiantaskforce.ca/
hbps://www.ncbi.nlm.nih.gov/pubmed/24206066
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CMAJ2014recommenda@onsrePSAtes@ngBenefit?
CMAJ2014recommenda@onsrePSAtes@ng:Harm?
USPreven@veServicesTaskForce(USPSTF)DRAFT2017
Menages55–69:Crecommenda*onMenage70+:D• TheUSPSTFrecommendsthatcliniciansinformmenages55to69years
aboutthepoten@albenefitsandharmsofprostate-specifican@gen(PSA)–basedscreeningforprostatecancer.
• Thedecisionaboutwhethertobescreenedforprostatecancershouldbeanindividualone.Screeningoffersasmallpoten@albenefitofreducingthechanceofdyingofprostatecancer.However,manymenwillexperiencepoten@alharmsofscreening,includingfalse-posi@veresultsthatrequireaddi@onaltes@ngandpossibleprostatebiopsy;overdiagnosisandovertreatment;andtreatmentcomplica@ons,suchasincon@nenceandimpotence.TheUSPSTFrecommendsindividualizeddecisionmakingaboutscreeningforprostatecancerakerdiscussionwithaclinician,sothateachmanhasanopportunitytounderstandthepoten@albenefitsandharmsofscreeningandtoincorporatehisvaluesandpreferencesintohisdecision.
• PleaserefertotheClinicalConsidera@onssec@onsonscreeninginAfricanAmericanmenandmenwithafamilyhistoryofprostatecancerformoreinforma@ononthesehigher-riskpopula@on
USPreven@veServicesTaskForce
PSAHarmsofScreeningCounselingTool:1000menx13yrs
hbps://canadiantaskforce.ca/
VIDEOhbps://canadiantaskforce.ca/tools-resources/videos/
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hbps://www.youtube.com/watch?v=bTgS0DuhaUU 2.CardiovascularRisks:Screening
• AAA• Diabetes• Lipids
Cardiovascular:AbdominalAor@cAneurysm(2017)
• ONE@meabdominalultrasoundfor
MEN• YES:ages65to80(weak/mod)• NO:over80(weak/low)
WOMEN:• No(strong/verylow)
• CanadianSocietyforVascularSurgeryStatement– ALLmen65-75– Considermenunder65withFhx– Considerwomenover65withhxofCerebrovascdx,smokers,orFHx
hbps://canadiantaskforce.ca/hbp://www.cmaj.ca/content/189/36/E1137.full.pdf+html
DiabetesScreening
CTFPHC2012
CanadianDiabetesAssn2013/2016update
RISKassessmentusingDiabe*cRiskCalculator
Q3-5years
ANNUAL
Whenisbloodtestrequired?
IfHiorVeryHirisk Age40thenq3yrsIfHiorVeryHiriskRiskfactors*
Frequencyofscreen Hiriskq3-5yrVeryhirisk:annual
Q3-5yrIfVeryhiorotherriskfactors,morefrequently
Preferredbloodtest HbA1C-cutoff6.5%FBSorOGTTacceptablealterna@ves
FBSorHbA1C
Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTT
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RiskCalculators:CANRISK(CanadianDiabetesRiskAssessmentQues*onnaire)hgp://www.diabetes.ca/documents/for-professionals/NBI-CANRISK.pdf
Highrisk33+
RiskCalculators:FINDRISC(FinnishDiabetesRiskScore)
AgeBMIWC
ExerciseDiet
BPmedsHxGLUFHx
HI:15-20
VeryHI21+
Diabetes:
CTFPHC2012
CanadianDiabetesAssn2013/2016update
Whenisbloodtestrequired?
Nostar@ngageIfHiorVeryHirisk
Age40thenq3yrsIfHiorVeryHiriskRiskfactors*
Preferredbloodtest HbA1C-@6.5%FBS(7.0)orOGTT(11.1)
FBSorHbA1C
Frequencyofscreen Hiriskq3-5yrVeryhirisk:annual
Lo-mod:q5?yHiriskq3yrVeryhiorotherriskfactors,morefrequently
Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTTbutshouldtestOGTTifalsoariskfactor
RiskfactorsforDM
hbp://guidelines.diabetes.ca/app_themes/cdacpg/resources/cpg_2013_full_en.pdf
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Diabetes:
CTFPHC2012
CanadianDiabetesAssn2013/2016update
Preferredbloodtest HbA1C-@6.5%FBS(7.0)orOGTT(11.1)
HbA1CFBS
Frequencyofscreen Hiriskq3-5yrVeryhirisk:annual
Over40:q3yHiriskq3yrVeryhiorotherriskfactors,morefrequently
Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTTbutshouldtestOGTTifalsoariskfactor
CDAscreeningalgorithm
hbp://guidelines.diabetes.ca/app_themes/cdacpg/resources/cpg_2013_full_en.pdf
Guidelines.diabetes.caLipidguidelines
SimplifiedLipid2015 CCS2016
ScreenMen 40-75 40-75
ScreenWomen 50-75 40-75
Useriskcalculator YesCKDuseQRISK2
Mod-FRS*orCLEM*(www.chiprehab.com}
Screenearlierifriskfactors Yes Yes,alsoifSouthAsianFirstNa@ons
hbp://www.cfp.ca/content/61/10/857hbp://ccs.ca/images/Guidelines/PocketGuides_EN/Pocket_Guides/Lipids%20Pocket%20Guide_2016.pdf
*notvalidatedforSouthAsian,Firstna@ons,otherimmigrantpopula@ons,considerQRISK2
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CCS:LipidGuidelinesScreenregardlessofagewithriskfactors:
– Evidenceofatherosclerosis– AAA– DM– BP– CKD– Obese– Currentsmoker– Lipiddeposits(arcus,xanthalasma)– HIV– Inflammatoryboweldisease– COPD– Erec@ledysfn– FHX:prematurecvd(55/65)ordyslipidemia– BPInpregnancy(new!)-medianageof1stcvseventage38!!
hbp://www.onlinecjc.ca/ar@cle/S0828-282X(16)30732-2/pdf
Lipidguidelines
SimplifiedLipid2015 CCS2016
LoriskScreenfrequency 5years 5years*
Nonfas@nglipids Yes YesifTG<4.5
Otherscreeningtests LimiteduseforCACscoreorLp(a)
1’preven@on,whototreat FRS10-19%moddosesta@nFRS20+%highdosesta@n
Sta@nindicatedgroupFRS10-19&LDL>3.5*FRS20+YES
Non-HDLcholorApoBareop@ons:notaffectedbyameal!!Withfood:LDLdown10%TGup20%
CCS:Sta@nindicatedcondi@onsTreatregardlessofLDL
1. Clinicalatherosclerosis-MI,ACS,CVA,TIA,Caro@ddx,PVD
2.AAA->3cmorpriorsurgery
3.DM:age40+-or15yrdura@on,or-age30+withmicrovasccomp
4.CKD:3mo+and-uACR>3.0OReGFR<60
5.LDL>=5.0mmol,familialhyperChol
hbp://www.onlinecjc.ca/ar@cle/S0828-282X(16)30732-2/pdf
Lipidguidelines
SimplifiedLipid2015 CCS2016
Monitoring:targetlipidsifRxd
NONoALT,CKrou@ne
LDL50%reduc@onorto2.0(nonHDL2.6)
Over75 Discourage,individualize FRSnotvalidated
Lifestyle Counselreexercise,healthydietEsp.MedDiet(strong)NOOmega3PUFAsuppsOtherdiets:seeguidelines
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3.Bonehealth&osteoporosis(2013)
• CTFPHCreferences2010guidelines– CMAJ:2010Clinicalprac@ceguidelinesofthediagnosisandmanagementofosteoporosisinCanada
• Purpose:topreventfragilityfractures(vsdiagnosingosteoporosis)
• Riskassessment-– Assessmenandwomenage50+forriskfactorsfor#
• 1.Lowbonedensity
WhentomeasureBMD?
hbp://www.osteoporosis.ca/health-care-professionals/guidelines/
3.Bonehealth&osteoporosis(2013)• Riskassessment-
– Assessmenandwomenage50+forriskfactorsfor#• 1.Lowbonedensity
– 10yrrisk:CAROCrecommendedasisCdndata
• 2.Fallsandfractures-askaboutFALLSinelderly– Ifyes:getupandgotest
• Annualheight:– Ifsuspectvertebralfracture:lateralxrayT/Lspine
• WhentomeasureVitDlevel:– Ifrecurrent#,pretreatmentorbonelossdespitetreatment
– ONLYaker3mosoftreatment&don’trepeatif>75nmol/L
Recommenda@ons:FracturePreven@on
• Exercise-– aerobic– resistance– balance– corestabilityifvert#
• FallPreven@on• CalciumandVitD
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4.STIs:WhototestCanadianSTIGuidelines(2013)
• Screenhighrisk– Sexac*veyouth,25y/o– Newpartnersormorethan2partnersinthepastyear– Serialmonogamy-seriesofrela@onshipsover@me– Nocontracep@onornonbarriermethods– ContactsofpeoplewithSTIs– Sexworkers/partners– Ivdrugusers/partners– Unsafesexualprac@ces– Homeless– Assault/abuse– HxofSTI– Anonymoussexualpartneringor“survivalsex”
hbps://www.canada.ca/en/public-health/services/infec@ous-diseases/sexual-health-sexually-transmibed-infec@ons/canadian-guidelines/sexually-transmibed-infec@ons/canadian-guidelines-
sexually-transmibed-infec@ons-17.html
STItes@ng• Whattotest:– *Chlamydia:swaborurine(M:novoidx2hrs)– *Gonorrhea:cervicalswab/urine– Syphilis:VDRLserology– HepBsag– HIV?
• Unprotectedanal/vagintercourse• Immune-compromised• Symptoma@c• Reques@ngit
– ZIKAvirustes@ng
*allsexac@veannuallyuptoage25hbp://healthycanadians.gc.ca/publica@ons/diseases-condi@ons-maladies-affec@ons/commibee-statement-
treatment-preven@on-zika-declara@on-comite-traitement-preven@on/index-eng.php?&_ga=2.142326650.977125862.1509904030-1094833840.1502453926#a9
STItes@ngZIKAvirustes@ng:
• Ifss3-dayspostarriveto14dayspostdeparturefromendemicarea
• Ifacutelyunwell>10dayssstestjustserology• <10dayssstestbothRT-PCRandserology• Malesposttravelwithillness-atleast2weekspostexposure
• Assympmaleswithtravelhistoryifpartnerconsideringpregnancyinnext6mos
• Recommenda@onforboth:abstain/condomsfor2mosposttravel
• Pregnantwomen:iftravelhx,shouldassess,considerscreen
hbp://healthycanadians.gc.ca/publica@ons/diseases-condi@ons-maladies-affec@ons/commibee-statement-treatment-preven@on-zika-declara@on-comite-traitement-preven@on/index-eng.php?
&_ga=2.142326650.977125862.1509904030-1094833840.1502453926#a9
Hepa@@sC(2017)• NOforlowrisk(strong/verylow)• YESonlyifRiskfactors
– Bloodtxpriorto1992– Iv/nasaldruguser– SexualcontactofHepCorivdruguser
– Dialysis– Incarcera@on– Taboo– Percutaneousexposure– MomwithHcv
• CanadianLiverFounda@on:one@metes@ngifborn1945to1975
hbps://canadiantaskforce.ca/
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Immuniza@on:AdultVaccines• TdapONCEakerage18,then
Tdq10yr• IPV:adulttravellersx1• MMR:Idoseborn>1970if
suscep@ble• Varicella:2dosesasadultif
suscep@ble• Meningococcal:onedose<=24
y/oifnotpreviouslyimmunized• Flushot-annual• Pneumonia-preventIPD&CAP
– Prevnar13@65y/o• @50ifimmsupp/hiv/HSCT
– Pneumo23@65:8weekslater• earlierifatrisk
• HPV• HZ
hbps://www.canada.ca/en/public-health/services/canadian-immuniza@on-guide.html
Adultpneumococcalvaccines
PREVNAR13
PNEUMO23
hbp://www.health.gov.on.ca/en/public/programs/immuniza@on/docs/pcv_hcp_qa_en.pdf
AdultVaccines:HPV,HZHPV(Cervarix,Gardasil,Gardasil9)
– Women9to44+;Menuptoage26+– NACI:NOUPPERAGELIMIT– CONSIDERFORALLMEN/WOMEN!!– Only2dosesrequiredunderage15
hbps://www.canada.ca/en/public-health/services/canadian-immuniza@on-guide.html
Zostavax Shingrex
Type live adjuvant
Dosing 1dose 2doses:0,2-6mos
PreventnHZages50-70
66-80% 93-97%
>70 32% 91%
PreventPHN
66% 88%
Cangivewithpneumo23
AvailableJan2018
Wait1yearpostHZ
History-Other
• ReviewofSystems?NO– ButDOaddresspa@entconcerns???
• Specialconsidera@ons**– Menover45:LUTS,ED– Womenover45:menopausescreen
• MQ6:Menses,VMS,VVA,Bladder,Sleep,Mood
• WhatNOTtoask/screenfor:– Depression– Cogni@veimpairment>65ifasymptoma@c
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PHYSICALEXAM PhysicalExam
• HT• WT• BMI• WC
Men Women
NorthAmerican 102cm(40”) 88cm(35”)
Europe,SubsaharanAfrica,Middleeast,Mediterranean
94cm 80cm
Asia,Japan,South/CentralAmerica
90cm 80cm
PhysicalExam
• Vision
– Snellen-elderly(B)• Hearing?
– whisperedvoicetest-elderly(B)
• BloodPressure
BP:CHEPguidelines20162017guidelinespending,nochangestoassessment
• Office:Electronicpreferredovermanual(C)– manual:averagereadings2&3
• Ifhighconfirmbyoutsidereadings:– ABPMorHBPM– HBPM:
• am/pmreadingsx7,averagelast12readings
• Ifofficehighandhomeislow:doABPM
Method DxofHTn
OfficeOBPM 140/90
AutomatedOfficeAOBP
135/85
HomeHBPM 135/85
AmbulatoryABPM Awake135/85or24hMean130/80
Diabe@cs 130/80
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2017CHEPguidelines
guidelines.hypertension.ca
Breastexam?NO
CanadianTaskForceonPreven@veHealthCare
Pelvicexam?NO(2016)
• TheCTFPHCrecommendsnotperformingascreeningpelvicexamina@on(ie.asymptoma@cpa@ent)toscreenfor– non-cervicalcancer,– pelvicinflammatorydisease,or– othergynecologicalcondi@onsinasymptoma@cwomen.(strong/mod)
CanadianTaskForceonPreven@veHealthCare
DigitalRectalExam?NO
CanadianTaskForceonPreven@veHealthCare
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GENERALLAB&SCREENINGTESTSJinasymptoma@cpa@ents
CHOOSINGWISELY:• NO:
– Hb– TSH– PSA– U/A– EKG– CXR– XST
Timesavers
Pa@entPrep/Handouts
ChoosingWisely
AddresscommonissuesinadvancePromoteacollabora@vediscussion
Makeyourownpa*enthandout?• Lifestyle
– Smoke– Etoh– Exercise– Diet– Ca++,VitD– Safetyinterven@ons
• Immuniza@ons– Tetq10– AnnualFlushot– Pneumoniavaccines– HPV– HZ
• Commonteststhatwemayorder– Bloodwork:DM,lipids
• NOPSA– EKG:no– CXR:no– BMD65orearlier– Mammoq2y@50– Papq3yr– FOBTq2yr@50
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Resources
• CanadianTaskForceforPreventa@veHealthwww.canadiantaskforce.ca/ctphc-guidelines
• NACIhbp://www.phac-aspc.gc.ca/naci-ccni/• ChoosingWiselyh^ps://choosingwiselycanada.org/
• Others:CDA,CHEP,CCS
Primrose2015Preven@veScreeningGuidelines
Updateonage-appropriatepreven@vemeasuresandscreeningforCanadianprimarycareproviderswww.cfp.ca/content/62/2/131.full
CFPCPreven@veCareChecklistshbp://www.cfpc.ca/projectassets/templates/resource.aspx?
id=1184&langType=4105
STAMPS
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Summary
• PHEisintendedasapa@ent-centeredpreven@onandscreeninginterven@oninHEALTHYindividuals
• Frequencyandcontentshouldbeindividualized– Don’toverlookyourpa@entswithchronicdx
• Notallguidelinesarecreatedequal• Thereiss@llan“art”tothescienceofmedicine
Thankyoususan.goldstein@utoronto.ca
PSAcounseling(2014)Harms&Benefits
• Resultsofscreening1,000menwiththePSAtestage55–69years,screenedovera13-yearperiod,andwithaPSAscreeningthresholdof3.0ng/ml
• 720menwillhaveanega@vePSAtest.• 178menwithaposi@vePSAinwhomfollow-uptes@ngdoesnotiden@fy
prostatecancer.• 4ofthese178willexperiencebiopsycomplica@onssuchasinfec@onand
bleedingsevereenoughtorequirehospitaliza@on.• 102menwillbediagnosedwithprostatecancer.• 33ofthese102prostatecancerswouldnothavecausedillnessordeath.
Becauseofuncertaintyaboutwhethertheircancerwillprogress,mostmenwillchoosetreatmentandmayexperiencecomplica@onsoftreatment.
• 5menwilldiefromprostatecancerdespiteundergoingPSAscreening.• 1manwillescapedeathfromprostatecancerbecauseheunderwent
PSAscreening
hbps://canadiantaskforce.ca/guidelines/published-guidelines/prostate-cancer/
Figure5
hbp://www.onlinecjc.ca/ar@cle/S0828-282X(16)30732-2/pdf
17-11-09
21
Pneumo23
HighriskgroupsforPneumonia• Chroniccerebralspinalfluid(CSF)leak• Chronicneurologiccondi@onthatmayimpairclearanceoforalsecre@ons• Cochlearimplants(includingthosechildrenwhoaretoreceiveimplants)• Chroniccardiacorpulmonarydisease• Diabetesmellitus• Asplenia(func@onaloranatomic)• Sicklecelldiseaseorotherhemoglobinopathies• Congenitalimmunodeficienciesinvolvinganypartoftheimmunesystem,includingB-lymphocyte
(humoral)immunity,T-lymphocyte(cell)mediatedimmunity,complementsystem(properdin,orfactorDdeficiencies),orphagocy@cfunc@ons
• Hematopoie@cstemcelltransplant(recipient)• HIVinfec@on• Immunosuppressivetherapyincludinguseoflongtermcor@costeroids,chemotherapy,radia@on
therapy,post-organtransplanttherapy,andcertainan@-rheuma@cdrugs• Chronickidneydisease,includingnephro@csyndrome• Chronicliverdisease(includinghepa@ccirrhosisduetoanycause)• Malignantneoplasmsincludingleukemiaandlymphoma• Solidorganorislettransplant(candidateorrecipient)
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