Current Practice Guidelines in Primary Care (2007) by Cuidar de Idosos

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Abbreviations AAA: abdominal aortic aneurysm ACE: angiotensin-converting enzyme AIDS: acquired immunodeficiency syndrome ALT: alanine aminotransferase AUDIT: Alcohol Use Disorder Identification Test BCG: bacille Calmette-Guérin BE: barium enema BHS: British Health Service BMI: body mass index BP: blood pressure BSE: breast self-examination CAGE: need to Cut down on drinking, Annoyed by criticism, Guilty about drinking, need for Eye-opener drinks (screening test for alcoholism) CAS: carotid artery stenosis CBE: clinical breast examination CEA: carotid endarterectomy CHD: coronary heart disease CHS: Canadian Hypertension Society CIN: cervical intraepithelial neoplasia CNS: Canadian Neurosurgical Society CT: computed tomography CXR: chest radiography DBP: diastolic blood pressure DRE: digital rectal examination DSM IV: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. DTaP: diphtheria and tetanus toxoids + acellular pertussis vaccine DTP: diphtheria-tetanus-pertussis EIA: enzyme immunoassay ERCP: endoscopic retrograde cholangiopancreatography FDA: Food and Drug Administration FEV1: forced expiratory volume in 1 second FOBT: fecal occult blood test

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FTA-ABS: fluorescent treponemal antibody, absorbed test GVHD: graft vs. host disease HAV: hepatitis A virus HbA1c: glycosylated hemoglobin HbsAg: hepatitis B surface antigen HBV: hepatitis B virus HCC: hepatocellular carcinoma HDL: high-density lipoprotein cholesterol Hib: Haemophilus influenzae Type B HIV: human immunodeficiency virus HMG-CoA: 3-hydroxy-3-methylglutaryl coenzyme A HPV: human papillomavirus HRT: hormone replacement therapy IM: intramuscular(ly) INH: isoniazid INR: international normalized ratio IPV: inactivated poliovirus vaccine IV: intravenous(ly) LDCT: low-dose computed tomography LDL: low-density lipoprotein cholesterol MI: myocardial infarction MMR: measles-mumps-rubella MPA: medroxyprogesterone acetate NCEP: National Cholesterol Education Program NIDDKD: National Institute of Diabetes and Digestive and Kidney Diseases NIDR: National Institute of Dental Research NIH: National Institutes of Health NNH: number needed to harm NNT: number needed to treat OGTT: oral glucose tolerance test OPV: oral poliovirus vaccine OR: odds ratio PAD: peripheral atherosclerotic disease

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PEF: peak expiratory flow PPD: purified protein derivative (tuberculin) PRIME-MD: Primary Care Evaluation of Mental Disorders PSA: prostate-specific antigen QALY: quality-adjusted life-year RCT: randomized controlled trial RPR: rapid plasmin reagin test RR: relative risk SBP: systolic blood pressure STD: sexually transmitted disease SVS: Society of Vascular Surgeons TB: tuberculosis TC: total cholesterol Td: tetanus-diphtheria toxoid TRUS: transrectal ultrasonography TSH: thyroid-stimulating hormone VDRL: Venereal Disease Research Laboratory (test for syphilis) WHO: World Health Organization

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Preface Current Practice Guidelines in Primary Care, 2007 is intended for primary care clinicians, including not only residents and practicing physicians in the specialties of family medicine, internal medicine, pediatrics, and obstetrics and gynecology, but also medical and nursing students during their ambulatory care rotations, registered nurses, nurse practitioners, and physician assistants. Its purpose is to make screening, prevention, and management recommendations readily accessible and available for clinical decision making. The recommendations included are issued by governmental agencies, expert panels, medical specialty organizations, and other professional and scientific organizations. Current Practice Guidelines in Primary Care, 2007 is essential for the busy clinician. New recommendations are continually being published by various organizations that express different positions on the same topics, and current guidelines require revision as new evidence from clinical and outcomes research emerges. Indeed, we update or completely revise approximately 40% of Current Practice Guidelines in Primary Care each year. The intent of this guide is both to help clinicians select the most appropriate clinical services and interventions for a given situation and to provide clinicians with quick access to the latest information. Current Practice Guidelines in Primary Care, 2007 has been updated using PubMed searches limited to articles published in English between 6/11/05 and 7/24/06, as well as via the websites of and contact with the major professional societies, the Agency for Healthcare Research and Quality "Guidelines Clearinghouse," and the U.S. Preventive Services Task Force. This updating " in the Contents). New strategy led to substantial modification of many guidelines (look for " checkmark material has been added addressing abdominal aortic aneurysm, coronary artery disease,

attention-deficit/hyperactivity disorder, hemochromatosis, cancer survivorship, chronic obstructive pulmonary disease, depression screening, stroke risk, and immunizations. We are grateful to Jennifer Vancura for her assistance in contacting and obtaining information from professional societies and updating internet addresses, as well as the following professional societies for providing updates/feedback on their content: AHRQ, AAD, AAFP, AAHPM, AAN, AAO, AAP, AACE, ACC, ACCP, ACP, ACPM, ACR, ADA, AGS, AHA, AMA, AOA, ASGE, ATS, AUA, Bright Futures, CTF, NAPNAP, NCI, NHPCO, ACIP, NIAAA, and USPSTF. Ralph Gonzales, MD, MSPH Associate Professor University of California, San Francisco San Francisco, California Jean S. Kutner, MD, MSPH file:///D|/local/PDF/E-Book(PDF)/Current%20Practice...idelines%20in%20Primary%20Care%20(2007)/Preface.htm (1 of 2) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:38:53]

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Associate Professor and Division Head University of Colorado at Denver, and Health Sciences Center Denver, Colorado December 2006

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Current Practice Guidelines in Primary Care 2007 Ralph Gonzales, Jean S. Kutner

Abbreviations Preface Disease

Disease

Screening

Prevention

Management

Appendices

Abdominal Aortic Aneurysm Alcohol Abuse & Dependence Anemia Attention-Deficit/Hyperactivity Disorder Cancer, Bladder Cancer, Breast Cancer, Cervical Cancer, Colorectal Cancer, Endometrial Cancer, Gastric Cancer, Liver Cancer, Lung Cancer, Oral Cancer, Ovarian Cancer, Pancreatic Cancer, Prostate Cancer, Skin Cancer, Testicular Cancer, Thyroid Carotid Artery Stenosis Child Abuse & Neglect Chlamydial Infection Cholesterol & Lipid Disorders, Adults Coronary Artery Disease Dementia Depression Diabetes Mellitus, Gestational Diabetes Mellitus, Type 2 Falls in the Elderly Family Violence & Abuse Hearing Impairment Hemochromatosis Hepatitis B Virus Infection, Chronic Hepatitis C Virus Infection, Chronic Human Immunodeficiency Virus Hypertension, Children & Adolescents Hypertension, Adults Lead Poisoning file:///D|/local/PDF/E-Book(PDF)/Current%20Practice...2007)/I%20-%20Disease%20Screening/1.%20Contents.htm (1 of 2) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:43]

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Obesity Osteoporosis Scoliosis Syphilis Thyroid Disease Tobacco Use Tuberculosis Visual Impairment, Glaucoma, & Cataract

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Note: Large images and tables on this page may necessitate printing in landscape mode. Copyright ©2007 The McGraw-Hill Companies. All rights reserved. CURRENT Practice Guidelines in Primary Care 2007 > Disease Screening >

Disease Screening: Abdominal Aortic Aneurysm Organization

Population

Recommendations

Comments

Source

Men aged 65–

One-time screening for

1. Surgical

USPSTF

75 years

AAA by ultrasonography

repair of AAA

in men aged 65–75 years.

5.5 cm

(Date) USPSTF (2005)

reduces AAAspecific mortality. 2. Unclear benefit-harm ratio in men who have never smoked and women.

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Disease Screening: Alcohol Abuse & Dependence Organization Population Recommendations Comments

Source

(Date) Bright

Adolescents Ask all adolescents

1. Parents

http://www.brightfutures.

should

org

Futures

annually about

(2002)

their use of alcohol. routinely receive instructions on monitoring their adolescent's social and recreational activities for use of alcohol.a 2. The finding of alcohol use or abuse should provoke an assessment of other conditions that co-vary with alcohol abuse, such as cigarette smoking, sexual activity, and mood disorders.

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3. Guidelines on treatment of alcohol abuse in adolescence have been published. (J Am Acad Child Adolesc Psychiatry 1998;37:122) NIAAA (2002) College students

Screen all students

1. 1,400

http://www.

on National Alcohol

college

collegedrinkingprevention.

Screening Day.b

students

gov

between the ages of 18 and 24 die each year from alcohol-related injuries. (J Studies Alcohol 2002;63:136) 2. Targeting only those with identified problems misses students who drink heavily or misuse alcohol occasionally. Nondependent, high-risk drinkers account for majority of alcohol-related deaths and file:///D|/local/PDF/E-Book(PDF)/Current%20P...ening/Alcohol%20Abuse%20and%20Dependence.htm (2 of 6) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:46]

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damage. 3. In 2001, 18% of U.S. college students had clinically significant alcohol-related problems in the past year. [Arch Gen Psychiatry 2005 Mar;62 (3):321] NIAAA (2005) Adults

Screen all adults

1. A free guide,

for heavy drinking

including

(see Screening

pocket version,

Instruments:

of "Helping

Alcohol Abuse).

patients who

Assess heavy

drink too

drinkers for alcohol

much: a

use disorders.

clinician's

Advise and assist

guide" is

with a brief

available at

intervention (see

http://www.

Alcohol

niaaa.nih.gov,

Dependence:

or by calling

Evaluation &

301-443-3860.

Management). Continue support at follow-up visits.

http://www.niaaa.nih.gov

2. The COMBINE study reported better 16-week abstinence rates with medical management using

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naltrexone, but not acamprosate. Combined behavioral intervention (CBI) plus placebo medical management was also more effective than CBI alone. There was no difference between any groups in abstinence rates at 1-year follow-up. (JAMA 2006;295:2003) AAFP (2004) USPSTF (2004)

Adults

Screen all adults,

1. A systematic

Ann Intern Med

particularly

review

2004;140:557

pregnant women,

concluded that

using relevant

the Alcohol Use

history or a

Disorders

standardized

Identification

screening

Test (AUDIT)

http://www.aafp.org/

instrument.

was most

online/en/home/clinical/

Implement brief

effective in

exam.html

behavioral

identifying

counseling

subjects with

interventions to

at-risk,

reduce alcohol

hazardous, or

misuse.c

harmful

http://www.ahrq.gov/ clinic/cpsix. htm#screening

drinking (sensitivity, file:///D|/local/PDF/E-Book(PDF)/Current%20P...ening/Alcohol%20Abuse%20and%20Dependence.htm (4 of 6) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:46]

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51%–79%; specificity, 78%–96%); while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%–94%; specificity 70%– 97%). (Arch Intern Med 2000;160:1977) d

2. Screening coupled with brief physician advice is costeffective (Med Care 2000;38:7) and produces small to moderate reductions in alcohol consumption. 3. Light to moderate alcohol consumption has been associated with some health benefits in file:///D|/local/PDF/E-Book(PDF)/Current%20P...ening/Alcohol%20Abuse%20and%20Dependence.htm (5 of 6) [2007/11/13 下午 12:39:46]

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nonpregnant adults, including reduced risk for coronary artery disease. aThe

importance of family attitudes toward alcohol is also acknowledged, and it is recommended that

clinicians urge parents to use alcohol safely and in moderation, to restrict children from family alcohol supplies, and to recognize the influence their own drinking patterns can have on their children and parenting. bNational

Alcohol Screening Day is April 5, 2007; sponsored by the National Institute on Alcohol Abuse

and Alcoholism and other organizations (http://mentalhealthscreening.org/ alcohol.asp). cHazardous

drinking is defined as more than 7 drinks per week for women and more than 14 drinks per

week for men. Harmful drinking describes people with physical, social, or psychological harm from drinking who do not meet criteria for dependence. (Arch Intern Med 1999;159) AGS recommends: All patients 65 or older should be asked about their use of alcohol at least annually. dSee

Appendix I: Screening Instruments: Alcohol Abuse for CAGE and AUDIT instruments.

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Disease Screening: Anemia Organization

Population

Recommendations

Comments

Source

Infants aged

Perform selective,

1. Reticulocyte

AAFP

6–12 months

single hemoglobin or

hemoglobin

hematocrit screening

content is a more

for high-risk infants.a

sensitive marker

(Date) AAFP (2006)

than serum hemoglobin level for iron-deficiency.

http:// www. aafp.org/ online/ en/ home/ clinical/ exam. html

USPSTF (2006)

Infants aged

Evidence is insufficient

1. Recommends

6–12 months

to recommend for or

routine iron

against routine

supplementation in

screening.

high-risk children

USPSTF

aged 6–12 months.

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USPSTF (2006)

Pregnant

Screen all women with

1. Insufficient

women

hemoglobin or

evidence to

hematocrit at first

recommend for or

prenatal visit.

against routine use of iron supplements for non-anemic pregnant women. (USPSTF)

USPSTF http:// www. ahrq. gov/ clinic/ cpsix. htm

2. When acute stress or inflammatory disorders are not present, a serum ferritin level is the most accurate test for evaluating iron deficiency anemia. Among women of childbearing age, a cut-off of 15 mg/ dL has sensitivity of 75%, specificity of 98%. (Br J Haematol 1993;85:787) aIncludes

infants living in poverty, blacks, Native Americans and Alaska Natives, immigrants from

developing countries, preterm and low birthweight infants, and infants whose principal dietary intake is unfortified cow's milk.

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Disease Screening: Attention-Deficit/Hyperactivity Disorder (ADHD) Organization Population

Recommendations Comments

Source

Children aged 6–

Initiate an

1. The sharp

Pediatrics

12 years with

evaluation for

rise in

2000;105:1158

inattention,

ADHD. Diagnosis

stimulant

hyperactivity,

requires the child

prescriptions

impulsivity,

meet DSM IV

between 1987

academic

criteria,a and direct

and 1996

(Date) AAFP (2000) AAP

underachievement, supporting

plateaued

or behavioral

evidence from

between 1996

problems.

parents or

and 2002. In

caregivers and

2002, 4.8% of

classroom teacher.

6–12-year-olds

Evaluation of child

received

with ADHD should

stimulant

include assessment

therapy,

for coexisting

compared with

disorders.

3.2% of 13–19year-olds. (Am J Psychiatr 2006;163:579) 2. An estimated 4.4% of the U. S. adult population meets criteria for ADHD;

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large majority is undiagnosed and untreated. (Am J Psychiatr 2006;163:716) 3. The FDA recently approved a "black box" warning regarding the potential for cardiovascular side effects of ADHD stimulant drugs. (NEJM 2006;354:1445) aDSM-IV

Criteria for ADHD: I: Either A or B. A: Six or more of the following symptoms of

inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level. Inattention: (1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. (2) Often has trouble keeping attention on tasks or play activities. (3) Often does not seem to listen when spoken to directly. (4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). (5) Often has trouble organizing activities. (6) Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). (7) Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools). (8) Is often easily distracted. (9) Is often forgetful in daily activities. B: Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level. Hyperactivity: (1) Often fidgets with hands or feet or squirms in seat. (2) Often gets up from seat when remaining in seat is expected. (3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). (4) Often has trouble playing or enjoying leisure activities quietly. (5) Is often "on the go" or often acts as if "driven by a motor." (6) Often talks excessively. Impulsivity: (1) Often blurts out answers before questions have been finished. (2) Often has trouble waiting one's turn. (3) Often interrupts or intrudes on others (e.g., butts into conversations file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...n-Deficit,Hyperactivity%20Disorder,%20ADHD.htm (2 of 3) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:48]

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or games). II: Some symptoms that cause impairment were present before age 7 years. III: Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home). IV: There must be clear evidence of significant impairment in social, school, or work functioning. V: The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

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Disease Screening: Cancer, Bladder Organization Population

Recommendations

Comments

Source

Asymptomatic Recommends

1. Benefits:

http://www.aafp.

persons

against routine

Based on

org/online/en/home/

screening for

fair

clinical/exam.html

bladder cancer in

evidence,

adults.

screening for

(Date) AAFP (2006) USPSTF (2004)

bladder and other

http://www.ahrq. gov/clinic/uspstf/ uspsblad.htm

urothelial

http://www.cancer.

cancers

gov/

would have

cancer_information/

little or no

testing

impact on mortality. Harms: Based on fair evidence, screening for bladder and other urothelial cancers would result in unnecessary diagnostic file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...-%20Disease%20Screening/Cancer,%20Bladder.htm (1 of 4) [2007/11/13 下午 12:39:49]

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procedures with attendant morbidity. (http://www. cancer.gov/ cancertopics/ pdq/ screening) 2. A high index of suspicion should be maintained in anyone with a history of smoking or exposure to another risk factor.a 3. FDA approved use of bladder markers in screening for bladder cancer. Decision analysis of total cost of screening a low- and high-risk population file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...-%20Disease%20Screening/Cancer,%20Bladder.htm (2 of 4) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:50]

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for bladder cancer using NMP22: (1) Screening all men, regardless of degree of risk, yields cost per cancer detected of $783,913, $269,028, and $139,305 for ages 50–59, 60–69, and 70–79 years, respectively. (2) Screening only highrisk yields cost per cancer detected of $3,310. [Urol Oncol 2006;24 (4):338]

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AccessMedicine - Print aIndividuals

who smoke have a fourfold to sevenfold increased risk of developing bladder cancer

than individuals who have never smoked. Additional environmental risk factors: exposure to aminobiphenyls; aromatic amines; azodyes; combustion gases and soot from coal; chlorination byproducts in heated water; aldehydes used in chemical dyes and in the rubber and textile industries; organic chemicals used in dry cleaning, paper manufacturing, rope and twine makers, and apparel manufacturing; contaminated Chinese herbs; arsenic in well water. Additional risk factors: prolonged exposure to urinary Schistosoma haematobium bladder infections, cyclophosphamide or pelvic radiation therapy for other malignancies.

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Disease Screening: Cancer, Breast Organization Population Recommendationsa, Comments (Date)

ACS (2005)

Source

1. Breast self-

http://www.cancer.

aged 20–

examination

org

39 years

does not

Women

CBE every 3 years.

improve breast cancer mortality (Br J Cancer 2003;88:1047) and increases the rate of false-positive biopsies. (J Natl Cancer Inst AAFP (2006) NCI (2002)

Women aged years

Mammography every 1–2 years.

2002;94:1445) 2. 25% of breast cancers

http://www.aafp.org/ online/en/home/ clinical/exam.html

diagnosed

http://www.cancer.

before age 40

gov

years are attributable to BRCA1 mutations.c These women may benefit file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...0-%20Disease%20Screening/Cancer,%20Breast.htm (1 of 6) [2007/11/13 下午 12:39:51]

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from more frequent mammography as well as earlier initiation of mammogram and/or the addition of breast ultrasound or MRI. (ACS) 3. Overall, in the U.S., ACS (2005)

Women aged years

Mammography and

mammography

http://www.cancer.

CBE yearly.

every 1–2

org

years has a sensitivity of 75% and specificity of 92.3% for detecting breast cancer. (Ann Intern Med 2003;138:168) Sensitivity is 69% in women aged 40–49; sensitivity is 83% in women 80 years. 4. Breast cancer–specific mortality is reduced by 20%–35% by

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USPSTF

Women

(2002)

aged

years

Mammography, with

mammography

http://www.ahrq.gov/

or without CBE,

screening

clinic/uspstf/uspsbrca.

every 1–2 years.

women aged

htm

50–69 years. (NEJM 2003;348:1672) 5. Annual screening of young (age 35– 49 years old) high-risk women with MRI and CTF (2001)

Women

Current evidence

aged 40–

does not support the

49 years

recommendation that screening mammogram be

mammography is superior to

http://www.ctfphc.org

either alone. (Lancet 2005;365:1769)

included in or

6. Digital

excluded from the

mammography

periodic health exam. is more accurate than film mammography for screening women under the age of 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women. (NEJM 2005;353:1773) file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...0-%20Disease%20Screening/Cancer,%20Breast.htm (3 of 6) [2007/11/13 下午 12:39:51]

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AGS (1999)

Women aged years

Mammography and

1. Encouraging

http://www.

CBE every 1–2

individualized

americangeriatrics.

years, with no upper

decisions may

org/education/

age limit for women

allow screening

cp_index.shtml

with an estimated

to be targeted

life expectancy of

years. AGS recommends, in addition, monthly BSE.

to older women for whom the potential benefit outweighs the potential burdens. (J Gen Intern Med 2001;16:779– 784) 2. Extending biennial screening to age 75–80 is estimated to cost $34,000– $88,000 per life-year gained. It is most costeffective to target healthy

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women rather than those with several competing risks for death. [Ann Intern Med 2003;139(10)] AAFP (2006) USPSTF (2005)

Women

Refer for genetic

http://www.aafp.org/

with family

counseling and

online/en/home/

history

evaluation for BRCA

clinical/exam.html

associated

testing.

with

http://www.ahrq.gov/ clinic/uspstf/

increased

uspsbrgen.htm

risk for deleterious mutations in BRCA1 or BRCA2 genes COG (2006)

Chest

Yearly mammogram

http://www.

radiation (

beginning 8 years

survivorshipguidelines.

20 Gy to

after radiation, or at

org

mantle,

age 25, whichever

mini-

occurs last.

mantle, mediastinal, chest, axilla)

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about the value of screening mammograms was triggered by a Cochrane review published

on October 20, 2001. (Lancet 2001;358:1340–1342) This review cited a number of methodologic and analytic flaws in the large long-term mammography trials. The USPSTF and NCI concluded that the flaws were problematic but unlikely to negate the consistent and significant mortality reductions observed in the trials. bSummary cIn

of current evidence: JAMA 2005;293:1245.

one study, nearly half of BRCA-positive women developed malignant disease detected by

mammography less than 1 year after a normal screening mammogram. [Cancer 2004;100(10)]

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Disease Screening: Cancer, Cervical Organization Population Recommendations Comments

Source

(Date) ACS (2006)

Women

Annual Pap smear

1. Cervical cancer is http://www.cancer.

within 3

until age 30 (every

causally related to

years after

2 years if liquid-

infection with HPV.

first sexual

based Pap test).

Other risk factors

intercourse (ACS)b

include early onset

or by age

of sexual

21, whichever comes firsta

At age

30, if 3

consecutive normal results, may screen every 2–3 years. Continue to screen annually if risk factors present. If negative on both Pap smear and HPV DNA test, rescreen with combined tests every 3 years. c

org http://www. survivorshipguidelines. org

intercourse; history of multiple sexual partners or male sexual partners who have had multiple partners; male partners whose other sexual partners have had cervical cancer; history of STDs (especially HPV, HIV, HSV); immunosuppression; smoking; history of cervical dysplasia or endometrial, vaginal, or vulvar cancer; no previous screening; and chronic GVHD.

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2. Long-term use of oral contraceptives may increase risk of cervical cancer in women who are positive for cervical human papillomavirus DNA. (Lancet 2002;359:1085) 3. A vaccine against HPV-16 significantly reduces the risk of acquiring transient and persistent infection and cervical cancer. (NEJM 2002;347:1645) [Obstet Gynecol 2006;107(1):4] 4. Benefits: Based on solid evidence, regular screening of appropriate women with the Pap test reduces mortality from cervical cancer. Screening is effective when started within 3 years after first vaginal intercourse. Screening is not helpful in women who do not have a cervix. Continued screening in elderly file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...-%20Disease%20Screening/Cancer,%20Cervical.htm (2 of 6) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:53]

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women who have had negative Pap tests is of minimal value. Harms: Based on solid evidence, regular screening with the AAFP (2006) USPSTF (2003)

Women

Pap smear at least

Pap test leads to

http://www.aafp.org/

who have

every 3 years.d

additional

online/en/home/

ever had

diagnostic

clinical/exam.html

sex and

procedures and

have a

treatment for low-

http://www.ahrq.gov/

cervixa

grade squamous intraepithelial

clinic/uspstf/uspscerv. htm

lesions (LSIL), with uncertain long-term consequences on fertility and pregnancy. Harms are greatest for younger women, who have a higher prevalence of LSIL, lesions that often regress without treatment. (http:// www.cancer.gov) 5. Testing for HPV DNA is more sensitive but less specific than cytological analysis for detecting cervical intraepithelial neoplasm (CIN). New Technologies for Cervical Cancer (NTCC) screening file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...-%20Disease%20Screening/Cancer,%20Cervical.htm (3 of 6) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:53]

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ACS (2006) USPSTF (2003)

Women

Discontinue routine

trial compared

http://www.cancer.

without a

Pap smear

conventional

org

cervix

screening in

cytology versus

women who have

liquid-based

had a total

cytology and

hysterectomy for

testing for high-risk

benign disease and

HPV types.

no history of

Recruitment data:

abnormal cell

(1) liquid-based

growth.

and conventional

http://www.ahrq.gov/ clinic/uspstf/uspscerv. htm

cytology showed similar sensitivity for detecting CIN; (2) liquid-based cytology increases proportion classified as ASCUS, LSIL, and HSIL; (3) HPV testing for high-risk types was more sensitive than both conventional and liquid-based cytology; (4) HPV testing alone with triage of HPVpositive women by cytology may be reasonable approach. (J Natl Cancer Inst 2006;98:765) (Lancet Oncol 2006;7:547)

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USPSTF

Women

Against routine

1. In one study,

http://www.ahrq.gov/

(2003)

aged > 65

screening if woman

women 65 years of

clinic/uspstf/uspscerv.

years

has had adequate

age and older were

htm

recent screening

21% less likely

and normal Pap

than younger

smears and is not

women to ever

otherwise at high

have had a Pap test

risk for cervical

and 33% less likely

cancer.

to have had a Pap

http://www.ahrq.gov/ clinic/cpsix. htm#screening

test recently. Physician recommendation is the strongest predictor of whether a woman receives a Pap test. AGS (2000)

http://www.

aged > 65

Pap smear every 1– (Ann Intern Med 3 years until age 2000;133:1021–

years

70. If no or

org/products/

Women

insufficient prior Pap smears, 2 annual smears before discontinuation.

1024) 2. Beyond age 70, there is little

americangeriatrics. positionpapers/ cer_carc_2000.shtml

evidence for or

J Am Geriatr Soc

against screening

2001;49:655

women who have been regularly screened in previous years. Individual circumstances such as the patient's life expectancy, ability to undergo treatment if cancer is detected, and ability to cooperate with and tolerate the Pap smear procedure may

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ACS (2006)

Women

Discontinue

aged

screening if

years

normal Paps in a

obviate the need

http://www.cancer.

for cervical cancer

org

screening.

row and no abnormal Pap in the last 10 yearse

aIf

sexual history is unknown or considered unreliable, screening should begin at age 18 years.

bNew

tests to improve cancer detection include liquid-based/thin-layer preparations, computer-assisted

screening methods, and human papillomavirus testing. (Am Fam Phys 2001;64:729) cAs

compared with annual screening for 3 years, screening performed once every 3 years after the last

negative test in women aged 30–64 years who have had

3 consecutive negative Pap smears is

associated with an average excess risk of approximately 3 in 100,000. (NEJM 2003;349:1501–1509) dMost

of the benefit can be obtained by beginning screening within 3 years of onset of sexual activity or

age 21. eWomen

with Hx cervical cancer, DES exposure, HIV infection, or weakened immune system should

continue to have screening as long as in good health.

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Disease Screening: Cancer, Colorectal Organization Population Recommendations

Comments

Source

(Date) ACG (2005)

African

Screen with

1. African

Am J

Americans,

colonoscopy as first-

Americans have a

Gastroenterol

aged

line method.

younger mean

2005;100:515

years

age of onset of colorectal cancer compared with other groups.

http://www.acg. gi.org/physicians/ clinicalupdates. asp#guidelines

2. African Americans have a greater incidence of cancerous lesions in the proximal large bowel. AAFP (2006) ACS (2006) ASGE (2006) US Multisociety Task Force on Colorectal

Aged

Screen with 1 of the

1. A positive

http://www.aafp.

years at

following strategies:

screening test

org/online/en/

average

b,c,d

should be

home/clinical/

followed by

exam.html

riska

1) FOBT annuallye 2) Flexible sigmoidoscopy every 5 years

colonoscopy.g 2. In a prospective study, one-time

Cancer (ACG,

3) FOBT annually

screening with

ACP, AGA,

plus flexible

FOBT and

http://www. cancer.org Gastrointestinal Endoscopy 2006;63:546

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ASGE) (2003) USPSTF (2002)

sigmoidoscopy

Gastroenterology

every 5 years

failed to detect

2003;124:544

4) Colonoscopy every 10 yearsf

24% of subjects with advanced colonic neoplasia. (NEJM

http://www.ahrq. gov/clinic/uspstf/ uspscolo.htm

2001;345:555) 3. A trial comparing colonoscopy and sigmoidoscopy reported that only 35% of women with advanced neoplasia would have had their lesions detected on sigmoidoscopy. (NEJM 2005;352:2061) 4. FOBT alone decreased colorectal cancer mortality by 33% compared with those who were not screened. (Gastroenterology 2004;126) 5. New techniques such as CT virtual colonoscopy (Ann Intern Med 2005;142:635) or file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...20Disease%20Screening/Cancer,%20Colorectal.htm (2 of 5) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:55]

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fecal DNA (NEJM 2004;351:2704) are not recommended as screening at this time. 6. Sensitivity and specificity for lesions

10 mm

ACBE vs. CT colonoscopy (CTC) vs. colonoscopy for follow-up of GI bleeding were: ACBE (48%; 90%) vs. CTC (59%; 96%) vs. colonoscopy (98%; 99%). (Lancet 2005;365:305) ACS (2006) US Multisociety Task Force on Colorectal Cancer (ACG, ACP, AGA, ASGE) (2003)

Persons at

Group I: Screening

http://www.

increased

colonoscopy at age

cancer.org

risk based

40 years, or 10

on family

years younger than

historyh

the earliest

Gastroenterology 2003;124:544

diagnosis in their family, and repeated every 5 years. Group II: Follow average risk recommendations, but begin at age 40 years.

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Group III: see Average Risk aRisk

factors indicating need for earlier/more frequent screening: personal history of colorectal

cancer or adenomatous polyps or hepatoblastoma, colorectal cancer or polyps in a first-degree relative < 60 years old or in 2 first-degree relatives of any age, personal history of chronic inflammatory bowel disease, and family with hereditary colorectal cancer syndromes. [Ann Intern Med 1998;128(1):900, NEJM 1994;331(25):1669, NEJM 1995;332(13):861] Additional high-risk group: history of

30 Gy radiation to whole abdomen; all upper abdominal fields; pelvic, thoracic,

lumbar, or sacral spine. Begin monitoring 10 years after radiation or at age 35, whichever occurs last. (http://www.survivorshipguidelines.org) Screening colonoscopy in those aged

80 years

results in only 15% of the expected gain in life expectancy in younger patients. (JAMA 2006;295:2357) ACG treats African Americans as high-risk group. See separate recommendation above. bA

positive result on an FOBT should be followed by colonoscopy. An alternative is flexible

sigmoidoscopy and air-contrast BE. cFOBT

should be performed on 2 samples from 3 consecutive specimens obtained at home.

dUSPSTF

did not find direct evidence that screening colonoscopy is effective in reducing colorectal

cancer mortality rates. eUse

the guaiac-based test with dietary restriction, or an immunochemical test without dietary

restriction. Two samples from each of 3 consecutive stools should be examined without rehydration. Rehydration increases the false-positive rate. fPopulation-based

retrospective analysis: risk of developing colorectal cancer remains decreased

for > 10 years following a negative colonoscopy. (JAMA 2006;295:2366) gColonoscopy

is the preferred test. If not available, double-contrast barium enema and flexible

sigmoidoscopy should be performed. hGroup

I: First-degree relative with colon cancer or adenomatous polyps at age < 60 years, or 2

first-degree relatives with colorectal cancer at any time. Group II: First-degree relative with colorectal cancer or adenomatous polyps at age

60 years, or 2 second-degree relatives with

colorectal cancer. Group III: 1 second-degree or third-degree relative with colorectal cancer. DRE = digital rectal exam; FOBT = fecal occult blood testing

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Disease Screening: Cancer, Endometrial Organization

Population

Recommendations

Comments

Source

All women

Inform women about

1. Presence of

http://

risks and symptoms of

endometrial cells

www.

endometrial cancer,

in Pap test from

cancer.

and strongly encourage

postmenopausal

org

women to report any

women not taking

unexpected bleeding or

exogenous

spotting.

hormones is

(Date) ACS (2006)

abnormal and requires further evaluation. Pap test is insensitive for endometrial screening. 2. Endometrial thickness of < 4 mm on transvaginal ultrasound is associated with low risk of endometrial cancer. [Obstet Gynecol 1991;78 (2):195] 3. Most cases of file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...0Disease%20Screening/Cancer,%20Endometrial.htm (1 of 4) [2007/11/13 下午 12:39:56]

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endometrial cancer are diagnosed as a result of symptoms reported by patients, and a high proportion of these cases are diagnosed at an early stage and have high rates of survival. (NCI) 4. Benefits: There is inadequate evidence that screening with endometrial sampling or transvaginal ultrasound decreases mortality. Harms: Based on solid evidence, screening with transvaginal ultrasound will result in unnecessary additional examinations because of low specificity. Based on solid evidence, endometrial biopsy may result in file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...0Disease%20Screening/Cancer,%20Endometrial.htm (2 of 4) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:39:56]

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discomfort, bleeding, infection, and rarely uterine perforation. (http://www. cancer.gov/ cancertopics/pdq/ screening) ACS (2006)

All women at

Annual screening at age 1. Variable

http://

high risk for

35 years with

screening with

www.

endometrial

endometrial biopsy.

ultrasound among

cancer.

women (aged 25–

org

cancer.a

65 years; n = 292) at high risk for HNPCC mutation detected no cancers from ultrasound. Two endometrial cases occurred in the cohort that presented with symptoms. (Cancer 2002;94:1708) 2. The WHI demonstrated that combined estrogen and progestin did not increase risk of endometrial cancer but did increase rate of endometrial file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...0Disease%20Screening/Cancer,%20Endometrial.htm (3 of 4) [2007/11/13 下午 12:39:56]

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biopsies and ultrasound exams prompted by abnormal uterine bleeding. (JAMA 2003;290) aHigh-risk

women are those known to carry hereditary nonpolyposis colorectal cancer–associated

genetic mutations, or at high risk to carry mutation, or who are from families with suspected autosomal dominant predisposition to colon cancer. HNPCC = hereditary nonpolyposis colorectal cancer; WHI = Women's Health Initiative

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Disease Screening: Cancer, Gastric Organization

Population Recommendations

Comments

Source

(Date) There are currently no

1. Population

recommendations

endoscopic

regarding screening for

screening for gastric

gastric cancer.

cancer in moderateto high-risk population subgroups is cost effective (non-U.S. populations). (Clin Gastroenterol Hepatol 2006;4:709) 2. Benefits: There is fair evidence that screening would result in no decrease in gastric cancer mortality in the United States. Harms: There is good evidence that EGD screening would result in rare but serious side effects, such as perforation,

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cardiopulmonary events, aspiration pneumonia, and bleeding. (http:// www.cancer.gov/ cancertopics/pdq/ screening)

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Disease Screening: Cancer, Liver (Hepatocellular Carcinoma, HCC) Organization

Population Recommendations

Comments

Source

Adults

Surveillance with

1. Chronic hepatitis

Gut

Gastroenterology

abdominal ultrasound

B and C are the

2003;52

(2003)

and AFP every 6

major risk factors

(Suppl

months should be

for HCC. In the

III):iii

considered for high-

United States,

risk groups.a

chronic hepatitis B

(Date) British Society of

and C account for 30%–40% of HCC. Other risk factors:

http:// www. bsg.org. uk/

alcoholic cirrhosis, hemochromatosis, alpha-1-antitrypsin deficiency, glycogen storage disease, porphyria cutanea tarda, tyrosinemia, Wilson's disease. 20%–50% of patients presenting with HCC have previously undiagnosed cirrhosis. (http:// www.cancer.gov/ cancertopics/pdq/

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screening) 2. Benefits: Based on fair evidence, screening would not result in a decrease in HCC-related mortality. Harms: Based on fair evidence, screening would result in rare but serious side effects associated with needle biopsy, such as needletrack seeding, hemorrhage, bile peritonitis, and pneumothorax. (http://www.cancer. gov/cancertopics/ pdq/screening) aAll

persons with established cirrhosis with HBV, HCV, or hemochromatosis; males with cirrhosis

due to alcohol or primary biliary cirrhosis. If surveillance offered, patients should be aware of implications of early diagnosis and lack of proven survival benefit.

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Disease Screening: Cancer, Lung Organization Population

Recommendations Comments

Source

(Date) AAFP (2006) ACS (2004) ACCP (2003) CTF (2003)

Asymptomatic Routine screening

1. Counsel all

http://www.

persons

for lung cancer

patients against

aafp.org/

with CXR, sputum

tobacco use. Over 50

online/en/

cytology, or low-

years, men who

home/clinical/

dose CT (LDCT) is

continued to smoke

exam.html

not recommended.

died, on average, 10 years earlier than lifelong nonsmokers. Smokers who quit gain life expectancy. (BMJ 2004;328) 2. Benefits: Based on fair evidence,

http://www. chestnet.org/ education/ guidelines/ index.php http://www. cancer.org

screening with

Chest

sputum or CXR does

2003;123:835–

not reduce mortality

885

from lung cancer. Evidence is inadequate to assess mortality benefit of

CA Cancer J Clin 2004;54:41

LDCT. Harms: Based

http://www.

on solid evidence,

ctfphc.org

screening would lead to false-positive tests and unnecessary invasive procedures. file:///D|/local/PDF/E-Book(PDF)/Current%20P...20-%20Disease%20Screening/Cancer,%20Lung.htm (1 of 3) [2007/11/13 下午 12:39:59]

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(http://www.cancer. gov/cancertopics/pdq/ screening) 3. The NCI is conducting the National Lung Screening Test (NLST), an RCT comparing LDCT and CXR for detecting and reducing lung cancer mortality among persons at risk for lung cancer. (http:// www.cancer.gov/nlst) 4. History of chest radiation therapy increases risk. Annual symptom history (cough, wheezing, shortness of breath, dyspnea on exertion) and pulmonary exam indicated. (http:// www. survivorshipguidelines. USPSTF

Asymptomatic Evidence is

(2004)

persons

CTF (2003)

org)

http://www.

insufficient to

5. Although CT

ahrq.gov/clinic/

recommend for or

screening for

uspstf/

against lung cancer

detection of lung

uspslung.htm

screening.

cancer increases the percentage of cases of lung cancer

http://www. ctfphc.org/

diagnosed in stage 1 among persons with a history of heavy

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smoking, the results of RCTs are not yet available to assess effect on mortality. (NEJM 2005;352:2714)

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Disease Screening: Cancer, Oral Organization Population

Recommendations Comments Source

(Date) AAFP (2006) USPSTF (2004)

Asymptomatic There is insufficient

1. Risk

http://www.aafp.org/

persons.

evidence to

factors:

online/en/home/

recommend for or

regular

clinical/exam.html

against routinely

alcohol or

screening for oral

tobacco

cancer.

use.

http://www.ahrq.gov/ clinic/uspstf/uspsoral. htm

2. NCI: Inadequate evidence to establish that screening would result in a decrease in mortality from oral cancer. (http:// www. cancer.gov)

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COG (2006)

History of

Annual oral cavity

http://www.

radiation to

exam.

survivorshipguidelines.

head,

org

oropharynx, neck, or total body. Acute/chronic GVHD.

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Disease Screening: Cancer, Ovarian Organization

Population

Recommendations

Comments

Source

Asymptomatic

Recommends against

1. Risk factors:

http://www.

womena

routine screening.

aged > 60 years;

aafp.org/

low parity;

online/en/

personal history

home/

of endometrial,

clinical/

colon, or breast

exam.html

(Date) AAFP (2006) USPSTF (2004)

cancer; family history of ovarian cancer; and hereditary ovarian cancer syndrome. Use of oral

http://www. ahrq.gov/ clinic/ uspstf/ uspsovar. htm

contraceptives decreases risk of ovarian cancer. 2. Benefit: There is inadequate evidence to determine whether routine screening for ovarian cancer with serum markers such as file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...-%20Disease%20Screening/Cancer,%20Ovarian.htm (1 of 3) [2007/11/13 下午 12:40:01]

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CA 125 levels, transvaginal ultrasound, or pelvic examinations would result in a decrease in mortality from ovarian cancer. Harm: Based on AAFP (2006) USPSTF (2005)

Women whose

Referral for genetic

family history

counseling and

is associated

evaluation for BRCA

with an

testing.

increased risk for deleterious mutations in BRCA1 or BRCA2 genes

solid evidence, routine screening for ovarian cancer would result in many

http://www. aafp.org/ online/en/ home/

diagnostic

clinical/

laparotomies for

http://www.

each ovarian

ahrq.gov/

cancer found.

clinic/

(http://www.

uspstf/

cancer.gov/

uspsbrgen.

laparoscopies and exam.html

cancertopics/pdq/ htm screening) 3. Preliminary results from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: At the time of baseline exam, positive predictive value for invasive cancer was 3.7% for an abnormal file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...-%20Disease%20Screening/Cancer,%20Ovarian.htm (2 of 3) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:40:01]

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CA 125, 1% for an abnormal transvaginal ultrasound, and 23.5% if both tests were abnormal. (Am J Obstet Gynecol 2005;193:1630) aLifetime

risk of ovarian cancer in a woman with no affected relatives is 1 in 70. If 1 first-degree

relative has ovarian cancer, lifetime risk is 5%. If 2 or more first-degree relatives have ovarian cancer, lifetime risk is 7%. Women with 2 or more family members affected by ovarian cancer have a 3% chance of having a hereditary ovarian cancer syndrome. These women have a 40% lifetime risk of ovarian cancer.

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Disease Screening: Cancer, Pancreatic Organization

Population

Recommendations

Comments

Source

Asymptomatic

Recommends against

1. Cigarette

http://

persons

routine screening.

smoking has

www.aafp.

consistently

org/online/

been

en/home/

associated

clinical/

with

exam.html

(Date) AAFP (2006) USPSTF (2004)

increased risk of pancreatic cancer.

http:// www.ahrq. gov/clinic/ uspstf/ uspspanc. htm

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Disease Screening: Cancer, Prostate Organization

Population

Recommendations

Comments

Source

Asymptomatic

Evidence insufficient

1. There is good

http://

men

to recommend for or

evidence that PSA

www.aafp.

against routine

can detect early-

org/

screening using PSA

stage prostate

online/en/

or DRE.

cancer, but mixed

home/

and inconclusive

clinical/

evidence that

exam.html

(Date) AAFP (2006) USPSTF (2002)

early detection improves health outcomes or mortality.

http:// www.ahrq. gov/clinic/ uspstf/

2. Benefit:

uspsprca.

Insufficient

htm

evidence to establish whether a decrease in mortality from prostate cancer occurs with screening by DRE or serum PSA. Harm: Based on good evidence, screening with PSA and/or DRE file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...%20Disease%20Screening/Cancer,%20Prostate.htm (1 of 6) [2007/11/13 下午 12:40:03]

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detects some prostate cancers that would never have caused important clinical problems. Based on good evidence, current prostate cancer treatments result in permanent side effects in many men, including erectile dysfunction and urinary incontinence. (http://www. cancer.gov/ cancertopics/pdq/ screening) 3. Further evaluation is recommended when PSA > 4. However, a study found an overall prevalence of prostate cancer of 15% in men with a PSA < 4. (NEJM 2004;350) 4. Men with localized, lowgrade prostate cancers (Gleason

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score 2–4) have a minimal risk of dying from prostate cancer during 20 years of follow-up (6 deaths per 1,000 person-years). (JAMA 2005;293:2095) 5. Radical prostatectomy (vs. watchful waiting) reduces disease-specific and overall mortality in patients with symptomatic early prostate cancer. (NEJM 2005;352:1977) Whether this benefit translates to asymptomatic patients identified through screening measures is unknown. 6. PSA rise of > 2 per year is associated with recurrence and death. (NEJM 2004;351) It is not known if using

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PSA velocity to determine treatment is useful. 7. An RCT using finasteride for chemoprevention of prostate cancer showed a reduced incidence of cancer in the treatment group but a greater proportion of highgrade tumors. Therefore, this strategy is not recommended. (NEJM 2003;349) 8. Information should be provided to all men about what is known and what is uncertain about the benefits, limitations, and harms of early detection and treatment of prostate cancer, so that they can make an informed decision about testing. (ACS) 9. AUA Best file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...%20Disease%20Screening/Cancer,%20Prostate.htm (4 of 6) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:40:03]

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Practices Policy: ACS (2006)

Men aged yearsa

Offer annual PSA and

PSA testing

http://

DRE if > 10-year life

detects more

www.

expectancy.

tumors than does

cancer.org

DRE. The most sensitive method for early detection of prostate cancer uses both DRE and PSA. Both tests should be employed in a program of early prostate cancer detection. Presently, no consensus on optimal strategies for using the different methods of PSA testing (age-adjusted PSA, free-to-total PSA ratio, PSA density). Prostate biopsy indicated if PSA

4.0 ng/mL;

or a significant PSA increase from one test to the next; or DRE abnormal. (Oncology 2000;14:267)

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in high-risk groups (one or more first-degree relatives diagnosed before age 65, African

Americans) should begin screening at age 45. Men at higher risk due to multiple first-degree relatives affected at an early age could begin testing at age 40. (http://www.cancer.org/)

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Disease Screening: Cancer, Skin Organization

Population

Recommendations

Comments

Source

Asymptomatic

Insufficient evidence

1. Appropriate

http://

persons

to recommend for or

biopsy

www.aafp.

against routine

specimens

org/online/

screeninga,b

should be taken

en/home/

of suspicious

clinical/

lesions. Persons

exam.html

(Date) AAFP (2006) USPSTF (2001)

with melanocytic precursor or marker lesions are at substantially increased risk

http:// www.ahrq. gov/clinic/ uspstf/ uspsskca. htm

for malignant melanoma and should be referred to skin cancer specialists for evaluation and surveillance. (USPSTF) 2. Benefits: Evidence is inadequate to file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...%20-%20Disease%20Screening/Cancer,%20Skin.htm (1 of 2) [2007/11/13 下午 12:40:04]

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determine whether visual examination of the skin in AAD (2001)

Personal

Self-exam of skin and

asymptomatic

http://

history of

lymph nodes

individuals

www.aad.

Physician skin exam

would lead to a

org

primary cutaneous melanoma

annually

reduction in mortality from melanomatous skin cancer. (http://www. cancer.gov/ cancertopics/ pdq/screening).

aClinicians

should remain alert for skin lesions with malignant features when examining patients

for other reasons, particularly patients with established risk factors. Risk factors for skin cancer include: evidence of melanocytic precursors, large numbers of common moles, immunosuppression, any history of radiation, family or personal history of skin cancer, substantial cumulative lifetime sun exposure, intermittent intense sun exposure or severe sunburns in childhood, freckles, poor tanning ability, and light skin, hair, and eye color. bConsider

educating patients with established risk factors for skin cancer (see above) concerning

signs and symptoms suggesting skin cancer and the possible benefits of periodic self-exam. (USPSTF) (ACS) (COG)

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Disease Screening: Cancer, Testicular Organization

Population

Recommendations

Comments

Source

Asymptomatic

Recommend against

1. Benefits:

http://

mena

screening

Based on fair

aafp.org/

asymptomatic men.

evidence,

online/en/

screening

home/

would not

clinical/

result in

exam.htm

(Date) AAFP (2006) USPSTF (2004)

appreciable decrease in mortality, in part because therapy at each stage is so effective.

http:// www.ahrq. gov/clinic/ uspstf/ uspstest. htm

Harm: Based on fair evidence, screening would result in unnecessary ACS (2004)

Asymptomatic

Testicular exam by

men

physician as part of routine cancer-related check-up.

diagnostic procedures. (http://www. cancer.gov/

http:// www. cancer.org

cancertopics/ pdq/screening)

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with history of cryptorchidism, orchiopexy, family history of testicular cancer, or

testicular atrophy should be informed of their increased risk for developing testicular cancer and counseled about screening. Such patients may then elect to be screened or to perform testicular self-exam. Adolescent and young adult males should be advised to seek prompt medical attention if they notice a scrotal abnormality. (USPSTF)

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Disease Screening: Cancer, Thyroid Organization

Population

Recommendations

Comments

Source

Asymptomatic

Insufficient evidence to

1. Neck

http://

persons

recommend for or

palpation for

www.

against routine

nodules in

aafp.org/

screening.a

asymptomatic

online/

individuals has

en/

(Date) AAFP (2006)

sensitivity 15%– home/ 38%; specificity

clinical/

93%–100%.

exam.

Only a small

html

proportion of nodular thyroid glands are neoplastic, resulting in a high falsepositive rate. (USPSTF) aIncludes

asymptomatic persons with a history of external upper-body irradiation in infancy or

childhood.

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Disease Screening: Carotid Artery Stenosis (asymptomatic) Organization

Population Recommendations

Comments

Source

(Date) USPSTF (2006)

Currently being updated 1. The prevalence

http://

of internal carotid

www.ahrq.

artery stenosis

gov/clinic/

(ICAS) of

uspstf/

70% is

low in persons with

uspsacas.

only atherosclerosis

htm

risk factors (1.8%– 2.3%), intermediate in those with angina or MI (3.1%), and highest in those with PAD (12.5%) or AAA (8.8%). Advanced age (> 54 years) and lower diastolic BP (< 83 mm Hg) increased prevalence of ICAS. (J Vasc Surg 2003;37:1226– 1233) 2. Asymptomatic Carotid Surgery Trial (ACST) file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...rotid%20Artery%20Stenosis,%20asymptomatic.htm (1 of 2) [2007/11/13 下午 12:40:07]

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(Lancet 2004;363:1491): The absolute risk reduction for stroke or death at 5 years was 5.4%, with significant benefit observed in women (4% absolute risk reduction) as well as in men (8.2% risk reduction). 3. Severe CAS and coexisting conditions: carotid stenting with use of emboli-protection device is not inferior to CEA. [NEJM 2004 Oct 7;351(15):1493– 1501]

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Disease Screening: Child Abuse & Neglect Organization

Population Recommendations

Comments

Source

Children

Insufficient evidence

1. By law, child

http://www.

to recommend for or

abuse must be

aafp.org/

against routine

reported to

online/en/

screening.

appropriate

home/clinical/

authorities in all 50

exam.html

(Date) AAFP (2006) USPSTF (2004)

All providers should be aware of physical

states.

http://www.

and behavioral signs

2. Additional

ahrq.gov/

and symptoms

resources found at

clinic/uspstf/

associated with

http://www.

uspsfamv.

abuse or neglect.a

endabuse.org.

htm

3. See AAP position

Ann Fam

statement on "The

Med

evaluation of sexual

2004;2:156–

abuse in

160

children." (Pediatrics 2005;116:506) aSigns

of abuse or neglect include burns, bruises, and repeated suspect trauma.

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Disease Screening: Chlamydial Infection Organization

Population

Recommendations

Comments

Source

Women

Strongly recommends

1. Antigen

USPSTF

screening; optimal

detection tests,

interval for screening

nonamplified

is uncertain.b

nucleic acid

(Date) AAFP (2006) ACPM (2003)

aged

years who

USPSTF (2001) are sexually active or at

hybridization,

increased

and amplified

riska

DNA assays may

http://www. aafp.org/ online/en/ home/clinical/ exam.html

provide improved

http://www.

sensitivity, lower

ahrq.gov/

expense,

clinic/uspstf/

availability, and/

uspschlm.htm

or timeliness of results over culture.

http://www. acpm.org/ clinical.htm

2. Noninvasive methods such as urine specimens and vaginal swabs appear reliable. 3. Early detection and treatment of women at risk for chlamydial infection file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...Disease%20Screening/Chlamydial%20Infection.htm (1 of 3) [2007/11/13 下午 12:40:09]

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(prevalence 7%) reduced the incidence of pelvic inflammatory disease from 28 per 1,000 womanyears to 13 per 1,000 womanyears. 4. Recent population-based studies show overall prevalence of chlamydial infection in 18– 26-year-old persons to be 4.7%, with rates sixfold higher among African Americans. Prevalence rates in men were 3.5%. (JAMA 2004;291:2229) AAFP (2006) ACPM (2003)

Pregnant

Screen during first

Am J Prev

women

trimester or first

Med

prenatal visit.

2003;24:287

USPSTF (2001)

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25 years, new male sex partners or 2 or more partners during preceding year,

inconsistent use of barrier methods, history of prior STD, African-American race, cervical ectopy. bFor

women with a previous negative screening test, the interval for rescreening should take into

account changes in sexual partners. If there is evidence that a woman is at low risk for infection (eg, in a mutually monogamous relationship with a previous history of negative screening tests for chlamydial infection), it may not be necessary to screen frequently. Rescreening at 6 to 12 months may be appropriate for previously infected women because of high rates of reinfection. USPSTF (2005) also recommends screening all high-risk sexually active women for gonorrheal infection.

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Disease Screening: Cholesterol & Lipid Disorders, Adults Organization

Population

Recommendations

Comments

Source

NCEP III

Men and

Check fasting

1. Age to stop

Circulation

(2004)

women

lipoprotein panel (if

screening is not

2002;106:3143

aged > 20

testing opportunity is

established.

years

nonfasting, use TC

Clinical trial data

and HDL) every 5

demonstrate

years if in desirable

that persons

range; otherwise see

older than 65

http://www.

Cholesterol & Lipid

years of age

nhlbi.nih.gov/

Management.b

derive the same

guidelines/

benefit from

cholesterol/

cholesterol

atp3upd04.htm

(Date)

Circulation 2004;110:227– 239

reduction as AAFP (2006) USPSTF (2001)

Men aged

Selective screening

20–35 years of individuals with Women aged 20–45 years

major CHD risk factors [hypertension, smoking, diabetes, family history of CHD before age 50 (male relatives) or age 60

younger adults. 2. Base treatment decisions on at least 2

http://www. aafp.org/online/ en/home/ clinical/exam. html

cholesterol levels. http://www. ahrq.gov/clinic/ 3. Intensive lipid- uspstf/uspschol. modulating

(female relatives),

therapy (LDL <

family history

60 mg/dL;

suggestive of familial

increase in HDL

hyperlipidemia]

15 mg/dL) is

htm

associated with file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...terol%20and%20Lipid%20Disorders,%20Adults.htm (1 of 2) [2007/11/13 下午 12:40:10]

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AAFP (2006) USPSTF (2001)

Men aged

"Strongly

plaque and

Am J Prev Med

35 years

recommended"

atheroma

2001;20

Women

Random total

volume

(35):73–76

aged

cholesterol and HDL

years

cholesterol or fasting lipid profile, periodicity based on

regression (the ASTEROID trial). (JAMA 2006;295:1556)

aafp.org/exam/ Geriatrics 2003;58:33–38

risk factors aAAP

http://www.

recommends annual screening if strong family history (parents or grandparents) of

cardiovascular events at or before age 55 years (MI, positive coronary angiogram, stroke, peripheral vascular disease, or sudden cardiac death) or presence of "several" risk factors (cigarette smoking, hypertension, obesity, diabetes, lack of physical activity). bClassify

TC < 200 mg/dL as desirable, 200–239 mg/dL as borderline, or

Classify HDL < 40 as low, and

60 as high. Classify LDL < 100 as optimal, 100–129 as near or

above optimal, 130–159 as borderline high, 160–189 as high, and mg/dL and HDL

240 mg/dL as high.

40 mg/dL, then repeat in 5 years; if TC

190 as very high. If TC < 200

200 mg/dL or HDL < 40 mg/dL, then

check fasting lipids and risk stratify based on LDL (see Cholesterol & Lipid Management). Advanced lipoprotein testing does not predict carotid intima-media thickness better than traditionally measured lipid values. [Ann Intern Med 2005 May 3;142(9):742–750]

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Disease Screening: Coronary Artery Disease Organization

Population

Recommendations

Comments

Source

Adults at low Recommends against

1. Key

Ann Intern Med

risk of CHD

routine screening with

questions to

2004;140:569

events

resting ECG, ETT, or

answer in RCT

electron-beam CT for

are (1) effect

coronary calcium.

of testing

(Date) AAFP (2006) AHA (2005) USPSTF (2004)

asymptomatic person on

http://www. ahrq.gov/clinic/ uspstf/ uspsacad.htm

subsequent

http://www.

CHD morbidity

aafp.org/online/

and mortality;

en/home/

(2) effect in

clinical/exam.

women; (3)

html

costAAFP (2006) AHA (2005) USPSTF (2004)

Adults at

Insufficient evidence

high risk of

to recommend for or

CHD events

against routine screening with ECG, ETT, or electron-beam CT.

effectiveness.

Ann Intern Med 2004;140:569 http://www. ahrq.gov/clinic/ uspstf/ uspsacad.htm http://www. aafp.org/online/ en/home/ clinical/exam. html

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Disease Screening: Dementia Organization Population

Recommendations Comments

Source

Insufficient

1. Screening

Ann Intern Med

instruments are

2003;138:925–

recommend for or

useful for

926

against routine

detecting

screening for

multiple

dementia.

cognitive

(Date) AAN (2003) USPSTF (2003) CTF (2001)

Elderly,

asymptomatic evidence to

deficits and

Ann Intern Med 2003;138:927– 937

determining a

Neurology

baseline for

2001;56:1133–

future

1142

assessments.

http://www.ahrq.

2. Reversible

gov/clinic/uspstf/

causes of

uspsdeme.htm

dementia include vitamin B12 deficiency,

http://www.ctfphc. org/

neurosyphilis, and hypothyroidism. Be aware of other causes of mental status changes, such as depression, delirium, file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...007)/I%20-%20Disease%20Screening/Dementia.htm (1 of 3) [2007/11/13 下午 12:40:12]

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AAN (2003) AGS (2003)

medication

Elderly, mild

Persons with MCI

cognitive impairment

should be evaluated effects, and coexisting regularly for

(MCI)a

progression to

illnesses.

dementia. [Review

of MCI: Lancet

Homocysteine

2006;367

lowering with B

(9518):1262]

vitamins and folate does not

http://www.aan. com/professionals http://www. americangeriatrics. org Neurology 2001;56:1133– 1142

improve

Mini Mental Status

cognitive

Exam: J Psychiatr

performance in

Res 1975;12:189,

healthy older

also see Mini

adults. (NEJM

Mental State

2006;354:2764) Examination in Appendix I, Screening Instruments: Cognitive Impairment

aTriggers

that should initiate an assessment for dementia include difficulties in (1) learning and

retaining new information, (2) handling complex tasks (eg, balancing a checkbook or cooking a meal), (3) reasoning ability (eg, a new disregard for social norms), (4) spatial ability and orientation (eg, difficulty driving, or getting lost), (5) language (eg, difficulties in word-finding), and (6) behavior (eg, appearing more passive or more irritable than usual). DSM-IV diagnosis of dementia requires: (1) evidence of decline in functional abilities and (2) evidence of multiple cognitive deficiencies. MCI criteria: memory complaint, preferably corroborated by an informant; objective memory impairment; normal general cognitive function; intact activities of daily living; not demented. 6%–25% of MCI patients progress to dementia each year. Note: American Academy of Neurology website includes an "AAN Encounter Kit for Dementia," a web-based algorithm to assist coding, diagnosis, and pharmacologic management of cognitive disorders in adults (MCI and dementia). (http://aan.com/professionals/practice/dementia)

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Disease Screening: Depression Organization

Population

Recommendations

Comments

Source

Children and

Insufficient evidence

1. Clues to

http://aafp.

adolescents

to recommend for or

depression

org/online/en/

against routine

include poor

home/clinical/

screening.

school

exam.html

(Date) AAFP (2006) USPSTF (2002)

performance, alcohol or drug use, and deteriorating parental or

http://www. ahrq.gov/clinic/ uspstf/ uspsdepr.htm

peer relationships. 2. Clues to suicide risk include family dysfunction, physical and sexual abuse, substance abuse, history of recurrent or severe depression, and prior suicide attempt or plans.a file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...7)/I%20-%20Disease%20Screening/Depression.htm (1 of 3) [2007/11/13 下午 12:40:13]

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Bright Futures

Adolescents

(2002)

Annual screening for

http://

behaviors or emotions

brightfutures.

that might indicate

aap.org/web/

depression or risk of suicide.

AAFP (2006) USPSTF (2002)

Adults

Recommend screening

1. See

http://aafp.

adults for depression.

screening

org/online/en/

instruments

home/clinical/

[Geriatric

exam.html

Screen adults in practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.

Depression Scale, Beck Depression Inventory (Short Form),

http://www. ahrq.gov/clinic/ uspstf/ uspsdepr.htm

PRIME-MD] in Appendix I, Screening Instruments: Depression. 2. Asking 2 simple questions may be as effective as longer instruments (see Appendix I, Screening Instruments: Depression). (J Gen Intern Med 1997;12:439)

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Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? 3. Optimal screening interval is unknown. NICE (2004)

High-risk

Recommend screening

http://www.

groupsb

in primary care and

nice.org.uk

general hospital settings. aSuicide

risk increases as the number of conditions increases. Parents of adolescents at risk for

suicide should reduce access to firearms, weapons, or potentially lethal drugs in the home. bHigh-risk

groups: past history of depression, significant physical illness causing disability, other

mental health problems such as dementia.

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Disease Screening: Diabetes Mellitus, Gestational (GDM) Organization

Population

Recommendations

Comments

Source

Pregnant

Evidence is insufficient

1. High-

http://www.

women

to recommend for or

quality

aafp.org/online/

against screening.

evidence

en/home/

that

clinical/exam.

screening

html

(Date) AAFP (2006) USPSTF (2003)

(vs. testing women with symptoms) for GDM reduces

http://www. ahrq.gov/clinic/ uspstf/uspsdiab. htm

important adverse health outcomes for mothers or ADA (2006)

Pregnant

Risk assess all women

their infants

Diabetes Care

women

at first prenatal visit. If

is lacking.

2006;29(Suppl

clinical characteristics consistent with a high risk of GDM,a do glucose testing as soon as possible. If no GDM at initial testing,b retest between 24–28 weeks' gestation.

2. Fasting

1):S4

plasma

http://www.

glucose

diabetes.org/

126 mg/dL

for-health-

or a casual

professionals-

plasma

and-scientists/

glucose

cpr.jsp

200 mg/dL

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Average-risk women:

meets

test at 24–28 weeks'

threshold for

gestation.

diabetes

Low-risk womenc: no glucose testing.

diagnosis, if confirmed on a subsequent day, and precludes the need for glucose challenge. (ADA)

aHigh

risk is defined as (1) obesity (BMI > 27 kg/m2) (see Appendix IV: Body Mass Index

Conversion Table), (2) strong family history of diabetes, (3) personal history of GDM, or (4) glycosuria. bUse

1 of 2 approaches to assess: (1) Screen with 50-g oral glucose load. If 1 hour

perform diagnostic 100-g OGTT or (2) diagnostic 100-g OGTT (positive test meets dL fasting; cLow

180 mg/dL at 1 hour,

155 mg/dL at 2 hours, and

130 mg/dL, 2 of:

95 mg/

140 mg/dL at 3 hours).

risk for GDM (may not need lab screening): < 25 years old; not of Hispanic, African, Native

American, South or East Asian, or Pacific Islands ancestry; weight normal before pregnancy; no history of abnormal glucose tolerance; no previous history of poor obstetric outcome; no known diabetes in first-degree relative. dRisk

factors (in addition to overweight): family history of type 2 diabetes in first- or second-

degree relative; race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander); signs of or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome). eRisk

factors (in addition to age

45 years) include (1) family history of diabetes in parents or

siblings; (2) membership in one of the following ethnic groups: African American, Latino, Native American, Asian American, or Pacific Islander; (3) history of impaired fasting glucose, impaired glucose tolerance, gestational diabetes, or mother with infant birthweight > 9 lb; (4) comorbid conditions, including hypertension (> 140/90 mm Hg) or dyslipidemia (HDL < 35 mg/dL or TGs > 250 mg/dL); (5) overweight (BMI

25 kg/m2); (6) polycystic ovary syndrome or acanthosis

nigricans; (7) history of vascular disease, and (8) habitually physically inactive.

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Disease Screening: Diabetes Mellitus, Type 2 Organization

Population

Recommendations

Comments

Source

Children

Fasting plasma

1. See

Diabetes Care

glucose at age 10

Appendix IV:

2006;29

years or onset of

Body Mass

(Suppl 1):S4

puberty, and every 2

Index

years if overweight

Conversion

(BMI > 85th

Table.

(Date) ADA (2006)

percentile for age and sex) plus 2 additional risk factors. d

http://www. diabetes.org/ for-healthprofessionalsand-scientists/ cpr.jsp http://www. aafp.org/ online/en/ home/clinical/ exam.html http://www. ahrq.gov/ clinic/uspstf/ uspsdiab.htm

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ADA (2006)

Adults

Consider screening

1. Cost

Diabetes Care

with fasting glucose

effectiveness

2006;29

or glucose tolerance

analysis

(Suppl 1):S4

test at 3-year

suggests that

intervals beginning at universal age 45, especially if BMI

25 kg/m2;

screening is very costly

consider testing

($360,966 per

earlier or more

QALY), in

frequently in

contrast to

http://www. diabetes.org/ for-healthprofessionalsand-scientists/ cpr.jsp

overweight patients if targeted

http://www.

diabetes risk factors

screening of

aafp.org/

present.e

hypertensives

online/en/

($34,375 per

home/clinical/

QALY). (Ann

exam.html

Intern Med 2004;140:689)

http://www. ahrq.gov/

2. Impaired

clinic/uspstf/

fasting glucose:

uspsdiab.htm

100 and < 126 mg/dL. 3. Impaired glucose tolerance: 2hour PG

140

and < 200 g/dL. 4. Diabetes defined as fasting glucose 126 mg/dL on 2 separate occasions, or symptoms of diabetes with random glucose 200 mg/dL. file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...Screening/Diabetes%20Mellitus,%20Type%202.htm (2 of 4) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:40:16]

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5. It has not been demonstrated that beginning diabetes control early as a result of AAFP (2006) USPSTF (2003)

Adults

Evidence is

screening

insufficient to

provides an

recommend for or

incremental

against screening

benefit

asymptomatic adults

compared with

for type 2 diabetes,

initiating

impaired glucose

treatment after

tolerance, or

clinical

impaired fasting

diagnosis.

glucose.

(USPSTF) 6. In hypertensives, there is strong evidence that more aggressive blood pressure control is beneficial when diabetes is present. 7. In hyperlipidemia, NCEP III recommends different treatment thresholds and targets when

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AAFP (2006) USPSTF (2003)

aHigh

Hypertensive

Recommends

diabetes is

screening (test and

present.

hyperlipidemic

frequency not

adults

known).

risk is defined as (1) obesity (BMI > 27 kg/m2) (see Appendix IV: Body Mass Index

Conversion Table), (2) strong family history of diabetes, (3) personal history of GDM, or (4) glycosuria. bUse

1 of 2 approaches to assess: (1) Screen with 50-g oral glucose load. If 1 hour

perform diagnostic 100-g OGTT or (2) diagnostic 100-g OGTT (positive test meets dL fasting; cLow

180 mg/dL at 1 hour,

155 mg/dL at 2 hours, and

130 mg/dL, 2 of:

95 mg/

140 mg/dL at 3 hours).

risk for GDM (may not need lab screening): < 25 years old; not of Hispanic, African, Native

factors (in addition to overweight): family history of type 2 diabetes in first- or second-

factors (in addition to age

45 years) include (1) family history of diabetes in parents or

25 kg/m2); (6) polycystic ovary syndrome or acanthosis

nigricans; (7) history of vascular disease, and (8) habitually physically inactive.

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Disease Screening: Falls in the Elderly Organization

Population

Recommendations

Comments

Source

All older

Ask at least yearly

1. See also

JAGS 2001;49:664–

persons

about falls.a,b

Falls in the

672

(Date) AAOS (2001) AGS

Elderly for

British

fall

Geriatrics

prevention

Society

and Appendix II:

http://www. americangeriatrics. org/products/ positionpapers/falls. pdf

Functional

http://www.bgs.org.

Assessment

uk/

Screening CTF (2005)

All persons

Recommend

in the

http://www.ctfphc.

admitted to

programs that target

Elderly.

org

long-term

the broad range of

care facilities environmental and resident-specific risk factors to prevent falls and hip fractures. c

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who report a single fall should be observed as they stand up from a chair without using their

arms, walk several paces, and return (see Appendix II: Functional Assessment Screening in the Elderly). Those demonstrating no difficulty or unsteadiness need no further assessment. Those who have difficulty or demonstrate unsteadiness, have

1 fall, or present for medical attention

after a fall should have a fall evaluation (see Falls in the Elderly). bRisk

factors: Intrinsic: lower extremity weakness, poor grip strength, balance disorders,

functional and cognitive impairment, visual deficits. Extrinsic: polypharmacy ( 4 prescription medications), environment (poor lighting, loose carpets, lack of bathroom safety equipment). cPost-fall

assessments may detect previously unrecognized health concerns.

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Disease Screening: Family Violence & Abuse Organization

Population

Recommendations

Comments

Children and

Insufficient evidence

1. By law, child

adolescents

to recommend for or

abuse must be

against routine

reported to

screening

authorities in all

Source

(Date) AAFP (2006) USPSTF (2004)

50 states. 2. See additional resources at http://www. endabuse.org. 3. Assess adolescents without parent/ partner in room. Family Violence

Children and

1. Assess caregivers/

1. Direct

http://

Prevention

adolescents

parents who

questions should

endabuse.

accompany their

be asked.

org/

Fund (2004)

children during new patient visits; at least once per year at well child visits; and thereafter whenever they disclose a new intimate relationship.

2. Inform patient about limits of practitioner/ patient

programs/ healthcare/ files/ Pediatric.pdf

confidentiality related to intimate partner

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2. Assess adolescents

violence prior to

during new patient

assessing.

visits; at least once per year at wellness visits; and thereafter

3. Use a private room.

whenever they

4. If interpreter

disclose a new

used, they should

intimate relationship.

not be

3. Ask whenever signs or symptoms raise concerns.a

acquaintance or family relative. Never use children as interpreters.

AAFP (2006) USPSTF (2004)

Women and

Insufficient evidence

1. Controversy

Ann Fam

elderly

to recommend for or

exists regarding

Med

against routine

the overall benefit 2004;2:156

screening

of mandatory reporting of domestic violence. (JAMA 1995;273:1781) 2. Prevalence of domestic violence among women seeking emergency department care was 26% in an

http://www. aafp.org/ online/en/ home/ clinical/ exam.html http://www. ahrq.gov/ clinic/uspstf/ uspsfamv. htm

urban ED and 21% in a suburban ED. (Arch Intern Med 2006;166:1107) 3. Some states have mandatory reporting of elder file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...Screening/Family%20Violence%20and%20Abuse.htm (2 of 3) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:40:19]

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abuse and neglect. aConcerns

exist when the child or adolescent has obvious physical signs of physical or sexual

abuse; behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or other signs of emotional distress; or chronic somatic complaints, or when adults present with obvious physical injuries or history of intimate partner abuse.

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Disease Screening: Hearing Impairment Organization

Population

Recommendations

Comments

Source

Infants

The hearing of all

1. Audiologic

Pediatrics

infants should be

evaluations

2000;106

screened using

should be in

(4):798–817

(Date) AAP (2002) Bright Futures (2000)

objective, physiologic progress before

Joint

measures to identify

Committee on

those with congenital

Infant

or neonatal-onset

Hearinga

hearing loss.

(2000) AAFP (2006) USPSTF (2001)

3 months of age. 2. Infants with confirmed hearing loss

http://www.aap. org http://www.jcih. org

should receive intervention

Normal-risk

Insufficient evidence

infants and

to recommend for or

children

against routine

of age.

screening of

3. The efficacy of

clinical/exam.

neonates.

universal

html

newborn hearing

http://www.

before 6 months

screening to improve longterm language outcomes

http://www. aafp.org/online/ en/home/

ahrq.gov/clinic/ uspstf/uspsnbhr. htm

remains uncertain. (JAMA 2001;286:2000– 2010)

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AAP (2003) Bright Futures (2002)

High-risk

Infants should be

Pediatrics

infants and

screened no later

2000;106

childrenb,c

than 3 months of

(4):798–817

age.

Joint

http://www.aap. org

Screen infants and

Committee on

children < 2 years of

Infant

Pediatrics

age with increased

Hearinga

2003;111:436–

risk.

(2000)

440

Screen every 6

http://www.jcih.

months until 3 years

org

of age and at appropriate intervals thereafter if there is risk for delayedonset hearing loss. AAP (2003)

High-risk

Children with

http://www.aap.

childrenc

frequent recurrent

org

otitis media or

Pediatrics

middle-ear effusion,

2003;111:436–

or both, should have

440

audiology screening and monitoring of communication-skills development. AAFP (2006) AGS (1997)

Adults

Question older adults

Review of

http://www.

periodically about

accuracy and

aafp.org/online/

hearing impairment,

precision of

en/home/

counsel about

bedside clinical

clinical/exam.

availability of

maneuvers for

html

hearing-aid devices,

diagnosing

and make referrals

hearing

for abnormalities

impairment:

when appropriate.

Elderly

J Am Geriatr Soc 1997;45:344

individuals who acknowledge file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...0Disease%20Screening/Hearing%20Impairment.htm (2 of 4) [2007/11/13 下午 12:40:20]

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they have hearing impairment require audiometry. Those who do not should be screened with whispered voice test. If passed, no further testing. Those unable to perceive whispered voice require audiometry. The Weber and Rinne tests should not be used for general screening. (JAMA 2006;295:416) aJoint

Committee on Infant Hearing member organizations: American Academy of Audiology;

American Academy of Otolaryngology–Head and Neck Surgery; American Academy of Pediatrics; American Speech-Language-Hearing Association; Council on Education of the Deaf; and Directors of Speech and Hearing Programs in State Health and Welfare Agencies. bIncreased

neonatal risk: family history of hereditary sensorineural hearing loss, intrauterine

infection, craniofacial anomalies, birthweight < 1,500 g, hyperbilirubinemia requiring exchange transfusions, ototoxic medications, bacterial meningitis, Apgar scores 0–4 and 0–6, mechanical ventilation lasting > 5 days, and stigmata associated with a syndrome known to include hearing loss. cIncreased

childhood risk: patient/caregiver concern regarding hearing, speech, language, or

developmental delay; bacterial meningitis; head trauma associated with loss of consciousness or skull fracture; stigmata associated with a syndrome known to include hearing loss; ototoxic medications; recurrent or persistent otitis media with effusion; disorders affecting eustachian tube

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function; neurofibromatosis type 2; and neurodegenerative disorders. Delayed-onset hearing loss: as above for increased childhood risk plus family history of hereditary childhood hearing loss and intrauterine infection. dSee

also Appendix II: Functional Assessment Screening in the Elderly.

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Disease Screening: Hemochromatosis (hereditary) Organization

Population Recommendations

Comments

Source

Adults

Insufficient evidence to

If testing

Ann Intern Med

recommend for or

performed,

2005;143:517–

against screening.a,b,c

cut-off

521

(Date) ACP (2005)

values for serum ferritin level > 200 g/L in women and > 300

http://www. acponline.org/ clinical/ guidelines/? hp#general

g/L in men and transferrin saturation > 55% may be used as criteria for case finding, but no general agreement about diagnostic criteria.

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clinicians who choose to screen, one-time screening of non-Hispanic white men with serum

ferritin level and transferrin saturation has highest yield. bIn

case-finding for hereditary hemochromatosis, serum ferritin and transferrin saturation tests

should be performed. cDiscuss

the risks, benefits, and limitations of genetic testing in patients with a positive family

history of hereditary hemochromatosis or those with elevated serum ferritin level or transferrin saturation.

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Disease Screening: Hepatitis B Virus Infection, Chronic Organization

Population

Recommendations

Comments

Source

Pregnant

Screen all women with

http://www.

women

HBsAga at first prenatal

aafp.org/

visit.

online/en/

(Date) AAFP (2006) USPSTF (2004) CDC (2002)

home/ clinical/ exam.html http://www. ahrq.gov/ clinic/ uspstf/ uspshepb. htm http://www. cdc.gov

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AAFP (2006) USPSTF (2004)

General

Routine screening is not

Most people

http://www.

population

recommended.

who become

aafp.org/

infected as

online/en/

adults

home/

recover fully

clinical/

from HBV

exam.html

infection and

http://www.

develop

ahrq.gov/

protective

clinic/

immunity.

uspstf/ uspshepb. htm

CDC (2006)

All infants,

Test for HBsAg

children,

http://www. cdc.gov/

adolescents, and adults born in Asia, the Pacific Islands, Africa, and other endemic countries CDC (2006)

Hemodialysis

Test for HBsAg

patients aImmunoassays

http://www. cdc.gov/

for HBsAg have sensitivity and specificity > 98%. (MMWR 1993;42:707)

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Disease Screening: Hepatitis C Virus Infection, Chronic Organization

Population

Recommendations

Comments

Source

General

Do not perform

1. 15%–25% of

http://www.

population

routine screening for

persons with

aafp.org/

(Date) AAFP (2006) USPSTF (2004)

HCV infection in adults acute hepatitis

online/en/

who are not at

C resolve their

home/clinical/

increased risk.a

infection; of the

exam.html

remaining, 10%– 20% develop cirrhosis within 20–30 years after infection,

http://www. ahrq.gov/ clinic/uspstf/ uspshepc.htm

and 1%–5% develop hepatocellular carcinoma. 2. Abstinence from alcohol is imperative in patients with chronic hepatitis C. 3. At-risk persons should be immunized with hepatitis A and hepatitis B file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...patitis%20C%20Virus%20Infection,%20Chronic.htm (1 of 4) [2007/11/13 下午 12:40:23]

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AAFP (2006) USPSTF (2004)

Persons at

Insufficient evidence

vaccine, as

http://www.

increased

to recommend for or

appropriate.

aafp.org/

riska

against routine

(CDC)

online/en/

screening.

4. Between 1999 and 2002,

home/clinical/ exam.html

the prevalence of anti-HCV in the United States was 1.6%, equating CDC (2006)

Persons at

Perform routine

increased

counseling, testing,

riska

and appropriate followup.b See HCV Infection Testing Algorithm for Asymptomatic Persons.

to an estimated 4.1 million antiHCV–positive persons nationwide. 1.3% or 3.2 million had chronic HCV infection.

http://www. cdc.gov/ ncidod/ diseases/ hepatitis/C/ plan/ Prev_control. htm

Injection drug use strongest risk factor. (Ann Intern Med 2006;144:705)

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risk includes injection drug use, receipt of clotting factor concentrates before 1987,

chronic hemodialysis, receipt of blood from a donor who later tested positive for HCV, receipt of blood transfusion or organ transplant before July 1992, health care workers after needle sticks or mucosal exposures to HCV-positive blood, children born to HCV-positive women, and persons with evidence of chronic liver disease (abnormal ALT levels). b2

types of tests are available for laboratory diagnosis of HCV infection: (1) detection of antibody

to HCV antigens, and (2) detection and quantification of HCV nucleic acid. See HCV Infection Testing Algorithm for Asymptomatic Persons.

HCV Infection Testing Algorithm for Asymptomatic Persons

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Disease Screening: Human Immunodeficiency Virus Organization

Population

Recommendations

Comments

Source

Adolescents

Strongly recommends

1. Protect client

http://

and adults

screening.

confidentiality and be

www.

at increased

voluntary with

aafp.org/

riska

informed consent.

exam/

(Date) AAFP (2006) USPSTF (2005)

Provide patients with option for anonymous testing, written materials about HIV testing.

http:// www. ahrq.gov/ clinic/ uspstf/

2. Initial screening

uspshivi.

test: EIA is

htm

considered reactive only when a positive result is confirmed in a second test of the original sample. Seroconversion is 95% within 6 months of infection. Specificity is > 99.5%. 3. False-positives with EIA: nonspecific reactions in persons with immunologic disturbances (eg, file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...creening/Human%20Immunodeficiency%20Virus.htm (1 of 3) [2007/11/13 下午 12:40:25]

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CDC (2001)

People at

Routine and targeted

systemic lupus

MMWR

increased

counseling, testing,

erythematosus or

2001;50

riska

and referral should be

rheumatoid arthritis),

(RR-19):1

based on type of

multiple transfusions,

clinical setting, HIV

recent influenza, or

prevalence, and

rabies vaccination.

behavioral and clinical risk of individual clients.

http:// www.cdc. gov/

4. Confirmatory testing is necessary using Western blot or indirect immunofluorescence assay. 5. Management of newly diagnosed HIV

CDC (2003)

Adults

Include HIV testing as infection has been a routine part of recently reviewed.

MMWR

medical care.

329–332

(NEJM

2003;52:

2005;353:1702–1710) http:// www.cdc. gov/

MFP (2006) USPSTF (2005)

All pregnant

Universal prenatal

Rapid HIV antibody

MMWR

women

counseling and

testing during labor

2001;50

voluntary testing.

identified 34 positive

(RR-

women among 4,849

19):59

women with no prior HIV testing documented (prevalence, 7 in 1,000). 84% of women consented to testing. Sensitivity

http:// www. ahrq.gov/ clinic/ uspstf/ uspshivi.

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was 100%, specificity

htm

was 99.9%, PPV was CDC (2001)

All pregnant

Routine prenatal HIV

90%. (JAMA

http://

women

testing unless patient

2004;292:219)

www.cdc.

"opts out."

gov/

Retest high-risk women at 36 weeks' gestation. aHigh

risk: seeking treatment for STDs; men having sex with men after 1975; past or present

injection drug use; past or current exchange of sex for money or drugs; sex partners of people who are HIV-infected, bisexual, or injection drug users; or history of blood transfusion between 1978 and 1985; receives health care in a high-prevalence or high-risk setting; men and women having unprotected sex with multiple partners; persons requesting HIV test. EIA = enzyme immunoassay

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Disease Screening: Hypertension, Adults Organization

Population

Recommendations

Comments

Source

British

Aged 18–80

Screen at least every

BMJ

Hypertension

years

5 years

2004;328:634

(Date)

Society (2004)

If SBP > 130 or DBP > 85, then annually

JNC VII

Aged > 18

Normal: recheck in 2

JAMA

(NHLBI)

years

years (see

Prehypertension:

2003;289:2560

Comments)

SBP 120–139 or

(2003)

Prehypertension: recheck in 1 year Stage 1 hypertension: confirm within 2 months Stage 2 hypertension: evaluate or refer to source of care within 1 month (evaluate and treat immediately if BP > 180/110)

DBP 80–89

Hypertension 2003;42:1206

2. Stage 1 hypertension: SBP 140–159 or DBP 90–99 3. Stage 2 hypertension: SBP

160 or DBP

100 (based on average of

measurements on

2 separate

office visits) 4. Perform physical exam and routine labs.a

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5. Pursue secondary causes of hypertension.b 6. Treatment goals are for BP < 140/90, unless diabetes or renal disease present AAFP (2006) USPSTF (2003)

Aged years

Strongly

(< 130/80). See

Hypertension

recommends

Hypertension,

2000;35:844

screening

JNC VII Management Algorithm. 7. Ambulatory BP monitoring is a better (and independent) predictor of

NEJM 2003;348: 2407 http://www. aafp.org/online/ en/home/ clinical/exam. html

cardiovascular

http://www.

outcomes

ahrq.gov/clinic/

compared with

uspstf/

office visit

uspshype.htm

monitoring; and covered by Medicare when evaluating whitecoat hypertension. (NEJM 2006;354:2368)

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AccessMedicine - Print aPhysical

exam should include: measurements of height, weight, and waist circumference;

funduscopic exam (retinopathy); carotid auscultation (bruit); jugular venous pulsation; thyroid gland (enlargement); cardiac auscultation (left ventricular heave, S3 or S4, murmurs, clicks); chest auscultation (rales, evidence of chronic obstructive pulmonary disease); abdominal exam (bruits, masses, pulsations); exam of lower extremities (diminished arterial pulsations, bruits, edema); and neurologic exam (focal findings). Routine labs include urinalysis, complete blood count, electrolytes (potassium, calcium), creatinine, glucose, fasting lipids, and 12-lead electrocardiogram. bPursue

secondary causes of hypertension when evaluation is suggestive (clues in parentheses) of:

(1) pheochromocytoma (labile or paroxysmal hypertension accompanied by sweats, headaches, and palpitations), (2) renovascular disease (abdominal bruits), (3) autosomal dominant polycystic kidney disease (abdominal or flank masses), (4) Cushing's syndrome (truncal obesity with purple striae), (5) primary hyperaldosteronism (hypokalemia), (6) hyperparathyroidism (hypercalcemia), (7) renal parenchymal disease (elevated serum creatinine, abnormal urinalysis), (8) poor response to drug therapy, (9) well-controlled hypertension with an abrupt increase in blood pressure, (10) SBP > 180 or DBP > 110 mm Hg, or (11) sudden onset of hypertension.

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Disease Screening: Hypertension, Children & Adolescents Organization

Population

Recommendations

Comments

Source

Age < 18

Insufficient evidence

1. Hypertension:

http://www.

years

to recommend for or

average SBP or

aafp.org/

against routine

DBP

online/en/

screening.

percentile for

home/clinical/

gender, age, and

exam.html

(Date) AAFP (2006) USPSTF (2003)

95th

height on

occasions. See Appendix III: 95th Percentiles of Blood Pressure for

http://www. ahrq.gov/ clinic/uspstf/ uspshype.htm

Boys and Girls. 2. Prehypertension: average SBP or DBP 90th–95th percentile. 3. Adolescents with BP

120/80

mm Hg are prehypertensive. 4. Evaluation of hypertensive children: assess for additional risk file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...ertension,%20Children%20and%20Adolescents.htm (1 of 2) [2007/11/13 下午 12:40:27]

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NHLBI (2004)

Age 3–20

Measure BP at least

factors.

Pediatrics

yearsa

once during every

5. Indications for

2004;114:

health care episode.

antihypertensive

555–576

drug therapy in children: symptomatic hypertension, Bright Futures

Age 3–21

(2002)

years

Annual screening.

secondary hypertension,

http://www.

target-organ

nhlbi.nih.gov/

damage, diabetes,

http://www.

persistent

brightfutures.

hypertension

org

despite nonpharmacologic measures.

aIn

children < 3 years old, conditions that warrant BP measurement: prematurity, very low birth

weight, neonatal complications; congenital heart disease; recurrent UTI, hematuria, or proteinuria; renal disease or urologic malformations; family history of congenital renal disease; solid-organ transplant; malignancy or bone marrow transplant; drugs known to raise BP; systemic illnesses; increased intracranial pressure.

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Disease Screening: Lead Poisoning Organization

Population

Recommendations

Commentsc

Source

Infants and

Selective screening at

1. Risk

Am J Prev Med

children

12 months for infants

assessment

2001;20:78

and children at high

should be

riska

performed

(Date) ACPM (2001)

during prenatal visits and

http://www. acpm.org/ clinical.htm

continue until 6 years of age. 2. CDC personal risk questionnaire: (1) Does your child live in or AAP (2005)

Infants and

Selective screening

regularly visit

Pediatrics

children

with blood lead level

a house (or

2005;116:1036

at 9–12 months, and

other facility,

again at 24 months

eg, daycare)

http://www.aap.

when levels peak, of

that was built

infants and children

before 1950?

at high

riska,b

org

(2) Does your child live in or regularly visit a house built before 1978 with recent or

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ongoing renovations or remodeling (within the last 6 months)? (3) AAFP (2006)

Does your

Infants at

Selective screening

age 12

with blood lead level

months

for those infants at

child have a sibling or playmate who

high riska

has or did

http://www.aafp. org/online/en/ home/clinical/ exam.html

have lead poisoning? (http://www. cdc.gov/nceh/ lead/guide/ guide97.htm) aCriteria

for being at high risk include: receipt of Medicaid or WIC; living in a community with

12% prevalence of elevated blood lead levels (BLLs) at

10 µg/mL; living in a community with

27% of homes built before 1950; or meeting 1 or more high risk criteria from a lead-screening questionnaire (see CDC comments in table). Additional criteria: living near lead industry or heavy traffic or living with someone whose job or hobby involves lead exposure or who uses lead-based pottery or takes traditional remedies that contain lead. bConfirm

elevated lead levels with venous sample after screening sample from fingerstick:

immediately if > 70 µg/mL, within 48 hours if 45–69 µg/mL, within 1 week if 20–44 µg/mL, and within 1 month if 10–19 µg/mL. See AAP guidelines for further treatment recommendations. See http://www.cdc.gov/nceh/lead for additional information on prevention and screening. cStudies

show poor rates of testing and follow-up testing in children at risk or with documented

lead poisoning. (JAMA 2005;293:2232; Am J Public Health 2004;94:1945)

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Disease Screening: Obesity Organization

Population

Recommendations

Comments

Source

NAPNAP

Children

Calculate BMI

1. Screen BP in

Extensive

(2006)

and

annually being

children with

guidance

adolescents

careful to ensure an

BMI > 85th

provided in J

accurate height and

percentile,

Pediatr Health

weight.

screen BP,

Care 2006;20

fasting glucose,

suppl(2)

(Date)

total cholesterol in teens with BMI > 85th– USPSTF (2005) Children

Insufficient evidence

and

to recommend for or

adolescents

against routine screening for overweight as a means to prevent adverse health outcomes.

95th percentile. 2. Overweight is defined as BMI 25–29.9 kg/m2 and obesity as BMI > 30 kg/m2. 3. Waist–hip ratio may also provide additional prognostic information beyond BMI and waist circumference. Among women

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AAP (2003)

Children

Calculate and plot

50–69 years of

http://www.aap.

and

BMI annually.a

age free of

org

adolescents

cancer, heart disease, and diabetes, waist– hip ratio is the

Pediatrics 2003;112:424– 430

best

NEJM

anthropometric

2005;352:2100–

predictor of total

2109

mortality. (Arch Intern Med 2000;160:2117) 4. Laparoscopic AAFP (2006) USPSTF (2003)

Age > 18

Screen all adults and

years

offer intensive counseling and behavioral interventions to promote sustained weight loss in adults.

gastric banding was superior to orlistat/

http://www.aafp. org/exam

behavioral

http://www.ahrq.

therapy, after 2

gov/clinic/uspstf/

years follow-up,

uspsobes.htm

on the following outcomes: percent excess weight loss (87% vs. 22%),

NHLBI (2000)

Age > 18

Calculate BMI and

metabolic

NHLBI. The

years

measure waist

syndrome (3%

Practical Guide:

circumference for all

vs. 24%), and

Identification,

patients.b

quality of life.

Evaluation, and

(Ann Intern Med

Treatment of

2006;144:625)

Overweight and Obesity in Adults, 2000

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combination of waist circumference and BMI should be used to evaluate the presence of

elevated health risk among children and adolescents. (Pediatrics 2005 Jun;115/6:1623–1630) bBMI

is calculated as: weight (kg)/height (m) squared. See Appendix IV: Body Mass Index

Conversion Table. Studies do not support a BMI range of 25–27 as a risk factor for all-cause and cardiovascular mortality among elderly (age

65 years) persons. (Arch Intern Med

2001;161:1194) BMI cut-offs may also need to be modified for some Asian populations. (http:// www.idi.org.au; Am J Clin Nutr 2001;73:123)

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Disease Screening: Osteoporosis Organization

Population

Recommendations

Comments

Source

Women

Routinea screening

1. The benefits

http://www.aafp.

aged

via bone mineral

of screening and

org/online/en/

density (BMD)

treatment are of

home/clinical/

U.S. Surgeon

at least

exam.html

General (2004)

moderate

(Date) AAFP (2006) CTF (2004)

AACE (2003)

years

magnitude for women at

risk

CMAJ 2004;170 (11)

NOF (2003)

by virtue of age

http://www.nof.

USPSTF (2002)

or presence of

org

other risk factors.b

Ann Intern Med 2002;137:526–

2. Dual energy x- 528 ray absorptiometry (DEXA) is the most accurate clinical method

http://www. ahrq.gov/clinic/ uspstf/uspsoste. htm

for identifying

http://www.

those with low

aace.com/pub/

BMD.c

guidelines/

3. Clinical

http://www.

prediction rules

surgeongeneral.

[Simple

gov/library

Calculated Osteoporosis file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...)/I%20-%20Disease%20Screening/Osteoporosis.htm (1 of 6) [2007/11/13 下午 12:40:31]

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Risk Assessment Estimate (SCORE); Osteoporosis AAFP (2006) U.S. Surgeon General (2004) AACE (2003) NOF (2003) USPSTF (2002)

Women at

Routinea screening

Risk Assessment

http://www.aafp.

increased

beginning at age 60

Instrument

org/online/en/

risk for

(ORAI); NOF

home/clinical/

osteoporotic

guidelines] do

exam.html

fracturesa,b,c

not perform well as a general screening

http://www.nof. org

method to

Ann Intern Med

identify

2002;137:526–

postmenopausal

528

women who are more likely to have osteoporosis.

http://www. aace.com/pub/ guidelines/

Are quite

http://www.

sensitive (98%–

surgeongeneral.

100%) but not

gov/library

specific (10– 40%). (Arch Intern Med 2005;165:530– 536)

http://www. ahrq.gov/clinic/ uspstf/uspsoste. htm

4. Refer to Osteoporosis: Screening algorithm.

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recommends follow-up BMD measure in 3–5 years for women with "normal" baseline score,

and if high risk, in 1–2 years. bExact

risk factors that should trigger screening in this age group are difficult to specify based on

evidence. Well-accepted high-risk factors include chronic steroid use ( 2 months), repeated fractures or fractures not caused by trauma, early menopause, blood relative with osteoporosis, known low BMD, low body weight (< 127 lb), cigarette use. See Risk Factors for Osteoporotic Fracture. cUse

of hip DEXA scans in > 65-year-old population associated with 36% fewer incident hip

fractures over 6 years. [Ann Intern Med 2005 Feb 1;142(3):173–181]

Osteoporosis: Screening

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Risk Factors for Osteoporotic Fracture Potentially Modifiable

Nonmodifiable

Current cigarette smoker

Personal history of fracture as an adult

Low body weight (< 127 lb)

History of fracture in first-degree relative

Estrogen deficiency:

Caucasian race

-Early menopause (age < 45 years) or bilateral ovariectomy -Prolonged premenopausal amenorrhea (> 1 year) Low calcium intake (lifelong)

Advanced age

Alcohol (> 2 drinks/day)

Female sex

Impaired eyesight despite adequate correction

Dementia

Recurrent falls Inadequate physical activity Poor health/frailty

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Italicized items—personal or family history of fracture, smoking, and low body weight—were demonstrated in a large, ongoing, prospective U.S. study to be key factors in determining the risk of hip fracture (independent of bone density). Source: National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Available at: http://www.nof.org/ physguide, accessed July 24, 2006.

Causes of Generalized Secondary Osteoporosis in Adults Drugs

Endocrine

Collagen

Nutritional

Other

Diseases or

Vascular

Conditions

Causes

Metabolic Causes

Diseases

Aluminum

Acromegaly

Epidermolysis Celiac

Anticonvulsants

Adrenal atrophy and

Cigarette smoking Cytotoxic drugs Excessive alcohol Excessive thyroxine Glucocorticosteroids & adrenocorticotropin (oral or inhaled) Gonadotropinreleasing hormone agonists Heparin Immune suppressants Lithium Tamoxifen (premenopausal

Addison's disease Congenital porphyria Cushing's syndrome Endometriosis Female athlete triad

Amyloidosis

bullosa

diseasea

Osteogenesis

Gastrectomy

spondylitis

Eating

AIDS/HIV

imperfecia

disorders

Ankylosing

Chronic

Malabsorption obstructive syndromes Nutritional

pulmonary disease

Gaucher's disease

disorders

Hemophilia

Gonadal insufficiency

Parenteral

Idiopathic

(primary &

nutrition

scoliosis

Pernicious

Inflammatory

Hemochromatosis

anemia

bowel disease

Hyperparathyroidism

Severe liver

Lymphoma &

disease

leukemia

secondary)

Hypophosphatemia

(especially

Mastocytosis

Diabetes mellitus,

primary

type 1

biliary

Multiple

Thyrotoxicosis

cirrhosis)

myeloma

Tumor secretion of

Sprue

Multiple

parathyroid

sclerosis

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use)

hormone–related

Rheumatoid

peptide

arthritis Sarcoidosis Spinal cord transection Stroke Thalassemia

Source: National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Available at: http://www.nof.org/ physguide, accessed July 24, 2006. aConsider

serologic screening of all osteoporotic patients for celiac disease. [Arch Intern Med 2005

Feb 28;165(4):393–399]

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Disease Screening: Scoliosis Organization

Population Recommendations

Comments

Source

Adolescents Recommends against

1. Positive

http://www.

predictive value

aafp.org/

of bending test

online/en/

is 42.8% for

home/clinical/

scoliosis of > 5

exam.html

(Date) AAFP (2006) USPSTF (2004)

routine screening.

degrees and 6.4% for > 15 degrees; sensitivity 74%, specificity 78%. Bright Futures (2002)

Adolescents Screen during physical exam annually in adolescents and

(Am J Public Health 1985;75:1377)

http://www. ahrq.gov/clinic/ uspstf/ uspsaisc.htm http://www. brightfutures. org

children > 8 years of age.

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Disease Screening: Syphilis Organization

Population

Recommendations

Comments

Source

Pregnant

Screen all pregnant

1. All reactive

http://www.

women

women with

nontreponemal

aafp.org/exam

nontreponemal test

tests should be

(eg, RPR or VDRL) at

confirmed with

first prenatal visit;

a more specific

repeat in third

treponemal test

trimester and at

(eg, FTA-ABS).

(Date) AAFP (2006) USPSTF (2004)

delivery for women at high risk of acquiring infection during pregnancy.

http://www. ahrq.gov/clinic/ uspstf/ uspssyph.htm

2. Sensitivity of nontreponemal tests varies with levels of antibodies: 62%–76% in early primary syphilis, 100% during secondary syphilis, and 70% in untreated late syphilis. In late syphilis, previously reactive results revert to

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nonreactive in 25% of patients. 3. Specificity of nontreponemal tests is 75%– 85% in persons with preexisting diseases or conditions (eg, collagen AAFP (2006) USPSTF (2004)

High-risk

Screen high-risk

personsa

persons with routine serologic test (eg, RPR or VDRL).

vascular diseases,

http://www.

injection drug

aafp.org/exam

use, advanced

http://www.

malignancy,

ahrq.gov/clinic/

pregnancy,

uspstf/

malaria,

uspssyph.htm

tuberculosis, viral and rickettsial diseases) and 100% in persons without preexisting diseases or conditions. 4. CDC Syphilis Elimination Effort (SEE): National goal of reducing primary and secondary syphilis cases to < 1,000/year. Syphilis is

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AAN (2001)

Patients with Do not screen unless

primarily

Neurology

dementia

clinical suspicion of

concentrated in

2001;56: 1143

neurosyphilis is

certain

present.

communities and in urban areas among men who have sex with men.

http://www. aan.com/ professionals/ practice/index. cfm

Offer "Community Mobilization Toolkit" to help public health practitioners mobilize community alliances to eliminate syphilis. (http:// www.cdc.gov/ stopsyphilis/)

aHigh

risk includes commercial sex workers, persons who exchange sex for money or drugs,

persons with other STDs (including HIV), and sexual contacts of persons with active syphilis.

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Disease Screening: Thyroid Disease Organization Population Recommendations Comments

Source

(Date) AAFP (2006) USPSTF (2004)

Children

Insufficient

1. Increased risk of

http://www.

and adults

evidence to

hypothyroidism

ahrq.gov/clinic/

recommend for or

among patients with

uspstf/

against screening.

autoimmune

uspsthyr.htm

diseases, unexplained depression, cognitive dysfunction, or hypercholesterolemia. 2. Individuals with symptoms and signs potentially attributable to thyroid dysfunctionb

Ann Intern Med 2004;140:125– 127 http://www. aafp.org/ online/en/ home/clinical/ exam.html

and those with risk factors for its developmentc may require more frequent TSH testing. 3. When there is suspicion of pituitary or hypothalamic disease, the serum FT4 concentration should be measured file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...-%20Disease%20Screening/Thyroid%20Disease.htm (1 of 3) [2007/11/13 下午 12:40:35]

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ATA (2000)

Women

Screen with serum

in addition to the

Arch Intern

aged

TSH at age 35

serum TSH.

Med

years

years, and every 5 years thereafter.a

4. Controversy exists regarding Rx benefit for patients with subclinical hypothyroidism (elevated TSH;

2000;160:1573 http://www. thyroid.org/ professionals/ publications/ guidelines.html

normal free thyroxine). AACE (2002)

Elderly

Periodic screening

http://www.

with sensitive TSH.a

aace.com/pub/ guidelines Endocr Pract 2002;8:457– 469

consensus conference with representatives of ATA and AACE concluded that there is insufficient

evidence to support population-based screening, but that aggressive case finding is appropriate in pregnant women, women aged > 60 years, and others at high risk for thyroid dysfunction. (JAMA 2004;291:228) bSigns,

symptoms, and comorbidities suggestive of hypothyroidism include previous thyroid

dysfunction, goiter, surgery or radiotherapy affecting the thyroid, diabetes mellitus, vitiligo, pernicious anemia, leukotrichia (prematurely gray hair), and medications (such as lithium carbonate and iodine-containing compounds, eg, amiodarone, radiocontrast agents, expectorants containing potassium iodide, and kelp). cRisk

factors include family history of thyroid disease, or personal history of pernicious anemia,

diabetes mellitus, and primary adrenal insufficiency. Laboratory test results suggestive of thyroid disease include hypercholesterolemia, hyponatremia, anemia, CPK and LDH elevations, hyperprolactinemia, hypercalcemia, alkaline phosphatase elevation, and hepatocellular enzyme elevation.

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Tobacco Use Organization

Population

Recommendation

Comments

Source

Children and

Evidence is insufficient

Teens with novelty- http://

adolescents

to recommend for or

seeking personality

www.

against routine

traits are at

aafp.org/

screening.

increased risk of

online/

initiating and

en/

progressing in

home/

smoking behaviors.

clinical/

(Pediatrics

exam.

2006;117:1216)

html

Screen for tobacco

Smoking cessation

http://

use. See Tobacco

lowers the risk of

www.

Cessation.

heart disease,

aafp.org/

stroke, and lung

online/

disease.

en/

(Date) AAFP (2006) USPSTF (2003)

AAFP (2006) USPSTF (2003)

Adults

home/ clinical/ exam. html

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AAFP (2006) USPSTF (2003)

Pregnant

Screen for tobacco use. 1. Extended or

women

http://

augmented

www.

counseling (5–15

aafp.org/

minutes) that is

online/

tailored for

en/

pregnant smokers

home/

is more effective

clinical/

(17% abstinence)

exam.

than generic

html

counseling (7% abstinence). 2. Cessation leads to increased birth weights.

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Disease Screening: Tuberculosis Organization

Population

Recommendations

Comments

Source

Persons at

Screening by

1. Persons with (+)

http://www.

increased

tuberculin skin test

PPD test should

aafp.org/

risk of

is recommended.b

receive CXR and

exam.xml

developing

Frequency of testing

clinical evaluation

TBa

should be based on

for TB. If no

likelihood of further

evidence of active

exposure to TB and

infection, provide

level of confidence in

INH prophylaxis if

MMWR

the accuracy of the

appropriate.

2000;49(RR-

(Date) AAFP (2006) ATS (2003) CDC (2003) Bright Futures (2002)

results.c

2. Persons with

MMWR

mm PPD test and

2003;52(RR02):15–18

06):1–54 http://www.

who have either HIV thoracic.org/ infection or evidence of old, healed TB have the

http://www. cdc.gov/

highest lifetime risk

http://www.

of reactivation (

brightfutures.

20%). Also at high

org

risk (10%–20%) are those with (1) recent PPD conversion, (2) age > 35 years and immunosuppressive therapy, and (3) file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...)/I%20-%20Disease%20Screening/Tuberculosis.htm (1 of 3) [2007/11/13 下午 12:40:37]

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induration > 15 mm and age < 35 years. (NEJM 2004; 350:2060) 3. Treatment (INH for 9 months) is recommended for foreign-born persons who have latent TB infection and who have been in the United States < 5 years. 4. Prior BCG vaccination is not considered a valid basis for dismissing positive results. 5. Patients at high risk of INH liver injury should be monitored during INH therapy (history of liver disorder, HIV infection, pregnant and immediate postpartum women, regular alcohol user). [MMWR 2001;50(34)]

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AccessMedicine - Print aIncreased

risk: persons infected with HIV, close contacts of persons with known or suspected TB

(including health care workers), persons with medical risk factors associated with reactivation of TB (eg, silicosis, diabetes mellitus, prolonged corticosteroid therapy, end-stage renal disease, immunosuppressive therapy), immigrants from countries with high TB prevalence (eg, most countries in Africa, Asia, and Latin America), medically underserved and low-income populations, alcoholics, injection drug users, persons with abnormal CXRs compatible with past TB, and residents of long-term care facilities (eg, correctional institutions, mental institutions, nursing homes). bTest:

Give intradermal injection of 5 U of tuberculin PPD and examine 48–72 hours later. Criteria

for positive skin test (diameter of induration): > 15 mm for low risk, > 10 mm for high risk (including children < 4 years of age), > 5 mm for very high risk (HIV, abnormal CXR, recent contact with infected persons). If negative, consider 2-step testing to differentiate between booster effect and new conversion. Perform second test within 13 weeks. False-negative results occur in 5%–10%, especially early in infection, with anergy, with concurrent severe illness, in newborns and infants < 3 months old, and with improper technique. cPeriodic

(eg, at ages 1, 4–6, and 6–11 years) tuberculin skin testing is recommended for children

who live in high-prevalence regions or who are otherwise at high risk.

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Disease Screening: Visual Impairment, Glaucoma, & Cataract Organization

Population

Recommendations

Comments Source

Infants and

Assess for eye

Ophthalmology

childrena

problems in the

2003;110:860–865

(Date) AAP (2003)

newborn period and then at all subsequent routine health

Pediatrics 2003;111:902–907

supervision visits. Visual acuity testing beginning at age 3 years. AOA (2002)

Infants and

Initial eye and vision

http://www.aoanet.

children

screening at birth,

org

then at age 6 months, age 3 years, and every 2 years thereafter.

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AAO (2002)

Infants and

Pediatric eye

http://www.aao.org/

children

evaluation screening

ppp

at newborn to 3 months of age, then at age 3–6 months, age 6–12 months, age 3 years, age 5 years, then every 1–2 years after age 5 years. AAFP (2006)

Children

USPSTF (2004)

Recommends

http://www.aafp.

screening to detect

org/online/en/home/

amblyopia,

clinical/exam.html

strabismus, and defects in visual acuity before age 5 years. AOA (2005)

http://www.ahrq. gov/clinic/uspstf/ uspsvsch.htm

Adults, no

Comprehensive eye

http://www.aoanet.

risk factors

and vision exam

org

every 2 years aged 18–40 years, every 2 years aged 41–60 years, and every 1 year aged

AAO (2005)

61 years.b

Adults, no

Comprehensive

http://www.aao.org/

risk factors

medical eye

ppp

evaluation every 5–10 years for age < 40 years, every 2–4 years for age 40–54 years, every 1–3 years for age 55–64 years, every 1–2 years for age

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USPSTF (2005)

Adults

Insufficient evidence

http://www.ahrq.

to recommend for or

gov/clinic/uspstf/

against screening

uspsglau.htm

adults for glaucoma. AAFP (2006)

Elderly

AGS (1997)

Perform routine eye

J Am Geriatr Soc

and Snellen visual

1997;45:344

acuity screening.

http://www. americangeriatrics. org/ http://www.aafp. org/online/en/home/ clinical/exam.html

aRefer

to ophthalmologist if high risk (very premature; family congenital cataracts, retinoblastoma,

or metabolic or genetic diseases; significant developmental delay or neurologic difficulties; systemic disease associated with eye abnormalities). bIncrease

frequency to every 1–2 years or as recommended for patients at risk (diabetes,

hypertension, family history of ocular disease, work in occupations that are highly demanding visually or are eye hazardous, taking medications with ocular side effects, contact lens wearers, history of eye surgery, other health concerns or conditions). cFor

patients with risk factors:

(1) Diabetes mellitus type 1: 5 years after onset then yearly (2) Diabetes mellitus type 2: At time of diagnosis then yearly (3) Diabetes mellitus before pregnancy: Before conception or early in first trimester, then every 1– 12 months, dependent on extent of retinopathy. (4) Glaucoma risk factors (elevated IOP, family history, African or Hispanic/Latino descent): Every 2–4 years for age < 40 years, every 1–3 years for age 40–54 years, every 1–2 years for age 55– 64 years, every 6–12 months for age

65 years

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Current Practice Guidelines in Primary Care 2007 Ralph Gonzales, Jean S. Kutner

Abbreviations Preface Disease

Disease

Screening

Prevention

Management

Appendices

Cancer Prevention: NCI Evidence Summary (2006) Diabetes, Type 2 Endocarditis Falls in the Elderly Hypertension Myocardial Infarction Osteoporosis Stroke

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Disease Prevention: Cancer Prevention: NCI Evidence Summary (2006) Cancer Type Minimize Risk Factor

Breasta,b

Strength of

Therapeutic

Strength of

Exposure

Evidence

Hormone replacement

Solid

Tamoxifen

Good

Ionizing radiation

Solid

Raloxifene

Good

Obesity

Solid

Bilateral

Solid

therapy

mastectomy Alcohol

Cervical

Human papillomavirus

Solid

infection

Oopherectomy

Good

Exercise

Solid

HPV-16/HPV-18

Fair

vaccinationc

Abstinence from sexual activity Barrier protection and/or spermicidal gel during sexual intercourse Cigarette smoke Colorectalb,d

Solid Nonsteroidal anti-

Solid

inflammatory drugs Postmenopausal

Inadequate

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Low-fat, high-fiber

Inadequate

diet Endometrial

Progesteronee

Solid

Oral contraceptives Solid Gastric

Helicobacter pylori

Solid

infection Excessive salt intake

Anti-H. pylori

Inadequate

therapy Fair

Dietary

Inadequate

interventions Deficient consumption

Fair

fruits/vegetables Liver

HBV vaccination

Solid

(newborns of mothers infected with HBV) Lung

Cigarette smoking

Solid

Beta-carotene,

Solid

pharmacological doses – in high-intensity smokers

Oral

Ovarianf

Radon

Solid

Tobacco

Solid

Alcohol

Inadequate

Postmenopausal

Fair

hormone replacement

Prophylactic

Good

oophorectomy – in high-risk women (eg, BRCA1/BRCA-2)

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Prostate

Finasteride (

Solid

Incidence, but not mortalityg)

Vitamin E Selenium

Insufficient

Lycopene Skin

UV radiation

Fair

Sunscreen

Fair

(nonmelanomatous skin cancer) Sunburns (melanoma) aNational

Inadequate

Surgical Adjuvant Breast and Bowel Project (NSABP) Study of Tamoxifen and Raloxifene

(STAR) trial: Raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer among post-menopausal women with at least a 5-year predicted breast cancer risk of 1.66% based on the Gail model. (http://bcra.nci.nih.gov/brc) Raloxifene has a lower risk of thromboembolic events and cataracts and a nonstatistically significant higher risk of noninvasive breast cancer than tamoxifen. Risk of other cancers, fractures, ischemic heart disease, and stroke is similar for both drugs. (JAMA 2006;295:2727) The National Cancer Institute is supporting a number of ongoing breast cancer prevention trials. (http://www.cancer.gov/clinicaltrials) bWomen's

Health Study: Alternate-day use of low-dose aspirin (100 mg) for an average 10 years

of treatment does not lower risk of total, breast, colorectal, or other site-specific cancers. There was a trend toward reduction in risk for lung cancer. (JAMA 2005;294:47–55) cOn

June 8, 2006, the U.S. Food and Drug Administration (FDA) announced approval of Gardasil,

the first vaccine developed to prevent cervical cancer, precancerous genital lesions, and genital warts due to human papillomavirus (HPV) types 6, 11, 16, and 18. The vaccine is approved for use in females 9–26 years of age. (http://www.fda.gov) GlaxoSmithKline is testing a bivalent vaccine against HPV types 16 and 18. (NEJM 2006;354:1109–1112) dCereal

fiber supplementation and diets low in fat and high in fiber, fruits, and vegetables do not

reduce the rate of adenoma recurrence over a 3-year to 4-year period. eProgesterone fOral

eliminates risk of endometrial cancer associated with unopposed estrogen use.

contraceptive use, at least 1 full term pregnancy, and breastfeeding associated with

risk

ovarian cancer. file:///D|/local/PDF/E-Book(PDF)/Current%2...20-%20NCI%20Evidence%20Summary,%202006.htm (3 of 4) [2007/11/13 下午 12:43:20]

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treatment increased erectile dysfunction, loss of libido, and gynecomastia.

Source: http://www.cancer.gov/cancertopics/pdq/prevention.

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Disease Prevention: Diabetes, Type 2 Organization

Population

Recommendations

Comments

Source

Patients

Counsel on increasing

1. Drug therapy

Diabetes Care

with

physical activity and

should not be

2006;29

impaired

weight loss. Follow-up

routinely used

(Suppl 1):S4

fasting

counseling important

to prevent

glucose or

for success.

diabetes until

(Date) ADA (2006)

glucose tolerance (Diabetes

Monitor for diabetes every 1–2 years.

more information is known about

Mellitus,

Pay close attention to,

cost-

Type 2)

and treat, other CVD

effectiveness.

risk factors (eg, tobacco use, hypertension, dyslipidemia).

http://www. diabetes.org/ for-healthprofessionalsand-scientists/ cpr.jsp

2. RCTs have proven the efficacy of increased physical activity (at least 30 minutes daily) and weight loss (at least 5%– 10% body weight) for preventing type 2 diabetes. Maintenance of modest weight

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loss through diet and physical activity reduces incidence of type 2 DM in high-risk persons by 40%–60% over 3–4 years. (Ann Intern Med 2004;140:951)

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Disease Prevention: Endocarditis Organization

Population

Recommendations

Comments

Source

High-risk

Give antibiotic

Bacteremia

Circulation

personsa

prophylaxisc,d before

occurred in 76%

2005;111:3167

bacteremia-

of children

producing

treated

procedures.e,f

prophylactically

(Date) AHA (2005)

Moderaterisk personsb

with placebo

http://www. americanheart. org

compared with 15% treated with amoxicillin. (Circulation 2004;109:2878) aPatients

at high risk for endocarditis include those with prosthetic heart valves (including

bioprosthetic and homograft valves), previous bacterial endocarditis, complex cyanotic congenital heart disease (including single ventricle states, transposition of the great arteries, tetralogy of Fallot), and surgically constructed systemic pulmonary shunts or conduits. bPatients

at moderate risk for endocarditis include those with most other congenital heart diseases

(excluding isolated secundum atrial septal defect and surgically repaired atrial septal defect, ventricular septal defect, or patent ductus arteriosus without residua beyond 6 months), acquired valvular dysfunction (eg, rheumatic heart disease), hypertrophic cardiomyopathy, and mitral valve prolapse with valvular regurgitation or thickened leaflets. cStandard

prophylaxis regimen for dental, oral, respiratory tract, or esophageal procedures:

amoxicillin (adults 2.0 g; children 50 mg/kg orally 1 hour before procedure). If unable to take oral medications, give ampicillin (adults 2.0 g IM or IV; children 50 mg/kg IM or IV within 30 minutes of procedure). If penicillin-allergic, give clindamycin (adults 600 mg; children 20 mg/kg orally 1 hour before procedure) or cephalexin or cefadroxil (adults 2.0 g; children 50 mg/kg orally 1 hour file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...II%20-%20Disease%20Prevention/Endocarditis.htm (1 of 2) [2007/11/13 下午 12:43:22]

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before procedure), or azithromycin or clarithromycin (adults 500 mg; children 15 mg/kg orally 1 hour before procedure). If penicillin-allergic and unable to take oral medications, give clindamycin (adults 600 mg; children 20 mg/kg IV within 30 minutes before procedure) or cefazolin (adults 1 g; children 25 mg/kg IM or IV within 30 minutes of procedure). See reference for recommended antibiotic regimens for other procedures. (JAMA 1997;277:1794) dBritish

Society for Antimicrobial Therapy recommends the addition of gentamicin, 1.5 mg/kg IV,

for patients at high risk of endocarditis undergoing gastrointestinal, genitourinary, ob-gyn, or respiratory tract invasive procedures. (J Antimicrob Chemother doi:10.1093/jac/dk1121) eBacteremia-producing

procedures include: (1) dental and oral procedures including dental

extractions, periodontal procedures, dental implant placement and reimplantation of avulsed teeth, endodontic (root canal) instrumentation, subgingival placement of antibiotic fibers or strips, initial placement of orthodontic bands but not brackets, intraligamentary local anesthetic injections, and prophylactic cleaning of teeth or implants where bleeding is anticipated; (2) respiratory tract procedures including tonsillectomy and adenoidectomy, surgical operations involving the respiratory mucosa, and bronchoscopy with a rigid bronchoscope; and (3) genitourinary tract procedures including prostatic surgery, cystoscopy, and urethral dilation. fProphylaxis

for high-risk but not moderate-risk patients is recommended for patients undergoing

gastrointestinal tract procedures including sclerotherapy, esophageal stricture dilation, ERCP with biliary obstruction, biliary tract surgery, surgical operations involving the intestinal mucosa, and colon and rectal endoscopy. (Dis Colon Rectum 2000;43:1193)

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Falls in the Elderly

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Disease Prevention: Hypertension Organization

Population

Recommendations

Comments

Source

Persons at risk Recommend weight

1. A 5-mm

Hypertension

for developing

loss, reduced sodium

Hg reduction

2003;42:1206–

hypertensiona

intake, moderate

of SBP in the

1252

alcohol consumption,

population

increased physical

would result

activity, potassium

in a 14%

supplementation,

overall

modification of eating

reduction in

patternsb

mortality due

(Date) JNC VII (2003) NHLBI (2003)

to stroke, a 9% reduction in mortality due to coronary heart disease, and a 7% decrease in all-cause mortality. 2. Weight loss of as little as 10 lb (4.5 kg) reduces BP file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...I%20-%20Disease%20Prevention/Hypertension.htm (1 of 2) [2007/11/13 下午 12:43:24]

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and/or prevents hypertension in a large proportion of overweight patients. aFamily

history of hypertension; African-American (black race) ancestry; overweight or obesity;

sedentary lifestyle; excess intake of dietary sodium; insufficient intake of fruits, vegetables, and potassium; excess consumption of alcohol. bSee

Lifestyle Modifications for Primary Prevention of Hypertension.

Lifestyle Modifications for Primary Prevention of Hypertension

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Disease Prevention: Myocardial Infarction Organization Population

Recommendations

Comments

Source

(Date) In a recent evaluation showing a 50% reduction in CHD

BMJ 2005;331

mortality, 81% were attributable to primary prevention of CHD

(7517):614

through tobacco cessation and lipid- and blood pressure– lowering activities. Only 19% of CHD mortality reduction occurred via these activities in patients with existing CHD (secondary prevention). USPSTF

Adults at

Strongly

1. Recent meta-

(2004)

increased risk

recommends

analysis

of CHD events

consideration of

concludes

aspirin

chemoprevention;

prophylaxis

optimum dose is

reduces

unknown (2002).

ischemic stroke risk in women (–17%) and MI events in men (–32%). No mortality benefit in either group. Risk of bleeding increased in both groups to a similar

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AHA (2002)

All

Begin risk factor

degree as the

Circulation

assessment at age

event rate

2002;106:388

20 years.

reduction.

Dietary guidelines: (1) Match energy intake with energy

(JAMA 2006;295:306– 313)

needs. (2) Reduce

2. New tests

saturated fat (<

being

10% calories),

developed to

cholesterol (< 300

identify high-

mg/day), and trans-

risk

fatty acids by

individuals:

substituting grains

noninvasive

and unsaturated

testing for skin

fatty acids. (3) Limit

tissue

salt intake (< 6 g/

cholesterol;

day). (4) Limit

inflammatory

alcohol (

markers (high-

2 drinks/

day in men;

reactive

women).

protein,

30 minutes of moderate intensity (15–20 minutes/ mile) for most days of week.

http://www. americanheart. org

interleukin-6, serum amyloid A), multislice computed tomography, leukocyte subtypes.

Control weight:

[JAMA 2005;

Achieve and

293:2582–

maintain BMI at

2583; JAMA

18.5–24.9 kg/m2

2005;293

(see Appendix IV:

(20):2471–

Body Mass Index

2478; J Am

Conversion Table).

Coll Cardiol

Strongly encourage

2000;102:2284

sensitivity C-

drink per day in

Physical activity:

Circulation

2005;45 (10):1638–

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smoking cessation.

AHA (2002) NCEP III (2002)

1643]

1. Short-term

Circulation

recommendations,

reduction in

2002;106:338

see Cholesterol &

LDL using

Lipid Disorders,

dietary

Adults; also see

counseling by

Cholesterol & Lipid

dietitians is

Management.

superior to that

Hyperlipidemiaa For screening

Circulation 2004;110:227– 239

achieved by physicians. (Am J Med 2000;109:549) 2. PROVE IT– TIMI22: Lowest rate of recurrent events (1.9/100 person-years) when LDL < 70 mg/dL and CRP < 1 mg/L after statin therapy. [NEJM 2005;352 (1):20–28] file:///D|/local/PDF/E-Book(PDF)/Current%20Prac...isease%20Prevention/Myocardial%20Infarction.htm (3 of 7) [2007/11/13 下午 12:43:26]

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JNC VII

Hypertension

(2003)

See Hypertension

1. Antiplatelet

Hypertension

for JNC VII

therapy with

2003;42:1206–

treatment

ASA not

1252

algorithms.

recommended for primary prevention of MI in hypertensive patients (benefit negated by harm). Antiplatelet

AHA (2002)

Hypertension

Goal: < 140/90; <

therapy

Circulation

130/85 if renal

recommended

2002;106:388

insufficiency or

for secondary

heart failure

prevention.

present; < 130/80 if

Glycoprotein

diabetes present.

IIb/IIIa inhibitors, ticlopidine, and clopidogrel have not been sufficiently evaluated in patients with hypertension. (Cochrane Database Syst Rev 2004;3: CD003186)

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ACP (2004)

Diabetes

Statins should be

Ann Intern Med

used for primary

2004;140:644–

prevention of

649

macrovascular

http://www.

complications if

acponline.org/

patient has type 2

clinical/

DM and other

guidelines/?

cardiovascular risk

hp#acg

factors (age > 55 years, left ventricular hypertrophy, previous cerebrovascular disease, peripheral arterial disease, smoking, or hypertension). AHA (2002)

Diabetes

Goals: normal

1. ACE

Circulation

fasting glucose (<

inhibitors

2002;106:388

110 mg/dL) and

should be first

near normal HbA1c

choice for

(< 7%), BP <

diabetics with

130/80 mm Hg; LDL- hypertension, C < 100 mg/dL (or

and may be

< 70 for high risk).

superior in

http://www. americanheart. org

reducing risk for acute MI, but not stroke. (Diabetes Care 2000;23:888; J Hypertens 2000;18:1671) 2. Improved outcomes demonstrated file:///D|/local/PDF/E-Book(PDF)/Current%20Prac...isease%20Prevention/Myocardial%20Infarction.htm (5 of 7) [2007/11/13 下午 12:43:26]

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for lower BP targets (< 130/80 mm Hg). [Diabetes Care 2002;25 (Suppl 1):S71] AHA (2004)

Women

In addition to

Circulation

standard

2004;109:672–

recommendations,

693

highlight:

http://www.

Waist circumference

americanheart.

< 35 in.

org

Evaluate and treat for depression. Omega-3-fatty acids and folic acid if high risk.a BP < 120/80. Lipids: LDL-C < 100 mg/dL, HDL-C > 50 mg/dL, triglycerides < 150 mg/dL. Aspirin (75–162 mg) or clopidogrel if high riska (not recommended if low risk). ACE inhibitors if high risk.a Estrogen plus progestin hormone therapy should NOT be used or file:///D|/local/PDF/E-Book(PDF)/Current%20Prac...isease%20Prevention/Myocardial%20Infarction.htm (6 of 7) [2007/11/13 下午 12:43:26]

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continued. Antioxidant supplements NOT recommended. aHigh

risk: CHD or risk equivalent or 10-year absolute CHD risk > 20%.

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Disease Prevention: Osteoporosis Organization Population Recommendations Comments

Source

(Date) AAFP (2006) AACE (2003) NOF (2003) NIH (2001)

Women

Counsel all women

1. Medical disorders

http://www.

about fracture risk

associated with

aafp.org/

reduction (dietary

osteoporosis include

online/en/

calcium, vitamin D,

hypogonadism (men), home/clinical/

weight-bearing

exercise, smoking

excess,

thyroid hormone

cessation, moderate hypercalciuria,

exam.html http://www. nof.org/

alcohol intake, fall

hyperparathyroidism,

risk reduction).a

and malabsorption.

JAMA

Anticonvulsant

2001;285:785–

therapy and use of

795

glucocorticoids are also associated with osteoporosis.c 2. For women receiving thyroid replacement therapy for nonmalignant

Endocrine Practice 2003;9 (6):545–564 NEJM 2001;345:941– 947; 989–992

conditions,

http://www.

periodically monitor

aace.com/pub/

TSH levels and

guidelines/

adjust dose. 3. Women's Health Initiative found that use of conjugated file:///D|/local/PDF/E-Book(PDF)/Current%20Pra...II%20-%20Disease%20Prevention/Osteoporosis.htm (1 of 4) [2007/11/13 下午 12:43:27]

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equine estrogen (0.625 mg/day) and medroxyprogesterone acetate (2.5 mg/day) reduced the risk of hip fracture by 33%. The change in bone mineral density after 3 years was 4.5% higher for lumbar spine and 3.6% higher for total hip for hormone users vs. non-users. (JAMA 2003;290: 1729– 1748) 4. Statin use did not improve fracture risk or bone density in the Women's Health Initiative Observational Study. (Ann Intern Med 2003;139:97–104) 5. USPSTF: Good evidence that the use of combined estrogen and progestin and of unopposed estrogen results in reduced risk for fracture. (Ann Intern Med 2005;142:855–860)

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calcium: 9–18 years, 1,500 mg/day; 19–50 years, 1,000 mg/day; > 50 years,

1,200 mg/day. Recommended vitamin D: 400–800 IU/day. Predictors of low bone mass include increased age, estrogen deficiency, white race, low weight and BMI, family history of osteoporosis, smoking, history of prior fractures, oral or inhaled glucocorticoid therapy use. Use of alcohol and caffeine-containing beverages is inconsistently associated with decreased bone mass. Grip strength and current exercise are associated with increased bone mass. bEarly

evidence indicates that testosterone replacement therapy may enhance bone mass in

hypogonadal men; longer-term studies are needed to better define risks and benefits. (JAGS 2001;49:179–187) cConsider

bisphosphonate (alendronate or risedronate) for all adult women who require > 7.5 mg

prednisone (or equivalent) for > 3 weeks.

Osteoporosis: Prevention for Women at Risk*

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Disease Prevention: Stroke Organization Population

Recommendations Comments

Source

Screen and treat in

http://www.

accordance with

americanheart.org

(Date) AHA/ASA

Hypertension

(2006)

JNC VII

AAN (2006)

http://www.aan.

(Hypertension).

com/ professionals/ practice/index.cfm Circulation 2006;113:873– 923

ACP (2003)

Atrial

Prioritize rate

1. Average

http://www.

fibrillation

control; de-

stroke rate in

acponline.org/

emphasize rhythm

patients with

clinical/

risk factors

guidelines/?

about 5% per

hp#acg

year. 2. Warfarin

Ann Intern Med 2003;139:1009

reduces the absolute risk of stroke by about 2.7% per year (NNT = 37) compared with file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...007)/II%20-%20Disease%20Prevention/Stroke.htm (1 of 5) [2007/11/13 下午 12:43:29]

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ACCP (2004)

Atrial

Give anticoagulation

1.5%

Chest

fibrillation

with warfarin;

reduction for

2004;126:429S–

target prothrombin

aspirin (NNT =

456S

time INR = 2.5

67). Risk of

(range, 2.0–3.0) as

major bleed on

noted below:

warfarin =

All patients with any high risk factor for strokeb

or > 1

moderate risk factor for strokec: Give warfarin as above.

0.6% per year (NNH = 167); risk of intracranial bleed = 0.3% per year (NNH = 333). (Ann

Patients with 1

Intern Med

moderate risk

1999;131:492)

factorc: Give aspirin or warfarin as above. Patients with no high or moderate risk factors: Give aspirin, 325 mg/day. AHA/ASA

Atrial

1. Warfarin therapy

Circulation

(2006)

fibrillation

if high stroke risk

2006;113: 873–

(> 4% per year); as

923

AAN (2006)

well as most moderate stroke risk (> 2.5% per year) with favorable bleed risk assessment. 2. See Atrial Fibrillation, for dosing recommendations.

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AHA/ASA

Diabetes

(2006) AAN (2006)

1. Endorse tight

http://www.

control of BP per

myamericanheart.

JNC VII.

org/portal/ professional/

2. Statin therapy.

guidelines

3. Consider ACE

http://www.aan.

inhibitor or ARB

com/

therapy for further

professionals/

stroke risk

practice/index.cfm

reduction.

Circulation 2006;113:873– 923 AHA/ASA (2006) AAN (2006)

Asymptomatic Carotid artery stenosis

1. Screen

Clear

http://www.

asymptomatic CAS

consensus

myamericanheart.

for other stroke risk

exists on

org/portal/

factors and treat

efficacy of

professional/

aggressively.

treatment for

guidelines

2. Aspirin unless contraindicated.

symptomatic CAS; treatment of

3. Prophylactic CEA

asymptomatic

for patients with

CAS is

high-grade (> 60%)

controversial.d

http://www.aan. com/ professionals/ practice/index.cfm Circulation

CAS when

2006;113:873–

performed by

923

surgeons with low (< 3%) morbidity/ mortality rates.

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AHA/ASA

Hyperlipidemia See screening

(2006) AAN (2006)

Atherosclerotic

Circulation

recommendations in

intracranial

2006;113:873–

Cholesterol & Lipid

stenosis:

923

Disorders, Adults.

Aspirin (1,300

See Cholesterol & Lipid Management.

mg/day) should be used in preference

Statin initiation per

to warfarin.

NCEP III for high

Warfarin—

stroke risk

significantly

hypertensive

higher rates of

patients with upper

adverse

limit LDL is

events with no

recommended.

benefit over aspirin. [NEJM 2005 Mar 31;352 (13):1305– 1316]

AHA/ASA

Sickle cell

Begin screening

Transfusion

(2006)

disease

with transcranial

therapy

Doppler (TCD) at 2

decreased

years of age.

stroke rates

AAN (2006)

Transfusion therapy is recommended for patients at high stroke risk per TCD

from 10% to < 1% per year. (NEJM 1998;339:5)

(high cerebral blood flow velocity > 200 cm/second). Frequency of screening not determined.

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AHA/ASA

Smoking

(2006) AAN (2006)

Strongly encourage

Circulation

patient and family

2006;113:873–

to stop smoking.

923

Provide counseling, nicotine replacement, and formal programs as available. Avoid environmental smoke.

aAssess

risk of stroke in all patients. See Appendix VI: Estimate of 10-Year Stroke Risk for risk

assessment tool. bHigh

risk factors for stroke in patients with atrial fibrillation include previous transient ischemic

attack or stroke or embolus, hypertension, poor LV function, age > 75 years, diabetes, rheumatic mitral valve disease, and prosthetic heart valves. cModerate

risk factors for stroke are age 65–75 years, diabetes, and coronary artery disease with

preserved LV function. dNet

benefit of carotid endarterectomy requires treatment by surgical team with low perioperative

risk of stroke/death (< 3%) and is enhanced for patients with symptomatic CAS when performed early (within 2 weeks of last ischemic event). (Lancet 2004;363:915) CEA remains the standard of care, even in high-risk surgical patients. [Ann Surg 2005 Feb;241(2):356–363].

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Current Practice Guidelines in Primary Care 2007 Ralph Gonzales, Jean S. Kutner

Abbreviations Preface Disease

Disease

Screening

Prevention

Management

Appendices

Alcohol Dependence: Evaluation & Management Arthritis Asthma Atopic Dermatitis Atrial Fibrillation Cancer Survivorship Carotid Artery Stenosis Cataract in Adults Cholesterol & Lipid Management COPD Management Coronary Artery Disease Depression Diabetes Mellitus Heart Failure Hypertension Obesity in Adults Obesity in Children Osteoporosis Palliative and End-of-Life Care Pap Smear Abnormalities Perioperative Cardiovascular Evaluation Perioperative Pulmonary Assessment Pneumonia Routine Prenatal Care Pregnancy Tobacco Cessation Upper Respiratory Tract Infection Urinary Tract Infections in Women

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Alcohol Dependence: Evaluation & Management

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Source: NIAAA

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Prescribing Medications The chart below contains excerpts from page 20 of NIAAA's Helping Patients Who Drink Too Much: A Clinical Guide. It does not provide complete information and is not meant to be a substitute for the patient package inserts or other drug references used by clinicians. For patient information, visit http://medlineplus. gov.

Contraindications

Key precautions

Disulfiram

Naltrexone

Acamprosate

(Antabuse®)

(ReVia®)

(Campral®)

Concomitant use of

Currently using

Severe renal

alcohol or alcohol-

opioids or in acute

impairment (CrCl

containing

opioid withdrawal;

30 mL/min)

preparations or

anticipated need

metronidazole;

for opioid

coronary artery

analgesics; acute

disease; severe

hepatitis or liver

myocardial disease

failure

High impulsivity;

Other hepatic

Moderate renal

likely to drink while

disease. If opioid

impairment (dose

using it; psychoses

analgesia is

adjustment for CrCl

(current or history);

required, larger

between 30–50 mL/

hepatic dysfunction

doses may be

min); depression or

required, and

suicidality

respiratory depression may be deeper and more prolonged.

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More common serious

Disulfiram-ethanol

Will precipitate

Anxiety;

adverse reactions

reaction; hepatitis;

severe withdrawal

depression; suicide

peripheral

if patient is

attempt (> 1%);

neuropathy;

dependent on

pregnancy

psychotic reactions;

opioids;

Category C

pregnancy Category

hepatotoxicity

(uncommon at usual doses); pregnancy Category C

Common side effects

Metallic after-taste;

Nausea; abdominal Diarrhea;

dermatitis

pain; constipation;

flatulence; nausea;

dizziness;

abdominal pain;

headache; anxiety

headache

and fatigue Examples of drug

Warfarin; isoniazid;

Opioid analgesics

No clinically

interactions

metronidazole; any

(blocks action)

relevant

nonprescription drug

interactions known

containing alcohol How to prescribe

Oral dose: 250 mg

Oral dose: 50 mg

Oral dose: 666 mg

daily (range, 125 mg

daily

(two 333-mg

to 500 mg)

tablets) three times daily or, for patients with moderate renal impairment (CrCl 30–50 mL/min), reduce to 333 mg (one tablet) three times daily

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Before prescribing:

(1) warn that patient

Evaluate for

Establish

should not take

possible current

abstinence

disulfiram for at

opioid use;

least 12 hours after

consider a urine

drinking and that a

toxicology screen

disulfiram-alcohol

for opioids,

reaction can occur

including synthetic

up to 2 weeks after

opioids. Obtain

the last dose; and

liver function tests.

(2) warn about alcohol in the diet (e. g., sauces and vinegars) and in medications and toiletries Follow-up: Monitor

Follow-up: Monitor

liver function tests

periodically

Note: Whether or not a medication should be prescribed and in what amount is a matter between individuals and their health care providers. The prescribing information provided here is not a substitute for a provider's judgment in an individual circumstance, and the NIH accepts no liability or responsibility for use of the information with regard to particular patients.

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Pharmacological Management of Arthritis of Hip and Knee

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Notes: 1. Quadriceps weakness may precede, initiate, and exacerbate knee osteoarthritis. (Rheum Dis Clin North Am 1999;25:283–398) 2. NSAIDs and COX-2 inhibitors are more efficacious than acetaminophen, but the superiority is modest. Because of greater toxicity of NSAIDs, acetaminophen should be first-line therapy. (Arthritis Rheum 2001;44:1587–1598) (Arthritis Rheum 2001;44:1477–1480) (NEJM 2006;354:841–848) 3. Hyaluronan intraarticular therapy has only been evaluated in knee osteoarthritis. Data on efficacy are inconsistent. (NEJM 2006;354:841–848) 4. Topical therapy primarily indicated for mild to moderate pain related to osteoarthritis of the knee. There are no studies of topical therapy for hip osteoarthritis. 5. COX-2 inhibitors are as efficacious as non-selective NSAIDs, but not more efficacious. In contrast to non-selective NSAIDs, COX-2 inhibitors do not impair platelet function or bleeding time. Note: Rofecoxib and valdecoxib withdrawn from market, and celecoxib may increase adverse cardiac events. 6. Use of concomitant gastroprotective therapy with misoprostol or a proton pump inhibitor is not recommended in the low-risk patient. 7. In a randomized trial, 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. The outcomes (pain, physical function) after arthroscopic debridement or lavage were no better than those after the placebo procedure over 24 months of follow-up. (NEJM 2002;347:81–88) However, total joint

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arthroplasty provides marked pain relief and functional improvement in the vast majority of patients with osteoarthritis, and has been shown to be cost-effective in selected patients. An NIH Consensus conference recommends total hip replacement when "radiographic evidence of joint damage and moderate-to-severe persistent pain and disability, or both, that is not substantially relieved by an extended course of non-surgical management" is present. 8. A meta-analysis of NSAIDs in osteoarthritic knee pain, after excluding trials that excluded NSAID nonresponders at entry, concluded that NSAIDs reduce short-term pain in osteoarthritis only slightly better than placebo. [BMJ 2004;329(7478):1317] 9. Randomized trial of traditional Chinese acupuncture (TCA) vs. sham acupuncture vs. conservative therapy on improvement in pain and function among patients with knee osteoarthritis. Success rates = 53% in TCA group, 51% in sham acupuncture group, and 29% in conservative therapy group. (Ann Intern Med 2006;145:12–20) 10. Randomized trial of glucosamine, chondroitin sulfate, both, celecoxib, or placebo for knee osteoarthritis: glucosamine and chondroitin sulfate alone or in combination were not significantly better than placebo in reducing knee pain. (NEJM 2006;354:795–808) Source: American College of Rheumatology.

Exercise Prescription for Older Adults with Osteoarthritis Pain

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Major risk factors for osteoarthritis: obesity, muscle weakness, heavy physical activity, inactivity, trauma, reduced proprioception, poor joint biomechanics, age, female gender, inheritance, congenital (ie, malformations). Adapted from American Geriatrics Society Consensus Practice Recommendations. (JAGS 2001;49:808–823) Source: AGS

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Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age Asthma: Severity Classification 2002 Determining Asthma Severity Severity Rating

Clinical Features before Treatmenta

Nighttime

Symptomsb

Lung Function

Symptoms Mild Intermittent

Symptoms

2 times a

2 times a month

FEV1 or PEF =

week

80% predicted

Asymptomatic and

PEF variability <

normal PEF between

20%

exacerbations Exacerbations brief (from a few hours to a few days); intensity may vary Mild Persistent

Symptoms > 2 times a

> 2 times a month

FEV1 or PEF =

week but < 1 time a day

80% predicted

Exacerbations may

PEF variability

affect activity

20%–30%

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Moderate Persistent Daily symptoms

> 1 time a week

FEV1 or PEF > 60% – < 80%

Daily use of inhaled

predicted

short-acting beta2-

PEF variability >

agonist

30%

Exacerbations affect activity Exacerbations = 2 times a week; may last days Severe Persistent

Continual symptoms

Frequent

Limited physical activity Frequent exacerbations

aThe

FEV1 or PEF < 60% predicted PEF variability > 30%

presence of one of the features of severity is sufficient to place a patient in that category. An

individual should be assigned to the most severe grade in which any feature occurs. The characteristics noted in this table are general and may overlap because asthma is highly variable. Furthermore, an individual's classification may change over time. bPatients

at any level of severity can have mild, moderate, or severe exacerbations. Some patients

with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. Source: National Heart, Lung and Blood Institute; NIH. http://www.nhlbi.nih.gov/guidelines/ asthma/index.htm Source: NHLBI

Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age: Treatment Asthma: Treatment 2002

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Step Down: Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible. Step Up: If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control (avoidance of allergens or other factors that contribute to asthma severity). "X" designates preferred treatment plan. Mild

Mild

Moderate

Severe

Intermittent

Persistent

Medications Long-term control Inhaled steroids

(high dose) and long-acting inhaled beta2-agonists

Inhaled steroids

(medium dose) Inhaled steroids

(low dose)a

Inhaled steroids

(low dose) and long-acting inhaled beta2-agonist

Corticosteroid tablets/syrupb

Quick relief Short-acting

An essential component of all treatment plans

bronchodilatord

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Education X

Step 1e

Step 2f

Step 3f

Referral aAlternatives bWhen

X include cromolyn or leukotriene receptor antagonist.

needed, make repeat attempts to reduce systemic steroids and maintain control with high-

dose inhaled steroids. cAlternatives

include low-dose inhaled corticosteroids and either leukotriene receptor antagonist or

theophylline. If needed (in patients with recurrent severe exacerbations), preferred treatment is medium-dose inhaled corticosteroid and long-acting inhaled beta2-agonists (or alternative substitutes for inhaled beta2-agonists include leukotriene receptor antagonist or theophylline). dAs

needed for symptoms. Intensity of treatment depends on severity of exacerbation. Use of

short-acting inhaled beta2-agonists more than 2 times per week may indicate need to initiate longterm therapy. eTeach

basic facts about asthma. Teach inhaler/spacer/holding chamber technique. Discuss roles

of medications. Develop self-management plan. Develop action plan for when and how to take rescue actions, especially for patients with a history of severe exacerbations. Discuss appropriate environmental control measures to avoid exposure to known allergens and irritants. fTeach

self-monitoring. Refer to group education if available. Review and update self-management

plan. Source: NHLBI; NIH. http://www.nhlbi.nih.gov/guidelines/asthma/index.htm Note: The stepwise approach presents general guidelines to assist clinical decision making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients. Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or starting at a higher level or therapy (eg, a course of systemic corticosteroids or higher dose of inhaled corticosteroids). A rescue course of systemic corticosteroids may be needed at any time and at any step. This may be especially common with file:///D|/local/PDF/E-Book(PDF)/Current%20P...7)/III%20-%20Disease%20Management/Asthma.htm (4 of 5) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:44:27]

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exacerbations provoked by respiratory infections. A short course of systemic corticosteroids is recommended. At each step, patients should control their environment to avoid or control factors that make their asthma worse (eg, allergens, irritants); this requires specific diagnosis and education. Referral to an asthma specialist for consultation or co-management is recommended if there are difficulties achieving or maintaining control of asthma or if the patient has severe persistent asthma. Referral may be considered if the patient has moderate persistent asthma. Evidence Synthesis: Relationship between inhaled corticosteroid (ICS) use and specific complications Children: 1. No association between ICS use and bone density. 2. Consistent association between ICS use and short-term growth rates. Overall effect small and may not be sustained. 3. No difference in adult height among children treated with ICS. Adults: 1. In general, no reduction in bone density in adults, although there may be a modest effect after many years. 2. Cataracts: no association in young patients; possible association in older patients. 3. Skin thinning/bruising: risk elevated in patients using ICS, with apparent dose-effect. Source: Chest 2003;124:2329 Source: NHLBI (updated 2004)

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Atopic Dermatitis: Management Algorithm

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Notes: 1. Eczema: pruritic dermatitis. 2. Other characteristics of atopic dermatitis (in the absence of an atopic history, 3 or more required for diagnosis): xerosis; ichthyosis/palmar hyperlinearity/keratosis pilaris; immediate, Type I skin test response; hand and/or foot dermatitis; cheilitis; nipple eczema; susceptibility to cutaneous infections; erythroderma; early age of onset; impaired cell-mediated immunity; recurrent conjunctivitis; infraorbital fold; keratoconus; anterior subscapular cataracts; elevated total serum immunoglobulin E; peripheral blood eosinophils. History: pruritic nature of rash, age of onset, duration, triggers, seasonal variation, eye complications, environmental exposures, chronicity, distribution of rash. Physical examination: morphology and distribution of the atopic skin lesions, especially diffuse xerosis, erythema, excoriation, papulation, crusting/oozing/ pustules indicative of infection, scaling, lichenification. Laboratory testing: skin or in vitro testing for specific allergens. The majority of patients have elevated serum IgE and eosinophilia; these findings are not useful in guiding clinical decisions. A diagnosis of atopic dermatitis cannot be made solely on the basis of laboratory testing. 3. Differential diagnosis of atopic dermatitis Immunodeficiencies: Wiskott-Aldrich syndrome, DiGeorge syndrome, Hyper-IgE syndrome, severe combined immune deficiency Metabolic diseases: Phenylketonuria, tyrosinemia, histidinemia, multiple carboxylase deficiency, essential fatty acid deficiency Neoplastic disease: Cutaneous T-cell lymphoma, histiocytosis X, SĂŠzary syndrome Infection and infestation: Candida, herpes simplex, Staphylococcus aureus, Sarcoptes scabiei Dermatitis: Contact, seborrheic, psoriasis, discoid eczema, frictional lichenoid dermatitis

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4. Severe atopic dermatitis: More than 20% skin involvement (or 10% skin involvement if affects eyelids, hands, or intertriginous areas) Extensive skin involvement and erythrodermic, at risk for exfoliation Requiring ongoing or frequent treatment with high potency topical glucocorticoids or systemic glucocorticoids Requiring hospitalization for severe eczema or skin infections related to atopic dermatitis Ocular or infectious complications Significant disruption of quality of life 5. Treatment of atopic dermatitis is directed at symptom relief and reduction of cutaneous inflammation. Topical corticosteroids are the mainstay of therapy. All patients require skin hydration in combination with an effective emollient. Potential trigger factors should be identified and eliminated. Calcineurin inhibitors, pimecrolimus, and tacrolimus have been shown to reduce the extent, severity, and symptoms. Tar may be associated with therapeutic benefits, but is limited by compliance. Short-term adjunctive use of topical doxepin may aid in the reduction of pruritus, but side effects may limit usefulness. Patients with atopic dermatitis are commonly colonized with Staphylococcus aureus. Without signs of infection, oral antibiotics have minimal therapeutic effect on the dermatitis. Topical or oral antibiotics can be beneficial when infection is present; development of resistance is a concern. 6. Response to therapy is classified as complete response, partial response, or treatment failure. Most patients will have a partial response with reduction in pruritus and extent of skin disease. 7. Monitor response to therapy and adjust medications and skin care according to severity of illness. Establish a plan to step up medications for flare-ups and to step down medications when the illness is under control. 8. In any patient who fails to respond to treatment, reassess the diagnosis. If presenting after the age of 16 years, consider contact dermatitis. If presenting as an adult, consider cutaneous Tcell lymphoma. Source: American Academy of Dermatology (AAD)

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Atrial Fibrillation: Evaluation & Management

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AccessMedicine - Print aParoxysmal bIf

atrial fibrillation episodes last more than 30 seconds, but

7 days. If

2 episodes, designate "persistent."

minimal or no symptoms, anticoagulation and rate control, "as needed."

cEvidence

of Wolff-Parkinson-White syndrome of preexcitation, hypotension, or congestive heart failure; ECG evidence of

acute MI or symptomatic hypotension, angina, or heart failure. Evidence Update: dThe

AFFIRM trial showed no significant benefit of rhythm control (beyond rate control) in mortality or stroke risk and

increased risk of death among older patients, those with congestive heart failure, and those with coronary disease. Rhythm control also increased hospitalization and adverse drug effects. (NEJM 2002;347:1825) Special considerations include patient symptoms, exercise tolerance, and patient preference. Current data do not support use of atrial pacing in the management of atrial fibrillation without symptomatic bradycardia. (Circulation 2005;111:240–243) eNon-valvular

atrial fibrillation stroke risk calculation (JAMA 2001;285:2864–2870) CHADS2 = congestive heart failure,

hypertension, age > 75 years, diabetes, and prior stroke or TIA. One point per factor, except 2 points for 2.5% per year. Low risk = score 0 or 1 =

1% per year. Moderate risk = score 2 = 2.5% per year. High risk = score

5% per

year. All prior stroke or TIA should be considered high risk. fIf

rate is difficult to control with pharmacologic therapy, consider AV node ablation or modification.

gSecond-line

therapy: amiodarone, dofetilide; third-line: disopyramide, procainamide, quinidine.

hSecond-line

therapy: amiodarone, dofetilide, sotalol; third-line: disopyramide, procainamide, quinidine.

iConsider

range 1.6 to 2.5 in patients aged > 75 years with increased risk of bleeding complications. ACCP recommends

oral anticoagulation for age > 75 years. For age 65–75 years and no other risk factors, ACCP recommends oral anticoagulant or aspirin (325 mg/day). Target INR for patients with mechanical valve = 3.0. CAD, coronary artery disease; HF, heart failure; LVH, left ventricular hypertrophy. Source: Adapted from AHA subcommittee on Electrocardiography and Electrophysiology, Circulation 1996;93:1262; and ACC/AHA/ESC, J Am Coll Card 2001;38:1265. ACCP: Chest 2004;126:429S–456S; AHA/ASA, Circulation 2006;113:e873 Source: American Heart Association/American College of Cardiology/European Society of Cardiology

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Cancer Survivorship Follow-Up, by Cancer Treatment History Cancer or Cancer Treatment History

Late Effect Type (see Cancer Survivorship by Late Effect table for specifics)

Any cancer experience

Psychosocial disorders

Any chemotherapy

Oral and dental abnormalities

Chemotherapy (alkylating agents)a

Gonadal dysfunction Hematologic disorders Ocular toxicity Pulmonary toxicity Renal toxicity Urinary tract toxicity

Chemotherapy (anthracycline antibiotics)a

Cardiac toxicity Hematologic disorders

Chemotherapy (bleomycin)a

Pulmonary toxicity

Chemotherapy (cytarabine, high-dose IV;

Clinical leukoencephalopathy

methotrexate, high-dose IV, IO, IT)

Chemotherapy (epipodophyllotoxins)a

Neurocognitive deficits Hematologic disorders

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Chemotherapy (heavy metals)a

Dyslipidemia Gonadal dysfunction Hematologic disorders Ototoxicity Peripheral sensory neuropathy Renal toxicity

Chemotherapy (methotrexate)

Osteopenia/osteoporosis Renal toxicity

Chemotherapy (non-classical alkylators)a

Gonadal dysfunction Hematologic disorders

Chemotherapy (plant alkaloids)a

Peripheral sensory neuropathy Raynaud's phenomenon

Corticosteroids (dexamethasone, prednisone)

Ocular toxicity Osteonecrosis Osteopenia/osteoporosis

Diagnosis between 1977 and 1985 (United

HIV

States) Diagnosis before 1972 (United States)

Chronic hepatitis B

Diagnosis before 1993 (United States)

Chronic hepatitis C

Hematopoietic cell transplant

Hematologic disorders Oncologic disorders Osteonecrosis Osteopenia/osteoporosis

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Radiation therapy (field- and dosedependent)

Cardiac toxicity Central adrenal insufficiency Cerebrovascular complications Chronic sinusitis Functional asplenia Gonadal dysfunction Growth hormone deficiency Hyperparathyroidism Hyperprolactinemia Hypothyroidism Neurocognitive deficits Ocular toxicity Oncologic disorders Oral and dental abnormalities Ototoxicity Overweight/obesity/metabolic syndrome Pulmonary toxicity Renal toxicity Urinary tract toxicity

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agents, by class:

Alkylating agents: Busulfan, carmustine (BCNU), chlorambucil, cyclophosphamide, ifosfamide, lomustine (CCNU), mechlorethamine, melphalan, procarbazine, thiotepa

●

Heavy metals: Carboplatin, cisplatin

●

Non-classical alkylators: Dacarbazine (DTIC), temozolomide

●

Anthracycline antibiotics: Daunorubicin, doxorubicin, epirubicin, idarubicin, mitoxantrone

●

Plant alkaloids: Vinblastine, vincristine

●

Epipodophyllotoxins: Etoposide (VP16), temiposide (VM26)

Note: Guidelines for surveillance and monitoring for late effects after treatment for adult cancers available via the National Comprehensive Cancer Network, Inc. (NCCN) (http://www.nccn.org/ professionals/physician_gls). Source: Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Children's Oncology Group, Version 2.0, March 2006 (for full guidelines and references, see http://www.survivorshipguidelines.org). See also: NEJM 2006;355:1722–1782.

Cancer Survivorship Follow-Up, by Late Effect Late Effect

Cancer or Cancer

Periodic Evaluation

Frequency

Chemotherapy

History: SOB, DOE,

Yearly

(anthracycline

orthopnea, chest

antibiotics)b

pain, palpitations,

Treatment History Cardiac toxicitya

Radiation (mantle,

nausea/vomiting

mediastinal, chest,

Exam: Murmur, S3,

axilla, thoracic spine,

S4, increased P2

whole abdomen, all upper abdominal fields)

sound, pericardial rub, rales, wheezes, jugular venous distention, peripheral edema

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Tests: ECHO or

At entry into

MUGA, EKG

long-term follow-up, periodically thereafter (increased frequency if chest radiation)

Tests: Fasting

Every 3–5

glucose and lipid

years

profile Endocrine disorders Central adrenal insufficiency

Radiation ( 40 Gy to

History: Failure to

Yearly

cranial, orbital/eye, ear/ thrive, anorexia, infratemporal,

dehydration,

nasopharyngeal)

hypoglycemia, lethargy, unexplained hypotension Tests: 8:00 AM

Yearly for 15

serum cortisol

years after treatment, and as clinically indicated

Dyslipidemia

Chemotherapy (heavy

Tests: Fasting lipid

At entry into

metals)b

panel

long-term follow-up

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Gonadal dysfunction (testicular and ovarian)

Chemotherapy

History: Pubertal

(alkylating agents,

(onset, tempo),

heavy metals, non-

sexual function,

classical alkylators)b

medication use

Yearly

impacting sexual function, menstrual/ pregnancy (females) Precocious puberty Gonadotropin deficiency

Radiation (cranial,

Exam: Height,

Yearly until

orbital/eye, ear/

weight, Tanner

sexually

infratemporal,

stage, testicular

mature

nasopharyngeal, whole

volume (males)

abdomen, pelvic, testicular, lumbar or sacral spine, TBI)

Tests: FSH, LH,

At age 13

testosterone (males),

years

estradiol (females)

(females) or age 14 years (males), and as clinically indicated

Semen analysis

Fertility evaluation

Growth hormone deficiency

Radiation (cranial,

History: Assessment

orbital/eye, ear/

of nutritional status

infratemporal, nasopharyngeal, TBI)

Yearly

Exam: Height,

Every 6

weight, BMI

months until growth completed, then yearly

Exam: Tanner staging Every 6 months until sexually mature

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Hyperparathyroidism

Radiation ( 40 Gy to

History: Heat

cranial,

intolerance,

nasopharyngeal,

tachycardia,

oropharyngeal, cervical

palpitations, weight

spine, neck,

loss, emotional

supraclavicular,

lability, muscle

mantle, mini-mantle)

weakness,

Yearly

hyperphagia Exam: Eyes, skin, thyroid, cardiac, neurologic Tests: TSH, free T4

Hyperprolactinemia

Radiation ( 40 Gy to

History:

Yearly

cranial, orbital/eye, ear/ Galactorrhea, infratemporal,

decreased libido

nasopharyngeal)

(males), menstrual history (females) Tests: Prolactin level

As clinically indicated

Hypothyroidism (central and primary)

Radiation ( 40 Gy to

History: Fatigue,

Yearly; more

cranial, orbital/eye, ear/ weight gain, cold

frequently

infratemporal,

intolerance,

during

nasopharyngeal; any

constipation, dry

periods of

cranial,

skin, brittle hair,

rapid growth

nasopharyngeal,

depressed mood

oropharyngeal, cervical spine, neck, supraclavicular, mantle, mini-mantle, TBI)

Exam: Height, weight, hair, skin, thyroid exam Tests: TSH, free T4

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Osteonecrosis (avascular necrosis)

Corticosteroids

History: Joint pain,

(dexamethasone,

swelling, immobility,

prednisone)

limited range of

Hematopoietic cell transplant

Yearly

motion Exam: Musculoskeletal exam

Osteopenia Osteoporosis

Chemotherapy

Tests: Bone density

At entry into

(methotrexate)

(DEXA or

long-term

quantitative CT)

follow-up,

Corticosteroids

then as

(dexamethasone,

clinically

prednisone)

indicated

Hematopoietic cell transplant Overweight Obesity Metabolic syndrome

Radiation (cranial,

Exam: Height,

orbital/eye, ear/

weight, BMI, blood

infratemporal,

pressure

nasopharyngeal, TBI)

Yearly

Tests: Fasting blood

Every 2

glucose, fasting

years if

serum insulin, fasting

overweight

lipid profile

or obese Every 5 years if normal weight

Hematologic disordersc

Chemotherapy

History: Fatigue,

Yearly for 10

(alkylating agents,

bleeding, easy

years post-

heavy metals, non-

bruising

exposure

classical alkylators, anthracycline antibiotics, epipodophyllotoxins)b

Exam: Pallor, petechiae, purpura

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Tests: CBC/ differential Infections Chronic hepatitis B

Diagnosis before 1972

Hepatitis B surface

(United States)

antigen (HBsAg)

Once

Hepatitis B core antibody (anti HBcAb) Chronic hepatitis C

Diagnosis before 1993

Hepatitis C antibody

(United States)

(hepatitis C PCR if

Once

positive) Chronic sinusitis

Radiation (cranial,

History: Rhinorrhea,

orbital/eye, ear/

postnasal discharge

Yearly

infratemporal,

Functional asplenia

nasopharyngeal)

Exam: Nasal, sinuses

Radiation ( 40 Gy to

Exam: Evaluate

spleen, whole

degree of illness and

abdomen, left upper

potential source of

quadrant, inverted Y)

infection

101°F

Tests: Blood culture HIV

Diagnosis between

HIV 1 and 2

1977 and 1985 (United

antibodies

Once

States) Neurologic disorders Cerebrovascular complicationsd

Radiation (cranial,

History: Hemiparesis,

orbital/eye, ear/

hemiplegia,

infratemporal,

weakness, aphasia

nasopharyngeal)

Exam: Neurologic

Yearly

exam

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Clinical leukoencephalopathye

Chemotherapy

History: Cognitive,

(cytarabine, high-dose

motor and/or sensory

Yearly

IV; methotrexate, high- deficits, seizures, dose IV, IO, IT) Radiation (cranial)

other neurologic symptoms Exam: Spasticity, ataxia, dysarthria, hemiparesis

Neurocognitive deficits

Chemotherapy

History: Educational

(cytarabine high dose

and/or vocational

IV; methotrexate high

progress

dose IV, IO, IT)

Yearly

Tests: Formal

At entry into

Radiation (cranial, ear/

neuropsychological

long-term

infratemporal, TBI)

evaluation

follow-up, then as clinically indicated

Peripheral sensory neuropathy

Chemotherapy (heavy

History: Peripheral

metals, plant alkaloids)b neuropathy

Yearly for 2– 3 years

Exam: Neurologic exam Raynaud's phenomenon

Plant alkaloids

History: Vasospasm

Yearly

of hands, feet, nose, lips, cheeks, or earlobes related to stress or cold temperatures Ocular toxicityf

Chemotherapy

History: Visual

(alkylating agents)b

difficulties, dry eye,

Corticosteroids (dexamethasone, prednisone) Radiation (cranial,

Yearly

persistent eye irritation, excessive tearing, light sensitivity, poor night vision, painful eye

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Exam: Visual acuity,

Yearly if

funduscopic exam,

ocular

evaluation by

tumors, TBI

ophthalmologist (if

radiation)

every 3

30 Gy;

years if no ocular tumor or Oncologic disordersg

All radiation fields Hematopoietic cell transplant

History: Targeted to

30 Gy

Yearly

irradiated field(s) Exam: Inspection/ examination as appropriate to irradiated field(s)

Oral and dental abnormalities

Any chemotherapy

History: Xerostomia

Radiation (cranial,

Exam: Oral exam

Yearly

nasopharyngeal, oropharyngeal, cervical spine, neck, supraclavicular,

Exam: Dental exam

Every 6

mantle, mini-mantle,

and cleaning

months

Chemotherapy (heavy

History: Hearing

Yearly

metals)b

difficulties, tinnitus,

TBI) Ototoxicityh

Radiation (cranial, ear/

vertigo

infratemporal,

Exam: Otoscopic

nasopharyngeal)

Tests: Complete pure

Yearly after

tone audiogram or

completion

brainstem auditory

of therapy x

evoked response

5 years, then every 5 years

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Psychosocial disordersi

Any cancer experience

Psychosocial

Yearly

Assessment: (Educational/ vocational progress, depression, anxiety, post-traumatic stress, social withdrawal, health care/insurance access) Pulmonary toxicityj

Chemotherapy

History: Cough, SOB,

(alkylating agents,

DOE, wheezing

bleomycin)b Radiation (mantle,

Yearly

Exam: Pulmonary exam

mediastinal, chest, whole lung, TBI)

Tests: CXR, PFTs

At entry into

(including DLCO and

long-term

spirometry)

follow-up, then as clinically indicated

Renal toxicityk

Chemotherapy (alkylating agents, heavy metals,

Exam: Blood pressure Yearly Tests: Urinalysis

methotrexate)b

Tests: BUN, Cr, Na,

At entry into

Radiation (whole

K, Cl, CO2, Ca, Mg,

long-term

abdomen, all upper

PO4

follow-up,

abdominal fields, TBI)

then as clinically indicated

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Urinary tract toxicityl

Chemotherapy

History: Hematuria,

(alkylating agents)b

urinary urgency/

Radiation ( 30 Gy to whole abdomen, pelvic, sacral spine)

Yearly

frequency, urinary incontinence/ retention, dysuria, abnormal urinary stream Tests: Urinalysis

aCardiac

toxicity: Cardiomyopathy, arrhythmias, left ventricular dysfunction, congestive heart

failure, pericarditis, pericardial fibrosis, valvular disease, myocardial infarction, atherosclerotic heart disease. bChemotherapeutic ●

agents, by class:

Alkylating agents: Busulfan, carmustine (BCNU), chlorambucil, cyclophosphamide, ifosfamide, lomustine (CCNU), mechlorethamine, melphalan, procarbazine, thiotepa

●

Heavy metals: Carboplatin, cisplatin

●

Non-classical alkylators: Dacarbazine (DTIC), temozolomide

●

Anthracycline antibiotics: Daunorubicin, doxorubicin, epirubicin, idarubicin, mitoxantrone

●

Plant alkaloids: Vinblastine, vincristine

●

Epipodophyllotoxins: Etoposide (VP16), temiposide (VM26)

cHematologic

disorders: Acute myeloid leukemia, myelodysplasia.

dCerebrovascular eClinical fOcular

complications: Stroke, moyamoya, occlusive cerebral vasculopathy.

leukoencephalopathy: Spasticity, ataxia, dysarthria, dysphagia, hemiparesis, seizures.

toxicity: Cataracts, orbital hypoplasia, lacrimal duct atrophy, xerophthalmia, keratitis,

telangiectasias, retinopathy, optic chiasm neuropathy, enophthalmos, chronic painful eye, maculopathy, papillopathy, glaucoma. gOncologic

disorders: Secondary benign or malignant neoplasm.

hOtotoxicity:

Sensorineural hearing loss, tinnitus, vertigo, tympanosclerosis, otosclerosis,

eustachian tube dysfunction, conductive hearing loss. iPsychosocial

disorders: Mental health disorders, risky behaviors, psychosocial disability due to

pain, fatigue, limitations in health care/insurance access. file:///D|/local/PDF/E-Book(PDF)/Current%20P...sease%20Management/Cancer%20Survivorship.htm (13 of 14) [2007/11/13 下午 12:44:33]

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toxicity: Pulmonary fibrosis, interstitial pneumonitis, restrictive lung disease,

obstructive lung disease. kRenal

toxicity: Glomerular and tubular renal insufficiency, hypertension.

lUrinary

tract toxicity: Hemorrhagic cystitis, bladder fibrosis, dysfunctional voiding, vesicoureteral

reflux, hydronephrosis, bladder malignancy. TBI = total body irradiation. Note: Guidelines for surveillance and monitoring for late effects after treatment for adult cancers available via the National Comprehensive Cancer Network, Inc. (NCCN) (http://www.nccn.org/ professionals/physician_gls). Source: Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Children's Oncology Group, Version 2.0, March 2006 (for full guidelines and references, see http://www.survivorshipguidelines.org).

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Carotid Artery Stenosis

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Cataract in Adults: Evaluation & Management Algorithm

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Notes: 1. Begin evaluation only when patients complain of a visual problem or impairment. Identifying impairment in visual function during routine history and physical examination constitutes sound medical practice. 2. Essential elements of the comprehensive eye and vision examination: Patient history: Consider cataract if: acute or gradual onset of vision loss; vision problems under special conditions (eg, low contrast, glare); difficulties performing various visual tasks. Ask about: refractive history, previous ocular disease, amblyopia, eye surgery, trauma, general health history, medications, and allergies. It is critical to describe the actual impact of the cataract on the person's function and quality of life. There are several instruments available for assessing functional impairment related to cataract, including VF-14, Activities of Daily Vision Scale, and Visual Activities Questionnaire. Ocular examination, including: Snellen acuity and refraction; measurement of intraocular pressure; assessment of pupillary function; external examination; slit-lamp examination; and dilated examination of fundus. Supplemental testing: May be necessary to assess and document the extent of the functional disability and to determine whether other diseases may limit preoperative or postoperative vision. Most elderly patients presenting with visual problems do not have a cataract that causes functional impairment. Refractive error, macular degeneration, and glaucoma are common alternative etiologies for visual impairment. 3. Once cataract has been identified as the cause of visual disability, patients should be counseled concerning the nature of the problem, its natural history, and the existence of both surgical and nonsurgical approaches to management. The principal factor that should guide decision making with regard to surgery is the extent to which the cataract impairs the ability to function in daily life. The findings of the physical examination should corroborate that the cataract is the major contributing cause of the functional impairment, and that there is a reasonable expectation that managing the cataract will positively impact the patient's functional activity. Visual acuity is not the sole determining factor and should not be used as a threshold file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...sease%20Management/Cataract%20in%20Adults.htm (2 of 3) [2007/11/13 ä¸&#x2039;ĺ?&#x2C6; 12:44:35]

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value. 4. Patients who complain of mild to moderate limitation in activities due to a visual problem, those whose corrected acuities are near 20/40, and those who do not yet wish to undergo surgery may be offered nonsurgical measures for improving visual function. Indications for surgery: cataract-impaired vision no longer meets the patient's needs; evidence of lens-induced disease (eg, phakomorphic glaucoma, phakolytic glaucoma); necessary to visualize the fundus in an eye that has the potential for sight (eg, diabetic patient at risk of diabetic retinopathy). 5. Contraindications to surgery: the patient does not desire surgery; glasses or visual aids provide satisfactory functional vision; surgery will not improve visual function; the patient's quality of life is not compromised; the patient is unable to undergo surgery because of coexisting medical or ocular conditions; a legal consent cannot be obtained; or the patient is unable to obtain adequate postoperative care. Routine preoperative medical testing (12-lead EKG, CBC, measurement of serum electrolytes, BUN, creatinine, and glucose), while commonly performed in patients scheduled to undergo cataract surgery, does not appear to measurably increase the safety of the surgery. 6. Patients with significant functional and visual impairment due to cataract who have no contraindications to surgery should be counseled regarding the expected risks and benefits of and alternatives to surgery.

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Cholesterol & Lipid Management

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Modifications to the ATP III Treatment Algorithm for LDL-C In high-risk persons, the recommended LDL-C goal is < 100 mg/dL. An LDL-C goal of < 70 mg/dL is a therapeutic option, especially for patients at very high risk. If LDL-C is

100 mg/dL, an LDL-lowering drug is indicated simultaneously with lifestyle

changes. If baseline LDL-C is < 100 mg/dL, institution of an LDL-lowering drug to achieve an LDLC level < 70 mg/dL is a therapeutic option. If a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are 200 mg/dL, non–HDL-C is a secondary target of therapy, with a goal 30 mg/dL higher than the identified LDL-C goal. For moderately high-risk persons (2+ risk factors and 10-year risk 10%–20%), the recommended LDL-C goal is < 130 mg/dL; an LDL-C goal < 100 mg/dL is a therapeutic option. When LDL-C level is 100–129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level < 100 mg/dL is a therapeutic option. Any person at high risk or moderately high risk who has lifestyle-related risk factors (e. g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level.

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When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, intensity of therapy should be sufficient to achieve at least a 30%–40% reduction in LDL-C levels. Source: Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227–239.

Metabolic Syndrome: Identification and Management Clinical Identification Risk Factor

Defining Level

Abdominal obesity (waist circumference) Men

102 cm ( 40 in.)

Women

88 cm ( 35 in.)

Triglycerides

150 mg/dL

HDL cholesterol Men

< 40 mg/dL

Women

< 50 mg/dL

Blood pressure

130/ 85 mm Hg

Fasting glucose

110 mg/dL

Management First-line therapy: Lifestyle modification leading to weight reduction and increased physical activity. Goal:

Body weight by

7%–10% over 6–12 months.

At least 30 minutes of daily moderate-intensity physical activity. Low intake of saturated fats, trans fats, and cholesterol. Reduced consumption of simple sugars. Increased intake of fruits, vegetables, and whole grains. Avoid extremes in intake of either carbohydrates or fats. Smoking cessation.

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Drug therapy for hypertension, elevated LDL cholesterol, and diabetes. Consider combination therapy with fibrates or nicotinic acid plus a statin. Low-dose ASA for patients at intermediate and high risk. Bariatric surgery for BMI > 35 mg/kg2.

Source: Circulation 2004;109:551–556.

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COPD Management Assessing Severity of COPD Exacerbation

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Source: ATS/ERS

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Coronary Artery Disease Post-Myocardial Infarction Risk Stratificationa

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Depression: Management Major Depression Disorder in Adults: Diagnosis and Treatment

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Source: Colorado Clinical Guidelines Collaborative (2006)

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Diabetes Mellitus: Management Management of Hyperglycemiaa

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Source: ADA

Prevention & Treatment of Diabetic Complications/Comorbidities, Table A Complication or

Goal

Comorbidity Hyperglycemiaa

HbA1c < 7.0%b Preprandial plasma glucose 90–130 mg/dL

Monitoring/

Action If Goal Not

Treatment

Met

HbA1c = every 6

See Management of

months if meeting

Hyperglycemia, above.

treatment goals; every 3 months in those not meeting

Peak

goals or whose

postprandial

therapy has

plasma

changed.

glucose < 180 mg/dL Retinopathy

Prevent vision

Optimize glycemic

loss

and blood pressure

Laser treatment

control. Annual retinal exam.c

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Neuropathy

Prevent foot

Annual foot examd

Refer high-risk

complications

and visual

patients to a foot care

inspection at every

specialist.

visit.

Nephropathy

Prevent renal

Optimize glucose

See belowe for

failure

and blood pressure

treatment; consider

control.

nephrology referral.

Annual creatinine urinary protein determination (see below). Spot albumin: creatinine testing preferred. Continued surveillance even if treated with ACE or ARB. Annual serum creatinine and GFR calculation. Limit protein intake to 0.8 g/kg in those with any degree of chronic kidney disease. Hypertension

Adult: BP

Measure at every

See Hypertension:

130/80f mm Hg

routine diabetes

Initiating Treatment. If

visit.g

ACEs or adrenergic receptor binders are used, monitor renal function and potassium levels.

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Hyperlipidemia

LDL < 100 mg/

Annual

Weight loss; increase

dLh

determination, and

in physical activity;

more frequently to

nutrition therapy;

achieve goals. If

follow NCEP

low-risk (LDL <

recommendations for

100, HDL > 60, TG

pharmacologic

< 150), then

treatment, Cholesterol

assess every 2

& Lipid Management.

TG < 150 mg/dL HDL > 40 mg/dL

years. Routine monitoring of liver and muscle enzymes in asymptomatic patients is not recommended unless patient has baseline enzyme abnormalities or is taking drugs that interact with statins. (ACP; Ann Intern Med 2004;140:644) Macrovascular

Prevent limb

1) Use aspirin

Use aspirin as

disease

ischemia, stroke,

therapy (75–162

secondary prevention

and MI

mg/day) as

if history of MI,

primary prevention

vascular bypass

for all patients

years or those with 1 cardiovascular risk factor. 2) Smoking

procedure, stroke or TIA, peripheral vascular disease, claudication and/or angina.

cessation. 3) Manage hyperlipidemia and file:///D|/local/PDF/E-Book(PDF)/Current%20Pr...0Disease%20Management/Diabetes%20Mellitus.htm (4 of 6) [2007/11/13 下午 12:44:40]

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hypertension as above. 4) Assess for peripheral arterial disease with pedal pulses ± ankle brachial pressure index via doppler. 5) Consider ACE inhibitor if age > 55 years, with or without hypertension, if cardiovascular risk factor present. aLess

intensive glycemic goals if severe or frequent hypoglycemia.

bPostprandial

glucose may be targeted if HbA1c goals are not met despite meeting preprandial

goals. cDilated

eye exam or 7-field 30-degree fundus photography by ophthalmologist or optometrist. In

setting of normal eye exam, less frequent screening can be considered by eye specialist. dIncludes

evaluation of protective sensation (monofilament test and tuning fork), vascular status,

and inspection for foot deformities or ulcers. eMicroalbuminuria

treatment: if type 1, use ACE inhibitor; if type 2 and hypertensive, use ACE or

ARB. Clinical albuminuria treatment: (1) Achieve BP < 130/80 mm Hg; (2) use ACE inhibitor or ARB; (3) tight glycemic control; and (4) decrease protein to 10% of dietary intake, especially in patients progressing despite optimal glucose and BP control. Refer to nephrologist if: estimated glomerular filtration rate < 30 mg/minute, creatinine > 2.0 mg/dL, or when management of hypertension or hyperkalemia is difficult. fALLHAT

trial showed no difference in cardiovascular and renal outcomes in diabetes treated with

diuretics or ACE (or ARB). (JAMA 2002;288:2981) Diuretics should be first line in black patients. (Ann Intern Med 2003;138:587) gACP

recommends tight BP control (SBP < 135, DBP < 80).

hLDL

< 70 mg/dL, using a high-dose statin, is an option in high-risk patients with DM and overt

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CVD. Source: Adapted from American Diabetes Association Position Statement "Standards of Medical Care for Patients With Diabetes Mellitus." Last updated January 2005. (http://www.diabetes.org/ for-health-professionals-and-scientists/cpr.jsp) For recommended quality improvement and public reporting measures, see "National Diabetes Quality Improvement Alliance Performance Measurement Set for Adult Diabetes." (2005) (http://www.nationaldiabetesalliance.org) Source: ADA

Prevention & Treatment of Diabetic Complications/Comorbidities, Table B Albuminuria Thresholds Categorya

24-hour

Timed collection

Spot collection

collection

( g/minute)

(albumin: creatinine ratio)

(mg/24 hour)

( g/mg) Normal

< 30

< 20

< 30

Microalbuminuria

30–299

20–200

30–299

Clinical (macro) albuminuria

300

> 200

300

Because of variability in urinary albumin excretion, 2 of 3 specimens collected within a 3- to 6month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds. Exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values. aTimed

urine and 24-hr collections are rarely necessary. Spot collection is encouraged as the

preferred test. Source: ADA (http://www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp)

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Heart Failure

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Source: ACC/AHA

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Hypertension: Initiating Treatment

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Source: The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

Lifestyle Modifications for Primary Prevention of Hypertensiona,b Modification

Recommendation

Approximate SBP Reduction (Range)

Weight reduction

Adopt DASH eating plan

Maintain normal body weight (BMI

5–20 mm Hg per 10 kg

18.5–24.9 kg/m2).

weight loss

Consume diet rich in fruits,

8–14 mm Hg

vegetables, and low fat dairy products with a reduced content of saturated and total fat. Dietary sodium reduction Reduce dietary sodium intake to

2–8 mm Hg

no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). Physical activity

Engage in regular aerobic physical

4–9 mm Hg

activity such as brisk walking (at least 30 min/day, most days of the week). Moderation of alcohol

Limit consumption to no more than 2–4 mm Hg

consumption

2 drinks (1 oz or 30 mL ethanol; eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighterweight persons.

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overall cardiovascular risk reduction, stop smoking. effects of implementing these modifications are dose and time dependent and could be

greater for some individuals. DASH = Dietary Approaches to Stop Hypertension

Recommended Medications for Compelling Indications Recommended Medicationsa

Compelling Indicationb

Diuretic

ACEI

ARB

Heart failure

Post-MI X

Diabetes

Recurrent stroke prevention aDrug

AldoANT

X X

High coronary disease risk

Chronic kidney diseasec

CCB

X X

abbreviations: ACEI, ACE inhibitor; ARB, angiotensin receptor blocker; AldoANT, aldosterone

antagonist; BB, beta-blocker; CCB, calcium channel blocker. bCompelling

indications for antihypertensive drugs are based on benefits from outcome studies or

existing clinical guidelines; the compelling indication is managed in parallel with the BP. cALLHAT:

Patients with hypertension and reduced GFR: No difference in renal outcomes

(development of ESRD and/or decrement in GFR of

50% from baseline) comparing amlodipine,

lisinopril, and chlorthalidone. [Arch Intern Med 2005 Apr 25;165(8):936–946]

Causes of Resistant Hypertension

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Improper BP Measurement Volume Overload and Pseudotolerance Excess sodium intake Volume retention from kidney disease Inadequate diuretic therapy Drug-Induced or Other Causes Nonadherence Inadequate doses Inappropriate combinations Nonsteroidal anti-inflammatory drugs; cyclooxygenase-2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anoretics) Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) Over-the-counter dietary supplements and medicines (eg, ephedra, mahuang, bitter orange) Associated Conditions Obesity Excess alcohol intake Identifiable Causes Sleep apnea Chronic kidney disease Primary aldosteronism Renovascular disease

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Steroid excess (Cushing syndrome; chronic steroid therapy) Pheochromocytoma Coarctation of aorta Thyroid or parathyroid disease Obstructive uropathy

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Obesity Management: Adults

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Source: NHLBI

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Obesity Management: Children

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Source: Expert Committee, Department of Health and Human Services

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Osteoporosis: Managementc

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Source: American Association of Clinical Endocrinologists

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Palliative and End-of-Life Care: Pain Managment. Principles of Analgesic Use By the mouth

The oral route is the preferred route for analgesics, including morphine.

By the clock

Persistent pain requires around-the-clock treatment to prevent further pain. PRN dosing is irrational and inhumane; it requires patients to experience pain before becoming eligible for relief.

By the WHO ladder

If a maximum dose of medication fails to adequately relieve pain, move up the ladder, not laterally to a different drug in the same efficiency group. Severe pain requires immediate use of an opioid recommended for controlling severe pain, without progressing sequentially through Steps 1 and 2.

Individualize treatment The right dose of an analgesic is the dose that relieves pain with acceptable side effects for a specific patient. Monitor

Monitoring is required to ensure the benefits of treatment are maximized while adverse effects are minimized.

Use adjuvant drugs

For example, an NSAID is almost always needed to help control bone pain. Nonopioid analgesics, such as NSAIDs or acetaminophen, can be used at any step of the ladder. Adjuvant medications also can be used at any step to enhance pain relief or counteract the adverse effects of medications.

Reprinted with permission from the American Academy of Hospice and Palliative Medicine. Pocket Guide to Hospice/Palliative Medicine.

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Palliative and End-of-Life Care: Pain Management World Health Organization (WHO) Analgesic Ladder

Reprinted with permission from the World Health Organization.

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Pap Smear Abnormalities: Management and Follow-Upa

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Perioperative Cardiovascular Evaluation for Noncardiac Surgery

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Source: ACC/AHA

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Perioperative Pulmonary Assessment

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Source: ACP

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Pneumonia, Community-Acquired

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Source: ATS

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Peri- and Postnatal Guidelines Breastfeeding

Strongly recommends education and counseling to promote breastfeeding through at least 6 months of age.

Hearing loss, sensorineural

Insufficient evidence for or against routine screening of newborns for hearing loss during the postpartum hospitalization period.

Hemoglobinopathies

Strongly recommends ordering screening tests for hemoglobinopathies in neonates.

Hyperbilirubinemia

Perform ongoing systematic assessments during the neonatal period for the risk of an infant developing severe hyperbilirubinemia.

Phenylketonuria

Strongly recommends ordering screening tests for phenylketonuria in neonates.

Thyroid function abnormalities Strongly recommends ordering screening tests for thyroid function abnormalities in neonates. Sources: AAFP 2005 and Pediatrics 2004;114:297–316

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Routine Prenatal Care, Table A Event1

Screening maneuvers

Preconception Visit 13**

Visit 2 (10– Visit 3 (16–

Visit 4 (22

Visit2

(6–8 Weeks) 12 Weeks)

18 Weeks)

Weeks)

Risk profiles4

Weight5

Height and

GC/

Blood

weight/BMI5

Chlamydia4

pressure6

Fetal heart

weight/BMI5

tones27

Blood

Fetal

Fundal

pressure6

anomaly/

height29

biochemical

screening23

Blood pressure6 Height and History and physical7 Cholesterol and HDL2 Cervical cancer

History and physical7* Rubella8

Rubella/

Varicella9

(optional)28

Domestic

Fundal

Varicella9

abuse10

height29

Domestic

Hemoglobin15

[Cervical

abuse10

ABO/Rh/Ab16

assessment30]

screening3

rubeola8

[Cervical

ultrasound

assessment30]

Syphilis17 Urine culture18 HIV19 [Blood lead screening20] file:///D|/local/PDF/E-Book(PDF)/Current%20P...e%20Management/Routine%20Prenatal%20Care.htm (1 of 4) [2007/11/13 下午 12:44:52]

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[VBAC21] Hepatitis B S Ag25 Counseling

PTL education

PTL education PTL

PTL

education

and

education

intervention

prevention11

and

prevention11

lifestyle

Prenatal and

education22

lifestyle

education22

Substance use2 Prenatal and Nutrition and weight2 Domestic abuse10 List of medications, herbal supplements, vitamins12 Accurate recording of menstrual dates13

Physical activity Nutrition Warning signs

Fetal growth Review

risk factors Discuss fetal anomaly biochemical screening23

Second trimester

visit 1

growth

Classes Family issues Length of stay

Quickening Breastfeeding

Follow up modifiable

of pregnancy

labs from

Course of care

Physiology

Physiology of pregnancy Follow up modifiable

Follow up

Gestational

modifiable

diabetes

risk factors

mellitus Follow up modifiable risk factors

risk factors [RhoGam16]

Immunization

Tetanus

and

booster3

Rubella/MMR4

Nutritional

chemoprophylaxis

[Varicella/

supplements24

VZIG9]

Influenza26

Hepatitis B

[Varicella/

vaccine7,25

VZIG9]

Folic acid

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supplement14 Superscript numbers refer to specific annotations (see http://www.icsi.org). [Bracketed] items refer to high-risk groups only. *It is acceptable for the history and physical laboratory tests listed under Visit 1 to be deferred to Visit 2 with the agreement of both the patient and the provider. **Should also include all subjects listed for the preconception visit if none occurred. Source: Copyright ©2005 by Institute for Clinical Systems Improvement. ICSI retains all rights to the material. Source: ICSI

Routine Prenatal Care, Table B Event

Visit 5 (28

Visit 6 (32

Visit 7 (36

Visits 8–11

Weeks)

(38–41 Weeks)

Screening maneuvers

PTL risk4

Weight5

Blood pressure6 Blood pressure6

Blood pressure6

Fetal heart

Fetal heart tones27 Fundal height29 Cervical assessment30 Gestational

tones27 Fundal height29

Weight5

Weight5 Blood pressure6

Fetal heart tones26 Fetal heart Fundal height29 Cervix exam33 Confirm fetal

tones27 Fundal height29 Cervix exam33

position34 Culture for group B streptococcus35

diabetes mellitus Domestic abuse10 [Rh antibody status16] [Hepatitis B Ag25] [GC/Chlamydia4]

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Counseling education

PTL labor

Prenatal and

intervention

education and

lifestyle

prevention11

education22

Prenatal and

lifestyle

education22

Work

Travel

Physiology of

Sexuality

Contraception

Pediatric

When to call

pregnancy

Preregistration care Fetal growth

Episiotomy

Follow up

modifiable risk

factors

Awareness of

Labor and

fetal movement32 delivery issues

Postpartum care Management of late pregnancy symptoms

provider Discussion of

Postpartum vaccinations Infant CPR Post-term management Follow up modifiable risk factors

postpartum

Labor and

depression

delivery update

Follow up modifiable risk factors

Warning signs/ PIH [VBAC21] Immunization and chemoprophylaxis

[ABO/Rh/Ab] [RhoGAM16]

Superscript numbers refer to specific annotations (see http://www.icsi.org). [Bracketed] items refer to high-risk groups only. Source: Copyright ©2005 by Institute for Clinical Systems Improvement. ICSI retains all rights to the material. Source: ICSI

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Tobacco Cessation Treatment Algorithm Five A's 1. Ask about tobacco use. 2. Advise to quit through clear personalized messages. 3. Assess willingness to quit. 4. Assist to quit,a including referral to Quit Lines (e.g., 1-800-NO-BUTTS). 5. Arrange follow-up and support. aPhysicians

can assist patients to quit by devising a quit plan, providing problem-solving counseling, providing

intratreatment social support, helping patients obtain social support from their environment/friends, and recommending pharmacotherapy for appropriate patients. Use caution in recommending pharmacotherapy in patients with medical contraindications, those smoking < 10 cigarettes per day, pregnant/breastfeeding women, and adolescent smokers. As of March 2005, Medicare covers costs for smoking cessation counseling for those who (1) have a smoking-related illness; (2) have an illness complicated by smoking; or (3) take a medication that is made less effective by smoking. (http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=130) Source: Fiore MC et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U. S. Department of Health and Human Services. Public Health Service, October 2000. Source: U.S. Public Health Service

Motivating Tobacco Users to Quit Five R's 1. Relevance: personal 2. Risks: acute, long-term, environmental 3. Rewards: have patient identify (e.g., save money, better food taste) 4. Road blocks: help problem-solve 5. Repetition: at every office visit

Tobacco Cessation Treatment Optionsa

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Pharmacotherapy Precautions/

Side

Dosage

Duration

Availability Cost/Dayb

Contraindications Effects First-line pharmacotherapies (approved for use for smoking cessation by the FDA) Bupropion SR

History of seizure

Insomnia

History of eating

Dry mouth

disorder

150 mg

7–12 weeks

Zyban

every

maintenance (prescription

morning

up to 6

for 3

months

$3.33

only)

days, then 150 mg twice daily. (Begin treatment 1–2 weeks pre-quit.) Nicotine gum

—

Mouth

1–24 cigs/ Up to 12

Nicorette,

$6.25 for 10

soreness

day: 2-

Nicorette

2-mg pieces

Dyspepsia

weeks

mg gum

Mint (OTC

(up to 24

only)

pieces/

$6.87 for 10 4-mg pieces

day). 25+ cigs/ day: 4mg gum (up to 24 pieces/ day). Nicotine inhaler

—

Local

6–16

Up to 6

Nicotrol

$10.94 for

irritation

cartridges/ months

Inhaler

10 cartridges

of mouth

day

(prescription

and throat Nicotine nasal spray

—

only)

Nasal

8–40

irritation

doses/day

3–6 months

Nicotrol NS

$5.40 for 12

(prescription doses only)

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Nicotine patch

—

Local skin

21 mg/24

reaction

hours

Insomnia

14 mg/24 hours 7 mg/24

4 weeks Then 2 weeks

Brand-name

CQ (OTC

patches

only),

$4.00–$4.50c

generic

Then 2

patches

weeks

(prescription

hours 15 mg/16

Nicoderm

and OTC) 8 weeks

hours

Nicotrol (OTC only)

Second-line pharmacotherapies (not approved for use for smoking cessation by the FDA) Clonidine

Rebound hypertension

Dry mouth 0.15– Drowsiness

3–10 weeks

Oral

Clonidine

0.75 mg/

Clonidine-

$0.24 for

day

generic,

0.2 mg;

Catapres

Dizziness

(prescription (transdermal)

Sedation

only),

$3.50

Transdermal Catapres (prescription only) Nortriptyline

Risk of arrhythmias Sedation Dry mouth

75–100

12 weeks

mg/day

Nortriptyline $0.74 for 75 HCl-generic

(prescription only)

aThe

information contained within this table is not comprehensive. Please see package insert for additional

information. bPrices

based on retail prices of medication purchased at a national chain pharmacy, located in Madison, WI, April

2000. cGeneric

brands of the patch recently became available and may be less expensive.

Source: U.S. Public Health Service.

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Approach to Cough Illness (Bronchitis) in Adults

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Source: CDC

Approach to Acute Sore Throat (Pharyngitis) in Adults

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Source: CDC

Approach to Acute Nasal and Sinus Congestion (Sinusitis) in Adults

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Source: CDC

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UTI in Women: Diagnosis and Management

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Source: University of Michigan Health System

Laboratory Charges and Relative Costs Test

Relative Cost

Urinalysis, dipstick

Urinalysis, complete microscopic

Urine culture

$$$

Complicating Factors Catheter Diabetes mellitus Immunosuppression Nephrolithiasis present Pregnancy Pyelonephritis symptoms (fever, nausea, back pain) Recent hospitalization or nursing home residence Recurrent UTIs (3/year) Symptoms for > 7 days Urologic structural/functional abnormality

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Treatment Regimens and Relative Costs Treatment Regimen

Relative Cost (generic)

First Line Trimethoprim/Sulfa DS BID x 3 days

Second Line (in preferred order) Ciprofloxacin 250 mg BID x 3 days

Levofloxacin 250 mg QID x 3 days

$$$$

Amoxicillin 500 mg TID x 7 days

Nitrofurantoin 100 mg QID x 7 days

Macrobid 100 mg BID x 7 days

1. The majority of UTIs occur in sexually active women. Risk increases by 3–5 times when diaphragms are used for contraception. Risk also increases slightly with not voiding after sexual intercourse and use of spermicides. Dysuria with either urgency or frequency, in the absence of vaginal symptoms, yields a prior probability of UTI of 70%–80%. Generally, UTI symptoms are of abrupt onset (< 3 days). 2. Guideline implementation decreases the proportion of patients with presumed cystitis who received urinalysis, urine culture, or an initial office visit and increases the proportion of women who receive a guideline-recommended antibiotic. Adverse outcomes (return office visit, sexually transmitted disease, pyelonephritis within 60 days of initial diagnosis) did not increase as a result of guideline implementation. (Saint S, et al. Am J Med 1999;106:636–641) 3. Dipstick analysis for leukocyte esterase, an indirect test for the presence for pyuria, is the least expensive and least time-intensive diagnostic test for UTI. It is estimated to have a sensitivity of 75%–96% and specificity of 94%–98%. Nitrite testing by dipstick is less useful, in large part because it is only positive in the presence of bacteria that produce nitrate reductase, and can be confounded by consumption of ascorbic acid. Microscopic examination of unstained, centrifuged urine by a trained observer under 40x power has a sensitivity of 82%–97% and a specificity of 84%–95%. For urine culture, sensitivity varies from 50%–95%, depending on the threshold for UTI, and specificity varies from 85%–99%. Because of the limited sensitivity of urine culture, and the delay required for results, urine culture is not recommended to diagnose or verify uncomplicated UTI. 4. Unlike women with uncomplicated UTI, care for women with complicating factors includes: ●

Culture: Obtain pretreatment culture and sensitivity.

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Treatment: Initiate treatment with trimethoprim/sulfa or quinolone for 7–14 days (quinolones contraindicated in pregnancy).

●

Follow-up UA: Obtain follow-up urinalysis to document clearing.

●

Possible structural evaluation: Lower threshold for urologic structural evaluation with cysto/IVP.

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Current Practice Guidelines in Primary Care 2007 Ralph Gonzales, Jean S. Kutner

Abbreviations Preface Disease

Disease

Screening

Prevention

Management

Appendices

Appendix I: Screening Instruments Appendix II: Functional Assessment Screening in the Elderly Appendix III: 95th Percentiles of Blood Pressure for Boys and Girls Appendix IV: Body Mass Index Conversion Table Appendix V: Cardiac Risk窶認ramingham Study Appendix VI: Estimate of 10-Year Stroke Risk Appendix VII: Immunization Schedules

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Screening Instruments: Alcohol Abuse Sensitivity and Specificity of Screening Tests for Problem Drinking Instrument

Screening

Threshold

Sensitivity/

Source

Name

Questions/

Score

Specificity (%)

77/58

53/81

29/92

87/70

BMJ 1997;314:420

77/84

J Gen Intern Med

66/90

Scoring CAGEa

See Screening Procedures for Problem Drinking

AUDIT

See Screening Procedures for Problem Drinking

aThe

Am J Psychiatr 1974;131:1121 J Gen Intern Med 1998;13:379

1998;13:379

CAGE may be less applicable to binge drinkers (eg, college students), the elderly, and minority

populations.

Screening Procedures for Problem Drinking 1. CAGE screening testa

Have you ever felt the need to

Cut down on drinking?

Have you ever felt

Annoyed by criticism of your drinking?

Have you ever felt

Guilty about your drinking?

Have you ever taken a morning

Eye opener?

INTERPRETATION: Two "yes" answers are considered a positive screen. One "yes" answer should arouse a suspicion of alcohol abuse.

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2. The Alcohol Use Disorder Identification Test (AUDIT).b (Scores for response categories are given in parentheses. Scores range from 0 to 40, with a cutoff score of

5 indicating

hazardous drinking, harmful drinking, or alcohol dependence.)

1) How often do you have a drink containing alcohol? (0) Never (1) Monthly or less (2) Two to four times a month (3) Two or three times a week (4) Four or more times a week 2) How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more

3) How often do you have six or more drinks on one occasion?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

4) How often during the past year have you found that you were not able to stop drinking once you had started?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

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5) How often during the past year have you failed to do what was normally expected of you because of drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

6) How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

7) How often during the past year have you had a feeling of guilt or remorse after drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

8) How often during the past year have you been unable to remember what happened the night before because you had been drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

9) Have you or has someone else been injured as a result of your drinking?

(0) No (2) Yes, but not in the past year (4) Yes, during the past year

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10) Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?

(0) No (2) Yes, but not in the past year (4) Yes, during the past year

aModified

from Mayfield D et al. The CAGE questionnaire: Validation of a new alcoholism screening

instrument. Am J Psychiatry 1974;131:1121. bFrom

Piccinelli M et al. Efficacy of the alcohol use disorders identification test as a screening tool for

hazardous alcohol intake and related disorders in primary care: A validity study. BMJ 1997;314:420.

Screening Instruments: Cognitive Impairment Screening Instruments: Cognitive Impairment

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Source: Reproduced with permission from "Mini-Mental State." A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189. ©1975, 1998 MiniMental LLC.

Screening Instruments: Depression Screening Tests for Depression Instrument Name

Screening

Threshold Score

Source

Questions/Scoring Beck Depression

See Beck

0–4: None or

Postgrad Med 1972;

Inventory (Short

Depression

minimal depression

Dec:81

Form)

Inventory, Short Form

5–7: Mild depression 8–15: Moderate depression > 15: Severe depression

Geriatric Depression

See Geriatric

Scale

Depression Scale

15: Depression

J Psychiatr Res 1983;17:37

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(1) During the past

"Yes" to either

questions)

month, have you

questiona

often been bothered

JAMA 1994;272:1749 J Gen Intern Med 1997;12:439

by feeling down, depressed, or hopeless? (2) During the past month, have you often been bothered by little interest or pleasure in doing things? Patient Health

http://www.pfizer.

Major depressive syndrome: if

download/do/phq-9. answers to #1a or b pdf

and

5 of #1a–i are

JAMA 1999;282:1737 J Gen Intern Med 2001;16:606

at least "More than half the days" (count #1i if present at all). Other depressive syndrome: if #1a or b and 2–4 of #1a–i are at least "More than half the days" (count #1i if present at all). 5–9: mild depression 10–14: moderate depression 15–19: moderately severe depression 20–27: severe depression

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86%–96%; specificity 57%–75%.

Inc.

Beck Depression Inventory, Short Form Instructions: This is a questionnaire. On the questionnaire are groups of statements. Please read the entire group of statements in each category. Then pick out the one statement in that group that best describes the way you feel today, that is, right now! Circle the number beside the statement you have chosen. If several statements in the group seem to apply equally well, circle each one. Sum all numbers to calculate a score. Be sure to read all the statements in each group before making your choice. A. Sadness

3 I am so sad or unhappy that I can’t stand it. 2 I am blue or sad all the time and I can’t snap out of it. 1 I feel sad or blue. 0 I do not feel sad.

B. Pessimism

3 I feel that the future is hopeless and that things cannot improve. 2 I feel I have nothing to look forward to. 1 I feel discouraged about the future. 0 I am not particularly pessimistic or discouraged about the future.

C. Sense of failure

3 I feel I am a complete failure as a person (parent, husband, wife). 2 As I look back on my life, all I can see is a lot of failures. 1 I feel I have failed more than the average person. 0 I do not feel like a failure.

D. Dissatisfaction

3 I am dissatisfied with everything. 2 I don’t get satisfaction out of anything anymore. 1 I don’t enjoy things the way I used to. 0 I am not particularly dissatisfied.

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E. Guilt

3 I feel as though I am very bad or worthless. 2 I feel quite guilty. 1 I feel bad or unworthy a good part of the time. 0 I don’t feel particularly guilty.

F. Self-dislike

3 I hate myself. 2 I am disgusted with myself. 1 I am disappointed in myself. 0 I don’t feel disappointed in myself.

G. Self-harm

3 I would kill myself if I had the chance. 2 I have definite plans about committing suicide. 1 I feel I would be better off dead. 0 I don’t have any thoughts of harming myself.

H. Social withdrawal

3 I have lost all of my interest in other people and don’t care about them at all. 2 I have lost most of my interest in other people and have little feeling for them. 1 I am less interested in other people than I used to be. 0 I have not lost interest in other people.

I. Indecisiveness

3 I can’t make any decisions at all anymore. 2 I have great difficulty in making decisions. 1 I try to put off making decisions. 0 I make decisions about as well as ever.

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J. Self-image change

3 I feel that I am ugly or repulsive-looking. 2 I feel that there are permanent changes in my appearance and they make me look unattractive. 1 I am worried that I am looking old or unattractive. 0 I don’t feel that I look any worse than I used to.

K. Work difficulty

3 I can’t do any work at all. 2 I have to push myself very hard to do anything. 1 It takes extra effort to get started at doing something. 0 I can work about as well as before.

L. Fatigability

3 I get too tired to do anything. 2 I get tired from doing anything. 1 I get tired more easily than I used to. 0 I don’t get any more tired than usual.

M. Anorexia

3 I have no appetite at all anymore. 2 My appetite is much worse now. 1 My appetite is not as good as it used to be. 0 My appetite is no worse than usual.

Source: Reproduced with permission from Beck AT, Beck RW. Screening depressed patients in family practice: A rapid technic. Postgrad Med 1972;52:81.

Geriatric Depression Scale

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Choose the best answer for how you felt over the past week 1. Are you basically satisfied with your life?

yes / no

2. Have you dropped many of your activities and interests?

yes / no

3. Do you feel that your life is empty?

yes / no

4. Do you often get bored?

yes / no

5. Are you hopeful about the future?

yes / no

6. Are you bothered by thoughts you can’t get out of your head?

yes / no

7. Are you in good spirits most of the time?

yes / no

8. Are you afraid that something bad is going to happen to you?

yes / no

9. Do you feel happy most of the time?

yes / no

10. Do you often feel helpless?

yes / no

11. Do you often get restless and fidgety?

yes / no

12. Do you prefer to stay at home, rather than going out and doing new things?

yes / no

13. Do you frequently worry about the future?

yes / no

14. Do you feel you have more problems with memory than most?

yes / no

15. Do you think it is wonderful to be alive now?

yes / no

16. Do you often feel downhearted and blue?

yes / no

17. Do you feel pretty worthless the way you are now?

yes / no

18. Do you worry a lot about the past?

yes / no

19. Do you find life very exciting?

yes / no

20. Is it hard for you to get started on new projects?

yes / no

21. Do you feel full of energy?

yes / no

22. Do you feel that your situation is hopeless?

yes / no

23. Do you think that most people are better off than you are?

yes / no

24. Do you frequently get upset over little things?

yes / no

25. Do you frequently feel like crying?

yes / no

26. Do you have trouble concentrating?

yes / no

27. Do you enjoy getting up in the morning?

yes / no

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28. Do you prefer to avoid social gatherings?

yes / no

29. Is it easy for you to make decisions?

yes / no

30. Is your mind as clear as it used to be?

yes / no

One point for each response suggestive of depression. (Specifically "no" responses to questions 1, 5, 7, 9, 15, 19, 21, 27, 29, and 30, and "yes" responses to the remaining questions are suggestive of depression.) A score of

15 yields a sensitivity of 80% and a specificity of 100%, as a screening test for geriatric

depression. Clin Gerontologist 1982;1:37. Source: Reproduced with permission from Yesavage JA et al. Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiatr Res 1982–83;17:37

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Functional Assessment Screening in the Elderly Target Area

Vision

Assessment

Abnormal

Procedure

Result

Ask: "Do you have

"Yes" and

difficulty driving or

inability to read

watching television

greater than

or reading or doing

20/40

Suggested Intervention

Refer to ophthalmologist.

any of your daily activities because of your eyesight?" Test each eye with Jaeger card while patient wears corrective lenses (if applicable). Hearing

Whisper a short,

Inability to

Examine auditory canals

easily answered

answer question

for cerumen and clean if

question such as "What is your name?" in each ear while the examiner’s face is out of direct view.

Inability to hear 1,000 or 2,000 Hz in both ears or inability to

necessary. Repeat test; if still abnormal in either ear, refer for audiometry and possible prosthesis.

hear frequencies in either ear

Use audioscope set at 40 dB; test using 1,000 and 2,000 Hz.

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Arm

Proximal: "Touch

Inability to do

Examine the arm fully

the back of your

task

(muscle, joint, and nerve),

head with both

paying attention to pain,

hands."

weakness, limited range of motion. Consider referral

Distal: "Pick up the

for physical therapy.

spoon." Leg

Observe the patient

Inability to

Do full neurologic and

after instructing as

complete task in

musculoskeletal

follows: "Rise from

15 seconds

evaluation, paying

your chair, walk 10

attention to strength, pain,

feet, return, and sit

range of motion, balance,

down."

and gait. Consider referral for physical therapy.

Continence of urine Ask, "Do you ever lose your urine and

"Yes" to both

Ascertain frequency and

questions

amount. Search for

get wet?"

remediable causes, including local irritations,

If yes, then ask,

polyuric states, and

"Have you lost urine

medications. Consider

on at least 6

urologic referral.

separate days?" Nutrition

Ask, "Without

"Yes" or weight

Do appropriate medical

trying, have you

is below

evaluation.

lost 10 lb or more in acceptable range the last 6 months?"

for height

Weigh the patient. Measure height.

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Mental status

Instruct as follows:

Inability to recall

Administer Folstein Mini-

"I am going to

all three objects

Mental State Examination.

name three objects

after 1 minute

If score is less than 24,

(pencil, truck,

search for causes of

book). I will ask you

cognitive impairment.

to repeat their

Ascertain onset, duration,

names now and

and fluctuation of overt

then again a few

symptoms. Review

minutes from now."

medications. Assess consciousness and affect. Do appropriate laboratory tests.

Depression

Ask, "Do you often

"Yes" or "Not

Administer Geriatric

feel sad or

very good, I

Depression Scale. If

depressed?" or

guess"

positive (score above 15),

"How are your

check for antihypertensive,

spirits?"

psychotropic, or other pertinent medications. Consider appropriate pharmacologic or psychiatric treatment.

ADL-IADLa

Ask, "Can you get

"No" to any

Corroborate responses with

out of bed

question

patient’s appearance;

yourself?" "Can you

question family members if

dress yourself?"

accuracy is uncertain.

"Can you make

Determine reasons for the

your own meals?"

inability (motivation

"Can you do your

compared with physical

own shopping?"

limitation). Institute appropriate medical, social, or environmental interventions.

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Home environment Ask, "Do you have

"Yes"

Evaluate home safety and

trouble with stairs

institute appropriate

inside or outside of

countermeasures.

your home?" Ask about potential hazards inside the home with bathtubs, rugs, or lighting. Social support

Ask, "Who would be

—

List identified persons in

able to help you in

the medical record.

case of illness or

Become familiar with

emergency?"

available resources for the elderly in the community.

aActivities

of Daily Living–Instrumental Activities of Daily Living.

Source: Modified from Lachs MS et al. A simple procedure for screening for functional disability in elderly patients. Ann Intern Med 1990;112:699. Geriatrics at your fingertips online edition 2005 (http://www.geriatricsatyourfingertips.org, accessed 7/24/06).

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95th Percentile of Blood Pressure for Boys Age SBP (mm Hg) by percentile of height (y)

DBP (mm Hg) by percentile of height

5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%

104 105

107

109

110

112

113

106 107

109

111

112

114

115

108 109

110

112

114

115

116

109 110

112

114

115

117

110 111

113

115

117

118

119

111 112

114

116

118

119

120

113 114

116

118

119

121

115 116

117

119

121

122

123

117 118

119

121

123

124

125

119 120

122

123

125

127

121 122

124

126

128

129

130

124 125

127

128

130

132

126 127

129

131

133

134

135

129 130

132

134

135

137

131 132

134

136

138

139

140

Source:http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm (accessed 7/24/04).

95th Percentile of Blood Pressure for Girls

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Age SBP (mm Hg) by percentile of height (y)

DBP (mm Hg) by percentile of height

5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%

104 104

105

107

108

109

110

105 106

107

108

110

111

112

107 107

108

110

111

112

113

108 109

110

111

113

114

115

110 111

112

113

115

116

112 112

114

115

116

118

114 114

115

117

118

119

120

116 116

117

119

120

121

122

118 118

119

121

122

123

124

119 120

121

123

124

125

126

121 122

123

124

126

127

128

123 123

125

126

127

129

124 125

126

127

129

130

131

125 126

127

128

130

131

132

125 126

127

129

130

131

132

Source:http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm (accessed 7/24/04).

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Body Mass Index Conversion Table Height in inches

BMI 25 kg/m2

BMI 27 kg/m2

BMI 30 kg/m2

(cm) Body weight in pounds (kg) 58 (147.32)

119 (53.98)

129 (58.51)

143 (64.86)

59 (149.86)

124 (56.25)

133 (60.33)

148 (67.13)

60 (152.40)

128 (58.06)

138 (62.60)

153 (69.40)

61 (154.94)

132 (59.87)

143 (64.86)

158 (71.67)

62 (157.48)

136 (61.69)

147 (66.68)

164 (74.39)

63 (160.02)

141 (63.96)

152 (68.95)

169 (76.66)

64 (162.56)

145 (65.77)

157 (71.22)

174 (78.93)

65 (165.10)

150 (68.04)

162 (73.48)

180 (81.65)

66 (167.64)

155 (70.31)

167 (75.75)

186 (84.37)

67 (170.18)

159 (72.12)

172 (78.02)

191 (86.64)

68 (172.72)

164 (74.39)

177 (80.29)

197 (89.36)

69 (175.26)

169 (76.66)

182 (82.56)

203 (92.08)

70 (177.80)

174 (78.93)

188 (85.28)

207 (93.90)

71 (180.34)

179 (81.19)

193 (87.54)

215 (97.52)

72 (182.88)

184 (83.46)

199 (90.27)

221 (100.25)

73 (185.42)

189 (85.73)

204 (92.53)

227 (102.97)

74 (187.96)

194 (88.00)

210 (95.26)

233 (105.69)

75 (190.50)

200 (90.72)

216 (97.98)

240 (108.86)

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76 (193.04)

205 (92.99)

221 (100.25)

246 (111.59)

Metric conversion formula = weight

Non-metric conversion formula =

(kg)/height (m2)

[weight (pounds)/height (inches2)] x

Example of BMI calculation: A person who weighs 78.93 kilograms and is 177 centimeters tall has a BMI of 25: weight (78.93 kg)/height (1.77 m2) = 25

704.5 Example of BMI calculation: A person who weighs 164 pounds and is 68 inches (or 5' 8") tall has a BMI of 25: [weight (164 pounds)/height (68 inches2)] x 704.5 = 25

Source: Adapted from NHLBI Obesity Guidelines in Adults, 1998.

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Estimate of 10-Year Cardiac Risk for Mena Age (y)

Points

20–34

–9

35–39

–4

40–44

45–49

50–54

55–59

60–64

65–69

70–74

75–79

13 Points

Total Cholesterol Age 20–39 Age 40–49 Age 50–59 Age 60–69 Age 70–79 <160

160–199

200–239

240–279

280

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Points Age 20–39 Age 40–49 Age 50–59 Age 60–69 Age 70–79 Nonsmoker 0

Smoker

HDL (mg/dL) Points 60

–1

50–59

40–49

< 40

Systolic BP (mm Hg) If Untreated If Treated < 120

120–129

130–139

140–159

160 Point Total

10-Year Risk %

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10-Year risk aFramingham

_____%

point scores.

Source: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication No. 01-3305, May 2001.

Estimate of 10-Year Cardiac Risk for Womena Age (y)

Points

20–34

–7

35–39

–3

40–44

45–49

50–54

55–59

60–64

65–69

70–74

75–79

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Points Total Cholesterol Age 20–39 Age 40–49 Age 50–59 Age 60–69 Age 70–79 <160

160–199

200–239

240–279

280

Points Age 20–39 Age 40–49 Age 50–59 Age 60–69 Age 70–79 Nonsmoker 0

Smoker

HDL (mg/dL) Points 60

–1

50–59

40–49

< 40

Systolic BP (mm Hg) If Untreated If Treated < 120

120–129

130–139

140–159

160

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Point Total

10-Year Risk %

10-Year risk aFramingham

_____%

point scores.

Source: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication No. 01-3305, May 2001.

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Estimate of 10-Year Stroke Risk for Men Age (y) Points Untreated Systolic Blood Pressure (mm Hg) Points 54–56

97–105

57–59

106–115

60–62

116–125

63–65

126–135

66–68

136–145

69–72

146–155

73–75

156–165

76–78

166–175

79–81

176–185

82–84

186–195

196–205

Treated Systolic Blood Pressure (mm Hg) Points History of Diabetes Points 97–105

106–112

Yes

113–117

118–123

124–129

130–135

136–142

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143–150

151–161

162–176

177–205

Cigarette Smoking Points Cardiovascular Disease Points No

Yes

Atrial Fibrillation Points Left Ventricular Hypertrophy on

Points

Electrocardiogram No

Yes

Point Total

10-Year Risk %

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10-Year Risk _____% Source: Modified Framingham Stroke Risk Profile. Circulation 2006;113:e873–923.

Estimate of 10-Year Stroke Risk for Women Age (y) Points Untreated Systolic Blood Pressure (mm Hg) Points 54–56

95–106

57–59

107–118

60–62

119–130

63–64

131–143

65–67

144–155

68–70

156–167

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71–73

168–180

74–76

181–192

77–78

193–204

79–81

205–216

82–84

Treated Systolic Blood Pressure (mm Hg) Points History of Diabetes Points 95–106

107–113

Yes

114–119

120–125

126–131

132–139

140–148

149–160

161–204

205–216

Cigarette Smoking Points Cardiovascular Disease Points No

Yes

Atrial Fibrillation Points Left Ventricular Hypertrophy on

Points

Electrocardiogram No

Yes

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Point Total

10-Year Risk %

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28 29 30 10-Year Risk _____% Source: Modified Framingham Stroke Risk Profile. Circulation 2006;113:e873–923.

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1. Hepatitis B vaccine (HepB). AT BIRTH: All newborns should receive monovalent HepB soon after birth and before hospital discharge. Infants born to mothers who are HBsAg-positive should receive HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. Infants born to mothers whose HBsAg status is unknown should receive HepB within 12 hours of birth. The mother should have blood drawn as soon as possible to determine her HBsAg status; if HBsAg-positive, the infant should receive HBIG as soon as possible (no later than age 1 week). For infants born to HBsAg-negative mothers, the birth dose can be delayed in rare circumstances but only if a physician's order to withhold the vaccine and a copy of the mother's original HBsAg-negative laboratory report are documented in the infant's medical record. FOLLOWING THE BIRTH DOSE: The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at age 1–2 months. The final dose should be administered at age 24 weeks. It is permissible to administer 4 doses of HepB (e.g., when combination vaccines are given after the birth dose); however, if monovalent HepB is used, a dose at age 4 months is not needed. Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg after completion of the HepB series, at age 9–18 months (generally at the next well-child visit after completion of the vaccine series). 2. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The fourth dose of DTaP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose and the child is unlikely to return at age 15–18 months. The final dose in the series should be given at age

4 years.

Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap—adolescent preparation) is recommended at age 11–12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a Td booster dose. Adolescents 13–18 years who missed the 11- to 12-year Td/Tdap booster dose should also receive a single dose of Tdap if they have completed the recommended childhood DTP/DTaP vaccination series. Subsequent tetanus and diphtheria toxoids (Td) are recommended every 10 years. 3. Haemophilus influenzae type b conjugate vaccine (Hib). Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB® or ComVax® [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination products should not be used for primary immunization in infants at ages 2, 4, or 6 months but can be used as boosters after any Hib vaccine. The final dose in the series should be administered at age 12 months. 4. Measles, mumps, and rubella vaccine (MMR). The second dose of MMR is recommended routinely at age 4–6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after age 12 months. Those who have not previously received the second dose should complete the schedule by age 11–12 years. 5. Varicella vaccine. Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i. e., those who lack a reliable history of chickenpox). Susceptible persons aged 13 years should receive 2 doses administered at least 4 weeks apart. file:///D|/local/PDF/E-Book(PDF)/Current%20Practice%20Guidelines...2007)/IV%20-%20Appendices/VII%20-%20Immunization%20Schedules.htm (2 of 8) [2007/11/13 下午 12:47:05]

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6. Meningococcal vaccine (MCV4). Meningococcal conjugate vaccine (MCV4) should be given to all children at the 11- to 12 year-old visit as well as to unvaccinated adolescents at high school entry (15 years of age). Other adolescents who wish to decrease their risk for meningococcal disease may also be vaccinated. All college freshmen living in dormitories should also be vaccinated, preferably with MCV4, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Vaccination against invasive meningococcal disease is recommended for children and adolescents aged 2 years with terminal complement deficiencies or anatomic or functional asplenia and certain other high risk groups (see MMWR 2005;54 [RR-7]:1–21); use MPSV4 for children aged 2–10 years and MCV4 for older children, although MPSV4 is an acceptable alternative. 7. Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children aged 2–23 months and for certain children aged 24–59 months. The final dose in the series should be given at age 12 months. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups. See MMWR 2000; 49(RR-9):1–35. 8. Influenza vaccine. Influenza vaccine is recommended annually for children aged 6 months with certain risk factors (including, but not limited to, asthma, cardiac disease, sickle cell disease, human immunodeficiency virus [HIV], diabetes, and conditions that can compromise respiratory function or handling of respiratory secretions or that can increase the risk for aspiration), healthcare workers, and other persons (including household members) in close contact with persons in groups at high risk (see MMWR 2005;54[RR-8]:1–55). In addition, healthy children aged 6–23 months and close contacts of healthy children aged 0–5 months are recommended to receive influenza vaccine because children in this age group are at substantially increased risk for influenza-related hospitalizations. For healthy persons aged 5–49 years, the intranasally administered, live, attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). See MMWR 2005;54(RR-8):1–55. Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if aged 6–35 months or 0.5 mL if aged 3 years). Children aged 8 years who are receiving influenza vaccine for the first time should receive 2 doses (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV). 9. Hepatitis A vaccine (HepA). HepA is recommended for all children at 1 year of age (i.e.,12–23 months). The 2 doses in the series should be administered at least 6 months apart. States, counties, and communities with existing HepA vaccination programs for children 2–18 years of age are encouraged to maintain these programs. In these areas, new efforts focused on routine vaccination of 1-year-old children should enhance, not replace, ongoing programs directed at a broader population of children. HepA is also recommended for certain high-risk groups (see MMWR 1999; 48[RR-12]1–37).

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