Browse the corpus

Routine Care of the Healthy Patient comprehensive physical examination in persons at increased TABLE 1. ComPonents of the History risk. Relatively linle harm arises fiom these examinations save Past medical conditions and surgeries for the opportunity cost of providing another service that may H osp ita lizatio n s be more valuable and the theoretical risk for overtesting and Major childhood illnesses and treatments (e.g., radiation exposure) overdiagnosis. Routine testing in asymptomatic patients' such Allergies and corresponding reactions as screening complete blood count. urinalysis. and ECG in Social history patients at low risk for cardiovascular disease. is not Alcohol use: frequency and quantity, previous use recommended. Tobacco use: frequency and quantity, previous use Preparticipation physical examination is often required Recreational drug use (including marijuana) for adolescents and young adults before participation in Spirituality organized sports. In conjunction with the American Academy Work and home situation of Family Physicians and several professional sports medicine Social support: Does the patient live alone? Whom can the organizations, the American Academy of Pediatrics (AAP) patient call if they have a problem? created the Preparticipation Physical Evaluation. In addition. Safety free templates for history physical examination. and clearance Home safety lorms are a\ailable on the AAP website (r.t'rt"w.aap.org en us' lntimate partner violence in women of reproductive age about the aap/Committees-Councils Sections/Council on Working smoke alarms sports-medicine. and fitness/PagesrPPE.aspx). Mandatory Water heater set to <49 "C (120 'Ff components include evaluating for exertional symptoms. fam' Weapons: The "5 Ls" for firearm safety counseling in the ily history ofpremature or sudden cardiac death. and presence home: ls it Locked? ls it Loaded? Are there Little of a heart murmur. children present? Anyone feeling Low in the house? ls the operator Learned about firearm safety? Digital stethoscopes. point of care ultrasonography. Sa{ety while driving smart phone applications, and other technological advances are gradually becoming more commonplace in the physical Seatbelt use examination. Several of these tools, particularly point of care Helmet use while motorcycling or bicycling ultrasonography, may improve diagnosis. although there is the No electronic device use while driving potential for overdiagnosis as well. Diet: intake of fruits and vegetables; avoidance of added sugars and processed foods XEY POIIIT Physical activity r The periodic health examination may help maintain a HVC Family history strong patient-provider relationship and improve surro Medication history gate outcomes, such as reduction in cardiovascular risk Prescription (including adherence) and over-the-counter medications factors and increased receipt ofpreventive servicesi Past and current hormone use for transgender patients however, the periodic health examination has not been Vitamins and supplements shown to reduce mortality or other patient important Herbal preparations and nontraditional therapies outcomes. Sexual historyb Partners How many sex partners have you had in the past 2 months? Screening 12 months? Principles of Screening Have you had sex with men, women, or both? Levels of prevention have traditionally been categorized as Practices primary secondary. and tertiary. Primary prevention is pre What kind of sexual contact have you had? Vaginal(penis vention of disease or injury before it occurs (for example. in vagina), anal(penis in rectum/anus), or oral sex (mouth on penis/vagina)? through immunization). Secondary prevention is early detec Protection/preg na ncy tion and treatment of disease in asymptomatic patients to slow Have you ever had a sexually transmitted infection? or stop disease progression. Most screening tests. such as those What do you do to protect yourself from sexually for colorectal and breast cancers, are secondary prevention transmitted infections? measures. Tertiary prevention involves reducing morbidity Are you or your partner trying to get pregnant? and mortality due to established disease. such as cardiac reha What are you doing to prevent pregnancy? bi litation after myocardial infarction. Review of systems Screening is appropriate for common conditions for "ln households with infants and young chiidren. which (1) early intervention can decrease morbidity and mor bwhen taking a sexual history, do not assume heterosexualltv, and use gender tality and (2) safe, acceptable, widely available, and reasonably neutral language when referring to partners ("partner" or "sn^.rse" rather than priced screening tests exist. Screening tests must also have "wife," "husband," "girlfriend," or "boyfriend"). adequate sensitivify and specificity to minimize false positive

comprehensive physical examination in persons at increased TABLE 1. ComPonents of the History risk. Relatively linle harm arises fiom these examinations save Past medical conditions and surgeries for the opportunity cost of providing another service that may H osp ita lizatio n s be more valuable and the theoretical risk for overtesting and Major childhood illnesses and treatments (e.g., radiation exposure) overdiagnosis. Routine testing in asymptomatic patients' such Allergies and corresponding reactions as screening complete blood count. urinalysis. and ECG in Social history patients at low risk for cardiovascular disease. is not Alcohol use: frequency and quantity, previous use recommended. Tobacco use: frequency and quantity, previous use Preparticipation physical examination is often required Recreational drug use (including marijuana) for adolescents and young adults before participation in Spirituality organized sports. In conjunction with the American Academy Work and home situation of Family Physicians and several professional sports medicine Social support: Does the patient live alone? Whom can the organizations, the American Academy of Pediatrics (AAP) patient call if they have a problem? created the Preparticipation Physical Evaluation. In addition. Safety free templates for history physical examination. and clearance Home safety lorms are a\ailable on the AAP website (r.t'rt"w.aap.org en us' lntimate partner violence in women of reproductive age about the aap/Committees-Councils Sections/Council on Working smoke alarms sports-medicine. and fitness/PagesrPPE.aspx). Mandatory Water heater set to <49 "C (120 'Ff components include evaluating for exertional symptoms. fam' Weapons: The "5 Ls" for firearm safety counseling in the ily history ofpremature or sudden cardiac death. and presence home: ls it Locked? ls it Loaded? Are there Little of a heart murmur. children present? Anyone feeling Low in the house? ls the operator Learned about firearm safety? Digital stethoscopes. point of care ultrasonography. Sa{ety while driving smart phone applications, and other technological advances are gradually becoming more commonplace in the physical Seatbelt use examination. Several of these tools, particularly point of care Helmet use while motorcycling or bicycling ultrasonography, may improve diagnosis. although there is the No electronic device use while driving potential for overdiagnosis as well. Diet: intake of fruits and vegetables; avoidance of added sugars and processed foods XEY POIIIT Physical activity r The periodic health examination may help maintain a HVC Family history strong patient-provider relationship and improve surro Medication history gate outcomes, such as reduction in cardiovascular risk Prescription (including adherence) and over-the-counter medications factors and increased receipt ofpreventive servicesi Past and current hormone use for transgender patients however, the periodic health examination has not been Vitamins and supplements shown to reduce mortality or other patient important Herbal preparations and nontraditional therapies outcomes. Sexual historyb Partners How many sex partners have you had in the past 2 months? Screening 12 months? Principles of Screening Have you had sex with men, women, or both? Levels of prevention have traditionally been categorized as Practices primary secondary. and tertiary. Primary prevention is pre What kind of sexual contact have you had? Vaginal(penis vention of disease or injury before it occurs (for example. in vagina), anal(penis in rectum/anus), or oral sex (mouth on penis/vagina)? through immunization). Secondary prevention is early detec Protection/preg na ncy tion and treatment of disease in asymptomatic patients to slow Have you ever had a sexually transmitted infection? or stop disease progression. Most screening tests. such as those What do you do to protect yourself from sexually for colorectal and breast cancers, are secondary prevention transmitted infections? measures. Tertiary prevention involves reducing morbidity Are you or your partner trying to get pregnant? and mortality due to established disease. such as cardiac reha What are you doing to prevent pregnancy? bi litation after myocardial infarction. Review of systems Screening is appropriate for common conditions for "ln households with infants and young chiidren. which (1) early intervention can decrease morbidity and mor bwhen taking a sexual history, do not assume heterosexualltv, and use gender tality and (2) safe, acceptable, widely available, and reasonably neutral language when referring to partners ("partner" or "sn^.rse" rather than priced screening tests exist. Screening tests must also have "wife," "husband," "girlfriend," or "boyfriend"). adequate sensitivify and specificity to minimize false positive 2

Routine Care of the Healthy patient and false negative results. population based screening and otherwise would not have become clinically apparent or case-finding are often confused. Case-finding is a strategr of caused harm in the patient's lifetime, is an extreme example targeted testing that relies on clinical judgment ofappropriate_ of length time bias. Overdiagnosis is an increasingly recog- ness and potential benefit for a given patient that meets nized harm ofbreast and prostate cancer screening and may evidence-based criteria for inclusion in a high-risk group. The also occur with incidental detection of thyroid and kidney evidence that case finding improves morbidity or mortality is cancers on imaging studies. Selection bias, also referred to as often weak or absent. volunteer bias, referral bias, or compliance bias, occurs The effectiveness of screening tests in reducing mor- when patients who undergo screening tests are healthier bidity and mortality is evaluated through clinical trials; and more interested in their health than nonadherent however, studies of screening tests are problematic and patients or the general population. Intention-to-treat analy subject to three types of bias. Lead-time bias occurs when ses, in which patients are analyzed according to their origi early detection artificially results in an increase in meas- nal group assignment in randomized clinical trials regardless ured survival. The time between early detection and clinical of intervention received. reduce selection bias. diagnosis is mistakenly counted as survival time; however, only the measured time with diagnosed disease, not sur- vival time, has increased (Figure l). Using disease-specific Screening Recommendations for Adults mortality rates rather than survival time as the primary The USPSTF and many specialfy societies routinely aggregate

and false negative results. population based screening and otherwise would not have become clinically apparent or case-finding are often confused. Case-finding is a strategr of caused harm in the patient's lifetime, is an extreme example targeted testing that relies on clinical judgment ofappropriate_ of length time bias. Overdiagnosis is an increasingly recog- ness and potential benefit for a given patient that meets nized harm ofbreast and prostate cancer screening and may evidence-based criteria for inclusion in a high-risk group. The also occur with incidental detection of thyroid and kidney evidence that case finding improves morbidity or mortality is cancers on imaging studies. Selection bias, also referred to as often weak or absent. volunteer bias, referral bias, or compliance bias, occurs The effectiveness of screening tests in reducing mor- when patients who undergo screening tests are healthier bidity and mortality is evaluated through clinical trials; and more interested in their health than nonadherent however, studies of screening tests are problematic and patients or the general population. Intention-to-treat analy subject to three types of bias. Lead-time bias occurs when ses, in which patients are analyzed according to their origi early detection artificially results in an increase in meas- nal group assignment in randomized clinical trials regardless ured survival. The time between early detection and clinical of intervention received. reduce selection bias. diagnosis is mistakenly counted as survival time; however, only the measured time with diagnosed disease, not sur- vival time, has increased (Figure l). Using disease-specific Screening Recommendations for Adults mortality rates rather than survival time as the primary The USPSTF and many specialfy societies routinely aggregate outcome in studies of screening tests can help minimize and review available evidence to inform clinical practice lead time bias. Length-time bias occurs when screening guidelines for screening, counseling, and use of preventive detects more cases of disease with a prolonged asympto medications. The USPSTF recommendations are available at matic phase than cases of disease with a short asympto- www.uspreventiveservicestaskforce.org. The Emergency matic phase. Slowly progressive disease is more likely than Care Research Institute (ECRI) is designated an Evidence aggressive disease to be detected with screening, leading to based Practice Center by the Agency for Healthcare Research an overestimation of survival benefit in those with screen- and Quality (AHRQ) and maintains a clinical practice guide- detected disease. An example of length-time bias is the line repository at https://guidelines.ecri.org. The American detection of indolent and slow growing prostate cancer College of Physicians (ACP) has developed several types of rather than more aggressive tumors with a short asympto- clinical recommendations, including clinical practice guide- matic phase, with a resultant overestimation of survival lines, clinical guidance statements, best practice advice, and benefit. Overdiagnosis, or finding and treating illness that recommendations regarding high value care, all of which are

outcome in studies of screening tests can help minimize and review available evidence to inform clinical practice lead time bias. Length-time bias occurs when screening guidelines for screening, counseling, and use of preventive detects more cases of disease with a prolonged asympto medications. The USPSTF recommendations are available at matic phase than cases of disease with a short asympto- www.uspreventiveservicestaskforce.org. The Emergency matic phase. Slowly progressive disease is more likely than Care Research Institute (ECRI) is designated an Evidence aggressive disease to be detected with screening, leading to based Practice Center by the Agency for Healthcare Research an overestimation of survival benefit in those with screen- and Quality (AHRQ) and maintains a clinical practice guide- detected disease. An example of length-time bias is the line repository at https://guidelines.ecri.org. The American detection of indolent and slow growing prostate cancer College of Physicians (ACP) has developed several types of rather than more aggressive tumors with a short asympto- clinical recommendations, including clinical practice guide- matic phase, with a resultant overestimation of survival lines, clinical guidance statements, best practice advice, and benefit. Overdiagnosis, or finding and treating illness that recommendations regarding high value care, all of which are A. Natural history Primary prevention Secondary prevention Tertiary prevention Prevent disease Detect and treat Reduce from developing asymptomatic disease complications I Death No disease Asymptomatic Disease course

A. Natural history Primary prevention Secondary prevention Tertiary prevention Prevent disease Detect and treat Reduce from developing asymptomatic disease complications I Death No disease Asymptomatic Disease course B. Lead-time bias: Early detection is not effective; survival is not increased I Death No disease Asymptomatic Disease course C. Early detection effective: Survival is increased. No disease Asymptomatic Early detection Disease course t Death Disease onset Clinical diagnosis ffi Survival after diagnosis fIGURE LTheeffectofearlydetection(screening)onsurvival afterdiagnosis.(/) Screeningisnotimplemented,andthediseasetakesitsnormal course(8) Leadlime bias occurs when survival time appears to be lengthened because disease is diagnosed in the screened patient during the preclinical phase, but the patient does not live longer. (Q Screening effectively detects disease during the asymptomatic phase, and survival time is lengthened. 3

Routine Care of the Healthy Patient available at wnvw.acponline.org/clinical information/guide- TABLE 2. U.S. Preventive Services Task Force Grading lines. Although there is much agreement among screening and Suggestions for Practice recommendations, guidelines often disagree when (1) suffi Grade Definition Suggestions for cient evidence is lacking and expert opinion plays a larger Practice role or (2) potential benefits and harms both exist and the A The USPSTF recommends Offer or provide the service. There is high this service. balance depends on a person's risk, preferences, and values. certainty that the net An additional resource to help clinicians identifiz appropriate benefit is substantial. screening tests and preventive services is Prevention TaskForce, an B The USPSTF recommends Offer or provide electronic tool that is available in Web and mobile application- the service. There is high this service. based formats at w\iwvuspreventiveservicestaskforce.org/apps/. certainty that the net With this tool, users can select USPSTF recommended practices benefit is moderate or there is moderate on the basis of patient age, sex, and other characteristics (such as certainty that the net tobacco use or pregnancy). benefit is moderate to Screening recommendations frequently change as sup substantial. portive evidence emerges. It is important to be aware of C The USPSTF recommends Offer or provide selectively offering or this service for changes in recommendations, reflect on the rationale and providing this service to selected patients implications of the changes, and incorporate these changes individual patients based depending on appropriately into practice. on professional judgment individual and patient preferences. circumstances. There is at least moderate Specific Screening Tests certainty that the net benefit is small. The following section describes screening recommendations from the USPSTF and other organizations. The grading system D The USPSTF recommends Discourage the against the service. There use of this service of the USPSTF (A, B, C, or D, or I statement) is explained in is moderate or high Table 2. certainty that the service has no net benefit or that the harms outweigh the Screening for Chronic Diseases benefits. Abdominal Aortic Aneurysm I statement The USPSTF concludes Read the Clinical The USPSTF recommends one time abdominal ultrasonogra that the current evidence Considerations is insufficient to assess the seaion of USPSTF phy to screen for abdominal aortic aneurysm (AAA) in all men balance of benefits and Recommendation aged 65 to 75 years who have ever smoked (grade B). Ever harms of the service. Statement. lf the smokers are commonly defined as persons who have smoked Evidence is lacking, of service is offered, more than 100 cigarettes (five packs) in their lifetime. Surgical poor quality, or patients should confliaing, and the understand the repair is usually considered once the diameter exceeds 5.5 cm. balance of benefits and uncertainty about The number needed to screen to prevent one death from AAA harms cannot be the balance of in this population is 714. In men aged 65 to 75 years who have determined. benefits and harms. never smoked, selective screening is recommended (grade C), USPSTF = U.S. Preventive Seruices Task Force. especially in those with a first-degree relative with a history of treated or ruptured AAA. The USPSTF assessed the benefits of Reproduced from U.S. Preventive Services Task Force. Procedure Manual. www.uspreventiveseruicestaskforce-org/Page/Name/procedure manual. Accessed screening for AAA in women aged 65 to 75 years who have ever June 17 .2021.

available at wnvw.acponline.org/clinical information/guide- TABLE 2. U.S. Preventive Services Task Force Grading lines. Although there is much agreement among screening and Suggestions for Practice recommendations, guidelines often disagree when (1) suffi Grade Definition Suggestions for cient evidence is lacking and expert opinion plays a larger Practice role or (2) potential benefits and harms both exist and the A The USPSTF recommends Offer or provide the service. There is high this service. balance depends on a person's risk, preferences, and values. certainty that the net An additional resource to help clinicians identifiz appropriate benefit is substantial. screening tests and preventive services is Prevention TaskForce, an B The USPSTF recommends Offer or provide electronic tool that is available in Web and mobile application- the service. There is high this service. based formats at w\iwvuspreventiveservicestaskforce.org/apps/. certainty that the net With this tool, users can select USPSTF recommended practices benefit is moderate or there is moderate on the basis of patient age, sex, and other characteristics (such as certainty that the net tobacco use or pregnancy). benefit is moderate to Screening recommendations frequently change as sup substantial. portive evidence emerges. It is important to be aware of C The USPSTF recommends Offer or provide selectively offering or this service for changes in recommendations, reflect on the rationale and providing this service to selected patients implications of the changes, and incorporate these changes individual patients based depending on appropriately into practice. on professional judgment individual and patient preferences. circumstances. There is at least moderate Specific Screening Tests certainty that the net benefit is small. The following section describes screening recommendations from the USPSTF and other organizations. The grading system D The USPSTF recommends Discourage the against the service. There use of this service of the USPSTF (A, B, C, or D, or I statement) is explained in is moderate or high Table 2. certainty that the service has no net benefit or that the harms outweigh the Screening for Chronic Diseases benefits. Abdominal Aortic Aneurysm I statement The USPSTF concludes Read the Clinical The USPSTF recommends one time abdominal ultrasonogra that the current evidence Considerations is insufficient to assess the seaion of USPSTF phy to screen for abdominal aortic aneurysm (AAA) in all men balance of benefits and Recommendation aged 65 to 75 years who have ever smoked (grade B). Ever harms of the service. Statement. lf the smokers are commonly defined as persons who have smoked Evidence is lacking, of service is offered, more than 100 cigarettes (five packs) in their lifetime. Surgical poor quality, or patients should confliaing, and the understand the repair is usually considered once the diameter exceeds 5.5 cm. balance of benefits and uncertainty about The number needed to screen to prevent one death from AAA harms cannot be the balance of in this population is 714. In men aged 65 to 75 years who have determined. benefits and harms. never smoked, selective screening is recommended (grade C), USPSTF = U.S. Preventive Seruices Task Force. especially in those with a first-degree relative with a history of treated or ruptured AAA. The USPSTF assessed the benefits of Reproduced from U.S. Preventive Services Task Force. Procedure Manual. www.uspreventiveseruicestaskforce-org/Page/Name/procedure manual. Accessed screening for AAA in women aged 65 to 75 years who have ever June 17 .2021. smoked as uncertain and makes no recommendation regard- ing screening in this population (l statement). This likely reflects the low prevalence of AAA in women (1'1,) versus men The USPSTF does not recommend screening for coronary (4"/,, 7"/,,) as well as limited evidence to recommend against artery disease with either resting or exercise ECG in asympto screening. The USPSTF specifically recommends against rou- matic patients at low risk, defined by the USPSTF as a l0 year tine screening in women who have never smoked and who cardiovascular event risk of less than l0'/. using the Pooled have no family history of AAA (grade D). Women, howevet Cohort Equations (grade D). In patients at intermediate or high may have higher risk for rupture with AAAs of smaller sizes. risk for such events, evidence was inadequate to assess the rela- tive benefits and harms of screening (l statement). Similarly, Cardiouascular and Cerebrouascular Disease the ACP recommends against screening low-risk and asympto Cardiovascular risk assessment is performed in asympto matic adults with resting ECG or stress testing. No specialty matic adults to evaluate a patient's risk for future cardiac organization recommends screening these populations with events; it does not identify preexisting disease and is there coronary calcium scoring or coronary angiography. fore considered separate from screening (see MKSAP 19 The USPSTF also does not recommend screening for Cardiovascular Medicine). carotid artery stenosis in the general adult population (grade D).

smoked as uncertain and makes no recommendation regard- ing screening in this population (l statement). This likely reflects the low prevalence of AAA in women (1'1,) versus men The USPSTF does not recommend screening for coronary (4"/,, 7"/,,) as well as limited evidence to recommend against artery disease with either resting or exercise ECG in asympto screening. The USPSTF specifically recommends against rou- matic patients at low risk, defined by the USPSTF as a l0 year tine screening in women who have never smoked and who cardiovascular event risk of less than l0'/. using the Pooled have no family history of AAA (grade D). Women, howevet Cohort Equations (grade D). In patients at intermediate or high may have higher risk for rupture with AAAs of smaller sizes. risk for such events, evidence was inadequate to assess the rela- tive benefits and harms of screening (l statement). Similarly, Cardiouascular and Cerebrouascular Disease the ACP recommends against screening low-risk and asympto Cardiovascular risk assessment is performed in asympto matic adults with resting ECG or stress testing. No specialty matic adults to evaluate a patient's risk for future cardiac organization recommends screening these populations with events; it does not identify preexisting disease and is there coronary calcium scoring or coronary angiography. fore considered separate from screening (see MKSAP 19 The USPSTF also does not recommend screening for Cardiovascular Medicine). carotid artery stenosis in the general adult population (grade D). 4

Routine Care of the Healthy Patient ! The rationale for this recommendation is based on the very TABLE 3. Risk Factors for Diabetes Mellitus low prevalence of carotid stenosis (0.5,1,,1,/.) and resulting First-degree relative with diabetes high rate of false-positive results yielded by commonly used ultrasonography. Auscultation of the neck for carotid bruits is High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific lslander) ineffective for screening as well. Screening for carotid stenosis History of cardiovascular disease in asymptomatic patients could lead to harm as a result of complications from angiographic studies or endarterectomy. Hypertension (>140/90 mm Hg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or Cognitiue Disorders triglyceride level >250 mg/dL(2.82 mmol/L) The USPSTF assessed the benefits of screening for cognitive Polycystic ovary synd rome impairment as uncertain (l statement) owing to lack of high Physical inactivity qualify evidence. Various screening tests with high predictive Other clinical conditions associated with insulin resistance value are available (see MKSAP 19 General Internal lr4edicine (e.9., severe obesity, acanthosis nigricans) 1). However, it is uncertain that early detection changes or History of gestational diabetes improves clinical outcomes. lnformation from American Diabetes Association.2. Classification and dragnosrs of diabetes: Standards of Medical Care in Dia b,etes-202 1 . Diabetes Care. 2O21 :44(Suppl 1 ):5 1 5 S33. doi : 1 0.2337 / dc2 1 5002 Depression and Anxiety The USPSTF suggests that all adults, including pregnant and postpartum women, be screened fbr depression, with ade (grade B). Screening can be accomplished by measuring tast- quate systems in place for subsequent assessment, treatment, ing plasma glucose or hemoglobin A,.. and follow up (grade B). Most adults can be screened with the In contrast to the USPSTF. the American Diabetes brief PHQ 2, which consists of two questions: "During the past Association (ADA) recommends that screening be performed 2 weeks, how often have you been bothered by feeling down, in patients of any age who are overweight or obese and have depressed, or hopeless?" and "During the past 2 weeks, have one or more risk factors for diabetes (Tabte 3). The ADA also you often been bothered by having little interest or pleasure in recommends screening all adults beginning at age 45 years, doing things? " Responses to each question may be scaled (0,3) regardless of risk factors, and repeating screening at 3 year or dichotomous (yes/no). A total score fbr both questions of 3 intervals. Patients with prediabetes (hemoglobin A," >5.7'7,, or greater or a single "yes" response indicates the possibility of impaired glucose tolerance, or impaired fasting glucose) clinically significant depression. Patients with a positive should be screened annually. screening result should be formally assessed for depression and complete the PHQ-9, which can be used for monitoring of Dgslipidemia depression. The USPSTF recommends calculating the cardiovascular dis Other screening instruments may be more accurate for ease risk in adults aged 40 to 75 years using the Pooled Cohort screening in specific patient populations; these include the Equations. This requires measurement of serum lipid Ievels to Ceriatric Depression Scale in older adults and the Edinburgh determine risk for an atherosclerotic cardiovascular disease Postnatal Depression Scale in postpaffum and pregnant women. (ASCVD) event. Effective interventions are available to prevent peripar- For adults 40 to 75 years of age, the American College ol tum depression, but there are no validated risk assessment Cardiologr (ACC)/American Heart Association (AHA) also rec- tools to identifiz women who might benefit. The USPSTF sug ommends routine assessment traditional cardiovascular risk gests that women with increased risk can be identified by one factors and calculation of the 10 year risk for ASCVD by using or more of the following risk f'actors: a history of depression, the Pooled Cohort Equations. For adults 20 to 39 years ofage, current depressive symptoms that do not reach a diagnostic ACC/AHA believes that it is reasonable to assess traditional threshold, low income, adolescent or single parenthood, ASCVD risk factors at least every 4 to 6 years. recent intimate partner violence, elevated anxiety symptoms, or a history of significant negative lif'e events. Hypertension Although the USPSTF does not provide a recommenda The USPSTF supports screening all adults beginning at age tion regarding screening for anxiety, the Women's Preventive 18 years for hypertension (grade A). Screening should occur Services Initiative suggests screening fbr anxiety in all women, annually in adults aged 40 years or older and in younger adults including those who are pregnant or in the postpartum period. at increased risk, including patients with high normal blood This can be performed in conjunction with screening for pressure (tgo to tgglss to 89 mm Hg), patients who are over- depression. weight or obese, and Black patients. Screening should other wise occur at 3 to s-year intervals. For more information, see Diabetes Mellitus MKSAP 19 Nephrologz. The USPSTF recommends screening for diabetes mellitus in The predictive value of screening for hypertension is adults aged 35 to 70 years who are overweight or obese improved through multiple serial measurements in a variety of

The rationale for this recommendation is based on the very TABLE 3. Risk Factors for Diabetes Mellitus low prevalence of carotid stenosis (0.5,1,,1,/.) and resulting First-degree relative with diabetes high rate of false-positive results yielded by commonly used ultrasonography. Auscultation of the neck for carotid bruits is High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific lslander) ineffective for screening as well. Screening for carotid stenosis History of cardiovascular disease in asymptomatic patients could lead to harm as a result of complications from angiographic studies or endarterectomy. Hypertension (>140/90 mm Hg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or Cognitiue Disorders triglyceride level >250 mg/dL(2.82 mmol/L) The USPSTF assessed the benefits of screening for cognitive Polycystic ovary synd rome impairment as uncertain (l statement) owing to lack of high Physical inactivity qualify evidence. Various screening tests with high predictive Other clinical conditions associated with insulin resistance value are available (see MKSAP 19 General Internal lr4edicine (e.9., severe obesity, acanthosis nigricans) 1). However, it is uncertain that early detection changes or History of gestational diabetes improves clinical outcomes. lnformation from American Diabetes Association.2. Classification and dragnosrs of diabetes: Standards of Medical Care in Dia b,etes-202 1 . Diabetes Care. 2O21 :44(Suppl 1 ):5 1 5 S33. doi : 1 0.2337 / dc2 1 5002 Depression and Anxiety The USPSTF suggests that all adults, including pregnant and postpartum women, be screened fbr depression, with ade (grade B). Screening can be accomplished by measuring tast- quate systems in place for subsequent assessment, treatment, ing plasma glucose or hemoglobin A,.. and follow up (grade B). Most adults can be screened with the In contrast to the USPSTF. the American Diabetes brief PHQ 2, which consists of two questions: "During the past Association (ADA) recommends that screening be performed 2 weeks, how often have you been bothered by feeling down, in patients of any age who are overweight or obese and have depressed, or hopeless?" and "During the past 2 weeks, have one or more risk factors for diabetes (Tabte 3). The ADA also you often been bothered by having little interest or pleasure in recommends screening all adults beginning at age 45 years, doing things? " Responses to each question may be scaled (0,3) regardless of risk factors, and repeating screening at 3 year or dichotomous (yes/no). A total score fbr both questions of 3 intervals. Patients with prediabetes (hemoglobin A," >5.7'7,, or greater or a single "yes" response indicates the possibility of impaired glucose tolerance, or impaired fasting glucose) clinically significant depression. Patients with a positive should be screened annually. screening result should be formally assessed for depression and complete the PHQ-9, which can be used for monitoring of Dgslipidemia depression. The USPSTF recommends calculating the cardiovascular dis Other screening instruments may be more accurate for ease risk in adults aged 40 to 75 years using the Pooled Cohort screening in specific patient populations; these include the Equations. This requires measurement of serum lipid Ievels to Ceriatric Depression Scale in older adults and the Edinburgh determine risk for an atherosclerotic cardiovascular disease Postnatal Depression Scale in postpaffum and pregnant women. (ASCVD) event. Effective interventions are available to prevent peripar- For adults 40 to 75 years of age, the American College ol tum depression, but there are no validated risk assessment Cardiologr (ACC)/American Heart Association (AHA) also rec- tools to identifiz women who might benefit. The USPSTF sug ommends routine assessment traditional cardiovascular risk gests that women with increased risk can be identified by one factors and calculation of the 10 year risk for ASCVD by using or more of the following risk f'actors: a history of depression, the Pooled Cohort Equations. For adults 20 to 39 years ofage, current depressive symptoms that do not reach a diagnostic ACC/AHA believes that it is reasonable to assess traditional threshold, low income, adolescent or single parenthood, ASCVD risk factors at least every 4 to 6 years. recent intimate partner violence, elevated anxiety symptoms, or a history of significant negative lif'e events. Hypertension Although the USPSTF does not provide a recommenda The USPSTF supports screening all adults beginning at age tion regarding screening for anxiety, the Women's Preventive 18 years for hypertension (grade A). Screening should occur Services Initiative suggests screening fbr anxiety in all women, annually in adults aged 40 years or older and in younger adults including those who are pregnant or in the postpartum period. at increased risk, including patients with high normal blood This can be performed in conjunction with screening for pressure (tgo to tgglss to 89 mm Hg), patients who are over- depression. weight or obese, and Black patients. Screening should other wise occur at 3 to s-year intervals. For more information, see Diabetes Mellitus MKSAP 19 Nephrologz. The USPSTF recommends screening for diabetes mellitus in The predictive value of screening for hypertension is adults aged 35 to 70 years who are overweight or obese improved through multiple serial measurements in a variety of 5

Routine Care of the Healthy Patient settings. Before treatment is initiated, when possible and in Risk assessment and screening fbr osteoporosis are fur the absence ofsevere hyperlension or end organ damage, the ther discussed in MKSAP 19 Endocrinolory and Metabolism. diagnosis should be confirmed with blood pressure measure ments outside of the clinical setting, such as ambulatory or Thyroid Dysfunction home blood pressure monitoring. The USPSTF concludes that evidence is insufficient to recom The ACC/AHA recommend annual evaluation of patients mend for or against screening fbr thyroid dysfunction (l state with normal blood pressure (<120/<80 mm Hg). Adults with ment). The American Thyroid Association and the American a elevated blood pressure or stage t hyperlension (130 to 139/80 Association of Clinical Endocrinologists, hou,ever. recommend to 89 mm Hg) who have an estimated 10 year ASCVD risk less measuring thyroid stimulating hormone in individuals at risk than 10'7, should be managed with nonpharmacologic therapy for hypothyroidism (for example, personal history of autoim and have a repeat blood pressure evaluation within 3 to mune disease. neck radiation, or thyroid surgery)r they addi 6 months. tionally recommend considering screening in adults aged 60 years or older. Obesity f,EY POIlIIS The USPSTF no longer recommends screening for obesity but does recommend referring or initiating weight loss interven . The U.S. Preventive Services Task Force supports routine screening for depression, hypertension. tobacco use, tions for adults with a BMI of 30 or higher (grade B).The ACC, and alcohol misuse in asymptomatic, a'verage risk the AHA, and The Obesity Socieg recommend annual screen- adults. ing with BMI and waist circumference measurements. o Adults aged 35 to 70 years who are overweight or obese Obstructiue Sleep Apnea should be screened for diabetes mellitus, according to According to the USPSTF, evidence is insufficient to assess the the U.S. Preventive Services Task Force. balance of benefits and harms of screening for obstructive . Lipid screening is indicated in adults aged 40 to 75 years sleep apnea in asymptomatic adults with the currently avail for the purposes of calculating 1O-year risk for athero- able tools (l statement). Because obstructive sleep apnea is sclerotic cardiovascular disease and guiding initiation of widely underrecognized, clinicians should have a low thresh- statin therapy for primary prevention. t old lor investigating for sleep apnea in patients nho have symptoms consistent with the disease (see MKSAP 19 Screening for Infectious Diseases Pulmonary and Critical Care Medicine). Screening for infectious diseases is primarily recommended for individuals at increased risk (Table 4 and Table 5), although Osteoporosis there are several diseases for which average risk patients The USPSTF recommends screening for osteoporosis in all should be screened. women aged 65 years or older and in women younger than According to the USPSTF, screening fbr chlamldia and 65 years who are at increased risk for osteoporosis, as deter gonorrhea should be performed in all sexually active women mined by a formal clinical risk assessment tool. The Fracture aged 24 years or younger because of increased prevalence in Risk Assessment (FRAX) is a commonly used clinical risk this population. In the absence olstudies on screening inter- assessment tool. avail able at r,r,.vwv. shef. ac. uk/ FRAX. Women vals, the USPSTF believes that repeat screening is reasonable in who have a lO-year FRAX risk for major osteoporotic fracture patients whose sexual history reveals ne\ r or persistent risk equal to or higher than that of a 65 year-old white woman factors since the last negative test result. Screening for these without additional risk factors (10 year risk of 8.4'7,) should diseases in men of this age and demographic is not recom undergo screening for osteoporosis. Screening can be accom- mended (l statement) owing to lack of evidence to support plished with bone mineral density measurement, most com benefits of screening. monly with dual energz x ray absorptiometry of the hip and One time screening for hepatitis C virus should be com lumbar spine. pleted in all patients aged 18 to 79 years. The USPSTF does not The USPSTF concludes that evidence is insufficient to promote screening in patients older than 79 years, although recommend routine screening for osteoporosis in men to the CDC does not specily an upper age limit. Patients with risk reduce the risk for fractures (l statement); however, the factors should also be retested regardless of age. Screening is National Osteoporosis Foundation recommends osteoporosis accomplished by testing for antibodies to the disease. followed screening in men aged 70 years or older. Screening may be by polymerase chain reaction viral load testing if results of considered in younger men at high risk for osteoporosis on the initial testing are positive (see MKSAP 19 Gastroenterologr and basis of risk factors. such as low body weight, recent weight Hepatology). ! loss, physical inactivity, use of oral glucocorlicoids. previous The USPSTF recommends that all persons aged 15 to fragility fracture, alcohol use, and androgen deprivation 65 years receive one time HIV screening regardless of risk, and through pharmacologic agents or orchiectomy. CDC recommends routine HIV screening for all persons aged

settings. Before treatment is initiated, when possible and in Risk assessment and screening fbr osteoporosis are fur the absence ofsevere hyperlension or end organ damage, the ther discussed in MKSAP 19 Endocrinolory and Metabolism. diagnosis should be confirmed with blood pressure measure ments outside of the clinical setting, such as ambulatory or Thyroid Dysfunction home blood pressure monitoring. The USPSTF concludes that evidence is insufficient to recom The ACC/AHA recommend annual evaluation of patients mend for or against screening fbr thyroid dysfunction (l state with normal blood pressure (<120/<80 mm Hg). Adults with ment). The American Thyroid Association and the American a elevated blood pressure or stage t hyperlension (130 to 139/80 Association of Clinical Endocrinologists, hou,ever. recommend to 89 mm Hg) who have an estimated 10 year ASCVD risk less measuring thyroid stimulating hormone in individuals at risk than 10'7, should be managed with nonpharmacologic therapy for hypothyroidism (for example, personal history of autoim and have a repeat blood pressure evaluation within 3 to mune disease. neck radiation, or thyroid surgery)r they addi 6 months. tionally recommend considering screening in adults aged 60 years or older. Obesity f,EY POIlIIS The USPSTF no longer recommends screening for obesity but does recommend referring or initiating weight loss interven . The U.S. Preventive Services Task Force supports routine screening for depression, hypertension. tobacco use, tions for adults with a BMI of 30 or higher (grade B).The ACC, and alcohol misuse in asymptomatic, a'verage risk the AHA, and The Obesity Socieg recommend annual screen- adults. ing with BMI and waist circumference measurements. o Adults aged 35 to 70 years who are overweight or obese Obstructiue Sleep Apnea should be screened for diabetes mellitus, according to According to the USPSTF, evidence is insufficient to assess the the U.S. Preventive Services Task Force. balance of benefits and harms of screening for obstructive . Lipid screening is indicated in adults aged 40 to 75 years sleep apnea in asymptomatic adults with the currently avail for the purposes of calculating 1O-year risk for athero- able tools (l statement). Because obstructive sleep apnea is sclerotic cardiovascular disease and guiding initiation of widely underrecognized, clinicians should have a low thresh- statin therapy for primary prevention. t old lor investigating for sleep apnea in patients nho have symptoms consistent with the disease (see MKSAP 19 Screening for Infectious Diseases Pulmonary and Critical Care Medicine). Screening for infectious diseases is primarily recommended for individuals at increased risk (Table 4 and Table 5), although Osteoporosis there are several diseases for which average risk patients The USPSTF recommends screening for osteoporosis in all should be screened. women aged 65 years or older and in women younger than According to the USPSTF, screening fbr chlamldia and 65 years who are at increased risk for osteoporosis, as deter gonorrhea should be performed in all sexually active women mined by a formal clinical risk assessment tool. The Fracture aged 24 years or younger because of increased prevalence in Risk Assessment (FRAX) is a commonly used clinical risk this population. In the absence olstudies on screening inter- assessment tool. avail able at r,r,.vwv. shef. ac. uk/ FRAX. Women vals, the USPSTF believes that repeat screening is reasonable in who have a lO-year FRAX risk for major osteoporotic fracture patients whose sexual history reveals ne\ r or persistent risk equal to or higher than that of a 65 year-old white woman factors since the last negative test result. Screening for these without additional risk factors (10 year risk of 8.4'7,) should diseases in men of this age and demographic is not recom undergo screening for osteoporosis. Screening can be accom- mended (l statement) owing to lack of evidence to support plished with bone mineral density measurement, most com benefits of screening. monly with dual energz x ray absorptiometry of the hip and One time screening for hepatitis C virus should be com lumbar spine. pleted in all patients aged 18 to 79 years. The USPSTF does not The USPSTF concludes that evidence is insufficient to promote screening in patients older than 79 years, although recommend routine screening for osteoporosis in men to the CDC does not specily an upper age limit. Patients with risk reduce the risk for fractures (l statement); however, the factors should also be retested regardless of age. Screening is National Osteoporosis Foundation recommends osteoporosis accomplished by testing for antibodies to the disease. followed screening in men aged 70 years or older. Screening may be by polymerase chain reaction viral load testing if results of considered in younger men at high risk for osteoporosis on the initial testing are positive (see MKSAP 19 Gastroenterologr and basis of risk factors. such as low body weight, recent weight Hepatology). ! loss, physical inactivity, use of oral glucocorlicoids. previous The USPSTF recommends that all persons aged 15 to fragility fracture, alcohol use, and androgen deprivation 65 years receive one time HIV screening regardless of risk, and through pharmacologic agents or orchiectomy. CDC recommends routine HIV screening for all persons aged 6

: Routine Care of the Healthy Patient drinking with brief behavioral counseling interventions to TABLE 6. Recommendations for Breast Cancer Screening reduce alcohol misuse (grade B). Screening instruments to in Women at Average Risk identify harmful drinking include the Alcohol Use Disorders Expert Group Recommendation Identification Test (AUDIT), the AUDIT-Consumption American Cancer Age 40-44y: Provide women with the (AUDIT-C), and single item screening. The AUDIT (https,// Society (2015) opportunity to begin annual screening pubs.niaaa.nih.gov/publications/Audit.pdfl is a validated mammography 10 item screening test that takes approximately 2 to 3 minutes Age 45-54 y: Perform annual screening to administerr the AUDIT C is a briefer (three item) version of mammography the AUDIT. With single item screening, the clinician asks. Age >55 y: Perform biennial screening "How many times in the past year have you had five [four for mammography with the opportunity to continue annual screening women] or more drinks in 1 day?" A positive test result, Do not perform CBE for breast cancer defined as any answer other than "zero," has a sensitivity and screening specificity of approximately 80'2, for unhealthy alcohol use. American Age 25-39 y: May offer CBE every 1 -3 y The USPSTF recommends asking adults aged 18 years or College of Age 40-49 y: Offer screening mammography older about the use of illegal or nonprescribed psychoactive Obstetricians and engage women in a shared decision- drugs if the physician is also able to offer treatment or refer the and making process; may offer annual CBE Gynecologists patient to treatment. Screening tools include the Drug Abuse (2017) Age 50-75 y: Perform annual or biennial Screening Test (DAST 10) (wr,rrw.integration.samhsa.gov/ screening mammography based on a clinical-practice/DAST 10.pdf) and the CAGE questionnaire shared decision-making process expanded to include drugs (CAGE AID) (www.integration. Age >75 y: Engage women in a shared samhsa.gov/images/res/CAGEAI D. pdf). decision-making process about discontinuing screening

drinking with brief behavioral counseling interventions to TABLE 6. Recommendations for Breast Cancer Screening reduce alcohol misuse (grade B). Screening instruments to in Women at Average Risk identify harmful drinking include the Alcohol Use Disorders Expert Group Recommendation Identification Test (AUDIT), the AUDIT-Consumption American Cancer Age 40-44y: Provide women with the (AUDIT-C), and single item screening. The AUDIT (https,// Society (2015) opportunity to begin annual screening pubs.niaaa.nih.gov/publications/Audit.pdfl is a validated mammography 10 item screening test that takes approximately 2 to 3 minutes Age 45-54 y: Perform annual screening to administerr the AUDIT C is a briefer (three item) version of mammography the AUDIT. With single item screening, the clinician asks. Age >55 y: Perform biennial screening "How many times in the past year have you had five [four for mammography with the opportunity to continue annual screening women] or more drinks in 1 day?" A positive test result, Do not perform CBE for breast cancer defined as any answer other than "zero," has a sensitivity and screening specificity of approximately 80'2, for unhealthy alcohol use. American Age 25-39 y: May offer CBE every 1 -3 y The USPSTF recommends asking adults aged 18 years or College of Age 40-49 y: Offer screening mammography older about the use of illegal or nonprescribed psychoactive Obstetricians and engage women in a shared decision- drugs if the physician is also able to offer treatment or refer the and making process; may offer annual CBE Gynecologists patient to treatment. Screening tools include the Drug Abuse (2017) Age 50-75 y: Perform annual or biennial Screening Test (DAST 10) (wr,rrw.integration.samhsa.gov/ screening mammography based on a clinical-practice/DAST 10.pdf) and the CAGE questionnaire shared decision-making process expanded to include drugs (CAGE AID) (www.integration. Age >75 y: Engage women in a shared samhsa.gov/images/res/CAGEAI D. pdf). decision-making process about discontinuing screening Screening for Abuse American Age <40 y: Do not perform screening College of The USPSTF recommends screening for intimate partner Physicians (2019) Age 40-49 y: Potential harms of screening mammography outweigh benefits in violence in all women of childbearing age and referring to average-risk women. Discuss benefits, appropriate social services if screening is positive (grade B). harms, and patient preferences; order Available screening tools include the Hurt, Insult, Threaten, biennial mammography screening only if an informed woman requests it Scream (HITS); Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT)I Slapped, Threatened, and Age 50-74 y: Encourage biennial mammography screening Throw (STaT); Humiliation, Afraid, Rape, Kick (HARK); Modified Childhood Trauma Questionnaire Short Form Age >75 y or life expectancy <1 0 y: Do not perform screening (CTQ SF); and Woman Abuse Screening Tool (WAST). Do not use CBE to screen for breast cancer The USPSTF states that evidence is currently insufficient in average-risk women of all ages to recommend universal screening in this population (l American Age 40 y: Begin annual screening statement). College of mammography Radiology (2017) Screening for Cancer National Age 25-39 y: Perform CBE every 1-3 y This section discusses cancer screening in asymptomatic, Comprehensive Age 40 y: Begin annual screening average risk persons. Screening for cancer in patients at high Cancer Network (2016) mammography and perform annual CBE risk is covered in the respective specialty books of MKSAP 19. U.S. Preventive Age 40-49 y: Decision to begin screening Services Task should be individualized (grade C) Breost Cancer Force (2016) The balance of benefits and harms of screening mammogra- Age 50 74 y: Perform biennial screening mammography(grade B) phy in average-risk women has shifted with the advent of increasingly effective breast cancer treatments, which reduce Age >75 y: lnsufficient evidence to assess the balance of benefits and harms of the benefits of early detection, as well as emerging informa- screening mammography (l statement) tion about overdiagnosis. Women at average risk include those CBE = clinical breast examination- without a personal history of breast cancer or a high risk breast lesion, genetic mutations conferring elevated risk for breast cancer, or a history ofradiation to the chest as a child. screening mammography, which imparts most of the benefits In average risk women aged 50 to 74 years, there is a clear of annual mammography with fewer harms. In women benefit to screening mammography, and all breast cancer younger than 50 years or aged 75 years or older. the balance of guidelines recommend screening mammography in this age benefits and harms is less clear, and screening recommenda group. Specific screening recommendations, however, vary by tions vary widely. Breast cancer screening with clinical breast specialty society (Table 6). The USPSTF recommends biennial examination is not recommended.

Screening for Abuse American Age <40 y: Do not perform screening College of The USPSTF recommends screening for intimate partner Physicians (2019) Age 40-49 y: Potential harms of screening mammography outweigh benefits in violence in all women of childbearing age and referring to average-risk women. Discuss benefits, appropriate social services if screening is positive (grade B). harms, and patient preferences; order Available screening tools include the Hurt, Insult, Threaten, biennial mammography screening only if an informed woman requests it Scream (HITS); Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT)I Slapped, Threatened, and Age 50-74 y: Encourage biennial mammography screening Throw (STaT); Humiliation, Afraid, Rape, Kick (HARK); Modified Childhood Trauma Questionnaire Short Form Age >75 y or life expectancy <1 0 y: Do not perform screening (CTQ SF); and Woman Abuse Screening Tool (WAST). Do not use CBE to screen for breast cancer The USPSTF states that evidence is currently insufficient in average-risk women of all ages to recommend universal screening in this population (l American Age 40 y: Begin annual screening statement). College of mammography Radiology (2017) Screening for Cancer National Age 25-39 y: Perform CBE every 1-3 y This section discusses cancer screening in asymptomatic, Comprehensive Age 40 y: Begin annual screening average risk persons. Screening for cancer in patients at high Cancer Network (2016) mammography and perform annual CBE risk is covered in the respective specialty books of MKSAP 19. U.S. Preventive Age 40-49 y: Decision to begin screening Services Task should be individualized (grade C) Breost Cancer Force (2016) The balance of benefits and harms of screening mammogra- Age 50 74 y: Perform biennial screening mammography(grade B) phy in average-risk women has shifted with the advent of increasingly effective breast cancer treatments, which reduce Age >75 y: lnsufficient evidence to assess the balance of benefits and harms of the benefits of early detection, as well as emerging informa- screening mammography (l statement) tion about overdiagnosis. Women at average risk include those CBE = clinical breast examination- without a personal history of breast cancer or a high risk breast lesion, genetic mutations conferring elevated risk for breast cancer, or a history ofradiation to the chest as a child. screening mammography, which imparts most of the benefits In average risk women aged 50 to 74 years, there is a clear of annual mammography with fewer harms. In women benefit to screening mammography, and all breast cancer younger than 50 years or aged 75 years or older. the balance of guidelines recommend screening mammography in this age benefits and harms is less clear, and screening recommenda group. Specific screening recommendations, however, vary by tions vary widely. Breast cancer screening with clinical breast specialty society (Table 6). The USPSTF recommends biennial examination is not recommended. 8

Routine Care of the Healthy Patient TABLE 7. Breast Cancer Deaths Averted per 1 0,000 Women Screened Over 10 Years Expert Group Recommendation PatientAge American Cancer Age 40-44 y: Engage men at higher risk Variable 40-49 50-59 60-69 70-74 Society (2010) (>2 first-degree relatives with prostate Years Years Years Years cancer before age 65 y) in shared decision making Breast cancer 3 (0-e) 8(2-17) 21 (11-32) 13 (0-32) deaths averted Age 45-49 y: Engage men at high risk (957"Ct) (African American race or first-degree relative with prostate cancer before age NNS for 10 y to 3333 1250 476 169 65 y) in shared decision making avoid one breast cancer Age >50 y with life expectancy >10 y: death Engage in shared decision making American Age 50-69 y: lnform men about the NNS = number needed to screen College of limited potential benefits and substantial Data from Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L. Physicians (2013) harms of screening for prostate cancer; Effectiveness of breast cancer screening: systematic review and meta analysis to test only men who request screening after update the 2009 U.S. Preventive Services Task Force recommendation. Ann lntern Med. 201 6;1 64:244 55. IPMID: 26756588] doir10.7326/M15-0969 informed discussion Age <50 y,>69 y, or with a life expectancy <10 y: Recommend against screening Shared decision making with consideration of the American Men at higher risk (African American race patient's level of risk, values, and preferences guides the Urological or with positive family history): screening decision. The benefit of screening is largest in Association lndividualize screening decisions women aged 60 to 69 years and is substantially Iower for (2013; reviewed Age <40 y: Recommend against younger and older women (Table 7). Potential harms of screen and confirmed screening 201 s) ing include false-positive results and overdiagnosis. For Age 40-54 y: Do not recommend routine patients starting mammography at age 40 or 50 years, the screening 10 year cumulative false-positive rates are 42% with biennial Age 55-69 y: Engage men considering screening and 6l'/,, with annual screening. Such results may PSA-based screening in shared decision making; proceed on the basis of patient cause unnecessary biopsies and substantial patient anxiety. values and preferences. lf proceeding Approximately 50'1, of women have dense breasts on with screening, consider PSA testing mammography, resulting in decreased sensitivity of mam every2yormore mography for breast cancer (more so with film than digital Age >70 y or with life expectancy <1 0-1 5 y: mammography). Radiologists use the Breast Imaging and Do not recommend routine screening Reporting Data System (BI RADS) to categorize mammogra- U.S. Preventive Age 55-69 y: Discuss potential benefits phy findings and assess breast density (see Women's Health). Services Task and harms of PSA based screening for Force (201 B) prostate cancer and individualize decision lncreased breast density is associated with an increased risk making by incorporating the patient's fbr breast cancer, but patients with dense breasts should not values and preferences be considered at high risk for breast cancer on the basis of Age >70 y: Recommend against PSA-based dense breasts alone. For women in whom increased breast screening b density is the sole risk factor for breast cancer, there is no evi- PSA = prostate speciflc antigen. dence that adding MRI or ultrasonography to mammography \ aflects breast cancer mortality, and most guidelines conclude clinicians engage in a discussion ofthe potential benefits versus :

TABLE 7. Breast Cancer Deaths Averted per 1 0,000 Women Screened Over 10 Years Expert Group Recommendation PatientAge American Cancer Age 40-44 y: Engage men at higher risk Variable 40-49 50-59 60-69 70-74 Society (2010) (>2 first-degree relatives with prostate Years Years Years Years cancer before age 65 y) in shared decision making Breast cancer 3 (0-e) 8(2-17) 21 (11-32) 13 (0-32) deaths averted Age 45-49 y: Engage men at high risk (957"Ct) (African American race or first-degree relative with prostate cancer before age NNS for 10 y to 3333 1250 476 169 65 y) in shared decision making avoid one breast cancer Age >50 y with life expectancy >10 y: death Engage in shared decision making American Age 50-69 y: lnform men about the NNS = number needed to screen College of limited potential benefits and substantial Data from Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L. Physicians (2013) harms of screening for prostate cancer; Effectiveness of breast cancer screening: systematic review and meta analysis to test only men who request screening after update the 2009 U.S. Preventive Services Task Force recommendation. Ann lntern Med. 201 6;1 64:244 55. IPMID: 26756588] doir10.7326/M15-0969 informed discussion Age <50 y,>69 y, or with a life expectancy <10 y: Recommend against screening Shared decision making with consideration of the American Men at higher risk (African American race patient's level of risk, values, and preferences guides the Urological or with positive family history): screening decision. The benefit of screening is largest in Association lndividualize screening decisions women aged 60 to 69 years and is substantially Iower for (2013; reviewed Age <40 y: Recommend against younger and older women (Table 7). Potential harms of screen and confirmed screening 201 s) ing include false-positive results and overdiagnosis. For Age 40-54 y: Do not recommend routine patients starting mammography at age 40 or 50 years, the screening 10 year cumulative false-positive rates are 42% with biennial Age 55-69 y: Engage men considering screening and 6l'/,, with annual screening. Such results may PSA-based screening in shared decision making; proceed on the basis of patient cause unnecessary biopsies and substantial patient anxiety. values and preferences. lf proceeding Approximately 50'1, of women have dense breasts on with screening, consider PSA testing mammography, resulting in decreased sensitivity of mam every2yormore mography for breast cancer (more so with film than digital Age >70 y or with life expectancy <1 0-1 5 y: mammography). Radiologists use the Breast Imaging and Do not recommend routine screening Reporting Data System (BI RADS) to categorize mammogra- U.S. Preventive Age 55-69 y: Discuss potential benefits phy findings and assess breast density (see Women's Health). Services Task and harms of PSA based screening for Force (201 B) prostate cancer and individualize decision lncreased breast density is associated with an increased risk making by incorporating the patient's fbr breast cancer, but patients with dense breasts should not values and preferences be considered at high risk for breast cancer on the basis of Age >70 y: Recommend against PSA-based dense breasts alone. For women in whom increased breast screening b density is the sole risk factor for breast cancer, there is no evi- PSA = prostate speciflc antigen. dence that adding MRI or ultrasonography to mammography \ aflects breast cancer mortality, and most guidelines conclude clinicians engage in a discussion ofthe potential benefits versus : I that evidence is insufficient to recommend adjunctive screen ing when dense breasts are present. The American College of harms of screening for prostate cancer before ordering testing. ; Radiologr, however, notes that ultrasonography may be con The USPSTF recommends that clinicians should not screen ; sidered in this circumstance. Furthermore, some states have men unless they express a preference for screening and recom legislated that women be informed when dense breasts are mends against routine prostate specific antigen (PSA) based noted on imaging and that this may increase the risk for breast screening for prostate cancer in men aged 70 years or older. cancer. Women with dense breasts should undergo further Benefits of screening fbr men aged 55 to 69 years include risk stratification; for those at high risk, additional screening prevention of one prostate cancer- related death for every may be considered (see MKSAP 19 Oncolory). 1000 men screened for 10 years (i.e., the number needed to screen is 1000). Risks include overdiagnosis, overtreatment, Prostate Cancer and false positive results that trigger unnecessary biopsies and t Screening lor prostate cancer in asymptomatic, average risk patient anxiety. Estimated rates of overdiagnosis and over men has been controversial, and recommendations among treatment vary widely. professional organizations continue to evolve (Table 8). For If the decision is made to proceed with screening, the men aged 55 to 69 years, the USPSTF recommends that American Urological Association (AUA) recommends choosing

I that evidence is insufficient to recommend adjunctive screen ing when dense breasts are present. The American College of harms of screening for prostate cancer before ordering testing. ; Radiologr, however, notes that ultrasonography may be con The USPSTF recommends that clinicians should not screen ; sidered in this circumstance. Furthermore, some states have men unless they express a preference for screening and recom legislated that women be informed when dense breasts are mends against routine prostate specific antigen (PSA) based noted on imaging and that this may increase the risk for breast screening for prostate cancer in men aged 70 years or older. cancer. Women with dense breasts should undergo further Benefits of screening fbr men aged 55 to 69 years include risk stratification; for those at high risk, additional screening prevention of one prostate cancer- related death for every may be considered (see MKSAP 19 Oncolory). 1000 men screened for 10 years (i.e., the number needed to screen is 1000). Risks include overdiagnosis, overtreatment, Prostate Cancer and false positive results that trigger unnecessary biopsies and t Screening lor prostate cancer in asymptomatic, average risk patient anxiety. Estimated rates of overdiagnosis and over men has been controversial, and recommendations among treatment vary widely. professional organizations continue to evolve (Table 8). For If the decision is made to proceed with screening, the men aged 55 to 69 years, the USPSTF recommends that American Urological Association (AUA) recommends choosing 9

Routine Care of the Healthy Patient less frequent screening intervals (>Z years), which may reduce this age group because patients who have not yet undergone overdiagnosis and the number of false-positive results while screening are the most likely to benefit (grade C). The USPSTF preserving most ofthe screening benefit. The AUA also recom suggests that screening may be discontinued in patients older mends that the interval for rescreening may be based on the than 85 years. In contrast, the ACP suggests discontinuing baseline PSA level. Screening is not recommended for men screening in average risk patients older than 75 years or when with life expectancy ofless than 10 to 15 years. the expected life expectancy is less than l0 years. There is little head to head comparative evidence that Colorectal Cancer any one recommended screening modality provides a greater There is significant variation in colorectal cancer screening benefit than the others. In addition, despite unequivocal evi guidelines. The ACP recommends screening fbr colorectal cancer dence that colon cancer screening reduces mortaliry an esti- in asymptomatic adults aged 50 to 75 years (gfade A). In contrast, mated one in three U.S. adults who are eligible for colon the USPSTF and the American Cancer Society (ACS) make a cancer screening has not been screened. Therefore. the qualified recommendation to initiate screening for colorectal USPSTF supports using the test that is most likely to result in cancer at age 45 years. The USPSTF also concludes with moder completion of screening. Understanding a patient's values and ate certainty that screening for colorectal cancer in adults aged preferences and selecting a test to which the patient is most 45 to 49 years has moderate net benefit (Grade B). According to likely to adhere may improve screening rates. The ACP sug the USPSTE, screening decisions in patients aged76 to 85 years gests a discussion with the patient and consideration of simi should be individualized according to life expectancy and ability lar factors in selecting a screening stratery. Clinicians should to tolerate treatment ofcolorectal cancer ifdiagnosed. Screening be familiar with the characteristics of each screening stratery history should also be considered before screening patients in to facilitate effective discussion with patients (Table 9).

less frequent screening intervals (>Z years), which may reduce this age group because patients who have not yet undergone overdiagnosis and the number of false-positive results while screening are the most likely to benefit (grade C). The USPSTF preserving most ofthe screening benefit. The AUA also recom suggests that screening may be discontinued in patients older mends that the interval for rescreening may be based on the than 85 years. In contrast, the ACP suggests discontinuing baseline PSA level. Screening is not recommended for men screening in average risk patients older than 75 years or when with life expectancy ofless than 10 to 15 years. the expected life expectancy is less than l0 years. There is little head to head comparative evidence that Colorectal Cancer any one recommended screening modality provides a greater There is significant variation in colorectal cancer screening benefit than the others. In addition, despite unequivocal evi guidelines. The ACP recommends screening fbr colorectal cancer dence that colon cancer screening reduces mortaliry an esti- in asymptomatic adults aged 50 to 75 years (gfade A). In contrast, mated one in three U.S. adults who are eligible for colon the USPSTF and the American Cancer Society (ACS) make a cancer screening has not been screened. Therefore. the qualified recommendation to initiate screening for colorectal USPSTF supports using the test that is most likely to result in cancer at age 45 years. The USPSTF also concludes with moder completion of screening. Understanding a patient's values and ate certainty that screening for colorectal cancer in adults aged preferences and selecting a test to which the patient is most 45 to 49 years has moderate net benefit (Grade B). According to likely to adhere may improve screening rates. The ACP sug the USPSTE, screening decisions in patients aged76 to 85 years gests a discussion with the patient and consideration of simi should be individualized according to life expectancy and ability lar factors in selecting a screening stratery. Clinicians should to tolerate treatment ofcolorectal cancer ifdiagnosed. Screening be familiar with the characteristics of each screening stratery history should also be considered before screening patients in to facilitate effective discussion with patients (Table 9). ?A8LE 9. Characteristics of Colorectal Cancer Screening Strategies Screening Strategy Frequency Reduction in Notes Mortality Rate Stool-based Tests (Cancer Detection) gFOBT Every year 32/" Performance characteristics of hig h-sensitivity gFOBT are superior to those of older tests Requires dietary restrictions; does not require bowel preparation, anesthesia, or transportation to and from the screening examination FIT Every year Unknown lmproved accuracy compared with gFOBT Does not require bowel preparation, anesthesia, or transportation to and from the screening examination FIT-DNA Every 1 -3 y Unknown Higher sensitivity but lower specificity than FlT, resulting in more false-positive results Direct Visualization Tests (Cancer Prevention) Colonoscopy Every 10y 687" Requires full bowel preparation

?A8LE 9. Characteristics of Colorectal Cancer Screening Strategies Screening Strategy Frequency Reduction in Notes Mortality Rate Stool-based Tests (Cancer Detection) gFOBT Every year 32/" Performance characteristics of hig h-sensitivity gFOBT are superior to those of older tests Requires dietary restrictions; does not require bowel preparation, anesthesia, or transportation to and from the screening examination FIT Every year Unknown lmproved accuracy compared with gFOBT Does not require bowel preparation, anesthesia, or transportation to and from the screening examination FIT-DNA Every 1 -3 y Unknown Higher sensitivity but lower specificity than FlT, resulting in more false-positive results Direct Visualization Tests (Cancer Prevention) Colonoscopy Every 10y 687" Requires full bowel preparation Usually requires sedation and a patient escort ACG/MSTF recommend split-dose preparation" CT colonography Every 5 y Unknown Requires bowel preparation lmaging only (cannot remove polyps or biopsy) Extracolonic findings are common Flexible sigmoidoscopy Every 5 y 27o/" Limited bowel preparation compared with colonoscopy Flexible sigmoidoscopy with FIT Flexible sigmoidoscopy 3B7o every 10 y with FIT every year

Usually requires sedation and a patient escort ACG/MSTF recommend split-dose preparation" CT colonography Every 5 y Unknown Requires bowel preparation lmaging only (cannot remove polyps or biopsy) Extracolonic findings are common Flexible sigmoidoscopy Every 5 y 27o/" Limited bowel preparation compared with colonoscopy Flexible sigmoidoscopy with FIT Flexible sigmoidoscopy 3B7o every 10 y with FIT every year ACG = American College of Castroenterology; FIT = fecal immunochemical test; gFOBT = g!aiac fecal occult blood test; MSTF - U.S. Multi-society Task Force on Colorectal Cancer hal{ of the preparation on the day o{ colonoscopy, starting 4 to 5 hours before the procedure start and finishing 3 hours beforJthe procedure start. Adapted from Davidson KW, Barry MJ, Mangione CM, et al; US Preventive Services Task Force- Screening for colorectal cancer: US preventive Services Task Force recommendation statement. JAMA. 2O21;325:1965 1 977. IPM lD: 340032 1 8] doi:1 0.1 001 /)ama.2O21 .6238 10

Routine Care of the Healthy Patient The ACP suggests colonoscopy every 10 years, flexible of prior screening cannot be confirmed should undergo sigmoidoscopy every 10 years plus fecal immunochemical screening with cytologr every 3 years, high-risk HPV testing testing (FIT) every 2 years, or FIT or high sensitivity guaiac every 5 years, or combined high risk HPV testing and cytologz based fecal occult blood testing every 2 years as acceptable every 5 years until the criteria for adequate screening have screening regimens. In contrast, the U.S. Multi Society Task been fulfilled. Force on Colorectal Cancer (MSTF), an initiative of U.S. gastro Screening should not be performed in women who have enterologi societies, has ranked colorectal cancer screening had hysterectomy with removal of the cervix unless a high- tests in tiers based on the available evidence. cost effective grade precancerous lesion (cervical intraepithelial neoplasia 2 ness, test availability, and several other factors. The MSTF rec- or 3) was present. in which case screening should be contin ommends colonoscopy every 10 years or annual FIT as first-tier ued for at least 20 years after hysterectomy. tests; CT colonography every 5 years, FIT DNA testing every 3 years, or flexible sigmoidoscopy every 5 to 10 years as sec Lung Cancer ond tier tests; and capsule colonography every 5 years as a Although lung cancer screening with chest radiography is not third tier test. The serum circulating methylated SEPTg DNA recommended, annual screening with low-dose CT in patients test is an FDA-approved screening strateS/. However, this test's who are heavy smokers results in a 2O% to 24o/,, reduction in sensitivity for detecting colorectal cancer is only 4B%, and the lung cancer mortality. The USPSTF recommends lung cancer MSTF does not recommend its use. screening with annual low dose CT for persons aged 50 years to B0 years with a 20 pack year smoking history; screening Ceruicql Cancer should be discontinued in former smokers who have not The USPSTF recommends screening women aged 21 to smoked for 15 years (see MKSAP 19 Pulmonary and Critical 65 years every 3 years with cy.tologr (Pap test). In women aged Care Medicine). 30 to 65 years who want to lengthen the screening interval, high risk human papillomavirus (HPV) testing (preferred) or Additiona.l Cancer Screening Tests cy.tologr combined with high risk HPV testing can be per- The USPSTF recommends using a brief familial risk assess- formed every 5 years. The USPSTF recommends against ment tool, such as the Ontario Family History Assessment screening women younger than 27 years regardless of sexual Tool, to screen lbr BRCAL/2 gene mutations risk in patients history because screening has not been shown to reduce cervi- with a personal or family history of breast, ovarian, tubal, or cal cancer incidence or mortalit5z compared with starting peritoneal cancer or who have an ancestry associated with the screening at age 21 years. mutations. Genetic counseling and possibly genetic testing In 2O2O, the ACS substantially shifted its recommenda should be provided to those identified to be at higher risk. tions fbr cervical cancer screening to focus on HPV testing. The The USPSTF. the Society of Gynecologic Oncologr, and the ACS recommends initiating screening at age 25 years with American College of Obstetricians and Gynecologists all rec- HPV testing alone (primary HPV testing) every 5 years until ommend against screening for ovarian cancer with serum age 65 years. When primary HPV testing is unavailable, CA 125 testing or ultrasonography in women at average risk. patients in this age range should preferably be screened with Women with a family history indicating a possible hereditary HPV cotesting (HPV testing with cervical c1,tology) every cancer syndrome should be referred to a genetic counselor for 5 years, or alternatively with cytologz alone every 3 years. consideration of genetic testing (see MKSAP 19 Oncolo5r). t Currently, there are two FDA-approved primary HPV tests and According to the USPSTE, evidence is insufficient to deter five FDA approved HPV tests for cotesting. mine the balance of benefits and harms of screening for skin Screening can be discontinued at age 65 years in non cancer with a visual skin examination (l statement). However, high-risk women with adequate prior screening, commonly the USPSTF recommends that persons younger than 24 years defined as three consecutive negative cytologz results or two who have fair skin receive counseling to minimize exposure to consecutive negative cytologi plus HPV test results within the ultraviolet radiation to reduce risk for skin cancer (grade B) past 10 years, with the most recent test occurring within and recommends offering selective counseling to adults older 5 years. In women older than 65 years with life expectancy of than age 24 years with fair skin types (grade C). at least 10 years and risk factors for cervical cancer (history of The USPSTF recommends against screening for pancre abnormal Pap smears, history of a high-grade precancerous atic cancer in asymptomatic adults (grade D). Because up to Iesion, in utero exposure to diethylstilbestrol, immunocom- 15'/n of pancreatic ductal adenocarcinomas are attributable to promise, previous HPV infection), continued screening should genetic factors, patients with a family history suggestive of a be considered. genetic syndrome associated with pancreatic cancer (BRCA1/2 Women who have never been screened have the highest mutations, Peutz Jeghers syndrome, Lynch syndrome) should incidence of and mortality from cervical cancer. The mortality be referred for genetic counseling and possible genetic reduction from screening in women who have not been previ testing. ously screened may be as high as 74%. Women older than Evidence is insufflcient to recommend routine anal can 65 years who have never been screened or in whom adequacy cer screening in average risk populations, but such screening

The ACP suggests colonoscopy every 10 years, flexible of prior screening cannot be confirmed should undergo sigmoidoscopy every 10 years plus fecal immunochemical screening with cytologr every 3 years, high-risk HPV testing testing (FIT) every 2 years, or FIT or high sensitivity guaiac every 5 years, or combined high risk HPV testing and cytologz based fecal occult blood testing every 2 years as acceptable every 5 years until the criteria for adequate screening have screening regimens. In contrast, the U.S. Multi Society Task been fulfilled. Force on Colorectal Cancer (MSTF), an initiative of U.S. gastro Screening should not be performed in women who have enterologi societies, has ranked colorectal cancer screening had hysterectomy with removal of the cervix unless a high- tests in tiers based on the available evidence. cost effective grade precancerous lesion (cervical intraepithelial neoplasia 2 ness, test availability, and several other factors. The MSTF rec- or 3) was present. in which case screening should be contin ommends colonoscopy every 10 years or annual FIT as first-tier ued for at least 20 years after hysterectomy. tests; CT colonography every 5 years, FIT DNA testing every 3 years, or flexible sigmoidoscopy every 5 to 10 years as sec Lung Cancer ond tier tests; and capsule colonography every 5 years as a Although lung cancer screening with chest radiography is not third tier test. The serum circulating methylated SEPTg DNA recommended, annual screening with low-dose CT in patients test is an FDA-approved screening strateS/. However, this test's who are heavy smokers results in a 2O% to 24o/,, reduction in sensitivity for detecting colorectal cancer is only 4B%, and the lung cancer mortality. The USPSTF recommends lung cancer MSTF does not recommend its use. screening with annual low dose CT for persons aged 50 years to B0 years with a 20 pack year smoking history; screening Ceruicql Cancer should be discontinued in former smokers who have not The USPSTF recommends screening women aged 21 to smoked for 15 years (see MKSAP 19 Pulmonary and Critical 65 years every 3 years with cy.tologr (Pap test). In women aged Care Medicine). 30 to 65 years who want to lengthen the screening interval, high risk human papillomavirus (HPV) testing (preferred) or Additiona.l Cancer Screening Tests cy.tologr combined with high risk HPV testing can be per- The USPSTF recommends using a brief familial risk assess- formed every 5 years. The USPSTF recommends against ment tool, such as the Ontario Family History Assessment screening women younger than 27 years regardless of sexual Tool, to screen lbr BRCAL/2 gene mutations risk in patients history because screening has not been shown to reduce cervi- with a personal or family history of breast, ovarian, tubal, or cal cancer incidence or mortalit5z compared with starting peritoneal cancer or who have an ancestry associated with the screening at age 21 years. mutations. Genetic counseling and possibly genetic testing In 2O2O, the ACS substantially shifted its recommenda should be provided to those identified to be at higher risk. tions fbr cervical cancer screening to focus on HPV testing. The The USPSTF. the Society of Gynecologic Oncologr, and the ACS recommends initiating screening at age 25 years with American College of Obstetricians and Gynecologists all rec- HPV testing alone (primary HPV testing) every 5 years until ommend against screening for ovarian cancer with serum age 65 years. When primary HPV testing is unavailable, CA 125 testing or ultrasonography in women at average risk. patients in this age range should preferably be screened with Women with a family history indicating a possible hereditary HPV cotesting (HPV testing with cervical c1,tology) every cancer syndrome should be referred to a genetic counselor for 5 years, or alternatively with cytologz alone every 3 years. consideration of genetic testing (see MKSAP 19 Oncolo5r). t Currently, there are two FDA-approved primary HPV tests and According to the USPSTE, evidence is insufficient to deter five FDA approved HPV tests for cotesting. mine the balance of benefits and harms of screening for skin Screening can be discontinued at age 65 years in non cancer with a visual skin examination (l statement). However, high-risk women with adequate prior screening, commonly the USPSTF recommends that persons younger than 24 years defined as three consecutive negative cytologz results or two who have fair skin receive counseling to minimize exposure to consecutive negative cytologi plus HPV test results within the ultraviolet radiation to reduce risk for skin cancer (grade B) past 10 years, with the most recent test occurring within and recommends offering selective counseling to adults older 5 years. In women older than 65 years with life expectancy of than age 24 years with fair skin types (grade C). at least 10 years and risk factors for cervical cancer (history of The USPSTF recommends against screening for pancre abnormal Pap smears, history of a high-grade precancerous atic cancer in asymptomatic adults (grade D). Because up to Iesion, in utero exposure to diethylstilbestrol, immunocom- 15'/n of pancreatic ductal adenocarcinomas are attributable to promise, previous HPV infection), continued screening should genetic factors, patients with a family history suggestive of a be considered. genetic syndrome associated with pancreatic cancer (BRCA1/2 Women who have never been screened have the highest mutations, Peutz Jeghers syndrome, Lynch syndrome) should incidence of and mortality from cervical cancer. The mortality be referred for genetic counseling and possible genetic reduction from screening in women who have not been previ testing. ously screened may be as high as 74%. Women older than Evidence is insufflcient to recommend routine anal can 65 years who have never been screened or in whom adequacy cer screening in average risk populations, but such screening 11

Routine Care of the Healthy Patient may be considered in high risk populations. The Infectious TABLE 10. Live Vaccines and Contraindications to Diseases Society of America suggests screening patients with Administration genital warts, men who have sex with men, and women who Live Vaccines have a history of abnormal cervical cytologr or participate in Live attenuated influenza vaccine (LAIV) receptive anal intercourse. Measles, mumps, rubella vaccine (MMR) The USPSTF recommends against screening for testicular Zoster vaccine, live (ZVL) cancer and thyroid cancer in asymptomatic adults (grade D)' Routine screening for bladder cancer is not recommended by Varicella vaccine (VAR) any expert group. Contraindications to Live Vaccines t(EY P0r lrTS Pregnancy or probable pregnancy within 4 wk

may be considered in high risk populations. The Infectious TABLE 10. Live Vaccines and Contraindications to Diseases Society of America suggests screening patients with Administration genital warts, men who have sex with men, and women who Live Vaccines have a history of abnormal cervical cytologr or participate in Live attenuated influenza vaccine (LAIV) receptive anal intercourse. Measles, mumps, rubella vaccine (MMR) The USPSTF recommends against screening for testicular Zoster vaccine, live (ZVL) cancer and thyroid cancer in asymptomatic adults (grade D)' Routine screening for bladder cancer is not recommended by Varicella vaccine (VAR) any expert group. Contraindications to Live Vaccines t(EY P0r lrTS Pregnancy or probable pregnancy within 4 wk . All women aged 50 to 74 years should undergo screening HIV with CD4 cell count <200 cells/gL or CD4 cells <15% of total lymphocytesu mammography; the recommended screening interval lmmunosuppressant therapy, including high-dose varies by expert group. glucocorticoids (>20 mg/d of prednisone or equivalent {or >2 wk) . The ACP recommends screening for colorectal cancer in Leukemia, lymphoma, or other bone marrow and lymphatic asymptomatic adults aged 50 to 75 years (grade A); in system malignancies contrast, the USPSTF and the American Cancer Society I Cellular immunodeficiency (ACS) make a qualified recommendation to initiate Solid-organ transplant recipient screening for colorectal cancer at age 45 years. Recent hematopoietic stem cell transplantation o The choice of modality for colorectal cancer screening "Live attenuated influenza vaccine is contraindicated in patients with HIV infection should be based on discussion with patients, including consideration of likelihood of adherence and patient [':"1':: "'i"1:"""'": . _ values and preferences.

. All women aged 50 to 74 years should undergo screening HIV with CD4 cell count <200 cells/gL or CD4 cells <15% of total lymphocytesu mammography; the recommended screening interval lmmunosuppressant therapy, including high-dose varies by expert group. glucocorticoids (>20 mg/d of prednisone or equivalent {or >2 wk) . The ACP recommends screening for colorectal cancer in Leukemia, lymphoma, or other bone marrow and lymphatic asymptomatic adults aged 50 to 75 years (grade A); in system malignancies contrast, the USPSTF and the American Cancer Society I Cellular immunodeficiency (ACS) make a qualified recommendation to initiate Solid-organ transplant recipient screening for colorectal cancer at age 45 years. Recent hematopoietic stem cell transplantation o The choice of modality for colorectal cancer screening "Live attenuated influenza vaccine is contraindicated in patients with HIV infection should be based on discussion with patients, including consideration of likelihood of adherence and patient [':"1':: "'i"1:"""'": . _ values and preferences. live attenuated influenza vaccine is contraindicated in preg nancy and immunocompromised patients and should be used lmmunization with caution in patients with significant medical conditions. In the United States, annual immunization recommendations including cardiovascular, pulmonary or liver disease; dialysis- are issued by the Advisory Committee on Immunization dependent end stage kidney disease; or diabetes. A high dose Practices (ACIP). ACIP recommendations can be accessed at quadrivalent vaccine became available for the 2020-2021 'ar,r,rv. cdc. gov vacci nes aci p. influenza season for persons aged 65 years or older, replacing It is important to adhere to recommended vaccine sched- the high dose trivalent vaccine. No pref'erential recommenda ules as closely as possible. Administering doses at longer tion is made for one influenza vaccine over another in persons than-recommended intervals does not appear to reduce in whom more than one vaccine is appropriate. immunologic response; however, doses should not be given at Persons with a history of eg1 allergr of any severity can shorter than recommended intervals. If a vaccination series is receive any influenza vaccine formulation; however, in per interrupted, it can be resumed at the point of interruption. sons who have had an egg related reaction that caused symp Whenever possible, multiple vaccines should be given simul toms other than hives, such as angioedema or respiratory taneously to improve vaccination rates. distress, the vaccine should be administered by a provider Vaccines can be safely administered to patients with mild trained in recognizing and managing severe allergic reactions. acute febrile illness, those who are convalescing from illness, Persons with a history ol Guillain Barrd syndrome related to and those who have previously developed low- or moderate previous influenza vaccination should not receive additional grade fever or local reactions with vaccination. Vaccines influenza vaccination. should be avoided if there is a history of anaphylaxis to the vaccine or the vaccine components. Live vaccines and their Tetanus, Diphtheria, and Pertussis contraindications are listed in Table lO. Primary vaccination against tetanus, diphtheria, and acellular pertussis consists of a five dose vaccine series administered Vaccinations Recommended for Al I Adults during childhood. Persons aged ll to 18 years who have com- Influenza pleted the primary series should receive a single dose of the Influenza revaccination is necessary each year, owing to fre tetanus toxoid, reduced diphtheria toxoid, and acellular per quent genetic changes in the influenza virus (antigenic drift). tussis (Tdap) vaccine. Adults aged 19 years or older who did not Annual vaccination is recommended for all individuals aged receive the Tdap vaccine at age 11 years or older should receive 6 months or older. The influenza vaccine should be adminis one dose of the Tdap vaccine. In adults who did not receive tered as soon as it becomes available, preferably by October. Tdap at or after age 11 years, one dose ofTdap, then Td or Tdap, but can be given at any time during the influenza season. The is recommended every 10 years.

live attenuated influenza vaccine is contraindicated in preg nancy and immunocompromised patients and should be used lmmunization with caution in patients with significant medical conditions. In the United States, annual immunization recommendations including cardiovascular, pulmonary or liver disease; dialysis- are issued by the Advisory Committee on Immunization dependent end stage kidney disease; or diabetes. A high dose Practices (ACIP). ACIP recommendations can be accessed at quadrivalent vaccine became available for the 2020-2021 'ar,r,rv. cdc. gov vacci nes aci p. influenza season for persons aged 65 years or older, replacing It is important to adhere to recommended vaccine sched- the high dose trivalent vaccine. No pref'erential recommenda ules as closely as possible. Administering doses at longer tion is made for one influenza vaccine over another in persons than-recommended intervals does not appear to reduce in whom more than one vaccine is appropriate. immunologic response; however, doses should not be given at Persons with a history of eg1 allergr of any severity can shorter than recommended intervals. If a vaccination series is receive any influenza vaccine formulation; however, in per interrupted, it can be resumed at the point of interruption. sons who have had an egg related reaction that caused symp Whenever possible, multiple vaccines should be given simul toms other than hives, such as angioedema or respiratory taneously to improve vaccination rates. distress, the vaccine should be administered by a provider Vaccines can be safely administered to patients with mild trained in recognizing and managing severe allergic reactions. acute febrile illness, those who are convalescing from illness, Persons with a history ol Guillain Barrd syndrome related to and those who have previously developed low- or moderate previous influenza vaccination should not receive additional grade fever or local reactions with vaccination. Vaccines influenza vaccination. should be avoided if there is a history of anaphylaxis to the vaccine or the vaccine components. Live vaccines and their Tetanus, Diphtheria, and Pertussis contraindications are listed in Table lO. Primary vaccination against tetanus, diphtheria, and acellular pertussis consists of a five dose vaccine series administered Vaccinations Recommended for Al I Adults during childhood. Persons aged ll to 18 years who have com- Influenza pleted the primary series should receive a single dose of the Influenza revaccination is necessary each year, owing to fre tetanus toxoid, reduced diphtheria toxoid, and acellular per quent genetic changes in the influenza virus (antigenic drift). tussis (Tdap) vaccine. Adults aged 19 years or older who did not Annual vaccination is recommended for all individuals aged receive the Tdap vaccine at age 11 years or older should receive 6 months or older. The influenza vaccine should be adminis one dose of the Tdap vaccine. In adults who did not receive tered as soon as it becomes available, preferably by October. Tdap at or after age 11 years, one dose ofTdap, then Td or Tdap, but can be given at any time during the influenza season. The is recommended every 10 years. 12

Routine Care of the Healthy Patient Unvaccinated adults should receive a three-dose series decision making in patients with HIV infection and a CD,l cell consisting of Td or Tdap, with at least one Tdap dose (pref'era count of 200 cells/trrL or greater. bly as the first dose). Adults who have received fewer than All adults aged 50 years or older, including those with a three doses of the primary series should complete the series previous episode of zoster, should receive the recombinant with the Td or Tdap vaccine, while ensuring that at least one (inactivated) herpes zoster vaccine to reduce the incidence o1' dose ofthe Tdap vaccine is received. zoster and postherpetic neuralgia. The recombinant vaccine is Pregnant women should receive at least one dose of the administered intramuscularly in two doses, with an interval of Tdap vaccine between 27 and 36 weeks' gestation with every 2 to 6 months between doses. Vaccination is recommended pregnancy. regardless of previous zoster inf'ection or vaccination with the live vaccine. The safety of the vaccines in pregnant women has Vaccinations Recommended for Some Adults not been determined. and the ACIP recommends delaying Varicella and Herpes Zoster immunization in pregnant women. Use of the lir,e attenuated All immunocompetent adults without evidence of varicella vaccine in individuals with HIV infection and a CD,l count less immunity should receive two varicella vaccine doses. Evidence than 200 pr L is under revicw. of varicella immunity includes laboratory confirmed disease or immunity, diagnosis or verificaticln of varicella or zoster by Pneumococcal Disease a provider, or documentation of age appropriate varicella vac Pneumococcal vaccination is recommended in all adults aged cination. U.S. birth before 1980 is also considered to be evi 65 years or older and in adults aged 19 to 64 years with certain dence of immuniry except in pregnant women and immuno high risk conditions (Table 1l). Two pneumococcal vaccines compromised persons (who are at risk fbr severe disease) and are available: the 13 valent conjugate vaccine (PCV13) and the health care workers (who are at risk for repeated varicella 23 valent polysaccharide vaccine (PPSV23). exposure and spreading the disease to those at high risk fbr All adults aged 65 years or older who have not previously severe disease). These patient groups must meet the other been vaccinated should receive PPSV23. In 2019. ACIP recom criteria for varicella immunity. Although varicella vaccination mended shared decision making regarding the use ol PCVlll is contraindicated in patients with severe immunosuppres lbr healthy adults aged 65 years or older. lf PCV13 is given, it sion, it can be considered on the basis of shared clinical should be administered at age 65 years, fbllowed one year later

Unvaccinated adults should receive a three-dose series decision making in patients with HIV infection and a CD,l cell consisting of Td or Tdap, with at least one Tdap dose (pref'era count of 200 cells/trrL or greater. bly as the first dose). Adults who have received fewer than All adults aged 50 years or older, including those with a three doses of the primary series should complete the series previous episode of zoster, should receive the recombinant with the Td or Tdap vaccine, while ensuring that at least one (inactivated) herpes zoster vaccine to reduce the incidence o1' dose ofthe Tdap vaccine is received. zoster and postherpetic neuralgia. The recombinant vaccine is Pregnant women should receive at least one dose of the administered intramuscularly in two doses, with an interval of Tdap vaccine between 27 and 36 weeks' gestation with every 2 to 6 months between doses. Vaccination is recommended pregnancy. regardless of previous zoster inf'ection or vaccination with the live vaccine. The safety of the vaccines in pregnant women has Vaccinations Recommended for Some Adults not been determined. and the ACIP recommends delaying Varicella and Herpes Zoster immunization in pregnant women. Use of the lir,e attenuated All immunocompetent adults without evidence of varicella vaccine in individuals with HIV infection and a CD,l count less immunity should receive two varicella vaccine doses. Evidence than 200 pr L is under revicw. of varicella immunity includes laboratory confirmed disease or immunity, diagnosis or verificaticln of varicella or zoster by Pneumococcal Disease a provider, or documentation of age appropriate varicella vac Pneumococcal vaccination is recommended in all adults aged cination. U.S. birth before 1980 is also considered to be evi 65 years or older and in adults aged 19 to 64 years with certain dence of immuniry except in pregnant women and immuno high risk conditions (Table 1l). Two pneumococcal vaccines compromised persons (who are at risk fbr severe disease) and are available: the 13 valent conjugate vaccine (PCV13) and the health care workers (who are at risk for repeated varicella 23 valent polysaccharide vaccine (PPSV23). exposure and spreading the disease to those at high risk fbr All adults aged 65 years or older who have not previously severe disease). These patient groups must meet the other been vaccinated should receive PPSV23. In 2019. ACIP recom criteria for varicella immunity. Although varicella vaccination mended shared decision making regarding the use ol PCVlll is contraindicated in patients with severe immunosuppres lbr healthy adults aged 65 years or older. lf PCV13 is given, it sion, it can be considered on the basis of shared clinical should be administered at age 65 years, fbllowed one year later PCVI 3 PPSV23 Risk Group UnderlyingMedicalCondition Recommended Recommended Revaccinationat 5 Years After First Dose

PCVI 3 PPSV23 Risk Group UnderlyingMedicalCondition Recommended Recommended Revaccinationat 5 Years After First Dose lmmunocompetent persons Chronic heart disease" X Chronic lung diseaseb X Diabetes mellitus X CSF leaks X X Cochlear implants X X Alcoholism X Chronic liver disease X Cigarette smoking X Persons with {unctional or Sickle cell disease/other X X X anatomic asplenia hemog lobinopathies Congenital or acquired asplenia X X X lmmunocompromised persons' X X X CSF = cereb,rospinal fluid; PCVl 3 = 1 3 valent pneumococcal conjugate vaccine; PPSV23 23 va ent pneumococcal polysaccharide vacc ne 'lncluding heart {ailure and cardiomyopathies. t ncluding COPD, emphysema, and asthma. and phagocytii disorders Iexcluding chronic granulomatous disease]); HIV nfectron; chron c kidney failure; nephrotic syndrome; leukemia; lymphoma; Hodgkin lymphoma; radiation therapy); solid-organ transplant; multiple rnyeloma. adultswithimmunocompromisngconditions: recommendationsof theAdvisoryCommlfteeonlmmunizationPractices(ACIP).MMWRMorbMorta WklyRep.2012;61:816'9. IPMID:230516121 13

Routine Care of the Healthy Patient by PPSV23. This recommendation does not change the recom immunity should be vaccinated. Pregnant women who lack nrendations regarding use of PPSV23 and PCV13 in high-risk immunity should be vaccinated at the time of delivery before patients aged 19 to 64 years. Among high risk patients who leaving the hospital or at the tinle of pregnancy termination. require vaccination with both PCVI3 and PPSV23 but who The MMR vaccine is a live virus vaccine and should not be have not yet received either vaccine, a single dose <lf PCV13 administered to immunocompromised individuals or preg- should be given first, followed by a single dose of PPSV23 given n:lnt women. at least B weeks later. Adults aged 19 to 64 years with high risk cc.rnditions who require vaccinatiol.t with both PCV13 and Meningococcal Disease PPSV23 and who have already received PPSV23 should be Meningococcal vaccines used in the adult population adn.rinistered a single dose of PCV13 no sooner than 1 year af ter include the quadrivalent meningococcal conjugate vaccine receiving the most recent PPSV23. A second dose of PPSV23 (MenACWY). which protects against serogroups A' C' W135. shriuld also be administered 5 years after the first PPSV23 dose and Y. and the meningococcal group B (MenB) vaccine' in adults aged 19 to 64 years with certain immunocomprolllis which protects against serogroup B disease' MenACWY is ing conditions (see Table 11). recommended in adolescents aged 11 to 18 years' If the patient was vaccinated at age 1l to 12 years (preferred), a Human Papillomavirus booster dose is administered at age 16 lears; if the initial H PV vaccination prevents persistent FIPV infection, which can dose was administered at age 13 to 15 years, a booster dose lead to cervical, anogenital, and nasopharyngeal cancers. A is administered at 16 to 18 years. A booster dose may be nine valent HPV vaccine is available and approved for use in administered to persons aged 19 to 2l years who did not both f'emales and males. Patients should be administered the receive a dose after age 16 years. ll the first dose is adminis vaccine series at age 11 or 12 years or between the ages of13 and tered after age 16 years, a booster dose is not required. First 26 years ifnot given previously. In unvaccinated patients aged year college students living ir.r residence halls should receive 27 lo 45 years, vaccination can be cor.tsidered on the basis of at least one dose of MenACWY within 5 years before college risk, using a shared decision making process. If administered entry. MenACWY vaccines are interchangeable. Routine befbre the age of 15 years, a two dose series is recommended. two dose series of MenB can be administered at age 16 to where:rs a three-dose series is recommended in older indi. 23 years on basis of shared clinical decision making. A viduals. Vaccination is not recommended during pregnancy, booster dose is not recommended unless the patient devel although no harmful eff'ects have been noted when inadver ops increased risk for meningococcal disease. MenB vac' tently given to pregnant women and pregnancy testing is not cines are not interchangeable and dosing schedules differ. lrecessilry befbre vaccination. Indications for meningococcal vaccination in adults at increased risk are summarized in Table 12. Measles, Mumps, and Rubella All U.S. adults born before 1957 are considered immune tcr Hepatitis A measles and mumps. Adults born in 1957 or later without Vaccination against hepatitis A is recommended for all persons : documented evidence of receiving one or more doses of the who desire vaccination and fbr persons who are at increased measles, mumps, and rubella (MMR) vaccine or laboratory risk lbr infection or complications of infection, including : confirmed immunity against all tl-rree diseases should receive pregnant women. Persons at increased risk include those who at least one MMR dose. A second MMR dose should be admir.r work in or travel to endemic areas. men who have sex with istered to postsecondary students. household or close personal men. individuals with chronic liver disease, individuals with contacts of immunocompromised persons with no evidence of l'llV infection, users of injection or noninjection illicit drugs, imnlunity. and international travelers. For persons who have homeless persons. persons who conduct hepatitis A related been previously vaccinated with two doses of a mumps virus research, household or close contacts of children adopted containing vaccine but are :rt increased risk because of an fiom endemic areas, and those who work in settings of possi I

by PPSV23. This recommendation does not change the recom immunity should be vaccinated. Pregnant women who lack nrendations regarding use of PPSV23 and PCV13 in high-risk immunity should be vaccinated at the time of delivery before patients aged 19 to 64 years. Among high risk patients who leaving the hospital or at the tinle of pregnancy termination. require vaccination with both PCVI3 and PPSV23 but who The MMR vaccine is a live virus vaccine and should not be have not yet received either vaccine, a single dose <lf PCV13 administered to immunocompromised individuals or preg- should be given first, followed by a single dose of PPSV23 given n:lnt women. at least B weeks later. Adults aged 19 to 64 years with high risk cc.rnditions who require vaccinatiol.t with both PCV13 and Meningococcal Disease PPSV23 and who have already received PPSV23 should be Meningococcal vaccines used in the adult population adn.rinistered a single dose of PCV13 no sooner than 1 year af ter include the quadrivalent meningococcal conjugate vaccine receiving the most recent PPSV23. A second dose of PPSV23 (MenACWY). which protects against serogroups A' C' W135. shriuld also be administered 5 years after the first PPSV23 dose and Y. and the meningococcal group B (MenB) vaccine' in adults aged 19 to 64 years with certain immunocomprolllis which protects against serogroup B disease' MenACWY is ing conditions (see Table 11). recommended in adolescents aged 11 to 18 years' If the patient was vaccinated at age 1l to 12 years (preferred), a Human Papillomavirus booster dose is administered at age 16 lears; if the initial H PV vaccination prevents persistent FIPV infection, which can dose was administered at age 13 to 15 years, a booster dose lead to cervical, anogenital, and nasopharyngeal cancers. A is administered at 16 to 18 years. A booster dose may be nine valent HPV vaccine is available and approved for use in administered to persons aged 19 to 2l years who did not both f'emales and males. Patients should be administered the receive a dose after age 16 years. ll the first dose is adminis vaccine series at age 11 or 12 years or between the ages of13 and tered after age 16 years, a booster dose is not required. First 26 years ifnot given previously. In unvaccinated patients aged year college students living ir.r residence halls should receive 27 lo 45 years, vaccination can be cor.tsidered on the basis of at least one dose of MenACWY within 5 years before college risk, using a shared decision making process. If administered entry. MenACWY vaccines are interchangeable. Routine befbre the age of 15 years, a two dose series is recommended. two dose series of MenB can be administered at age 16 to where:rs a three-dose series is recommended in older indi. 23 years on basis of shared clinical decision making. A viduals. Vaccination is not recommended during pregnancy, booster dose is not recommended unless the patient devel although no harmful eff'ects have been noted when inadver ops increased risk for meningococcal disease. MenB vac' tently given to pregnant women and pregnancy testing is not cines are not interchangeable and dosing schedules differ. lrecessilry befbre vaccination. Indications for meningococcal vaccination in adults at increased risk are summarized in Table 12. Measles, Mumps, and Rubella All U.S. adults born before 1957 are considered immune tcr Hepatitis A measles and mumps. Adults born in 1957 or later without Vaccination against hepatitis A is recommended for all persons : documented evidence of receiving one or more doses of the who desire vaccination and fbr persons who are at increased measles, mumps, and rubella (MMR) vaccine or laboratory risk lbr infection or complications of infection, including : confirmed immunity against all tl-rree diseases should receive pregnant women. Persons at increased risk include those who at least one MMR dose. A second MMR dose should be admir.r work in or travel to endemic areas. men who have sex with istered to postsecondary students. household or close personal men. individuals with chronic liver disease, individuals with contacts of immunocompromised persons with no evidence of l'llV infection, users of injection or noninjection illicit drugs, imnlunity. and international travelers. For persons who have homeless persons. persons who conduct hepatitis A related been previously vaccinated with two doses of a mumps virus research, household or close contacts of children adopted containing vaccine but are :rt increased risk because of an fiom endemic areas, and those who work in settings of possi I outbreak, the ACIP recommends administering a third dose of ble exposure (group homes, nonresidential day care facilities munlps virus containing vaccine to improve protection. fbr developmentally disabled persons, and health care pro- : []ealth care workers should be considered separately. For grams serving users of injection or noninjection drugs). those who',tere born in or after 1957 and who lack evidence of Immunization can be provided as a two dose series of single immunity to measles, mumps, or rubella, a two dose MMR antigen hepatitis A vaccine or a three dose series of combina- i : series, with at least 4 weeks between doses, should be admir.r tion hepdtitis A and B vuccine. istered fbr measles or mumps intmunity, whereas at least a sir.rgle dose should be administered fbr rubella immunity. The Hepatitis B srrme irdministration schedule should be considered in health Hepatitis B vaccination is recomnrended for any nonimmune care workers born before 1957. adult who desires vaccination or who is considered to be at high :

outbreak, the ACIP recommends administering a third dose of ble exposure (group homes, nonresidential day care facilities munlps virus containing vaccine to improve protection. fbr developmentally disabled persons, and health care pro- : []ealth care workers should be considered separately. For grams serving users of injection or noninjection drugs). those who',tere born in or after 1957 and who lack evidence of Immunization can be provided as a two dose series of single immunity to measles, mumps, or rubella, a two dose MMR antigen hepatitis A vaccine or a three dose series of combina- i : series, with at least 4 weeks between doses, should be admir.r tion hepdtitis A and B vuccine. istered fbr measles or mumps intmunity, whereas at least a sir.rgle dose should be administered fbr rubella immunity. The Hepatitis B srrme irdministration schedule should be considered in health Hepatitis B vaccination is recomnrended for any nonimmune care workers born before 1957. adult who desires vaccination or who is considered to be at high : Ir.r women of childbearing age, it is necessary to deter risk for infection (Table 13). The typical hepatitis B vaccination : mir.re rubella immunity. Nonpregnant women who lack series is a three dose series, with doses administered at 0, l, and 14

Routine Care of the Healthy Patient TABLE 1 2 lndications for Meningococcal Vaccination in Adults with lncreased Risk for Meningococcal Disease Population MenACWY MenB Persistent complement component Primary vaccination followed by booster Primary vaccination followed by booster deficiencies (C5-C9, faaor H, factor D, every 5 y 1 y later and every 2-3 y thereafter properdin) or persons taking complement inhibitors (e.9, eculizumab or ravulizumab) Functional or anatomic asplenia (including Primary vaccination followed by booster Primary vaccination followed by booster sickle cell disease) every 5 y 1 y later and every 2-3 y thereafter HIV infection Primary vaccination followed by booster Same as general population every 5 y Microbiologists routinely exposed to Primary vaccination followed by booster Primary vaccination followed by booster Nelsseria me ni ngitid is every 5 y 1 y laterand every 2-3 ythereafter

HIV infection Primary vaccination followed by booster Same as general population every 5 y Microbiologists routinely exposed to Primary vaccination followed by booster Primary vaccination followed by booster Nelsseria me ni ngitid is every 5 y 1 y laterand every 2-3 ythereafter Exposure to vaccine-preventable Single dose if >5 y since vaccination Primary vaccination; booster if >1 y since serogroup meningococcal disease primary series outbreak Travel or residence in country with Primary vaccination followed by booster Same as general population hyperendemic or epidemic every 5 y meningococcal disease College freshmen living in residence halls Primary vaccination Same as general population Military recruits Primary vaccination followed by booster Same as general population every 5 y (depending on military assignment) MenACWY = meningococcal groups A, C, W and Y; MenB = meningococcal group B. AdaptedfromMbaeyiSA,BozioCH,DuffyJ,etal Meningococcalvaccination:recommendationso{theAdvisoryCommitteeonlmmunizationPractices,UnitedStates,2020. MMWR Recomm Rep. 2020;69:1 4 1 . IPMID: 3341 7592] doi: 1 0.1 5585/mmwr.rr6909a 1 I

MenACWY = meningococcal groups A, C, W and Y; MenB = meningococcal group B. AdaptedfromMbaeyiSA,BozioCH,DuffyJ,etal Meningococcalvaccination:recommendationso{theAdvisoryCommitteeonlmmunizationPractices,UnitedStates,2020. MMWR Recomm Rep. 2020;69:1 4 1 . IPMID: 3341 7592] doi: 1 0.1 5585/mmwr.rr6909a 1 I \ 6 months. A vaccine with a novel adjuvant requires only fwo TABLE 13. Populations With an lndication for i Hepatitis B Vaccination doses administered at least 4 weeks apart; it appears to be more I Any nonimmune adult desiring vaccination immunogenic than previous vaccines. Safety data for use of the I two dose vaccine in pregnant women is not available. Sexually active persons who are not in a monogamous I

\ 6 months. A vaccine with a novel adjuvant requires only fwo TABLE 13. Populations With an lndication for i Hepatitis B Vaccination doses administered at least 4 weeks apart; it appears to be more I Any nonimmune adult desiring vaccination immunogenic than previous vaccines. Safety data for use of the I two dose vaccine in pregnant women is not available. Sexually active persons who are not in a monogamous I L relationship (any person with more than one sexual partner Checking serum antibodies is not typically recommended within the past 6 mo) after routine vaccination but is indicated in persons in whom t Sexual partners of persons who are HBsAg positive subsequent clinical management is dependent on knowledge I L Men who have sex with men of serologic response (e.g., patients on chronic hemodialysis, persons with HIV health care and public saf'ety workers, and I Household contacts of persons who are HBsAg positive needle sharing partners of persons who are positive for hepa Residents and staff members of institutions for persons who I titis B surface antigen). t are developmentally disabled I t Persons who are current or recent users of injection drugs Health care and public safety workers with anticipated risk for Vaccinations Recommended for I I exposure Specific Populations Persons with end-stage kidney disease, including those Health care workers are at increased risk fbr acquiring and L receiving hemodialysis and peritoneal dialysis transmitting hepatitis B, influenza, measles, mumps, I L lnternational travelers to regions with intermediate or high rubella, pertussis, and varicella. All health care workers, I levels of endemic hepatitis B infection regardless ol patient contact, should receive the influenza t Persons with chronic liver disease vaccine annually. Health care workers without immunity i L Persons with HIV infection should be vaccinated against hepatitis B; measles, mumps, I Pregnant patients with risk for infeaion or serious outcome and rubella; and varicella. In addition, all health care work L from infection. ers who have not previously received the Tdap vaccine I I Persons with diabetes mellitus who are aged <60 y should receive one dose, irrespective of when they last received the Td vaccine. Persons with diabetes mellitus who are aged )60 y, on the basis t I

L relationship (any person with more than one sexual partner Checking serum antibodies is not typically recommended within the past 6 mo) after routine vaccination but is indicated in persons in whom t Sexual partners of persons who are HBsAg positive subsequent clinical management is dependent on knowledge I L Men who have sex with men of serologic response (e.g., patients on chronic hemodialysis, persons with HIV health care and public saf'ety workers, and I Household contacts of persons who are HBsAg positive needle sharing partners of persons who are positive for hepa Residents and staff members of institutions for persons who I titis B surface antigen). t are developmentally disabled I t Persons who are current or recent users of injection drugs Health care and public safety workers with anticipated risk for Vaccinations Recommended for I I exposure Specific Populations Persons with end-stage kidney disease, including those Health care workers are at increased risk fbr acquiring and L receiving hemodialysis and peritoneal dialysis transmitting hepatitis B, influenza, measles, mumps, I L lnternational travelers to regions with intermediate or high rubella, pertussis, and varicella. All health care workers, I levels of endemic hepatitis B infection regardless ol patient contact, should receive the influenza t Persons with chronic liver disease vaccine annually. Health care workers without immunity i L Persons with HIV infection should be vaccinated against hepatitis B; measles, mumps, I Pregnant patients with risk for infeaion or serious outcome and rubella; and varicella. In addition, all health care work L from infection. ers who have not previously received the Tdap vaccine I I Persons with diabetes mellitus who are aged <60 y should receive one dose, irrespective of when they last received the Td vaccine. Persons with diabetes mellitus who are aged )60 y, on the basis t I of shared clinical decision making Patients with anatomic or functional asplenia are at ! I lncarcerated persons increased risk for infection from encapsulated organisms. t such as Haemophilus inJ'luenzae type B, meningococcus, and i HBsAg = hepatitis B surface antrgen. L pneumococcus, and should be appropriately vaccinated. I i 15

Routine Care of the Healthy Patient Pirtients who have undergone hematopoietic stem cell prevention of ASCVD because of lack of net benefit; sPecifi transplantation should receive lhe Haemophilus influenzae cally. low dose aspirin may be considered for primary preven type B vaccine. ti<-rn of ASCVD in adults aged 40 to 70 years who are at higher Vaccination recommendations tbr international travelers ASCVD risk but not at increased bleeding risk. Similarly, the vary depending on the destination. 1'rip specific recommen ADA reaffirmed its recommendations in 2019 that low-dose dations from the CDC can be accessed at wr,vwnc.cdc.gov/ aspirin may be considered in patients with diabetes who are at travel. For more information on vaccination in travelers, see i ncreased cardiovascular risk.

Vaccination recommendations tbr international travelers ASCVD risk but not at increased bleeding risk. Similarly, the vary depending on the destination. 1'rip specific recommen ADA reaffirmed its recommendations in 2019 that low-dose dations from the CDC can be accessed at wr,vwnc.cdc.gov/ aspirin may be considered in patients with diabetes who are at travel. For more information on vaccination in travelers, see i ncreased cardiovascular risk. MKSAP 19 Infectious Disease. The decision to initiate low dose aspirin should be infbrmed by the totality of ASCVD risk and bleeding risk as l(EY P0lilTS well as patient values and pref'erences. Factors that increase . Annual influenza vaccination is recommended for all bleeding risk include concurrent anticoagulant or NSAID use, individuals aged 6 months or older. history of gastrointestinal ulcer, upper gastrointestinal pain, . Pregnant women should receive at least one dose of the uncontrolled hypertension, male sex, and increasing age. After tetanus toxoid, reduced diphtheria toxoid, and acellular age 70 years, the benefit of aspirin decreases and bleeding pertussis vaccine between 27 and 36 weeks' gestation risks are higher; thus, neither the ACC/AHA nor the ADA rec with every pregnancy. ommends aspirin for primary prevention in this age group. . All adults aged 50 years or older should receive the There is some evidence for the use of aspirin in cancer recombinant (inactivated) herpes zoster vaccine, prevention. lvith one trial showing a 34'X, to 407, reduction in regardless of previous immunization or clinical infec crilorectal cancer mortality with at least 5 to 10 years of aspirin tion, to reduce the incidence ofzoster and postherpetic therapy. The benefit is not apparent until 10 to 20 years aFter neuralgia. initiation of aspirinr no mortality benefit was observed in the o Pneumococcal vaccination is recommended in all adults first 10 years offollow up. Prophylactic aspirin use is :rlso recommended for preg aged os years or older and adults aged 19 to 64 years with nant women at high risk for preeclampsia and should be certain high risk conditions. considered in those at moderate risk (see Women's Health). r Patients with anatomic or functional asplenia should be vaccinated against Haemophilus influenzae type B, meningococcal, and pneumococcal diseases. Healthy Lifestyle Counseling tlealthy lif'estyle counseling is directed at the leading prevent able causes of death. Tobacco and obesity contribute signiti Aspirin for Primary Prevention cantly to the top two leading causes ofdeath. heart disease and Because of its low cost and eflicacy ir.r preventing cardiovas cancer, which account for almost 50'){, ol all deaths in the cullr and cerebrovascular events, aspirin can be considered United States. Other preventable causes of death include alco fbr primary prevention of vascular disease. In 2016, the hol and drug use, infectious diseases, toxins, accidents, and USPSTF recommended low dose aspirin tbr the primary pre firearms. vention of ASCVD and colorectal cancer in willing adults aged Tobacco cessation is a high priority intervention fiom a 50 to 59 years with a 10 year ASCVD risk of 10')(, or higher health and cost effectiveness standpoint. Smokers should be (using the Pooled Cohort Equation risk calculator). a life ofl'ered pharmacologic therapy and behavioral interv'entions. expectancy of at least 10 years. ancl no increased risk for For more information. see MKSAP 19 General Internal bleeding (grade B). The USPSTF suggests individualizing the Medicine 1. decision in adults aged 60 to 69 years with a 10 year ASCVD All patients who are overweight or obese should undergo risk o1 10'1, or higher (grade C). counseling on the benefits of a healthy weight, regular exer In 2018, however, three large trials, ASCEND, ARRIVE, cise, and a healthy diet (see Behavioral Counseling). ancl ASPREE, showed that primary prevention with aspirin led lnjury prevention, including seat belt use, use of safety to no reduction in nonfatal myocardial infarction or mortality. helmets lbr motorcycles and bicycles, and home safety meas In 2019, a meta analysis of the use of aspirin for primary pre ures, should be emphasized. Patients should be counseled to ventiolr was updated; it included nrore than 164,000 patients use smoke alarms in the home and to set water heaters to and showed no benefit in any mortality end point. Reductions lower than 49 "C (l2o "F) in households with infants or young ir.r nonfatal myocardial inlarction (relative risk [RR]. 0.82; children (see Table 1). O.72 O.94) and ischemic stroke (RR. O.B7: O.79 0.95) were Even small changes at the population level, such as ofliet by a significant increase in bleeding events. including improving social determinants of health, can create large pre r.r'rajor bleeding (RR. 1.5; 1.33 1.69). intracranial bleeding (RR, ventive benefits. Healthy People 2020 is a CDC initiative with l|\2:1.12 1.55), and major gastrointestinal bleeding (RR, 1.52; the goal of creating social and physical environments that 1.34 1.73). Subsequently, the ACC/AHA recommended that promote good health, and Healthy People 2030 is currently in aspirir-r sl-rould be used inftequently in the routine primary development. Using strategies ftorr-r bel-ravioral econor-r-r ics,

MKSAP 19 Infectious Disease. The decision to initiate low dose aspirin should be infbrmed by the totality of ASCVD risk and bleeding risk as l(EY P0lilTS well as patient values and pref'erences. Factors that increase . Annual influenza vaccination is recommended for all bleeding risk include concurrent anticoagulant or NSAID use, individuals aged 6 months or older. history of gastrointestinal ulcer, upper gastrointestinal pain, . Pregnant women should receive at least one dose of the uncontrolled hypertension, male sex, and increasing age. After tetanus toxoid, reduced diphtheria toxoid, and acellular age 70 years, the benefit of aspirin decreases and bleeding pertussis vaccine between 27 and 36 weeks' gestation risks are higher; thus, neither the ACC/AHA nor the ADA rec with every pregnancy. ommends aspirin for primary prevention in this age group. . All adults aged 50 years or older should receive the There is some evidence for the use of aspirin in cancer recombinant (inactivated) herpes zoster vaccine, prevention. lvith one trial showing a 34'X, to 407, reduction in regardless of previous immunization or clinical infec crilorectal cancer mortality with at least 5 to 10 years of aspirin tion, to reduce the incidence ofzoster and postherpetic therapy. The benefit is not apparent until 10 to 20 years aFter neuralgia. initiation of aspirinr no mortality benefit was observed in the o Pneumococcal vaccination is recommended in all adults first 10 years offollow up. Prophylactic aspirin use is :rlso recommended for preg aged os years or older and adults aged 19 to 64 years with nant women at high risk for preeclampsia and should be certain high risk conditions. considered in those at moderate risk (see Women's Health). r Patients with anatomic or functional asplenia should be vaccinated against Haemophilus influenzae type B, meningococcal, and pneumococcal diseases. Healthy Lifestyle Counseling tlealthy lif'estyle counseling is directed at the leading prevent able causes of death. Tobacco and obesity contribute signiti Aspirin for Primary Prevention cantly to the top two leading causes ofdeath. heart disease and Because of its low cost and eflicacy ir.r preventing cardiovas cancer, which account for almost 50'){, ol all deaths in the cullr and cerebrovascular events, aspirin can be considered United States. Other preventable causes of death include alco fbr primary prevention of vascular disease. In 2016, the hol and drug use, infectious diseases, toxins, accidents, and USPSTF recommended low dose aspirin tbr the primary pre firearms. vention of ASCVD and colorectal cancer in willing adults aged Tobacco cessation is a high priority intervention fiom a 50 to 59 years with a 10 year ASCVD risk of 10')(, or higher health and cost effectiveness standpoint. Smokers should be (using the Pooled Cohort Equation risk calculator). a life ofl'ered pharmacologic therapy and behavioral interv'entions. expectancy of at least 10 years. ancl no increased risk for For more information. see MKSAP 19 General Internal bleeding (grade B). The USPSTF suggests individualizing the Medicine 1. decision in adults aged 60 to 69 years with a 10 year ASCVD All patients who are overweight or obese should undergo risk o1 10'1, or higher (grade C). counseling on the benefits of a healthy weight, regular exer In 2018, however, three large trials, ASCEND, ARRIVE, cise, and a healthy diet (see Behavioral Counseling). ancl ASPREE, showed that primary prevention with aspirin led lnjury prevention, including seat belt use, use of safety to no reduction in nonfatal myocardial infarction or mortality. helmets lbr motorcycles and bicycles, and home safety meas In 2019, a meta analysis of the use of aspirin for primary pre ures, should be emphasized. Patients should be counseled to ventiolr was updated; it included nrore than 164,000 patients use smoke alarms in the home and to set water heaters to and showed no benefit in any mortality end point. Reductions lower than 49 "C (l2o "F) in households with infants or young ir.r nonfatal myocardial inlarction (relative risk [RR]. 0.82; children (see Table 1). O.72 O.94) and ischemic stroke (RR. O.B7: O.79 0.95) were Even small changes at the population level, such as ofliet by a significant increase in bleeding events. including improving social determinants of health, can create large pre r.r'rajor bleeding (RR. 1.5; 1.33 1.69). intracranial bleeding (RR, ventive benefits. Healthy People 2020 is a CDC initiative with l|\2:1.12 1.55), and major gastrointestinal bleeding (RR, 1.52; the goal of creating social and physical environments that 1.34 1.73). Subsequently, the ACC/AHA recommended that promote good health, and Healthy People 2030 is currently in aspirir-r sl-rould be used inftequently in the routine primary development. Using strategies ftorr-r bel-ravioral econor-r-r ics, 16

Routine Care of the Healthy Patient such as making healthy choices the default option or nudging TABLE 14. Motivational lnterviewing (gently steering people in a cefiain direction), may improve Engage health outcomes. For example, upon building construction, Obtain a genuine understanding of the patient's behavior in stairs can be placed front and center and elevators on the side. a nonjudgmental way. Sugar and sodium-laden processed foods shelved at store Reflect back what the patient says, using slightly different checkouts can be replaced with fresh fruits and vegetables. wording, to facilitate understanding and establish rapport. t Keeping healthy food options in clear containers at home and Avoid making assumptions aboutthe patient's motivation. wrapping unhealthier options in aluminum foil, or not pur Focus chasing them altogether, may also be helpful. Pricing and taxation strategies and food stamp programs can help promote Listen and practice change talk(giving positive reasonsfor changing the behavior)versus sustain talk (explaining why the purchase of fruits and vegetables and deter the purchase of the patient mightwantto sustain the behavior). unhealthy processed foods, tobacco, and alcohol. Food banks Acknowledge sustain talkand gently encourage the patient and food pharmacies can also encourage the consumption of to elaborate during change talk: fruits and vegetables, especially in urban deserts. Making Elaborate: "Tell me more." "Yes, I see." neighborhoods and cities safer and improving bicycle lanes, Affirm: "You wantto be a good role model for your children." walking paths, and stairs may encourage physical activity and reduce inequalities in health. Reflect: "lt sounds like that really affected you." "You're going to start running again."

such as making healthy choices the default option or nudging TABLE 14. Motivational lnterviewing (gently steering people in a cefiain direction), may improve Engage health outcomes. For example, upon building construction, Obtain a genuine understanding of the patient's behavior in stairs can be placed front and center and elevators on the side. a nonjudgmental way. Sugar and sodium-laden processed foods shelved at store Reflect back what the patient says, using slightly different checkouts can be replaced with fresh fruits and vegetables. wording, to facilitate understanding and establish rapport. t Keeping healthy food options in clear containers at home and Avoid making assumptions aboutthe patient's motivation. wrapping unhealthier options in aluminum foil, or not pur Focus chasing them altogether, may also be helpful. Pricing and taxation strategies and food stamp programs can help promote Listen and practice change talk(giving positive reasonsfor changing the behavior)versus sustain talk (explaining why the purchase of fruits and vegetables and deter the purchase of the patient mightwantto sustain the behavior). unhealthy processed foods, tobacco, and alcohol. Food banks Acknowledge sustain talkand gently encourage the patient and food pharmacies can also encourage the consumption of to elaborate during change talk: fruits and vegetables, especially in urban deserts. Making Elaborate: "Tell me more." "Yes, I see." neighborhoods and cities safer and improving bicycle lanes, Affirm: "You wantto be a good role model for your children." walking paths, and stairs may encourage physical activity and reduce inequalities in health. Reflect: "lt sounds like that really affected you." "You're going to start running again." Wellness When reflecting, make a guess in the form of a statement.

such as making healthy choices the default option or nudging TABLE 14. Motivational lnterviewing (gently steering people in a cefiain direction), may improve Engage health outcomes. For example, upon building construction, Obtain a genuine understanding of the patient's behavior in stairs can be placed front and center and elevators on the side. a nonjudgmental way. Sugar and sodium-laden processed foods shelved at store Reflect back what the patient says, using slightly different checkouts can be replaced with fresh fruits and vegetables. wording, to facilitate understanding and establish rapport. t Keeping healthy food options in clear containers at home and Avoid making assumptions aboutthe patient's motivation. wrapping unhealthier options in aluminum foil, or not pur Focus chasing them altogether, may also be helpful. Pricing and taxation strategies and food stamp programs can help promote Listen and practice change talk(giving positive reasonsfor changing the behavior)versus sustain talk (explaining why the purchase of fruits and vegetables and deter the purchase of the patient mightwantto sustain the behavior). unhealthy processed foods, tobacco, and alcohol. Food banks Acknowledge sustain talkand gently encourage the patient and food pharmacies can also encourage the consumption of to elaborate during change talk: fruits and vegetables, especially in urban deserts. Making Elaborate: "Tell me more." "Yes, I see." neighborhoods and cities safer and improving bicycle lanes, Affirm: "You wantto be a good role model for your children." walking paths, and stairs may encourage physical activity and reduce inequalities in health. Reflect: "lt sounds like that really affected you." "You're going to start running again." Wellness When reflecting, make a guess in the form of a statement. Sleep and stress reduction are also components of a healthy Evoke lifesty4e. The AHA and the American Academy of Sleep Ir4edicine Help patient formulate and verbalize their new goals, what recommend that adults sleep at least 7 hours per night for opti they are hoping for, reasons to change, and what would be a good first step. mal health. Developing effective strategies for stress reduction is an important component of wellness and resiliency. Meditation, lf patient feels unable to express goals, hopes, and/or reasons to change, offer suggestions of what other patients mindfulness based stress reduction, exercise, spending time in have done in similar situations. nature, strong personal relationships, volunteering, community Plan involvement, cultivating hobbies, and spiritual activities are all Discuss specific aoals and resources to achieve goals associated with better health outcomes. Loneliness and social and parameters for monitoring progress and evaluating isolation have been associated with a 29% increase in coronary s u ccess.

Sleep and stress reduction are also components of a healthy Evoke lifesty4e. The AHA and the American Academy of Sleep Ir4edicine Help patient formulate and verbalize their new goals, what recommend that adults sleep at least 7 hours per night for opti they are hoping for, reasons to change, and what would be a good first step. mal health. Developing effective strategies for stress reduction is an important component of wellness and resiliency. Meditation, lf patient feels unable to express goals, hopes, and/or reasons to change, offer suggestions of what other patients mindfulness based stress reduction, exercise, spending time in have done in similar situations. nature, strong personal relationships, volunteering, community Plan involvement, cultivating hobbies, and spiritual activities are all Discuss specific aoals and resources to achieve goals associated with better health outcomes. Loneliness and social and parameters for monitoring progress and evaluating isolation have been associated with a 29% increase in coronary s u ccess. heart disease anda32% increase in stroke. ldentify barriers to success and make a plan to combat these Climate change could cause numerous deleterious effects barriers in advance. on human health, including higher rates of respiratory and heat related illness, skin cancer, increased prevalence ofvec tor-borne (malaria, chikungunya, dengue fever) and water additional risk factors for cardiovascular disease (hyperten- borne (cholera) diseases, food and water insecurig, and sion, dyslipidemia). For adults who do not meet these criteria, malnutrition. The ACP advises that physicians become edu- the USPSTF recommends an individualized approach to offer cated about climate change, its effect on human health, and ing or referring these patients to behavioral counseling to how to respond to future challenges. promote a healthy lifestyle, owing to smaller benefits (grade C). Behavior change is inherently difficult because it disrupts Behavioral Counseling the status quo and habits that may have developed over dec Behavioral counseling is an integral part of helping patients ades. Such strategies as motivational interviewing can be par optimize their health and habits. The USPSTF recommends ticularly effective in establishing a partnership to create using the 5 As for clinical counseling for patients regarding Iifestyle changes (Table 14). These techniques can help patients tobacco use and cessation: Ask the patient about tobacco use; identify feasible and desirable steps toward reaching goals. Advise the patient to quit through clear, personalized mes Other helpful strategies include habit replacement; pairing sages; Assess the patient's willingness to quit; Assist the (combining a less desirable activity with a more desirable one, patient with their attempt to quit; and Arrange for follow-up such as only watching television while exercising); and replac and support. Although moderate intensi[z (31 360 minutes) ing or substituting processed foods with healthier alternatives. and high intensity (>360 minutes) interventions have shown Using a multidisciplinary team of health care professionals better results than briefinterventions (1-30 minutes), even 1- (dietitians, nurses, and psychologists) can be helpful when to S-minute interventions have proved effective in reducing available. tobacco use and alcohol misuse. Behavioral counseling does not need to be complex or The USPSTF also recommends behavioral counseling time consuming. Studies have shown that patients who were interventions to promote a healthful diet and physical activity informed of being overweight by their physicians were more (grade B) for adults who are overweight or obese and have likely to report significant weight loss. Advising patients to

heart disease anda32% increase in stroke. ldentify barriers to success and make a plan to combat these Climate change could cause numerous deleterious effects barriers in advance. on human health, including higher rates of respiratory and heat related illness, skin cancer, increased prevalence ofvec tor-borne (malaria, chikungunya, dengue fever) and water additional risk factors for cardiovascular disease (hyperten- borne (cholera) diseases, food and water insecurig, and sion, dyslipidemia). For adults who do not meet these criteria, malnutrition. The ACP advises that physicians become edu- the USPSTF recommends an individualized approach to offer cated about climate change, its effect on human health, and ing or referring these patients to behavioral counseling to how to respond to future challenges. promote a healthy lifestyle, owing to smaller benefits (grade C). Behavior change is inherently difficult because it disrupts Behavioral Counseling the status quo and habits that may have developed over dec Behavioral counseling is an integral part of helping patients ades. Such strategies as motivational interviewing can be par optimize their health and habits. The USPSTF recommends ticularly effective in establishing a partnership to create using the 5 As for clinical counseling for patients regarding Iifestyle changes (Table 14). These techniques can help patients tobacco use and cessation: Ask the patient about tobacco use; identify feasible and desirable steps toward reaching goals. Advise the patient to quit through clear, personalized mes Other helpful strategies include habit replacement; pairing sages; Assess the patient's willingness to quit; Assist the (combining a less desirable activity with a more desirable one, patient with their attempt to quit; and Arrange for follow-up such as only watching television while exercising); and replac and support. Although moderate intensi[z (31 360 minutes) ing or substituting processed foods with healthier alternatives. and high intensity (>360 minutes) interventions have shown Using a multidisciplinary team of health care professionals better results than briefinterventions (1-30 minutes), even 1- (dietitians, nurses, and psychologists) can be helpful when to S-minute interventions have proved effective in reducing available. tobacco use and alcohol misuse. Behavioral counseling does not need to be complex or The USPSTF also recommends behavioral counseling time consuming. Studies have shown that patients who were interventions to promote a healthful diet and physical activity informed of being overweight by their physicians were more (grade B) for adults who are overweight or obese and have likely to report significant weight loss. Advising patients to 17

Routine Care of the Healthy Patient maintain a healthy weight and adopt healtiry practices, includ- the risk for ASCVD and type 2 diabetes. However, artificially ing eliminating sugar-containing beverages, implementing a sweetened beverages may be a useful replacement for sugar reduced-calorie diet, avoiding processed foods, and practicing containing beverages as a transition to drinking water (plain. mindful eating, can be beneficial (see Nutrition and Physical carbonated. or with unsweetened flavor). Activity). Providers may also help patients by modeling Adults of legal drinking age should be advised to limit healthy behaviors; evidence shows that doctors who improve consumption of alcohol to no more than one drink per day for their health habits may be better able to counsel their patients women and two drinks per day for men. regarding preventive and healthful behaviors. Physical Activity Nutrition lncreased physical activity decreases risk for most chronic Plant-based and Mediterranean diets as well as consumption diseases and cancer. The U.S. Department of Health and of fruits, vegetables, legumes, and vegetable- and lean-animal Human Services 2018 Physical Activity Guidelines for protein (mostly fish) are consistently associated with lower Americans recommend that adults perlorm at least 150 to all cause mortality than other types of diets and should be the 300 minutes of moderate intensity or 75 minutes of vigorous primary components of dietary intake. Dietary guidelines intensity aerobic activity per week. ideally spread throughout from both the U.S. Department of Health and Human Services the week. Muscle strengthening activities should be per and the ACC/AHA recommend following a healthy eating pat formed at least 2 days per week. Physical activity does not have tern that consists of a variety of vegetables, whole fruits, leg to take the form of formal exercise or be performed for lengthy umes, nuts, whole grains, and fish while minimizing intake of intervals. Any physical activity is better than none. and adults added sugars, saturated and trans fats, sodium, and refined should move more and sit less. Patients should be encouraged carbohydrates. Common nutrient deficiencies and associated to discover ways to naturally and habitually incorporate physi conditions are listed in Table 15. cal activity into their daily life. In the Adventist Health Study 2 cohort, consuming meat as a primary source of protein increased mortality by 61'7, with a corresponding 40% reduction in mortality in those who Supplements and Herbal Therapies replaced meat with nuts and seeds as their protein source. Dietary supplements, including vitamins, minerals. botani Similarly, foods that include trans and saturated fats have con cals, herbals, metabolites, and amino acids, are categorized as sistently been shown to be harmful and increase mortality, foods by the FDA. Therefore, manufacturers are not required and highly processed foods increase the risk for ASCVD and to demonstrate efficacy or safety of their products unless the type 2 diabetes. supplement includes ingredients that were introduced alter Water should be recommended as the drink of choice. 1994. Manufacturers are not allowed to make specific medical Sugar-containing and artifi cially sweetened beverages increase claims: however, the product's intended elfect on body struc ture or function may be described. TABLE 15. Common Nutrient Deficiencies Patients take dietary supplements lor various reasons, such as to prevent and treat illness, manage symptoms, and Nutrient Associated Disease/Disorder and Deficiency Manifestations enhance health. In the United States, approximately 50')(, ol adults report using vitamins or dietary supplements. The Vitamin D Osteoporosis, fractures, weakness USPSTF recommends against the use of p-carotene or vitamin Calcium Osteoporosis, fractures, weakness E supplements for the prevention ofcardiovascular disease or Vitamin C Scurvy: perifollicular hemorrhage, poor cancer and has concluded that the current evidence is insuf- wound healing, gingivitis ficient to assess the use of multivitamins for the prevention of lron Anemia cardiovascular disease or cancer. Folate Anemia In general, there is little good quality evidence showing Vitamin B,2 Anemia, mental status and psychiatric the efficacy of dietary supplementation. and use carries the changes, subacute combined degeneration of potential for harm. There are several populations. however. lor the dorsal and lateral spinal cord column which vitamin or supplement use is recommended. Women of $rridoxine Skin problems, neuropathy childbearing age are advised to take 0.4 to 0.8 mg (400 800 pg) (vitamin Bu) of folic acid daily to prevent fetal neural tube defects. Vegans Thiamine Beriberi, Wernicke-Korsakoff syndrome: (vitamin B,) and older adults may consider vitamin B1 , supplementation to peripheral neuropathy, heart failure, nystagmus, ataxia, ophthalmoplegia, address dietary deficiency. Calcium and/or vitamin D may also encephalopathy be considered for older adults or individuals with suboptimal Vitamin K Coagulopathy, elevated INR bone health. Calcium supplementation may increase the risk r Vitamin A Dry eyes, dry skin, night blindness for cardiovascular disease and kidney stones, thus eating a calcium rich diet may be a preferable means of assuring ade Dietary fiber lntestinal problems quate intake. Persons with age related macular degeneration

maintain a healthy weight and adopt healtiry practices, includ- the risk for ASCVD and type 2 diabetes. However, artificially ing eliminating sugar-containing beverages, implementing a sweetened beverages may be a useful replacement for sugar reduced-calorie diet, avoiding processed foods, and practicing containing beverages as a transition to drinking water (plain. mindful eating, can be beneficial (see Nutrition and Physical carbonated. or with unsweetened flavor). Activity). Providers may also help patients by modeling Adults of legal drinking age should be advised to limit healthy behaviors; evidence shows that doctors who improve consumption of alcohol to no more than one drink per day for their health habits may be better able to counsel their patients women and two drinks per day for men. regarding preventive and healthful behaviors. Physical Activity Nutrition lncreased physical activity decreases risk for most chronic Plant-based and Mediterranean diets as well as consumption diseases and cancer. The U.S. Department of Health and of fruits, vegetables, legumes, and vegetable- and lean-animal Human Services 2018 Physical Activity Guidelines for protein (mostly fish) are consistently associated with lower Americans recommend that adults perlorm at least 150 to all cause mortality than other types of diets and should be the 300 minutes of moderate intensity or 75 minutes of vigorous primary components of dietary intake. Dietary guidelines intensity aerobic activity per week. ideally spread throughout from both the U.S. Department of Health and Human Services the week. Muscle strengthening activities should be per and the ACC/AHA recommend following a healthy eating pat formed at least 2 days per week. Physical activity does not have tern that consists of a variety of vegetables, whole fruits, leg to take the form of formal exercise or be performed for lengthy umes, nuts, whole grains, and fish while minimizing intake of intervals. Any physical activity is better than none. and adults added sugars, saturated and trans fats, sodium, and refined should move more and sit less. Patients should be encouraged carbohydrates. Common nutrient deficiencies and associated to discover ways to naturally and habitually incorporate physi conditions are listed in Table 15. cal activity into their daily life. In the Adventist Health Study 2 cohort, consuming meat as a primary source of protein increased mortality by 61'7, with a corresponding 40% reduction in mortality in those who Supplements and Herbal Therapies replaced meat with nuts and seeds as their protein source. Dietary supplements, including vitamins, minerals. botani Similarly, foods that include trans and saturated fats have con cals, herbals, metabolites, and amino acids, are categorized as sistently been shown to be harmful and increase mortality, foods by the FDA. Therefore, manufacturers are not required and highly processed foods increase the risk for ASCVD and to demonstrate efficacy or safety of their products unless the type 2 diabetes. supplement includes ingredients that were introduced alter Water should be recommended as the drink of choice. 1994. Manufacturers are not allowed to make specific medical Sugar-containing and artifi cially sweetened beverages increase claims: however, the product's intended elfect on body struc ture or function may be described. TABLE 15. Common Nutrient Deficiencies Patients take dietary supplements lor various reasons, such as to prevent and treat illness, manage symptoms, and Nutrient Associated Disease/Disorder and Deficiency Manifestations enhance health. In the United States, approximately 50')(, ol adults report using vitamins or dietary supplements. The Vitamin D Osteoporosis, fractures, weakness USPSTF recommends against the use of p-carotene or vitamin Calcium Osteoporosis, fractures, weakness E supplements for the prevention ofcardiovascular disease or Vitamin C Scurvy: perifollicular hemorrhage, poor cancer and has concluded that the current evidence is insuf- wound healing, gingivitis ficient to assess the use of multivitamins for the prevention of lron Anemia cardiovascular disease or cancer. Folate Anemia In general, there is little good quality evidence showing Vitamin B,2 Anemia, mental status and psychiatric the efficacy of dietary supplementation. and use carries the changes, subacute combined degeneration of potential for harm. There are several populations. however. lor the dorsal and lateral spinal cord column which vitamin or supplement use is recommended. Women of $rridoxine Skin problems, neuropathy childbearing age are advised to take 0.4 to 0.8 mg (400 800 pg) (vitamin Bu) of folic acid daily to prevent fetal neural tube defects. Vegans Thiamine Beriberi, Wernicke-Korsakoff syndrome: (vitamin B,) and older adults may consider vitamin B1 , supplementation to peripheral neuropathy, heart failure, nystagmus, ataxia, ophthalmoplegia, address dietary deficiency. Calcium and/or vitamin D may also encephalopathy be considered for older adults or individuals with suboptimal Vitamin K Coagulopathy, elevated INR bone health. Calcium supplementation may increase the risk r Vitamin A Dry eyes, dry skin, night blindness for cardiovascular disease and kidney stones, thus eating a calcium rich diet may be a preferable means of assuring ade Dietary fiber lntestinal problems quate intake. Persons with age related macular degeneration 18

Patient Safety and Ouality lmprovement can take a specific formulation of vitamins, zinc, and copper. Persons taking proton pump inhibitors or metformin can Patient Safety and Ouality consider supplementation with vitamin B,r. Omega 3 fatty acids in fish oils may help hypertriglyceridemia and improve lmprovement cardiovascular health. Melatonin may be useful for jetlag. lntroduction Probiotics may be helpful for antibiotic associated diarrhea, Quality improvement (QI) refers to a systematic approach to Closfridioides diJJicile infection, ulcerative colitis, and perio- ana\zing practice performance with the aim of providing opti dontal disease. mal evidence based care in a reproducible and reliable manner Although reports show that multivitamins are the most while also improving patient safegr. QI also aims to improve the commonly used supplement, persons eating a well balanced health care process by reducing waste and unnecessary treat diet are unlikely to benefit from a multivitamin. Multivitamins ments while ensuring that all patients receive equitable care should not be used in the absence ofa specific indication and regardless ofrace, ethnicity, or socioeconomic background. The are not effective in compensating for a poor diet. Health spas focus on practice performance data can be at the patient level and wellness centers offlering intravenous infusions of saline (such as screening), the system level (such as hospital readmis and electrolytes and high dose vitamins are increasing in sion rates), or the population ievel (such as regional morlality popularity. Vaping of vitamins has also been marketed to rates). The process ofQI is ideally continuous, occurring in real deliver higher concentrations of vitamins to the body. None of time with rapid cycle improvements and iterative change made these methods has any evidence supporting their use, and by ongoing observations. Successful QI requires participation they carry many potential risks. from all health care team members as well as patients. In addition to questionable efficacy, supplement use is asso- ciated with risk fbr both direct and indirect harms (Table 16). Direct harms include side effects; interactions with other drugs; Patient Safety and Ouality lssues and harms related to inclusion of unadverlised additives, com at the Clinician Level pounds, or toxins. Vitamin E, fish oil, and several herbal supple Physicians have the potential to both recognize and mitigate ments may interact with anticoagulant or antiplatelet threats to patient safety. In addition, substantial variability in medications, potentially increasing the risk fbr bleeding or physician-delivered care and nonadherence to evidence based inadequate anticoagulation. Smokers should avoid p carotene guidelines may contribute to lack of quality care. Accordingly, because evidence has linked B carotene with increased risk for QI interventions that are developed with physician input are lung cancer. Pregnant women should avoid excessive vitamin A much more likely to succeed than those developed without because it has been linked to birlh defects. Antioxidant supple such consultation. Physicians also have the opportunity to ments, such as vitamins C and E, may reduce the effectiveness improve patient safety in everyday clinicai work by fbcusing of chemotherapy. Vitamin K, which is a common ingredient in on common domains of error, such as medications and transi- multiple vitamin injections, may decrease the effectiveness of tions of care. Despite this, physicians participate in less than warfhrin. Biotin may interfere with serum troponin and thyroid 35% of QI interventions. Common reasons for physicians not function testing. Harms may also occur indirectiy when herbal participating include lack of skills, inadequate time, financial supplement use replaces or delays standard treatments. disincentives, and perceived threats to autonomy. Despite these risks, many patients strongly believe in sup plement use, and the physician's role is to inform these patients of potential side effects. The National Institutes of Medication Errors Health's MedlinePlus directory of herbs and supplements Medication errors, defined as preventable inappropriate (https://medlinepius.gov/druginfo/herb All.html) and the medication use, are the most common type of medical error. U.S. Department of Agriculture's website Nutrition.gov They are estimated to occur at a rate of 5 errors per 100 medi (r.m,lw.nutrition.gov/dietary supplements) are useful resources. cation administrations. Medication errors can occur at any stage (prescribing/transcribing, dispensing, administering/ t(EY P0ttrs taking, or monitoring) and by any person in the process . Manufacturers of dietary supplements are not required (clinician, pharmacist, nurse, or patient). Errors may be to demonstrate efficacy or safety unless the supplement those of omission, such as a physician not prescribing an includes ingredients that were introduced after 1994. indicated medication, or commission, such as prescribing an . Given the prevalence of use and potential for harm, incorrect medication or dose. physicians should make inquiring about supplement Physicians form the first line of defense in preventing use a routine component of the medication history. medication errors (Table 17). ln prescribing medications, phy sicians need to review a patient's complete medical record, HVC . The U.S. Preventive Services Task Force recommends including medical history; medication list, including prescrip against the use of B-carotene or vitamin E supplements tion and over-the counter medications, herbal remedies, and for the prevention of cardiovascular disease or cancer. supplements; allergies; and laboratory data (such as renal and

can take a specific formulation of vitamins, zinc, and copper. Persons taking proton pump inhibitors or metformin can Patient Safety and Ouality consider supplementation with vitamin B,r. Omega 3 fatty acids in fish oils may help hypertriglyceridemia and improve lmprovement cardiovascular health. Melatonin may be useful for jetlag. lntroduction Probiotics may be helpful for antibiotic associated diarrhea, Quality improvement (QI) refers to a systematic approach to Closfridioides diJJicile infection, ulcerative colitis, and perio- ana\zing practice performance with the aim of providing opti dontal disease. mal evidence based care in a reproducible and reliable manner Although reports show that multivitamins are the most while also improving patient safegr. QI also aims to improve the commonly used supplement, persons eating a well balanced health care process by reducing waste and unnecessary treat diet are unlikely to benefit from a multivitamin. Multivitamins ments while ensuring that all patients receive equitable care should not be used in the absence ofa specific indication and regardless ofrace, ethnicity, or socioeconomic background. The are not effective in compensating for a poor diet. Health spas focus on practice performance data can be at the patient level and wellness centers offlering intravenous infusions of saline (such as screening), the system level (such as hospital readmis and electrolytes and high dose vitamins are increasing in sion rates), or the population ievel (such as regional morlality popularity. Vaping of vitamins has also been marketed to rates). The process ofQI is ideally continuous, occurring in real deliver higher concentrations of vitamins to the body. None of time with rapid cycle improvements and iterative change made these methods has any evidence supporting their use, and by ongoing observations. Successful QI requires participation they carry many potential risks. from all health care team members as well as patients. In addition to questionable efficacy, supplement use is asso- ciated with risk fbr both direct and indirect harms (Table 16). Direct harms include side effects; interactions with other drugs; Patient Safety and Ouality lssues and harms related to inclusion of unadverlised additives, com at the Clinician Level pounds, or toxins. Vitamin E, fish oil, and several herbal supple Physicians have the potential to both recognize and mitigate ments may interact with anticoagulant or antiplatelet threats to patient safety. In addition, substantial variability in medications, potentially increasing the risk fbr bleeding or physician-delivered care and nonadherence to evidence based inadequate anticoagulation. Smokers should avoid p carotene guidelines may contribute to lack of quality care. Accordingly, because evidence has linked B carotene with increased risk for QI interventions that are developed with physician input are lung cancer. Pregnant women should avoid excessive vitamin A much more likely to succeed than those developed without because it has been linked to birlh defects. Antioxidant supple such consultation. Physicians also have the opportunity to ments, such as vitamins C and E, may reduce the effectiveness improve patient safety in everyday clinicai work by fbcusing of chemotherapy. Vitamin K, which is a common ingredient in on common domains of error, such as medications and transi- multiple vitamin injections, may decrease the effectiveness of tions of care. Despite this, physicians participate in less than warfhrin. Biotin may interfere with serum troponin and thyroid 35% of QI interventions. Common reasons for physicians not function testing. Harms may also occur indirectiy when herbal participating include lack of skills, inadequate time, financial supplement use replaces or delays standard treatments. disincentives, and perceived threats to autonomy. Despite these risks, many patients strongly believe in sup plement use, and the physician's role is to inform these patients of potential side effects. The National Institutes of Medication Errors Health's MedlinePlus directory of herbs and supplements Medication errors, defined as preventable inappropriate (https://medlinepius.gov/druginfo/herb All.html) and the medication use, are the most common type of medical error. U.S. Department of Agriculture's website Nutrition.gov They are estimated to occur at a rate of 5 errors per 100 medi (r.m,lw.nutrition.gov/dietary supplements) are useful resources. cation administrations. Medication errors can occur at any stage (prescribing/transcribing, dispensing, administering/ t(EY P0ttrs taking, or monitoring) and by any person in the process . Manufacturers of dietary supplements are not required (clinician, pharmacist, nurse, or patient). Errors may be to demonstrate efficacy or safety unless the supplement those of omission, such as a physician not prescribing an includes ingredients that were introduced after 1994. indicated medication, or commission, such as prescribing an . Given the prevalence of use and potential for harm, incorrect medication or dose. physicians should make inquiring about supplement Physicians form the first line of defense in preventing use a routine component of the medication history. medication errors (Table 17). ln prescribing medications, phy sicians need to review a patient's complete medical record, HVC . The U.S. Preventive Services Task Force recommends including medical history; medication list, including prescrip against the use of B-carotene or vitamin E supplements tion and over-the counter medications, herbal remedies, and for the prevention of cardiovascular disease or cancer. supplements; allergies; and laboratory data (such as renal and 19