Items in AFP with MESH term: Mass Screening
ABSTRACT: Colorectal cancer is a significant contributor to morbidity and mortality in the United States. Studies published in the early 1990s, showing that screening for colorectal cancer can reduce colorectal cancer-related mortality, led many organizations to recommend screening in asymptomatic, average-risk adults older than 50 years. Since then, however, national screening rates remain low. Several important studies published over the past four years have refined our understanding of existing screening tools and explored novel means of screening and prevention. The most important new developments, which are reviewed in this article, include the following: Additional trial results support the effectiveness of fecal occult blood testing in reducing the incidence of, and mortality from, colorectal cancer. New studies document the sensitivity of fecal occult blood testing, sigmoidoscopy, and double-contrast barium enema compared with colonoscopy. Cost-effectiveness models show that screening by any of several methods is cost-effective compared to no screening. Randomized trials show that calcium is effective but fiber is not effective in preventing reoccurrence of adenomatous polyps. Preliminary data suggest that nonsteroidal anti-inflammatory drugs may prevent adenomatous polyps and that DNA stool tests and virtual colonoscopy may show promise as screening tools. This new information provides further support for efforts to increase the use of colorectal cancer screening and prevention services in adults older than 50 years.
ABSTRACT: Ten percent of the population abuses drugs or alcohol, and 20 percent of patients seen by family physicians have substance-abuse problems, excluding tobacco use. These patients can be identified by relying on regular screening or a high index of suspicion based on "red flags" that can be noted in various clinical situations. The modified CAGE questionnaire is an excellent screening instrument, but several alternatives are available. The best screening test is one that the physician will routinely use well. Laboratory indicators such as gamma-glutamyl transpeptidase, mean corpuscular volume, and carbohydrate-deficient transferrin are nonspecific but can add to the evidence of alcohol abuse. If problem alcohol use is diagnosed, even brief physician advice can be helpful. If the problem has progressed to addiction, referral to an addiction specialist or treatment center is recommended. Special issues arise in dealing with substance abuse in adolescents, elderly patients, and patients with mental illness, but the family physician can play an important role in recognizing this common problem.
Hepatitis B - Article
ABSTRACT: Hepatitis B causes significant morbidity and mortality worldwide. More than 400 million persons, including 1.25 million Americans, have chronic hepatitis B. In the United States, chronic hepatitis B virus infection is responsible for about 5,000 annual deaths from cirrhosis and hepatocellular carcinoma. Hepatitis B virus is found in body fluids and secretions; in developed countries, the virus is most commonly transmitted sexually or via intravenous drug use. Occupational exposure and perinatal transmission do occur but are rare in the United States. Effective vaccines for hepatitis B virus have been available since 1982; infant and childhood vaccination programs introduced in the 1990s have resulted in a marked decrease in new infections. Risk factors for progression to chronic infection include age at the time of infection and impaired immunity. From 15 to 30 percent of patients with acute hepatitis B infection progress to chronic infection. Medical therapies for chronic hepatitis B include interferon alfa-2b, lamivudine, and the nucleotide analog adefovir dipivoxil.
Subclinical Thyroid Disease - Article
ABSTRACT: Subclinical thyroid dysfunction is defined as an abnormal serum thyroid-stimulating hormone level (reference range: 0.45 to 4.50 microU per mL) and free thyroxine and triiodothyronine levels within their reference ranges. The management of subclinical thyroid dysfunction is controversial. The prevalence of subclinical hypothyroidism is about 4 to 8.5 percent, and may be as high as 20 percent in women older than 60 years. Subclinical hyperthyroidism is found in approximately 2 percent of the population. Most national organizations recommend against routine screening of asymptomatic patients, but screening is recommended for high-risk populations. There is good evidence that subclinical hypothyroidism is associated with progression to overt disease. Patients with a serum thyroid-stimulating hormone level greater than 10 microU per mL have a higher incidence of elevated serum low-density lipoprotein cholesterol concentrations; however, evidence is lacking for other associations. There is insufficient evidence that treatment of subclinical hypothyroidism is beneficial. A serum thyroid-stimulating hormone level of less than 0.1 microU per mL is associated with progression to overt hyperthyroidism, atrial fibrillation, reduced bone mineral density, and cardiac dysfunction. There is little evidence that early treatment alters the clinical course.
Diagnosis and Management of Preeclampsia - Article
ABSTRACT: Preeclampsia is a pregnancy-specific multisystem disorder of unknown etiology. The disorder affects approximately 5 to 7 percent of pregnancies and is a significant cause of maternal and fetal morbidity and mortality. Preeclampsia is defined by the new onset of elevated blood pressure and proteinuria after 20 weeks of gestation. It is considered severe if blood pressure and proteinuria are increased substantially or symptoms of end-organ damage (including fetal growth restriction) occur. There is no single reliable, cost-effective screening test for preeclampsia, and there are no well-established measures for primary prevention. Management before the onset of labor includes close monitoring of maternal and fetal status. Management during delivery includes seizure prophylaxis with magnesium sulfate and, if necessary, medical management of hypertension. Delivery remains the ultimate treatment. Access to prenatal care, early detection of the disorder, careful monitoring, and appropriate management are crucial elements in the prevention of preeclampsia-related deaths.
Diabetic Nephropathy: Common Questions - Article
ABSTRACT: Diabetic nephropathy, or diabetic kidney disease, affects 20 to 30 percent of patients with diabetes. It is a common cause of kidney failure. Diabetic nephropathy presents in its earliest stage with low levels of albumin (microalbuminuria) in the urine. The most practical method of screening for microalbuminuria is to assess the albumin-to-creatinine ratio with a spot urine test. Results of two of three tests for microalbuminuria should be more than 30 mg per day or 20 mcg per minute in a three- to six-month period to diagnose a patient with diabetic nephropathy. Slowing the progression of diabetic nephropathy can be achieved by optimizing blood pressure (130/80 mm Hg or less) and glycemic control, and by prescribing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patients with diabetes and isolated microalbuminuria or hypertension benefit from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In the event that these medications cannot be prescribed, a nondihydropyridine calcium channel blocker may be considered. Serum creatinine and potassium levels should be monitored carefully for patients receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. These medications should be stopped if hyperkalemia is pronounced.
ABSTRACT: All pregnant women should be offered screening for asymptomatic bacteriuria, syphilis, rubella, and hepatitis B and human immunodeficiency virus infection early in pregnancy. Women at increased risk should be tested for hepatitis C infection, gonorrhea, and chlamydia. All women should be questioned about their history of chickenpox and genital or orolabial herpes. Routine screening for bacterial vaginosis is not recommended. Influenza vaccination is recommended in women who will be in their second or third trimester of pregnancy during flu season. Women should be offered vaginorectal culture screening for group B streptococcal infection at 35 to 37 weeks' gestation. Colonized women and women with a history of group B streptococcal bacteriuria should be offered intrapartum intravenous antibiotics. Screening for gestational diabetes remains controversial. Women should be offered labor induction after 41 weeks' gestation.
ABSTRACT: Reading difficulties are common and are associated with poor long-term academic achievement. Evaluation of a child's developmental, educational, and family histories in conjunction with standardized screening tests (e.g., Ages and Stages Questionnaires, Parents' Evaluation of Developmental Status, Safety Word Inventory and Literacy Screener) can increase recognition of risk factors for reading difficulties. Validated, office-based, standardized screening tests and school-administered standardized achievement tests (e.g., California Achievement Tests, Iowa Tests of Basic Skills, Metropolitan Achievement Tests, Stanford Achievement Test) can be used to assess school-age children with reading difficulties. Reading difficulties in children often are caused by environmental and organic risk factors. However, many children have reading or learning disabilities and will have lifelong difficulties with reading despite adequate intervention. Children with substantial reading difficulties should receive a full educational assessment. There is good evidence that individualized instruction emphasizing increased phonologic awareness can have a favorable long-term effect on academic achievement.
Celiac Disease - Article
ABSTRACT: As many as one in every 100 to 200 persons in the United States has celiac disease, a condition resulting from an inappropriate immune response to the dietary protein gluten. The manifestations of celiac disease range from no symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malignancies. When celiac disease is suspected, initial testing for serum immunoglobulin A (IgA) tissue transglutaminase (tTG) antibodies is useful because it offers adequate sensitivity and specificity at a reasonable cost. A positive IgA tTG result should prompt small bowel biopsy with at least four tissue samples to confirm the diagnosis. However, 3 percent of patients with celiac disease have IgA deficiency. Therefore, if the serum IgA tTG result is negative but clinical suspicion for the disease is high, a serum total IgA level may be considered. Screening of asymptomatic patients is not recommended. The basis of treatment for celiac disease is adherence to a gluten-free diet, which may eliminate symptoms within a few months. Patients should also be evaluated for osteoporosis, thyroid dysfunction, and deficiencies in folic acid, vitamin B12, fat-soluble vitamins, and iron, and treated appropriately. Serum IgA tTG levels typically decrease as patients maintain a gluten-free diet.
ABSTRACT: Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older.