Dr. James Manos (MD)
January 22, 2016
Preventive medicine
‘Prevention is better than cure’ (Hippocrates, ancient Greek doctor – the father of Western medicine, 460 – 370 B.C.)
Note: in this text, the writer expresses his point of view. Some advice is empirical, so you should consult your family doctor beforehand.
Preventive medicine: regular check-ups & prevention of medical diseases in all ages
Preventive medicine: regular check-ups
· An annual health check-up is advised. It should include a physical examination (by a doctor) and lab tests that include a CBC/ FBC (complete/full blood count), an ESR, a basic biochemistry profile, including blood lipids (fats such as cholesterol & triglycerides) and CRP, and urinalysis.
· Also, an ECG (electrocardiogram) is advised on people over 35 years old and those with heart problems, including heart arrhythmias. Cardiac (heart) arrhythmias should be diagnosed with an ECG (electrocardiogram) and treated, particularly atrial fibrillation (common in patients with hyperthyroidism and alcoholics) that increases the risk for stroke (patients may need to take anticoagulants to prevent it).
· People over their fifties should be screened with an abdominal ultrasound for an abdominal aneurysm.
· For the elderly and those with heart disease, a cardiac Echo (Echocardiogram) is helpful. The former may have cardiac valve calcification.
· On people with atherosclerosis (hardening of the arteries) and stroke or TIA (transient ischemic attack), a carotid ultrasound (Doppler/ Triplex) is needed (blocked carotid arteries predispose to stroke).
· Venus ultrasound (Duplex; Triplex) of the lower extremities is needed on people with leg swelling (edema) and leg varices.
· Regular ophthalmological (eye) examination by an ophthalmologist is required for the elderly, patients with hypertension and diabetes, or patients taking medications that may affect the eyes as adverse effect (including amiodarone, a drug for heart arrhythmias that may predispose to cataract) and cortisone (even if it is in inhaled form, as in asthmatics, it may predispose to cataract). In the elderly, eye screening may help with the early diagnosis of age-related macular degeneration (AMD), a significant cause of blindness. A test called OCT (Optical Coherence Tomography) is diagnostically beneficial to detecting this eye disease. Eye tonometry is needed to exclude glaucoma in people with high eye pressure, but normal-tension glaucoma (with normal eye pressure) may also occur. A visual acuity test is important. A test using the Amsler grid vision test helps detect macular degeneration. Glaucoma and diabetic eye disease are the leading causes of blindness in the West.
Prevention of medical diseases in all ages
Primary causes of mortality in all ages
The latest numbers on causes of death in the United States compiled by the CDC show injuries lead the way in several age groups.
Cancer, heart disease, and other illnesses creep into the top spot as people age.
For anyone between 45 and 64, malignant neoplasms (cancerous tumors) take the lead.
Other top-rated causes of death include suicide, diabetes, liver disease, homicide, and Alzheimer's.
Another chart shows unintentional falls as the leading cause of non-fatal injuries in nearly every age group.
Focusing on injuries, car accidents, and poisoning are lead causes of death.
Primary causes of mortality in people aged less than 1 year old are (lined from most important to less important): congenital abnormalities, short gestation, maternal pregnancy complications, SIDS (sudden infant death syndrome), unintentional injury, and placenta cord. Membranes, bacterial sepsis.
Leading causes of mortality in people aged 1 – 4 years are (lined from most important to less important): unintentional injury, congenital abnormalities, homicide, malignant neoplasms, heart disease, influenza (flu) & pneumonia.
Primary causes of mortality in people aged 5 – 9 years are (lined from most important to less important): unintentional injury, malignant neoplasms, congenital abnormalities, homicide, chronic low respiratory disease, and heart disease.
Leading causes of mortality in people aged 10 – 14 years are (lined from most important to less important): unintentional injury, malignant neoplasms, suicide, congenital abnormalities, homicide, and heart disease.
Primary causes of mortality in people aged 15 – 24 years are (lined from most important to less important): unintentional injury, suicide, homicide, malignant neoplasms, heart disease, and congenital abnormalities.
Leading causes of mortality in people aged 25 – 34 years are (lined from most important to less important): unintentional injury, suicide, homicide, malignant neoplasms, and heart disease.
Primary causes of mortality in people aged 35 – 44 years are (lined from most important to less important): unintentional injury, malignant neoplasms, heart disease, suicide, and homicide.
Causes of mortality in people aged 45 – 54 years (from more frequent to less) are malignant neoplasms, heart disease, unintentional injury, liver disease, suicide, and diabetes mellitus.
Causes of mortality in people aged 55 – 64 years (from more frequent to less) are malignant neoplasms, heart disease, unintentional injury, chronic low respiratory disease, diabetes mellitus, liver disease, and cerebrovascular accident (stroke).
Causes of mortality in people aged more than 65 years (from more frequent to less) are heart disease, malignant neoplasms, chronic low respiratory disease, cerebrovascular accident (stroke), Alzheimer’s disease (AD), diabetes mellitus, influenza (flu) & pneumonia.
Total causes of mortality (from more frequent to less) are heart disease, malignant neoplasms, chronic low respiratory disease, unintentional injury, cerebrovascular accident (stroke), Alzheimer’s disease (AD), diabetes mellitus, influenza (flu) & pneumonia, nephritis (kidney disease), suicide.
Accidents
Accidents are the 1st cause of death for people aged 15 – 44.
· Accidents constitute a significant cause of death or disability at any age (and the first cause of mortality in people younger than 44). Routine seat belt use & helmet use (bicycles, motorcycles, skateboards) must be encouraged. Pregnant women should be taught to wear their seat belts correctly.
· Everyone must realize that driving under the influence (DUI) (alcohol or illicit drugs) can be fatal.
· Also, swimming (e.g., in a pool or sea) under the influence of alcohol and/or illegal drugs may be lethal.
· Children should never swim unattended.
Domestic violence & abuse
Gun (or any other weapon such as a knife) possession and use must be investigated. Screening for domestic violence (women, elderly, pregnant, children) regarding all ages.
· Screening in domestic violence/ abuse to children, women, pregnant and the elderly.
Illicit drug & alcohol abuse
Assessment of substance use history, illicit drug misuse, and alcohol abuse screening in all ages (especially younger ones).
· Periodically alcohol abuse screening in all people, including teenagers (who may also be addicted to alcohol).
Depression & Suicide
Screening for depression and suicide attention in all ages, especially in people aged 15 –24, where suicide is the second cause of death.
· Depression is relatively common in the elderly, divorced, single, bereaved, after childbirth (but it needs to be differentiated from postpartum psychosis, which is a severe psychiatric disease) or in menopause, in people with financial and/or problems, medical problems, relationship troubles, neglect, mental abuse, and physical or sexual abuse.
Dementia
Screening for dementia (e.g., with an MMSE (mini-mental state examination test)) and depression (e.g., with Hamilton rating scale) for people older than 65 years old.
Hearing & visual (eye) problems
· Screening for hearing and visual (eye) problems (they also contribute to accidents such as falls), especially in people older than 65. Unilateral (from one side) hearing loss in the elderly often relates to age (presbycusis). However, a unilateral hearing loss that may be sudden may be caused by a tumor such as an acoustic neuroma (it is a benign – noncancerous tumor) or a tumor of the cerebellopontine angle!
· Periodically visual & hearing checks on people older than sixty-five.
· Glaucoma (increased eye pressure) screening by an ophthalmologist (eye doctor).
· Regular ophthalmological (eye) examination by an ophthalmologist is needed in the elderly, patients with hypertension and diabetes, or patients taking medications that may affect the eyes as adverse effect (including amiodarone, a drug for heart arrhythmias that may predispose to cataract) and cortisone (even if it is in inhaled form, as in asthmatics, it may predispose to cataract). In the elderly, eye screening may help with the early diagnosis of age-related macular degeneration (AMD), a significant cause of blindness. A test called OCT (Optical Coherence Tomography) is diagnostically beneficial for people with AMD. Eye tonometry is needed to exclude glaucoma in people with high eye pressure, but normal-tension glaucoma (with normal eye pressure) may also occur. A vision acuity test and an Amsler grid test are helpful in screening for macular degeneration. Glaucoma and diabetic eye disease are the leading causes of blindness in the West.
Thyroid disease
Thyroid disease screening, especially if family history and if indicated by symptoms such as arrhythmias (including atrial fibrillation (AF)), bradycardia (low heart rate), insomnia, depressed mood, anxiety, weight problems (low or high weight), etc. Thyroid function tests include TSH, T3, T4, fT3, fT4, and in some cases, anti-thyroid antibodies.
· Also, mandatory newborn screening to prevent cretinism (a severely impaired physical and mental growth due to untreated congenital deficiency of thyroid hormones in congenital hypothyroidism).
Development and puberty
Development, including weight, height, and introduction to puberty, should be recorded (there are special charts for development) so that failure to thrive and delayed or premature puberty should be sought, and endocrinological disorders should be investigated. Children with short stature may benefit from growth hormone (GH) replacement therapy when deficient in this hormone, while other endocrinological diseases should be treated appropriately.
Medications & dietary supplements
· Assessment of medication use: concordance, abuse, side effects, contraindications & interactions with other drugs. The assessment also includes over-the-counter drugs (OTC), ‘vitamins,’ herbs, dietary supplements, self-medications, and the ‘Pill.’
Prevention of coronary artery disease/ ischemic heart disease (CAD/ IHD)
· Coronary artery disease (CAD) is directly related to high blood cholesterol; however, only 42% of coronary heart disease (CHD) patients have high cholesterol!
· Dyslipidemia (increased blood fats) is an abnormal amount of blood lipids (fats) such as cholesterol and triglycerides. It predisposes to ischemic heart disease (IHD), which is the cause of myocardial infarction (heart attack).
· ‘Statin’ cholesterol-lowering drugs (such as simvastatin, e.g., ‘Lipitor®’) lower cholesterol and help prevent heart attacks.
· The ‘statins’ have side effects such as myopathy (muscle disease; it sometimes may be severe and manifest as rhabdomyolysis that may cause kidney failure) and elevated liver function enzymes [LFTs, ‘transaminases, such as SGOT (AST) & SGPT (ALT)]. CK ((CPK) creatine phosphokinase, an enzyme that indicates muscle damage) and transaminases (enzymes that show liver function) should be screened regularly (e.g., every 3 months) on people taking statin drugs.
· To prevent dyslipidemia (high blood fats) that predisposes to coronary artery disease and heart attack, a regular check of blood cholesterol & triglyceride levels is needed (e.g., annually).
· All children should be screened early with a biochemistry lipid profile for high cholesterol and/or triglycerides, especially if they are obese. Blood pressure should also be measured.
· In children with familial dyslipidemias, there is an early onset of coronary artery disease (CAD).
· Aspirin (usually 75 mg for heart attack prevention; the enteric-coated aspirin is preferred as it has fewer chances to irritate the stomach, causing peptic ulcer) may prevent heart attack and stroke in high-risk patients, but before taking it, a doctor’s consultation and a coronary artery disease risk stratification are needed, because there are contraindications for antiplatelet drugs such as aspirin, including people with peptic ulcers, bleeding tendency, etc. It has side effects (such as peptic ulcer disease (PUD)) and many interactions (e.g., on people who take blood thinners, it may increase bleeding diathesis (tendency). If aspirin is not tolerated, then clopidogrel may be used instead. A special drug for gastric protection (PPI or H2RA) is advised.
· High blood pressure (hypertension) should be managed, especially in diabetics.
· Diabetes mellitus (DM) is a disease in which arteriosclerosis (hardening of the arteries) occurs faster. If blood sugar levels are not regulated, it may cause premature heart attack, stroke, blindness, gangrene in the leg, and kidney failure. Hypertension has the same end-organ effects, except foot gangrene.
· Counseling about diet and regular exercise for all ages.
· Estimation of coronary heart disease risk.
· Screening for coronary artery disease (CAD) in high-risk patients older than 45.
· Blood lipids (fats such as cholesterol & triglycerides), blood pressure & blood sugar regulation in normal ranges – treatment of dyslipidemia (increased blood lipids), hypertension, and diabetes mellitus. Weight reduction in obese & overweight people.
· All people should follow a diet low in saturated & trans-fat and include 3 servings of fish weekly (especially fat fish for omega-3) & fruits & vegetables. Also, alcohol intake should remain moderate.
· Eating at least five servings of fruits and vegetables daily is essential for good health and is recommended by WHO and all doctors.
· Regular aerobic exercise of more than 30 min, at least 5 times weekly, of moderate intensity is advised (e.g., jogging, cycling, brittle walking, rowing, etc.).
· In all ages, periodic Blood Pressure (BP), weight, and Body Mass Index measurements are advised.
· Specific risk factors for coronary artery disease (CAD) are dyslipidemia (increased LDL ‘bad cholesterol’ and decreased HDL ''good'' cholesterol), high serum homocysteine (folic acid and B6 & B12 vitamin lower it), increased high sensitivity CRP (if other causes are excluded), lipoprotein (a), high fibrinogen, diabetes mellitus (DM)/ insulin resistance and metabolic syndrome, male gender, male aged more than 45 years old, postmenopausal women, tobacco smokers, hypertensive (with high blood pressure), overweight/ obese, patients with a family history of premature CHD and patients with a sedentary lifestyle.
· Body weight control, if overweight or obese, should be encouraged.
· Low BMI (body mass index) in young women may indicate anorexia nervosa.
· Hypertension (high blood pressure), hyperlipidemia (high blood fats), and diabetes mellitus (high blood sugar) should be treated maliciously.
· Information about the health risks of smoking at all ages. Smoking cessation should be encouraged.
· On people older than 25 years, assess cardiac risk factors:
· Non – modifiable: male gender, age (men >_45 women >_ 55), ethnic origin (e.g., India), personal or family history, socioeconomic status, IUGR [intrauterine growth restriction) and small birth weight], and premature CAD (coronary artery disease).
· Modifiable: smoking, dyslipidemia (increased blood fats such as cholesterol & triglycerides), hypertension (high blood pressure), diabetes mellitus (DM) (elevated blood sugar), a diet high in fats, obesity, sedentary lifestyle (decreased physical activity), heart failure, behavior – personality (competitiveness, aggression, feeling under time pressure), increased plasma fibrinogen, increased Lipoprotein (a), increased blood homocysteine and decreased blood folate, vitamin B12, B6, and folate deficiency ((their deficiency increases homocysteine levels) and depression. Alcohol in low doses is protective for the cardiovascular system; however, it induces hypertension and numerous physical problems in high doses.
Prevention of stroke
Stroke (AKA cerebrovascular accident) risk factors assessment: advanced age, hypertension (high blood pressure), diabetes mellitus (high blood sugar), atrial fibrillation (a heart arrhythmia that predisposes to embolism from the heart that causes stroke), previous stroke or TIA (transient ischemic attack), MI (myocardial infarction (heart attack)), artificial heart valves, hyperviscosity (e.g., multiple myeloma or Waldenstrom’s macroglobulinemia) & polycythemia vera, smoking, obesity, high alcohol intake, and low physical activity/ sedentary lifestyle. Patients with sustained/chronic atrial fibrillation (a heart arrhythmia) should take anticoagulation under the guidance of a cardiologist.
Lungs
A Pulmonary (LUNG) function test (spirometry) is recommended for people with lung disease (including asthma) and smokers to assess the development of chronic obstructive pulmonary disease (COPD).
· Cystic fibrosis screening: newborn or antenatal (before birth) screening
Immunization status
Immunization status for children
Immunization status for adults
· Reassessment of vaccination status at 50 years old and again at 65 years old people.
· Special indications for specific risk groups.
Tetanus & Diphtheria (Td adult) & pertussis (Tdap) (pertussis causes whooping cough)
· Adults should substitute a 1-time dose of Tdap for a Td booster, then boost with Td every 10 years.
Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination. 1 dose of the Tdap vaccine should be administered to pregnant women during each pregnancy (preferably during 27 to 36 weeks' gestation) regardless of the interval since prior Td or Tdap vaccination.
Persons aged 11 years or older who have not received the Tdap vaccine or for whom vaccine status is unknown should receive a dose of Tdap followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years after that.
Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid-containing vaccine.
Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or end a primary vaccination series, including a Tdap dose.
For unvaccinated adults, the first 2 doses should be administered at least 4 weeks apart, and the third dose 6 to 12 months after the second.
The remaining doses should be administered to incompletely vaccinated adults (i.e., less than 3 doses).
Meningococcus (causes meningitis)
· Meningococcal vaccination on children and high-risk adults.
· 2 doses of quadrivalent meningococcal conjugate vaccine at least 2 months apart to adults of all ages with anatomical or functional asplenia or persistent complement component deficiencies. HIV infection is not an indication of routine vaccination with MenACWY. If an HIV-infected person of any age is vaccinated, 2 doses of MenACWY should be administered at least 2 months apart.
· Among the 13 identified capsular types of N. meningitidis, six (A, B, C, W135, X, and Y) account for most disease cases worldwide. Type A has been the most prevalent in Africa and Asia but is rare – practically absent in North America. In the United States, serogroup B is the predominant cause of disease and mortality, followed by serogroup C. The multiple subtypes have hindered the development of a universal vaccine for meningococcal disease.
· Recently, there are available vaccines that help protect against all three serogroups (B, C, and Y) of meningococcal disease that are commonly seen in the US:
· Serogroup B meningococcal vaccines (Bexsero® and Trumenba®) (new vaccines that cover B serogroup that is more common in the USA and other developed countries)
· Meningococcal conjugate vaccines (Menactra®, Menveo®, and MenHibrix®)
· Meningococcal polysaccharide vaccine (Menomune®)
Hepatitis B virus (HBV)
· Vaccination for hepatitis B (HBV) for high-risk groups.
· Vaccination for hepatitis B for persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection: sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than 1 sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection drug users; and men who have sex with men (MSM); — health care personnel and public safety workers who are potentially exposed to blood or other infectious body fluids; — persons with diabetes who are younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on the likelihood of acquiring HBV infection, including the risk posed by an increased need for assisted blood glucose monitoring in long-term care facilities, the possibility of experiencing chronic sequelae if infected with HBV, and the likelihood of immune response to vaccination; — persons with end-stage renal disease, including patients receiving hemodialysis, persons with HIV infection, and persons with chronic liver disease; — household contacts and sex partners of hepatitis B surface antigen– positive persons, clients and staff members of institutions for persons with developmental disabilities, and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and — all adults in the following settings: STD treatment facilities, HIV testing and treatment facilities, facilities providing drug abuse treatment and prevention services, health care settings targeting services to injection drug users or men who have sex with men, correctional facilities, end-stage renal disease programs and facilities for chronic hemodialysis patients, and institutions and nonresidential day care facilities for persons with developmental disabilities.
Hepatitis A virus (HAV)
· Vaccination for hepatitis A (HAV) for children and adults (that have no antibodies against HAV) of elevated risk
· Vaccination for hepatitis A (HAV) for the following groups: men who have sex with men and persons who use injection or non-injection illicit drugs; — persons working with HAV-infected primates or with HAV in a research laboratory setting; — persons with chronic liver disease and persons who receive clotting factor concentrates; — persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A; and — unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. (See footnote 1 for more information on travel recommendations.) The first dose of the 2-dose hepatitis A vaccine series should be administered as soon as adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.
MMR (measles, mumps & rubella)
· MMR (measles, mumps & rubella) vaccination, including for women of childbearing age whose rubella antibody status should be checked before pregnancy. MMR should be considered in adults with a lab-test for antibodies or lack of immunity on MMR (that didn’t have these diseases). MMR should not be given to HIV - positive patients with CD4+ lymphocytes less than 200 cells/μL. MMR is contraindicated in pregnancy and immunocompromised patients. MMR is contraindicated in cancer patients receiving chemotherapy and/or radiotherapy, patients with Hodgkin’s, and hematopoietic stem cell transplant recipients.
· MMR for adults: 1 or 2 doses.
· Adults born before 1957 are generally considered immune to measles and mumps. All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable proof of immunity for measles, mumps, or rubella.
· For women of childbearing age, rubella immunity should be determined regardless of birth year. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive the MMR vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility.
VZV (varicella-zoster virus) (causes chickenpox, and its reactivation causes shingles)
· A new vaccine also includes protection from the varicella-zoster virus (VZV) that causes chickenpox (the new vaccine is called MMRV, V for varicella).
· Varicella vaccination for adults: two doses. All adults without evidence of immunity to varicella (as defined below) should receive two doses of the single-antigen varicella vaccine or a second dose if they have received only one dose. Vaccination should be emphasized for those who have close contact with persons at high risk for severe disease (e.g., health care personnel and family contacts of persons with immunocompromising conditions) or are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of the varicella vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility. The second dose should be administered 4 to 8 weeks after the first dose. Evidence of immunity to varicella in adults includes any of the following: documentation of 2 doses of varicella vaccine at least 4 weeks apart; U.S.-born before 1980, except health care personnel and pregnant women; history of varicella based on diagnosis or verification of varicella disease by a healthcare provider; history of herpes zoster based on diagnosis or verification of herpes zoster disease by a health care provider; or laboratory evidence of immunity or laboratory confirmation of disease.
· Varicella vaccine should not be given in HIV - positive patients with CD4+ lymphocytes less than 200 cells/μL. It is also contraindicated in pregnancy, women who may become pregnant within 1 month after the vaccination, and immunocompromised patients. The VZV vaccine is contraindicated in cancer patients receiving chemo, with Hodgkin’s and hematopoietic stem cell transplant recipients.
VZV vaccination for shingles
· VZV also causes shingles (also called herpes zoster) on reactivation of the same virus (the initial infection causes chickenpox). There is a zoster vaccine for adults older than 50 years old to prevent Shingles.
A single dose of the zoster vaccine is recommended for adults aged 60 years or older, regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the U.S. Food and Drug Administration for use among and can be administered to persons aged 50 years or older, ACIP recommends that vaccination begins at age 60 years.
Persons aged 60 years or older with chronic medical conditions may be vaccinated unless their situation constitutes a contraindication, such as pregnancy or severe immunodeficiency.
HPV (human papillomavirus)
· There are more than one hundred types of HPV. About thirty or so types can cause genital infections. Some can cause genital warts. Other types can cause cervical or other genital cancers. The additional seventy or so HPV types can cause infections and warts elsewhere on the body, such as on the hands. Certain HPV types are classified as ‘high-risk’ because they lead to abnormal cell changes and can cause genital cancers: cervical cancer and cancer of the vulva, anus, and penis. Researchers say that virtually all cervical cancers – more than 99% – are caused by these high-risk HPV viruses. The most common high-risk strains of HPV are types 16 and 18, which cause about 70% of all cervical cancers. If the body clears the infection, the cervical cells return to normal. But if the body does not fight the infection, the cells in the cervix can continue to change abnormally. This can lead to precancerous changes or cervical cancer. HPV can also invade the mouth during oral sex. Those infections usually cause no symptoms, but a lingering infection with a cancer-linked strain can lead to oropharyngeal cancer.
· For sexually active women, HPV (human papillomavirus) immunization is recommended. The HPV virus is related to cervical cancer. HPV is suggested for females (3 doses) aged 9 – 26. Recently HPV vaccine has also been administered in men, especially for elevated risk such as men who have sex with men (MSM).
· Two vaccines are licensed for use in females, the bivalent HPV vaccine (HPV2) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4).
· For females, HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 26 years, if not previously vaccinated.
· For males, HPV4 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 21 years if not previously vaccinated. Males aged 22 through 26 years may be vaccinated.
· HPV4 is recommended for men who have sex with men through age 26 years for those who did not get any or all doses when they were younger.
· Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 26 years for those who did not get any or all doses when they were younger.
· A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should be administered 4 to 8 weeks (minimum interval of 4 weeks) after the first dose; the third dose should be administered 24 weeks after the first dose and 16 weeks after the second dose (minimum interval of at least 12 weeks).
· HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the vaccination series, no intervention is required; the remainder of the 3-dose series should be delayed until completion or termination of pregnancy.
Influenza virus (causes flu)
· Annual vaccination against influenza is recommended for all persons aged 6 months or older. Persons aged 6 months or older, including pregnant women and persons with a hives-only allergy to eggs, can receive the inactivated influenza vaccine (IIV). An age appropriate IIV formulation should be used. Adults aged 18 years or older can receive the recombinant influenza vaccine (RIV). RIV does not contain any egg protein and can be given to persons with egg allergies of any severity. Healthy, non-pregnant persons aged 2 to 49 without high-risk medical conditions can receive intranasally administered live, attenuated influenza vaccine (LAIV) or IIV. Healthcare personnel who care for severely immunocompromised persons who require care in a protected environment should receive IIV or RIV; healthcare personnel who receive LAIV should avoid providing care for severely immunosuppressed persons for 7 days after vaccination.
· Special risk groups that should do the influenza vaccination annually include patients with chronic disorders due to cardiovascular or pulmonary problems (including asthma), chronic metabolic diseases (including diabetes mellitus), chronic renal problems, hemoglobinopathies, immunosuppression (including immunosuppression caused by HIV or drugs), pregnancy during influenza period, patients with asplenia (spleen removed), conditions that compromise respiratory function and/or respiratory secretions handling and/or that increase the risk for aspiration (e.g., stroke, seizures, other neuromuscular problems, spinal cord injury, and cognitive impairment), healthcare workers and employees in long-term health care facilities (e.g., nursing homes), nursing home residents, etc.
· Smokers should have a vaccination against influenza (flu)
Pneumococcus (Streptococcus pneumonia) (causes pneumonia & meningitis)
· Vaccination against S. pneumonia (pneumococcus) on all people older than 65. Also, on high-risk groups up to 65 years old.
· Vaccination against pneumococcus is needed in children & adults. The 2 vaccines include the pneumococcal (13-valent pneumococcal conjugate vaccine [PCV13] and the 23-valent pneumococcal polysaccharide vaccine [PPSV23]) vaccination. When indicated, only a single dose of PCV13 is recommended for adults. No additional dosage of PPSV23 is indicated for adults vaccinated with PPSV23 at or after age 65 years. When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit. When indicated, PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.
· On adults aged 65 years or older who have not received PCV13 or PPSV23: they should be administered PCV13 followed by PPSV23 in 6 to 12 months.
· If they have not received PCV13 but have received a dose of PPSV23 at age 65 years or older: they should be administered PCV13 at least 1 year after the dose of PPSV23 received at age 65 years or older.
· If they have not received PCV13 but have received 1 or more doses of PPSV23 before age 65: they should be administered PCV13 at least 1 year after the most recent dose of PPSV23; they should be administered a dose of PPSV23 6 to 12 months after PCV13, or as soon as possible if this time window has passed, and at least 5 years after the most recent dose of PPSV23.
· If they have received PCV13 but no PPSV23 before age 65, they should be administered PPSV23 6 to 12 months after PCV13 or as soon as possible if this time window has passed.
· If they have received PCV13 and 1 or more doses of PPSV23 before age 65, they should be administered PPSV23 6 to 12 months after PCV13, or as soon as possible if this time window has passed, and at least 5 years after the most recent dose of PPSV23.
· Adults aged 19 through 64 years with immunocompromising conditions or anatomical or functional asplenia (defined below) who have not received PCV13 or PPSV23: they should be administered PCV13 followed by PPSV23 at least 8 weeks after PCV13; the second dose of PPSV23 should be administered at least 5 years after the first dose of PPSV23.
· If they have not received PCV13 but have received 1 dose of PPSV23: they should be administered PCV13 at least 1 year after the PPSV23; the second dose of PPSV23 should be administered at least 8 weeks after PCV13 and at least 5 years after the first dose of PPSV23.
· If they have not received PCV13 but have received 2 doses of PPSV23: they should be administered PCV13 at least 1 year after the most recent dose of PPSV23.
· If they have received PCV13 but no PPSV23: they should be administered PPSV23 at least 8 weeks after PCV13; they should be administered a second dose of PPSV23 at least 5 years after the first dose of PPSV23.
· If they have received PCV13 and 1 dose of PPSV23: they should be administered a second dose of PPSV23 at least 5 years after the first dose of PPSV23.
· Adults aged 19 through 64 with cerebrospinal fluid leaks or cochlear implants should be administered PCV13 followed by PPSV23 at least 8 weeks after PCV13.
· Adults aged 19 through 64 years with chronic heart disease (including congestive heart failure and cardiomyopathies, excluding hypertension), chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), chronic liver disease (including cirrhosis), alcoholism, or diabetes mellitus: they should be administered PPSV23.
· Adults aged 19 through 64 who smoke cigarettes or reside in a nursing home or long-term care facilities should be administered PPSV23.
· Immunocompromising conditions that are indications for pneumococcal vaccination are Congenital or acquired immunodeficiency (including B- or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders excluding chronic granulomatous disease), HIV infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, multiple myeloma, solid organ transplant, and iatrogenic immunosuppression (including long-term systemic corticosteroids and radiation therapy).
· Anatomical or functional asplenia are indications for pneumococcal vaccination, such as sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, and splenectomy. Pneumococcal vaccines should be administered at least 2 weeks before immunosuppressive therapy or an elective splenectomy and as soon as possible to adults newly diagnosed with asymptomatic or symptomatic HIV infection.
· Smokers should have a vaccination against influenza (flu) and Streptococcus pneumonia (pneumococcus).
Haemophilus influenzae type b (Hib)
One dose of the Hib vaccine should be administered to persons with anatomical or functional asplenia or sickle cell disease or undergoing elective splenectomy if they have not previously received the Hib vaccine.
Hib vaccination 14 or more days before splenectomy is suggested.
Recipients of a hematopoietic stem cell transplant (HSCT) should be vaccinated with a 3-dose regimen 6 to 12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses.
Hib vaccine is not recommended for adults with HIV infection since their risk for Hib infection is low.
Poliomyelitis (Polio) virus
Most adults do not need the polio vaccine because they were already vaccinated as children. But three groups of adults are at higher risk and should consider polio vaccination in the following situations:
People who are traveling to polio-endemic or high-risk areas of the world. They should ask their healthcare provider for specific information on whether they need to be vaccinated.
People working in a laboratory and handling specimens that might contain polioviruses.
People who are healthcare workers treating patients who could have polio or have close contact with a person who could be infected with poliovirus.
Adults in these three groups who have never been vaccinated against polio should get 3 doses of IPV.
Adults in these three groups who have had 1 or 2 doses of the polio vaccine in the past should get the remaining 1 or 2 doses. It doesn’t matter how long it has been since the previous dose(s).
Adults at increased risk of exposure to poliovirus and who have previously completed a regular series of polio vaccines (IPV or OPV) can receive one - lifetime booster dose of IPV.
Sexually transmitted infections (STIs)
· Safe sex counseling for everyone (condom use & contraception, but mention the side effects and contraindications, e.g., migraine, deep vein thrombosis (DVT), etc.) and complications (e.g., liver problems, breast cancer, endometrial cancer, pulmonary embolism risk, etc.).
· Chlamydia, gonorrhea, HIV, hepatitis B (and C), HSV, and syphilis testing for high-risk sexual behavior or history of STDs.
· Pap test (cervical smear for cytology) for cervical cancer prevention starting from the beginning of sexual life.
STIs screening
· Safe sex and contraceptive counseling for sexually active females.
· Below is a brief overview of STD testing recommendations:
· All adults and adolescents aged 13 to 64 should be tested at least once for HIV.
· Annual chlamydia screening of all sexually active women younger than 25 years and older with risk factors such as new or multiple sex partners or a sex partner with a sexually transmitted infection.
· Annual gonorrhea screening for all sexually active women younger than 25 years and older with risk factors such as new or multiple sex partners or a sex partner with a sexually transmitted infection.
· Syphilis, HIV, chlamydia, and hepatitis B screening for all pregnant women, and gonorrhea screening for at-risk pregnant women starting early in pregnancy, with repeat testing as needed, to protect the health of mothers and their infants.
· Screening at least once a year for syphilis, chlamydia, and gonorrhea for all sexually active gay, bisexual, and other men who have sex with men (MSM). MSM with multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6-month intervals).
· Anyone practicing unsafe sex or sharing injection drug equipment should get tested for HIV at least once a year. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months).
· Gynecological pelvic examination for women
· The American College of Obstetricians and Gynecologists (ACOG) has issued updated guidelines for annual ‘Well Woman’ assessments with specific recommendations on when to perform pelvic exams in asymptomatic women and when to begin clinical breast exams.
· ACOG recommends that pelvic exams be performed only when indicated by medical history for patients younger than 21 years. No evidence supports the routine exam for an asymptomatic patient before age 21 years, ‘although it is recognized that pelvic pathology sometimes is identified by a pelvic examination on an asymptomatic patient.’ Speculum exams for cervical cancer screening should begin at the age of 21 years, irrespective of the sexual activity of the patient.
· ACOG recommends yearly full pelvic examinations for patients aged 21 years and older but notes that the advice is based on ‘expert opinion, and limitations of the internal pelvic examination should be recognized.’ For example, the bimanual examination is useful for evaluating the uterus but has a low sensitivity for detecting ‘adnexal masses,’ which include ovarian cysts and ectopic pregnancies.
· Although annual pelvic exams for women older than twenty-one seem ‘logical,’ the opinion notes that ‘[n]o evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient.’ Also, no data exists on when and how often to perform the exam. Whether or not to perform a complete pelvic examination ‘should be a shared decision after a discussion between the patient and her health care provider.’
· The exam is always appropriate for patients with symptoms ‘suggestive of female genital tract problems. These include menstrual disorders, vaginal discharge, infertility, or pelvic pain. Perimenopausal patients with abnormal uterine bleeding, changes in bowel or bladder function, or vaginal discomfort should have a pelvic examination. The exam is also called for in older, menopausal women with abnormal bleeding, vaginal bulge, urinary or fecal incontinence, or vaginal dryness.
HPV (human papillomavirus)
· There are more than one hundred types of HPV. About thirty or so types can cause genital infections. Some can cause genital warts. Other types can cause cervical or other genital cancers. The other seventy or so HPV types can cause infections and warts elsewhere on the body, such as on the hands. Certain HPV types are classified as ‘high-risk’ because they lead to abnormal cell changes and can cause genital cancers: cervical cancer and cancer of the vulva, anus, and penis. Researchers say that virtually all cervical cancers – more than 99% – are caused by these high-risk HPV viruses. The most common high-risk strains of HPV are types 16 and 18, which cause about 70% of all cervical cancers. If the body clears the infection, the cervical cells return to normal. But if the body doesn't clear the infection, the cells in the cervix can continue to change abnormally. This can lead to precancerous changes or cervical cancer. HPV can also invade the mouth during oral sex. Those infections usually cause no symptoms, but a lingering infection with a cancer-linked strain can lead to oropharyngeal cancer.
Prevention of osteoporosis
Screening for osteoporosis in all postmenopausal women.
Risk factors for osteoporosis:
a) Non - modifiable risk factors:
· Personal history of fracture as an adult
· History of a fracture in a first-degree relative
· White race
· Advanced age
· Female sex
· Dementia
· Poor health/ fragility.
b) Modifiable risk factors:
· Current cigarette smoking
· Low body weight (< 127 lbs. (57 Kg))
· Low lifelong calcium intake
· Alcoholism
· Impaired eyesight despite adequate correction
· Recurrent falls
· Inadequate physical activity
· Estrogen deficiency, e.g., early menopause, bilateral ovariectomy, prolonged premenopausal amenorrhea
Corticosteroids also increase the risk of osteoporosis.
Indications for Bone Mineral Density (BMI) testing from the International Society for Clinical Densitometry:
a) All women aged sixty-five and older.
b) All men aged seventy and older.
c) Adults with a fragility fracture.
d) Adults with a disease or condition associated with low bone density.
e) Anyone being treated for low bone density to monitor the treatment effect.
f) Anyone not receiving therapy for whom evidence of bone loss would lead to treatment.
Recommendations from the USPSTF (2011):
The USPSTF recommends screening for osteoporosis in women aged 65 years and older and younger women whose fracture risk is equal to or greater than that of 65-year-old white women with no additional risk factors.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.
The sensitivity of USPSTF was 24%, specificity was 83%, the positive predictive value was 12%, the negative predictive value was 92%, and the area under the curve was 0.62, or just slightly better than chance alone. The number needed to be scanned to detect one case of osteoporosis was nine.
Workup for osteoporosis consists of laboratory studies to establish baselines, look for potential secondary causes of osteoporosis, and measure BMD (bone mineral density) to assess bone loss and estimate fracture risk. Densitometry techniques include single-photon absorptiometry (SPA), dual-photon absorptiometry (DPA), dual-energy x-ray absorptiometry (DXA), and quantitative computed tomography (QCT).
The primary imaging modalities used to measure BMD are DXA, QCT, and quantitative ultrasound. Currently, DXA is the most accurate and recommended method for BMD measurement. It can detect changes in bone density only 6-12 months after a previous BMD measurement.
Quantitative CT is an alternative to DXA useful in patients with very small or considerable body sizes, older patients with advanced degenerative disease or morphological abnormalities, and patients treated with parathyroid hormone or corticosteroids. It allows for the measurement of trabecular and cortical bone mineral density. Nuclear medicine does not have an established role in bone density screening; however, it is an essential tool in evaluating occult fractures. Quantitative ultrasonography of the calcaneus is an alternative to general screening. It relies on the principle of sound wave attenuation, which depends on the bone mineral density and macroscopic architecture. However, as the index measurement does not directly correlate with BMD, some studies have shown a weak correlation with measurements obtained from DXA scans.
Home safety counseling to avoid falls (that are a pandemic among the elderly with osteoporosis and a significant cause of death and fractures such as a hip fracture), e.g., avoid climbing a ladder or a small chair (e.g., removing the curtains for washing), climbing stairs while on physical disability, etc. Visual (eye) and balance (e.g., ataxia or ear problems from the labyrinth or neurological problems that cause vertigo) problems also contribute to falls.
Denosumab is a new treatment for osteoporosis with high efficiency in treating this disease. It is also beneficial for pain due to osteoporotic fractures (e.g., on the spine's vertebrae). It contains monoclonal antibodies, and its mechanism inhibits the maturation of osteoclasts (cells that break down the bone) by binding to and inhibiting RANKL.
Abdominal aortic aneurysm screening
Abdominal ultrasound for AAA (abdominal aortic aneurysm) screening in men over fifties, especially in smokers.
The U.S. Preventive Services Task Force recommends one-time screening for abdominal aortic aneurysm (AAA) for men aged 65 – 75 who have smoked at least one hundred cigarettes in their lifetime.
Screening should be routinely recommended only when a positive net benefit (benefits outweigh harms) exists. There is good evidence that screening and surgical repair of large aneurysms (5.5 cm or higher) in men 65 – 75 years of age who have ever smoked leads to decreased AAA-related deaths.
Only men aged 65 – 75 who have ever smoked have a net benefit from screening for AAA. This group stands to benefit the most from early detection and reparative surgical treatment due to a relatively higher prevalence of larger AAAs compared to other patient groups.
Men aged 65 – 75 who have never smoked and men younger than 65 are at lower risk for AAAs, particularly AAAs of a size likely to rupture.
Men over 75 are at higher risk for AAAs, but the increased presence of comorbidities and limited life expectancy decreases the likelihood that they will benefit from screening.
Women are at lower risk for AAAs. Thus, the net benefit from screening is small, and routine screening is not recommended.
Prevention of dental caries & plaque
An annual dental test by a dentist is important to screen for dental caries & dental plaque (a biofilm or mass of bacteria that grows on surfaces within the mouth).
· Tooth brushing after every meal (or at least after the three main meals: in the morning, lunch & dinner), especially if the meal is rich in carbohydrates and especially sugar. Stevia is a safe sweetener, but other artificial sweeteners (including cyclamate and aspartame) have been connected in lab tests with various adverse effects, including cancer when consumed in the long term. Fructose is not an optimal alternative as it may cause fatty liver disease.
· After tooth brushing in the evening, a mouthwash (rinse) is advised with oral fluids containing zero alcohol (as alcohol relates to oral cancer, according to Australian research of 2009).
· Dental products containing Sanguinaria canadensis (bloodroot) may cause oral leukoplakia (a precancerous lesion; also common in smokers & alcohol abusers).
· Some dentists say chewing sugarless gums after a meal or a drink (if tooth brushing is unavailable) may prevent dental caries, mainly if they contain xylitol, a sugar alcohol used as a sweetener.
Thanks for reading!
Reference
Bibliography
Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J.L., Loscalzo J.L., Harrison’s Manual of Medicine, 18th edition, McGraw–Hill, 2013.
Longmore M., Wilkinson I.B., Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, 8th edition, Oxford University Press, 2010.
Ahmed N., Clinical Biochemistry, Oxford University Press, 2010.
Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.
Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.
Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.
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Disease prevention & health maintenance, p. 1103 – 1130, Harrison’s Manual of Medicine, Fauci A.S., Braunwald E.B., Kasper D.L., Hauser S.L., Longo D.L., Jameson J.L., Loscalzo J., 17th edition, Mc Graw Hill Medical, 2009. mcgraw-hillmedical.com
Screening in the future, p. 160 – 161, Oxford Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick, 2nd edition, Oxford University Press,2005. www.oup.com
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