PREVENTIVE MEDICINE
Vaccines
Smoking cessation
AAA screening
Lipids
DM Screening
Osteoporosis
Cancer screening - Oncology
...
VACCINATIONS
MMR Vaccine
Indicated for all persons
born after 1957
MMR
Absolute contraindications
– Anaphylactic reaction to eggs is no longer a
contraindication to MMR.
– Pregnancy
– Immun...
Note:
Pregnant women should wait to get
MMR vaccine until after they have
given birth. Women should avoid
getting pregnant...
Influenza
Inactivated vaccine
Indications

Age 65 years and older
Children aged 6 months to 18 years
Nursing Home resident...
Meningococcal Vaccine
A routine vaccination ( Meningococcal
conjugate vaccine, MCV4) is recommended at
age 11-12 years or...
Meningococcal vaccine
The populations at increased risk for
meningococcal disease:
college freshmen living in dormitories
...
Chemoprophylaxis

The primary mode of prevention of sporadic
meningococcal disease involves antimicrobial
chemoprophylaxis...
Chemoprophylaxis
One of the following chemo-prophylactic agents can
be used
Rifampin : can be used in children and adults....
Who are defined Close contacts for patients with
Menigococcal disease?
Close contacts of a patient who has meningococcal
d...
Quiz
A 24 y/o college freshman who lives in a dormitory brought
to the ER with complaints of fever, headache and neck
stif...
Pneumococcal Vaccine
Two types
Pneumococcal Conjugate vaccine ( 7 valent – PCV7)
– pediatric vaccine, given to infants and...
Pneumococcal Conjugate Vaccine

Infants and Children Under 2 Years of Age

PCV is given as a series of 4 doses, one dose a...
Pneumococcal Polysaccharide Vaccine
Children under < 2yrs of age may not respond to this vaccine
– so, not used.
Indicatio...
PPV – Repeat Dose
One dose of PPV is sufficient. In some conditions,
a second dose is indicated :
For those people aged 65...
Hepatitis A vaccine

Indications

– Persons traveling to or working in countries endemic with infection
(Start vaccine at ...
Hepatitis B Vaccine
Children and Adolescents

All children should get their first dose of hepatitis B vaccine at
birth and...
Polio
Indications
Health care workers in close contact with
patients excreting wild poliovirus or who
handle lab specimens...
Polio Vaccine
Contraindications
IPV:
Pregnancy
Anaphylactic allergy to streptomycin or
neomycin.
OPV:
If the Vaccine recip...
HIV and Immunization
–
–
–
–

–
–

–
–
–
–
–

Live Vaccines that are contraindicated in HIV

Varicella Vaccine
Oral Polio Vaccine ( IPV is safe...
Varicella Zoster
Causes Chickenpox and Herpes Zoster
Chicken pox – primary infection.
Shingles is an activation of laten...
Varicella Vaccine

Popular brand – Varivax
Live virus vaccine
Indications ( CDC 1999)

Children > 1 year of age without pr...
Varicella Vaccine – Evidence of immunity
Evidence of immunity includes
– Documentation of two doses of varicella vaccine
–...
Varicella Vaccine
Contraindications

– in pregnancy ( to prevent congenital varicella). Also, women should
not get pregnan...
VZIG

Varicella zoster immune globulin (VZIG) used to prevent
disease after exposure to chickenpox  But it is costly
and ...
Quiz
A 8 years old boy brought to you by his
mom for office visit. He is healthy and
attends school. One of his friends at...
Varicella Zoster Vaccine
Popular brand – Zostavax
A live attenuated vaccine of VZV
Indicated in elderly patients age equal...
VZV vaccine – Why important?
Vaccine reduces incidence of herpes
zoster by 50% ( Number needed to treat
= 60 i.e; 60 patie...
Vaccination in Pregnancy
A. These vaccines only have a very Small risk in controlled animal studies
– Td (Tetanus and Diphtheria Toxoid) - Give aft...
MMR - Pregnancy
Measles-mumps-rubella (MMR) vaccine and its component
vaccines should not be administered to pregnant wome...
Quiz
A 35 y/o woman comes for an antenatal visit. Her
LMP was 8 weeks ago. She tells you that she 2
weeks after she missed...
Yellow fever Vaccine
Live attenuated vaccine
Indications: Travel to Yellow Fever
endemic areas
Sub-Saharan Africa
Amazon b...
Human Papilloma Virus Vaccine ( Gardasil)

Indications
Prevention of Cervical Dysplasia – use in
women routinely at age 12...
Smoking Cessation
Smoking Cessation
At first visit, ask patient for tobacco use.

(The USPSTF strongly recommends that clinicians screen all...
Smoking Cessation
Drug interventions : These interventions
are aimed to reduce the withdrawl
symptoms in a patient who has...
USPTF Recommendation Grades
A—Strongly Recommended: The USPSTF
strongly recommends that clinicians provide
[the service] t...
Dyslipidemia
Screening!
USPTF Recommendations

Screening Men

Screen all men aged 35 and older for lipid disorders (Grade A)
Screening men aged 20...
Lipid Screening
All these patients should get a
fasting lipid panel as a screening test
: In general, screen people with
i...
When to stop?
There are no data on at what age
screening should be stopped.
However, available data suggest that
lipid-low...
Type 2 DM
Screening
Screening is with Fasting blood sugar –
fasting blood sugar greater than or equal to
126 mg% , on tw...
USPTF Recommendations

Screen all asymptomatic patients with
sustained blood pressure ( either treated
or untreated) > 135...
OSTEOPOROSIS
Screen with DEXA scan
Start Calcium + vitamin D in post
menopausal Women
Rx with Bisphosphonates
Prevent ...
USPTF Recommendations
All women aged 65 and older be screened
routinely for osteoporosis. (Grade B)
For women with risk fa...
Steroid Induced Osteoporosis
In patients requiring prolonged
steroid therapy ( > 3 months) :
Use calcium and vitamin D to ...
Abdominal Aorta Aneurysm
AAA Screening and Treatment
Probable Risk Factors

Risk Factors for Abdominal Aortic
Aneurysm

OR or RR

Importanc
e

Age >60 years

OR, 1.93

High

M...
AAA
“Consider a history of
AAA in a first-degree
relative to be a strong
predictor of risk”
Key Points because it is
Use ultrasound to screen for AAA,

more sensitive and specific than abdominal
palpation.
Recommen...
AAA
Be aware that physical exam is only moderately
sensitive for detecting an AAA >5.0 cm in diameter
and is even less sen...
Spectrum of presentation - AAA
Recognize that AAA can be:
Asymptomatic
Incidentally noted on abdominal
examination or an i...
CASE STUDY

A 68-year-old asymptomatic man comes to the office for
his health maintenance examination. He has a 5-year
his...
Ans. B
Surgery for abdominal aortic
aneurysm is indicated if the
aneurysm is symptomatic, exceeds
5.0 to 5.5 cm in diamete...
Fall Prevention
Under Neurology
Safety issues in children
 Crib safety
Avoiding thermal injuries
Crib safety
crib bars should not be more than 2 inches apart.
Use bumpers to avoid suffocation from mattresses
and to prev...
Jet Lag
Jet Lag
General Advise :
Avoid Alcohol and Caffeine
Maintain adequate hydration
Coordinate extended sleep during flight to...
Cancer Screening
-Normal risk population vs.
High risk population
-Oncology section
Upcoming SlideShare
Loading in …5
×

Preventive medicine

993 views

Published on

ARCHER NOTES

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
993
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
64
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Preventive medicine

  1. 1. PREVENTIVE MEDICINE Vaccines Smoking cessation AAA screening Lipids DM Screening Osteoporosis Cancer screening - Oncology Seat belts Safety issues in children Jet Lag ARCHER ONLINE USMLE REVIEWS WWW.CCSWORKSHOP.COM All rights reserved
  2. 2. VACCINATIONS
  3. 3. MMR Vaccine Indicated for all persons born after 1957
  4. 4. MMR Absolute contraindications – Anaphylactic reaction to eggs is no longer a contraindication to MMR. – Pregnancy – Immunodeficiency ( in HIV, MMR is recommended if CD4 > 200 as benefits outweigh risks ) Conditions that are not a contraindication to vaccine – – – – – Tuberculosis or positive PPD Lactation Pregnancy in household contact or mother Household contact with Immunodeficiency (e.g. HIV) Anaphylactic reaction to egg or neomycin is no longer a contraindication to MMR
  5. 5. Note: Pregnant women should wait to get MMR vaccine until after they have given birth. Women should avoid getting pregnant for 4 weeks after getting MMR vaccine.
  6. 6. Influenza Inactivated vaccine Indications Age 65 years and older Children aged 6 months to 18 years Nursing Home residents Patients with Chronic cardiopulmonary disease (e.g. Asthma): any age Long term Aspirin use under age 18 years - Prevents Reye's Syndrome People who can serve as vectors – Health care workers , Nursing home personnel , Family members of high risk patients, Families and child care workers caring for children under age 5 years Students in Institutional settings Pregnancy – 2nd or 3rd tromester Human Immunodeficiency Virus Breast Feeding – – – Contraindications Age under 6 months Anaphylaxis to eggs or other vaccine components Acute febrile illness ( Temp > 104 F)
  7. 7. Meningococcal Vaccine A routine vaccination ( Meningococcal conjugate vaccine, MCV4) is recommended at age 11-12 years or at high school entry if not previously vaccinated ( age 15 years) MPSV4 should be used for children 2 to 10 years old, and adults over 55, who are at risk  In other age groups, recommended for patients who are at increased risk of meningococcal disease
  8. 8. Meningococcal vaccine The populations at increased risk for meningococcal disease: college freshmen living in dormitories microbiologists who are routinely exposed to isolates of N. meningitdis military recruits persons who travel to or reside in countries in which N. meningitdis is hyperendemic or epidemic, particularly if contact with the local population will be prolonged persons who have terminal complement component deficiencies persons who have anatomic or functional asplenia or in HIV patients
  9. 9. Chemoprophylaxis The primary mode of prevention of sporadic meningococcal disease involves antimicrobial chemoprophylaxis of close contacts of a patient with invasive meningococcal disease). (YOU SHOULD KNOW WHO IS A CLOSE CONTACT!!) Who needs it? – all close contacts of a patient with meningococcal disease. Oropharyngeal or nasopharyngeal cultures of contact are not useful in determining the need for chemoprophylaxis ( don’t do them) When ? Chemoprophylaxis should be given ASAP (ideally <24 hours after identification of the index patient) because the rate of secondary disease for close contacts is highest immediately after onset of disease in the index patient, chemoprophylaxis given after 14 days of onset of illness in the index patient is of no value.
  10. 10. Chemoprophylaxis One of the following chemo-prophylactic agents can be used Rifampin : can be used in children and adults. Not recommended in pregnancy due to teratogenecity in animals. Also, remember contraceptive failure can occur from Rifampin interaction with OCPills  so, if a reproductive age group women is taking Rifampin counsel her regarding the use of alternative contraceptive measures while taking Rifampin Ciprofloxacin : can be used in adults. Not recommended for people < age of 18 years and in Pregnancy or lactation because it was known to cause cartilage damage inimmature experimental animals. However, literature review indicates no reports of irreversible cartilage damage in children or adolescents  so, if no other alternative is available, it can be used for chemoprophylaxis in this age groups. Ceftriaxone : single IM dose – 250mg in adults and 125mg in children
  11. 11. Who are defined Close contacts for patients with Menigococcal disease? Close contacts of a patient who has meningococcal disease include household members child-care center contacts persons directly exposed to the patient’s oral secretions (e.g., by kissing, mouth-to-mouth resuscitation, endotracheal intubation,or endotracheal tube management). (REMEMBER  People in the same household or day-care center, or anyone with direct contact with a patient's oral secretions (such as a boyfriend or girlfriend) is at increased risk of acquiring the infection )
  12. 12. Quiz A 24 y/o college freshman who lives in a dormitory brought to the ER with complaints of fever, headache and neck stiffness. Lumbar puncture revealed gram negative diplococci. He was started on ceftriaxone and vancomycin. However, over the next two hours he develops complicated disease with renal failure and purpura. He becomes comatose and was intubated by the anesthetist for airway protection. After knowing that the patient likely has a meningococcal disease, the ER staff, the anesthetist and the residents who initially cared for the patient are very concerned and requests chemoprophylaxis. What is the most appropriate course of action? Give Rifampin to the resident who collected blood from the patient Give Rifampin to the anesthetist Give Ceftriaxone to the RN who took care of the patient Give Rifampin to the ER physician who initially evaluated the patient
  13. 13. Pneumococcal Vaccine Two types Pneumococcal Conjugate vaccine ( 7 valent – PCV7) – pediatric vaccine, given to infants and toddlers < 2 yrs of age) Pneumococcal Polysaccharide vaccine ( 23 valent vaccine - PPV)  Adult vaccine, given to adult children > 2yrs of age and adults with certain chronic illnesses) Pneumococcal vaccine is indicated because it can reduce common Streptococcus Pneumoniae infections (age <6) Community acquired Pneumonia Otitis media Bacterial Meningitis Prevents Streptococcus bacteremia
  14. 14. Pneumococcal Conjugate Vaccine Infants and Children Under 2 Years of Age PCV is given as a series of 4 doses, one dose at each of these ages: 2 months, 6 months, 4 months and 12-15 months Children who miss their vaccines at these ages should still get the vaccine. The number of doses and the intervals between doses will depend on the child’s age. Children 2 through 4 Years of Age Healthy children between their 2 through 4 years of age who have not completed the PCV series should get 1 dose. Children with medical conditions such as: – -sickle cell disease – Asplenia, – Cochlear implants, – HIV/AIDS or other diseases that affect the immune system (such as diabetes, cancer, or liver disease) – chronic heart or lung disease – children on immunosuprressive medications medications such as chemotherapy or steroids IN THESE CHILDREN, GIVE 2 DOSES 2 MONTHS APART IF THEY HAVE NOT COMPLETED THE FOUR DOSE SERIES. Age 5 years or older  this vaccination not recommended
  15. 15. Pneumococcal Polysaccharide Vaccine Children under < 2yrs of age may not respond to this vaccine – so, not used. Indications: All adults 65 years of age or older. Anyone over 2 years of age who have chronic illness : heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis Anyone over 2 years of age with immunosuppressive disease/ condition: Hodgkin’s disease, lymphoma, leukemia, kidney failure, multiple myeloma, nephrotic syndrome, HIV infection or AIDS, damaged spleen, or no spleen, organ transplant Anyone over 2 years of age taking immunosuppressive therapy long-term steroids, certain cancer drug, radiation therapy Alaskan Natives and certain Native American populations. One dose of PPV is sufficient. However, in some classes two doses recommended – next slide Pregnancy ?  the safety of pneumococcal vaccine in pregnancy not established. Women who are at risk for this infection should get vaccinated prior to their pregnancy.
  16. 16. PPV – Repeat Dose One dose of PPV is sufficient. In some conditions, a second dose is indicated : For those people aged 65 and older who got their first dose when they were under 65, if 5 or more years have passed since that dose. A second dose is also recommended for people who: - have a damaged spleen or no spleen - have sickle-cell disease - have HIV infection or AIDS - have cancer, leukemia, lymphoma, multiple myeloma - have kidney failure - have nephrotic syndrome - have had an organ or bone marrow transplant - are taking medication that lowers immunity (such as chemotherapy or long-term steroids) In Children 10 years old and younger, give this second dose 3 years after the first dose. If older than 10, give it 5 years after the first dose.
  17. 17. Hepatitis A vaccine Indications – Persons traveling to or working in countries endemic with infection (Start vaccine at least 4 weeks before departure ) – Men who have sex with men – Drug use – Persons who work with HAV-infected primates or with HAV in a research laboratory setting – Persons with chronic liver disease – Persons with clotting factor disorders – Food handlers where health authorities or private employers determine vaccination to be cost-effective – All children as Primary Series at age 1 year (New recommendation in U.S. as of 2006 ) – children may act as reservoirs/vaccination may eradicate infection from population NOTE : HAV vaccine is safe in HIV patients – but having HIV itself is not an absolute indication. HAV vaccine should be given to all HIV pts that are at risk or those who have HCV to avoid fulminant hepatitis Contraindications: A history of hypersensitivity to alum or the preservative 2-phenoxyethanol
  18. 18. Hepatitis B Vaccine Children and Adolescents All children should get their first dose of hepatitis B vaccine at birth and should have completed the vaccine series by 6-18 months of age. Children and adolescents through 18 years of age who did not get the vaccine when they were younger should also be vaccinated. Adults : All unvaccinated adults at risk for HBV infection should be vaccinated. This includes: sex partners of people infected with HBV, men who have sex with men, IV Drug users people with more than one sex partner, chronic liver or kidney disease, Health care/ lab workers handling human blood household contacts of people infected with HBV, residents and staff in institutions for the developmentally disabled Hemodialysis Patients HIV Patients Contraindications  Anaphylactic reaction to baker's yeast
  19. 19. Polio Indications Health care workers in close contact with patients excreting wild poliovirus or who handle lab specimens from such patients. Travelers to developing countries In immunocompromised patients ( hiv), if polio vaccine is indicated – give IPV. Household members and nursing personnel in close contact with immunocompromised patients should not receive OPV ( They should be given IPV)
  20. 20. Polio Vaccine Contraindications IPV: Pregnancy Anaphylactic allergy to streptomycin or neomycin. OPV: If the Vaccine recipient or if prospective vaccine recepient;’s household contact is immunodeficient or immunosuppressed (including HIV infection) Pregnancy - only a relative contraindication. If immediate protection is needed, use OPV. • Anaphylactic allergy to neomycin or streptomycin
  21. 21. HIV and Immunization
  22. 22. – – – – – – – – – – – Live Vaccines that are contraindicated in HIV Varicella Vaccine Oral Polio Vaccine ( IPV is safe) Oral typhoid vaccine ( parenteral inactivated typhoid vaccine is safe alternative) Yellow fever vaccine (Yellow fever vaccine virus poses a theoretical risk of encephalitis to those with severe immunosuppression or known HIV infection  such patients should not receive the vaccine. If travel to an endemic area unavoidable, patients should be advised of the risk, instructed in methods for avoiding vector mosquitos, and supplied with vaccination waiver letters by their physicians . Live Vaccines in HIV that are indicated because Benefit exceeds Risk Measles Mumps Rubella Vaccine (MMR Vaccine) Non-Live Vaccines indicated in HIV Immunogenecity will be better if the CD4 count is higher. If you are starting HAART, Consider delaying the vaccination until CD4 Count>200. Vaccination is optional in patients with low CD4 despite therapy. Pneumovax Vaccine Given after diagnosis and then every 6 years Conjugated H Influenza type b capsular vaccine Influenza Vaccine ( Inactivated vaccine) Hepatitis A Vaccine (it’s a killed vaccine) in at risk patients and those with HCV Hepatitis B Vaccine if anti-hbs is negative.
  23. 23. Varicella Zoster Causes Chickenpox and Herpes Zoster Chicken pox – primary infection. Shingles is an activation of latent virus
  24. 24. Varicella Vaccine Popular brand – Varivax Live virus vaccine Indications ( CDC 1999) Children > 1 year of age without prior infection In adults who never have been vaccinated or never had chicken pox for Post chicken pox -exposure vaccination within 3-5 days  can reduce the incidence of chickenpox Non Pregnant women of childbearing age who are not immune (Pregnant women should wait until after they give birth to receive the vaccine. Women should not get pregnant until four weeks after the vaccine) Susceptible family members and other contacts of HIV-infected or immunodeficient persons should receive the chickenpox vaccine, because of the risk that natural chickenpox and its complications present for these patients. persons who live or work in environments in which transmission of VZV is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings) persons who live and work in environments in which transmissioncan occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel) international travelers adolescents and adults living in households with children. CDC (2007)  RECOMMENDS VACCINATION FOR ALL ADULTS AND ADOLESCENTS WITHOUT EVIDENCE OF IMMUNITY ( Check antibody, if not present just immunize) Many states have mandatory requirement of chicken pox immunization prior to attending child care centers, students in all grade levels, persons attending college or other postsecondary educational institutions  evidence of immunization needs to be submitted before entering the institution eg: evidence of immunity includes – see next slide 
  25. 25. Varicella Vaccine – Evidence of immunity Evidence of immunity includes – Documentation of two doses of varicella vaccine – Blood tests that show you are immune to varicella or laboratory confirmation of prior disease – Born in the United States before 1980, excluding health-care workers, pregnant women, and immunocompromised persons. These individuals need to meet one of the other criteria for evidence of immunity. – Receipt from a healthcare provider of a) a diagnosis of chickenpox or b) verification of a history of chickenpox – Receipt from a healthcare provider of a) a diagnosis of herpes zoster (shingles) or b) verification of a history of herpes zoster (shingles). No need the chickenpox vaccine, if any of the above criteria for evidence of immunity is met
  26. 26. Varicella Vaccine Contraindications – in pregnancy ( to prevent congenital varicella). Also, women should not get pregnant for four weeks following vaccination – Anaphylactic reaction to neomycin – Active Tuberculosis. – Should not be given for 5 months following the receipt of antibodycontaining (e.g., blood transfusion) products ( as it can inactivate vaccine virus) – Hx of congenital immune deficiency in a first degree relative – Immunosuppressed patients eg: AIDS (remember mild HIV is not a contraindication. Should be considered for HIVinfected children with age specific CD4+ T-lymphocyte lymphocyte percentages >15% and may also be considered in adults with CD4 > 200 ), high dose steroids – May be safe in Lactation – Realize that low grade fever, pregnant family member are not a contraindication Vaccine protocol ( CDC – 2007 recommendations require 2 doses for all age groups listed) Age under 13 years – Administer 2 doses recommended - 1st dose at age 12–15 months - 2nd dose at age 4–6 years If giving after age over 13 years – give 2 doses 2 doses, 4–8 weeks apart If giving in early HIV – give 2 doses 3 months apart
  27. 27. VZIG Varicella zoster immune globulin (VZIG) used to prevent disease after exposure to chickenpox  But it is costly and only provides temporary protection  hence, VZIG is recommended only for those at high risk of developing severe disease who are not eligible to receive chickenpox vaccine. (All other patients should get varivax in 3-5 days post exposure) The groups that cannot get Varivax and hence, the need for VZIG : Newborns whose mothers have developed chickenpox 5 days prior to 2 days after delivery ( un vaccinated newborns of these mothers may develop fatal varicella) Premature babies exposed to varicella in the first month of life Children with leukemia or lymphoma who have not been vaccinated Persons with cellular immunodeficiencies or other immune system problems eg: Advanced HIV Persons receiving immunosuppressive medications – high dose steroids, immunosuppressants etc Pregnant women VZIG  best effective only if given within 96 hrs of exposure to Varicella (chickenpox) or to Zoster. Rx after 96 hrs is of uncertain value. Varicella vaccine and VZIG never given together ( varicella is a live vaccine and will be ineffective) Contraindications : hx of prior serious reaction to human immunoglobulin or severe thrombocytopenia
  28. 28. Quiz A 8 years old boy brought to you by his mom for office visit. He is healthy and attends school. One of his friends at school became sick with chickenpox. Boy didn't get any chickenpox vaccine before. Mom asks you what to do? 1. Give Ig. 2.give vaccine 3. Give Ig and vaccine. 4 do nothing 5. Give acyclovir
  29. 29. Varicella Zoster Vaccine Popular brand – Zostavax A live attenuated vaccine of VZV Indicated in elderly patients age equal to or greater than 60 to prevent herpes zoster and to reduce its sequelae such as post herpetic neuralgia. Dose : given 0.65 ml sub cutaneous in deltoid Contraindications : ( Realize that the virus load injected here is 14 times greater than in Varivax) – Hx of anaphylactic reaction to Gelatin, Neomycin or any other vaccine components. – Hx of immunodeficiency eg: leukemia, lymphoma, advanced HIV – Persons with active, untreated tuberculosis – Persons receiving immunosuppressive therapy, including high dose steroids. – Concomitant acute febrile illness with fever > 102 Side effects : Rash similar to chicken pox or Shingles can commonly occur after vaccine. Immunity lasts for 4 years
  30. 30. VZV vaccine – Why important? Vaccine reduces incidence of herpes zoster by 50% ( Number needed to treat = 60 i.e; 60 patients need to be treated to prevent one case. NNT = 1/incidence  so realize that higher incidence can mean lower NNT, making the successful intervention more cost effective.)  so, since shingles is more common in age > 60, vaccine is most cost effective in this age group. Post herpetic neuralgia is the most debilitating complication of Herpes Zoster  VZV vaccine reduces PHN by 66%
  31. 31. Vaccination in Pregnancy
  32. 32. A. These vaccines only have a very Small risk in controlled animal studies – Td (Tetanus and Diphtheria Toxoid) - Give after first trimester if the last dose was more than 10 years – Hepatitis A Vaccine -Give if patient is travelling to endemic area or hx of IVDA in pregnancy – Hepatitis B Vaccine - Recommended in pregnancy if they have Hepatitis B risk factor (having more than one sex partner during the previous 6 months, been evaluated or treated for an STD, recent or current injection drug use, or having had an HBsAg-positive sex partner – Influenza Vaccine - Indicated in all pregnan woman in Influenza season, Give after first trimester ( inactivated vaccine should be used. Not live attenuated influenza vaccine) – Polyvalent pneumococcal Vaccine - preferably, avoid during pregnancy – Polio Vaccine (live and inactivated) - Avoid during pregnancy. But if high risk polio exposure may give IPV – Rabies Vaccine for post exposure prophylaxis B. These vaccines have strong evidence of risk to the human fetus – Yellow Fever Vaccine (Live vaccine) – AVOID! ( should be given only if travel to endemic area is unavoidable and if risk of exposure determined as high) C. These have Very high risk to the human fetus : CONTRAINDICATED! – Measles Vaccine – Mumps Vaccine – Rubella Vaccine – BCG vaccine – Small Pox Vaccine ( but pregnant women with defibitive evidence of small pox exposure should be vaccinated as benefit outweighs risk ) – Varicella Vaccine (Varivax) – theoretic risk of congenital varicella. So, avoid! If pregnant woman is exposed to chicken pox, use VZIG D. Quadrivalent HPV vaccine is not recommended for use in pregnancy. ( Data
  33. 33. MMR - Pregnancy Measles-mumps-rubella (MMR) vaccine and its component vaccines should not be administered to pregnant women. A risk to the fetus from administration of these live virus vaccines cannot be excluded for theoretical reasons  So, women should be counseled to avoid becoming pregnant for 28 days after vaccination with MMR or its components. If vaccination of an unknowingly pregnant woman occurs or if she becomes pregnant within 4 weeks after MMR vaccination, she should be counseled about the theoretical basis of concern for the fetus  Remember, however, MMR vaccination during pregnancy should not be regarded as a reason to terminate pregnancy Rubella-susceptible women who are not vaccinated because they state they are or may be pregnant should be counseled about the potential risk for CRS and the importance of being vaccinated as soon as they are no longer pregnant.  but, never give vaccine during pregnancy. Women who inadvertently received Rubella vaccine should be counseled about theoretical risk of CRS but its not an indication to terminate pregnancy  A registry of susceptible women vaccinated with rubella vaccine between 3 months before and 3 months after conception – the "Vaccine in Pregnancy (VIP) Registry" – was kept between 1971 and 1989. No evidence of CRS occurred in the offspring of the 226 women who received the current RA 27/3 rubella vaccine and continued their pregnancy to term.
  34. 34. Quiz A 35 y/o woman comes for an antenatal visit. Her LMP was 8 weeks ago. She tells you that she 2 weeks after she missed her menstrual period she checked herself with home pregnancy kit and tested positive. She is concerned now because she received Rubella vaccination 4 weeks ago after an exposure without knowing that she was pregnant. She read about the dangers to fetus on the internet and is very worried now. The next step in management : A. Refer her to medical termination of pregnancy B. Tell her that there is a high established risk to fetus and she should strongly consider termination of pregnancy C. Counsel her about theoretical risk to fetus and continue pregnancy care D. Administer Rubella immunoglobulin E. Reassure her that there is no risk to fetus.
  35. 35. Yellow fever Vaccine Live attenuated vaccine Indications: Travel to Yellow Fever endemic areas Sub-Saharan Africa Amazon basin of South America Contraindications Immunocompromised Patient : HIV Infection and those on Immunosuppressive medications Pregnancy (relative contraindication, if the travel is unavoidable while pregnant, you can use it!) Infant under age 6 months Hypersensitivity to egg products Effectiveness lasts for 10 years
  36. 36. Human Papilloma Virus Vaccine ( Gardasil) Indications Prevention of Cervical Dysplasia – use in women routinely at age 12 . If not vaccinated at age 12, you can give for age below 26 yrs of age. After that, no benefiit This vaccine is a mixture of primary capsid proteins of 4 HPV types that cause genital warts ( 6 & 11) and that cause cervical cancer ( 16 & 18) Given IM in 3 doses  Schedule: 0, 2, and 6 months
  37. 37. Smoking Cessation
  38. 38. Smoking Cessation At first visit, ask patient for tobacco use. (The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products; and that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke ) Counsel all patients about smoking cessation at least during first visit and then, at each follow-up visit. Repeated encouragement is important Some Important Benefits of Smoking cessation : In COPD patients , After 5 years, smoking cessation produced a reduced decline in FEV1 Reductions in fatal and nonfatal cardiovascular disease and coronary heart disease. Reduces the overall mortality Reduces the incidence of lung cancer Smoking cessation during 1st trimester pregnancy can substantially reduce the number of pre-term births.
  39. 39. Smoking Cessation Drug interventions : These interventions are aimed to reduce the withdrawl symptoms in a patient who has strong intention to quit smoking Bupropion for 8 to 12 weeks. Ask the patient set a smoking cessation date for about 1 week after starting therapy Nicotine replacement therapy : Several preparations available eg: transdermal patch, nicotine gum, nicotine nasal spray, and nicotine inhalers. There is no difference between these preparations in their effectiveness. Started on highest dose and then tapered off over several weeks. Varenecline : New drug that’s been shown to be effective in smoking cessation by reducing craving and curbing the desire to smoke.
  40. 40. USPTF Recommendation Grades A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms. B—Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms. C—No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. D—Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits. I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. Quality of Evidence The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor): Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes. Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
  41. 41. Dyslipidemia Screening!
  42. 42. USPTF Recommendations Screening Men Screen all men aged 35 and older for lipid disorders (Grade A) Screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (GradeB). Screening Women at Increased Risk Strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for CAD. (Grade: A). Screen women aged 20 to 45 for lipid disorders if they are at increased risk for CAD. (Grade: B). Screening Young Men and All Women Not at Increased Risk The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. (Grade: C). A repeat level should be obtained every 5 years if the first test was normal
  43. 43. Lipid Screening All these patients should get a fasting lipid panel as a screening test : In general, screen people with increased risk for CAD Diabetes ( or any other CAD equivalent), A positive family history of premature CVD A family history of dyslipidemia evidence of hyperlipidemia on physical examination ( Xanthomas, xanthelesmas etc) increased risk of CAD with two or more other cardiovascular risk factors ( Male sex, Hypertension, smoking etc).
  44. 44. When to stop? There are no data on at what age screening should be stopped. However, available data suggest that lipid-lowering treatment is effective in elderly patients up to age 80 Patients over age 80 have not been well studied.
  45. 45. Type 2 DM Screening Screening is with Fasting blood sugar – fasting blood sugar greater than or equal to 126 mg% , on two separate occasions confirms DM ( Also, Random blood glucose > 200 with symptoms indicate DM  but it needs confirmation with a fasting blood sugar on another day)
  46. 46. USPTF Recommendations Screen all asymptomatic patients with sustained blood pressure ( either treated or untreated) > 135/80 mm hg ( that means all patients with “Hypertension” must be screened ) USPSTF says that there is insufficient evidence to recommend screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower ( “I” recommendation) Eventhough, its not USPTF recommendation, screen all patients with hyperlipidemia also for diabetes ( ADA recommendation)
  47. 47. OSTEOPOROSIS Screen with DEXA scan Start Calcium + vitamin D in post menopausal Women Rx with Bisphosphonates Prevent Steroid Induced Osteoporosis Screening test : DEXA scan (T score) To monitor treatment efficacy or to rescreen, repeat DEXA scan every 2 years
  48. 48. USPTF Recommendations All women aged 65 and older be screened routinely for osteoporosis. (Grade B) For women with risk factors, screening should begin at age 60 ( RISK FACTORS : Low Body mass index ( < 127lbs), short women, smokers, Family hx of osteoporotic fracture, personal history of osteoporotic fracture as an adult), use of steroids for more than 3 months and consumption of alcohol > 2 drinks per day) ( Grade B) The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures. ( Grade C)
  49. 49. Steroid Induced Osteoporosis In patients requiring prolonged steroid therapy ( > 3 months) : Use calcium and vitamin D to prevent osteoporosis. Obtain baseline Dexa scan. If baseline Dexa scan reveals osteopenia or osteoporosis, start Bisphosphonates also. Repeat Dexa scan in one year. Stress induced amenorrhea + osteoporosis/ stress fractures/ anorexia nervosa – these entities discussed under Gyn section
  50. 50. Abdominal Aorta Aneurysm AAA Screening and Treatment
  51. 51. Probable Risk Factors Risk Factors for Abdominal Aortic Aneurysm OR or RR Importanc e Age >60 years OR, 1.93 High Male sex 5.6-12.21 High Smoking 1.8-5.57 High First-degree relative with history of AAA 4.3 High Hypertension 1.4 (diastolic) Low Possible Risk Factors Peripheral vascular disease Low Coronary artery disease Low Height Low
  52. 52. AAA “Consider a history of AAA in a first-degree relative to be a strong predictor of risk”
  53. 53. Key Points because it is Use ultrasound to screen for AAA, more sensitive and specific than abdominal palpation. Recommend one-time screening for AAA with ultrasound to asymptomatic men aged 65 to 79 years, especially those who are or have ever been smokers. Do not screen women for AAA, because no benefit has been shown in this group. Do not repeat screening for persons whose initial screening test is normal. Refer patients with an AAA 5.5 cm in diameter to a vascular surgeon for consideration of elective repair Recognize that data from randomized clinical trials indicate that ultrasound screening for AAA
  54. 54. AAA Be aware that physical exam is only moderately sensitive for detecting an AAA >5.0 cm in diameter and is even less sensitive for smaller diameters or in obese patients; it does not rule out an aneurysm if normal; and if a pulsatile mass 3 cm is palpated, it is highly suggestive of AAA and should be confirmed by ultrasonography. Consider ultrasound as the preferred test for AAA screening, with a sensitivity for large AAAs and a specificity of nearly 100%; note that minor measurement variations (usually <0.5 cm) may result in misclassification of some borderline cases. Repeat measurements of AAAs <5.5 cm periodically with ultrasound to determine when elective repair should be performed (every 6 months for AAAs 4.0 cm and every 2 to 3 years for AAAs <4.0 cm). In case of suspected AAA rupture , CT is the test of choice if the pt is hemodynamically stable. If pt is unstable, send directly to OR ( look for peritoneal
  55. 55. Spectrum of presentation - AAA Recognize that AAA can be: Asymptomatic Incidentally noted on abdominal examination or an imaging study A cause of: ( suspect rupture and consult vascular surgeon if pt develops these symps) – Abdominal, flank, or back pain ( get a CT r/o rupture) – Hypotension ( direct to OR) – Syncope – Sudden collapse and shock Advise the pt with hx of known AAA that he should promptly report sudden
  56. 56. CASE STUDY A 68-year-old asymptomatic man comes to the office for his health maintenance examination. He has a 5-year history of treated hypertension and hyperlipidemia. His medications include lisinopril, 20 mg daily, hydrochlorothiazide, 25 mg daily, and atorvastatin, 10 mg daily. He smokes one-half pack of cigarettes per day. On physical examination, his heart rate is 88/min and blood pressure is 152/88 mm Hg. The remainder of the physical examination is unremarkable. Electrocardiography shows sinus rhythm and left ventricular hypertrophy by voltage. An abdominal ultrasound shows a 4.6-cm infrarenal abdominal aortic aneurysm. In addition to counseling the patient to discontinue smoking, which of the following is the best management plan? ( A ) Follow-up abdominal ultrasound in 12 months ( B ) Atenolol, 100 mg daily, and follow-up abdominal ultrasound in 6 months ( C ) Increase lisinopril to 40 mg daily, and follow-up abdominal ultrasound in 6 months ( D ) Initiation of roxithromycin and follow-up abdominal ultrasound in 6 months ( E ) Surgical repair of abdominal aortic aneurysm
  57. 57. Ans. B Surgery for abdominal aortic aneurysm is indicated if the aneurysm is symptomatic, exceeds 5.0 to 5.5 cm in diameter,or expands >0.5 cm within 6 months. ß-blockers should be considered for patients with abdominal aortic aneurysm if there are other indications for their use, such as coronary artery disease or hypertension.
  58. 58. Fall Prevention Under Neurology
  59. 59. Safety issues in children  Crib safety Avoiding thermal injuries
  60. 60. Crib safety crib bars should not be more than 2 inches apart. Use bumpers to avoid suffocation from mattresses and to prevent injury from head banging. Prone position is associated with increased risk of SIDS. So, position the infant on their side or back while sleeping. Thermal injury – Set the water heater temperature below 120F to prevent accidental scalding by sitting in the water( Most heaters are set at 150F and can cause scalds in infants) Use child seat in the cars and place the child seat in the rear.
  61. 61. Jet Lag
  62. 62. Jet Lag General Advise : Avoid Alcohol and Caffeine Maintain adequate hydration Coordinate extended sleep during flight to destination – Try to Match sleep to destination time zone Equilibration requires 12-24 hour per time zone crossed Management for flights >8 hours Melatonin Sleep medication may be given on day of travel and for 2-3 days after – Short acting Benzodiazepine (e.g. Halcion) – Zolpidem
  63. 63. Cancer Screening -Normal risk population vs. High risk population -Oncology section

×