Current Medical Diagnosis and Treatment 2007 (Current Medical Diagnosis & Treatment) - page 5

Editors: McPhee, Stephen J.; Papadakis, Maxine A.; Tierney, Lawrence M.

Title: Current Medical Diagnosis & Treatment, 46th Edition

Copyright ©2007 McGraw-Hill

> Front of Book > Quote

Quote

From inability to let alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, and science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.

—Sir Robert Hutchison

Editors: McPhee, Stephen J.; Papadakis, Maxine A.; Tierney, Lawrence M.

Title: Current Medical Diagnosis & Treatment, 46th Edition

Copyright ©2007 McGraw-Hill

> Front of Book > Notice

Notice

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.

Editors: McPhee, Stephen J.; Papadakis, Maxine A.; Tierney, Lawrence M.

Title: Current Medical Diagnosis & Treatment, 46th Edition

Copyright ©2007 McGraw-Hill

> Table of Contents > 1 - Approach to the Patient & Health Maintenance

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Approach to the Patient & Health Maintenance

Michael Pignone MD, MPH

Stephen J. McPhee MD

General Approach to the Patient

The approach to diagnosis begins with the history and pertinent physical examination—both susceptible to errors of omission and commission. The medical interview serves several functions. It is used to collect information of help in diagnosis (the “history” of the present illness), to assess and communicate prognosis, to establish a therapeutic relationship, and to reach agreement with the patient about further diagnostic procedures and therapeutic options. It also serves as an opportunity to influence patient behavior, such as in motivational discussions about smoking cessation or medication adherence. Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.

Patient Adherence

For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet, taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex. Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines. Many patients with medical problems, even those with access to care, do not seek appropriate care or may drop out of care prematurely. Adherence rates for short-term, self-administered therapies are higher than for long-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient's perception of overmedication.

As an example, in HIV-infected patients, adherence to antiretroviral therapy is a crucial determinant of treatment success. Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels, CD4 cell counts, and mortality. Adherence levels of > 95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are < 90% adherent and that adherence tends to decrease over time. Patient reasons for nonadherence include simple forgetfulness, being away from home, being busy, and changes in daily routine. Other reasons include psychiatric disorders (depression or substance abuse), uncertainty about the effectiveness of treatment, lack of knowledge about the consequences of poor adherence, regimen complexity, and treatment side effects.

Patients seem better able to take prescribed medications than to comply with recommendations to change their diet, exercise habits, or alcohol intake or to perform various self-care activities (such as monitoring blood glucose levels at home). For short-term regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common (almost half of English-speaking patients are unable to read and understand standard health education materials), other forms of communication—such as illustrated simple text, videotapes, or oral instructions—may be more effective. For non-English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.

To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimen, ensure understanding by using the “teach-back” method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications (preferably one or two doses daily), suggest ways to help in remembering to take doses (time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing (medication boxes). Single-unit doses supplied in foil-backed wrappers can increase adherence but should be avoided for patients who have difficulty opening them. Medication boxes

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with compartments (eg, Medisets) that are filled weekly are useful. Microelectronic devices can provide feedback to show patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped. The clinician can also enlist social support from family and friends, recruit an adherence monitor, and provide rewards and recognition for the patient's efforts to follow the regimen.

Adherence is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care. Clinicians can improve patient adherence by inquiring specifically about the behaviors in question. When asked, many patients admit to incomplete adherence with medication regimens, with advice about giving up cigarettes, or with engaging only in “safe sex” practices. Although difficult, sufficient time must be made available for communication of health messages. Other ways of assessing medication adherence include pill counts and refill records; monitoring serum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from β-blockers. In some conditions, even partial adherence, as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such as HIV antiretroviral therapy or treatment of tuberculosis, partial adherence may be worse than complete nonadherence.

Guiding Principles of Care

Ethical decisions are often called for in medical practice, at both the “micro” level of the individual patient-clinician relationship and at the “macro” level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest, and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses (see Chapter 5).

The clinician's role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. “To cure sometimes, to relieve often, and to comfort always” is a French saying as apt today as it was five centuries ago—as is Francis Peabody's admonition: “The secret of the care of the patient is in caring for the patient.”

Aliotta SL et al: Enhancing adherence to long-term medical therapy: a new approach to assessing and treating patients. Adv Ther 2004;21:214.

Connor J et al: Do fixed-dose combination pills or unit-of-use packaging improve adherence? A systematic review. Bull World Health Organ 2004;82:935.

DeWalt DA et al: Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004;19:1228.

Domino FJ: Improving adherence to treatment for hypertension. Am Fam Physician 2005;71:2089.

Haynes RB et al: Helping patients follow prescribed treatment: clinical applications. JAMA 2002;288:2880.

McDonald HP et al: Interventions to enhance patient adherence to medication prescriptions: scientific review. JAMA 2002; 288:2868.

Van Wijk BL et al: Effectiveness of interventions by community pharmacists to improve patient adherence to chronic medication: a systematic review. Ann Pharmacother 2005;39:319.

Vermeire E et al: Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005;(2):CD003638.

Health Maintenance & Disease Prevention

Preventive medicine can be categorized as primary, secondary, or tertiary. Primary prevention aims to remove or reduce disease risk factors (eg, immunization, giving up or not starting smoking). Secondary prevention techniques promote early detection of disease or precursor states (eg, routine cervical Papanicolaou screening to detect carcinoma or dysplasia of the cervix). Tertiary prevention measures are aimed at limiting the impact of established disease (eg, partial mastectomy and radiation therapy to remove and control localized breast cancer). Table 1-1 gives data for deaths from preventable causes in the United States. Table 1-2 compares recommendations for periodic health examinations as developed by the United States Preventive Services Task Force, the

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American College of Physicians, and the Canadian Task Force on the Periodic Health Examination. Despite emerging consensus on many of the services, controversy persists for others. Many effective preventive services are underutilized. One analysis concluded that the following services had the most potential for improvement, based on their effectiveness and underuse: counseling about smoking cessation; screening older adults for vision impairment; screening and counseling adults and adolescents about alcohol abuse; screening older adults for colorectal cancer; screening young women for chlamydia infection; and vaccinating older adults against pneumococcal disease.

Table 1-1. Estimated annual deaths from preventable causes in the United States in 2000.

Preventable Cause Estimated Number of Deaths (% total deaths)
Tobacco 435,000 (18%)
Poor diet and physical inactivity 365,000 (15%)
Alcohol 85,000 (3%)
Motor vehicle 43,000 (2%)
Firearms 29,000 (1%)
Illicit drug use 17,000 (0.7%)
From Mokdad AH et al: Actual causes of death in the United States, 2000. JAMA 2004;291:1238. Errata in: JAMA 2005;293:293,298.

Table 1-2. Expert recommendations for preventive care for asymptomatic, low-risk adults.

Preventive Service USPSTF1 CTF2 Other Organizations
Screening tests
Blood pressure Recommended for all adults; interval not stated Fair evidence for inclusion in routine care Joint National Committee VII: Recommended for all adults at each clinical encounter
Serum lipids Recommended for all middle-aged and older adults and for young adults with multiple risk factors Insufficient evidence for or against inclusion National Cholesterol Education Panel Adult Treatment Panel III: Recommended for all adults age 21 and older
Depression screening Recommended (B recommendation)3 Fair evidence for exclusion from routine care  
Counseling
Healthy diet Recommended for patients with increased risk; insufficient evidence for or against in average-risk patients Fair evidence for inclusion  
Physical activity Recommended Fair evidence for inclusion  
Immunizations and chemoprevention
Aspirin chemoprevention Recommended for adults at increased risk for coronary heart disease (CHD) Insufficient evidence for or against use American Heart Association: Recommended for adults at increased risk for CHD
Influenza vaccination Recommended for all adults 65 and older and for selected high-risk groups Not addressed  
Pneumococcal vaccination Recommended for immunocompetent adults older than age 65 or for adults younger than age 65 at increased risk Insufficient evidence for or against in immunocompetent free-living adults older than age 55  
1United States Preventive Services Task Force; recommendations available at http://www.ahrq.gov
2Canadian Task Force on Preventive Health Care; recommendations available at http://www.ctfphc.org/
3The USPSTF recommends that clinicians routinely 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.)

Jemal A et al: Trends in the leading cause of death in the United States, 1970-2002. JAMA 2005;294;1255.

Prochazka AV et al: Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med 2005;165:1347.

Prevention of Infectious Diseases

Much of the decline in the incidence and fatality rates of infectious diseases is attributable to public health measures—especially immunization, improved sanitation, and better nutrition.

Immunization remains the best means of preventing many infectious diseases. In the United States, childhood immunization has resulted in near elimination of measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, and tetanus. Haemophilus influenzae type b invasive disease has been reduced by more than 95% since the introduction of the first conjugate vaccines. However, substantial vaccine-preventable morbidity and mortality continue to occur among adults from vaccine-preventable diseases, such as hepatitis A, hepatitis B, influenza, and pneumococcal infections. For example, in adults in the United States, there are an estimated 50,000–70,000 deaths annually from influenza, hepatitis B, and invasive pneumococcal

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disease. Yet in 2002, only about 65% of elderly persons reported receiving influenza and pneumococcal vaccines. The American College of Physicians recommends that clinicians should review each adult's immunization status at age 50; assess risk factors that would indicate a need for pneumococcal vaccination and annual influenza immunizations; reimmunize at age 65 those who received an immunization against pneumococcus more than 6 years before; ensure that all adults have completed a primary diphtheria-tetanus immunization series, and administer a single booster at age 50; and assess the postvaccination serologic response to hepatitis B vaccination in all recipients who have ongoing risks of exposure to blood or body fluids (eg, sharp injuries, blood splashes).

Recently, strategies have also been proposed to improve influenza, pneumococcal polysaccharide, and hepatitis B targeted vaccination; in other words, improve coverage among those adults aged 65 years or younger who are at high risk for exposure or disease. Strategies to enhance vaccinations in general include increasing community demand for vaccinations; enhancing access to vaccination services; and provider- or system-based interventions, such as reminder systems. Clinicians can substantially improve immunization rates by use of standing orders and algorithms, expanded nurse decision-making, patient education and incentives, and partnership with community pharmacies. Increasing reports of pertussis among US adolescents, adults, and their infant contacts have stimulated vaccine development for older age groups. A safe and effective tetanus-diphtheria 5-component acellular pertussis vaccine (Tdap) is now available for use in adolescents and adults. On October 26, 2005, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of a single dose of Tdap for adults aged 19–64 years to replace the next booster dose of tetanus and diphtheria toxoids vaccine (Td). The ACIP also recommended Tdap for adults who have close contact with infants younger than 12 months, for pregnant women, and women who are planning a pregnancy.

In 2002, the ACIP approved a schedule for the routine vaccination of persons aged 19 years and older. Recommended immunization schedules for children and adolescents are set forth in Table 30-4. Persons traveling to countries where infections are endemic should take precautions described in Chapter 30. Immunization registries—confidential, population-based, computerized information systems that collect vaccination data about all residents of a geographic area—can be used to increase and sustain high vaccination coverage.

Skin testing for tuberculosis and treating selected patients reduce the risk of reactivation tuberculosis (see Table 9-12). Attention to technique helps separate negative from positive results. A more precise measurement of induration from the PPD can be obtained by drawing a line on the skin with a medium ballpoint pen, starting 1–2 cm away from the skin reaction and then stopping when resistance is felt. Patients with HIV infection are at an especially high risk for tuberculosis. This is discussed in Chapter 31, as is multidrug-resistant tuberculosis.

HIV infection is now the major infectious disease problem in the world, and it affects 850,000–950,000 persons in the United States. Since sexual contact is a common mode of transmission, primary prevention relies on eliminating unsafe sexual behavior by promoting abstinence, later onset of first sexual activity, decreased number of partners, and use of latex condoms. Appropriately used, condoms can reduce the rate of HIV transmission by nearly 70%. In one study, couples with one infected partner who used condoms inconsistently had a considerable risk of infection: the rate of seroconversion was estimated to be 13% after 24 months. No seroconversions were noted with consistent condom use. Unfortunately, as many as one-third of HIV-positive individuals continue unprotected sexual practices after learning that they are HIV-infected. Tailored group educational intervention focused on practicing “safer sex” can reduce their transmission-risk behaviors with partners who are not HIV-positive. Other approaches to prevent HIV infection include treatment of sexually transmitted diseases, development of vaginal microbicides, and vaccine development. Increasingly, cases of HIV infection are transmitted by injection drug use. HIV prevention activities should include provision of sterile injection equipment for these individuals.

With regard to secondary prevention, many HIV-infected persons in the US currently receive the diagnosis at advanced stages of immunosuppression, and almost all will progress to AIDS if untreated. On the other hand, highly active antiretroviral therapy (HAART) substantially reduces the risk of clinical progression or death in patients with advanced immunosuppression. Screening tests for HIV are extremely (> 99%) accurate. While the benefits of HIV screening appear to outweigh its harms, current screening is generally based on individual patient risk factors. Such screening can identify persons at risk for AIDS but misses a substantial proportion of those infected. Nonetheless, the yield from screening higher prevalence populations is substantially greater than that from screening the general population, and more widespread screening of the population remains controversial.

In immunocompromised patients, live vaccines are contraindicated but many killed or component vaccines are safe and recommended. Asymptomatic HIV-infected patients have not shown adverse consequences when given live MMR and influenza vaccinations as well as tetanus, hepatitis B, H influenzae type b, and pneumococcal vaccinations—all should be given. However, if poliomyelitis immunization is required, the inactivated poliomyelitis vaccine is indicated. In symptomatic HIV-infected patients, live virus vaccines such as MMR should generally be avoided, but annual influenza vaccination is safe.

Whenever possible, immunizations should be completed before procedures that require or induce immunosuppression (organ transplantation or chemotherapy), or that reduce immunogenic responses (splenectomy). However, if this is not possible, the patient may mount only a partial immune response, yet even this partial response

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can be of benefit. Patients who undergo allogeneic bone marrow transplantation lose preexisting immunities and should be revaccinated. In many situations, family members should also be vaccinated to protect the immunocompromised patient, although oral live polio vaccine should be avoided because of the risk of infecting the patient.

New cases of poliomyelitis have been reported in the United States, Haiti, and the Dominican Republic recently, slowing its eradication in the Western Hemisphere.

The 2001 anthrax attacks in the United States have raised concern about the nation's vulnerability to a smallpox attack. Resumption of smallpox vaccination was undertaken for some health care workers, police and firemen, etc. However, smallpox vaccine has a higher complication rate than any other vaccine currently being used. Expected adverse events in a mass smallpox vaccination campaign include fever (less than one case per five vaccine recipients), rash (less than one case per one hundred recipients), encephalitis (less than three cases per million), and death (less than two cases per million). Careful prevaccination exclusion of high-risk individuals (those with eczema or immunosuppression or coronary artery disease) is essential to minimize such complications.

During the 2002–2004 smallpox vaccination campaign, only 214 neurologic events were reported among 665,000 persons vaccinated against smallpox, and these were generally mild and self-limited. Serious neurologic events, such as postvaccinal encephalitis, Bell's palsy, and Guillain-Barré syndrome, occurred with expected incidences. No neurologic sequelae were identified at a rate above baseline estimates. In terms of overall complications, among 37,901 volunteers receiving 38,885 doses of smallpox vaccine in 2003, there were 100 serious adverse events reported, resulting in 85 hospitalizations, 10 life-threatening illnesses, 2 permanent disabilities, and 3 deaths. Among the serious adverse events, there were 21 cases of myocarditis, pericarditis, and ischemic cardiac events. Serious adverse events were more common among older persons being revaccinated than among younger persons being vaccinated for the first time. Rigorous smallpox vaccine safety screening and educational programs contributed to low rates of preventable life-threatening adverse reactions.

The current epidemic of highly pathogenic H5N1 avian influenza within duck and poultry populations in Southeast Asia raises serious concerns that genetic reassortment will result in a human influenza pandemic. In 2003 through 2005, there were 138 confirmed cases of human infection with H5N1 avian influenza in Vietnam, Thailand, Indonesia, China, and Cambodia, with a mortality rate of > 50%. To prevent and prepare for an increase in human cases, public health officials are working to improve detection methods and to stockpile effective antivirals, such as oseltamivir. While vaccines are the mainstay of prophylaxis against influenza, there are technical and safety issues that must be overcome in the development of an avian influenza vaccine for use in humans.

Burns IT et al: Immunization barriers and solutions. J Fam Pract 2005;54(1 Suppl):S58.

Casey CG et al: Adverse events associated with smallpox vaccination in the United States, January-October 2003. JAMA 2005;294:2734.

Chou R et al: US Preventive Services Task Force: Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005;143:55.

Middleton DB et al: Vaccine schedules and procedures. J Fam Pract 2005;54(1 Suppl):S37.

Pichichero ME et al: Combined tetanus, diphtheria, and 5-component pertussis vaccine for use in adolescents and adults. JAMA 2005;293:3003.

Sejvar JJ et al: Neurologic adverse events associated with smallpox vaccination in the United States, 2002–2004. JAMA 2005; 294:2744.

Willis BC et al: Task Force on Community Preventive Services: Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged < 65 years at high risk: a report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep 2005;54(RR-5):1.

Zeitlin GA et al: Avian influenza. Curr Infect Dis Rep 2005; 7:193.

Prevention of Cardiovascular Disease

Cardiovascular diseases, including coronary heart disease and stroke, represent two of the most important causes of morbidity and mortality in developed countries. Several risk factors increase the risk for coronary disease and stroke. They can be divided into those that are modifiable (eg, lipid disorders, hypertension, cigarette smoking) and those that are not (eg, gender, age, family history of early coronary disease). This section considers the role of screening for and treating modifiable risk factors.

Impressive declines in age-specific mortality rates from heart disease and stroke have been achieved in all age groups in North America during the past 2 decades. The chief reasons for this favorable trend appear to be modification of risk factors, especially cigarette smoking and hypercholesterolemia, plus more aggressive detection and treatment of hypertension and better care for patients with heart disease. In addition, it now appears that screening for abdominal aortic aneurysm in men aged 65–75 years is associated with a significant reduction in mortality (odds ratio, 0.57 [95% CI, 0.45 to 0.74]); this benefit has not been found for women.

Fleming C et al: Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2005;142:203.

Cigarette Smoking

Cigarette smoking remains the most important cause of preventable morbidity and early mortality. In 2000, there were an estimated 4.8 million premature deaths in the world attributable to smoking, 2.4 million in developing countries and 2 million in industrialized countries. More than three-quarters (3.8 million) of these deaths were in

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men. The leading causes of death from smoking were cardiovascular diseases (1.7 million deaths), chronic obstructive pulmonary disease (COPD) (1 million deaths), and lung cancer (0.9 million deaths). Nicotine is highly addictive, raises brain levels of dopamine, and produces withdrawal symptoms on discontinuation. Cigarettes are responsible for one in every five deaths in the United States, yet smoking prevalence rates have been increasing among high school and college students. Cigar smoking has also increased; there is also continued use of smokeless tobacco (chewing tobacco and snuff), particularly among young people. Tobacco dependence may have a genetic component.

Smokers have twice the risk of fatal heart disease, 10 times the risk of lung cancer, and several times the risk of cancers of the mouth, throat, esophagus, pancreas, kidney, bladder, and cervix; a twofold to threefold higher incidence of stroke and peptic ulcers (which heal less well than in nonsmokers); a twofold to fourfold greater risk of fractures of the hip, wrist, and vertebrae; four times the risk of invasive pneumococcal disease; and a twofold increase in cataracts. In the United States, over 90% of cases of COPD occur among current or former smokers. Both active smoking and passive smoking are associated with deterioration of the elastic properties of the aorta (increasing the risk of aortic aneurysm) and with progression of carotid artery atherosclerosis. Smoking has also been associated with increased risks of leukemia, of colon and prostate cancers, of breast cancer among postmenopausal women who are slow acetylators of N-acetyltransferase-2 enzymes, osteoporosis, and Alzheimer's disease. In cancers of the head and neck, lung, esophagus, and bladder, smoking is linked to mutations of the P53 gene, the most common genetic change in human cancer. Patients with head and neck cancer who continue to smoke during radiation therapy have lower rates of response than those who do not smoke. Olfaction and taste are impaired in smokers, and facial wrinkles are increased. Heavy smokers have a 2.5 greater risk of age-related macular degeneration. Smokers die 5–8 years earlier than never-smokers.

The children of smokers have lower birth weights, are more likely to be mentally retarded, have more frequent respiratory infections and less efficient pulmonary function, have a higher incidence of chronic ear infections than children of nonsmokers, and are more likely to become smokers themselves.

In addition, exposure to environmental tobacco smoke has been shown to increase the risk of cervical cancer, lung cancer, invasive pneumococcal disease, and heart disease; to promote endothelial damage and platelet aggregation; and to increase urinary excretion of tobacco-specific lung carcinogens. The incidence of breast cancer may be increased as well. Of approximately 450,000 smoking-related deaths in the United States annually, as many as 53,000 are attributable to environmental tobacco smoke.

Smoking cessation lessens the risks of death and of myocardial infarction in people with coronary artery disease; reduces the rate of death and acute myocardial infarction in patients who have undergone percutaneous coronary revascularization; lessens the risk of stroke; slows the rate of progression of carotid atherosclerosis; and is associated with improvement of COPD symptoms. On average, women smokers who quit smoking by age 35 add about 3 years to their life expectancy, and men add more than 2 years to theirs. Smoking cessation can increase life expectancy even for those who stop after the age of 65. Fortunately, adult rates in the United States are now at an all-time low—23%—but rates are climbing for young people.

Although tobacco use constitutes the most serious common medical problem, it is undertreated. Over 70% of smokers see a physician each year, but only 20% of them receive any medical quitting advice or assistance. (Persons whose physicians advise them to quit are 1.6 times as likely to attempt quitting.) About 4% of smokers are able to quit each year.

The five steps for helping smokers quit are summarized in Table 1-3. Common elements of supportive smoking cessation treatments are reviewed in Table 1-4. A system should be implemented to identify smokers, and advice to quit should be tailored to the patient's level of readiness to change. Pharmacotherapy to reduce cigarette consumption is ineffective in smokers who are unwilling or not ready to quit. Conversely, all patients trying to quit should be offered pharmacotherapy except those with medical contraindications, women who are pregnant or breast-feeding, and adolescents. Nicotine replacement therapy doubles the chance of successful quitting. Guidelines for its use are presented in Table 1-5. Suggestions for the nicotine patch are listed in Table 1-6 and for nicotine gum in Table 1-7. The nicotine patch, gum, and lozenges are available over-the-counter, and nicotine nasal spray and inhalers by prescription. When the spray is combined with the patch, cessation rates are substantially higher. The sustained-release antidepressant drug bupropion (150–300 mg/d orally) is an effective smoking cessation agent and is associated with minimal weight gain, although seizures are a contraindication. It acts by boosting brain levels of dopamine and norepinephrine, mimicking the effect of nicotine. Bupropion, either alone or in combination with a nicotine patch, has been shown to produce significantly higher abstinence rates (30–35% at 1 year) than either a patch alone or placebo. Weight gain was less in the combined program (Table 1-8).

Weight gain occurs in most patients (80%) following smoking cessation. For many it averages 2 kg, but for others (10–15%) major weight gain—over 13 kg—may occur.

Clinicians should not show disapproval of patients who have not stopped smoking or who are not ready to make a quit attempt. Thoughtful advice that emphasizes the benefits of cessation and recognizes common barriers to success can increase motivation to quit and quit rates. An intercurrent illness such as acute bronchitis or acute myocardial infarction may motivate even the most addicted smoker to quit. Individualized or group counseling is very cost-effective, even more so than treating hypertension. Smoking cessation

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counseling by telephone (“quitlines”) has proved effective. An additional strategy is to recommend that any smoking take place out of doors to limit the effects of passive smoke on housemates and coworkers. This can lead to smoking reduction and quitting. The clinician's role in smoking cessation is summarized in Table 1-3.

Table 1-3. Actions and strategies for the primary care clinician to help patients quit smoking.

Action Strategies for Implementation
Step 1. Ask–Systematically Identify All Tobacco Users at Every Visit
Implement an officewide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented1 Expand the vital signs to include tobacco use.
   Data should be collected by the health care team.
   The action should be implemented using preprinted progress note paper that includes the expanded vital signs, a vital signs stamp or, for computerized records, an item assessing tobacco-use status.
Alternatives to the vital signs stamp are to place tobacco-use status stickers on all patients' charts or to indicate smoking status using computerized reminder systems.
Step 2. Advise–Strongly Urge All Smokers to Quit
In a clear, strong, and personalized manner, urge every smoker to quit Advice should be
   Clear: “I think it is important for you to quit smoking now, and I will help you. Cutting down while you are ill is not enough.”
   Strong: “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.”
   Personalized: Tie smoking to current health or illness and/or the social and economic costs of tobacco use, motivational level/readiness to quit, and the impact of smoking on children and others in the household.
Encourage clinic staff to reinforce the cessation message and support the patient's quit attempt.
Step 3. Attempt–Identify Smokers Willing to Make a Quit Attempt
Ask every smoker if he or she is willing to make a quit attempt at this time If the patient is willing to make a quit attempt at this time, provide assistance (see step 4).
If the patient prefers a more intensive treatment or the clinician believes more intensive treatment is appropriate, refer the patient to interventions administered by a smoking cessation specialist and follow up with him or her regarding quitting (see step 5).
If the patient clearly states he or she is not willing to make a quit attempt at this time, provide a motivational intervention.
Step 4. Assist–Aid the Patient in Quitting
A. Help the patient with a quit plan Set a quit date. Ideally, the quit date should be within 2 weeks, taking patient preference into account.
Help the patient prepare for quitting. The patient must:
   Inform family, friends, and coworkers of quitting and request understanding and support.
   Prepare the environment by removing cigarettes from it. Prior to quitting, the patient should avoid smoking in places where he or she spends a lot of time (eg, home, car).
   Review previous quit attempts. What helped? What led to relapse?
   Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks.
B. Encourage nicotine replacement therapy except in special circumstances Encourage the use of the nicotine patch or nicotine gum therapy for smoking cessation (see Table 1-5, Table 1-6, and Table 1-7 for specific instructions and precautions).
C. Give key advice on successful quitting Abstinence: Total abstinence is essential. Not even a single puff after the quit date.
Alcohol: Drinking alcohol is highly associated with relapse. Those who stop smoking should review their alcohol use and consider limiting or abstaining from alcohol use during the quit process.
Other smokers in the household: The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to maintain abstinence in a household where others still smoke.
D. Provide supplementary materials Source: Federal agencies, including the National Cancer Institute and the Agency for Health Care Policy and Research; nonprofit agencies (American Cancer Society, American Lung Association, American Heart Association); or local or state health departments.
Selection concerns: The material must be culturally, racially, educationally, and age appropriate for the patient.
Location: Readily available in every clinic office.
Step 5. Arrange–Schedule Follow-Up Contact
Schedule follow-up contact, either in person or via telephone1 Timing: Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.
Actions during follow-up: Congratulate success. If smoking occurred, review the circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience and is not a sign of failure. Identify the problems already encountered and anticipate challenges in the immediate future. Assess nicotine replacement therapy use and problems. Consider referral to a more intense or specialized program.
1Repeated assessment is not necessary in the case of the adult who has never smoked or not smoked for many years and for whom the information is clearly documented in the medical record.
Modified and reproduced, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA 1996;275:1270.

Critchley JA et al: Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290:86.

Murphy-Hoefer R et al: A review of interventions to reduce tobacco use in colleges and universities. Am J Prev Med 2005;28:188.

Parmet S et al: JAMA patient page. Smoking and the heart. JAMA 2003;290:146.

Schroeder SA: What to do with a patient who smokes. JAMA 2005;294:482.

Stead LF et al: Telephone counselling for smoking cessation. Cochrane Database Syst Rev 2003;(1):CD002850.

Stevens LW: JAMA patient page. Kicking the habit. JAMA 2002; 288:532.

Ziedalski TM et al: Smoking cessation: techniques and potential benefits. Thorac Surg Clin 2005;15:189.

Lipid Disorders

Lower low-density lipoprotein (LDL) cholesterol concentrations and higher high-density lipoprotein (HDL) levels are associated with a reduced risk of coronary heart disease. Elevated triglyceride levels and elevated plasma lipoprotein(a) are independent risk factors for coronary heart disease. The absolute benefits of screening for—and treating—abnormal lipid levels depend on the presence of other cardiovascular risk factors. If other risk factors are present, cardiovascular risk is higher and the benefits of therapy are greater. Patients with diabetes mellitus or known cardiovascular disease are at still higher risk and benefit from treatment even when lipid levels are normal.

Evidence for the effectiveness of statin-type drugs is better than for the other classes of lipid-lowering agents. Multiple large randomized, placebo-controlled trials have demonstrated important reductions in total mortality, major coronary events, and strokes with lowering levels of LDL cholesterol by statin therapy for patients with known cardiovascular disease. Statins also reduce cardiovascular events for patients with diabetes. For patients with no previous history of cardiovascular events, statins reduce coronary events for men, but less evidence is available for women.

Table 1-4. Common elements of supportive smoking treatments.

Component Examples
Encouragement of the patient in the quit attempt Note that effective cessation treatments are now available.
Note that half the people who have ever smoked have now quit.
Communicate belief in the patient's ability to quit.
Communication of caring and concern Ask how the patient feels about quitting.
Directly express concern and a willingness to help.
Be open to the patient's expression of fears of quitting, difficulties experienced, and ambivalent feelings.
Encouragement of the patient to talk about the quitting process Ask about
   Reasons that the patient wants to quit.
   Difficulties encountered while quitting.
   Success the patient has achieved.
   Concerns or worries about quitting.
Provision of basic information about smoking and successful quitting Inform the patient about
   The nature and time course of withdrawal.
   The addictive nature of smoking.
   The fact that any smoking (even a single puff) increases the likelihood of full relapse.
Modified, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA 1996;275:1270.

Guidelines for therapy are discussed in Chapter 28.

Collins R et al: MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet 2003;361:2005.

Law MR et al: Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 2003;326:1423.

Walsh JM et al: Drug treatment of hyperlipidemia in women. JAMA 2004;291:2243.

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Hyperhomocysteinemia

Elevated plasma homocysteine may be an independent risk factor for coronary artery disease. Elevated levels can be reduced with folate and pyridoxine treatment and with smoking cessation (although not smoking reduction), but their clinical significance is unknown. Randomized trials of vitamin supplementation in patients with prior cardiovascular disease have generally yielded negative results. At this time, there is insufficient evidence to justify screening for elevated serum homocysteine, but patients should be encouraged to maintain an adequate dietary intake of folate, pyridoxine (vitamin B6), and vitamin B12.

Table 1-5. Clinical guidelines for prescribing nicotine replacement products.

  1. Who should receive nicotine replacement therapy?
    Available research shows that nicotine replacement therapy generally increases rates of smoking cessation. Therefore, except in special circumstances, the clinician should encourage the use of nicotine replacement with patients who smoke. Little research is available on the use of nicotine replacement with light smokers (ie, those smoking ≤ 10-15 cigarettes/d). If nicotine replacement is to be used with light smokers, a lower starting dose of the nicotine patch or nicotine gum should be considered.
  2. Should nicotine replacement therapy be tailored to the individual smoker?
    Research does not support the tailoring of nicotine patch therapy (except with light smokers as noted above). Patients should be prescribed the patch dosages outlined in Table 1-6.
    Research supports tailoring nicotine gum treatment. Specifically, research suggests that 4-mg gum rather than 2-mg gum be used with patients who are highly dependent on nicotine (eg, those smoking > 20 cigarettes/d, those who smoke immediately upon awakening, and those who report histories of severe nicotine withdrawal symptoms). Clinicians may also recommend the higher gum dose if patients request it or have failed to quit using the 2-mg gum.
Modified with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA 1996;275:1270.

Homocysteine Studies Collaboration: Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA 2002;288:2015.

Tice JA et al: Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond. JAMA 2001;286:936.

Toole JF et al: Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA 2004;291:565.

Hypertension

Over 43 million adults in the United States have hypertension, but 31% are unaware of their elevated blood pressure; 17% are aware but untreated; 29% are being treated but have not controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled. In every adult age group, higher values of systolic and diastolic blood pressure carry greater risks of stroke and congestive heart failure. Systolic blood pressure is a better predictor of morbid events than diastolic blood pressure. Clinicians can apply specific blood pressure criteria, such as those of the Joint National Committee, to decide at what levels treatment should be considered in individual cases. Table 11-1 presents a classification of hypertension based on blood pressures. Primary prevention of hypertension can be accomplished by strategies aimed at both the general population and special high-risk populations. The latter include persons

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with high-normal blood pressure or a family history of hypertension, blacks, and individuals with various behavioral risk factors such as physical inactivity; excessive consumption of salt, alcohol, or calories; and deficient intake of potassium. Effective interventions for primary prevention of hypertension include reduced sodium and alcohol consumption, weight loss, and regular exercise. Potassium supplementation lowers blood pressure modestly, and a diet high in fresh fruits and vegetables and low in fat, red meats, and sugar-containing beverages also reduces blood pressure. Interventions of unproved efficacy include pill supplementation of potassium, calcium, magnesium, fish oil, or fiber; macronutrient alteration; and stress management. A major cause of the recent impressive decline in stroke deaths has been

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improved diagnosis and treatment of hypertension. Diets rich in fruits and vegetables may also protect against stroke. Pharmacologic management of hypertension is discussed in Chapter 11.

Table 1-6. Suggestions for the clinical use of the nicotine patch.

Parameter of Clinical Use Suggestions
Patient selection Appropriate as a primary pharmacotherapy for smoking cessation.
Precautions Pregnancy: Pregnant smokers should first be encouraged to attempt cessation without pharmacologic treatment. The nicotine patch should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors should be considered in lactating women.
Cardiovascular diseases: While not an independent risk factor for acute myocardial events, the nicotine patch should be used only after consideration of risks and benefits among particular cardiovascular patient groups: those in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with severe or worsening angina pectoris.
Skin reactions: Up to 50% of patients using the nicotine patch will have a local skin reaction. Skin reactions are usually mild and self-limiting but may worsen over the course of therapy. Local treatment with hydrocortisone cream (2.5%) or triamcinolone cream (0.5%) and rotating patch sites may ameliorate such local reactions. In fewer than 5% of patients do such reactions require the discontinuation of nicotine patch treatment.
Dosage1 Treatment of 8 weeks or less has been shown to be as efficacious as longer treatment periods. Based on this finding, we suggest the following treatment schedules as reasonable for most smokers. Clinicians should consult the package insert for other treatment suggestions. Finally, clinicians should consider individualizing treatment based on specific patient characteristics such as previous experience with the patch, number of cigarettes smoked, and degree of addiction.
  Brand Duration (weeks) Dosage (mg/h)
Nicoderm and Habitrol 4 21/24
then 2 14/24
then 2 7/24
Prostep 4 22/24
then 4 11/24
Nicotrol 4 15/16
then 2 10/16
then 2 5/16
Prescribing instructions Abstinence from smoking: The patient should refrain from smoking while using the patch.
Location: At the start of each day, the patient should place a new patch on a relatively hairless location between the neck and the waist.
Activities: There are no restrictions while using the patch.
Time: Patches should be applied as soon as patients awaken on their quit day.
1These dosage recommendations are based on a review of the published research literature and do not necessarily conform to package insert information.
Reproduced, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA 1996;275:1270. Updated and revised, with permission, from Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/default.htm

Table 1-7. Suggestions for the clinical use of nicotine gum.

Parameter of Clinical Use Suggestions
Patient selection Appropriate as a primary pharmacotherapy for smoking cessation.
Precautions Pregnancy: Pregnant smokers should first be encouraged to attempt cessation without pharmacologic treatment. Nicotine gum should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking.
Cardiovascular diseases: Although not an independent risk factor for acute myocardial events, nicotine gum should be used only after consideration of risks and benefits among particular cardiovascular patient groups: those in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with serious or worsening angina pectoris.
Adverse effects: Common adverse effects of nicotine chewing gum include mouth soreness, hiccups, dyspepsia, and jaw ache. These effects are generally mild and transient and can often be alleviated by correcting the patient's chewing technique (see “Prescribing instructions” below).
Dosage Dosage: Nicotine gum is available in doses of 2 mg and 4 mg per piece. Patients who smoke less than 25 cigarettes per day should be prescribed the 2-mg gum initially. The 4-mg gum should be prescribed to patients who express a preference for it, have failed with the 2-mg gum but remain motivated to quit, and/or smoke more than 25 cigarettes per day. The gum is most commonly prescribed for the first few months of a quit attempt. Clinicians should tailor the duration of therapy to fit the needs of each patient. Patients using the 2-mg strength should use not more than 30 pieces per day, whereas those using the 4-mg strength should not exceed 20 pieces per day.
Prescribing instructions Abstinence from smoking: The patient should refrain from smoking while using the gum.
Chewing technique: The gum should be chewed slowly until a “peppery” taste emerges, then “parked” between cheek and gum to facilitate nicotine absorption through the oral mucosa. Gum should be slowly and intermittently chewed and parked for about 30 minutes.
Absorption: Acidic beverages (eg, coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before and during chewing.
Scheduling of dose: A common problem is that patients do not use enough gum to get the maximum benefit: they chew too few pieces per day and do not use the gum for a sufficient number of weeks. Instructions to chew the gum on a fixed schedule (at least 1 piece every 1 to 2 hours) for at least 1 to 3 months may be more beneficial than ad lib use.
Reproduced, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA 1996;275:1270. Updated and revised, with permission, from Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/default.htm

Chobanian AV et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560.

Law MR et al: Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ 2003;326:1427.

Sheridan S et al: Screening for high blood pressure: a review of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2003;25:151.

Chemoprevention

As discussed in Chapters 10 and 24, regular use of low-dose aspirin (81–325 mg) can reduce the incidence of myocardial infarction in men. Low-dose aspirin reduces stroke but not myocardial infarction in middle-aged women. Antioxidant vitamin (vitamin E, vitamin C, and beta-carotene) supplementation produced no significant reductions in the 5-year incidence of—or mortality from—vascular disease, cancer, or other major outcomes in high-risk individuals with coronary artery disease, other occlusive arterial disease, or diabetes mellitus.

Table 1-8. Suggestions for the clinical use of bupropion SR.

Parameter of Clinical Use Suggestions
Patient selection Appropriate as a first-line pharmacotherapy for smoking cessation.
Precautions Pregnancy: Pregnant smokers should be encouraged to quit first without pharmacologic treatment. Bupropion SR should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking. Similar factors should be considered in lactating women (FDA Class B).
Cardiovascular diseases: Generally well tolerated; infrequent reports of hypertension.
Side effects: The most common side effects reported by bupropion SR users were insomnia (35-40%) and dry mouth (10%).
Contraindications: Bupropion SR is contraindicated in individuals with a history of seizure disorder, a history of an eating disorder, who are using another form of bupropion (Wellbutrin or Wellbutrin SR), or who have used an MAO inhibitor in the past 14 days.
Dosage Patients should begin with a dose of 150 mg every morning for 3 days, then increase to 150 mg bid. Dosing at 150 mg bid should continue for 7-12 weeks following the quit date. Unlike nicotine replacement products, patients should begin bupropion SR treatment 1-2 weeks before they quit smoking. For maintenance therapy, consider bupropion SR 150 mg bid for up to 6 months.
Prescribing instructions Cessation prior to quit date: Recognize that some patients will lose their desire to smoke prior to their quit date, or will spontaneously reduce the amount they smoke.
Scheduling of dose: If insomnia is marked, taking the evening dose earlier (in the afternoon, at least 8 hours after the first dose) may provide some relief.
Alcohol: Use alcohol only in moderation.
MAO = monoamine oxidase inhibitor.
Modified, with permission, from Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/default.htm

Hayden M et al: Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136:161.

Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:23.

Ridker PM et al: A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005;352:1293.

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Vivekananthan DP et al: Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials. Lancet 2003;361:2017.

Prevention of Physical Inactivity

Lack of sufficient physical activity is the second most important contributor to preventable deaths, trailing only tobacco use. A sedentary lifestyle has been linked to 28% of deaths from leading chronic diseases. The Centers for Disease Control and Prevention (CDC) has recommended that every adult in the United States should engage in 30 minutes or more of moderate-intensity physical activity on most days of the week. This guideline complements previous advice urging at least 20–30 minutes of more vigorous aerobic exercise three to five times a week.

Patients who engage in regular moderate to vigorous exercise have a lower risk of myocardial infarction, stroke, hypertension, hyperlipidemia, type 2 diabetes mellitus, diverticular disease, and osteoporosis. The benefits of exercise appear to be dose-dependent, with a major difference in benefit between no and mild to moderate exercise and a smaller difference in benefit between moderate and vigorous exercise. Current evidence supports the recommended guidelines of 30 minutes of moderate physical activity on most days of the week in both the primary and secondary prevention of coronary heart disease (CHD). In fact, there appears to be a linear dose-response relationship between physical activity and CHD, at least up to a certain level of activity. Leisure time physical activity is associated with about a 30–50% reduction in risk of CHD in both men and women, in middle-aged and older persons, and in men with established CHD.

In older nonsmoking men, walking 2 miles or more per day is associated with an almost 50% lower age-related mortality. The relative risk of stroke was found to be less than one-sixth in men who exercised vigorously compared with those who were inactive; the risk of type 2 diabetes mellitus was about half among men who exercised five or more times weekly compared with those who exercised once a week. Glucose control is improved in diabetics who exercise regularly, even at a modest level. In sedentary individuals with dyslipidemia, high amounts of high-intensity exercise produce significant beneficial effects on serum lipoprotein profiles. Physical activity is associated with a lower risk of colon cancer (although not rectal cancer) in men and women and of breast and reproductive organ cancer in women. Finally, weight-bearing exercise (especially resistance and high-impact activities) increases bone mineral content and retards development of osteoporosis in women and contributes to a reduced risk of falls in older persons.

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Exercise may also confer benefits on those with chronic illness. Men and women with chronic symptomatic osteoarthritis of one or both knees benefited from a supervised walking program, with improved self-reported functional status and decreased pain and use of pain medication. Exercise produces sustained lowering of both systolic and diastolic blood pressure in patients with mild hypertension. In addition, physical activity can help patients maintain ideal body weight. Individuals who maintain ideal body weight have a 35–55% lower risk for myocardial infarction than with those who are obese. Physical activity reduces depression and anxiety; improves adaptation to stress; improves sleep quality; and enhances mood, self-esteem, and overall performance.

In longitudinal cohort studies, individuals who report higher levels of leisure time physical activity are less likely to gain weight. Conversely, individuals who are overweight are less likely to stay active. However, the amount of physical activity necessary to control body weight may be > 30 minutes per day; at least 45–60 minutes of daily moderate-intensity physical activity may be necessary to maximize weight loss and prevent significant weight regain. Moreover, adequate levels of physical activity appear to be important for the prevention of weight gain and the development of obesity. Physical activity also appears to have an independent effect on health-related outcomes when compared with body weight, suggesting that adequate levels of activity may counteract the negative influence of body weight on health outcomes.

However, physical exertion can rarely trigger the onset of acute myocardial infarction, particularly in persons who are habitually sedentary. Increased activity increases the risk of musculoskeletal injuries, which can be minimized by proper warm-up and stretching, and by gradual rather than sudden increase in activity. Other potential complications of exercise include angina pectoris, arrhythmias, sudden death, and asthma. In insulin-requiring diabetics who undertake vigorous exercise, the need for insulin is reduced; hypoglycemia may be a consequence.

Only about 20% of adults in the United States are active at the moderate level—and only 8% currently exercise at the more vigorous level—recommended for health benefits. Instead, 60% report irregular or no leisure time physical activity.

The value of routine electrocardiography stress testing prior to initiation of an exercise program in middle-aged or older adults remains controversial. Patients with ischemic heart disease or other cardiovascular disease require medically supervised, graded exercise programs. Medically supervised exercise prolongs life in patients with congestive heart failure. Exercise should not be prescribed for patients with decompensated congestive heart failure, complex ventricular arrhythmias, unstable angina pectoris, hemodynamically significant aortic stenosis, or significant aortic aneurysm. Five- to 10-minute warm-up and cool-down periods, stretching exercises, and gradual increases in exercise intensity help prevent musculoskeletal and cardiovascular complications.

Physical activity can be incorporated into any person's daily routine. For example, the clinician can advise a patient to take the stairs instead of the elevator, to walk or bike instead of driving, to do housework or yard work, to get off the bus one or two stops earlier and walk the rest of the way, to park at the far end of the parking lot, or to walk during the lunch hour. The basic message should be the more the better and anything is better than nothing.

To be more effective in counseling about exercise, clinicians can also incorporate motivational interviewing techniques, adopt a whole practice approach (eg, use practice nurses to assist), and establish linkages with community agencies. Clinicians can incorporate the “5 As” approach:

  • Ask (identify those who can benefit).

  • Assess (current activity level).

  • Advise (individualize plan).

  • Assist (provide a written exercise prescription and support material).

  • Arrange (appropriate referral and follow up).

Such interventions have a moderate effect on self-reported physical activity and cardiorespiratory fitness, even if they do not always help patients to achieve a predetermined level of physical activity. In their counseling, clinicians should advise patients about both the benefits and risks of exercise, prescribe an exercise program appropriate for each patient, and provide advice to help prevent injuries or cardiovascular complications.

Hillsdon M et al: Interventions for promoting physical activity. Cochrane Database Syst Rev 2005;(1):CD003180.

Huang N: Motivating patients to move. Aust Fam Physician 2005;34:413.

Jakicic JM et al: Physical activity considerations for the treatment and prevention of obesity. Am J Clin Nutr 2005;82(1 Suppl):226S.

Wannamethee SG et al: Physical activity and cardiovascular disease. Semin Vasc Med 2002;2:257.

Wareham NJ et al: Physical activity and obesity prevention: a review of the current evidence. Proc Nutr Soc 2005;64:229.

Prevention of Overweight & Obesity

Obesity is now a true epidemic and public health crisis that both clinicians and patients must face. Normal body weight is defined as a body mass index (BMI), calculated as the weight in kilograms divided by the height in meters squared, of < 25 kg/m2; overweight is defined as a BMI = 25.0–29.9 kg/m2, and obesity as a BMI > 30 kg/m2. The prevalence of obesity in US children, adolescents, and adults has grown dramatically since 1990. Currently, 59 million Americans (16%) are overweight or obese. Prevalence varies by race and age, with older

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African American and Latina women having the greatest prevalence of obesity. This trend has been linked both to declines in physical activity and to increased caloric intake in diets rich in fats and carbohydrates. As noted above, only about 20% of Americans are physically active at a moderate level, and only 8% at a more vigorous level, and 60% report irregular or no leisure time physical activity. In addition, only 3% of Americans meet four of the five recommendations for the intake of grains, fruits, vegetables, dairy products, and meat of the Food Guide Pyramid. Only one of four Americans eats the recommended five or more fruits and vegetables per day.

Obesity is clearly associated with type 2 diabetes mellitus, hypertension, cancer, osteoarthritis, cardiovascular disease, obstructive sleep apnea, and asthma. One of the most important sequelae of the rapid surge in prevalence of overweight and obesity between 1990 and 2000 has been a dramatic 30–40% increase in the prevalence of type 2 diabetes mellitus. In addition, almost one-quarter of the US population currently has the metabolic syndrome, putting them at high risk for the development of coronary heart disease. The relationship between overweight and obesity and diabetes, hypertension, and coronary artery disease is thought to be due to insulin resistance and compensatory hyperinsulinemia. Persons with a BMI ≥ 40 have death rates from cancers that are 52% higher for men and 62% higher for women than the rates in men and women of normal weight. Significant trends of increasing risk of death with higher BMIs are observed for cancers of the stomach and prostate in men and for cancers of the breast, uterus, cervix, and ovary in women, and for cancers of the esophagus, colon and rectum, liver, gallbladder, pancreas, and kidney, non-Hodgkin's lymphoma, and multiple myeloma in both men and women.

In the Framingham Heart Study, overweight and obesity were associated with large decreases in life expectancy. For example, 40-year-old female nonsmokers lost 3.3 years and 40-year-old male nonsmokers lost 3.1 years of life expectancy because of overweight, and 7.1 years and 5.8 years of life expectancy, respectively, because of obesity. Obese female smokers lost 7.2 years and obese male smokers lost 6.7 years of life expectancy compared with normal-weight smokers, and 13.3 years and 13.7 years, respectively, compared with normal-weight nonsmokers. Clinicians must work to identify and provide the best prevention and treatment strategies for patients who are overweight and obese. Patients with abdominal obesity (high waist to hip size ratio) are at particularly increased risk.

Prevention of overweight and obesity involves both increasing physical activity and dietary modification to reduce caloric intake. Clinicians can help guide patients to develop personalized eating plans to reduce energy intake, particularly by recognizing the contributions of fat, concentrated carbohydrates, and large portion sizes (see Chapter 29). To prevent the long-term chronic disease sequelae of overweight or obesity, clinicians must work with patients to modify other risk factors, eg, by smoking cessation (see above) and strict glycemic and blood pressure control (see Chapters 27 and 11).

Treatment of obesity involves dietary counseling and therapy, pharmacotherapy (see Chapter 29), and surgery. Counseling interventions or pharmacotherapy can produce modest (3 to 5 kg) sustained weight loss over 6–12 months. Pharmacotherapy appears safe in the short term; long-term safety is still not established. Counseling appears to be most effective when intensive and combined with behavioral therapy. Maintenance strategies can help preserve weight loss.

In dietary therapy, one randomized trial comparing a low-carbohydrate, high-protein, high-fat (Atkins) diet to a low-calorie, high-carbohydrate, low-fat (conventional) diet, the low-carbohydrate diet produced a greater weight loss (absolute difference, approximately 4%) than did the conventional diet for the first 6 months, but the differences were not significant at 1 year. In a second randomized trial, severely obese persons with a high prevalence of diabetes or the metabolic syndrome lost more weight during 6 months on a carbohydrate-restricted diet than on a calorie- and fat-restricted diet. Adherence was poor and attrition was high in both studies. Longer and larger studies are required to determine the long-term safety and efficacy of low-carbohydrate, high-protein, high-fat diets. Finally, a recent randomized trial comparing four popular diets (Atkins, Ornish, Weight Watchers, and Zone diets) assessed both adherence rates to and effectiveness of the diets for weight loss and cardiac risk factor reduction. Individual participants were randomly assigned to Atkins (carbohydrate restriction), Zone (macronutrient balance), Weight Watchers (calorie restriction), or Ornish (fat restriction) diets. At 1 year, each of the diets modestly reduced body weight (by a mean of 2.1–3.3 kg), LDL/HDL cholesterol ratio (by approximately 10%), and serum levels of C-reactive protein and insulin, but overall self-reported dietary adherence rates were low (50–65%).

Weight loss strategies using dietary, physical activity, or behavioral interventions can produce significant improvements in weight among persons with prediabetes and a significant decrease in diabetes incidence. Multicomponent interventions including very-low-calorie or low-calorie diets hold promise for achieving weight loss in adults with type 2 diabetes mellitus.

Bariatric surgical procedures, eg, vertical banded gastroplasty and Roux-en-Y gastric bypass, are reserved for patients with morbid obesity whose BMI exceeds 40, or for less severely obese patients (with BMIs between 35 and 40) with high-risk comorbid conditions such as life-threatening cardiopulmonary problems (eg, severe sleep apnea, Pickwickian syndrome, and obesity-related cardiomyopathy) or severe diabetes mellitus. In selected patients, surgery can produce substantial weight loss (10 to 159 kg) over 1 to 5 years, with rare but sometimes severe complications.

Avenell A et al: What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. J Hum Nutr Diet 2004;17:317.

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Buchwald H et al: Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724.

Dansinger ML et al: Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005;293:43.

McTigue KM et al: Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;139:933.

Norris SL et al: Long-term non-pharmacological weight loss interventions for adults with prediabetes. Cochrane Database Syst Rev 2005;(2):CD005270.

Norris SL et al: Long-term non-pharmacologic weight loss interventions for adults with type 2 diabetes. Cochrane Database Syst Rev 2005;(2):CD004095.

Olsen J et al: Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease. Int J Technol Assess Health Care 2005;21:194.

Reaven GM: Importance of identifying the overweight patient who will benefit the most by losing weight. Ann Intern Med 2003;138:420.

Snow V et al: Clinical Efficacy Assessment Subcommittee of the American College of Physicians: Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2005;142:525.

Torpy JM et al: JAMA patient page. Obesity. JAMA 2003;289: 1880.

Cancer Prevention

Primary Prevention

Cigarette smoking is the most important preventable cause of cancer. Primary prevention of skin cancer consists of restricting exposure to ultraviolet light by wearing appropriate clothing and use of sunscreens. In the past 2 decades, there has been a threefold increase in the incidence of squamous cell carcinoma and a fourfold increase in melanoma in the United States. Individuals who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemoprevention may be an important part of primary cancer prevention (see Chapter 40). Use of tamoxifen, raloxifene, and aromatase inhibitors for breast cancer prevention is discussed in Chapters 16 and 40. Hepatitis B vaccination can prevent hepatocellular carcinoma, and the recent development of a human papillomavirus vaccine holds promise for prevention of cervical cancer.

Screening & Early Detection

Screening has been shown to prevent death from cancers of the breast, colon, and cervix. Current cancer screening recommendations from the American Cancer Society, the Canadian Task Force on Preventive Health Care, and the United States Preventive Services Task Force are shown in Table 1-9.

The appropriate form and frequency of screening for breast cancer is controversial. A large randomized trial of breast self-examination conducted among factory workers in Shanghai found no benefit. A systematic review performed for the United States Preventive Services Task Force found that mammography was moderately effective in reducing breast cancer mortality for women 40–74 years of age. The absolute benefit was greater for older women, and the risk of false-positive results was high for all women.

All current recommendations call for cervical and colorectal cancer screening. Prostate cancer screening, however, is controversial, as no completed studies have answered the question whether early detection and treatment after screen detection produce sufficient benefits to outweigh harms of treatment. Providers and patients are advised to discuss how to proceed in light of this uncertainty. Single serum prostate-specific antigen (PSA) measurements appear to offer relatively high sensitivity and specificity to detect prostate cancer. The sensitivity is about 65%, the specificity about 80%, and the positive predictive value for prostate cancer is about 45%. When both the digital rectal examination and serum PSA are abnormal, PSA specificity increases, but sensitivity falls (to 30%) and predictive value rises only slightly. Whether early detection through screening and subsequent treatment alter the natural course of the disease remains to be seen. There are still no data on the morbidity and mortality benefits of screening. Unlike the American College of Physicians, the American Cancer Society recommends that providers offer annual PSA testing for men over age 50. Screening is not recommended by any group for men who have estimated life expectancies of less than 10 years. Decision aids have been developed to help men weigh the arguments for and against PSA screening.

Annual or biennial fecal occult blood testing reduces mortality from colorectal cancer by 16–33%. The risk of death from colon cancer among patients undergoing at least one sigmoidoscopic examination is reduced by 60–80% compared with that among those not having sigmoidoscopy. Colonoscopy has also been advocated as a screening examination. While it is more accurate than flexible sigmoidoscopy for detecting cancer and polyps, its value in reducing colon cancer mortality has not been studied. Recent studies have shown that CT colography (virtual colonoscopy) is also able to detect cancers and polyps with reasonable accuracy.

Screening for cervical cancer with a Papanicolaou smear is indicated in sexually active adolescents and in adult women every 1–3 years. Screening for vaginal cancer with a Papanicolaou smear is not indicated in women who have undergone hysterectomies for benign disease with removal of the cervix—except in diethylstilbestrol (DES)-exposed women (see Chapter 17). Women over age 70 who have had normal results on three or more previous Papanicolaou smears may elect to stop screening.

Table 1-9. Cancer screening recommendations for average-risk adults, 2003.

  Test ACS1 CTF2 USPSTF3
Breast Self-examination (BSE) Monthly for women over age 20. Fair evidence that BSE should not be used. Insufficient evidence to recommend for or against.
Clinical breast examination Every 3 years age 20-40 and annually thereafter. Every 1-2 years in women aged 40-59. Insufficient evidence to recommend for or against.
Mammography Annually age 40 and older. Every 1-2 years in women aged 40-59. Current evidence does not support the recommendation that screening mammography be included in or excluded from the periodic health examination of women aged 40-49. Recommended every 1-2 years for women aged 40 and over (B).
Cervix Papanicolaou test Annually beginning within 3 years after first vaginal intercourse or no later than age 21. Annually at age of first intercourse or by age 18; can move to every-2-year screening after two normal results. Every 3 years beginning at onset of sexual activity.
After age 30, women with three normal tests may be screened every 2-3 years.
Women may choose to stop screening after age 70 if they have had three normal (and no abnormal) results within the last 10 years.
Colon Stool test for occult blood4 Screening recommended, with the combination of fecal occult blood test and sigmoidoscopy preferred over stool test or sigmoidoscopy alone. Barium enema and colonoscopy also considered reasonable alternatives. Good evidence for screening every 1-2 years over age 50. Screening strongly recommended (A), but insufficient evidence to determine best test.
Sigmoidoscopy Fair evidence for screening over age 50 (insufficient evidence about combining stool test and sigmoidoscopy).
Double-constrast barium enema Not addressed.
Colonoscopy Insufficient evidence for or against use in screening.
Digital rectal exam (DRE) Not recommended. No recommendation. Not recommended.
Prostate DRE DRE and PSA should be offered annually to men age 50 and older who have at least a 10-year life expectancy. Information should be provided to men about the benefits and risks, and they should be allowed to participate in the decision. Men without a clear preference should be screened. Insufficient evidence for or against including in routine care. Insufficient evidence to recommend for or against.
Prostate-specific antigen (PSA) blood test Fair evidence against including in routine care.
Other Cancer-related checkup Every 3 years for men 20-40 and annually thereafter; should include counseling and perhaps oral cavity, thyroid, lymph node, or testicular examinations. Not assessed. Not assessed.
1American Cancer Society recommendations, available at http://www.cancer.org
2Canadian Task Force on Preventive Health Care recommendations available at http://www.ctfphc.org
3United States Preventive Services Task Force recommendations available at http://www.ahrq.gov
4Home test with three samples.
Recommendation A: The USPSTF strongly recommends that clinicians routinely 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.)
Recommendation B: The USPSTF recommends that clinicians routinely provide the service to eligible patients. (The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.)

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Andriole GL et al: PLCO Project Team: Prostate Cancer Screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial. J Natl Cancer Inst 2005;97:433.

Anthonisen NR et al: Lung Health Study Research Group: The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann Intern Med 2005;142:233.

Aus G et al: Individualized screening interval for prostate cancer based on prostate-specific antigen level: results of a prospective, randomized, population-based study. Arch Intern Med 2005;165:1857.

Bill-Axelson A et al: Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005;352:1977.

Denny L et al: Screen-and-treat approaches for cervical cancer prevention in low-resource settings: a randomized controlled trial. JAMA 2005;294:2173.

Harper DM et al: GlaxoSmithKline HPV Vaccine Study Group: Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomized controlled trial. Lancet 2004;364:1757.

Harris R et al: Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:917.

Humphrey LL et al: Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:347.

Pignone M et al: Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132.

Prochaska JO et al: Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Prev Med 2005;41:406.

Saraiya M et al: Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review. Am J Prev Med 2004;27:422.

Sawaya GF et al: Risk of cervical cancer associated with extending the interval between cervical-cancer screenings. N Engl J Med 2003;349:1501.

Torpy JM et al: JAMA patient page. Colon cancer screening. JAMA 2003;289:1334.

Villa LL et al: Prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in young women: a randomised double-blind placebo-controlled multicentre phase II efficacy trial. Lancet Oncol 2005;6:271.

Weissfeld JL et al: PLCO Project Team: Flexible sigmoidoscopy in the PLCO cancer screening trial: results from the baseline screening examination of a randomized trial. J Natl Cancer Inst 2005;97:989.

Prevention of Injuries & Violence

Injuries remain the most important cause of loss of potential years of life before age 65. Road traffic injuries, self-inflicted injuries, falls, and interpersonal violence are the major sources of injuries. Injuries affect mostly older women and young men, often causing long-term disability. Although there has been a steady decline in motor vehicle accident deaths per miles driven, road traffic injuries remain the tenth leading cause of death and the ninth leading cause of the burden of disease. Although seat belt use protects against serious injury and death in motor vehicle accidents, at least one-fourth of adults and one-third of teenagers do not use seat belts routinely. Air bags are protective for adults but not for small children.

Each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. By the end of 2000, bicycle helmet use in 15 communities monitored by the CDC's National Center for Injury Prevention and Control had risen from 40% to 55%, exceeding the Healthy People 2000 goal. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home.

Long-term alcohol abuse adversely affects outcome from trauma and increases the risk of readmission for new trauma. Alcohol and illicit drug use are associated with an increased risk of violent death. There is a causal link between alcohol intoxication and injury due to assault. Harm reduction can be achieved through practical measures, such as using plastic glasses and bottles in licensed premises; controlling prices of drinks; and targeted policing based on police, accident, and emergency data.

Males aged 16–35 are at especially high risk for serious injury and death from accidents and violence, with blacks and Latinos at greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes increases with the number of passengers. Deaths from firearms have reached epidemic levels in the United States and will soon surpass the number of deaths from motor vehicle accidents. Having a gun in the home increases the likelihood of homicide nearly threefold and of suicide fivefold. In 2002, an estimated 877,000 individuals successfully committed suicide. Educating physicians to recognize and treat depression as well as restricting access to lethal methods have been found to reduce suicide rates.

In elderly patients, the risk of hip fracture when falling can be reduced by as much as 80% by wearing hip protectors, but only about half of patients use them regularly. Oral vitamin D supplementation with 700–800 IU/d appears to reduce the risk of hip and other nonvertebral fractures in both ambulatory and institutionalized elderly persons, but 400 IU/d is not sufficient for fracture prevention.

Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse—in particular, routine assessment of women for risk of domestic violence. Inclusion of a single question about domestic violence in the medical history—“At any time, has a partner ever hit you, kicked you,

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or otherwise physically hurt you?”—increased identification of this common problem from nil to 11.6%. Another screening device consists of three questions: (1) “Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?” (2) “Do you feel safe in your current relationship?” (3) “Is there a partner from a previous relationship who is making you feel unsafe now?” Asking these questions increased identification of domestic violence to 30% of women in an emergency department. The effect of screening and identifying intimate partner violence on health outcomes has not been well studied to date.

Physical and psychological abuse, exploitation, and neglect of older adults are serious underrecognized problems. Clues to elder mistreatment include the patient's appearance, recurrent urgent-care visits, missed appointments, suspicious physical findings, and implausible explanations for injuries.

Bischoff-Ferrari HA et al: Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 2005;293:2257.

Cusens B et al: Prevention of alcohol-related assault and injury. Hosp Med 2005;66:346.

JAMA patient page. Partner violence. JAMA 2002;288:662.

Mann JJ et al: Suicide prevention strategies: a systematic review. JAMA 2005;294:2064.

McClure R et al: Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database Syst Rev 2005;(1):CD004441.

Nelson HD et al: Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U. S. Preventive Services Task Force. Ann Intern Med 2004;140:387.

Rivara FP et al: Injury prevention. (Two parts.) N Engl J Med 1997;337:543, 613. ,

Substance Abuse: Alcohol & Illicit Drugs

Substance abuse is a major public health problem in the United States and is estimated to be a factor in 41% of highway fatality accidents. The lifetime prevalence of alcoholism is estimated to be between 12% and 16%. Approximately two-thirds of high school seniors are regular users of alcohol. Underdiagnosis of alcohol abuse is substantial, both because of patient denial and lack of detection of clinical clues. A substantial decline in alcohol-related fatalities testifies to the success of educational and law-enforcement efforts to stop drinking and driving. Even so, alcohol-impaired driving remains prevalent, especially among men aged 18–34 years. Binge drinking among college students has recently increased.

As with cigarette use, clinician identification and counseling about alcoholism may improve the chances of recovery. About 10% of all adults seen in medical practices are problem drinkers. An estimated 15–30% of hospitalized patients have problems with alcohol abuse or dependence, but the connection between patients' presenting complaints and their alcohol abuse is often missed. The CAGE test (see Table 1-10) is both sensitive and specific for chronic alcoholism. However, it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized for being less applicable to minority groups or to women. Others recommend asking three questions: (1) How many days per week do you drink (frequency)? (2) On a day when you drink alcohol, how many drinks do you have in one day (quantity)? (3) On how many occasions in the last month did you drink more than five drinks (binge drinking)? The Alcohol Use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems (Table 1-10). It has been found to accurately detect hazardous drinking, harmful drinking, and alcohol dependence and does not seem to be affected by ethnic or gender bias. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods (see Table 1-11 and Chapter 25) can produce a 10–30% reduction in long-term alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant long-term reductions in unhealthy drinking behaviors. Several pharmacologic agents are effective in reducing alcohol consumption. In acute alcohol detoxification, standard treatment regimens use long-acting benzodiazepines, the preferred medications for alcohol detoxification, because they can be given on a fixed schedule or through “front-loading” or “symptom-triggered” regimens. Adjuvant sympatholytic medications can be used to treat hyperadrenergic symptoms that persist despite adequate sedation. For maintenance, persons who receive short-term treatment with naltrexone have a lower chance of alcoholism relapse. Compared with placebo, naltrexone can lower the risk of treatment withdrawal in alcohol-dependent patients. Nalmefene is not recommended for treatment of alcohol dependence.

Use of illegal drugs—including cocaine, methamphetamine, and so-called “designer drugs”—either sporadically or episodically remains an important problem. Disturbing trends include an increase in use of marijuana and inhalants among eighth graders and high school students and an increase in abuse of prescription pain medications. Many drug users are employed, and many use drugs during pregnancy. Cocaine or tobacco use during early pregnancy substantially increases the risk of miscarriage. Abuse of anabolic-androgenic steroids has been associated with use of other illicit drugs, alcohol, and cigarettes and with violence and criminal behavior. As with alcohol abuse, the recognition of drug abuse presents special problems and requires that the clinician actively consider the diagnosis. Clinical aspects of substance abuse are discussed in Chapter 25.

Currently, evidence does not support the use of carbamazepine, disulfiram, mazindol, phenytoin, nimodipine,

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lithium, antidepressants, or dopamine agonists in the treatment of cocaine dependence. Buprenorphine has potential as a medication to ameliorate the signs and symptoms of withdrawal from opioids and has been shown to be effective in reducing concomitant cocaine and opiate abuse. Slow tapering with temporary substitution of methadone and buprenorphine—accompanied by medical supervision and ancillary medications—can reduce withdrawal severity, but most patients relapse to heroin use. Cessation of methadone maintenance is possible using buprenorphine by transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Evidence does not support the use of naltrexone in maintenance treatment of opioid addiction. Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an approach to treat opioid dependence. However, a randomized comparison of buprenorphine-assisted rapid opioid detoxification with naltrexone induction and clonidine-assisted opioid detoxification with delayed naltrexone induction found no significant differences in rates of completion of inpatient detoxification, treatment retention, or proportions of opioid-positive

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urine specimens, and the anesthesia procedure was associated with more potentially life-threatening adverse events.

Table 1-10. Screening for alcohol abuse.

1. CAGE screening test1
   Have you ever felt the need to Cut down on drinking?
   Have you ever felt Annoyed by criticism of your drinking?
   Have you ever felt Guilty about your drinking?
   Have you ever taken a morning Eye opener?
   INTERPRETATION: Two “yes” answers are considered a positive screen. One “yes” answer should arouse a suspicion of alcohol abuse.
2. The Alcohol Use Disorder Identification Test (AUDIT).2 (Scores for response categories are given in parentheses. Scores range from 0 to 40, with a cutoff score of ≥ 5 indicating hazardous drinking, harmful drinking, or alcohol dependence.)
   1. How often do you have a drink containing alcohol?
      (0) Never (1) Monthly or less (2) Two to four times a month (3) Two or three times a week (4) Four or more times a week
   2. How many drinks containing alcohol do you have on a typical day when you are drinking?
      (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more
   3. How often do you have six or more drinks on one occasion?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   4. How often during the past year have you found that you were not able to stop drinking once you had started?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   5. How often during the past year have you failed to do what was normally expected of you because of drinking?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   7. How often during the past year have you had a feeling of guilt or remorse after drinking?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?
      (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
   9. Have you or has someone else been injured as a result of your drinking?
      (0) No (2) Yes, but not in the past year (4) Yes, during the past year
   10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
      (0) No (2) Yes, but not in the past year (4) Yes, during the past year
1Modified from Mayfield D et al: The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974;131:1121.
2From Piccinelli M et al: Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study. BMJ 1997;314:420.

Table 1-11. Basic counseling steps for patients who abuse alcohol.

Establish a therapeutic relationship
Make the medical office or clinic off-limits for substance abuse
Present information about negative health consequences
Emphasize personal responsibility and self-efficacy
Convey a clear message and set goals
Involve family and other supports
Establish a working relationship with community treatment resources
Provide follow-up
From the United States Department of Health Human Services, U.S. Public Health Service, Office of Disease Prevention Health Promotion. Clinician's Handbook of Preventive Services: Put Prevention Into Practice. U.S. Government Printing Office, 1994.

Blondell RD: Ambulatory detoxification of patients with alcohol dependence. Am Fam Physician 2005;71:495.

Breen CL et al: Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Drug Alcohol Depend 2003;71:49.

Collins ED et al: Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA 2005;294:903.

Fudala PJ et al: Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med 2003;349:949.

Isaacson JH et al: Prescription drug use and abuse. Risk factors, red flags, and prevention strategies. Postgrad Med 2005; 118:19.

JAMA patient page. Cocaine addiction. JAMA 2002;287:146.

Montoya ID et al: Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther 2004;75:34.

Saitz R et al: Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study. Ann Intern Med 2003;138:372.

Sofuoglu M et al: Novel approaches to the treatment of cocaine addiction. CNS Drugs 2005;19:13.

Srisurapanont M et al: Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev 200525;(1):CD001867.

Whitlock EP et al: Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557.