Adults and Older AdultsScreening

Anemia in adults, defined as a hemoglobin level below the 5th percentile of the reference distribution range for age and gender, is most prevalent in young women (4.5%) and elderly men (4.8%). Anemia is also more common in individuals of low socioeconomic status and in African Americans. Common causes of anemia include iron and vitamin deficiencies (folate and vitamin B-12), occult blood loss, chronic illness, and hemoglobinopathies. Although most forms of anemia are treatable, the benefits of treating asymptomatic individuals are unclear. For this reason, most authorities either recommend against routine screening of adults for anemia or recommend screening only high-risk adults (eg, elderly men, pregnant women, adults with chronic disease).

The hemoglobinopathies are genetic disorders that affect the production and function of hemoglobin molecules. These disorders include sickle cell disease and trait, the thalassemias, and other rarer conditions. Hemoglobinopathies tend to occur in defined ethnic and racial groups, predominantly African Americans in this country. However, they are also found in individuals of Caribbean, Latin American, Asian, and Mediterranean descent. Approximately 50,000 African Americans are affected by sickle cell disease, and another 2million carry the trait. Fewer than 1000 Americans have betathalassemia major, but sizable numbers of Italian Americans, Greek Americans, and immigrants from Southeast Asia carry the genetic trait. In adult populations, screening is useful primarily for providing preconception and prenatal genetic counseling to carriers.

See chapters 1 and 8 for discussions about screening for anemia and hemoglobinopathies in children and adolescents.

American College of Physicians --

Routine screening for anemia is not recommended in adults without clinical indications.

American College of Obstetricians and Gynecologists --

Hemoglobin levels should be measured as part of routine preventive care for women with a history of excessive menstrual flow and for women 65 years of age or older at high risk.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening of asymptomatic, nonpregnant adults, although recommendations against can be made on the grounds of low prevalence, cost, and potential adverse effects of iron therapy.

American College of Obstetricians and Gynecologists --

Screening should be provided to women of reproductive age who are of Caribbean, Latin American, Asian, Mediterranean, or African descent.

Canadian Task Force on the Periodic Health Examination --

A family and genetic history should be obtained from all patients of Mediterranean, African, Middle Eastern, East Indian, Hispanic, or Asian ancestry who may become parents. Screening with hemoglobin electrophoresis or thin layer isoelectric focusing is recommended for pregnant, at-risk women but not for other adults.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against screening for hemoglobinopathies by hemoglobin electrophoresis in young adults from ethnic and racial groups known to be at increased risk for sickle cell disease, thalassemias, and other hemoglobinopathies in order for them to be able to make informed reproductive choices. Recommendations to offer such testing may be made on other grounds, including burden of suffering and patient preference. If provided, testing should be accompanied by counseling, which should include a description of the significance of the disease, how it is inherited, the availability of a screening test, and the implications to the individual and their offspring of a positive result.

Sickle Cell Anemia (New Hope for People With). This and other publications are available from the FDA Office of Consumer Affairs, HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Table 27.1. Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia in Smokers

Table 27.2. Altitude Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia

Approximately 50 million Americans have blood pressure elevations that warrant monitoring or drug therapy. These persons are at increased risk for coronary artery disease, peripheral vascular disease, stroke, renal disease, and retinopathy. Treatment of hypertension is very effective. Use of antihypertensive therapy has contributed to a 59% reduction in age-adjusted stroke mortality and a 50% reduction in mortality from coronary artery disease since 1972. The benefits of antihypertensive therapy are greatest for persons with the most markedly elevated blood pressure; however, even patients with stage 1, or mild hypertension, benefit from treatment. Recent research has demonstrated the importance of treating "isolated" systolic hypertension, especially in older adults.

American Academy of Family Physicians --

Blood pressure should be measured periodically in all patients over 21 years of age.

American College of Obstetrics and Gynecology --

Blood pressure should be measured as part of periodic evaluation visits, which should occur yearly or as appropriate.

American College of Physicians --

Blood pressure should be measured in adults every 1 to 2 years. Normotensive patients should have blood pressure measurements at least yearly if any of the following pertains: (1) diastolic blood pressure between 85 and 89 mm Hg; (2) African-American heritage; (3) moderate or extreme obesity; (4) a first-degree relative with hypertension; (5) a personal history of hypertension.

Canadian Task Force on the Periodic Health Examination --

Case-finding (screening patients seen for any reason) should be considered in all persons aged 21 to 84 years; individual clinical judgement should be exercised in all other cases except pregnant women (for whom blood pressure should be measured as part of prenatal care).

National High Blood Pressure Education Program (NHBPEP) of the National Heart, Lung, and Blood Institute --

Blood pressure measurements should be performed on adults at least every 2 years and at each patient visit if possible. Patients with diastolic blood pressures of 85 to 89 mm Hg should have their blood pressure rechecked within 1 year. See Tables 28.1 and 28.2 for classification of blood pressure and recommendations for follow-up.

US Preventive Services Task Force --

Adults should have blood pressure measured periodically, with the optimal interval left to clinical discretion.

High Blood Pressure: Treat it for Life; Check Your Healthy Heart IQ; High Blood Pressure and What You Can Do About It; Six Good Reasons to Control Your High Blood Pressure; Eat Right to Lower Your Blood Pressure. To order these and other materials, in both English and Spanish, contact the National Heart, Lung, and Blood Institute Information Center. PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.

The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. To order this report in either English or Spanish, contact the National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.

Table 28.1. Classification of Blood Pressure for Adults Aged 18 Years and Older *

Table 28.2. Recommendations for Follow-Up Based on Initial Set of Blood Pressure Measurements for Adults Aged 18 and Over

Table 28.3. Life-style Modifications for Hypertension Control

Obesity is a major public health concern in the United States. More than one-third of all American adults are overweight, and this proportion continues to increase. (NOTE: Obesity is an excess of body fat. Overweight refers to an excess of body weight relative to height. Because it is more readily quantified than obesity, overweight is often used as a proxy for obesity.) Overweight is associated with significantly increased mortality and multiple health risks, such as noninsulin-dependent diabetes mellitus (type 2), hypertension, hypercholesterolemia, stroke, and coronary heart disease, as well as several types of cancer. Abdominal adiposity, as measured by waist-to-hip circumference ratio (WHR) or absolute waist circumference, is associated with an increased risk of diabetes, hypertension, coronary heart disease, stroke, and death from all causes.

Even modest weight loss by overweight individuals, accomplished by changing the diet, increasing physical activity, and other interventions, can decrease the risk of most forms of morbidity associated with being overweight. The goal of any intervention should be making lifestyle changes that are permanent.

See chapter 3 for information on body measurement of children and adolescents. See chapters 56 and 57 for information on counseling adults about nutrition and physical activity.

American Academy of Family Physicians --

All patients should be measured for height and weight periodically.

American College of Obstetricians and Gynecologists --

Height and weight should be measured as part of periodic evaluation visits, which should occur yearly or as appropriate.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend the inclusion or exclusion of height and weight measurement and BMI calculation in the periodic health examination, given the lack of long-term effectiveness of weight reduction therapy in the large majority of obese individuals. Weight reduction can be cautiously recommended in persons with obesity and coexistent diabetes, hypertension, or hyperlipidemia.

US Department of Agriculture, US Department of Health and Human Services --

Calculation of the ratio of waist circumference to hip circumference can be used, in addition toheight and weight measurements, to help evaluate body weight.

US Preventive Services Task Force --

All adults should receive periodic measurement of height and weight. The optimal frequency for measuring height and weight in adults is a matter of clinical discretion. There is insufficient evidence to recommend for or against determination of the waist/hip ratio (WHR) as a routine screening test for obesity.

1. To ensure accuracy, measure height while the patient is barefoot or in socks or stockings only. Make sure that the patient is standing as erect as possible, with feet flat on the floor. Height-measuring rods attached to scales should be regularly checked for accuracy, because they become inaccurate with use.

2. Use a balance beam or electronic scale (not a spring-type scale) to measure weight. The measurement will be most accurate if the patient is wearing minimal or no clothing. Calibrate scales on a regular basis.

3. Historically, the definition of "healthy" weight has been a subject of debate. Typically, two different methods have been used for evaluating weight: (1) comparison with the Metropolitan Life Insurance Tables, and (2) calculation of body mass index (BMI).

Clinicians have been most accustomed to using height-weight tables. Early tables were adapted from those developed in 1959 by the Metropolitan Life Insurance Company and were based on weights associated with minimal mortality. Although these tables were widely circulated and used, they had significant limitations: they included subjective estimates of body frame size and were based on an insured population, which may not be representative of the overall US population.

Today, most authorities endorse using BMI to evaluate healthy weight for adults. The formula for calculating BMI is:

Weight(kg)
Height(m)²

Although authorities previously suggested that the ranges of "healthy" BMI and weight should increase with age, most authorities now do not believe that such age adjustments are valid. Table 29.1 presents an easy way to calculate an individual's BMI based on the person's height and weight.

In 1995, the US Departments of Agriculture and Health and Human Services published new healthy weight ranges for adult men and women in Dietary Guidelines for Americans (see Selected References). These ranges, proposed by an expert committee and adopted by the Departments, are based on an extensive review of the literature pertaining to weight-related risk of morbidity and mortality over a range of BMI values. The weight ranges are presented in Table 29.2 and Figure 29.1. Note that the higher weights apply to people with more muscle and bone.

The upper boundary of healthy weight corresponds to a BMI of about 25, based on the significant increase in risk of mortality that occurs among persons with BMI values above this cutoff point. The lower boundary of healthy weight represents a BMI of 19, although whether a weight below this level is unhealthy remains unclear. BMI values above 28 to 29, the boundary between moderate and severe overweight, are associated with an increasingly higher risk of disease and death.

4. Research indicates that WHR or absolute weight circumference may be stronger predictors of mortality than are measures of general body adiposity. Determination of WHR is also useful for assessing patients, particularly those who have weight that is borderline-high and a personal or family medical history placing them at increased health risk. Determine the WHR by measuring the abdominal (waist) circumference and the hip circumference. Measure the abdominal circumference at the level of the umbilicus (or the level of greatest anterior extension of the abdomen) while the patient is standing. Determine the hip circumference by measuring the greatest circumference at the level of the buttocks. Obtain both measurements after a normal expiration by the patient and without indenting the skin. The formula for calculating WHR is:

Abdominal Circumference
Hip Circumference

WHR values above 1.0 for men and above 0.8 for women are associated with an increased risk of diabetes, hypertension, heart disease, and stroke. An absolute waist circumference measurement greater than 100 cm is also associated with an increased disease risk. However, evidence suggests that WHR or waist circumference and disease risk may not have as strong an association in some minority populations.

5. Bioelectric impedance analysis (BIA), a new technique for quickly estimating body composition, is currently used in many different practice settings. In theory, this technique measures the electrical impedance, or resistance, to the flow of electricity, in the body. From this measurement, an estimate of total body water (TBW) is calculated. An estimate of fat-free mass and body fat (adiposity) can then be determined. However, no industry standards for BIA currently exist, and a person's body fat measurement may vary by as much as 10% of body weight depending on the technique, machinery, conditions, and equations used. Variables that can affect the measurements include body position, hydration status, consumption of foods and beverages, ambient air and skin temperature, recent physical activity, and conductance of the examining table. Only when these variables become controlled and standardized may BIA prove to be a quick, accurate, and noninvasive way to determine body fat.

Nutrition and Health: Dietary Guidelines for Americans. 4th ed. US Dept of Agriculture and US Dept of Health and Human Services, 1995. This material is available from the Consumer Information Center 3C, Dept 514-X, Pueblo, CO 81009.

Check Your Weight and Heart Disease I.Q. This information is available in both English and Spanish. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Weight Control: Losing Weight and Keeping It Off. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Bioelectric Impedance Analysis in Body Composition Measurement; Understanding Adult Obesity; Weight Cycling. The National Institute of Diabetes and Digestive and Kidney Disease, 1 WIN Way, Bethesda, MD 20892-3665; (800)946-8098.

Table 29.1. Body Weights in Pounds According to Height and Body Mass Index *

Table 29.2. Healthy Weight Ranges for Adult Men and Women

Cancer will eventually develop in approximately 30% of Americans; three of every four families will be affected. Many cancers can be cured if they are detected early and treated in the early stages. See Table 30.1 for data on the incidence and mortality of major types of cancer.

This chapter presents information regarding detection of several cancers through physical examination. Screening tests for early detection of specific cancers are addressed in separate chapters.

Cancer of the breast can manifest as visual and physical changes of the breast and axilla. Most clinical trials have evaluated the effectiveness of screening for breast cancer in women with either mammography alone or mammography combined with clinical breast examination (CBE). No direct evidence suggests superior effectiveness of CBE alone compared with no screening. When CBE is performed by a clinician, its sensitivity for detection of cancer is approximately 45%. The overall sensitivity of breast self-examination (BSE) is about 26%. The sensitivity of BSE decreases with advancing age: from 41% in women aged 35 to 39 years to only 21% for women aged 60 to 74 years. See chapter 36 for information on the epidemiology of breast cancer and screening mammography.

American Cancer Society --

Women should have clinical breast examinations every 3 years from age 20 to 39 years.

American College of Obstetricians and Gynecologists --

Women over age 18 years should have clinical breast examination during the periodic evaluation, yearly, or as appropriate.

Canadian Task Force on the Periodic Health Examination --

Clinical breast examination is not recommended for screening women less than 50 years of age.

American Academy of Family Physicians --

Mammography and clinical breast examination should be offered to women aged 50 to 69 every 1 to 2 years.

American Cancer Society, American College of Obstetricians and Gynecologists, and American College of Physicians --

Annual clinical breast examination should be performed on women 40 years of age and older.

Canadian Task Force on the Periodic Health Examination --

Clinical breast examination screening should be performed annually on women 50 to 69 years of age. Clinical breast examination should be used in conjunction with mammography for screening.

US Preventive Services Task Force --

Breast cancer screening should be performed in women 50 to 69 years of age through mammography every one to two years with or without annual clinical breast examination. There is insufficient evidence to recommend for or against clinical breast examination alone in this age group or in any other age group. Although there is insufficient evidence, recommendations to screen high risk women beginning at age 40 and women over 70 may be made on other grounds.

There is no evidence specifically evaluating clinical breast examination in screening high-risk women under 50 years of age; recommendations for screening such women may be made on the basis of their high burden of suffering and the higher positive predictive value of screening. There is limited and conflicting evidence of the value of clinical breast examination screening in women 70 to 74 years of age and no evidence for women over 75; however, recommendations for screening women 70 years of age and older who have a reasonable life expectancy can be made on the basis of the high burden of suffering of this age group. There is insufficient evidence to recommend the use of clinical breast exam alone, without mammography, for screening.

An estimated 30,750 new cases of oral cavity and pharyngeal cancer will be diagnosed in 1997, and approximately 8440 deaths are expected to occur during that period. Most deaths occur within 3 or 4 years of diagnosis. The incidence of oral cancer among men is more than twice that among women; the highest rates are seen among men over age 40 years. In the United States, 90% of oral cancer cases are attributable to the use of tobacco and to a lesser extent, alcohol.

American Cancer Society --

Individuals 20 to 39 years of age should have a cancer checkup, including examination of the oral region, every 3 years; those 40 years of age and older should have one yearly.

American College of Obstetricians and Gynecologists --

Examinations of the oral cavity in women 40 years of age and older should be part of periodic health examinations performed annually, as appropriate.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence for inclusion or exclusion of oral cancer screening in the periodic health examination. Annual examination by physicians and/or dentists should be considered for men and women over 60 years of age who have a known risk factor for oral premalignancy and invasive oral cancers, such as tobacco use in any form and regular alcohol consumption.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening of asymptomatic persons for oral cancer by primary care clinicians. Although direct evidence of a benefit is lacking, clinicians may wish to include an examination for cancerous and precancerous lesions of the oral cavity in the periodic health examination of persons who chew or smoke tobacco (or did so previously), older persons who drink regularly, and anyone with suspicious symptoms or lesions detected through self-examination. All patients, especially those over 65 years of age, should be advised to receive a complete dental examination on a regular basis.

Pelvic examination is used to detect and identify cancers of the female genital tract. Use of the Pap smear testing during pelvic examination to identify cervical neoplasms and premalignant lesions (chapter 37) has been an unqualified success. Some authors have advocated performing bimanual examination during the pelvic examination to detect some pelvic neoplasms, including ovarian cancer, which has the highest mortality of all the gynecologic cancers. Approximately 26,800 new cases of ovarian cancer will occur in the United States in 1997, with an estimated 14,600 deaths occurring in that period. Ovarian cancer will develop in one of every 70 women. A woman's risk of ovarian cancer is increased by nulliparity; older age at the time of first pregnancy or live birth; fewer pregnancies; and a personal history of breast, endometrial, or colorectal cancer. Often, no signs or symptoms of ovarian cancer occur until late in the course of disease, and the cancer is often of considerable size by the time it is detectable by pelvic examination.

American Cancer Society --

Pelvic examination should be performed every 1 to 3 years for women aged 18 to 39 and annually for women over age 40.

American College of Obstetricians and Gynecologists --

Women who have become sexually active or are 18 years of age and older should have annual pelvic examinations as part of a periodic health examination.

Canadian Task Force on the Periodic Health Examination (CTFPHE) and US Preventive Services Task Force --

Routine pelvic examination is not recommended for the detection of ovarian cancer. There is insufficient evidence to recommend for or against screening of asymptomatic women at increased risk for ovarian cancer. The CTFPHE states that it would be reasonable to examine the adnexa if a pelvic examination were being done for another reason, such as cervical inspection or Pap smear.

Digital rectal examination (DRE) can be used to identify colorectal and prostate cancers. The DRE is of limited value as a screening test for colorectal cancer, because fewer than 10% of colorectal cancers can be palpated. See chapter 34 for information on the epidemiology of colorectal cancer and screening with fecal occult blood testing.

Rectal examination does afford an opportunity for limited palpation of the prostate gland in men. See chapter 39 for information on the epidemiology of prostate cancer and screening with prostate-specific antigen (PSA). The sensitivity and specificity of digital rectal examination for detecting prostate cancer are 33% to 69% and 49% to 97%, respectively. Scant evidence exists suggesting that screening by digital rectal examination decreases mortality from prostate cancer. Some authorities believe that the limited effectiveness of DRE may be attributable to either its inability to detect tumors at an early, treatable stage or the fact that some tumors grow so rapidly that yearly screening cannot detect most of them at an early, treatable stage, or both.

American Academy of Family Physicians --

Clinicians should counsel men age 50 to 65 about the known risks and uncertain benefits of screening for prostate cancer.

American Cancer Society --

Annual digital rectal examination should be performed for men aged 50 and over as part of prostate cancer screening (chapter 39). In men and women age 50 and over, a rectal examination should be done as part of colorectal cancer screening every 5 to 10 years, depending on the type of screening test used.

American College of Obstetricians and Gynecologists --

Digital rectal examination should be included in the periodic health examination of women 50 years of age and older as part of the pelvic exam.

American Society of Colon and Rectal Surgeons --

Annual digital rectal examination should be performed for asymptomatic, low-risk individuals 40 years of age and older and for asymptomatic individuals over 35 years of age with either a family history of colorectal adenomatous polyps or cancer in one or more first-degree relatives.

American Urological Association --

Annual digital rectal examination is recommended as part of prostate cancer screening for all men age 50 and over and for those at high risk starting at age 40 (chapter 39).

Canadian Task Force on the Periodic Health Examination(CTFPHE) --

There is insufficient evidence to recommend for or against the use of digital rectal examination to screen for prostate cancer. The CTFPHE has stated that evidence is insufficient to advise physicians who currently include digital rectal exam in examination on men 50 to 70 years of age to discontinue the practice.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine digital rectal examination as an effective screening test for prostate cancer in asymptomatic men. No recommendation has been made regarding the use of the examination for colorectal cancer screening.

Skin cancer is the most common type of cancer in the United States. Approximately 900,000 new cases of basal and squamous cell carcinoma, as well as
40,300 cases of malignant melanoma, will be diagnosed in 1997. An estimated 7300 deaths from malignant melanoma and approximately 2190 deaths from other types of skin cancer will occur in 1997. The incidence of malignant melanoma is increasing at the rate of 4% per year. Virtually 100% of skin cancers are curable if they are diagnosed and excised early. Skin cancers occur more commonly in fair-skinned individuals who have been exposed to the sun, radiation, or ultraviolet light for prolonged periods of time. Chronic overexposure to sunlight is the cause of 95% of all basal cell carcinomas. Other risk factors for basal cell and squamous cell carcinomas include exposure to radiation, complications of burning or scarring, and contact with arsenic. Basal cell cancer is more common in older adults and affects men more frequently than women. Both basal cell and squamous cell cancers can occur in anyone with a history of prolonged sun exposure, and both are most likely to occur in sun-exposed areas. Factors placing individuals at increased risk for malignant melanoma include the presence of atypical moles and a personal or family history of skin cancer, especially malignant melanoma.

American Academy of Dermatology and Skin Cancer Foundation --

Annual skin examinations are recommended for all patients.

Canadian Task Force on the Periodic Health Examination (CTFPHE), and US Preventive Services Task Force (USPSTF) --

There is insufficient evidence to recommend for or against routine screening for skin cancer by primary care clinicians with total skin examination. Clinicians should remain alert for skin lesions with malignant features when examining patients for other reasons, particularly in those with established risk factors. Risk factors include: melanocytic precursor or marker lesions (eg, atypical moles), large numbers of common moles, immunosuppression, a family or personal history of skin cancer, substantial cumulative lifetime sun exposure, intermittent intense sun exposure or severe sunburns in childhood, freckles, poor tanning ability, and light skin, hair, and eye color. The USPSTF states that clinicians should consider referring patients with melanocytic precursor or marker lesions to skin care specialists. The CTFPHE states that patients with family melanoma syndrome should receive total body skin examinations and be considered for referral to a specialist. Both the CTFPHE and the USPSTF state that there is insufficient evidence to recommend for or against routine counseling of patients to perform skin self-examination or to use sunscreens to prevent skin cancer. The CTFPHE states that use of sunscreen is recommended for patients with prior history of solar keratosis. The USPSTF states that use of sunscreen may be appropriate for such patients.

American Cancer Society --

Patients should undergo a cancer checkup that includes examination of the skin every 3 years for those 20 to 39 years of age, and yearly after age 40.

American College of Obstetricians and Gynecologists --

Skin examination should be performed for individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (eg, dysplastic nevi and certain congenital nevi).

Testicular cancer accounts for only about 1% of all cancers in men. However, it is the most common cancer in white men aged 20 to 34 years; 7200 new cases and 350 deaths are expected to occur in 1997. The prognosis for testicular cancer is very good, especially if it is treated early. The major risk factor is a history of cryptorchidism. Other risk factors include a previous history of testicular cancer, gonadal dysgenesis, Klinefelter's syndrome, and in utero exposure to diethylstilbestrol (DES). Testicular cancer is more common in white men than in African Americans; incidence rates are intermediate in Hispanics, American Indians, and Asians.

The two screening tests proposed for testicular cancer are health provider palpation of the testes and patient self-examination of the testes. No information is available on the sensitivity, specificity, or positive predictive value of testicular examination in asymptomatic men by either modality. Published evidence that self-examination can detect testicular cancer in asymptomatic men is limited to a small number of case reports.

American Cancer Society --

Testicular examination should be a part of the cancer checkup received by men every 3 years from 20 to 39 years of age and annually beginning at age 40.

American Urological Association --

Yearly clinical examinations should begin at age 15.

Canadian Task Force on the Periodic Health Examination and US Preventive Services Task Force (USPSTF) --

There is insufficient evidence to recommend for or against routine screening of asymptomatic men for testicular cancer by physician examination or patient self-examination. The USPSTF has stated that recommendations against such screening can be made on other grounds, such as the current excellent prognosis of testicular cancer patients and the likelihood that a large number of false-positive results would result from screening. Patients with an increased risk of testicular cancer (those with a history of cryptorchidism or testicular atrophy) should be informed of their increased risk of testicular cancer and counseled about the options for screening (physician or self-examination). Adolescent and young adult males should be advised to seek prompt medical attention if they notice a testicular or intrascrotal abnormality.

Approximately 16,100 cases of thyroid cancer will be diagnosed in 1997 in the United States; approximately 1239 deaths will be attributable to the disease. Persons at increased risk include those who have undergone irradiation of the head and neck as children and persons with a family history of multiple endocrine neoplasia, type II. Thyroid malignancy occurs twice as frequently in women as in men.

American Academy of Family Physicians --

Use of ultrasound screening in asymptomatic persons for detection of thyroid cancer is not recommended.

American Cancer Society --

A cancer checkup, including palpation of the thyroid, should be performed every 3 years on individuals 20 to 39 years of age and yearly for individuals aged 40 years and over.

American College of Obstetricians and Gynecologists --

Thyroid palpation should be part of the periodic health examination for all women over the age of 18 years.

Canadian Task Force on the Periodic Health Examination and US Preventive Services Task Force (USPSTF) --

There is insufficient evidence for or against the performance of thyroid palpation for screening for thyroid cancer. The USPSTF has stated that a recommendation for screening patients with a history of external upper-body (primarily head and neck) irradiation in infancy and childhood can be made on other grounds, such as patient preference or anxiety.

Breast Cancer: Steps to Finding Breast Lumps Early. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

How To Do Breast Self Examination; Breast Cancer - Questions and Answers; Cancer Facts for Women. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251; 1-800-ACS-2345. Internet address: http://www.cancer.org

Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://acog.com

Questions and Answers About Evaluating Breast Changes; Benign Breast Lumps and other Benign Breast Changes; What You Need To Know About Ovarian Cancer; The Pap Test: It Could Save Your Life (Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; 1-800-4-CANCER.

Chances are You Need a Mammogram; Are You Age 50 or Older? A Mammogram Could Save Your Life (English and Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Detecting and Treating Breast Problems. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (202)638-5577. Internet address: http://www.acog.com

Nonmalignant Conditions of the Breast (ACOG Technical Bulletin 156; 1991). American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; 1-800-762-2264. Internet address: http://www.acog.com

Mammography Awareness Kit. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Head & Neck Cancer: Know What the Warning Signs Are. American Academy of Otolaryngology-Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.

Facts on Oral Cancer; Self Oral Screen in Six Orderly Steps. American Cancer Society, 1599Clifton Rd, NE, Atlanta, GA 30329-4251; (800)ACS-2345. Internet address: http://www.cancer.org

What You Need to Know about Oral Cancer. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Preventing Cancer; Cancer of the Ovary. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

What You Need To Know About Ovarian Cancer; The Pap Test: It Could Save Your Life (Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; 1-800-4-CANCER.

Preventing Cancer; Cancer of the Ovary. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Cervical Cytology: Evaluation and Management of Abnormalities. Technical Bulletin 183. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; 1-800-762-2264. Internet address: http://www.acog.com

The Pap Test. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington DC 20024; (800)762-2264. Internet address: http://www.acog.com

For Men Only: Prostate Cancer; Cancer Facts for Men. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251; 1-800-ACS-2345. Internet address: http://www.cancer.org

Prostate Disease: What Every Man Over 40 Should Know. Prostate Health Council, c/o American Foundation for Urologic Disease, Inc, 1128 N Charles St, Baltimore, MD 21201. Written requests only.

The prostate puzzle. Consumer Reports. 1993;58(7):459-465.

Colorectal Cancer, Questions & Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite 1080, Palatine, IL 60067; (708)359-9184.

Colonoscopy: Questions and Answers; Polyps of the Colon and Rectum: Questions and Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite1080, Palatine, IL 60067; (708)359-9184.

What You Need to Know about Cancer of the Colon and Rectum. Office of Cancer Communications, National Cancer Institute, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Skin Cancer: Saving Your Skin From Sun Damage. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

The ABCDs of Moles & Melanomas; Dysplastic Nevi and Malignant Melanoma: A Patient's Guide; Skin Cancer: If You Can Spot It, You Can Stop It. The Skin Cancer Foundation, POBox 561, New York, NY 10156; (212)725-5176.

Facts on Skin Cancer. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251. (800)ACS-2345. Internet address: http://www.cancer.org

Prevention and Early Detection of Malignant Melanoma. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251. (800)ACS-2345. Internet address: http://www.cancer.org

Testicular Cancer & Testicular Self-Examination. American Urological Association, Inc, 1120 N Charles St, Baltimore, MD 21201-5559; (410)727-1100.

PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and standard telephone line or through medical libraries. Ask a medical librarian for assistance or call (800)4-CANCER (line 3). In Hawaii, on Oahu, call 524-1234.

OncoLink - The University of Pennsylvania Cancer Center Resource. Internet address: http://cancer.med.upenn.edu

Table 30.1. Leading Sites of Cancer Incidence and Death -- 1997 Estimates *

High blood cholesterol is an important modifiable risk factor for coronary heart disease (CHD) -- the leading cause of death for both men and women in the United States. This year, as many as 1.5 million Americans will have a new or recurrent myocardial infarction, and about one third of these individuals will die. Large, population-based studies have demonstrated that total cholesterol levels are directly related to the incidence of CHD. The Multiple Risk Factor Intervention Trial (MRFIT) found that the 6-year risk of death from CHD in normotensive, nonsmoking, middle-aged men with blood cholesterol levels less than 182 mg/dL was one fourth that of men with blood cholesterol levels of 245 mg/dL or higher. An analysis of 22 epidemiologic studies has shown that elevated cholesterol is also a risk factor for CHD in women and in individuals > 65 years of age. Epidemiologic studies have also shown that cholesterol lipoprotein subfractions play an important role in CHD. LDL-cholesterol is directly, and HDL-cholesterol is inversely, associated with the incidence of CHD.

No long-term study has compared interventions to reduce cholesterol levels and CHD incidence based on routine cholesterol screening with interventions based on selective case-finding or with universal dietary advice. Because the recent increase in cholesterol screening had been accompanied by an improved knowledge and public awareness of dietary risk factors, isolating the contribution of screening from other factors that may account for improved outcomes may be difficult. The major evidence to support cholesterol screening is the ability of cholesterol-lowering interventions to reduce the risk of CHD in patients with high cholesterol.

A meta-analysis of cholesterol-lowering trials performed mainly in middle-aged men found that lowering blood cholesterol levels through dietary management or drug therapy significantly reduces the risk of CHD death and nonfatal myocardial infarction. The West of Scotland Coronary Prevention Study Group, a primary prevention trial, showed a reduction in cardiovascular mortality associated with drug treatment with no difference between treatment groups in the rate of death due to noncardiovascular causes. Similarly, the Scandinavian Simvastatin Survival Study, a secondary prevention trial, showed that in patients with a history of myocardial infarction, the reduction in CHD mortality associated with drug treatment was accompanied by a reduction in total mortality.

See chapter 4 for information on cholesterol screening for children and adolescents.

American Academy of Family Physicians --

Males aged 35 to 65 years and females aged 45 to 65 years should be screened periodically for high cholesterol levels.

American College of Obstetricians and Gynecologists --

Adults (19 years of age and older) should have cholesterol measured every 5 years until 64 years of age, then every 3 to 5 years thereafter. (These are currently under review for a possible change to recommendations consistent with the US Preventive Services Task Force.)

American College of Physicians --

Screening for total cholesterol in the primary prevention of CHD is appropriate but not mandatory in men between 35 and 65 years of age and for women between 45 and 65 years of age. Screening for total cholesterol is not recommended for men younger than 35 years of age or women younger than 45 years of age unless the history or physical examination suggests a familial lipoprotein disorder, or at least two other characteristics place them at increased risk for developing CHD. There is insufficient evidence to recommend for or against screening in men and women between the ages of 65 and 75. Screening of individuals over 75 years of age is not recommended. In those individuals who are screened for the primary prevention of CHD, the total cholesterol level should be measured once. It should be repeated periodically if the measured value is near a treatment threshold. All patients with known CHD or whose history of other kinds of vascular disease places them at very high risk of CHD should have measurements of total cholesterol.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence for the inclusion or exclusion of universal screening for hypercholesterolemia in a periodic health examination. Nonetheless, case-finding through repeated measurements of the nonfasting total blood cholesterol level should be considered in men 30 to 59 years of age.

National Cholesterol Education Program (NCEP) of the National Heart, Lung, and Blood Institute --

Adults (20 years of age and older) should have a measurement of total blood cholesterol at least once every 5 years; HDL-cholesterol should be measured at the same time if accurate results are available. Lipoprotein analysis should be performed for all patients with CHD. In patients without CHD, lipoprotein analysis should be performed in any of the following circumstances: (1) if the total cholesterol is 240 mg/dL or above; (2) if the total cholesterol is 200 to 239 mg/dL and the patient also has two or more CHD risk factors; (3) if the patient has an HDL-cholesterol less than 35 mg/dL. See Tables 31.1 and 31.2 and Figures 31.1, 31.2, and 31.3 for NCEP recommendations on CHD risk factors and patient classification and identification.

US Preventive Services Task Force --

Periodic screening for high serum cholesterol is recommended for all men 35-65 years of age and women 45-65 years of age. There is insufficient evidence to recommend for or against screening asymptomatic persons after 65 year of age, but screening may be considered on a case-by-case basis. Older persons with major CHD risk factors (smoking, hypertension, diabetes) who are otherwise healthy may be more likely to benefit from screening, based on their high risk of CHD and the proven benefits of lowering cholesterol in older persons with symptomatic CHD. Cholesterol levels are not a reliable predictor of risk after age 75, however. There is also insufficient evidence to recommend for or against screening of young adults, although this may be recommended on other grounds to young adults at high risk, such as the greater absolute risk attributable to high cholesterol and potential long-term benefits of early lifestyle interventions. Risk factors include: family history of very high cholesterol, premature CHD in a first-degree relative (before age 50 in men or age 60 in women), diabetes, smoking, or hypertension. The appropriate interval for periodic screening is not known. Periodic screening is most important when cholesterol levels are increasing (eg, middle-aged men, perimenopausal women, and persons who have gained weight). An interval of five years has been recommended by experts, but longer intervals may be reasonable for low-risk subjects (including those with previously desirable cholesterol levels). There is insufficient evidence to recommend for or against routine measurement of HDL-cholesterol or triglycerides at initial screening.

Cholesterol: What You Can Do to Lower Your Level. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000; http://www.aafp.org

Cholesterol and Your Health. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (800)762-2264. Internet address: http://www.acog.com

Cholesterol and Your Heart; Dietary Treatment of Hypercholesterolemia: A Manual for Patients; Eat Less Fat and High Cholesterol Foods; Heart Rx (a kit of materials for patients, providers, and staff). To order these and many other materials, contact the American Heart Association, 7320 Greenville Ave, Dallas, TX 75231. To receive the telephone number of your state office, call the main office at: (800)242-8721; materials vary by state. Internet address: http://www.amhrt.org

American Heart Association Low-Fat, Low-Cholesterol Cookbook. This publication is available at retail bookstores. Internet address: http://www.amhrt.org

Eat Right to Lower Your High Blood Cholesterol and Step by Step: Eating to Lower Your High Blood Cholesterol; So You Have High Blood Cholesterol. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm. Information is available in both English and Spanish. The following materials are available in Spanish: Learn Your Cholesterol Number (Conozca su nivel de colesterol); Protect Your Health-Lower Your Blood Cholesterol (Proteja su corazon-baje su colesterol); and Heart-Healthy Latino Recipes (Platillos Latinos).

Summary of the Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Full report: National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Information is available in both English and Spanish. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Table 31.1. NCEP Coronary Heart Disease Risk Factors Other Than LDL-Cholesterol *

Table 31.2. Treatment Decisions Based on LDL-Cholesterol

**If the first two LDL-cholesterol levels differ by more than 30 mg/dL, perform a third test within 1 to 8 weeks, and use the average value of the three tests.

Adapted from: National Cholesterol Education Program. Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 1993. USDHHS Publication NIH 93-3095.

Cognitive impairment includes deficits in memory, abstract thinking, judgement, speech, coordination, planning, or organization. A functional impairment is a deficit in an individual's ability to perform either the basic activities of daily living (ADLs), such as as dressing, bathing, and eating, or instrumental activities of daily living (IADLs) -- such as using transportation, shopping, or handling finances. A functional impairment can be the result of a cognitive, physical, social, or psychological disorder. Dementia is a syndrome of progressive decline in multiple cognitive abilities that eventually leads to functional impairment. The most common form of dementia is Alzheimer's disease.

It is estimated that between 5% and 10% of persons older than 65 years of age suffer from some form of cognitive impairment, and this increases dramatically with age. The most common causes of cognitive impairment, Alzheimer's disease and vascular infarctions, are largely untreatable. However, approximately 10% to 15% of cases of cognitive impairment in older adults are attributable to treatable causes, such as hypothyroidism and drug intoxications. In some instances, early intervention can result in the arrest or reversal of cognitive defects. Approximately 2% to 8% of community-dwelling elderly persons suffer from impairments of ADLs. As many as 25% of community-dwelling older adults may suffer from functional impairment in carrying out IADLs.

Cognitive and functional impairment are growing health concerns in the United States because of the aging population. In some instances, early identification of these impairments can lead to the reversal or slowing of the progression of the impairment. In other instances, early identification alerts affected persons and their families to potentially hazardous situations and is of value in terms of planning support services.

See chapter 58 on polypharmacy.

The Alzheimer's Disease and Related Dementias Panel of the Agency of Health Care Policy and Research --

Health care providers should perform an initial assessment of dementia on clients with symptoms of increasing difficulties in the following areas: learning and retaining new information; handling complex tasks; reasoning ability; spatial ability and orientation; language or behavior.

American College of Obstetricians and Gynecologists --

Women over 65 years of age should be screened for changes in cognitive function as part of their routine preventive visits.

American College of Physicians --

Functional assessment screening by the clinician is useful for evaluating the health status of elderly patients and determining their needs for in-home assistance, home health services, or institutional placement. In the acute-care setting, functional assessment in selected patients facilitates discharge planning and is essential in patients over 75 years of age. Primary care providers should incorporate into the routine medical management of older adults procedures for measuring functional deficits and identifying dependency needs. Employing a comprehensive screening instrument followed by targeted screening instruments can be useful in systematically assessing functional deficits that otherwise might be overlooked by conventional examination methods.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend for or against active screening for cognitive impairment in people over 65 years of age. However, prudent clinicians should be alert for symptoms suggestive of cognitive impairment and conduct appropriate assessments.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening for dementia in asymptomatic elderly persons. Clinicians should periodically ask patients about their functional status at home and at work, and they should remain alert to changes in performance with age. When possible, information about daily activities should be solicited from family members and other persons. Brief tests, such as the Mini-Mental State Exam, should be used to assess cognitive function in patients in whom the suspicion of dementia is raised by restrictions in daily activities, concerns of family members, or other evidence of worsening function (eg, trouble with finances, medications, transportation). Possible effects of education and cultural differences should be considered when interpreting abnormal results.

Memory and Aging: Alzheimer's Disease and Related Disorders. To order this and many other materials, contact the Alzheimer's Association, 919 N Michigan Ave, Suite 1000, Chicago, IL 60611;(800)272-3900.

Memory Loss: What's Normal, What's Not. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114; (800)944-0000. Internet address: http://www.aafp.org

Where Did I Put My Keys? American Association of Retired Persons, Fulfillment Services, 601 E St, NW, Washington, DC 20049; (202)434-2534.

Age Page -- Senility: Myth or Madness; Age Page -- Confusion and Memory Loss in Old Age: It's Not What You Think. National Institute on Aging, Bldg 31, Room 5C27, Bethesda, MD 20892; (301)496-1752. Internet address: http://www.nih.gov/nia/health/pubpub/pubpub.htm

Early Alzheimer's Disease. AHCPR Publication no. 96-0704. Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring MD 20907; (800)358-9295. Internet address: http://www.ahcpr.gov

Administration on Aging. 330 Independence Ave., SW, Washington, DC 20201, (202)619-1006. The national office can provide phone numbers and addresses for state and local agencies on aging. Internet address: http://www.aoa.dhhs.gov

The Elder Care Locator (800)667-1116 provides toll-free access to state agency networks.

Older Voices. To order this trainer's manual and resource materials for communication problems of older persons, contact the American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; (301)897-5700.

Early Identification of Alzheimer's Disease and Related Dementias: Quick Reference Guide for Clinicians (Number 19). AHCPR Publication no. 97-0703. Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring Md 20907; (800)358-9295. The full text of guideline documents for online retrieval is available on the AHCPR Home Page. Click on "Clinical Practice Guidelines Online." Internet address: http://www.ahcpr.gov/guide

Table 32.1. Mini-Mental State Examination

Table 32.2. Questions for Evaluating Instrumental Activities of Daily Living (IADLs)

Table 32.3. Questions for Evaluating Activities of Daily Living (ADLs)

Major depressive episodes are common in adults, affecting more than 9 million Americans and costing between $33 million and $40 billion yearly. Depression affects persons of all ages, genders, and races. See Table 33.1 for a list of risk factors for major depression.

Between 5% and 10% of patients in primary care practices and 10% to 14% of medical inpatients meet the criteria for major depression, and many patients with depressive disorders are seen only by nonpsychiatric health-care providers. Research has shown that up to 50% of depressed persons seen in primary care settings are not recognized as having this disorder. Patients with major depressive disorders have a great deal of functional impairment, resulting in lost time on the job, decreased job performance, and decreased family and social functioning. Effective medical treatments are available for major depression.

American College of Obstetricians and Gynecology --

All women should receive age-specific psychosocial evaluations to detect depression and other problems.

American College of Physicians --

Elderly patients should undergo functional assessment screening, including measures of emotional status.

Canadian Task Force on the Periodic Health Examination --

There is fair evidence to exclude the use of depression detection tests from the periodic health examination of asymptomatic people. However, physicians should be sensitive to the possibility of depression in their patients, particularly those at high risk.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against performance of routine screening tests for depression in asymptomatic primary care patients. Clinicians should, however, maintain an especially high index of suspicion for depressive symptoms in adolescents and young adults, persons with a family or personal history of depression, those with chronic illnesses, those who have or perceive they have experienced a recent loss, and those with sleep disorders, chronic pain, or multiple unexplained somatic complaints.

Depression Is a Treatable Illness: A Patient's Guide. Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; 1-800-358-9295.

Depression. ACOG Patient Education Pamphlet AP106. Washington, DC: American College of Obstetricians and Gynecologists, 1994. Internet address: http://www.acog.com

To obtain free brochures about clinical depression, including information on depression in women, depression in the workplace, and depression co-morbid with medical, psychiatric, and substance abuse disorders, contact the National Institute of Mental Health, 5600 Fishers Ln, Room 10-85, Rockville, MD 20857; (800)421-4211. Internet address: http://www.nimh.nih.gov

Many types of materials are available from the National Mental Health Association, 1021 Prince St, Alexandria, VA 22314; (800)969-6642.

The National Depressive and Manic Depressive Association, 730 North Franklin Street, Suite 501, Chicago, IL 60610. (800)826-3632.

The National Mental Health Services Knowledge Exchange Network (KEN), P.O. Box 42490, Washington, DC 20015. KEN is a national, one-stop resource for mental health information and referrals that is accessible through a toll-free telephone number, (800)789-CMHS (2647); a toll-free electronic bulletin board system (BBS), (800)790-CMHS (2647). Internet address: http://www.mentalhealth.org/

Depression in Primary Care: Detection and Diagnosis (vol 1; AHCPR publication 93-0550); Treatment of Major Depression (vol 2; AHCPR publication 93-0551). These publications are available through the US Government Printing Office; call (202)510-1800.

Diagnosis and Treatment (Quick Reference Guide for Clinicians; AHCPR publication 93-0552). Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295.

Depression in Women. American College of Obstetricians and Gynecologists Technical Bulletin #182, 1992. ACOG Resource Center, 409 12th St., SW, Washington, DC 20024-2188; 1-800-762-2264. Internet address: http://www.acog.com

Diagnosis and Treatment of Depression in Late Life (NIH Consensus Development Conference, November 4-6, 1991; NIH Consensus Statements vol 9, no 3). NIH Consensus Clearing House, PO Box 2577, Kensington, MD 20891, 1-888-644-2667.

Table 33.1. Risk Factors for Depression

Table 33.2. Criteria for Major Depressive Disorder

Table 33.3. Center for Epidemiologic Studies Depression Scale *

In 1997, approximately 131,200 new cases of colorectal cancer will occur, resulting in 54,900 deaths. Principal risk factors for colorectal cancer include a history of one of the familial polyposis syndromes, familial cancer syndromes, colorectal cancer in first-degree relatives, or a personal history of ulcerative colitis, adenomatous polyps, or endometrial, ovarian, or breast cancer. Colorectal cancer detected at an early stage can be successfully treated with surgery.

Malignancies and, to a lesser extent, polyps, bleed intermittently. Fecal occult blood tests (FOBT) can detect this bleeding by identifying occult blood or breakdown products of blood in fecal material. The reported sensitivity of FOBT for detecting colorectal cancer in asymptomatic individuals ranges from 26% to 92% but with most data suggesting a sensitivity of less than 40%. The specificity ranges form 90% to 99%. Measures of sensitivity and specificity are usually based on two samples from three consecutive and easily passed stools.

Until recently, no studies had shown that fecal occult blood testing resulted in decreased mortality. In 1993, however, Mandel et al found that yearly fecal occult blood testing using rehydrated stool specimens decreased mortality from colorectal cancer by about one third. In that study, guaiac-impregnated paper slides were used to test for fecal blood.

Rehydration of dried samples before testing can increase sensitivity but also produces more false-positive results. The predictive value of a positive fecal occult blood test for colorectal cancer in general populations is only 5% to 10%. Thus, up to 75% of cancers will be missed, and for every case of colorectal cancer that is detected by fecal occult blood testing, up to 20 patients will undergo workups that will be negative.

See chapters 30 and 41 for information about other methods of screening for colorectal cancer.

American Academy of Family Physicians --

Adults aged 40 years and older with a family history of early colorectal cancer and all adults aged 50 years and older should be screened for colorectal cancer with fecal occult blood testing (annually), sigmoidoscopy, colonoscopy, or barium enema.

American Cancer Society --

Annual fecal occult blood testing is recommended in combination with flexible sigmoidoscopy every 5 years in normal risk individuals beginning at 50 years of age. The American Cancer Society further recommends that digital rectal examination be performed along with sigmoidoscopy. (See chapter 41 for details.)

American College of Obstetrics and Gynecology --

Fecal occult blood testing should be done for all women 50 years of age and older as part of their periodic health examination.

American College of Physicians --

Persons who decline screening colonoscopies and barium enemas, and especially people who decline screening flexible sigmoidoscopies, should be offered annual fecal occult blood testing from 50 to 70 or 80 years of age. No recommendation is made about the optimal frequency for screening with FOBT. In general, persons who have positive results on a fecal occult blood test should have a full colonic examination. More research is needed to understand and improve the sensitivity and specificity of the fecal occult blood test.

Canadian Task Force on the Periodic Health Examination(CTFPHE) --

There is insufficient evidence to recommend including or excluding fecal occult blood testing in the periodic health examination of individuals over 40 years of age. There is also insufficient evidence to provide fecal occult blood testing to adults at risk because of family history. Patients with true cancer family syndrome should be screened with colonoscopy, not fecal occult blood testing.

US Preventive Services Task Force --

Screening for colorectal cancer is recommended for all persons 50 years of age or older. This can be accomplished with annual fecal occult blood testing or sigmoidoscopy (frequency unspecified). There is insufficient evidence to determine which method is preferable or whether combining both methods produces results superior to either method alone.

1. Three types of tests are available for detecting fecal occult blood: guaiac-impregnated cards and other carriers that detect the peroxidase-like activity of hemoglobin (Hemoccult); quantitative tests based on the conversion of heme to fluorescent porphyrins (HemoQuant); and immunoassay tests for human hemoglobin. Currently only the first two types are routinely used in practice. Guaiac-based tests have the disadvantage of giving false-negative and false-positive results because of dietary factors, and thus are more accurate if patients restrict their diets (see Table 34.1). Guaiac-based tests have the advantages of being relatively easy for patients and clinicians to use and relatively specific for lower gastrointestinal tract bleeding. The quantitative porphyrin tests are not affected by dietary factors and are potentially more sensitive than the other tests, depending on the cut point designated for a positive result. Recent evidence indicates, however, that at matched levels of specificity, the quantitative porphyrin tests are not significantly more sensitive than guaiac-based tests. Quantitative porphyrin tests have the potential disadvantages of not being specific for lower gastrointestinal tract bleeding and of requiring interpretation by a laboratory.

2. Do not collect a stool sample from patients with hematuria or obvious rectal bleeding (eg, from hemorrhoids). Instruct women to avoid collecting stool samples during or just after a menstrual period.

3. If possible, patients should avoid using medications that cause gastric irritation and bleeding for at least 48 hours before and during the testing period. Such medications include aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, anticoagulants, reserpine, antimetabolites, and chemotherapeutic agents. Consumption of excess amounts of alcohol should be avoided. The manufacturer of Hemoccult recommends avoidance of aspirin and NSAIDs for 7 days before the test. When guaiac-based tests are used, patient adherence to the dietary guidelines in Table 34.1 for at least 48 hours before and during the testing period can help avoid false-positive and false-negative results. Despite previous reports, dietary iron does not cause false-positive test results. To prevent false-positive test results, avoid applying antiseptic preparations containing iodine to the anal area immediately before and during the testing period.

4. When guaiac-impregnated cards are used, collect two separate samples from different sections of three consecutive bowel movements; use the supplied applicator and apply thin smears of the samples to the cards. Instruct patients to return samples as soon as possible for processing. Optimally, processing of the cards should occur within 6 days of collection but definitely not after 14 days. Rehydration of the samples with a drop of water before application of the developer increases sensitivity by approximately 30% to 40%, but it also decreases specificity by 2% to 3%, leading to significantly more false-positive results. For this reason, authorities disagree about the use of rehydration. A positive result on even one sample qualifies the entire test as positive. Store both cards and developer at room temperature, protected from heat and light.

5. Patients who return samples through the mail should use special US Postal Service-approved envelopes. These may be obtained by contacting the manufacturers of the fecal occult blood test system.

6. Because of the intermittent nature of bleeding in patients with colorectal cancer, malignancy cannot be conclusively ruled out by repeat fecal occult blood testing.

7. Follow-up of a positive fecal occult blood test requires diagnostic procedures such as sigmoidoscopy, colonoscopy, or barium enema.

Colonoscopy: Questions and Answers; Colorectal Cancer: Questions & Answers; Polyps of the Colon and Rectum: Questions and Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite 1080, Palatine, IL 60067; (708)359-9184.

What You Need to Know about Cancer of the Colon and Rectum. Office of Cancer Communications, National Cancer Institute, Bethesda, MD 20892; (800)4-CANCER; Internet address: http://cancernet.nci.nih.gov

Product Instructions for Hemoccult.

Table 34.1. Additional Instructions for Patients Using Guaiac-Based Tests

The prevalence of hearing loss increases with advancing age and is very common in older adults. Approximately one fourth of adults aged 65 to 74 years and half of adults aged 85 years and older report some degree of hearing loss. Hearing loss, particularly when it develops late in life and is progressive in nature, can compromise an individual's ability to perform many important activities, such as using the telephone, driving, and shopping. Hearing loss also may lead to social withdrawal, depression, and exacerbation of coexisting psychiatric problems. Some older people with hearing loss also have cognitive impairment, and evidence suggests that improvement of hearing may contribute to improvement in cognitive ability. Many types of hearing loss can be improved with the use of hearing aids; however, only 10% to 15% of patients who could benefit from a hearing aid actually use one.

See chapter 6 for information about hearing screening for children and adolescents.

American Academy of Family Physicians --

Clinicians should question elderly adults about hearing impairment and counsel about the availability of treatment when appropriate.

American College of Obstetricians and Gynecologists --

Women 65 years and older should be evaluated for hearing loss.

American Speech-Language-Hearing Association --

Considerable debate concerning the efficacy of selected screening protocols for older adults has taken place in recent years. Whether the choice of protocol actually influences compliance with the follow-up recommendations remains unclear. The clinician may choose to use a hearing handicap questionnaire, pure-tone audiometry, or both. The rationale for using a questionnaire and pure-tone audiometry in combination is that compliance with audiologic recommendations is often greater when individuals perceive their hearing loss to be a handicap. Selection of the protocol should take into consideration cost, compliance data for the particular population, and the specificity, sensitivity, and predictive values of screening. Equipment used should be appropriately calibrated, and self-assessment scales must be reliable. Compliance-improving strategies (eg, educational materials) should be an integral part of any screening program and appropriate follow-up services should be available.

Canadian Task Force on the Periodic Health Examination --

There is fair justification for looking for hearing loss in adults seen for other reasons. Further study is warranted if adults report being hard of hearing or fail to respond to the normal spoken voice; have a medical or family history placing them at high risk for hearing loss (eg, family history of hearing loss, occupational history of exposure to noise, pursuit of noisy leisure activities, or history of recurring ear problems). Screening for hearing impairment using an audioscope, a single question about hearing difficulty, or whispered voice out of the patient's field of vision is recommended as part of the periodic health examination for persons 65 years of age and older.

US Preventive Services Task Force --

Screen older patients for hearing impairment by periodically questioning them about their hearing. Counseling should be provided about the availability of hearing aid devices and referrals made for abnormalities as appropriate. The optimal frequency of such screening is left to clinical discretion. An otoscopic examination and audiometric testing should be performed on all persons with evidence of impaired hearing by patient inquiry. There is insufficient evidence to recommend routinely screening adults with audiometric testing. Screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines.

Answers to Questions About Noise and Hearing Loss; How to Buy a Hearing Aid. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; (800)638-TALK (voice or TTY); (301)897-8682 (in Maryland). To order, call (301)897-5700, ext. 218. Internet address: http://www.asha.org

Age Page: Hearing and the Elderly. National Institute on Aging. Bldg 31, Room 5C27, 31 Center Drive, MSC 2922 Bethesda, MD 20892-2922; (301)496-1752. Internet address: http://www.nih.gov/nia/health/pubpub/pubpub.htm

Older Voices. To order this trainer's manual and resource materials for communication problems of older persons, contact the American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; (301)897-5700, ext 218. For general information, call (800)638-8255; http://www2.asha.org

Table 35.1. Hearing Handicap Inventory in the Elderly Screening Questionnaire

Breast cancer is the most common type of cancer in women and the second leading cause of cancer death in American women after lung cancer. The American Cancer Society predicts that there will be an estimated 180,200 new cases of breast cancer in women and 43,900 related deaths in 1997. In the United States, a woman's average lifetime risk for developing breast cancer is approximately one in eight. Breast cancer mortality increases with age. Mortality from breast cancer does not plateau, even in extreme old age. After age, the next strongest risk factor is a family history of breast cancer in a first-degree relative (sister or mother). Very modest increases in risk are also associated with nulliparity, first pregnancy after 30 years of age, menarche before 12 years of age, menopause after 50 years of age, postmenopausal obesity, some types of benign breast disease, high socioeconomic status, and a personal history of ovarian or endometrial cancer.

Mortality from breast cancer is strongly influenced by stage at detection. The 5-year survival rate for women in whom local disease is found is 96%. In contrast, the 5-year survival rate for women with distant metastasis is only 20%. Survival rates at every stage of diagnosis are lower among African-American women compared with Caucasian women.

Mammography is the most effective approach to early detection of breast cancer and is associated with sensitivity of 70% to 90% and specificity of 90% to 95%. Although mammography can detect small tumors in younger women, controversy exists regarding whether mammography screening reduces mortality in women younger than age 50 years.

Well-maintained, modern mammography equipment is very safe, requiring very low levels of radiation. Screening does, however, carry the added risk of morbidity attributable to any unnecessary biopsies that are performed following false-positive mammography results.

See chapter 30 for information about clinical breast examination to detect breast cancer.

American Academy of Family Physicians (AAFP), American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP), American College of Preventive Medicine (ACPM), American Medical Association, Canadian Task Force on the Periodic Health Examination (CTFPHE), National Cancer Institute (NCI) and the US Preventive Services Task Force (USPSTF) --

Routine mammography screening is recommended. Yearly screening is recommended by ACS, ACOG and CTFPHE. AAFP, ACP, ACPM, NCI, and USPSTE recommend a frequency of 1 to 2 years. The CTFPHE, AAFP and USPSTF recommend screening until 70 years of age. The AAFP and USPSTF indicate that there is insufficient evidence to recommend for or against screening of women 70 years of age or older, although recommendations for this can be made on other grounds for women in this age category with a reasonable life expectancy. ACPM advises that women aged 70 or older should continue undergoing mammography screening provided their health status permits breast cancer treatment. ACP states that the use of mammography above 75 years of age should be discouraged. The American Geriatrics Society recommends that women over 65 years of age receive mammograms at least every 2 or 3 years until at least 85 years of age.

American Academy of Family Physicians --

Recommends counseling about potential risks and benefits of mammography and clinical breast exam for women ages 40 to 49 years.

American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), American Medical Association (AMA), and National Cancer Institute (NCI) --

The ACS recommends that women begin annual mammography at age 40. ACOG, NCI, and the AMA recommend screening mammograms every 1 to 2 years for women 40 to 49 years of age.

American College of Physicians and Canadian Task Force on the Periodic Health Examination --

Women under 50 should not be screened.

American College of Preventive Medicine and US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening in this age group, but screening high risk younger women may be appropriate despite the lack of direct evidence of benefit.

National Institutes of Health Consensus Development Panel on Breast Cancer Screening for Women Ages 40 to 49 (an independent panel) --

Currently available data does not warrant a universal recommendation for mammography for all women in their forties. Each woman should decide whether to undergo mammography.

American College of Obstetricians and Gynecologists --

Women with a family history of premenopausally diagnosed breast cancer in a first-degree relative should have mammography regularly beginning at 35 years of age.

American College of Physicians --

High-risk women should receive the same recommendations as average-risk women, unless a woman expresses great anxiety about breast cancer and insists on more intensive screening.

American College of Preventive Medicine and US Preventive Services Task Force --

Although there is no direct evidence evaluating mammography in high-risk women under 50 years of age, recommendations for screening such women can be made on other grounds. Women at high risk include those with a family history of premenopausal breast cancer in a first-degree relative or those with a history of breast and/or gynecologic cancer.

Canadian Task Force on the Periodic Health Examination --

Physicians may elect to recommend mammography starting at age 35 for women at high risk, especially those whose first-degree relatives have had breast cancer diagnosed before menopause.

Breast Cancer: Steps to Finding Breast Lumps Early. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

What You Need To Know About Breast Cancer; A Mammogram Once a Year for Life; Smart Advice for Women 40 and Over: Have a Mammogram. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A24, Bethesda, MD 20892; (800)4-CANCER.

Chances are You Need a Mammogram; Are you age 50 or Older? A Mammogram Could Save Your Life. Available in both English and Spanish. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Educating Older Women About Mammography: A Guide For Program Planners and Volunteer Leaders. American Association of Retired Persons, 1909 K Street, NW, Washington, DC 20049; (202)434-2277.

Detecting and Treating Breast Problems. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (202)638-5577. Internet address: http://www.acog.com

Mammography Awareness Kit. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

OncoLink The University of Pennsylvania Cancer Resource. Internet address: http://cancer.med.upenn.edu

PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and standard telephone line, or through medical libraries. Ask a medical librarian for assistance or call (800)4-CANCER (line 3). In Hawaii, on Oahu, call 524-1234.

In 1997 approximately 14,500 cases of invasive cervical cancer are expected to be diagnosed in the United States and 4800 women are expected to die of the disease. The major risk factor for cervical cancer is sexually transmitted infection with human papillomavirus (HPV). Other risk factors include early age at first intercourse, having multiple sexual partners, long-term use ( > 5 years) of oral contraceptives, low socioeconomic status, and cigarette smoking. Rates for carcinoma in situ reach a peak in both African-American and white women between the ages of 20 and 30 years. After age 25 years, the incidence of invasive cancer in African-American women increases dramatically with advancing age. In Caucasian women, the incidence rises more slowly. Over 25% of invasive cervical cancers occur in women older than age 65 years, and 40% to 50% of all women who die of cervical cancer are older than age 65 years.

The effectiveness of early detection through Papanicolaou (Pap) smear testing and early treatment has been impressive, resulting in a marked decrease in mortality from cervical cancer. The incidence of invasive cervical cancer has decreased an estimated 70% because of screening. Nonetheless, a large proportion of women, particularly elderly African-American women and middle-aged women of lower socio-economic status, do not have regular Pap smears. In some geographic areas, as many as 75% of women over age 65 years report not having a Pap smear within the previous 5 years.

Depending on the technique used, Pap testing has a sensitivity of 50% to 90% and a specificity of 90% to 99%. A large proportion of false-negative Pap smear results are thought to be attributable to inadequate collection technique (up to 50% of all false-negative results) and inadequate laboratory interpretation. Because of the long lead time from development of precancerous changes until development of invasive carcinoma (8 to 9 years by some estimates), almost all precancerous or early-stage malignancies initially missed can be detected by repeat testing.

American Academy of Family Physicians --

All women who are or have been sexually active and who have a cervix should be offered a Pap smear at least every 3 years. Use of Pap smears is not recommended in women who have had hysterectomies for reasons other than cancer.

American Cancer Society and American College of Obstetricians and Gynecologists, and National Cancer Institute --

All women should begin having annual Pap tests at the onset of sexual activity or at 18 years of age, whichever occurs first. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently in low-risk women at the discretion of the patient and clinician.

American College of Physicians --

Sexually active women between 20 and 65 years of age should be screened with a Pap smear every 3 years. Women 66 to 75 years of age who have not been screened within the 10 years prior to age 66 should be screened every 3 years. Women at increased risk for cervical cancer should be screened every 2 years. Initial screening tests may be done as frequently as annually for two or three examinations to ensure diagnostic accuracy.

American College of Preventive Medicine --

Screening for cervical cancer by regular Pap tests should be performed in all women who are or have been sexually active, and should be instituted after a woman first engages in sexual intercourse. If the sexual history is unknown or considered unreliable, screening should begin at age 18. At least two initial screening tests should be performed one year apart. For women who have had at least two normal annual smears, the screening interval may be lengthened at the discretion of the patient and physician but should not exceed three years. Screening may be discontinued at age 65 if the following criteria are met: the women has been regularly screened, has had two satisfactory smears, and has had no abnormal smears within the previous nine years. For all women over age 65 who have not been previously screened, three normal annual smears should be documented prior to discontinuation of screening.

Canadian Task Force on the Periodic Health Examination --

Pap smears to screen for cervical cancer are recommended for women who have been sexually active. The optimum frequency of screening is not known, but it is suggested that women in the general population be screened annually until two normal smears are reported and then every 3 years to age 69 years. More frequent screening should be considered for women with risk factors: age of first sexual intercourse less than 18 years, many sexual partners or a consort with many partners, smoking, or low socioeconomic status.

US Preventive Services Task Force --

All women who are or have been sexually active should have regular Pap tests. Testing should begin at the age when the woman first engages in sexual intercourse. Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at age 18. There is little evidence that annual screening achieves better outcomes than screening every 3 years. Pap tests should be performed at least every 3 years. The interval for each patient should be recommended by the physician based on risk factors (eg, early onset of sexual intercourse, history of multiple sexual partners, low socioeconomic status). Women infected with human immunodeficiency virus require more frequent screening according to established guidelines. There is insufficient evidence to recommend for or against an upper age limit for Pap testing, but recommendations can be made on other grounds to discontinue regular testing after 65 years of age in women who have had regular previous screening with consistently normal results. Women who have undergone a hysterectomy in which the cervix was removed do not require Pap testing, unless the hysterectomy was performed because of cervical cancer or its precursors.

1. Attempt to ensure that performance of a Pap smear is not an unpleasant or painful experience for the patient. Be sure to clearly explain the importance of the procedure and the steps used to carry it out.

2. Instruct patients not to douche on the day of the examination. Do not perform a Pap smear if the patient has significant menstrual flow or obvious inflammation.

3. Perform the Pap smear before performing the bimanual examination and before obtaining culture specimens. In general, do not lubricate the speculum with anything except water, because contamination of Pap smear specimens with lubrication jelly tends to obscure cellular detail. Use of a small amount of lubricating jelly may be necessary for speculum insertion in some older patients.

4. Visualize the cervix and vagina completely before collecting the specimen. Gently remove any excess cervical mucus with a swab.

5. The traditional gold standard for the adequacy of a Pap smear has been the presence of endocervical cells in the sample: 90% of cervical cancers develop at the junction of the squamous epithelium of the ectocervix and the columnar epithelium of the endocervix (located at the external os in young women and inside the endocervical canal in older women). Studies differ regarding whether the presence of endocervical cells actually improves detection rates of abnormalities, but the presence of endocervical cells and/or squamous metaplastic cells remain widely accepted as a standard of adequacy for Pap smears.

6. A variety of implements have been used to obtain Pap smear samples, including simple cotton swabs, wooden and plastic spatulas, and endocervical and combined endocervical-exocervical brushes. The best sensitivity (defined as presence of endocervical cells) is achieved by using both a spatula (preferably Ayer's type) and an endocervical brush. Use the spatula first, because bleeding is commonly caused by the endocervical brush, and endocervical cells are susceptible to drying effects.

7. Gently yet firmly rotate the spatula around the os at least one complete turn to obtain a 360 ° sample. Promptly transfer the specimen to a glass slide (or to a preservative vial if your laboratory is using a thin layer technique). Patients who have been exposed to DES should also have smears taken circumferentially with a spatula from the upper two thirds of the vagina. To obtain the endocervical sample, insert the brush into the os no deeper than the length of the bristled section. Rotate the brush 360 ° (avoiding excessive rotation), then transfer the specimen by rolling the brush on a glass slide or by placing the material in a preservative vial as instructed by your laboratory for the thin layer technique.

8. Apply specimens to the slides uniformly and without clumping. Perform fixation promptly, and take care to minimize air drying of the specimens. If one slide is used for both specimens, collect, transfer, and fix the endocervical sample as quickly as possible. Use of two separate slides can help avoid prolonged air exposure of the spatula specimen while the endocervical specimen is being collected. Use of two slides does, however, double the amount of work for the cytotechnologist. Use of a combined endocervical-exocervical brush requires collection and fixation of only a single specimen (thus decreasing the risk of air drying), but such use has been shown to be somewhat less sensitive than use of a spatula and an endocervical brush.

9. Inquire about the quality control procedures of the laboratories to which specimens are sent. Laboratories should be certified by the American Society of Cytopathology, the College of American Pathologists, the Health Care Financing Administration, the Joint Commission on the Accreditation of Health Care Organizations, or the New York State Department of Health.

10. Many authorities recommend that laboratories use the new Bethesda System developed by a National Cancer Institute consensus conference for reporting results (Table 37.1). The Bethesda System attempts to standardize classification categories and provides for reporting on aspects of the sample not addressed in traditional Pap smear reports, such as adequacy of the sample submitted. In the Bethesda System, HPV infection is classified as a low-grade squamous intraepithelial lesion. Both moderate and severe dysplasia are classified as high-grade squamous intraepithelial lesions. Some concern exists, although unsubstantiated by research, that these classifications may lead to excessive use of colposcopic examination for patients with HPV infection or moderate dysplasia. The American College of Obstetricians and Gynecologists has issued guidelines for Pap smear reporting and follow-up in their publication Cervical Cytology: Evaluation and Management of Abnormalities (Selected References).

11. General recommendations for initial follow-up of abnormal PAP smears according to the American College of Obstetricians and Gynecologists include:

ASCUS (Atypical Squamous Cells of Undetermined Significance): The prognosis of women with ASCUS varies depending on the cytopathologist or laboratory. Clinicians are encouraged to communicate with the cytopathologist or to monitor a number of patients with an ASCUS report to help determine the appropriate follow-up and the need for colposcopy.

LSIL (Low-grade Squamous Intraepithelial Lesions): Repeat Pap test at intervals of 4 to 6 months and colposcopy if abnormalities persist.

High-grade Squamous Intraepithelial Lesions: Colposcopy and directed biopsy.

12. Only about 60% of women with abnormal Pap smear results return for follow-up. Establish a tracking system to make sure that Pap smears are performed regularly, that results return in a timely fashion, that patients with abnormal results are contacted, and that women who are not seen frequently are called or contacted by letter about the importance of getting Pap smears and other needed preventive care. Encourage patients to keep track of the results and prompt their own Pap smears through use of a patient-held record form or card.

The Pap Test. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington DC 20024; (800)762-2264. Internet address: http://www.acog.com

The Pap Test: It Could Save Your Life. To order this information (in Spanish), contact the Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; 1-800-4-CANCER.

Cervical Cytology: Evaluation and Management of Abnormalities. Technical Bulletin 183. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; 1-800-762-2264. Internet address: http://www.acog.com

Recommended Actions to Assure Quality Pap Tests (Pap Smears). The American Society of Clinical Pathologists. American Society of Clinical Pathologists, 1225 New York Ave, NW, Suite 250, Washington, DC 20005; 202-347-4450. Internet address: http://www.ascp.org

PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and a standard telephone line or through medical libraries. Ask a medical librarian for assistance or call (800)4-CANCER (line 3). In Hawaii, on Oahu, call 524-1234.

Cancer Facts and Figures 1997.

Table 37.1.The Revised Bethesda System for Reporting Cervical and/or Vaginal Cytologic Diagnoses

An estimated 16 million Americans suffer from diabetes mellitus (DM), and approximately half of these cases are undiagnosed. Diabetes mellitus is the seventh leading cause of death in the United States. Approximately 5% of all persons with diabetes have type 1 DM, an absolute insulin deficiency, and require insulin for survival. Onset of type 1 DM is bi-modal, with the largest peak in the number of new cases occurring during childhood and a smaller peak occurring in early adulthood. Type 1 DM can occur as late as the eighth or ninth decade. Persons with type 1 DM tend to present with symptoms, and the disease is usually diagnosed soon after its clinical onset. The remaining 95% of individuals with diabetes have type 2 DM, a relative insulin deficiency and insulin resistance. As such, onset of their disease is insidious. They can be relatively symptom-free for years before diagnosis. Risk factors for type 2 DM include advancing age (older than age 45 years), obesity, family history, and a history of gestational DM.

Although DM affects approximately 6.2% of the US population, the prevalence of DM is significantly higher among certain ethnic groups, including Hispanics, African Americans, and American Indians. Diabetic complications are varied and serious. DM accounts for 30% of all cases of end-stage renal disease, and it is the leading cause of blindness and non-traumatic lower extremity amputations in adults. Other complications include neuropathy, cardiovascular disease, and peripheral vascular disease.

Screening can identify occult cases of type 2 DM. The most accurate method of screening is measurement of a fasting plasma glucose. Measurement of urine glucose has been used in the past but is much less accurate and is no longer recommended. Evidence indicates that early treatment of patients with established type 1 DM decreases the number of long-term, microvascular complications. This is also probably true of type 2 DM. Evidence also suggests that weight reduction, exercise, and diet change are beneficial for secondary prevention in type 2 DM. Primary prevention trials for both type 1 and 2 DM are presently underway. Most authorities recommend screening only those persons who are at increased risk for developing DM.

Screening for gestational DM, often performed as an aspect of prenatal care, is beyond the scope of this book.

American College of Obstetricians and Gynecologists --

Patients with one or more of the following risk factors should be screened for diabetes: family history in parents or siblings; obesity (body weight greater than 120% of ideal); high-risk ethnicity (American Indian, Hispanic, African American); history of glucose intolerance; hypertension or hyperlipidemia; history of gestational diabetes or macrosomia.

American College of Physicians --

Screening for DM in healthy asymptomatic individuals is not recommended. Screening is reasonable in obese adults over the age of 40 years if a diagnosis of DM would motivate weight loss. Screening may also be indicated for women planning to become pregnant who are at increased risk of DM and in other people with one or more of the following risk factors: history of DM in a first-degree relative, age over 50 years, weight more than 25% over ideal body weight, personal history of gestational DM, and membership in an ethnic group with a high prevalence of DM.

American Diabetes Association --

Screening for DM every 3 years should be considered for all adults age 45 and above. Testing should be considered at a younger age or more frequently in people with the following risk factors: history of DM in a first-degree relative; more than 20% over ideal body weight; American Indian, Hispanic, or African American heritage; on previous testing had impaired fasting glucose or impaired glucose tolerance; hypertension, HDL cholesterol at or below 35 mg/dL and/or a triglyceride level at or above 250 mg/dL; personal history of gestational DM or of one or more infants weighing more than 9 lb at birth.

Canadian Task Force on the Periodic Health Examination --

Screening for diabetes mellitus in asymptomatic nonpregnant adults is not recommended. Selective case-finding (screening patients seen for other reasons) may be considered for adults with the following risk factors: obesity, older age, family history of diabetes, belonging to a high-risk ethnic group.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against universal screening for type 2 diabetes in nonpregnant adults. Although evidence of a benefit of early detection is not available for any group, clinicians may decide to screen selected persons at high risk of type 2 DM on other grounds, including the increased predictive value of a positive test in individuals with risk factors and the potential (although unproven) benefits of reducing asymptomatic hyperglycemia through diet and exercise. Individuals at high risk of diabetes include obese men and women over 40, patients with a strong family history of diabetes, and members of certain ethnic groups (American Indians, Hispanics, African Americans).

Diagnosis Diabetes. To order this and other materials, contact the American Diabetes Association, 1660 Duke St, Alexandria, VA 22314; (800)232-3472.

The National Diabetes Information Clearinghouse has the following fact sheets and booklets available: Diabetes in African Americans; Diabetes in Hispanics; Diabetes Research and Training Centers; Diabetic Neuropathy: The Nerve Damage of Diabetes; Diabetes Overview; Diabetes Control and Complications Trial; Diabetes Statistics; Hypoglycemia; Kidney Disease of Diabetes; Insulin-Dependent Diabetes; Noninsulin-Dependent Diabetes; The Diabetes Dictionary (available in Spanish); End-Stage Renal Disease: Choosing a Treatment That's Right for You; Directory of Diabetes Resources (available in Spanish). 1 Information Way, Bethesda, MD 20892-3560, phone 301-654-3327.

Table 38.1. Criteria for Diagnosing Diabetes in Nonpregnant Adults

Prostate cancer is the most frequently diagnosed cancer in men in the United States, with 209,900 new cases estimated for 1997 and 41,800 deaths. Prostate cancer is the second leading cause of cancer death in men. Risk factors for prostate cancer include increasing age (80% of prostate cancers are diagnosed in men over 65), African American race, family history, and (perhaps) increased dietary fat intake. Although prostate cancer is common, its course is extremely variable. Some prostate cancers grow rapidly, metastasize, and quickly lead to death. Many other prostate cancers, however, are clinically silent and found only incidentally at autopsy. Autopsy studies indicate that approximately 30% of men over age 50 have histologic evidence of prostate cancer, yet carry only a 3% lifetime risk for death from this disease.

The principal screening tests for prostate cancer are the digital rectal examination (DRE) (chapter 30) and elevated levels of certain tumor markers (eg, prostate-specific antigen (PSA) and prostatic acid phosphatase). PSA is a glycoprotein that is specific to the prostate but not to prostate cancer. Thus, it is produced by all types of prostate tissue, whether normal, hyperplastic, or malignant. Incomplete information regarding true- and false-negative results makes accurate calculations of the sensitivity and specificity of PSA screening impossible. The positive predictive value of a positive PSA test (values greater than 4 ng/dL) are reported in the range of 20% to 30%. Many men with benign prostatic hyperplasia will have an elevated PSA level, and some men with prostate cancer will have PSA tests in the normal range. Prostatic acid phosphatase has a much lower sensitivity and positive predictive value than PSA; thus, PSA has largely replaced it in screening.

Whether to screen asymptomatic men for prostate cancer with PSA testing is controversial. Unlike the use of Pap smears and mammograms, there are no data indicating that PSA screening decreases mortality from prostate cancer. Definitive evidence is lacking that treatments such as radical prostatectomy are superior to "watchful waiting" for localized prostate cancer.

See chapter 30 for information about digital rectal examination to detect prostate cancer.

American Academy of Family Physicians --

Clinicians should counsel men ages 50 to 65 years about the known risks and uncertain benefits of screening for prostate cancer.

American Cancer Society --

Annual PSA testing in combination with annual digital rectal exam should be offered annually beginning at age 50 to all men who have a life expectancy of at least 10 years, or earlier to men at high risk for prostate cancer.

American College of Physicians --

Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen. The College strongly recommends that physicians help enroll eligible men in ongoing clinical studies.

American College of Radiology --

Annual PSA testing is recommended for all men aged 50 years and older. Annual PSA testing beginning at age 40 is recommended for African American men and men with a family history of prostate cancer.

American Urological Association --

Annual PSA testing in combination with annual digital rectal examination should be offered to all men aged 50 years and older with a life expectancy of ten years or more. Annual screening should be offered at age 40 to men at high risk for prostate cancer.

Canadian Task Force on the Periodic Health Examination --

Routine use of PSA testing as part of the periodic health examination is not recommended.

US Preventive Services Task Force --

Routine screening for prostate cancer with serum tumor markers (eg, PSA), digital rectal examination, or transrectal ultrasound is not recommended.

Prostate Disease: What Every Man Over 40 Should Know, and other patient materials on prostate cancer and PSA testing. Prostate Health Council. American Foundation for Urologic Disease, 1128 N. Charles Street, Baltimore, MD 21201.

The Prostate Puzzle. Consumer Report. 1993; 58(7):459-465.

PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and standard telephone line, or through medical libraries. Ask a medical librarian or call 1-800 4-CANCER (option 3). In Hawaii, on Oahu, call 524-1234.

Sexually transmitted diseases (STDs) are common and damaging communicable diseases. Chlamydial infection, gonorrhea, and syphilis are easily treated when diagnosed early. If these conditions are not detected and treated, serious complications can result. Although no cure for HIV infection currently exists, early diagnosis and treatment can delay onset of acquired immunodeficiency syndrome (AIDS) and permit persons who are infected to avoid transmitting the virus. Groups at particularly high risk for STDs and HIV infection include sexually active persons younger than age 25 years, those who have multiple sexual partners, persons with a prior history of an STD, persons who practice anal intercourse, prostitutes and their sex partners, users of illicit drugs, and inmates of detention centers.

Prevention and control of STDs and HIV infection depend on four major activities: (1) educating persons who are at risk about means of reducing transmission; (2) detecting untreated cases, both symptomatic and asymptomatic; (3) effectively diagnosing and treating infection and counseling infected individuals; and (4) evaluating, counseling, and treating the sex partners of infected persons. Screening -- along with early diagnosis, counseling, and treatment -- plays an essential role in preventing STDs and HIV infection.

Many sexually transmitted diseases (AIDS; chancroid; Chlamydia trachomatis [genital infections only]; gonorrhea; hepatitis B; hepatitis C/non-A, non-B; HIV infection [pediatric cases only]; and syphilis) are currently designated as infectious diseases notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

See chapters 23 and 59 for information on STD and HIV prevention counseling in adolescents and adults, respectively; chapters 14 and 48 for information on hepatitis B immunization and prophylaxis in children/adolescents and adults, respectively; chapters 25 and 61 for information about counseling on preventing unintended pregnancy in adolescents and adults, respectively. Screening for and treatment of STDs during pregnancy is an important component of prenatal care, but this topic is beyond the scope of this book.

The reported incidence of syphilis (all stages) increased dramatically between 1985 and 1990, from 28.5 to 54.3 cases per 100,000 population. The incidence decreased to 32.0 cases per 100,000 population in 1994. The incidence of congenital syphilis increased from 7 cases per 100,000 live births in 1985 to 107.2 cases per 100,000 live births in 1991, and decreased to 94.3 cases per 100,000 live births in 1992. More than 30,000 new cases of primary and secondary syphilis occur annually, and the prevalence of HIV infection among syphilis-infected persons is increasing.

The usual presentation of primary syphilis is a single painless ulcer or chancre on the genitalia. The ulcer usually heals spontaneously in 4 to 6 weeks without antibiotic therapy. Primary syphilis may not manifest at all, however, and may go unrecognized. Most untreated cases of primary syphilis progress to secondary syphilis. Clinical manifestations of secondary syphilis, which include skin lesions and generalized nontender lymphadenopathy, appear approximately 6 weeks after the healing of the chancre. These lesions subside in 2 to 6 weeks, and untreated patients enter the latent stage of the disease. About one third of untreated cases of latent syphilis eventually manifest as neurosyphilis or other late complications, such as gummatous lesions of bone, tissue, and skin, as well as cardiovascular problems (aortic valve lesions and aneurysms). Neurosyphilis can occur at any point in the course of untreated syphilis and may consist of meningitis, meningovascular lesions, psychiatric illnesses, and tabes dorsalis. Early diagnosis and treatment can prevent these grave complications.

All major authorities, including the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists, American College of Physicians (ACP), American Medical Association (AMA), Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention, and US Preventive Services Task Force (USPSTF) --

Syphilis screening should be performed on individuals at high risk of developing syphilis, sexual partners of known syphilis cases, and individuals with multiple sexual partners -- especially in areas where syphilis prevalence is high. AAP, AMA, and ACP also recommend that males who engage in sex with other males be routinely screened; AAFP, AAP, AMA, and USPSTF also suggest screening prostitutes and persons who trade sex for drugs. AAFP also recommends syphilis screening for individuals seeking treatment for other sexually transmitted diseases.

American Academy of Family Physicians --

Syphilis screening should be performed on sexual contacts of syphilis cases and prostitutes and on individuals seeking treatment for other sexually transmitted diseases.

Chlamydial infection is the most common sexually transmitted disease in the United States, causing more than 4 million infections each year since 1992. Gonorrhea is the second most common sexually transmitted disease, with an estimated 1.1 million infections reported in 1992. These two infections usually cause urethritis in men and cervicitis in women. The clinical presentation of gonococcal infection is usually swifter and more dramatic than that of chlamydial infection, but the two conditions cannot be distinguished solely by history and physical findings. Often the two causative organisms are transmitted together; thus, the infections must be treated simultaneously. Usual symptoms in men include penile discharge and dysuria. Occasionally these infections can lead to epididymitis. Women may experience vaginal discharge and symptoms of pelvic inflammatory disease (PID). PID can result in infertility. Unlike chlamydial infection, gonorrhea may also cause pharyngitis, proctitis, and a disseminated infection involving dermatitis, tenosynovitis, and arthritis; rarely, it may cause meningitis and endocarditis. Both chlamydial infection and gonorrhea may cause only subtle symptoms, or infection may occur entirely without symptoms, particularly in females. Therefore, screening to detect asymptomatic carriers is important for preventing complicated infections and for controlling the spread of infection in the community.

American Academy of Family Physicians --

High-risk women, including those who exchange sex for money or drugs, have multiple or new sexual partners, have a history of sexually transmitted disease, and/or nonuse or inconsistent use of barrier contraceptives should be screened for gonorrhea and chlamydia.

American Academy of Pediatrics and American Medical Association --

All sexually active adolescents should be screened annually for chlamydia and gonorrhea. Screening for boys can be performed with the use of a dipstick urinalysis test for leukocyte esterase.

American College of Obstetricians and Gynecologists, Centers for Disease Control and Prevention, andUS Preventive Services Task Force --

Asymptomatic individuals attending STD, family planning, or adolescent health clinics should be screened for chlamydia and gonorrhea. Those who have multiple sexual partners and sexually active individuals less than 20 years of age should also be screened. Prostitutes and individuals with a history of STDs should also be screened. Recent sexual partners of individuals with a documented gonococcal or chlamydial infection should be tested and treated.

Canadian Task Force on the Periodic Health Examination --

Persons at high risk should be screened for gonorrhea and chlamydia. For gonorrhea, those at high risk are: males or females under 30 years of age who have had at least two sexual partners in the previous year, had first intercourse at less than 16 years of age, prostitutes, and sexual contacts of individuals known to have a sexually transmitted disease. There is fair evidence to support screening and treatment of pregnant women for chlamydia during the first trimester as well as annual screening and treatment of high-risk groups (sexually active females less than 25 years of age, men and women with a new partner or mulitple sexual partners in the preceding year, women who use nonbarrier contraceptive methods, women with symptoms of chlamydial infection: cervical friability, mucopurulent discharge, or intermenstrual bleeding). There is fair evidence to exclude routine screening for chlamydia in the general population.

US Preventive Services Task Force --

Females at risk should be routinely screened for chlamydia and gonorrhea. For chlamydia, all sexually active adolescents should be screened and other women at risk due to: a history of prior STDs, a new partner or multiple sex partners, age under 25 years, inconsistent barrier contraceptive use, cervical ectopy, or being unmarried. In areas of high prevalence, screening of all women for chlamydia is justified. For gonorrhea, women at risk are: commercial sex workers, those with repeated episodes of gonorrhea, and women under 25 years of age with two or more sex partners in last year. In settings where prevalence is high, broader screening for gonorrhea may be justified. There is insufficient evidence to recommend for or against screening asymptomatic men for chlamydia and gonorrhea. In settings where prevalence is high, such as urban adolescent clinics, screening of males for chlamydia and gonorrhea may be justified on other grounds, including the potential benefits of early treatment for preventing transmission to uninfected sex partners. Screening of males with a dipstick urinalysis for leukocyte esterase is convenient and inexpensive, but is less sensitive and specific for asymptomatic chlamydial infections than more expensive urine assays and also requires confirmation of positive results.

From 1981 through 1996, a total of 573,800 cases of AIDS in persons aged 13 years or older were reported to the Centers for Disease Control and Prevention. In 1995, approximately 50,000 deaths were attributed to AIDS. Although the number of deaths due to AIDS during the first 6 months of 1996 decreased for the first time since monitoring began, HIV infection remained the leading cause of death among persons aged 25 to 44 years in 1995. Seroprevalence studies show that HIV infection is present in 0.2% to 8.9% of patients visiting emergency departments and in 0.1% to 7.8% of patients admitted to acute-care hospitals. Groups at high risk of contracting HIV are identified in Recommendations of Major Authorities.

Many HIV-infected individuals are unaware of their status, since the characteristic symptoms of AIDS usually do not develop until years after infection. Early knowledge of HIV infection allows infected individuals to seek early treatment, which has been shown to delay the onset of AIDS, and to change high-risk behavior. Counseling and screening are, therefore, essential strategies for preventing the spread of HIV infection and the progression of symptoms. Screening high-risk individuals may be useful even when their test results are negative. The related counseling may change their behavior and thus may keep them free of disease.

All major authorities including American College of Obstetricians and Gynecologists, American Medical Association (AMA), Canadian Task Force on the Periodic Health Examination (CTFPHE), Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force (USPSTF) -- HIV screening should be offered to patients with another STD; homosexual and bisexual men; past or present injection drug users; individuals with a history of prostitution or multiple sexual partners; individuals whose past (or present) sexual partners are HIV-infected or injection drug users; patients with a history of blood transfusion between 1978 and 1985; and individuals born in or with long-term residence in a community where HIV is prevalent. AMA also recommends offering testing and counseling to high-risk individuals receiving family planning services or undergoing surgery. CDC recommends that health facilities with an HIV seroprevalence rate of at least 1% or an AIDS diagnosis rate of one or more per 1000 discharges should consider a policy of routine counseling and voluntary HIV testing for patients aged 15 to 54 years. The CDC recommends informing all new mothers who have not been screened for HIV of the potential benefits of screening for their infants. The CTFPHE recommends HIV antibody screening for neonates of HIV-positive women. The USPSTF recommends screening of infants born to high-risk mothers whose antibody status is not known.

American Academy of Family Physicians --

HIV screening should be offered to the following individuals: men who had sex with men after 1975; past or present injection drug users; persons who exchange sex for money or drugs and their sex partners; those with current or past sex partners who were injection drug users, bisexual, or HIV-positive; persons seeking treatment for STDs; and infants born to high-risk mothers (as described above) whose HIV status is unknown.

Serologic studies for the presence of antibodies to HIV-1 are the standard method of screening for HIV infection. Enzyme immunoassay (EIA) is the most widely used screening test for HIV-1 infection. Because any screening test can result in a false-positive reaction, positive results are validated with confirmatory testing, usually a Western blot test. HIV culture and polymerase chain reaction (PCR) testing are currently not used for screening.

On December 23, 1994, the FDA approved the first HIV oral test system in the United States, intended for use in subjects 13 years of age or older. This test is not as accurate as the approved HIV-antibody tests used on blood. Studies show that for every 100 persons infected with HIV, the oral-fluid-based test will miss one or two, and for every 100 persons who are not infected, test results will be incorrectly positive in approximately two. The test system includes a specially treated cotton pad on a stick and a preservative solution in a plastic container. A trained collector instructs the subject to place the pad between the lower gum and cheek to obtain a sample of oral fluid. The pad is then stored in the preservative until the sample is processed and analyzed by a qualified laboratory using an enzyme-linked immunosorbent assay (ELISA) specifically licensed for testing oral fluid samples. FDA approved this HIV test system with the following restrictions:

• The test system is available for purchase and distribution only through physicians.
• The test system may be administered only by individuals properly trained in its use.
• The test must not be provided to subjects for home use.
• Testing of the oral fluid samples for HIV antibodies may be carried out only with the Oral Fluid Vironostika HIV-1 Microelisa System, manufactured by Organon Teknika Corporation of Durham, NC.
• The test may be used for diagnosis only and must not be used to screen blood donors.
• Before the oral fluid specimen is collected, subjects must be given information on HIV prevention and transmission, as well as technical information regarding the oral test. Because there are no confirmatory tests that use oral fluid samples, subjects must be informed that in the event of a positive oral fluid sample, they should have blood samples drawn and tested to verify their HIV status.

On August 6, 1996, the FDA approved the first HIV test that uses urine samples to detect the presence of antibodies to HIV-1 using an enzyme-linked immunosorbent assay (ELISA) method. This test will be available under two brand names: Calypte HIV-1 Urine EIA^TM and Seradyn Sentinel^TM HIV-1 Urine EIA. The test can be ordered only by a physician, and samples will be analyzed in certified medical laboratories. Any initially reactive sample will be retested twice. If either of the second tests is reactive, the screening test will be considered positive. A positive screening test must be followed by a blood test to confirm the results.

A patient information sheet provided with the new test will outline the limitations of urine HIV-1 testing in addition to HIV/AIDS information. After reading the information sheet, the person being tested will initial a statement confirming the receipt of the pretest counseling, peel off the sample label, and apply it to the urine collection cup.

The urine-based ELISA test is not approved to screen blood donors. In clinical studies, urine and blood samples were taken from 298 patients diagnosed with AIDS and tested with both the Calypte HIV-1 Urine EIA and a licensed ELISA test using a blood specimen. The urine test was positive as an initial screening test 99.3% of the time in persons known to have AIDS. In asymptomatic HIV-1-infected patients, the test would be expected to miss one or two persons out of every 100. Other studies showed that the urine-based test would give a falsely positive result in one or two persons of 100 without HIV-1 antibodies in their blood, compared to one in 1000 with a blood-based ELISA test.

How to Prevent Sexually Transmitted Diseases; Genital Herpes, Gonorrhea and Chlamydia Infections, Pelvic Inflammatory Disease. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

National STD Hotline. (800)227-8922.

AIDS: How To Reduce Your Risk of Catching It. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Surgeon General's Report to the American Public on HIV Infection and AIDS; Condoms and Sexually Transmitted Diseases... Especially AIDS. CDC National AIDS Information Hot Line; 1-800-342-AIDS (English speaking); 1-800-344-SIDA (Spanish speaking); 1-800- AIDS-TTY (hearing impaired). All phone calls are confidential.

HIV in America: A Profile of the Challenges Facing Americans Living With HIV. National Association of People Living with AIDS, 1413 K St, NW, Washington, DC 20005; (202)898-0435.

Hemophilia and AIDS Network for the Dissemination of Information, 110 Green St, New York, NY 10012; (800)424-2634.

National AIDS Information Clearinghouse, PO Box 6003, Rockville, MD 20850; (800)458-5231 (English and Spanish).

Gonorrhea and Chlamydial Infections (technical bulletin #190), 1994. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Gynecologic Herpes Simplex Virus Infection (technical bulletin #119). American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

HIV Infection and Physician Emotions (videotape and discussion guide). American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Table 40.1. Conditions That May Cause Falsely Reactive Syphilis Tests

Table 40.2. Pre- and Post-test Information for HIV Testing

Colorectal cancer is the third leading cause of death from cancer in the United States. The disease most often afflicts persons older than age 40 years. Of the three widely used methods of screening for colorectal cancer (digital rectal examination, sigmoidoscopy, and fecal occult blood testing), examination using a sigmoidoscope is the most specific and sensitive. The specificity of sigmoidoscopy approaches 100%, because this procedure enables the examiner to perform a biopsy during the procedure. The sensitivity of sigmoidoscopy is largely determined by the skill of the examiner and the length of the instrument. Approximately 30% of colorectal cancers are within reach of the 25-cm rigid sigmoidoscope. The 35-cm flexible sigmoidoscope can reach 45% to 50% of cancers, and the 60-cm flexible sigmoidoscope can reach 50% to 60% of cancers.

Screening with sigmoidoscopy has been limited by costs, patient and provider compliance, and earlier controversies about the effectiveness of this approach. Patient compliance problems have been somewhat diminished by development of the more comfortable flexible instruments. The 35-cm sigmoidoscope is particularly well accepted by patients, and the 60-cm sigmoidoscope is relatively well accepted. The controversy about effectiveness had stemmed from a lack of evidence that screening with sigmoidoscopy decreases mortality from colorectal cancer. Two recent case-control studies (Selby et al, 1992; Newcomb et al, 1992) demonstrated significant decreases (59% and 79%, respectively) in the risk of death from colorectal cancer among screened patients. In the Selby study, a significant benefit of rigid sigmoidoscopy was suggested even if screening was performed as infrequently as every 10 years.

See chapters 30 and 34 for information about colorectal cancer and other methods of screening for it.

American Academy of Family Physicians --

Individuals aged 50 years and older and those aged 40 years and older with a family history of early colorectal cancer should be screened for colorectal cancer with fecal occult blood tests, sigmoidoscopy, colonoscopy, or barium enema.

American Cancer Society (ACS) and American Gastroenterological Association --

Patients at normal risk should be screened with sigmoidoscopy every 5 years in combination with yearly fecal occult blood testing beginning at 50 years of age. Other recommended screening options beginning at age 50 include: colonoscopy every 10 years or double contrast barium enema every 5 to 10 years. The ACS further advises that digital rectal examination be performed along with the endoscopic or radiological procedure.

American College of Obstetricians and Gynecologists --

Patients at normal risk should be screened with sigmoidoscopy every 3 to 5 years beginning at 50 years of age.

American College of Physicians --

Men and women should be offered flexible sigmoidoscopies every 10 years from 50 to 70 years of age. In most settings and for most people, this strategy will provide the best balance of benefits and harms, logistic feasibility, and costs. In settings where it is logistically feasible and cost is reasonable, persons who want to achieve the maximum protection against colorectal cancer should be offered colonoscopy every 10 years from 50 to 70 years of age. In some settings, air-contrast barium enemas every 10 years from 50 to 70 years of age might be logistically preferable to colonoscopies, and some patients might prefer that procedure. For persons who decline these options, annual fecal occult blood testing should be offered.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to support the inclusion or exclusion of sigmoidoscopic or colonoscopic screening of asymptomatic individuals over 40 years of age in the periodic health examination.

US Preventive Services Task Force --

Screening for colorectal cancer is recommended for all persons 50 years of age or over. Sigmoidoscopy and fecal occult blood testing are effective methods of screening. There is insufficient evidence to determine which of these methods is preferable or whether the combination of both methods produces greater benefit than either method alone. There is insufficient evidence to recommend a periodicity for sigmoidoscopy screening.

All major authorities --

Patients at increased risk of colorectal cancer should consider more intensive screening. What constitutes increased risk and the nature and frequency of recommended screening differs slightly among the authorities.

American Cancer Society --

For patients having a first-degree relative with a history of colorectal cancer at 55 years of age or younger, the entire colon and rectum should be examined with colonoscopy or air-contrast barium enema every 5 years beginning at 35 to 40 years of age. Members of families with a history of familial adenomatous polyposis should receive earlier screening utilizing flexible sigmoidoscopy. Members of families with a history of hereditary nonpolyposis colorectal cancer require earlier and more intense surveillance utilizing colonoscopy. Individuals with inflammatory bowel disease are at exceptionally high risk and require individualized treatment. Patients under age 55 years with a first-degree family member with a history of colorectal cancer are at increased risk and may need earlier and more frequent examinations. People with a history of breast, ovarian, or endometrial cancer are at some increased risk but should follow screening recommendations for normal-risk patients.

American College of Obstetricians and Gynecologists --

Colonoscopy should be a part of primary preventive care for individuals with a personal history of inflammatory bowel disease or colonic polyps, or a family history of familial polyposis coli, colorectal cancer, or cancer family syndrome.

American College of Physicians --

Individuals who have one or more first-degree relatives with colorectal cancer should be offered colonoscopy at 40 years of age and at least every 10 years thereafter.

American Gastroenterological Association --

Individuals with a first-degree relative who has had colorectal cancer or an adenomatous polyp should be screened beginning at age 40 years. Gene carriers for familial adenomatous polyposis (FAP) or people with a family history of FAP whose gene carrier status is indeterminate should be offered yearly flexible sigmoidoscopy beginning at puberty to see if they are expressing the gene. If polyposis is present, they should begin to consider when they should have colectomy. People with a family history of hereditary nonpolyposis colorectal cancer should be offered an examination of the entire colon (via colonoscopy or double contrast barium enema, preferably with sigmoidoscopy) every 1 to 2 years starting between the ages 20 and 30 years and every year after age 40 years. In patients with long-standing, extensive inflammatory bowel disease, surveillance colonoscopy should be considered, along with the extent and duration of the disease, as a guide to when or if colectomy should be considered. A common practice is to perform surveillance colonoscopy every 1 to 2 years beginning after 8 years of disease in patients with pancolitis or after 15 years in those with colitis involving only the left colon.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend for or against the inclusion or exclusion of sigmoidoscopy in the periodic health examination of asymptomatic individuals over 40 years old (including those with a family history of one or two relatives with colorectal cancer). There is fair evidence to exclude sigmoidoscopy from the periodic health examination of individuals with true cancer family syndrome; however, there is fair evidence for the inclusion of colonoscopy in the periodic health examination of individuals with true cancer family syndrome.

US Preventive Services Task Force --

In high-risk groups, there is insufficient evidence to recommend for or against early or frequent screening or the use of colonoscopy rather than sigmoidoscopy. However, early and frequent colonoscopy screening of patients with a family history of familial polyposis coli or cancer family syndrome or with personal histories of previous adenomatous polyps or colorectal cancer may be recommended on other grounds, including the increased risk of colorectal cancer and of lesions in the proximal colon.

Performing sigmoidoscopies requires technical training and practice. It is beyond the scope of this book to explain the performance of this procedure; only very basic aspects will be addressed.

Sigmoidoscopy should be performed only by or under the supervision of a trained examiner. Training should be obtained from an experienced endoscopist. Training may consist of diagnostic instruction with audiovisual materials, endoscopic models, and photo atlases, followed by patient demonstrations and successful completion of a number of supervised examinations.

Most authorities recommend use of a flexible sigmoidoscope (preferably 60 cm in length) rather than a rigid sigmoidoscope because of better patient acceptance and the ability to visualize lesions higher in the sigmoid colon.

Proper bowel preparation is essential for performance of an adequate screening examination. Recommendations for bowel preparation differ somewhat. The minimum preparation consists of administration of two enemas a few hours before examination.

All authorities agree that patients found to have adenomatous polyps of 1 cm or larger need colonoscopic examination of the entire colon. Approximately 10% of individuals screened will have small tubular adenomas less than 1 cm in diameter. Controversy exists about whether patients with these lesions need colonoscopic follow-up in view of their low potential for malignancy.

Clinicians need to perform sigmoidoscopy routinely to maintain competence. Performing procedures only occasionally may lead to missed or inappropriate diagnoses and a high rate of complications.

Colorectal Cancer: Questions & Answers; Colonoscopy: Questions and Answers; Polyps of the Colon and Rectum: Questions and Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite 1080, Palatine, IL 60067; (708)359-9184.

What You Need to Know about Cancer of the Colon and Rectum. Office of Cancer Communications, National Cancer Institute, Bethesda, MD 20892; (800)4-CANCER.

Thyroid dysfunction affects 1% to 4% of adults in the United States. The annual incidence of hypothyroidism is 0.08%. The estimated annual incidence of hyperthyroidism is 0.05%. Both forms of thyroid dysfunction are more common in women, older adults, and persons with a family history of thyroid disease. Laboratory evidence of hypothyroidism is found in up to 10% of women and 2% of men aged 60 years and older. Other risk factors for thyroid hypofunction include prior autoimmune conditions, history of head or neck surgery or radiation exposure, Down's syndrome, and the postpartum state. In most affected persons, symptoms typically develop shortly after the onset of thyroid dysfunction. Lethargy, weight gain, confusion, cold intolerance, constipation, alopecia, dyspnea, myalgias, and paresthesias are common features of hypothyroidism. Restlessness, emotional lability, insomnia, heat intolerance, dyspnea, palpitations, ophthalmopathy, diarrhea, muscle atrophy, weakness, tremors, and tachycardia are symptoms of hyperthyroidism.

Some individuals, particularly older adults, can experience an insidious onset of thyroid disease. Apathetic hyperthyroidism occurs without the usual goiter, ophthalmopathy, and signs of sympathetic nervous system hyperactivity. Symptoms of hypothyroidism, such as fatigue, constipation, dry skin, and poor concentration may be attributed to the aging process or may be less frequent in older populations. Because hypothyroidism can cause secondary dyslipidemia, patients with subclinical hypothyroidism may first present with high cholesterol levels. Studies suggest that some patients with subclinical disease or mild alterations in thyroid function tests may benefit from early treatment if they are identified through screening. For this reason, some authorities recommend screening of certain high-risk populations for thyroid dysfunction.

See chapters 8 and 30 for information about screening for congenital hypothyroidism and thyroid cancer, respectively.

American College of Obstetricians and Gynecologists --

Thyroid-stimulating hormone (TSH) levels should be obtained every 3 to 5 years from all women aged 65 years and older and from younger women with an autoimmune condition or strong family history of thyroid disease.

American College of Physicians --

Routine screening for thyroid disease is not indicated in asymptomatic individuals nor in patients admitted to the hospital for acute medical or psychiatric illnesses; testing may be indicated to identify unsuspected disease in women over 50 years of age who have general symptoms that could be caused by thyroid disease.

American Thyroid Association --

Tests of thyroid function should not be a part of multiphasic screening for patients who are not suspected of having thyroid disease except in certain high-risk populations. Suspect populations include individuals with a strong family history of thyroid disease, elderly patients, postpartum women 4 to 8 weeks after delivery, and patients with autoimmune diseases.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to support screening for hyperthyroidism and hypothyroidism among asymptomatic adults. The high prevalence of hypothyroidism among perimenopausal and postmenopausal women warrants a high index of suspicion and liberal use of the sensitive thyroid stimulating hormone (TSH) assay in the presence of even vague and subtle complaints.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults --

Because hypothyroid states can raise LDL-cholesterol levels, any patient with LDL-cholesterol exceeding 190 mg/dL should be tested for hypothyroidism.

US Preventive Services Task Force --

Routine screening for thyroid disorders is not warranted in asymptomatic adults. There is insufficient evidence to recommend for or against screening for thyroid disease with thyroid function tests in high-risk patients, including the elderly, postpartum women, and persons with Down's syndrome, but recommendations for such screening may be made on other grounds, such as the high prevalence of disease and the increased likelihood that symptoms of thyroid disease will be overlooked in these patients. Clinicians should remain alert for subtle or nonspecific symptoms of thyroid dysfunction when examining such patients, and maintain a low threshold for diagnostic evaluation of thyroid function.

Your Thyroid Gland: A Guide for the Patient. American Academy of Otolaryngology-Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.

Directory of Organizations for Endocrine and Metabolic Diseases; Thyroid Hormone Action and Nuclear Receptors; Attention Deficit Hyperactivity Disorder and Generalized Resistance to Thyroid Hormone. National Institute Diabetes and Digestive and Kidney Diseases, Bldg 31, Rm 9A04, Bethesda, MD 20892; (301)496-3583. Internet address: http://www.niddk.nih.gov/health/endo/endo.htm

In 1995, a total of 22,860 new cases of active tuberculosis (TB) were reported in the United States. This marked the third consecutive year that the number of reported cases decreased and reflected the lowest rate of reported TB cases since national surveillance began in 1953. During the 1980s and early 1990s, the number of TB cases increased significantly. Factors that contributed to the increase included adverse social and economic conditions, the human immunodeficiency virus (HIV) epidemic, immigration of individuals with Mycobacterium tuberculosis infection, and clinician and patient noncompliance with recommended screening and treatment regimens. Efforts to control the spread of TB were also complicated by the emergence of strains of M. tuberculosis resistant to multiple drugs.

The more recent decline in the number of TB cases probably reflects a number of factors, according to the Centers for Disease Control and Prevention, including (1) improved laboratory methods to allow prompt identification of M. tuberculosis; (2) broader use of drug-susceptibility testing; (3) expanded use of preventive therapy in high-risk groups; (4) decreased transmission of M. tuberculosis in congregate settings (eg, hospital and correctional facilities) because of implementation of infection-control guidelines; and (5) improved follow-up of persons with TB.

In the United States, control of tuberculosis depends on screening high-risk populations and providing preventive therapy to persons in whom active disease is most likely to develop. Groups at high risk for TB infection include: (1) close contacts of persons known or suspected to have TB; (2) persons infected with HIV; (3) persons who inject illicit drugs or other locally identified high-risk substance abusers (eg, crack cocaine users); (4) persons who have medical risk factors known to increase the risk for TB disease if infection occurs; (5) residents and employees of high-risk congregate settings (eg, correctional institutions, nursing homes, mental institutions, other long-term residential facilities, and shelters for the homeless); (6) health care workers who serve high-risk clients; (7) foreign-born persons, including children, who have arrived within 5 years from countries with a high incidence or prevalence of TB; and (8) some medically underserved, low-income populations. Conditions and chronic diseases that predispose patients to development of TB disease include HIV infection, diabetes mellitus, end-stage renal disease, and hematologic and reticuloendothelial diseases; history of intestinal bypass or gastrectomy, chronic malabsorption syndromes, silicosis, cancers of the upper
gastrointestinal tract or oropharynx, prolonged steroid use and immunosuppressive therapy; and being 10% or more below desirable body weight.

Prophylaxis with isoniazid is very effective in preventing the onset of clinical tuberculous disease. Use of isoniazid for 12 months in an at-risk population has been shown to reduce the occurrence of TB disease by 54% to 88%. Its efficacy is directly related to the length of prophylaxis, the extent of patient compliance with the prophylactic regimen, and the susceptibility of the infecting organism to isoniazid. The effectiveness of bacillus of Calmette and Guérin (BCG) vaccination is considerably less certain; effectiveness rates varied from 0% to 76% in major trials.

See chapter 9 for information on TB screening, preventive therapy, and BCG immunization in children and adolescents.

Tuberculosis is currently designated as an infectious disease notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

All major authorities, including American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Thoracic Society, Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention, and US Preventive Services Task Force --

Tuberculin skin testing should be performed on all individuals at high risk. The need for repeat skin testing should be determined by the likelihood of continuing exposure to infectious TB.

American Thoracic Society (ATS), Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force --

Adults with a reactive skin test and no evidence of active disease should be considered for preventive therapy with isoniazid based on age and risk factors. ATS and CDC also recommend that anergic patients recently exposed to an active TB case or from populations where the prevalence of TB is greater than 10% (injection drug users, homeless individuals, migrant laborers, and first-generation immigrants from Asia, Africa, or Latin America) should be considered for isoniazid prophylaxis even when their skin test is negative.

American Thoracic Society, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force --

Vaccination with BCG is not recommended for adults in the United States. However, CDC recommends that BCG vaccination should be considered for health care workers who work in settings in which (a) a high percentage of TB patients are infected with M. tuberculosis resistant to both isoniazid and rifampin, (b) transmission of such drug-resistant M. tuberculosis strains is likely, and (c) comprehensive infection control precautions have been implemented and have not been successful.

Canadian Task Force on the Periodic Health Examination --

recommends BCG vaccination for tuberculin-negative contacts of persons with active TB in Canadian communities in which the infection rate is high.

CDC has issued recommendations for preventive therapy in previously untreated adults without evidence of active TB (Table 43.1). Certain anergic patients should be considered for preventive therapy regardless of their skin test reaction. Other groups for whom prophylaxis is indicated include adults who have had close contact with a person with infectious TB in the past 3 months and individuals who are members of populations in which the prevalence of TB is greater than 10% (eg, injection drug users, homeless persons, migrant laborers, and persons born in Asia, Africa, or Latin America).

Initiate preventive therapy with isoniazid (INH). The correct daily dose of isoniazid for adults is 5 mg/kg (maximum, 300 mg) taken orally. For noncompliant adult patients, isoniazid may be administered by a health professional on a twice-weekly schedule of 15 mg/kg per dose (maximum, 900 mg). In general, continue isoniazid prophylaxis for at least 6 months, up to a maximum of 12 months. Patients who are HIV-positive or have evidence of prior untreated TB on chest X-ray should receive isoniazid prophylaxis for 12 months. If a patient has had contact with a person known to have infectious TB that is resistant to isoniazid, consider administering preventive therapy with rifampin (600 mg by mouth daily for 1 year).

Contraindications to isoniazid prophylaxis include acute or active liver disease of any etiology or previous adverse reaction to isoniazid. Among adults over 35 years of age, the incidence of mild isoniazid-induced liver function test abnormalities is 10% to 20%. During the course of therapy, adults over age 35 years should undergo baseline and periodic (monthly) testing for transaminase (ALT or AST) levels. If the transaminase level is three to five times higher than the upper limit of the laboratory normal range, consider discontinuing isoniazid. Closely monitor individuals who use alcohol daily or in whom chronic liver disease is suspected for isoniazid-induced hepatitis. Supplementation with pyridoxine (vitamin B₆, 50 mg by mouth daily) may be helpful in preventing neuropathy in certain patients on isoniazid, such as those with diabetes, uremia, alcoholism, or malnutrition. Delay therapy for pregnant women who are candidates for preventive treatment until after delivery. If it is likely that the woman has been recently infected, therapy may be instituted after completion of the first trimester of pregnancy.

While patients are taking isoniazid, monitor them monthly for signs and symptoms of adverse reactions. These include drug fever or rash, hypersensitivity reactions, peripheral neuritis, and hepatitis. Signs and symptoms of hepatitis include loss of appetite, nausea, vomiting, persistent dark urine, jaundice, fever, and abdominal tenderness especially in the right upper quadrant. Patients who are taking other medications concurrently with isoniazid should be monitored for potential drug interactions.

Routine BCG vaccination is not recommended for adults in the United States.

The Tice strain is the only BCG preparation currently available in the United States. The dose and administration is the same for both adults and children ( see chapter 9 for details).

Do not administer BCG vaccine to individuals who may be immunocompromised or immunosuppressed, including those with known or suspected HIV infection.

Side effects occur in 1% to 10% of vaccinated individuals and may include severe or prolonged ulceration at the vaccination site, lymphadenitis, and lupus vulgaris.

Tuberculosis: Get the Facts; Tuberculosis: Connection between TB and HIV; Questions and Answers about TB. Centers for Disease Control and Prevention, Attn: Information, Technology and Services Office, NCHSTP, CDC, 1600 Clifton Rd NE, M/S E-06, Atlanta, GA 30333; or National Center for HIV, STD, and TB Prevention Voice Information System: (404)639-1819.

Facts About the TB Skin Test; Facts About Tuberculosis. American Lung Association, 1740 Broadway, New York, NY 10019-4374; (212)315-8700.

Multidrug Resistant Tuberculosis; TB Care Guide; Core Curriculum on Tuberculosis; TB Treatment: A Clinical Care Guide; Improving Patient Adherence to Tuberculosis Treatment; Reported TB in the United States; Tuberculosis Control Laws-United States. To order these and other documents, contact the Centers for Disease Control and Prevention, Attn: Information, Technology and Services Office, NCHSTP, CDC, 1600 Clifton Rd, NE, M/S E-06, Atlanta, GA 30333; or the National Center for HIV, STD, and TB Prevention Voice Information System: (404)639-1819.

Table 43.1. Criteria for Determining Need for Preventive Therapy by Category and Age Group

Examination of urine for signs of occult disease has a long tradition in medical care. The development of modern "dipsticks" that can perform multiple tests in a matter of minutes has made urinalysis inexpensive and quick. Most of the abnormalities detected by screening adults with urinalysis are indicative of benign disorders, such as idiopathic proteinuria, or of conditions for which the value of treatment is unclear, such as occult bacteriuria. For this reason, most authorities recommend use of screening urinalysis only for certain conditions in specific high-risk populations.

Urinalysis is most often recommended to screen for occult bacteriuria. Urinary tract infections are a significant source of disease and morbidity in diabetic women, pregnant women, and older persons (particularly women). Table 44.1 shows the prevalence of asymptomatic bacteriuria in selected adult populations and the positive predictive value of nitrite and leukocyte esterase (LE) dipstick tests for detecting asymptomatic bacteriuria in these populations. The positive predictive value of urinalysis in these groups is relatively low, except in institutionalized older adults and women with diabetes.

Treatment of asymptomatic bacteriuria in institutionalized older adults has not been shown to decrease morbidity or mortality or even to lead to sustained periods without bacteriuria. Some evidence suggests that treating elderly women in the community leads to fewer symptomatic infections, but the significance of such an approach for long-term health is unknown. The theory that treatment of women with diabetes leads to fewer symptomatic urinary tract infections and decreased long-term morbidity is plausible but not proven. Treating asymptomatic bacteriuria in pregnant women is of definite proven benefit. For this reason, pregnant women are routinely screened with urine culture, which is more sensitive and specific than dipstick testing.

Screening has also been advocated to detect occult hematuria, which can be indicative of urinary tract malignancies. The incidence of these malignancies increases significantly after age 40 years, and they occur twice as frequently in men as in women. Dipsticks are reasonably accurate for detecting hematuria, but microscopic hematuria is not specific for bladder cancer or other urologic cancers. The positive predictive value of a positive heme dipstick test for malignancy in older men has been found to be between 6% and 8%. Unnecessary evaluations for a potential urinary tract malignancy can be harmful. Intravenous pyelograms, for example, can lead to diminished renal function and, rarely, death.

Screening for proteinuria in the general population is of little value, because most causes are either benign or untreatable. Screening for diabetes with urinalysis is very inaccurate and is better accomplished with plasma glucose measurements (chapter 38). See chapter 10 for a discussion of the use of screening urinalysis in children.

All major authorities --

Screening urinalysis is recommended in prenatal care for pregnant women.

American Academy of Family Physicians and US Preventive Services Task Force (USPSTF) --

Routine screening of males and most females for asymptomatic bacteriuria is not recommended. In diabetic or elderly ambulatory women evidence is insufficient to recommend for or against screening for asymptomatic bacteriuria, but recommendations against such screening may be made on other grounds, including the high likelihood of recurrence and the potential adverse effects of antibiotic therapy. The USPSTF recommends screening for asymptomatic bacteriuria by urine culture in all pregnant women.

American College of Obstetricians and Gynecologists --

Urinalysis for asymptomatic bacteriuria is recommended for women over 65 years of age or with diabetes mellitus as part of periodic evaluation visits, which should occur yearly or as appropriate.

American College of Physicians --

Urinalysis and urine culture should not be routinely used to screen for asymptomatic bacteriuria.

Canadian Task Force on the Periodic Health Examination --

Dipstick urinalysis for protein to prevent progressive renal disease is recommended for patients with insulin-dependent diabetes mellitus. Urinalysis to detect asymptomatic bacteriuria in the elderly is not recommended. However, for ambulatory elderly women the evidence is insufficient to recommend for or against screening for asymptomatic bacteriuria.

Urinary Tract Infections. American College of Obstetricians and Gynecologists. ACOG Patient Education Pamphlet AP050. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.org

Urinary Tract Infection: A Common Problem for Some Women. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Urinary Tract Infection in Adults. National Institute of Diabetes and Digestive and Kidney Diseases' National Kidney and Urologic Diseases Information Clearinghouse, 3 Information Way, Bethesda, MD 20892-3580; (301)654-4415. Internet address: http://www.niddk.nih.gov/health/endo/endo.htm

Table 44.1. Prevalence of Asymptomatic Bacteriuria in Adults and Estimated Positive Predictive Values of Nitrite and Leukocyte Esterase Dipstick Tests

Table 44.2. Causes of Inaccurate Nitrite Dipstick Tests

Table 44.3. Causes of Inaccurate Leukocyte Esterase (LE) Dipstick Tests

Vision loss is common in adults, and the prevalence of vision loss increases with advancing age. Approximately 13% of persons aged 65 years and older and 28% of those aged 85 years and older report some degree of visual impairment. More than 90% of older adults need corrective lenses at some time. Common visual disorders affecting adults include cataracts, macular degeneration, glaucoma, and diabetic retinopathy. Such disorders frequently contribute to trauma from falls, automobile crashes, and other types of accidental injuries. According to one study, 18% of hip fractures are attributable to impaired vision. Many older adults are unaware of decreases in their visual acuity, and up to 25% of such persons may have the wrong corrective lens prescription.

Surgical treatment of cataracts can lead to improved vision and quality of life. Medical and surgical treatment of glaucoma may help prevent visual loss. Early laser surgical treatment can help prevent visual loss attributable to diabetic retinopathy and (in some cases) macular degeneration. Visual acuity testing can be performed easily and accurately by primary care clinicians. Glaucoma screening, however, as usually practiced by primary care clinicians using a Schiotz tonometer, is relatively insensitive and nonspecific. The predictive value of a positive Schiotz test is only about 5%.

American Academy of Family Physicians --

Vision screening with Snellen acuity testing is recommended for the elderly.

American Academy of Ophthalmology --

A comprehensive eye examination, including screening for visual acuity and glaucoma by an ophthalmologist, should be performed every 3 to 5 years in African Americans aged 20 to 39 years, and, regardless of race, every 2 to 4 years in individuals aged 40 to 64 years, and every 1 to 2 years beginning at age 65 years. Diabetic patients, at any age, should have exams at least yearly.

American College of Obstetricians and Gynecologists --

Women 65 years of age and older should be evaluated for visual acuity yearly or as appropriate.

American Optometric Association --

Comprehensive eye and vision examinations are recommended for normal-risk adults as follows: 19 to 40 years of age, every 2 to 3 years; 41 to 60 years of age, every 2 years; 61 years of age and older, yearly. Adults 19 to 60 years of age at increased risk for eye disease (eg, with diabetes, hypertension, family history of glaucoma, work in highly visually demanding or eye hazardous occupations, taking certain systemic medications with ocular side effects) should have examinations every 1 to 2 years or as recommended.

Canadian Task Force on the Periodic Health Examination --

There is fair evidence to include in the periodic health examination visual acuity testing with a Snellen sight chart for adults aged 65 years or older. In addition, funduscopy or retinal photography is recommended for elderly patients (> 65 years) with diabetes of at least 5 years' duration. The place of funduscopy in the detection of age-related macular degeneration and glaucomatous changes is controversial. For patients at high risk for glaucoma (eg, positive family history, African American race, severe myopia, diabetes), a prudent recommendation would be to include periodic assessment by an ophthalmologist.

National Eye Institute --

A comprehensive eye examination, including screening for visual acuity and glaucoma, should be performed by an eye care professional every 2 years beginning at age 40 years in African Americans and at age 60 years in all other individuals. Diabetic patients, at any age, should have yearly exams.

US Preventive Services Task Force --

Routine vision screening with Snellen acuity testing is recommended among the elderly. The frequency is left to clinical discretion. Selected questions about vision may be helpful in detecting vision problems in the elderly, but do not appear to be as sensitive or specific as direct assessment of acuity. There is insufficient evidence to recommend for or against routine screening for diminished visual acuity among non-elderly adults. There is also insufficient evidence to recommend for or against routine screening by primary care clinicians for elevated intraocular pressure or early glaucoma. Effective screening for glaucoma is best performed by eye specialists who have access to specialized equipment to evaluate the optic disc and measure visual fields. Recommendations may be made on other grounds to refer patients at high risk for glaucoma for evaluation by eye specialists including: the substantial prevalence of unrecognized glaucoma in these populations, the progressive nature of untreated disease, and expert consensus that reducing intraocular pressure may slow the rate of visual loss with early glaucoma or severe intraocular hypertension. Patients at high risk for glaucoma include: African Americans over 40 years of age; Caucasians over 65 years of age; patients with diabetes, severe myopia, or a family history of glaucoma. The optimal frequency for glaucoma screening has not been determined.

Your Vision, the Second Fifty Years; Do Adult Vision Problems Cause Reading Problems? and other publications. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

Age-Related Macular Degeneration; Cataracts; Diabetic Retinopathy; Don't Lose Sight of Diabetic Eye Disease; Don't Lose Sight of Glaucoma; Glaucoma. National Eye Health Education Program, National Institutes of Health, 2020 Vision Pl, Bethesda, MD 20892; (301)496-5248. Internet address: http://www.nei.nih.gov

Age Page Aging and Your Eyes. National Institute on Aging, Bldg 31, Room 5C27, 31 Center Dr MSC 2922 Bethesda, MD 20892-2922; (301)496-1752. Internet address: http://www.nih.gov/nia

Glaucoma; Cataracts; Strabismus in Adults; Cataract Surgery; Diabetic Retinopathy. American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request. Internet address: http://www.eyenet.org

Policy Statement: Frequency of Ocular Examinations; National Eyecare Project (for those who do not have an eye doctor); Glaucoma 2001 Project (for people at risk for glaucoma). American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request. Internet address: http://www.eyenet.org

Comprehensive Adult Eye and Vision Examination and other clinical practice guidelines. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

National Eye Institute Statement on Detection of Glaucoma; National Eye Institute Statement on Vision Screening in Adults. National Eye Health Education Program, National Institutes of Health, 2020 Vision Pl, Bethesda, MD 20892; (301)496-5248. Internet address: http://www.nei.nih.gov

Table 45.1. Visual Impairment Questionnaire