Guide to Clinical Preventive Services, 2006: Section 2 (Continued)

Section 2. Recommendations for Adults (Continued)

Musculoskeletal Conditions

Primary Care Interventions to Prevent Low Back Pain in Adults

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against the routine use of interventions to prevent low back pain in adults in primary care settings.
Rating: I Recommendation.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. February 2004. http://www.ahrq.gov/clinic/3rduspstf/lowback/lowbackrs.htm.

Clinical Considerations

Although exercise has not been shown to prevent low back pain, regular physical activity has other proven health benefits, including prevention of cardiovascular disease, hypertension, type 2 diabetes, obesity, and osteoporosis.
Neither lumbar supports nor back belts appear to be effective in reducing the incidence of low back pain.
Worksite interventions, including educational interventions, have some short-term benefit in reducing the incidence of low back pain. However, their applicability to the primary care setting is unknown.
Back schools may prevent further back injury for individuals with recurrent or chronic low back pain, but their long-term effectiveness has not been well studied.

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Screening for Osteoporosis in Postmenopausal Women

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures (see Clinical Considerations for discussion of women at increased risk).
Rating: B Recommendation.

The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.
Rating: C Recommendation.

This USPSTF recommendation was first published in: Ann Intern Med 2002;137:526-8. http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm.

Clinical Considerations

Modeling analysis suggests that the absolute benefits of screening for osteoporosis among women aged 60-64 who are at increased risk for osteoporosis and fracture are comparable to those of routine screening in older women. The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight <70 kg ) is the single best predictor of low bone mineral density.^67,68 Low weight and no current use of estrogen therapy are incorporated with age into the 3-item Osteoporosis Risk Assessment Instrument (ORAI).^67,68 There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65. At any given age, African-American women on average have higher bone mineral density (BMD) than white women and are thus less likely to benefit from screening.
Among different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. Other technologies for measuring peripheral sites include quantitative ultrasonography (QUS), radiographic absorptiometry, single energy x-ray absorptiometry, peripheral dual-energy x-ray absorptiometry, and peripheral quantitative computed tomography. Recent data suggest that peripheral bone density testing in the primary care setting can also identify postmenopausal women who have a higher risk for fracture over the short term (1 year). Further research is needed to determine the accuracy of peripheral bone density testing in comparison with dual-energy x-ray absorptiometry (DXA). The likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer used, and the relevance of the reference range.
Estimates of the benefits of detecting and treating osteoporosis are based largely on studies of bisphosphonates. Some women, however, may prefer other treatment options (for example, hormone replacement therapy, selective estrogen receptor modulators, or calcitonin) based on personal preferences or risk factors. Clinicians should review with patients the relative benefits and harms of available treatment options, and uncertainties about their efficacy and safety, to facilitate an informed choice.
No studies have evaluated the optimal intervals for repeated screening. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeated screening to identify new cases of osteoporosis. Yield of repeated screening will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture.
There are no data to determine the appropriate age to stop screening and few data on osteoporosis treatment in women older than 85. Patients who receive a diagnosis of osteoporosis fall outside the context of screening but may require additional testing for diagnostic purposes or to monitor response to treatment.

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Obstetric and Gynecologic Conditions

Screening for Bacterial Vaginosis in Pregnancy

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely screening high-risk pregnant women for bacterial vaginosis (BV). (See Clinical Considerations for discussion of populations at high risk.)
Rating: I Recommendation.

The USPSTF recommends against routinely screening average-risk asymptomatic pregnant women for BV.
Rating: D Recommendation.

This USPSTF recommendation was first published in: Am J Prev Med 2001;20(3S):59-61. http://www.ahrq.gov/clinic/ajpmsuppl/bvrr.htm.

Clinical Considerations

For women with a history of preterm delivery, screening for BV is an option. A single previous episode of preterm delivery by itself may not reliably identify a population of women who will benefit from screening and treatment. Nevertheless, screening may be appropriate in specific circumstances. Studies demonstrating a benefit of screening and treatment were performed among populations of women at especially high risk (35 percent to 57 percent) of preterm birth. Clinicians should consider previous history of preterm delivery, other risk factors, and time of presentation in making the decision whether or not to screen for BV in women at high risk.
For clinicians electing to screen high-risk women, the optimal screening test is not certain. Accepted clinical criteria for BV include vaginal pH >4.5, amine odor on the application of KOH, appearance of a homogeneous vaginal discharge, and presence of clue cells on a microscopic examination of a wet mount. Presence of at least 3 of these 4 criteria is generally considered diagnostic of BV. The use of more limited criteria (e.g., clue cells alone) has not been evaluated.
Neither the optimal time to screen high-risk pregnant women nor the optimal treatment regimen for pregnant women with BV is clear. The 3 trials that demonstrated a reduction in preterm birth screened in the second trimester (13 to 24 weeks of pregnancy) used various regimens of oral metronidazole alone or oral metronidazole and erythromycin.
Treatment is appropriate for pregnant women with symptomatic BV infection. These women were excluded from most screening trials and may be at higher risk than those without symptoms. Treatment can relieve symptoms such as vaginal discharge.

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Behavioral Interventions to Promote Breastfeeding

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding.
Rating: B Recommendation.

The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care providers; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions.
Rating: I Recommendation.

This USPSTF recommendation statement was first published in: Am J Fam Med 2003;1(2):79-80. http://www.ahrq.gov/clinic/3rduspstf/brstfeed/brfeedrr.htm.

Clinical Considerations

Effective breastfeeding education and behavioral counseling programs use individual or group sessions led by specially trained nurses or lactation specialists, usually lasting 30 to 90 minutes. Sessions generally begin during the prenatal period and cover the benefits of breastfeeding for infant and mother, basic physiology, equipment, technical training in positioning and latch-on techniques, and behavioral training in skills required to overcome common situational barriers to breastfeeding and to garner needed social support.
Hospital practices that may help support breastfeeding include early maternal contact with the newborn, rooming-in, and avoidance of formula supplementation for breastfeeding infants.
Commercial discharge packs provided by hospitals that include samples of infant formula and/or bottles and nipples are associated with reducing the rates of exclusive breastfeeding.
Mothers who wish to continue breastfeeding after returning to work, especially those working fulltime, may need to use an electric or mechanical pump to maintain a sufficient breast milk supply.
Few contraindications to breastfeeding exist. In developed countries, infection with human immunodeficiency virus (HIV) in the mother is considered a contraindication to breastfeeding, as is the presence of current alcohol and drug use/dependence. Some medications (prescription and non-prescription) are contraindicated or advised for use "with caution" and appropriate clinical monitoring among lactating women.⁶⁹ Clinicians should consult appropriate references for information on specific medications, including herbal remedies.

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Screening for Gestational Diabetes Mellitus

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for gestational diabetes.
Rating: I Recommendation.

This USPSTF recommendation was first published in: Obstet Gynecol 2003;101:393-5. http://www.ahrq.gov/clinic/3rduspstf/gdm/gdmrr.htm.

Clinical Considerations

Better quality evidence is needed to determine whether the benefits of screening for gestational diabetes mellitus (GDM) outweigh the harms. Until such evidence is available, clinicians might reasonably choose either not to screen at all or to screen only women at increased risk for GDM.
Patient characteristics most strongly associated with increased risk for GDM include maternal obesity (usually defined as a body mass index [BMI] of 25 or more), older age (usually defined as older than 25 years), family or personal history of diabetes, or a history of GDM in a prior pregnancy. Expert groups have also identified certain ethnic groups as being at increased risk for GDM (such as Hispanic, African American, American Indian, and South or East Asian). Using all the above criteria, however, would identify 90 percent of all pregnant women as being at increased risk for GDM.
The optimal approach to screening and diagnosis is uncertain. Expert panels in the United States recommend a 50-g 1-hour glucose challenge test (GCT) at 24 to 28 weeks’ gestation, followed by a 100-g 3-hour oral glucose tolerance test (OGTT) for women who screen positive on the GCT. Different screening and diagnostic strategies recommended by the World Health Organization (WHO) are commonly used outside of North America. The American Diabetes Association (ADA) and the WHO have published specific criteria for diagnosis, but the USPSTF could not determine the relative benefits of any specific approach.^70,71

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Screening for Rh (D) Incompatibility

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Rating: A Recommendation.

The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks’ gestation, unless the biological father is known to be Rh (D)-negative.
Rating: B Recommendation.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. February 2004. http://www.ahrq.gov/clinic/3rduspstf/rh/rhrs.htm.

Clinical Considerations

Administration of a full (300µg) dose of Rh (D) immunoglobulin is recommended for all unsensitized Rh (D)-negative women after repeated antibody testing at 24-28 weeks’ gestation.
If an Rh (D)-positive or weakly Rh (D)-positive (e.g., D^u-positive) infant is delivered, a dose of Rh (D) immunoglobulin should be repeated postpartum, preferably within 72 hours after delivery. Administering Rh (D) immunoglobulin at other intervals after delivery has not been studied.
Unless the biological father is known to be Rh (D)-negative, a full dose of Rh (D) immunoglobulin is recommended for all unsensitized Rh (D)-negative women after amniocentesis and after induced or spontaneous abortion; however, if the pregnancy is less than 13 weeks, a 50µg dose is sufficient.
The benefit of routine administration of Rh (D) immunoglobulin after other obstetric procedures or complications such as chorionic villus sampling, ectopic pregnancy termination, cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, abdominal trauma, antepartum fetal death, or stillbirth is uncertain due to inadequate evidence.

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Vision Disorders

Screening for Glaucoma

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening adults for glaucoma.
Rating: I Recommendation.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality. Rockville, MD, March 2005. http://www.ahrq.gov/clinic/uspstf/uspsglau.htm..

Clinical Considerations

Primary open angle glaucoma (POAG) is a chronic condition characterized by a loss of retinal ganglion cell axons. It is manifested initially by peripheral visual field loss; in an uncertain number of cases, it progresses to impairment in important visionrelated function and even to irreversible blindness.
The diagnosis of POAG is not made on the basis of a single test but on the finding of characteristic degenerative changes in the optic disc and defects in visual fields. Although increased intraocular pressure (IOP) has previously been considered an important part in the definition of this condition, it is now known that many people with POAG do not have increased IOP; hence, there is little value of using tonometry to screen for POAG.
Increased IOP, family history, older age, and being of African American descent place an individual at increased risk for glaucoma. Older African Americans have a higher prevalence of glaucoma and perhaps a more rapid disease progression, and if it is shown that screening for glaucoma reduces the development of visual impairment, African Americans would likely have greater absolute benefit than whites. People with a limited life expectancy would likely have little to gain from glaucoma screening.
The natural history of glaucoma is heterogeneous and not well defined. There is a subgroup of people with POAG in whom there is either no disease progression, or the progression is so slow that the condition would never have an important effect on their vision. The size of this subgroup is uncertain and may depend on the ethnicity and age of the population. Others experience more rapidly progressing disease, leading to reduced visionrelated function within 10 years. Whether an individual's glaucoma will progress cannot be predicted with precision, but those with higher levels of IOP and worse visual fields at baseline, and those who are older, tend to be at greater risk for the more rapid progression of glaucoma. Whether the rate of progression of visual field defects remains uniform throughout the course of glaucoma is unknown.
Measurement of visual fields can be difficult. The reliability of a single visual field measurement may be low; several consistent visual field measurements are needed to establish the presence of defects. Dilated opthalmoscopy or slit lamp exam are used by specialists to examine changes in the optic disc; however, even experts vary in their ability to detect glaucomatous optic disc progression. Additionally, there is no agreed-upon single standard to define and measure progression of visual field defects.
The primary treatments for POAG reduce IOP; these include medications, laser therapy, or surgery. These treatments effectively reduce the development and progression of small, visual field defects. The magnitude of their effectiveness, however, in reducing impairment in vision-related function is uncertain. Harms caused by these interventions include formation of cataracts, harms resulting from cataract surgery, and harms of topical medication.

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References:

1. Gail MH, Costantino JH, Bryant J, et al. Weighing the risks and benefits of tamoxifen treatment for preventing breast cancer. J Natl Cancer Inst 1999;91:1829-46.

2. Martin-Hirsch P, Lilford R, Jarvis G, Kitchener HC. Efficacy of cervical-smear collection devices: a systematic review and meta-analysis [published erratum appears in Lancet 2000 Jan 29;355(9201):414]. Lancet 1999;354(9192):1763-70.

3. Smith RA, Cokkinides V, von Eschenbach AC, et al. American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin 2002;52(1):8-22.

4. Hildesheim A, Hadjimichael O, Schwartz PE, et al. Risk factors for rapid-onset cervical cancer. Am J Obstet Gynecol 1999;180(3 Pt 1):571-7.

5. Janerich DT, Hadjimichael O, Schwartz PE, et al. The screening histories of women with invasive cervical cancer, Connecticut. Am J Public Health 1995;85(6):791-4.

6. Hartman KE, Hall SA, Nanda K, Boggess JF, Zolnoun D. Screening for Cervical Cancer. Systematic Evidence Review. No. 25. (Prepared by the Research Triangle Institute-University of North Carolina Evidence-based Practice Center under contract No. 290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality. January 2002. Available on the AHRQ Web site at: www.ahrq.gov/clinic/serfiles.htm.

7. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care, 2nd ed. Washington, DC: ACOG;2002: 121-34, 140-1.

8. Mitchell HS, Giles GG. Cancer diagnosis after a report of negative cervical cytology. Med J Aust 1996;164(5):270-3.

9. Sigurdsson K. Trends in cervical intra-epithelial neoplasia in Iceland through 1995: evaluation of targeted age groups and screening intervals. Acta Obstet Gynecol Scand 1999;78(6):486-92.

10. Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH, Mulrow CD, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.