Good morning and welcome to the morning session on the United States Preventive Services Task Force with Dr. Jill Wellen. Good morning everybody. Just a few words of introduction to this session. It is a, you know, as you know you've done clinical preventive services already in the course and the idea here is that as a specialty preventive medicine we adhere to the USPSTF recommendations when there are multiple recommendations about different preventive services. The USPSTF is our go-to and so as such it's really important for exam purposes for you to know the recommendations and especially the services that are recommended and the services that are recommended against. But what we found is that it's good for you to actually have your arms around all of the recommendations so that, you know, if you have a list that you're picking out which one do they recommend, you can feel confident that, you know, you've seen them all and that you know which ones to apply. So often, or you know really until this year, I guess we're gonna be saying that a lot, we've had people that are taking the recertification exam right after this this course and so this was really a session to kind of cram together on the USPSTF recommendations so that they're top of mind and again that you feel like you have your arms around them. So the first part, really about the first hour, we're going to be going through all of the recommendations just in a way that you can sort of quiz yourself. You know that you have them in your coursebook and also we'll just look at a few things that you can also use as study aids. But we recommend that for this first part that you, you know, quiz yourself and we'll put up a recommendation and then we'll say what what is the USPSTF recommendation and then we'll show it. So that's the idea of this. It's really designed for cramming and you know again if you're not taking the exam the next day it might not be the first part of this is not so critical and then the second half we will be we will be talking using you know going through some problems some questions. So before we start I have a little question in the chat that I want to address because I understand it's come up during the course as well. So the recertification exam there's always a question about what's on it right well there's always a question I mean really there's a question on what's on both exams and we do the best we can to cover what we're told by ABLM is on the exam and I think for my first session on Saturday I talked about you know that they have an outline and that's pretty much what we get as well. So what we've been told about the recertification exam is that it goes by the same outline as the certification exam but that it's geared toward the specialty exam. So if you're in you know which you are because you're in this talk right now you're in the general preventive medicine and public health specialty area. So you know we're told that that's the outline then that you follow. Now what you'll see is that there aren't as you know there's some biostats and there's there's definitely epi on there but it's not as extensive as the outline for the core in those areas and you know we found that there's more emphasis on the clinical applications. So another reason why we go through this again there is a session over the weekend that covers clinical preventive services and we're doing it again kind of taking the core part of you know the USPSTF recommendations which is really key and kind of redoing it. So it's been a little bit hard for us to make sure we're not having too much overlap between those two sessions but on the other hand it is a really important part of the research. So it's an important part of both exams but so you know anytime people ask what's on the exam we're going to be doing a little bit of a song and dance because we don't exactly know but we do cover the outlines that we've been pointed to. So that's our goal and another part of that goal is really to not cover anything that wouldn't be on the exam because there's so much material right. All right so if you want to I know that's it's never a satisfactory answer but you know we do the best we can and we're really guided by those outlines by the APLM. Okay so as I said right we're going to be going just the first part really first half of this is to to go through the actual recommendations. Now this actually they've changed their website I think this was from 2019 and since then the USPSTF website itself has a different look to it but it's a good study tool for the exam you know if you just even use just the website and you know you can easily get to the recommendations. They have a whole you know their whole list I think there's close to 100 recommendations and you know you can quiz yourself there. Another really good resource that well here I'm showing you the recommendations and you can see they're all listed and you know you can even just quiz yourself like I said on on what the grade is for each of them and then you can click and get more information as needed. And then just to remind you what their grades are I know you went through this in the clinical preventive medicine session but you know A and B are recommended it's just level of evidence or level of benefit that they differ and they don't make a distinction on the exam between those two and then D is the other one you want to be sure you know that it's recommended against and then as you know C is use your clinical judgment and consultation with the patient and then I insufficient evidence. This is another tool that I found you know it could be really useful for studying. It's it's kind of set up as a it's called the adult preventive health care schedule. It originated in the American Journal of Family Practice AJFP or anyway they had an article in there where they did this where they put the preventive services recommendation the screening recommendations in a what looks like a vaccine schedule and so you know you can see the actual ages this is adult and you know you can see what the recommendations are for the men and women and really useful because it's all right there. So I put the the link there at the bottom and they do update it. So this one was 2018 I guess this is the latest one but they update it now fairly often or every year. Again just because in the past we don't have as many opportunities for discussion but in the past sometimes people you know don't remember so I want to just remind you that remember the USPSTF recommendations applied to asymptomatic people where you can apply this to everybody and you know we get into trouble when we start you know thinking that it's a recommendation for someone who has symptoms or you know so we just really want to make that distinction and also it's for services offered in a primary care setting. So you know this the arguments we have with specialty organizations other specialties really shouldn't go on because this is about applying it to everybody and in a primary care setting and like it routinely offered to the general population. Excuse me I'm just gonna check the chat to just make sure the biostats and epi on the research and then you did get an answer from one of your colleagues that is correct. You know it's on the specialty outline right and and so I'm given that that specialty outline is what the research is about. Little added information is just from experience now remember the research is only about a hundred questions and a lot of it is focused on clinical practice and I mean you know prevention not treatment or but and you know they they tout it as being more practical exam. So yeah the biostats are on the outline and so are epi things but you know it's not as much of a focus I think Dr. Tai's exam or answer sounded like like the best one where it it would be but not as intense for sure as the initial exam for both of those. Okay let's get back here. All right so literally we're just gonna go through these and some of them are really easy and you know I'm like that and we'll just confirm it and then some of them you know you may not be familiar but so we'll we'll just try to get this through this as efficiently as we can. If you're thinking oh I don't want to do this just now. I just want to go through the questions then I would say you know you can return and at 10 o'clock I guess Eastern and that's when we'll be starting the questions. So okay so breast cancer screening we know that that's recommended and but for 40 to 49 it's you know something that you make a decision with on an individual basis and then there isn't sufficient evidence for people older than 75. Genetic screening not at high risk it's actually a D don't do it high risk B and then the other modalities there's insufficient evidence you want to know what high risk is a personal or family history of any of these cancers and you know it more like a first-degree relative or you have Ashkenazi Jewish ancestry. Cervical cancer that's 21 to 65 years pap smear every three years or women 30 to 65 years can have a pap plus HPV every five years. So and remember that this doesn't apply to women that are at high risk with high-grade precancerous cervical lesions or immunocompromised or exposure to DES. And then you know we don't screen women younger than 21 or older than 65 with adequate prior screening and then of course if you don't have a cervix you're not being screened. So those are D's. All right colorectal cancer there is an update in progress for this so it hasn't come out yet but so we're still with our current recommendations and basically that is to do whatever test people will do. There's not a preference over any of these it's just the different frequencies and it's for people 50 to 75 years and that gets an A. So you know just keep track of the FOBT is going to need to be every year as is fit alone but fit in DNA is every three and then you know sigmoidoscopy doesn't really get used that much anymore in the US but colonoscopies every 10 years. And then 76 to 85 you know that's a decision that you need to make on a basis you know which would also include life expectancy considerations. And they don't apply to again patients with high-risk conditions so Lynch syndrome, FAP or inflammatory bowel disease. Lung cancer it looks like there's a needed update for this as well. It hasn't been updated yet. This was low-dose CT for adults 55 to 80 with a 30 pack year history of smoking and then having smoked within the last 15 years. So that was taken as you probably know almost directly from one study that showed benefit here but also did show over diagnosis. So that's a B and that's one that you know question about you're gonna see questions that have them quitting greater than 15 years ago or you know not having the sufficient pack year history or not within that age group that's gonna be the type of question that could be asked. Prostate cancer with PSA. You probably know that that we're looking at a C for the 55 to 69. At one point they had a D for everybody but now this is an area of discussion with the patient but it is a D for patients over 70. And then just to round out the cancer screening just so again the idea being that you've heard it all. So there's insufficient evidence for the three that I have listed there bladder, oral, and skin. And then ovarian, pancreatic, testicular, and thyroid are grouped together because those all get these do not screen for those cancers. All right and then counseling for cancer. Tobacco use. You're going to want to ask all patients about the use and then provide you know FDA approved cessation treatment. You want to ask pregnant women also of course. School-aged children and adolescents also with the B recommendation. And then but there's insufficient evidence to use pharmacotherapy and pregnant women or using electronic nicotine delivery systems. So those things aren't recommended. Skin cancer for younger people with fair skin. This is counseling about you know protection against the Sun. That's going to be a B. And for older people with fair skin that's an individual basis. And then adults just in general there isn't sufficient evidence for that. And then preventive medications. So for cancer probably and this is for cardiovascular disease too because they actually whoops do not have sufficient evidence for recommending that to all people. And then that includes you know supplements. And in particular though you want to know that beta carotene or vitamin E supplements for the prevention of cancer, cardiovascular disease are given a D. And that's because of a study that showed and at least in lung cancer for sure that there was an increased risk with these supplements. So that's an important one to know. Further so aspirin for a prevention of colorectal cancer and heart disease. Again just waiting for an update. And for now though it aspirin is recommended for for 50 to 59 and with you know a relatively you know higher risk of cardiovascular disease of 10-year risk. For people 60 to 69 it gets a C. That's an individual decision. And then there's insufficient evidence for people outside of that age group. So an important thing to be able to do is to you know calculate the CVD risk. And we have a question in our question set where we go through that. Tamoxifen and other aromatase inhibitors for the prevention of breast cancer. For everybody that's don't do that obviously. But if you have a high risk patient you can discuss the risks and benefits. And that again this is a primary care setting. So you would be consulting with the specialist on that. And then just to remind you of you know how we determine you know risk of for developing breast cancer. You know you and the risk and benefits really of balancing them. For the that calculation is more beneficial for women in their 40s with this high risk. But no predisposition to thrombocytopenic events. And women in their 50s you know it's a little bit less of you know benefit. The equation is a little bit different. But then for younger or older women you know it's really not doesn't really. Especially for older women that the complications from chemo for from chemo prevention is really a important consideration. And then just to remind you like we have different calculators for breast cancer risk. But again the Gale model is one of the most common. And these are the characteristics that are included in the calculation of the risk. So you know older age younger age of menarche, older age at first live birth, increased BMI, first degree relative. We already talked about history of breast biopsy is in there. And then race with white and Native Americans having higher risk. And this is what what it actually looks like if you looked it up on online. All right. Moving from cancer to heart disease. First of all screening. And AAA screening is another one that's got some nuances to it that you want to be aware of. So it's really for men who have smoked. So if you have a male that's 65 to 75 and hasn't been screened yet, a one-time screen during that age range for males who have ever smoked is recommended. But then for everybody else, it's not. So males that have never smoked, you can consider it. It's an individual decision. Females who have ever smoked, however, there's insufficient evidence. And females who have never smoked, that's actually recommended against. So the only group that's clearly, it's clearly recommended for men who have ever smoked 65 to 75 of one-time screening. Blood pressure, high blood pressure screening, it should occur for all adults. And however, there's insufficient evidence for children and adolescents. Carotid artery stenosis, screening for that, is actually, there's, it's a D recommendation. You don't screen for that. Peripheral artery disease has an I. And atrial fibrillation also has an I. But there is an update in progress for that. Abnormal glucose, when really, you know, the screening for diabetes, essentially, that's recommended for 40 to 70 year olds who are overweight or obese. And if a problem is detected, then it's recommended that they be referred to intensive behavioral therapy to promote healthful diet and physical activity. As far as screening for what's called non-traditional risk factors, so you can see a whole list there. Those, there is insufficient evidence for any kind of screening with, including ankle brachial index, which would be what screening for peripheral artery, artery disease, etc. So as far as using a resting or exercise ECG, for low-risk people, that's recommended against. It gets a D. And for medium or high-risk, you know, screening people, screening people, again. Asymptomatic people, everybody walks in. Are you going to give them an ECG? It's recommended against for low-risk. And there's no evidence for it in medium to high-risk. And then we looked at this aspirin recommendation in the context of colorectal cancer. But it also, you know, is like, applies to heart disease as well. All right, statins. They are recommended for higher-risk people, 40 to 75 years old. And that's with at least one risk factor for CBD and a greater than 10% 10 year CBD risk. And I'm not sure how you could have one, but you, you know, you have that without more than one or one risk factor. And then, so it's really based on whether, you know, what the 10 year CBD risk is. And these are the ages that are covered 40 to 75. It should be considered at least, depending on CBD, 10 year CBD risk. And then after 75, there's insufficient evidence. Buried within this is that 40 to 75 year olds, to determine whether they should be on a statin, they need a test of cholesterol levels, right? So there used to be a recommendation about screening for lipids. But then when this recommendation came in, it really became buried in this. So essentially, there is a recommendation to do, to test cholesterol with the idea that you're using that to determine what, as part of your determination of whether a person should be on a statin. And then counseling. Promote a healthy diet, physical activity or the CBD prevention in asymptomatic adults that actually gets a C. You know, it's not recommended against and you can consider it, but it's not an A or B recommendation. Intensive behavioral dietary counseling for patients with hyperlipidemia and other risk factors for CBD, that actually is recommended. So, you know, we're talking about, you know, looking at risk and and then tailoring of what we do according to that risk. All right, that's cardiovascular disease. I'm going to just check to see how we're doing time-wise here. Okay, we're doing great. All right, so moving to infectious disease, and I know you had a very intense session on infectious disease, and so I just want to pull out the screening recommendations and so you can, you know, know what USPSTF says about this. So screening for chlamydia is really for all women who are 24 or younger, who are sexually active, should be screened. And older than 24 at increased risk, and we have an increased risk slide coming up, that's going to be also screening. For men, it's insufficient evidence. So high risk for chlamydia, we said younger than 24, sexually active, or a history of, you know, STIs, and then multiple sexual partners or new sexual partners, and exchanging sex for money or drugs, of course. And then risks for pregnant women are the same as non-pregnant, and then just a few groups that have higher risk or have had prevalence, higher prevalence. Okay, gonorrhea is basically the same, that sexually active or at increased risk, sexually active under 24 and under for women, or at increased risk if they're older than that, with men having an eye for screening. And then, again, the list is similar to what we saw with chlamydia. In fact, I think these may have been put together as one recommendation because they're, you know, similar, they're the same recommendations for the same groups screening for it. HIV, we have adults 15 to 65. That's that really kind of opt out situation where it's recommended to screen all people in that age range. And then for anybody who's at increased risk as well. And then increased risk for HIV, you know, similar to other STIs, as well as, you know, injection drug use and other sexual practices. Syphilis, screen everybody at increased risk. And then, you know, again, a lot of the same high risk behaviors as you see for other STIs. Herpes, asymptomatic people, we don't screen. In fact, it's given a D, right? Bacteria for asymptomatic men and non-pregnant women, that also gets a D. We don't screen. Hepatitis B. So this is high risk. We screen. And high risk is any of these factors of injection drug use. And then other sexual practices or also you can see hemodialysis or cytotoxic immunotherapy is also on that list. I'm going to just check the chat for a minute and see if I'm falling behind with that. No, no. There's a question for chlamydia and GC just being a certain, the ethnicities are not considered high risk. It's just a note that was included in the actual recommendations on the website. So, you know, when I'm putting this together, I try to give you all the information. So they noted that there is a higher prevalence in certain groups. And that I think what that would mean, although they don't say it explicitly, I don't know if you have dug into USPSTF recommendations. Sometimes you'll find that when you go beyond their actual statement of screen, there are some gaps. So I'm going to fill this gap, given that disclaimer sort of that I think what they mean when they note that there's higher prevalence in certain groups is just to be more, you know, to be mindful that you want to check for high risk, you know, factors in that population, you know, just be aware. I think that that was all that that note was in the actual USPSTF literature. So it does not mean that those groups are high risk. And I should go back and just show you what I'm talking about. You know, just noting that, you know, you're not if it's not on your radar, but you know, if you're interacting with different populations, you just want to make sure you're thinking about the recommendation. Okay, um, so hepatitis C, if people are at increased risk, that gets a B, and then they have this one time screening for a certain cohort, which is, you know, kind of the baby boomer cohort that also gets a B. Okay, um, actually, I that that was the on the books until this year. And I just want to note to you that in 2020, that was changed. So the age range was they had it specifically for the baby boomer cohort, right? But now it's been extended to adults ages 18 to 79. And really, this is a result of, you know, having treatment for it, right? So, um, kind of you can see the evolution of, like, you know, we're gonna we're not gonna scream very heavily if we don't have a treatment, but you know, for hepatitis C, the story is a happy one. And so, just in 2020, this was changed. So for exam purposes, you know, that's always the exam lags behind. So typically, when these things change, within, you know, a few years of when you take before you take the exam, they really shouldn't be testing you on it, because it's just, you know, it's just not fair to know which one they want to apply. And then this is a high risk for HCV. But now that the it's extended 18 to 79, you know, it's just this isn't as as important as it was when you're looking for high risk people. They actually have a recommendation for latent TB to screen for it. I think it's kind of funny, because I think this one was sort of a newer recommendation, even though it's for something that we've been doing for a long time, right? So interesting. And then just again, a note that that is going to be countries of origin. And if you're a healthcare worker, being increased risk. Counseling for infectious disease, STIs, for sexually active adolescents, that is recommended and for adults at increased risk. And HIV preventive medication, so pre exposure prophylaxis, for people at high risk. Another thing that's evolved, very helpful on control of the disease. All right, injury and violence screening. Women of childbearing age, for intimate partner violence, that's recommended, but for other types of family violence, they're actually using insufficient evidence. So USPSTF recommendation is to screen women for IPV. And then others, you know, screening everybody for other types of family violence does not have enough evidence. Prevention of falls in community dwelling older adults. Exercise interventions are recommended. But there is a multifactorial interventions, which I think is probably includes like, you know, environment assessment and things like that. You're told to consider them. And then vitamin D prevent falls is actually recommended against. So, you know, you might be taking vitamin D for other reasons. But USPSTF recommendation, specifically taking it to prevent falls is not recommended. Mental health and substance abuse, cognitive impairment, there's insufficient evidence. Depression, all adults, including pregnant women, that is recommended. For adolescents, it's also recommended. So but for children under 11 or 11 and under, it is insufficient evidence. So anybody over 12, screening for depression is recommended. Screening specifically for suicide risk is there's not sufficient evidence. And there is an update in progress for these. Was a drug use just, you know, again, remember, just sitting down and screening everybody. There's insufficient evidence for screening for that. But tobacco cessation, of course, is something that we want to do. So that is to ask about it and then provide, you know, FDA approved treatments. And that includes for pregnant women. But remember, we already covered this when we were looking at cancer counseling, that there isn't sufficient evidence for using pharmacotherapy in pregnant women. And again, with the nicotine, electronic nicotine delivery systems, but we do want to address adolescents about prevent it to prevent initiation of smoking. So adolescents are included in the recommended addressing of tobacco use. Alcohol misuse, all adults screening for it. But for adolescents, there's insufficient evidence. All right, so now we have a metabolic, nutritional and endocrine conditions, screening and counseling. So remember, abnormal glucose, that's for age 40 to 70, overweight or obese. Thyroid dysfunction, there is insufficient evidence for screening on non-pregnant adults. Vitamin D deficiency, insufficient evidence. And celiac disease, also insufficient evidence. So it's really just glucose that we're looking at, not thyroid. But, you know, again, these things are being looked at again. So as you know, the recommendations can change based on the evidence. Obesity, of course, we should screen all adults, and then children as well. Okay, so we screen everybody, but intensive counseling and behavioral interventions are also recommended. So this is something, you know, we want to screen for and provide support. Support and promoting healthy diet and physical activity for asymptomatic adults. Now, that should be applied on an individual basis. But intensive interventions for overweight and obese patients with CBD risk factors, that is recommended for everybody. So distinction there between asymptomatic, all asymptomatic adults versus adults with CBD risk factors who are overweight and obese. Hormone replacement therapy, as you probably know, is recommended against, and that's for estrogen and progestin, as well as just unopposed estrogen. Osteoporosis screening, so now we're to musculoskeletal disorders. It is recommended, of course, for women 65 and older or younger women with increased risk of fracture, which we can use a risk calculator for that, which I'll show you. Men, there's insufficient evidence. So risk assessment tools, you know, there are several FRACs you may be familiar with. Osteoporosis risk assessment instrument, I don't want to, these are the ones that were named in the USPSTF literature. And this is just what FRACs looks like. So age is important. Sex, obviously, height and weight, and then history of fracture or fracture. If a parent had fractured hip, smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis from medications, alcohol, you know, high alcohol use, and then the actual bone mineral density, which you'd have to screen for, so it's kind of an interesting, that will calculate your risk. But a little circular, you're trying to decide if you screen for it, and you need to put in that bone mineral density. All right, vision and hearing disorders, just putting this in here because, not because they're recommended, but just so that you know. So if it comes up, you can say, well, I didn't really know, but I'm not sure about vision and hearing. So glaucoma is insufficient evidence for asymptomatic, every asymptomatic person that walks in your office, impaired visual acuity in older adults. At the time, there was insufficient evidence. What they do recommend as far as visual screening is looking at assessing three to five-year-olds for amyloid opia, that gets a B, but everything else gets an, or has an I for visual impairment assessment, everybody at a primary care visit. Hearing loss also, it's an I, but it also means that they continue to look at the evidence. COPD screening, spirometry adults, that's recommended against, and again, if you pull up and say, okay, that's like screening everybody, it makes sense that you're, going to get results that might be even harmful if they put people on a diagnostic odyssey or something like that. Sleep apnea, there's insufficient evidence and pelvic exam, there's insufficient evidence. Moving to pregnant women, just again for completeness sake, so bacteria, we do wanna screen women for that associated with the preterm birth and also kidney infection, syphilis screen and hepatitis B, all of these have A for STIs and the chlamydia is basically the same as the general population. Vaginosis, if they're not at high risk for preterm delivery, that actually gets a D, high risk for preterm delivery, there's insufficient evidence. And then herpes as with the general population, you don't screen. And then again, for completeness sake, RH compatibility, you do screen for that and then whether you repeat again is also recommended, which is slightly less evidence. Iron deficiency and anemia, insufficient evidence. Gestational diabetes, after 24 weeks it is recommended but insufficient evidence for before that. And then blood levels in pregnant women, that actually gets a D. And we wanna screen for tobacco and alcohol use in pregnant women just as with the general population and as with the general population, there's insufficient evidence for screening for illicit drug use. And then counseling a pregnant woman, it is recommended to counsel to support breastfeeding. And then for also a perinatal depression assessment and treatment. And these are some risk factors for high risk for perinatal depression. So, history depression, personal history depression or other things that women at high risk for that. Preventive medication in pregnancy, of course, folic acid supplementation, but iron supplementation actually gets an I from USPSTF. And then a low dose aspirin after 12 weeks for women at high risk for preeclampsia gets a B recommendation from USPSTF. Actually, let me just check the chat box for a minute just to make sure I'm not missing. Okay. The thyroid recommendation. So, we're on pregnant women right now and I, so there's a question that says, you mentioned thyroid screening in non-pregnant adults, is there a recommendation for screening for pregnant adults? So, what I can say is that I don't think so, but and I'm covering every recommendation on the books. So, if we don't see it addressed here, we have a little bit more to go with the pregnant women, then I would say that there probably isn't a recommendation on the books for thyroid screening for pregnant women. It's not a very direct answer, but and definitely, you can search and find it if that's not satisfactory, but we're covering every single recommendation, believe me. So, if I haven't covered it, they don't recommend it. And so, here's some risk factors for high risk of preeclampsia. We're gonna give aspirin to prevent, you know, then we need to know what's high risk. So, of course, if you have a history of it and then placental abruption or fetal death, and then some comorbid conditions as well. So, that's gonna be an assessment that you need to make, really dig in and see. Infants, okay. So, we didn't cover anything about thyroid in pregnant women. So, I would say there's not a specific one for pregnant women. Iron deficiency, anemia for infants, actually insufficient evidence for screening all infants for that. What is recommended is obviously medication to prevent gonococcal ophthalmia and torum. So, that's a children. Again, you can see we're getting down to recommendations that you never heard of, and you probably never heard of them because they aren't recommended. So, for speech delay, there's insufficient evidence for that. For, you know, dental caries, insufficient evidence that you screen all children at a primary care visit to look for dental caries. I mean, it's not addressing dentists. So, and then elevated blood and lead levels, increased risk of insufficient evidence, but actually at average risk, they give it a D. But, you know, this is like, again, everybody at potentially increased risk, they're just saying that the evidence is not sufficient to make a blanket recommendation. And then here are some risk factors for increased blood levels. But, you know, if you're not screening for it, then I'm not sure why we put that on there. And then for pregnant women, they have additional risk factors. Screening for autism is there's insufficient evidence and lipid disorders, insufficient evidence. So really, you know, we're not, we don't have a lot of screening for children and obesity, obviously, and depression, but not some of these other really specific things. Tobacco use, this was actually a 2020 recommendation where you do give counseling to prevent tobacco use and, but then the interventions for smoking cessation, there's still insufficient evidence to make a recommendation on that. And then illicit drug use, as we've talked about in other populations as children as well, that's insufficient evidence. Dental caries, oral fluoride supplementation for children over six months, that is recommended. Fluoride varnish at age of tooth eruption is also recommended. So we're not screening for dental caries, but we want to make sure that all kids are getting the fluoride. And adolescence, idiopathic scoliosis, that does not have sufficient evidence. And so let's see, how are we doing, Conway? Okay, we're right about on, because I told people if they didn't want to go through all the recommendations, which we just did, and which you can do, you know, to refresh your memory, going to the website or using that little tool I referred you to, you know, you can really feel like you've gone through it all. So we'll just recap by doing the A and B recommendations and the D recommendations. And then you can kind of know that in between, anything that's not on these lists don't have explicit recommendations. So A and B recommendations, you know, breast cancer, cervical cancer, colorectal cancer, lung cancer, and tobacco cessation. But then remember, you know, we don't want to do genetic screening on everybody for breast cancer. Cervical cancer is just for 21 to 65. And then, you know, pancreatic, ovarian, testicular, and thyroid have D recommendations for screening for those cancers. And prostate, over 70. Okay. Oops. Preventive medications, actually tamoxifen for high risk and low-dose aspirin, 50 to 59. Remember low-dose aspirin, 69 was a C recommendation. So it's just the, I believe it's a B recommendation for 50 to 59. And then D recommendations, you know, beta carotene or vitamin E supplements, they actually increase risk in people, for instance, risk for lung cancer. And then tamoxifen for low risk for breast cancer. Heart disease, what you do want to do is a triple A screen for men who are smokers, do it one time between those ages. High blood pressure, all adults. Abnormal glucose, 40 to 70 overweight or obese. The D recommendations are for women who are non-smokers for triple A. Carotid artery disease, one of these screening. And then screening for CHD in low risk patients with ECG or other modalities. And then preventive medication for heart disease. The low-dose aspirin comes in again. And then the statins. And remember buried in there, if you're assessing someone's 10-year CBD risk, you're going to be looking at their lipids. So not an explicit lipid recommendation, but it's in there. And then we didn't have D recommendations for anything for heart disease, infectious disease, you know, screening particularly for people at high risk. And then hep C, remember that's just changed. It's not just the cohort now, it's 18 to 79. And then let's see, D recommendations. Herpes, genital herpes we don't screen for and asymptomatic bacteria. And then we also, latent TB, made it to USPSTF. HIV, medications for infectious disease, pre-exposure prophylaxis for HIV. And then other screening, other A and B recommendations. Alcohol misuse, diabetes we covered before, osteoporosis for women, obesity and depression. And D recommendations are for COPD. You don't want to be screening everybody for that. And then again, I want to just point you to this little tool that I gave you the link to in a previous slide. You can see where this is a great tool to study from as well. So you can see alcohol misuse, depression, hypertension, you know, all of them are listed here in a just really nice way to visualize the age ranges, et cetera. And the USPSTF has their own, this EPSS you may be familiar with, you may have it on your phone. It's a little, you know, it's not highly specific. So I think you put in smoking status and age and, you know, not too many things. So you'll get a lot of recommendations back, it seems, when you plug an individual patient's characteristics in. But nonetheless, it's a helpful, handy tool, especially when you have it on your phone. Okay, that is it for the review. And again, let me just check my time here. Okay, so the next part is we're going to go through some questions. And well, first let me check chat here. And we've got some troubleshooting. That is going on with the Zoom and my slides. It's probably more of a problem because I was clicking through the recommendations. It won't be as much of a problem, I think, when we have for this next part, where we're going through some questions. So let me just switch my slides. And pull up the question set. And just a word about this. One is that I believe in your book, you may have only eight questions, but I've expanded it. So there are more questions here. Also, I've made some changes. I believe this will not be an issue. But if these questions are not exactly what you have, it's because I was trying to change them to be more of a positive. Some of them in the past have said, what should you not screen for? And we're trying to make it into a more positive, what should you screen for? That shouldn't be an issue. But if it is, I'll tell you what we'll do about it. And then finally, when you answer MOC questions on the platform, they only allow one correct answer. And so for some of these, and I think listed on top of this, if it's in your book, it should say you can have more than one answer. So in putting these questions up on the MOC, there was that problem. So you're going, oh no, there's all these problems. I'm sure that's all you heard. I'm gonna tell you the most important thing is that you will get this slide set, you will get this. And then everything we talk about here is gonna be, you're gonna have the correct answers. So, and explanations, okay? So regardless of what's going on in those other places, this is where you'll get the correct answers and the explanations. And so hopefully, but obviously, if you have any questions, just let me know. I'm just gonna check chat one more time. Okay, since we haven't started, I will answer this question, even though it's not related to USPSTF, but there's a question about recommended database for Biostats questions, you know, and other topics. So I would say, let's talk about Biostats. It's hard to make a Biostats question that's not worthwhile. So I would say that you're okay with using question banks and I'm just gonna say in general, cause I'm not gonna pull out any one. But so I think you're pretty safe in going to a question bank and getting Biostats questions, because they're gonna have to be at a certain level to even be asked as a question. And then I think, you know, you'll be able to get something out of it, some kind of application or, you know, some concept. For other topics, it's less clear or it's more variable. Yeah, I can recommend go get Biostats questions and do all because I just, you know, pretty much anywhere you get them will be fine. Other topics, that's tricky because, you know, sometimes there's a lot of filler questions where they're just like, you know, maybe irrelevant topics or, you know, too easy. I've seen a lot of them be too easy, be quirky. Sometimes I've seen banks have like be full of acronyms, you know, and it's just like the question after question about what does FDA stand for or something like that. So I'm glad you asked specifically about Biostats because I can recommend just doing them wherever you get them, but other ones are trickier. And you need to, you know, there are some standard good banks, but I can't really recommend one in particular, but just be careful, but Biostats, go for it. Okay, so here is a patient scenario and this is a typical, like, you know, how you'll get, in some ways you almost get TMI about these patients, but, and then, you know, just pick out what you need to know to know what kind of screening recommendation to make. So 45 year old man looks like he's not having really any symptoms of, he does take aspirin every day, doesn't smoke, no family history of early heart disease and we're told his cholesterol is normal. And, you know, all this about being at high risk for STIs, no, he's not overweight, not hypertensive, so you've already screened for high blood pressure and he wants to, you know, be up to date on his preventive services. So given that you have all the support services necessary to address any positive findings, which of the following would you recommend to this patient? Well, colorectal screening, that's for 50 and above, so that would not be correct. Depression, we do screen all adults according to USPSTF, so that isn't a correct answer. Diabetes, let's see, he is not overweight, so that would not be correct. And then prostate cancer screening, you know, that is a C recommendation, but he's not of the right age. So, and that's what I'm saying here, colorectal screening, cancer screening, 50, not overweight, not diabetes and not at high risk for prostate cancer. So then that's a C recommendation anyway, so they really can't have you answer something about a C recommendation. For the above patient, is his current aspirin use supported by USPSTF guidelines? Well, he's 45, and we know that that USPSTF guideline is for 50 to 59, so the answer here would be no, and that's the explanation. Let me see if, I'm going to just pay attention to the chat box a little bit. Okay. Okay, good. Actually, sometimes in the chat, we get news that something's been resolved and that's always nice. Okay. 20-year-old woman, and she has no medical illnesses, does not smoke or drink. Her grandfather was a heavy smoker and died of lung cancer, and otherwise no history of cancer. She's sexually active. Which of the following preventive services should be recommended for this patient? So, well, we do know that we're screening everybody for blood pressure, for hypertension. She is younger than 21, so we would not screen for cervical cancer, but we would screen she's sexually active and under age 24, so we would apply chlamydia screening. Remember, there's not a specific recommendation for lipids, but it's buried in that 40 to 70 year old age group for statin use, so she's not in the right age group. So that's what we have in the explanation. So here's a question where we had two answers, so if it shows up on the MOC like the one that you take for credit, it may have been altered so that there's only one answer. Okay, I'm gonna, I think you guys are sharing with each other some board questions, and I see board vitals mentioned. Since you mentioned it, I mean, I agree with the assessment of board vitals. It's just okay. It's not, yeah, I think if you've used that, then you know what I mean by some questions just being kind of filler questions. All right, 66 year old female. She has a 12-year history of hypertension. She's been a pack-a-day smoker for 45 years, but she doesn't drink alcohol. She's 20 years post menopausal and has been keeping up with her half smears, and so while evaluating her hypertension treatment, you want to take advantage of this to look to see what she needs preventive services wise. So which of the following would you recommend for this patient? All right, well, a triple A we know is not recommended for women. It's just male smokers, so that would not be correct. Cervical cancer screening can end at 65 if they've been screened properly before that, and we know that COPD is, that gets a D recommendation in asymptomatic people. So the answer here is osteoporosis screening over 65, or if we had some information if she was younger than 65 that she was at high risk for fracture. Okay, more chat on question banks, and good to know about some of these other options. Thank you for helping each other on that, because that is, you know, where you want to go next, right? It's applying all this to actually answering questions, so good to know that there are some some good banks out there. So here's what I just said, the explanation. All right, a 78 year old man presents because he's concerned about his high blood, his blood pressure, because he, you know, checked it at the drugstore. He was a smoker until 10 years ago, and then, you know, we assess for all these other things. You take his blood pressure, and that's a little high. He looks like he, well, we figured out the BMI from those measurements, and it was 32. So, you know, and then it's like, given that you can support anything that you find positive on a screen, which would you provide for this patient? AAA is on there again, but then this is a smoker, but he's outside the age range, 65-75. Alcohol misuse, we do everybody, so that would be a correct answer. Cardioid artery disease screening, you do not do. That has a D recommendation as well, and then prostate cancer screening. It has a D for over 70, so the answer here is B. And then he has a 70 year old brother that comes in and has quit smoking 10 years ago. He has a little bit of, he has some high blood pressure there, so we've already screened for blood pressure, and his BMI is 26.5. So, which of the following preventive services should be recommended for this patient? Well, he's in, he's a smoker, and he's in the age range for AAA, so that would be an answer here, and I guess I don't have anything else to say about that. Colorectal cancer screening, that's going to be 50 to 75, so that is an answer as well. And then he is overweight, so, and he's 70, so he's just in, barely in that diabetes screening. And then we know that osteoporosis screening is not recommended for men, so this was one of those questions that in past versions it had been which of the following preventive services would not be recommended for this patient, but it makes it a little bit better question if you're going through and saying, I can pick more of these than just one. So, so here's the explanation. Okay, 50 year old man, was seen last five years ago smoking a pack of cigarettes since he was 15, so major pack year history. He has no intention of quitting. He feels fine. He does drink a little bit, and his cholesterol is total is 235. There's no family history of coronary artery disease, and he is, we didn't calculate his BMI, but it looks like it's probably fine. So what preventive services should recommend to this patient? Well, he falls, he's 50, and for lung cancer screening, the age range is 55 to 80, so that would not be recommended. Colonoscopy, just turned 50, so you can offer that, right? Diabetes, they were saying, we didn't calculate the BMI, but we're saying he's not overweight, so that would not be correct. And, you know, just because this is on the books, on the USPSTF books right now, he would be, daily low-dose aspirin could be recommended to this patient, and it has a B recommendation for this type of patient. So he's 50, he's in the 50 to 59, and then remember, we need to kind of have an idea of his CBD risk, his 10-year CBD risk, and he smokes, which really, you know, puts you up there. He's a man, he's 50, and then the cholesterol is high, so, and HDL as well, so that combination is going to make him at high risk. So that's what I'm going through here, as a male smoker with those cholesterol levels, that just buys him higher risk for CBD. And then we talked about the lung cancer screening, he would be when he reaches 55, because even if he quit now, he would have still not quit within, or quit within the last 15 years. I did calculate the BMI here, it's 24.4. So I just want to show you one risk, this is a Framingham risk score, and if I plug in his characteristics, then he gets a 12-year, 10-year risk, or 12% 10-year risk. So, you know, I think the point there would be for a man, you know, with high cholesterol and a smoker, even regardless of his blood pressure, he's going to be in that risk. So if, you know, the, kind of good to play around with these risk calculators so you can see what, what really puts you in that risk, higher risk, so that, you know, if that ends up being something you have to assess, that you can do it pretty quickly. Okay, let me see, I'm gonna check my chat again, just keep up here. When the BMI is not included, should we assume they're fine, or get a calculator? Oh gosh, my best answer, right, would be what do I remember from the exam? Did they, I think typically they do give you the BMI. I think, I think that's a good, I love how you're getting exam strategies though, I think, you know, the statement in the chat of if, do we assume they're fine, you know, I, yeah, if it looks close like that guy, I mean, then you're gonna, I would, that's what I would do, that would be my strategy. Typically on exams, something has to be really clear, but it's, you know, that they're pointing to it, so if they don't give you the BMI, and if they give you the height and weight, you're gonna have a sense of, you know, if they're 400 pounds, but okay, not a very satisfying answer, but a good thing to think about. I think, basically, I do believe they give you the BMI if it's something you need to assess. All right, we have a 59 year old woman, no family history, cardiovascular disease, never smoked, doesn't drink alcohol, last PAP was four years ago with HPV being negative as well, so pretty good blood pressure, but she is overweight, so that's our assessment. She doesn't need cervical cancer screening, right, because if you have PAP and HPV together, that's every five years. Colorectal cancer screening, if she hasn't had it, she does need to have that. Depression is everybody, so that would be recommended, and then intimate partner violence screening, remember that that's for women of childbearing age, so we're assuming that she's out of that range, and so that would not be recommended, so for this particular patient, it would be colorectal cancer and depression. All right, so as I said, depending on, well, I know that you probably only got eight questions in your book, so these are bonus questions, and let me see how much time I have for my bonus questions. Okay, plenty of time. All right, so these are five bonus questions. With all this talk of the board question banks, I just, these aren't that easy to write, so sometimes that's the problem, and write well and not make mistakes, and so, but I ventured out and decided to write some new ones, so a 37-year-old woman, no significant medical history and no problem with substance use. She's, you know, in a formal relationship. I'm not sure what that means. So which of the following was recommended by USPSTF in regard to screening for intimate partner violence in this patient? So just kind of digging down a little bit, I think that's why, you know, we give the dating history, so the point here being that you, we say screen all women of reproductive age, so that's the answer here. You might be, you know, you don't have to assess whether they're in a relationship or not, you know, I mean, that would be part of the screen probably, but you do want to initiate the screen. So, and here's more on screening for intimate partner violence, you know, you have risk factors, but it recommends screening all women of childbearing age for IPV. And then I'm giving you several instruments that can be used to screen. I think a lot of these are, you know, short screens, but they don't recommend any particular screen, they just give you a list of possible screening tools. A 42-year-old woman presents for a wellness visit. She's concerned about cardiovascular disease, no history of smoking, she doesn't have hypercholesterolemia, hypertension, she has no symptoms. Her father died of a heart attack at age 60, so according to USPSTF, which is the following best, assesses the patient's CBD risk. So, you know, this is another way that gets, not such a straightforward way of asking the recommendation, but we can just look at this list and know that cardiac stress test, calcium score, and ankle brachial index are not recommended in the, they don't get an A or B recommendation from the USPSTF. So, well, the serum lipid profile would be the one to pick. So, you know, again, not as straightforward as some of the other questions, but a way that they could ask it and just be solid in knowing that the only one in that list that's recommended is lipids, and that's to assess whether they should be put on a stat, people 40 to 70. And that is what I'm saying. Okay, 40 to 75, yes. And then it recommends against those others. And whole big explanation, but ABI gets an I, and ECG actually gets a D. All right, 75 year old woman presents for a wellness visit. She has well-controlled hypertension, no history of smoking, and then a BMI of 27. So, which of the following interventions should be recommended if she's been found to have a moderate benefit for preventing falls? So, we're saying, you know, we've assessed and, you know, we want to initiate fall prevention. Again, looking at, and my explanations came on before I was ready, but remember that we, vitamin D was recommended against, actually, and then we had multifactorial intervention that was not given. I think there was insufficient evidence for that, but the one thing that is recommended are exercises. So, that would be the answer here. So, exercises for preventing falls are recommended, and none of these other things get, you know, reach an A and B level for fall prevention. And, you know, vitamin D actually has a D recommendation. All right, so we have a 70 year old black man comes in for an annual visit, personal history of diabetes, well-controlled, and remote history of smoking, no family history of prostate cancer. He reports no urinary symptoms. He's never been screened for prostate cancer, but would like to discuss the PSA. According to the USPSTF recommendation regarding screening for prostate cancer, how should he proceed with this patient? Well, this is, you know, where definitely if you talk to urologists and, you know, you get in trouble, right, because you'd really want to make sure there were no symptoms, but the recommendations are for 70 and above that it's a D recommendation for the USPSTF. So, the recommendation would be to not test. Simply going by the letter of USPSTF recommendation, which is D. Okay, and this is my last bonus question. So, let's let's see what we got. 38 year old woman comes in for wellness visit. She quit smoking five years ago after her 15-pack year history. She describes her health as good, reports no symptoms, but her cousin was recently diagnosed with thyroid cancer and she asked if she should be screened for it. So, based on the USPSTF recommendation on screening for thyroid cancer, which is a calling would be advised for the patient. Screen now, wait till she's 40, should not be screened, or she should be screened only if she has a family history of thyroid cancer. And again, my explanation came up and ruined my thunder, but remember thyroid cancer screening is an asymptomatic, which we've established this person is, then she should not be screened. So, knowing A and B, but also knowing D is helpful as well. All right, let me check the chat. Okay, the answers in the book don't correspond to the answers we just did. Okay, so yes, I did try to clear up what was going on with the questions that you got. So, you're right, that actually absolutely could be the case. The two questions that for sure are different are the ones that I used to have, what should they not be screened for, and I've changed those to what they should be screened for. So, look at the question and make sure, you know, the answers, that the correct answers, everything that is in this slide set is correct. And I would just use this because the questions are close enough. There's nothing added that you would get from just looking at the course book questions. So, I would just, bottom line, to make it easy, just go by these. They are similar. They got changed because they had knots in them and I took the knots out, made them positives. And also with the MOC, the ones that you get on the platform, they only allowed for one answer and some of these had multiple answers. So, you know, again, go by this slide set. I'll make sure that it's clear how to get this and then I would just, you know, I believe if you, you know, went through it and said, oh, this one says not and now it's positive, that would all make sense, but, you know, I don't want confusion. So, I think the best way is to just go by these questions and answers. So, yes, you will get this slide set. And, yeah, it's one of those things that, you know, ah, we don't like to make that kind of mistake, but it just happens sometimes. So, sorry about that. We just want to be clear. This is the set that you should look at. Not that the others are wrong, but they're different and it might get confusing. Okay, well, I mean, it's kind of weird not to see your faces and not to just wish you the best, but this is the point where if there's nothing else coming through on the chat, I can give you some, some time back. But, you know, absolutely. Whenever you take the exam, I wish you the best. I'm thankful that you guys were able to help each other with the question bank questions and, you know, just, and we'll be very interested in your feedback, especially this year because this was, you know, all new to us. So, thank you so much and I'm gonna call the staff and let them know that we're done unless there's anything else, but best of luck.

USPSTF

preventive medicine

clinical practice

recertification exams

cancer screenings

cardiovascular disease prevention

infectious disease screening

mental health

substance use interventions

lifestyle counseling

obesity and diabetes screening

Dr. Jill Wellen

preventive services guidelines