PREVENTIVE HEALTH CARE

DANA BARTLETT, RN, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely about toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center.

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in Chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of tPreventive Health Carehe Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

ABSTRACT

Health prevention programs that involve annual physical evaluations and screening is an accepted method to effectively reduce the incidence and negative impact of common diseases. In the United States, research has focused on initiatives to improve community-based programs to increase healthy lifestyles throughout all age groups. New strategies to promote healthier populations must consider prior barriers to preventive healthcare and environmental influences that impact the risk and outcome of a disease state. By developing a solid understanding of health prevention, enhanced strategies to improve health outcomes may be reached by health teams that support healthier populations in U.S. regions and worldwide.

1 NurseCe4Less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.

Continuing Education Credit Designation This educational activity is credited for 5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need Health professionals worldwide need to know the recommended screening tests that may lead to early detection or prevention of medical problems that cause morbidity and mortality if left undiagnosed and untreated. Strategies across geographic and national boundaries are continuously developing with a high focus on social, economic, environmental and health factors that are linked and correlate with patterns of disease. Healthy populations require that health prevention research and policies move beyond a “one size fits all” and that interdisciplinary health teams remain knowledgeable about standard health screening guidelines and prevention throughout the lifespan.

Course Purpose To provide members of the interdisciplinary health team with knowledge of the current recommendations for preventive health screening tests and techniques, as well as of the recommendations lifestyle changes that will promote a healthy population.

Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members.

Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, Noah Carpenter, MD, Kellie Wilson, PharmD, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

2 NurseCe4Less.com Self-Assessment of Knowledge Pre-Test:

1. One of the limitations of screening tests is

a. screening guidelines are often changed and updated. b. these tests rarely provide a high degree of specificity or sensitivity. c. the guidelines differ for children and adults. d. the benefits seldom outweigh the risks.

2. Screening tests must be used with the understanding that

a. they are seldom able to detect diseases. b. most of them are associated with harmful side effects. c. they are not diagnostic. d. they cannot be used for children.

3. Adults should be screened for alcohol misuse

a. unless the patient is pregnant. b. only if they use illicit drugs. c. only if they engage in risky drinking behavior. d. in all cases.

4. Breast cancer is

a. more common in women < 50 years of age. b. the most common cancer in women. c. primarily caused by cigarette smoking. d. not detectable without a biopsy.

5. What is the recommendation of the U.S. Preventive Services Task Force (USPSTF) regarding the use of mammograms to screen for breast cancer in women age 75 or older?

a. They should have a mammogram annually. b. The USPSTF recommends against a mammogram in all cases. c. They should have a biennial mammogram. d. There is no recommendation.

3 NurseCe4Less.com Introduction

Preventative healthcare involves disease identification in specific at-risk populations, and preventive health programs typically include an interdisciplinary health team that is knowledgeable of screening guidelines for acute and chronic health conditions. Health prevention strategies should aim at the delivery of specific interventions and therapies to reduce the chance of developing a chronic disease, and the promotion of successful health outcomes through strong patient engagement. A primary role of all health professionals is to educate patients about health prevention and screening practices, and to raise awareness of how poor health habits can lead to the development of many common, chronic diseases. Good health prevention education promotes awareness in individuals and communities about needed changes to health behaviors to help avoid disease through a lifelong commitment to healthy lifestyle choices.

Screening for Disease Detection and Prevention

Screening tests are done to detect potential health disorders or diseases in a patient who does not have symptoms of a health condition. Screening tests are not considered diagnostic but they are used to identify a group of the population who should be tested to determine the presence or absence of disease. Through early detection, a patient may be made aware of the potential disorder or disease and make lifestyle changes to address it. The patient may also receive regular monitoring and treatment to reduce the risk of disease.1

The goal with screening for disease is to prevent chronic medical problems that often result in increased morbidity and mortality. Poor dietary choices, lack of exercise and obesity has been identified as a major risk factor for the development of multiple health problems, including metabolic disease, heart disease and cancer.1,2 Harmful patterns of food intake, such as those dense in sugar, saturated fat, and poor portion control, and not enough exercise have been studied and reported to have a direct correlation with the incidence of chronic disease.1,2

4 NurseCe4Less.com Annual health screening is an effective method for detecting and preventing poor health habits that cause acute and chronic diseases. Although broad screening guidelines are often a helpful start to discussing personal health choices, in a heterogeneous population the use of screening guidelines are not likely to detect all cases of disease. Screening guidelines are continuously evolving and being updated, so screening on a case-by-case basis is recommended. When appropriate, screening should be accompanied by a physical examination and patient interview with a health professional.

Health screening is most beneficial when a disease is known to be an important public health problem. A screening examination has the best outcome when completed during an early, asymptomatic phase of a disease and after identifying people who may benefit from treatment.1,2 Also, treatment that is readily available and where the benefits of treatment outweigh health risks generally yield improved outcomes. In general, screening tests should be simple to perform, cost-effective, easy to interpret and they must be sensitive and specific to the disease being screened.

Alcohol Use Disorder

The unhealthy use of alcohol by Americans is endemic. The 2015 National Survey on Drug Use and Health noted that 24.9% of Americans reported binge alcohol use in the past month and 6.9% reported heavy drinking in the past month.3 Almost three of every 10 Americans uses alcohol in an unhealthy way, and 14% met the criteria for alcohol use disorder.3 The unhealthy use of alcohol may go unrecognized in the primary care setting and studies have supported screening of the population for unhealthy alcohol use.4 How often and who should be screened for alcohol use depends on several factors, such as age and an individual’s experience with alcohol and/or drug use. Different screening guidelines are available, and the U.S. Preventive Services Task Force (USPSTF) recommendations are to screen for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women.4

5 NurseCe4Less.com The AUDIT and the Audit-C screening tools are accurate and widely accepted and have been used in primary care settings for assessment of alcohol use disorder.5 These screening tools have been shown to be useful in identifying hazardous drinking and if they are used in conjunction with interventions, they can be used to help initiate behavioral changes in patients who engage in harmful or hazardous drinking.5,6

Alcohol Use Disorders Identification Test – AUDIT

In the AUDIT, the answers are scored as follows: 0 for never and 1-4 for ascending frequency of use. Questions 9 and 10 are scored as 0, 2, and 4 for ascending frequency. Health clinicians are guided to ask the following questions when using the AUDIT screening tool.5

AUDIT

1. How often do you have a drink containing alcohol? a. Never b. Monthly or less c. 2-4 times a month d. 2-3 times a week e. 4 or more times a week

2. How many alcoholic drinks do you have on a typical day drinking? a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 to 9 e. 10 or more

3. How often do you have five or more drinks on one occasion? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

4. During the past year, how often have you found that you were unable to stop drinking? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

6 NurseCe4Less.com

5. During the past year, how often have you failed to do what was normally expected of you because of drinking? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

7. During the past year, how often have you had a feeling of guilt or remorse after drinking? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

8. During the past year, have you been unable to remember what happened the night before because you had been drinking? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

9. Have you or someone else been injured as a result of your drinking? a. No b. Yes, but not in the past year c. Yes, during the past year

10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? a. No b. Yes, but not in the past year’ c. Yes, during the past year

A score of ≥8 is associated with harmful or hazardous drinking with use of the AUDIT screening tool. A score of ≥13 in women and ≥15 or more in men is likely to indicate an alcohol use disorder.

7 NurseCe4Less.com Alcohol Use Disorders Identification Test-Consumption - AUDIT-C

The Audit-C asks three questions and for men a score of ≥4 is considered positive. In women, a score of ≥3 or more is considered positive. Generally, the higher the AUDIT-C score the more likely drinking is affecting health and safety. The questions are listed in the table below.5

AUDIT-C

How often did you have a drink containing alcohol in the past year? If the answer is never, score questions 2 and 3 as zero.

a. Never - 0 points b. Monthly or less - 1 point c. 2 to 4 times a month - 2 points d. 3 or 4 times per week - 3 points e. 4 or more times a week - 4 points

How many drinks did you have on a typical day when you were drinking in the past year?

a. 1 or 2 - 0 points b. 3 or 4 - 1 point c. 5 or 6 - 2 points d. 7 to 9 - 3 points e. 10 or more - 4 points

How often did you have 6 or more drinks on one occasion in the past year?

a. Never - 0 points b. Less than monthly - 1 point c. Monthly - 2 points d. Weekly - 3 points e. Daily or almost daily - 4 points

Research: Alcohol Use Prevention and Road Safety

The following case studies were obtained from a PubMed search. The authors focused on a public program that was presented at the World Health Organization (WHO) global conference, reviewing the results of specific prevention models aimed at reducing the incidence of driving while under the

8 NurseCe4Less.com influence of alcohol.7 A descriptive study (2015 to 2018) was done of two Brazilian programs: 1) Traffic Safety Movement and 2) Safe Life Program, both with a goal to reduce road accident deaths. A geographic setting was decided where a reduction of 8.3 deaths per 100,000 inhabitants in 2020 (São Paulo) and in 2016 (Brasília) was planned with an overarching lower incidence rate of harmful use of alcohol.

The WHO has reported that approximately 85% of deaths caused by a noncommunicable disease (NCD) occur either in poor or in developing countries. High risk factors of a NCD involve excessive alcohol consumption, smoking, unbalanced diets and lack of exercise, and a main cause of traffic accidents is due to drinking and driving.

The WHO reported that approximately 1.25 million people every year will die from a road accident, and another 50 million are injured. In young people (between 15 and 29 years of age), traffic accidents comprise a leading cause of death globally. Roadside death is predicted to become the 7th reason for loss of life worldwide by 2030 if the current trends persist. The WHO has promoted worldwide awareness of traffic accident death numbers and the need to improve public awareness to reduce the number of deaths, as well as permanent physical and/or mental injury. The authors stated that the Global Burden of Disease Study (2015) reported “0.32% of all deaths worldwide (around 54.7 million) are caused by disorders due to harmful use of alcohol.”7

The São Paulo Traffic Safety Movement and Safe Life Program of Brasília, presented at the Global Conference, targeted prevention and reduction of traffic-related deaths and the goal of saving lives, also highlighting the positive effects of addressing harmful alcohol use and risks associated with drinking and driving. The Traffic Safety Movement was described as a public policy with “very strong educational leanings.”7 The implementation of this program involved improving public awareness and information. Various sectors of government shared information and worked collaboratively toward the same goals to reach WHO objectives to lower traffic deaths due to alcohol use on a global scale.

9 NurseCe4Less.com The authors reported that the Traffic Safety Movement involved 122 actions that were divided into three types: 1) engineering, 2) education and 3) communication plus control. Under these three types were improvements to the local infrastructure, such as the use of footbridges, traffic lights, bicycle paths, and lowering of the speed limit. Initial results from the program showed that goals were met. In 2016, an estimated 460 lives were saved, representing 6.5% fewer deaths than in 2015. In 2017, a sharp increase of 7,600 casualties were avoided. Projecting toward 2020, without such a prevention program, there would be an estimated doubling of 7,760 accidents.

The WHO recommendations for a worldwide challenge to lower road deaths required a collaborative model based on principles of public and private agency participation. The private sector invested shared knowledge and processes, team driven energy and mobilization to promote the project. Public agents included government departments, law enforcement, and healthcare, for example, with a focus on the prevention of excessive alcohol use associated with driving. Both public and private agencies worked together to educate and offer guidance to the general population. An operational method was developed and adapted to promote consistent results that conformed to the goals of reducing traffic-related deaths. Information was updated monthly, which helped to assess the safety and progress of traffic accident prevention.

A review of study outcomes helped to reassess processes and to further develop an improved system to prevent traffic-related death or irreversible damage as a result of drinking and driving. Civil police reports also were used to determine the number of traffic deaths and cause. Out of the total number of recorded deaths, the majority of victims were men.

The target goal for reducing fatalities was 50% by 2020, which was in keeping with the WHO road safety plan worldwide. The authors stated that the second program in their study, the Safe Life Program, “went even further and set more ambitious goals. The goal of this project was to reduce harmful use of alcohol by 10% by 2020. This challenge meant bringing forward the deadline set by WHO itself for the same rate to be reached around the world.”7

10 NurseCe4Less.com The Safe Life Program focused on three factors: road safety, health and education. Road safety and health showed results, indicating that the model was appropriate. The education factor involved a school and community-based preventive program (implemented in 2019).

The Safe Life Program undertook a comprehensive review of their survey and found that 34% of the fatalities in 2016 were related to alcohol consumption, and the highest percentage of deaths involved individuals between the ages of 30 and 39 (34%), followed by the age ranges of 20 to 29 years and 40 to 49 years, with each age group showing a fatality rate of 21 percent. The authors stated that “all the effort to save lives was worthwhile. In 2017 alone, 133 lives were saved in traffic. This meant 34% fewer deaths (down to 255), compared with the total of 392 people who had lost their lives in traffic accidents in the Federal District in 2016. In other words, in just one year, the program had almost reached the target set for 2020.”7

The tool recommended by the WHO for treating and managing cases was called a brief intervention. The AUDIT screening was used to effectively identify individuals at greater risk. The needs and conditions of each patient was identified.

Professionals worked to identify and quantify the hospitalizations caused by harmful use of alcohol. Studying the information that was obtained allowed the researchers to have a better understanding of the scenario, both in relation to the causes for hospitalization and in relation to the patients’ profiles. Based on the assessment done, men aged 40 to 49 years were defined as the critical profile for the project, and solutions for the problem were discussed. The goal for prevention of alcohol use in the population involved 15 hours of training for 41 doctors and nurses to put protocols into effect. A total of 1,645 people underwent screening and 77 of them were referred for treatment in the geographic areas identified for this study.

The number of hospitalizations relating to harmful use of alcohol were found to be reduced. Within a brief time, consistent progress was identified

11 NurseCe4Less.com through education and proper local governance aimed at lowering alcohol use while driving.

Prevention of Underage Alcohol Use

Prevention of underage alcohol use was a major goal of the project. Between April to May 2018 the use of alcohol among underage students between the ages of 13 to 17 years were studied in both public and private schools. The results from the survey were reviewed to determine proper monitoring and project management.

The Safe Life Program was based on a public-private partnership model, allowing for flexible management and quick results. Leadership concepts were developed, as well as activities and knowledge regarding public policies. The organizational chart and both the format and the governance of the Safe Life Program made it possible to state that the project constituted an innovative public-private partnership to prevent NCDs.

Discussion:7

The authors reported that the results implemented in Brazil helped to reduce the number of traffic-related deaths by 35% (2017). In the same year, 7,600 deaths were avoided in São Paulo. Prevention of traffic related deaths reportedly correlated with changes in people’s habits and actions, notably alcohol use.

These two local projects involving government and civilian participants established by the WHO for prevention and reduction of alcohol related deaths were noteworthy. The authors stated that the “participation and mobilization of private sector efforts have ensured agility in the projects and have stimulated formation and strengthening of a results-driven culture.”7

These programs were described as innovative policies aimed at the prevention of the risk factors involved in NCDs. The project management (shared between the private sector, civil society and government) resulted in

12 NurseCe4Less.com a sustainable public policy model that, according to the authors, can be reproduced in other jurisdictions. Involvement of the road safety agencies working to combat traffic accidents, and the synergy achieved through management committees, have been fundamental to the project’s success.

Both models use and cross-reference information. Data previously scattered across various departments and sectors of government dealing with traffic, healthcare and surveillance were analyzed. Adoption of public policies based on the knowledge and results obtained from the two programs provided solid support for enabling the sustainable development goals, i.e., to ensure healthy lives and promote wellbeing at all ages. Additionally, both programs involving innovative public policies addressed health issues caused by external factors accounting for a disability and loss. Prevention of external causes of deaths and injuries in this research study, i.e., traffic-related violence, strongly correlated with changes in habits and actions, especially excessive consumption of alcohol.

Tobacco Use Disorder

Tobacco use is an enormous public health concern. It is the leading cause of preventable death in the United States.8 The number of Americans who smoke has decreased by more than one-half in the past 50 years, but tobacco and cigarette smoking are still the primary causes of certain cancers, heart disease, common respiratory diseases, and many other acute and chronic pathologies.

It has also been proven that second-hand smoke is a significant cause of serious acute and chronic health problems in children and adults. Secondhand smoke is smoke that is produced from burning tobacco or smoke that is exhaled by someone smoking tobacco. There is no safe level of second- hand smoke. Sidestream smoke is the smoke that emits from the burning end of a cigarette or cigar. It contains higher levels of toxic chemicals and smaller particles that may more easily enter a person’s lungs.

13 NurseCe4Less.com Smoking and tobacco use are still common in the United States. Statistics about smoking and tobacco use are listed in the table below.

Smoking and Tobacco Use in the United States8-10

● In the US 15.8% of males and 12.2% of females aged 18 years or older currently smoke cigarettes every day or some days.

● Cigarette smoking is the leading cause of preventable disease and death in the United States, accounting for more than 480,000 deaths every year, or 1 of every 5 deaths.

● E-cigarette use is less common than cigarette smoking, but approximately 10.8 million Americans use e-cigarettes, and e-cigarettes are the most commonly used nicotine product among American youth.

● Approximately 24% of American Indians/Alaska Natives, 15.2% of White Americans, and 14.9% of Black Americans/non-Hispanics are current smokers.

The adverse effects of smoking are not limited to cigarette smokers. Secondhand smoke is a significant cause of heart disease, lung cancer, and stroke, it can cause exacerbations of asthma, ear infections and respiratory infections in children.11 It is a contributory factor to the development of many other illnesses like diabetes.12 There is no safe level of secondhand smoke and close proximity to secondhand smoke is not necessary for a significant exposure to occur.11 Studies have shown that living in a multi-residential building can expose non-smokers to second-hand smoke.12 The health effects of secondhand smoke include asthma attacks, bronchitis, chronic obstructive pulmonary disease (COPD), ear infections, heart disease, lung cancer, pneumonia, stroke, and sudden infant death syndrome (SIDS).

Smoking Cessation Interventions

There are interventions that can prevent people from smoking and there are behavioral counseling techniques and medications that have been shown to be effective at helping smokers quit. Nonetheless, nicotine, the primary active component of cigarette smoke, can lead to strong cravings in a person

14 NurseCe4Less.com and develop into a tobacco use disorder.13 Since tobacco is legal the prevention of smoking and smoking cessation pose considerable challenges.

Behavioral-based interventions alone or performed in combination with pharmacotherapy can be effective for helping people quit smoking.13 These interventions may include self-help interventions using educational resources like printed material or videos, web-based and text-based resources, and telephone applications and telephone contact counseling, which have all been used with success.13 Acupuncture and hypnosis have obtained mixed reviews in the literature relative to the level of success for smoking cessation that each technique provides.14 The specific intervention chosen will depend on availability, cost, and patient preference.

Pharmacotherapy (with or without behavioral interventions) can significantly influence smoking cessation rates in adults. There are three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation: bupropion, nicotine replacement therapy (NRT), and varenicline. These drugs have been proven to be very effective for smoking cessation.15 Electronic cigarettes have been reported to be an effective smoking cessation intervention, but at this time there is no conclusive evidence that they are effective or safe for this purpose.16

Most adult smokers want to quit and many make the effort, but most fail and at any given time only 1 of every 10 people who try and stop smoking are successful.17 There are many reasons why smokers find it difficult to quit and to maintain abstinence, including side effects of cessation such as cravings and withdrawal, weight gain, mood changes, poor social support, access problems for smoking cessation programs, poor preparation for quitting, and incorrect use of medications. These issues, along with the properties of nicotine that lead to tobacco use disorder, clearly present smokers with a considerable challenge when they try to quit and to cease the smoking habit long-term.

15 NurseCe4Less.com EHR: Screening and Prevention

Improving tobacco use screening and exposure to second-hand smoke has become an area of focus for many electronic health records (EHRs) with smoking prevention and cessation patient teaching tools built into the admission process. Most clinic and hospital clinicians will screen for tobacco use during patient admission, such as asking patients how many years or how much they smoke each day.

A patient who reports a smoking history may be offered educational handouts that promote health prevention and resources for smoking cessation. Several examples of smoking cessation programs include: ● Freedom from Smoking: a program offered by the American Lung Association with an available website that provides a “Get Help” portal: http://www.lung.org/stop-smoking/i-wantto-quit/how-to-quit- smoking.htmlv. ● The American Lung Association: offers a helpline at 1-800-LUNGUSA. ● Smokefree.gov: a website of the United States Department of Health and Human Services. It includes information on healthy habits, how smoking affects one's health, and tips on preparing to quit. It also includes resources specifically for women, teens, and Spanish-speaking patients. ● 1-800-QUIT Now (1-800-784-0669): a toll-free number that connects smokers to Quit For Life program, sponsored by the American Cancer Society.

Research: Smoking Cessation Program

The following case report was obtained through a PubMed search. The authors looked specifically at women who smoked during pregnancy and their motivation to quit or remain abstinent. The smoking cessation approach that was evaluated was the Motivation and Problem Solving (MAPS). MAPS was designed to consider general life stressors and substance use together, and involves a wellness plan utilizing counselling sessions relative to motivation enhancement and skill training strategies.18

16 NurseCe4Less.com The MAPS wellness plan is developed with the client during initial sessions and the plan is adjusted during the course of the patient’s treatment. The goal of MAPS is to keep the patient engaged in treatment and to enhance the patient’s sense of wellbeing, thereby improving the patient’s chance of success at maintaining abstinence from tobacco use. Smoking behavior is evaluated in the context of life stressors that may include lifestyle changes, a mood disorder (anxiety, depression) and interpersonal conflict. MAPS includes motivational interviewing to improve the patient’s level of motivation and commitment to smoking cessation.

MAPS: Smoking Cessation in Pregnant Women

The authors discussed smoking and relapse during pregnancy and at 8 weeks postpartum in the U.S., comparing MAPS with conventional smoking abstinence techniques (42% MAPS versus 28% conventional abstinence methods). MAPS is currently being tried for alcohol use, diet and physical activity. MAPS for smoking cessation includes techniques of “motivation, self- efficacy, coping behaviors, perceived stress and negative effect.”18 These are factors that may influence smoking cessation success.

Intervention strategies involved the patient’s sociocultural background. Within the broad context of smoking behaviors, the researchers considered 1) high-risk situations, such as partner smoking behavior and social norms, 2) outcome expectancies related to smoking cessation, 3) prior smoking cessation trials, 4) and patient attitudes, knowledge and beliefs about smoking.

A patient’s motivation to quit or remain abstinent was studied by looking at the patient’s coping mechanisms, identity, transition to motherhood in the context of smoking, and interactions with a healthcare system. Documentation of the study results focused on these socio-cultural variations.

The authors stated that additional data was obtained “through questionnaires from 143 smoker and ex-smoker pregnant women seeking prenatal care.”18 They also set out to identify differences between smokers

17 NurseCe4Less.com and ex-smokers relative to “education, home smoking rules, number of previous pregnancies and living children, heaviness of smoking, age of smoking onset, number of quit attempts, importance assigned to quitting/staying quit, confidence in quitting/staying quit, partner’s smoking status, dyadic efficacy for smoking cessation, dyadic coping, partner interactions, and relationship quality.”18

The study sought to enroll 120 pregnant women during the first 28 weeks of pregnancy who were self-reported smokers in a smoking cessation program called Quit Together. Women selected were “18 years or older, married or living with a partner, owning a phone, willing to provide phone contact for their partner, and willingness and cognitive ability to understand and sign the informed consent to participate in the trial. Partners are contacted and invited to enroll in the study in the first two weeks after study enrollment.”18 Women participating in the study were asked to complete a self-administered Quit Together questionnaire, which involved questions on a woman’s sociodemographics, reproductive and medical history, tobacco and alcohol use, partner relationship and support for smoking cessation, and on a woman’s emotional health.

Counselors involved in the program had received special training in MI and practiced interventions through role-playing. A program research team was formed to supervise counselors’ activity, and supervisors were trained in clinical psychology with expertise in MI and a MAPS role focused on supervising counseling sessions. Supervisors provided feedback to MAPS counselors either in person or via telecommunications, such as Skype. The supervisor also reported to the research team on interventions and progress of study participants. Monthly meetings were held to review outcomes and the commitment of study participants to quit smoking.

Counselling sessions were telephone-based, led by the counselors, and typically lasted 20–30 minutes. Telephone counseling sessions were offered during pregnancy and 2 months postpartum. Up to 8 sessions were included in a counseling session and were offered by female counselors to pregnant smokers; 6 sessions during pregnancy and 2 after birth. Also, up to 4 sessions

18 NurseCe4Less.com were offered by a male counselor to the woman’s partners; 3 during pregnancy and 1 after birth. Counseling sessions were individually determined based upon the preferences and needs of study participants. Dyadic efficacy enhancing techniques during counseling sessions focused on couple activities or prior successes in the area of behavior change.

The authors discussed in detail the types of protocol used during counseling sessions. They discussed comparisons of intervention outcomes with control groups, and outlined data quality control that was implemented, including accuracy checks, outlier examination, missing data patterns, distributional assumptions, and the intervention/control balance on a variety of characteristics at baseline. Separate analyses were done on women and their partners. This appeared to be a robust study that considered the specific population of women during pregnancy and 2 months postpartum, looking at a variety of health and environmental factors, including the participation and support of partners.

Discussion:

Quit Together utilized MAPS to increase maternal smoking cessation during pregnancy and smoking abstinence after birth. The focus was on smoking abstinence for both women and their partners. The couple approach emphasized the “dyadic efficacy for smoking cessation, the anticipated contribution to the field of research on smoking cessation during and around pregnancy, and the high potential to be adopted in the universal health system…”18 MAPS-trained counselors delivered “proactive phone counseling.”18

Study authors identified limitations of their approach: 1) possible conflicted relationships between women and their partners, 2) potential low compliance and study participant retention, 3) difficulty verifying smoking status during phone meetings, and 4) missed data values for the assessment of intervention efficacy were some of the difficulties identified. Quit Together maternal smoking abstinence considered the “number of quit attempts, cigarettes per day among those who continued smoking, maternal motivation,

19 NurseCe4Less.com self-efficacy, dyadic efficacy for smoking cessation, paternal smoking abstinence, and cigarettes per day among those who smoke.”18

The authors sought to determine the positive effect of MAPS on prenatal and postnatal family smoking, considering the short- and long-term health benefits for the mother, partner and their child. They noted that while the study focused on pregnancy and couple-smoking cessation, the MAPS approach could be a useful intervention for health prevention involving nutrition, physical activity and family health during a woman’s reproductive years.

Lung Cancer

Lung cancer is the most common cause of death from cancer in American adults.19 After skin cancer, it is the second most common cancer.20 The American Cancer Society estimates that in 2019 there will 228,150 new cases of lung cancer and 142,670 deaths from lung cancer.20 Cigarette smoking is believed to cause 85% to 90% of all lung cancer.19

Targeted screening in high-risk populations has been shown to increase the incidence of detection of lung cancer and to reduce the mortality rate.19 The USPSTF and professional organizations like the American Cancer Society and the American Society of Clinical Oncology recommend that asymptomatic adults aged 55 to 80 years who have a 30 pack-year history of smoking and currently smoke or have quit smoking within the past 15 years should have annual screening with low dose computed tomography.19,20 The 2014 USPSTF Clinical Guidelines stated: “Annual screening for lung cancer with low-dose computed tomography is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking.”21

Research: National Lung Screening Trials

The following study reported on lung cancer screening. The authors reported on the National Lung Screening Trials (NLST), which focused on the

20 NurseCe4Less.com effectiveness of low dose chest computed tomography (LDCT) to detect lung cancer in the early stages and to prevent disease mortality.22 The authors noted that the utilization of LDCT continues to be low.

The primary purpose of the study was to understand the attitudes and beliefs among primary care clinicians regarding LDCT lung cancer screening.22 Additionally, the study, conducted at a Veteran’s Administration (VA) health facility assessed clinician knowledge gaps to identify existing opportunities to reinforce accessible and evidence-based lung cancer screening.

Primary care clinicians were interviewed (using a 20-item closed and open-ended interview) that included 33 physicians and 5 nurse practitioners/physician assistants. Half of clinicians considered LDCT as “very effective”, and 47.4% of clinicians reported often recommending LDCT as a lung cancer screening tool. Most clinicians referred patients for LDCT based on their smoking history, including factors of patient health status, sex, family history, past medical history, and occupational exposures. Clinician knowledgeable about the use of LDCT as a lung screening tool was generally good, however the effectiveness LDCT for lung cancer early detection was not as well understood. Some patient referrals for LDCT was found to not be based on evidence-based guidelines.

The authors reported that in 2013, the USPSTF had issued a Grade B recommendation for annual lung cancer screening among asymptomatic adults (55 to 80 years of age) with a 30 pack-year smoking history, currently smoked, or had quit smoking for 15 years. Lung cancer mortality among participants screened with LDCT was compared to those screened with chest radiographs (CXR), and there was 20.0% decreased mortality from lung cancer in those screened with LDCT as compared with those screened with CXR. Other studies exploring physician attitudes and experiences with LDCT screening have been previously done, however the authors suggested that their study (conducted at a single VA facility) highlighted that nearly 60% of study participants were aware of USPSTF guidelines, yet unable to recall eligibility criteria and that clinicians held variable interest in completing lung cancer screening.

21 NurseCe4Less.com The topic of lung cancer screening in VA and other community hospitals raised in prior studies showed that barriers impacting effective lung cancer screening included “time constraints, competing demands, lack of access to decision aids and patient characteristics.”22 In some studies, not all clinicians were aware of the USPSTF lung cancer screening guidelines, and few felt knowledgeable enough to recommend lung cancer screening to patients. Also, many were reportedly skeptical about the efficacy of that screening test and viewed cost (uninsured patients) and geographic locations (rural) as barriers for considering lung cancer screening.

VA-based pulmonologists have reported being familiar with national lung cancer screening guidelines, however held varied perceptions, which led to both over-screening and under-screening of patients at risk for lung cancer. One study (2016) reported that although family physicians discussed LDCT with high-risk patients, they did so inconsistently and patient referrals for LDCT were low. Another study (2016) comparing patient-provider discussions about lung cancer screening between 2012 and 2014, on or about the time of the USPSTF guidelines, showed that discussions between the provider and patient on lung cancer screening had been more prevalent prior to release of the lung cancer screening guidelines (17% in 2012 and 10% in 2014). Of significance, patient-provider discussions on lung cancer screening had been low during both periods.

Identifying Patients for LDCT Screening

Smoking status is well understood to be a key factor for referring a patient to be screened for lung cancer. Secondary factors for making patient referrals for lung cancer screening included family history, prior history of cancer, and occupational exposures. Additional factors identified by some clinicians for making referrals for lung cancer screening included sex and a patient’s overall health status. Some study respondents stated they were typically less enthusiastic about referring any patients for lung cancer screening.

22 NurseCe4Less.com Public Health Significance of Lung Cancer Screening

The authors referred to the report of the National Lung Screening trial, which suggested that “the use of low-dose chest CT scans, among high-risk smokers resulted in a 15–20% reduction in lung cancer deaths relative to screening with chest x-rays. This reduction in the lung cancer death rate is equivalent to three fewer deaths per thousand people screened over the 6.5 years of follow-up (17.6 lung cancer deaths/1000 versus 20.7 lung cancer deaths/1000).”22 Physicians were asked to comment on the clinical and public health significance of these findings.

Many respondents believed the public health significance of the current national reports had important implications for their practice. There were contrasting views on how many lives could be saved through the use of LDCT screening, and some felt the evidence supporting LDCT did not outweigh the cost risk. There were questions about third party payer coverage and the identity of national organizations supporting the current screening guidelines. Also, some respondents suggested that the rates of the long term effectiveness of LDCT were needed.

Discussion:

The authors raised that the USPSTF guidelines for lung cancer screening (grade B) allowed for approximately 10.5 million people in the United States to be eligible for lung cancer screening “with the potential to prevent 18,000 lung cancer deaths.”22 They reported that “nearly 82% of survey respondents in this study noted that recommendations from the USPSTF were relevant to their medical practice. The USPSTF also reinforced that LDCT screening recommendations should be used in addition to, rather than as a replacement for, smoking cessation interventions. A grade B recommendation means that the USPSTF recommends the service based on a high certainty that the net benefit is moderate, or a moderate certainty that the net benefit is moderate to substantial; clinicians should offer this service.”22 Further, electronic medical systems had potential to assure that guideline eligible patients (age

23 NurseCe4Less.com 55–79, 30+ pack-year history, current smokers or quit <15 years) would be referred for LDCT screening.

The authors found that while primary care clinicians endorse the effectiveness of LDCT for lung cancer early detection, they are recommending LDCT to their patients less frequently. The authors also listed national organizations - the American Cancer Society, American Association for Thoracic Surgery, American College of Chest Physicians and the National Comprehensive Cancer Network - that endorsed lung cancer screening. However, the American Academy of Family Physicians found the data did not support recommending for or against LDCT screening for lung cancer. The Centers for Medicare and Medicaid Services and private insurers (2015) began to offer coverage for LDCT lung cancer screening as a health preventive service based on patient eligibility criteria in keeping with the USPSTF and other organizations. They raised a need for the ongoing promotion of education on LDCT lung cancer screening, specifically for primary care clinicians who reported being left with unanswered questions.

Breast Cancer

Breast cancer is the most common cancer in women.23 Every year in the United States approximately 245,000 women are diagnosed as having breast cancer and approximately 41,000 will die from the disease.23 Breast cancer also occurs in men, but it is much less common; approximately 2200 men are diagnosed and approximately 460 die each year from breast cancer.23

Risk factors for breast cancer may include age >50 years, early menarche, late menopause, hormone replacement therapy, family history of breast cancer, obesity, and excessive alcohol use.24,25 Screening for breast cancer includes screening for neoplasms and screening for genetic susceptibility to breast cancer.

Breast cancer screening has been shown to increase the rate of detection and to significantly reduce mortality. There is no evidence for a

24 NurseCe4Less.com benefit of breast self-examination or physical examination of the breasts by a practitioner.21-26

American Cancer Society Screening Recommendations

Recommendations by the American Cancer Society breast cancer screening program for women who are at average risk for breast cancer include those highlighted here.27

● Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (X-rays of the breast) if they wish to do so. ● Women age 45 to 54 should get mammograms every year. ● Women 55 and older should switch to mammograms every 2 years or can continue yearly screening. ● Screening should continue if a woman is in good health and is expected to live 10 years or longer. ● All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. They also should know how their breasts normally look and feel and report any breast changes to a healthcare provider right away.

USPSTF Screening Recommendations

The USPSTF recommendations for breast cancer screening suggest that women aged 40-49 should be considered for a biennial mammogram.28 The decision to do a mammogram should be made on an individual basis, depending on the woman’s circumstances and values.

Women aged 50-74 should have a mammogram every two years. The USPSTF does not recommend the use of mammograms in women age 75 or older. The USPSTF recommendations apply to women aged ≥40 years that are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women.28

25 NurseCe4Less.com There is convincing evidence that using mammography to screen for breast cancer reduces overall mortality from breast cancer. This reduction in risk becomes increased for women aged 50 to 74 years. Harms of screening include psychological effect, additional medical visits, imaging and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure.28 The level of harm appears to be moderate for each age group.

Breast Cancer Genetic Testing Recommendations

The American Society of Breast Surgeons recommendations for genetic testing for breast cancer suggest that all patients who have a personal history of breast cancer should be offered genetic testing.29 Genetic testing for breast cancer should be available to patients who do not have a personal history of breast cancer if they met testing guidelines of the National Comprehensive Cancer Network.

The USPSTF position on genetic screening for breast cancer suggests that primary care clinicians should assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations.30 If the patient has a positive result on the risk assessment, she should receive genetic counseling and if needed, genetic testing. Genetic assessment, counseling, and testing should not be done unless the risk factors are present.30

Research: Nutrition and Breast Cancer Prevention

The following case report was obtained from a PubMed search that focused on nutrition in the prevention of breast cancer. The authors stated that as early as the 1990s, a diet of cruciferous vegetables (e.g., cabbage, broccoli) was reported to protect against various types of cancer.31 Their study specifically looked at how consumption of cruciferous vegetables impacted breast cancer risk, which included “a hospital-based case-control study in 1491 patients with breast cancer and 1482 controls.”31 The study was

26 NurseCe4Less.com conducted between 1982 and 1998 and study participants were mostly Caucasian (99%) women between the ages of 21 to 97 years. The study reportedly adjusted for age, year of admission, family income, body mass index, cigarette smoking, age at menarche, parity, age at first birth, family history of breast cancer, hormone replacement therapy, and total meat intake. Study participants self-reported on menopausal status.

Cruciferous vegetables were identified as having cancer preventive properties that may prevent or inhibit breast cancer development through “modulating activity of phase I and phase II enzymes, inhibiting cell proliferation, regulating the expression of estrogen receptor, altering the metabolism of estrogen, or suppressing cyclooxygenase 2 (COX-2).”31 While there is strong evidence from cell and animal studies supporting the preventive effect of cruciferous vegetable consumption against breast cancer, studies within the general population typically show differing outcomes. For example, one case-control study may show a correlation between cruciferous vegetable intake among premenopausal women only, yet another report may indicate reduced risk only among postmenopausal women.

Worldwide studies also generate mixed reports, such as those focused in Asian populations. The authors suggested that part of the reason for study outcome inconsistencies may include the fact that cruciferous vegetables may not have been studied comprehensively and that there have been changing dietary patterns in worldwide populations relative to fruit and vegetable consumption, altering risk-association over time in such studies. Nonetheless, cruciferous vegetable consumption in breast cancer cases and controls were studied by the authors on a large scale with the goal to validate existing studies examining the effects of cruciferous vegetable intake on breast cancer risk. Raw versus cooked vegetable consumption were also compared in commonly consumed cruciferous vegetables such as broccoli, cabbage, cauliflower, brussels sprouts, kale, turnip, collard, and mustard greens, and were documented separately. Total meat intake was used as a potential confounding factor in overall diet composition (pork chops, hotdogs, canned ham, ham, salami, liver, pork sausage, beef, bacon, chicken, and hamburger).

27 NurseCe4Less.com The consumption of cruciferous vegetables were studied with consumption pattern changes that, over time relative to pre- and post- menopausal women, were found to be influenced by the aforementioned factors. The authors stated that “when individual cruciferous vegetables were examined, only broccoli and cauliflower intakes showed a significant inverse association with breast cancer risk; and consistently, the associations were observed only in premenopausal women and appeared to be stronger with raw vegetable consumption than with their cooked vegetable counterparts.”31 The consumption of cruciferous vegetables increased over time in both cases and controls, although the increase in cases was slower and smaller than in controls.

Discussion:31

The study suggested that cruciferous vegetable intake, especially broccoli and cauliflower, was associated with a reduced breast cancer risk. The authors also raised the fact that few previous studies investigated raw compared with cooked cruciferous vegetable intake in relation to breast cancer risk. They noted that eating or cooking styles vary across different populations, and studied the three most commonly consumed cruciferous vegetables in the United States — broccoli, cauliflower, and cabbage — in raw and cooked forms. Both broccoli and cauliflower “showed stronger inverse associations with breast cancer risk when consumed raw than when consumed cooked.”31 Further, it was reported that “the inverse association of cruciferous vegetable consumption with breast cancer risk seems to be more apparent in premenopausal women.”31

There is an association between cruciferous vegetables and changes in estrogen metabolism, which the authors suggested influences cancer risk in pre- and postmenopausal women, albeit, other preventive factors could apply. The encouragement of vegetable consumption and anticipated positive outcomes from changes in dietary patterns is anticipated to correspond with positive health benefits and the reduction of disease risk in the general public.

28 NurseCe4Less.com Cervical Cancer

The American Cancer Society has estimated there will be 13,170 new cases of cervical cancer detected and 4250 women who will die of cervical cancer in the United States in 2019.32 Risk factors for cervical cancer may include HPV infection, smoking, a high number of sex partners, early age at first intercourse, having three or more children, and long-term use of oral contraceptives.32,33 Cervical cancer screening decreases the incidence and mortality of cervical cancer.34,35

The recommendations for cervical cancer screening are essentially universal, although there are some variations. A Pap test should be done every three years for women 21 and older.35,36 Women should be screened even if they are sexually abstinent, and screening at a younger age is not recommended; however, screening should be considered if the patient is less than 21 and is immunocompromised or had an abnormal Pap test.35,36 The decision about when, how, and how often to screen for cervical cancer should be made on a case by case basis.

Starting at age 30, women should be offered Pap testing and testing for HPV infection. If this approach is used and the tests are normal, the screening interval can be extended to every five years.37 It is not known when screening should be stopped, but women who are 65 and older and have had normal tests in the previous 10 years should be offered the choice to stop screening. The USPSTF recommendations for cervical cancer screening are noted as follows:37 ● Women aged 21-29: Screen three years with a Pap smear. ● Women aged 30-65: Screen every three years with a Pap smear, every five years with HPV testing alone, or every five years with a Pap smear and HPV testing or a Pap smear and HPV testing. ● Women < 21 years: Do not screen. ● Women older than age 65 who have had adequate prior screening and are not high risk: Do not screen. ● Women after hysterectomy with removal of the cervix and with no history of high-grade pre-cancer or cervical cancer: Do not screen.

29 NurseCe4Less.com Research: Cervical Cancer Screening and HPV Vaccination

The following study was obtained from a PubMed search and the authors reported that a majority of cervical cancer cases occur in low-and lower- middle-income countries (LLMICs) due to multiple factors, including a lack of cervical cancer screening programs, lack of treatment of cervical lesions identified by screening, human papillomavirus (HPV) vaccine not being provided due to vaccine cost, barriers of healthcare to administer the HPV vaccine, and perceptions of the HPV vaccine as a low priority.38

The HPV-16 and 18 are reportedly the cause of 70% of cervical cancer; and, along with the HPV types 31/33/45/52/58, these viruses are the cause of approximately 90% of cervical cancers worldwide. Although the prevalence of HPV types varies geographically, the authors reported a higher prevalence of HPV52 and 58 in East Asia and North America and HPV31, 33 and 45 tend to be more common in Europe.

First Generation Vaccines

The authors reported the following facts relative to first generation vaccines:38 ● 2vHPV activates innate immunity through Toll-like receptor 4. ● Both 4vHPV and 2vHPV have greater than 90% efficacy against cervical intraepithelial neoplasia grade 1–3, adenocarcinoma in situ, and invasive cervical carcinoma due to HPV16/18 in women aged 15–26 years. ● Both vaccines might provide protection against other HPV-related cancers such as vulvar, vaginal, and anal cancer ● Only 4vHPV is licensed against HPV-related cancers and against HPV6- and HPV11-related genital warts. ● Neutralizing antibodies are believed to be the primary mediator of protection for HPV vaccines, however the actual level required for protection remains unknown. ● Seroconversion occurs in 99–100% vaccinated persons in randomized double-blind placebo-controlled trials.

30 NurseCe4Less.com ● Antibody responses (following vaccination peak at 7 months, one month following dose 3) at titers between 10- and 100-fold higher than the levels found following natural infection, and may persist > 10 years several-fold higher than natural infection.

The high vaccine efficacy has led to the use of HPV vaccine in young adolescents prior to becoming sexually active. Studies evaluating 4vHPV or 2vHPV in adolescent girls/boys and in women following a three-dose schedule resulted in “at least one- to two-fold higher type-specific antibodies in the younger age group.”F38 Two doses given to adolescents six months apart reportedly showed antibody responses non-inferior to women who were given the standard three-dose schedule. In 2014, the WHO revised its recommendation to include a two-dose HPV vaccine schedule for girls aged < 15 years, provided the interval between each dose is at least six months.

Vaccine Efficacy

The use of 9vHPV reportedly protects against the nine most common cancer-causing HPV types and against the majority of genital warts. This vaccine was licensed in the last five years therefore study outcomes based on worldwide population use is pending. There is current evidence however that the 9vHPV is safe and is “highly efficacious against HPV infection and anogenital precancer lesions in both men and women.”38

The authors reported that 9vHPV is “shown to be safe and generally well tolerated in participants aged 9–26 years, with a similar adverse event profile to that of 4vHPV (which is used in many countries globally as part of national immunization programs).”38 Common adverse events were reported as injection-site pain, swelling, and redness, and were more common for 9vHPV than 4vHPV with increasing doses. Most adverse events were identified as mild to moderate. Vaccine-related serious adverse events were reported as rare and possibly due to preexisting medical conditions.

31 NurseCe4Less.com Future Directions of HPV Vaccination

Future directions of HPV vaccination was identified by the authors. The 9vHPV has been licensed in a number of world regions including the United States and is being used in national immunization programs either school- based or through primary care. The authors also stated that the impact of 9vHPV and the HPV prevalence in some countries has led to changes in screening guidelines that replace Pap screening because of the effects of HPV vaccination on Pap abnormalities.

Australia has been identified as the first country to eliminate cervical cancer by 2028. The elimination of cervical cancer is defined as “four new cases per 100,000 women each year.”38 A predicted reduction of cervical cancer to less than one case per 100,000 women by 2066 was also mentioned. The authors also identified that the national HPV vaccine schedule in Quebec, Canada consists of one dose of 9vHPV followed by a dose of 2vHPV six months later for boys and girls at age nine. This involves a mixed schedule with potential cost-savings based on the lower cost for 2vHPV.

Discussion:38

The HPV vaccines are considered safe and have similar safety profiles between the mixed vaccine schedule and the standard schedule worldwide. The clinical significance remains unknown and long-term follow up is needed relative to the prevalence of genital warts and other HPV-related diseases.

The use of 9vHPV in LLMICs is not expected due to its high cost as compared to 2vHPV or 4vHPV vaccines. The efficacy and immunogenicity of a single-dose HPV vaccine (9vHPV and 2vHPV) is being studied and may change how vaccines are made available in LLMICs. Single-dose schedules or mixed HPV vaccine schedules will be important considerations in how the HPV vaccine is implemented worldwide.

32 NurseCe4Less.com Prostate Cancer

Prostate cancer is the most commonly diagnosed cancer in men.39 One in nine men will develop prostate cancer during his lifetime, and the American Cancer Society estimates that in the United States in 2019, 174,560 new cases of prostate cancer will be diagnosed and there will 31,260 deaths from prostate cancer.32 Risk factors for prostate cancer may include having a first- degree relative who had prostate cancer, African American ethnicity, and age > 65 years.40,41

The need for and the usefulness of screening for prostate cancer is a complex and controversial topic so that a full discussion of the issue is beyond the scope of this section. Prostate cancer is common but death from this disease is relatively uncommon. The five-year survival rate for localized and regional prostate cancer is 100%.42 The life-time risk of dying of prostate cancer is 2.5 percent.43

Screening for prostate cancer does not have a large positive effect on reducing mortality from the disease.44 Many of the cancers detected by prostate cancer screening do not require treatment and aggressive treatment that may be initiated based on a prostate screening result can have many adverse effects.45,46

Although there is no standard approach to screening for prostate cancer, there are recommendations from authoritative sources and the USPSTF recently (2018) published guidelines.45 Screening for prostate cancer is not recommended for men < age 50 unless they have risk factors for prostate cancer. Those at higher risk of prostate cancer include African American ethnicity, men who have specific BRCA genetic mutation, and men who have a family history of prostate cancer.44

The preferred screening test is PSA measurement done every two years.44 Digital rectal examination is not recommended.44 The USPSTF recommends that men 55 to 69 should be screened for prostate cancer only after carefully considering the risks and benefits.45,46

33 NurseCe4Less.com Research: Prostate Cancer Risk and Dairy Intake

The following study was obtained through a PubMed search where the authors discussed the correlation between dairy consumption and prostate cancer.47 While dairy products are generally known to contain many essential nutrients, some dairy are also potentially high in saturated fatty acid that is associated with chronic diseases, including cancer. The authors suggested that “it is important to investigate dairy products separately by fat content and fermentation method.”47

The authors raised a unique and controversial area of research in the field of health prevention related to the effect of dairy intake on prostate cancer risk. They stated that the “Dietary Guidelines for Americans 2015– 2020 recommends lower fat options of dairy products, although positive associations of prostate cancer risk with low-fat milk intake and an inverse association with whole milk consumption have been reported in the most recent meta-analysis of prospective studies, the strongest study design in observational studies. This meta-analysis is included as the latest summary of dairy products and prostate cancer risk in the latest World Cancer Research Fund and American Institute for Cancer Research expert report.”47 There was a significant inverse association between whole milk and prostate cancer risk; total dairy product, total milk, and total cheese intakes were significantly positively associated with prostate cancer risk but yogurt, skim milk, ice cream, and butter had no significant associations with prostate cancer risk.

The authors suggested the potential effects of dairy on carcinogenesis may differ by product. For example, “lactose enhances calcium absorption, which affects calcium and vitamin D levels, both of which may affect prostate cancer risk. Animal fat is hypothesized to promote prostate carcinogenesis by increasing testosterone levels, consequently activating pro-oncogenes and deactivating tumor suppressor genes.”47 The proliferation of cancer cells through milk intake is believed to be a result of elevated insulin-like growth factor-I (IGF-1) that is linked to an increased risk of prostate cancer. One meta-analysis of 12 prospective studies showed there was a 38% increase in prostate cancer risk with high concentrations of IGF-1.

34 NurseCe4Less.com Dairy product intakes as well as other food item and nutrient intakes, were evaluated by the study’s authors through the use of a 36-page diet health questionnaire (DHQ), noting the participants’ usual consumption frequency and portion size of 124 food and beverage items over the past 12 months. The DHQ included a total of 57 questions related to dairy product intake. This included questions on the frequency, portion size, fat content, and/or how dairy was consumed, i.e., with or without other food. Milk, cream, sour cream, cream cheese, cottage cheese, cheese sauce, other cheeses, yogurt, frozen yogurt, ice cream, and butter consumption were identified.

Food items were broken down by fat content into regular- or low-fat products. Milk was broken down to whole milk, 2%-fat milk, 1%-fat milk, skim, nonfat, or 0.5%-fat milk, and/or half and half. Food consumption frequency ranged from “never” to “two or more times per day” and beverage consumption frequency ranged from “six or more times per day.” Three categories of portion size were provided.

Prostate cancer screenings were conducted and those with positive screening results (a PSA test result > 4.0 ng/mL or suspicious DRE result) were referred to primary healthcare physicians for further diagnostic examinations. Prostate cancer incidence and deaths from any cause over 13 follow up years were ascertained through a patient questionnaire and verified by the medical records. The authors reported that prostate cancer diagnoses included clinical staging and Gleason score. Prostate cancer was classified as advanced or non-advanced.

The authors reported 4134 confirmed prostate cancer cases out of the 49,472 men included in the study between 1998 and 2013. Participants were classified into quartiles of total dairy product consumption, the fourth quartile (> 194.7 g/1000 kcal) had the most prostate cancer cases, although this was minor. Additionally, it was found that study participants in the highest quartile of total dairy intake were slightly older, non-Hispanic white, had a personal history of diabetes, never or former alcohol drinkers, and never smoked, compared with those in the lowest quartile. In the higher quartiles, the

35 NurseCe4Less.com maximum PSA levels tended to be higher but no clear pattern in prostate cancer screening frequency emerged based on PSA and DRE.

Across quartiles of total dairy consumption, there was no clear pattern of educational level, family history of cancer, body mass index (BMI), ibuprofen use, and physical activity engagement. Men who were at the higher quartiles also reported lower total energy intake than those in the lower quartiles. The authors also reported the following findings:47 ● Total dairy products had no statistically significant association with prostate cancer risk. ● There were no associations with low-fat dairy products or regular-fat dairy products. ● Grouping dairy products by fermentation methods, neither fermented dairy products nor non-fermented dairy products had a statistically significant association with prostate cancer risk. ● Milk intake variables, i.e., fat content, were not associated with a risk of prostate cancer. ● Association of 2%-fat milk intake by advanced status of prostate cancer did not differ. The rest of the dairy variables were not associated with risk of advanced or non-advanced prostate cancer.

When the authors stratified prostate cancer cases by clinical stage or Gleason scores alone, no statistically significant associations of dairy product intake variables with prostate cancer risk was found, except for regular-fat dairy products and late-stage prostate cancer. Notably, regular-fat dairy products had a significant positive association with late-stage prostate cancer but not with early-stage prostate cancer; and no statistically significant association of low-fat dairy product intake with either early-stage or late-stage prostate cancer was found.

Discussion47

The authors reported that the intakes of total dairy products or dairy products separately by fermentation methods were not statistically significantly associated with a risk of prostate cancer in their study cohort.

36 NurseCe4Less.com They stated that “When we stratified prostate cancer by severity, our study found a statistically significant positive association between 2%-fat milk consumption and risk of advanced prostate cancer; however, the associations did not differ between advanced and non-advanced prostate cancer. Similarly, the consumption of regular-fat dairy products was positively associated with risk of late-stage prostate cancer; however, the associations did not differ by clinical stage. There were no statistically significant associations of other dairy product intake variables with prostate cancer risk stratified by advanced status, clinical stage, or Gleason scores.”47

A statistically significant positive association between total dairy product consumption and prostate cancer risk was reported based on 15 previous prospective studies, however, at small risk. The authors also reported a statistically significant positive association between total dairy product intake and prostate cancer risk in three previous studies, which were listed as the 1) Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) study, 2) National Health and Nutrition Examination Survey (NHANES) Epidemiologic Follow-up Study cohort, and 3) the National Institute of Health-American Association of Retired Persons (NIH-AARP) Diet and Health study.

The authors observed a “statistically significant positive association of regular-fat dairy intake with late stage, but not a high-Gleason score, both of which are considered advanced prostate cancer.” They stated that while their findings aligned with a few prior studies, they could not exclude the possibility of chance findings and that future studies were needed to “stratify prostate cancer by each of the prostate cancer characteristics to further elucidate etiology of dietary factors in prostate cancer.”47 Future studies correlating milk or dairy intake with prostate cancer risk could extend to other ethnic groups. Findings of a small positive correlation between 2%-fat milk intake and the risk of advanced prostate cancer and between regular-fat dairy product intake and the risk for late-stage prostate cancer, would need to be confirmed in other study populations.

37 NurseCe4Less.com Skin Cancer

Skin cancer is divided into two categories: non-melanoma and melanoma. Basal cell carcinoma and squamous cell carcinoma are the two non-melanoma skin cancers. These cancers are not usually reported to cancer registries, so their true incidence and prevalence are not known:48,49 They account for approximately 97% of all skin cancers but the incidences of morbidity and mortality from these neoplasms are very small.50

Malignant melanoma is much less common than non-melanoma skin cancers but it is much more serious. The incidence of malignant melanoma has been increasing for years. Malignant melanoma can metastasize to any organ but in most cases it will metastasize to the skin and lymph nodes.51,52 The five-year survival rate for melanoma skin cancer, localized, regional, and distant (metastasized) is 98%, 64%, and 23%, respectively.53

Risk factors for nonmelanoma and melanoma skin cancer include Caucasian ethnicity, fair skin, the presence of multiple nevi, and family history of melanoma.51,52 There does not seem to be any benefit from universal screening for skin cancer: the USPSTF concluded that “... the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults.”49,50

Clinicians and patients should remember that skin lesions should be considered potentially malignant if they are rapidly changing, and if there are changes in the size of a skin lesion or if its border is asymmetric, if it is > 6m, or it is multi-colored, these features may indicate that the lesion is malignant; these are called the ABCDE criteria, asymmetry, border, color, diameter, evolution.51

Research: Skin Cancer Screening and Patient Adherence

Despite the highly preventable nature of skin cancer, it remains the most commonly diagnosed form of cancer in the United States. Recommendations for a complete skin cancer prevention regimen include

38 NurseCe4Less.com engaging in photoprotection (e.g., sunscreen use), avoiding skin cancer risk behaviors (e.g., tanning), and receiving total body skin exams from a health care provider. The following study was obtained from a PubMed search and the authors reported engagement in skin cancer preventive behaviors among study participants in a high-risk area with a goal of determining the need for increased health education on skin cancer prevention.54

What the authors discovered was that study participants showed suboptimal avoidance of skin cancer risk behaviors. Their study showed that “Over half of participants (52%) reported four or more blistering sunburns before age 20, and 46% reported indoor tanning at least one during their lifetime.”54 Complete skin cancer prevention education was needed to improve photoprotection behaviors and to avoid skin cancer risk behaviors as well as morbidity and mortality risk due to skin cancer.

As the most commonly diagnosed cancer in the United States, the authors noted that certain geographic regions in the U.S., have higher rates of melanoma, which is the deadliest form of skin cancer. Currently, Utah is the U.S., region with the highest incidence rate of melanoma (incidence of 32.8 per 100,000 compared to the national average of 19.9). The recommendations for a comprehensive skin cancer prevention regimen according to the American Academy of Dermatology, 2015, Skin Cancer Foundation, 2015b, and the World Health Organization, 2015 were identified by the authors as: 1) Engaging in photoprotective behaviors (using sunscreen, seeking shade, wearing protective clothing), 2) Avoiding skin cancer risk behaviors (sunburns, tanning), and 3) Receiving total body skin exams (TBSEs).

Although TBSEs were not recommended for the total population according to the U.S. Preventive Task Force (2015), the authors noted that studies determined the early detection of melanoma from TBSEs could result in early detection and effective treatment. Skin cancer prevention behaviors “are modifiable and could be amenable to health education strategies, whereas certain risk factors for skin cancer (e.g., fair skin, presence of moles, family history of skin cancer) are not modifiable.”54 The authors reported that

39 NurseCe4Less.com the evidence suggests that public adherence to skin cancer prevention and screening behaviors is poor in the U.S. population. Therefore, the need for health professionals to be proactive with health prevention education is highly needed to help reduce the numbers of people exposing themselves to frequent sunburns, irregular photoprotection, and to high levels of ultraviolet radiation.

Discussion:

The authors of this study proposed that a national program focused on TBSEs sponsored by the American Academy of Dermatology (AAD) would assist clinicians to educate local communities on skin cancer prevention. They reported on how community-based screening had already been found in previous studies to improve public response to develop a skin care regime. A skin cancer prevention regime through the AAD could provide a “unique opportunity for providing skin cancer prevention education. Understanding to what extent individuals who attend free TBSE screenings engage in photoprotection and avoid skin cancer risk behaviors is an essential first step in designing tailored educational programs on skin cancer prevention that could be used in this setting.”54

Comprehensive skin cancer prevention education should emphasize photoprotective behaviors and avoidance of skin cancer risk behaviors. The reported rates of skin cancer risk behaviors are high. The authors concluded that health education regarding skin cancer prevention should include an emphasis on the avoidance of high risk behaviors as a critical component of an effective skin cancer prevention regimen.

Colorectal Cancer

Colorectal cancer is the third-most common cancer in the United States.55 The lifetime risk for colorectal cancer is 4.49% for men and 4.15% for women and the American Cancer Society estimates that in 2019 there will be 101,420 new cases of colon cancer and 44,180 new cases of rectal cancer.55

40 NurseCe4Less.com Risk factors for colorectal cancer include alcohol use, obesity, smoking, a diet that is high in red meat, sedentary lifestyle, a family or personal history of the disease, inflammatory bowel disease, age > 50, type 2 diabetes, and African American ethnicity.56

There is unequivocal evidence that colorectal cancer screening and removal of pre-malignant adenomas can decrease mortality from colorectal cancer.57 The specific risks of the invasive screening procedures, colonoscopy and sigmoidoscopy, include infection, adverse effects from sedating drugs used during the procedures, perforation and bleeding. Major adverse effects like perforation after invasive screening procedures like colonoscopy or sigmoidoscopy are very uncommon, occurring in 0.03% of patients.58 The risk of contrast enemas and CT colonography is exposure to radiation.

There are many different tests that can be used for colorectal screening tests, each with benefits, risks, and considerations of cost, safety, patient acceptability, and availability. Doubeni (2019) stated that the best screening test for colorectal cancer is the one that is acceptable to the patient and the one that the patient will complete.58

The American Cancer Society’s recommendation for screening for colorectal cancer in patients who have an average risk for the disease state that screening should be started at age 45. A patient is at average risk for colorectal cancer if any of the following are present: ● A personal history of colorectal cancer or certain types of polyps ● A family history of colorectal cancer ● A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease) ● A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non- polyposis colon cancer or HNPCC) ● A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer

41 NurseCe4Less.com Screening can be done by colonoscopy, sigmoidoscopy, test for occult blood in the stool (FOBT), a blood test known as a fecal immunochemical test or FIT, testing the stool for DNA, or a Computed Tomography (CT) colonoscopy.58 Screening should continue until age 75. From age 76 to 85, screening should be done on a case by case basis. There is no recommendation to screen for colorectal cancer after age 85.58

USPSTF Screening Recommendations

Screening for colorectal cancer should start at age 50 years and continuing until age 75 years. The decision to screen adults aged 76 to 85 years should be done on a case by case basis, considering the patient’s overall health and prior screening history.59

Stool-based tests should be done every year, colonoscopy should be done every 10 years, and CT colonoscopy should be done every five years. Flexible sigmoidoscopy should be done every five years or if used with a yearly FIT, every 10 years.59

Research: Colorectal Cancer Screening

The authors of this research study reported on colorectal cancer (CRC) and the decline of incidence and mortality worldwide due to colorectal screening programs.60 They identified that screening tools commonly used have been the fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy. Computed tomography (CT) colonography has been most recently included in CRC screening. Unfortunately, the effectiveness of a CRC screening program may be impacted by poor testing availability and by suboptimal screening compliance, resulting in advanced or metastatic disease.

New molecular markers for highly accurate, non-invasive CRC screening tests include DNA, proteins, messenger RNA (mRNA), and microRNA (miRNA), which have all shown potential. Aside from fecal hemoglobin, only DNA-based markers have been developed for clinical testing. Stool DNA testing has been approved in the United States (2014) for population-wide screening of average

42 NurseCe4Less.com risk, asymptomatic individuals. The authors focused on the “development and validation of a multi-target stool DNA test for CRC screening that has recently been approved by the US Food and Drug Administration (FDA) for CRC screening.”60 Additional studies to determine optimal screening, patient compliance with screening, rates of false positive results, the use of DNA testing in high-risk populations is needed.

Adenomatous Polyp and CRC

Colorectal cancer is caused by the growth of a colonic adenomatous polyp. An adenoma can progress to become an advanced adenoma (> 1 cm in size, villous histology), and becomes a CRC. While this may usually take 10–15 years to develop there may be some physiological factors that could cause the cancer to grow much faster. CRC screening becomes important to find the polyp, to remove it and to kill the cancer.

More is being learned about the molecular changes in polyps and tumor behavior in CRC. The authors stated that CRCs are classified into four subgroups based on molecular features: 1) Hypermutable-Microsatellite unstable, 2) Hypermutable-Microsatellite Stable, 3) Microsatellite Stable (chromosome Unstable), and 4) CpG Island Methylator Phenotype (CIMP) cancers.

Each subclass has its own set of driver genes in the differing CRC molecular subgroups, however there are some mutant genes (APC and TGFBR2/SMAD4) that have been identified as common among all the molecular subgroups. They have a key role in the signaling pathways in CRC overall, but there are some that are restricted to one subclass of CRC. The authors stated that the most common alterations identified in CRC include: APC,CTNNB1, KRAS, BRAF, SMAD4, TGFBR2, TP53, PIK3CA, ARID1A, SOX9, FAM123B, and ERBB2, which appear to promote colorectal tumorigenesis. Neoplastic cells develop due to the deregulation of other signaling pathways. The tumor microenvironment (gut microbiome, inflammatory state of adjacent tissue, etc.) is also key, as it “modulates the way these mutations affect CRC

43 NurseCe4Less.com formation.”60 Alterations in genes drive the formation of CRC in the context of tumor promoting factors obtained from adjacent tissue.

Use of the newer molecular markers for CRC screening was described by the authors as a well established non-invasive detection method for CRC. Guaiac-based methods for fecal occult blood testing (gFOBT) beginning in the mid-1960s has been shown in randomized controlled clinical trials (RCT) to reduce mortality by 11–33% (20 year follow up). However, the gFOBT as a CRC screening test involves modest specificity for CRC, which can generate many false positive test results when used in population-based screening programs, and it also has modest sensitivity for colon polyps. These limitations of gFOBT have led to the development of fecal immunochemical tests (FIT), which detect blood by a human hemoglobin specific immunoassay. The authors stated that prior studies have shown FIT assays have numerous benefits over the gFOBT by: ● detecting both the presence and quantity of fecal hemoglobin, modifying the sensitivity and specificity of the assays to detect polyps and CRC ● showing superior sensitivity and specificity for CRC and advanced adenomas ● only one sample is required for analysis, as opposed to three ● a more acceptable sample collection to the general public, increasing compliance with screening

The more sensitive fecal immunochemical test for CRC screening leads to only 20-30% detection rate of adenomas > 1 cm in diameter. Also, occult blood testing detection of right colon lesions is less than those that occur in the left colon, which the authors identify as a significant issue given the increased incidence of right-sided CRCs reported over the last two decades. The discovery of left-sided lesions, however, is not unique to fecal hemoglobin testing and has been reported in RCTs studying the use of invasive flexible sigmoidoscopy, and currently more RCTs are in progress with a focus on the use of colonoscopy to diagnose right-sided colonic adenomatous polyps early enough to avoid morbidity and mortality.

44 NurseCe4Less.com Discussion:

The focus of the authors’ study was on the utility of non-invasive testing for CRC screening and the development of tests based on the detection of specific molecular alterations (e.g. abnormal protein or mRNA expression, gene mutations, abnormally methylated genes, etc.) found to exist in body fluids, such as blood, urine, stool so that individuals with asymptomatic colon polyps or CRC can be identified. The feasibility of this approach continues to be studied and more research is needed to determine its effectiveness to identify a colonic lesion before it becomes a deadly cancer.

The authors concluded that the “development of molecular marker assays for CRC screening have demonstrated the feasibility of these assays and the discovery of a myriad of promising markers. The ultimate generation of a clinically robust and accurate molecular marker assay has been a slow and iterative process, which has now resulted in an FDA approved assay that is being implemented clinically. MT-sDNA can now be added to our CRC screening armamentarium.”60 As the research on the molecular detection of colorectal and other gastrointestinal cancers continues to develop there will likely be more screening tools of higher performance to prevent colorectal and other GI cancers in the future.

Oral Cancer

Oral cancer may develop on the tongue, the mouth and gums and the area of the throat at the back of the mouth.61 Oral cancers account for 2-4% of all cancers in the United States, and the American Cancer Society estimates that in 2019, 53,000 people will develop oral or oropharyngeal cancer and 10,860 people will die from the disease.62 These cancers are almost always squamous cell carcinomas, and they can occur in the gums, the lining of the cheeks, lips, tongue, and the floor and the roof of the mouth. Risk factors for developing oral cancer are smoking and tobacco use, alcohol use, and infection with the human papillomavirus HPV-16.61,63

45 NurseCe4Less.com The National Cancer Institute and the USPSTF have concluded that there is inadequate evidence to determine if screening would result in a decrease in mortality from head and neck squamous cell cancers.64

Research: Oral Leukoplakia and Oral Cancer Prevention

There is evidence that oral leukoplakia carries a higher risk of oral cancer than in people with normal oral mucosa. The following study was published through Cochrane Oral Health with a goal to determine how people affected by leukoplakia can benefit from (local or systemic) surgical, medical or complementary treatments. The study focused on the prevention of oral cancer due to leukoplakia, a white patch formed in the mouth lining that cannot be rubbed off.65

The authors explained that oral leukoplakia is not generally noticeable by the patient. They stated that “It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia.”65

There were 14 randomised controlled trials (RCTs) of medical and complementary treatments that the authors reviewed, which involved 909 total participants. The treatments they considered included “herbal extracts, anti-inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT.”65 They reported on cancer development in studies where three treatments were measured: systemic vitamin A, systemic beta carotene and topical bleomycin.

For the prevention of cancer, none of the treatments raised proved effective after two years of data compilation for vitamin A and beta carotene, and seven years for bleomycin. While some studies of vitamin A and beta carotene showed a possibility of effectiveness for improving or healing oral lesions, a high rate of relapse was noted in participants where treatment had

46 NurseCe4Less.com resolved the lesions. The side effects of treatment were addressed, which occured in a high number of subjects and varied in severity. The authors determined there was good treatment acceptance by study participants based on drop-out rates.

Prior studies were evaluated as having limitations in their design and results with low quality relative to their evidence for the outcome of oral cancer development. In this area of cancer prevention research, larger, improved studies of longer duration are needed that included the benefit of drug treatment and alternative treatments (vitamins), the effectiveness and safety of surgery, and of the elimination of other risk factors, such as smoking.

Leukoplakia Groups, Conditions and Causes

A helpful delineation of 'leukoplakia' and its current treatment was described by the authors. They explained that conditions involving leukoplakia may include frictional keratosis, lichen planus, white sponge nevus, and hairy leukoplakia, which all require biopsy and histopathological studies to rule out epithelial dysplasia or carcinoma. Additionally, tobacco smoking or chewing can lead to leukoplakia. Use of alcohol, and a systemic infection or virus need further investigation.65

Leukoplakia is generally described in two groups: 1) homogeneous leukoplakia (uniform flat appearance with possible superficial irregularities), and consistent texture, and 2) non-homogeneous leukoplakia, which is a predominantly white or white and red lesion (erythroleukoplakia) showing an irregular texture, possible ulceration, speckled, nodular or wart-like in appearance. The histological features of both leukoplakia types are variable and “may include ortho-keratosis or para-keratosis of various degrees, acanthosis or atrophy of the squamous epithelium, mild inflammation in the corium, dysplastic changes of various grades (i.e., mild, moderate or severe), carcinoma in situ or carcinoma. Some cases of predominantly white lesions that are difficult to diagnose, in spite of the availability of a biopsy.”65

47 NurseCe4Less.com Disease Prevalence65

The prevalence of leukoplakia varies according to geographical areas and demographic groups, however is an estimated < 1% to > 5% within the general population. More than 1000 individuals had been studied and the authors reported that the pooled prevalence was estimated to be between 1.49% and 4.27%. In another Japan study an age-adjusted incidence rate per 100,000 person-years of 409.2 among males and 70 among females was reported, and in an Indian study, distinctive risk factors for oral cancer in a population found there to be lower figures (240 for males and 3 for females).

As a potentially malignant disorder, leukoplakia transforms into squamous cell carcinoma with a rate that has been reported to vary between 0% to 36.4%. One study investigating malignant transformation on the basis of European epidemiological data determined that the “upper limit of the annual transformation rate of oral leukoplakia is unlikely to exceed 1%.”65 The authors also noted that non-homogeneous leukoplakias have a higher risk of transformation compared to the homogeneous variants.

Discussion:65

This research study focused on the many approaches to leukoplakia treatment for the prevention of cancer development. The authors described approaches that included surgical excision with different techniques (scalpel, cryosurgery, photodynamic therapy, laser surgery and vaporisation), medical treatment (topical or systemic), cessation of risk activities (smoking and alcohol) and no intervention but strict surveillance.

Many of the treatments for leukoplakia to prevent cancer have potentially serious adverse effects. Therefore, the authors suggested that the “wait and see” approach based on specific standardized clinical and histological surveillance was typically used to catch early cancer and to begin cancer treatment.

48 NurseCe4Less.com Coronary Heart Disease and Hypertension

Coronary heart disease and its associated conditions are the leading cause of death in the United States. Risk factors for the development of coronary heart disease includes those that are modifiable and non-modifiable. Modifiable risk factors include cigarette smoking, diabetes, diet, elevated serum lipids and cholesterol, hypertension, obesity, and sedentary lifestyle. Non-modifiable risk factors are age, gender, and family history of coronary heart disease. People who have coronary heart disease (CHD) are typically asymptomatic until they have advanced disease, and the first sign of CHD is often a major event like angina, arrhythmia, or myocardial infarction.66

The USPSTF does not recommend specific screening tests for coronary heart disease for asymptomatic adults who do not have coronary heart disease or diabetes.21 The USPSTF and authoritative sources do recommend that people be screened for the presence of the risk factors for coronary heart disease and counseled on smoking cessation, diet, exercise and management of diabetes and hypertension.66

Hypertension

Hypertension is defined as a systolic blood pressure of 130 to 139 mmHg and higher or diastolic blood pressure of 80 to 89 mmHg and higher.67 Hypertension is one of the most important preventable causes of cardiovascular disease, diabetes, stroke, and renal failure.68 More than 100 million Americans have hypertension, but only about 75% are being treated and approximately 52.5% who are treated have their blood pressure under control.68

There is a direct relationship between blood pressure and adverse effects; the higher the blood pressure the greater the risk for complications and morbidities and the risk of developing cardiovascular disease doubles with each 20 mmHg increase in systolic blood pressure and each 10 mmHg increase in diastolic blood pressure.68 Risk factors for the development of primary hypertension (the most common form of the disease) may include age,

49 NurseCe4Less.com smoking, obesity, family history, African American race, excessive sodium intake, excessive alcohol intake, physical inactivity, diabetes and dyslipidemia.67,69

The USPSTF screening recommendations, derived from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - JNC 7 Report include those listed below.70 These recommendations are basically the same as those from authoritative sources and other professional organizations like the American College of Cardiology/American Heart Association.67

● Adults 18 years of age and older be screened for hypertension. ● Adults 18-39 who have normal blood pressure and who do not have risk factors should be screened every three to five years. ● Adults 40 years of age and older and people who have risk factors for hypertension should be screened every year.

The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present on several occasions. Blood pressure can be measured in a physician’s office, by using ambulatory blood pressure monitoring, or using a home blood pressure monitoring to confirm the presence of hypertension after an initial diagnosis has been made.70

Research: Benefit of Exercise for Disease Prevention

Exercise interventions were the focus of the study discussed in this section. The authors reviewed selected articles and classified them into 7 categories: 1) musculoskeletal system diseases, 2) metabolic system diseases, 3) cardio-cerebral vascular system diseases, 4) nervous system diseases, 5) respiratory system diseases, 6) urinary system diseases, and 7) cancers.71 Different disease types were identified that were associated with each category. Exercise protocols and their duration, frequency, and intensity level were discussed relative to each category and the authors focused on how a prescribed exercise rehabilitation affected different diseases. The protocols were primarily identified as aerobic exercise, resistance training, home-based

50 NurseCe4Less.com exercise, multimodal exercise, and other exercises including a combination of exercises.

Classification of Exercise Types

Aerobic exercise involves high repetition and low resistance demands and the authors described it as a well-established approach to improving aerobic capacity and health. Walking and running, yoga, Tai Chi, Pilates, and cycling are examples of aerobic exercise.

During periods of postoperative rehabilitation or severe disease, aerobic exercise can be performed at low, moderate, or high intensity. Cycling, treadmill, or stationary bicycle can be paced at high-intensity interval training (HIIT) for individuals who have acceptable cardiorespiratory function. HIIT can improve blood pressure and aerobic capacity in obese youths.

Resistance exercise has become considered helpful to athletes in improving their performance and is currently now part of the recommended activities to maintain overall health and to lower the risk of cardiovascular disease and other comorbid conditions, such as elevated lipid panels, low energy and depression, and metabolic syndrome. At home, people can incorporate resistance exercise through the use of elastic exercise bands, body weights, and exercise machines. Both the upper body and lower muscles can be conditioned with the use of resistance exercises.

Combinations of aerobic exercise and resistance training both enhances cardiorespiratory function and improves muscle strength. Before patients are prescribed a combination program of aerobic and resistance training they should receive a complete physical assessment and cleared by a medical provider to start an exercise program. The most common combination exercise regimes include walking and riding a bicycle. Depending on the patient’s strength and physical health, a combination exercise regime of < 6 weeks is considered short-term, and > 6 weeks is classified as long-term.

51 NurseCe4Less.com Home exercise is a concept that enhances a person’s ability to continue long-term exercise training in the comfort of home. Being at home is believed to allow for an exercise program that can be part of a person’s daily routine, and that is “simple and easy.”71 The authors stated that home exercise may only improve aerobic exercise and not as much endurance. Although intended to be simple and doable, the home exercise is still a prescribed training, which may include high-intensity leg-strengthening exercises.

Other training exercises varying in intensity were reviewed by the authors however not all will be covered here. The main concept conveyed in their study was that exercise regimes prescribed for recovery and long-term endurance were available for providers to design with their patients and treatment team committed to heart health and cardiovascular disease prevention. Other benefits of muscle strengthening derived from exercise programs included improved balance and coordination, back functioning and posture, possible lowering of physical pain, and stronger gait and endurance. The exercises prescribed were also evaluated as helpful for patients with nervous system diseases in need of rehabilitation and cancer-related fatigue depending on the form of exercise.

With regard to heart and lung function, proper exercise can improve blood circulation, increase the body’s oxygen supply, and improve blood vessel condition. It is well known that exercise typically lowers blood lipids and prevents the development of arteriosclerosis and thrombosis. The effects of exercise effectively prevent cardiovascular diseases, including coronary artery disease, congestive heart failure and stroke.

The authors reported that exercise interventions for coronary artery disease included home-based exercises and aerobic exercises. They listed the most common forms of exercise in this category as walking, cycling, jogging, and Tai Chi. Specifically, they reported that the long-term, moderate-intensity walking exercise “decreased the severity of sleep apnea in coronary artery disease patients.”71 Also, HIIT reduced the morbidity and mortality of coronary artery disease and prevented atherosclerosis. A patient’s heart function and quality of life reportedly improved and the risk of heart disease decreased.

52 NurseCe4Less.com In earlier smaller trials, advanced individual training was reportedly more effective for the rehabilitation of patients with coronary artery disease (CAD) as compared to aerobic continuous training. Other studies showed that long-term home exercise was superior to traditional hospital-based cardiac rehabilitation in terms of cardiopulmonary function measures, improving postoperative recovery. Exercise interventions in general usually improved coronary artery disease-related risk factors, such as body composition and blood pressure. The authors concluded that compared with moderate continuous training, long-term aerobic and home exercise regimes in patients with coronary artery disease proved more effective to improve physical condition.

Patients who were stroke victims, whether ischemic or hemorrhagic, are typically initially treated with thrombolytics. Following the acute phase, there is a high disability rate among stroke victims and early exercise intervention “is extremely important for the recovery and improvement of exercise capacity.”71

Exercise interventions for stroke included aerobic exercise, resistance exercise and combined exercise regimes. Balance training was specifically reported to be helpful following a stroke event. Exercise routines for stroke victims were listed as “walking, cycling, jogging, power sports, Tai Chi, moving objects in the home, and picking up objects.”71 A moderate-intensity aerobic cycle was determined to improve the aerobic capacity and walking ability in stroke patients with hemiplegia. Patient cognition and exercise control also improved in patients with hemiplegia.

The authors stated that aerobic exercise that was vigorous “was also a method used to effectively improve the aerobic capacity of stroke patients with hemiplegia.”71 Balance training combined with resistance exercise led to an improvement of a stroke victim’s balance ability in 3 months, and there was improvement of walking ability in 3–6 months. Blood levels showed a correlating improvement in plasma lipids and glucose levels, as well. Other physical benefits reported included improved lung function and exercise capacity.

53 NurseCe4Less.com For patients diagnosed with congestive heart failure (CHF), poor venous system condition and insufficient arterial perfusion typically led to cardiac dysfunction. Some people with poor heart function believe they should avoid exercise and heart stimulation but the authors reported that recent research has shown that moderate exercise benefited CHF patients. Aerobic exercise, resistance exercise, and HIIT were recommended routines that included long- term walking with breathing exercise to improve blood oxygen saturation as well as a person’s mood and quality of life.

For CHF patients, the authors identified that long-term, moderate- intensity “stretching combined with cycling improved and enhanced muscle metabolic reflex control. HIIT protocols improved the patients’ quality of life by changing their levels of health.” Although easy to implement and well- tolerated, HIIT was not found to be more effective compared to continuous aerobic exercise. The focus of the exercise program was to improve aortic dilatation ability, increase systolic blood pressure, and vascular response. Exercise interventions usually improve cardiopulmonary function in CHF patients. The authors concluded that compared with continuous aerobic exercise training or no exercise, “HIIT improved the cardiac contraction function and quality of life.”71 HIIT has been often used in the long-term treatment of CHF patients.

Discussion:71

Clinicians need to educate patients that the lack of exercise leads to the risk of chronic diseases, rising medical costs and economic burden for patients, their families, and community health systems. The authors aptly proposed that “Guiding people to take part in exercise properly to enhance physical fitness is more urgent and more important than ever.”71

Exercise prescription and the prevention of heart disease had other corresponding health benefits, such as improved mental health, musculoskeletal strength and balance, and pain control. While health providers can help to develop an effective exercise program for patients based on randomized controlled trials, the authors also emphasized the importance

54 NurseCe4Less.com of adopting an individualized approach when promoting rehabilitation and disease prevention. The exercise program developed should be individualized, based upon the patient’s heart health condition and physical tolerance.

Diabetes and Lipid Disorders

Approximately 9.4% of Americans have diabetes, 34% percent of the population 20 years of age or older have prediabetes, and approximately 25% of the people who have diabetes are undiagnosed.72 Almost half of Asian Americans and Hispanic Americans who have diabetes are undiagnosed. The prevalence of diabetes is increasing, and diabetes is the primary cause of, or a major contributing factor in the development of many serious diseases such as blindness, heart disease, and kidney failure.72

Screening for and early treatment of diabetes can be beneficial.72 The American Diabetes Association (ADA) has recommendations for testing for diabetes or pre-diabetes in asymptomatic adults,73 and for people with medical conditions associated with diabetes.74

Diabetes/Prediabetes Testing in Asymptomatic Adults

Screening for prediabetes and type 2 diabetes by using an assessment of risk factors or validated tools should be considered in asymptomatic adults. Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in all adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more other risk factors for diabetes.73

For people age 45 years and older, testing should begin regardless of risk. The following criteria for diabetes testing are recommended:73 ● If tests are normal, it is reasonable to repeat testing at a minimum of 3- year intervals. ● A fasting plasma glucose, 2-hour plasma glucose during a75-g oral glucose tolerance test, and A1C measurement are equally appropriate to test for prediabetes and type 2 diabetes.

55 NurseCe4Less.com ● Women who have had gestational diabetes should have lifelong testing done. ● If the patient has prediabetes or type 2 diabetes, identify and treat other cardiovascular disease risk factors. ● Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in if the patient is overweight (BMI ≥85th percentile) or obese (BMI ≥95th percentile) and has other risk factors for diabetes.

For people of any age who have risk factors for diabetes or prediabetes, screening may be indicated.73 Screening for Risk factors for diabetes screening include obesity, risk of insulin resistance, a first-degree relative with diabetes, ethnicity (African American, Native American, Pacific Islander, Latino, Asian American), history of CVD, hypertension, polycystic ovary disease in women, sedentary lifestyle, and HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L).73

Screening for Medical Complications Associated with Diabetes

The ADA recommends that cardiovascular risk factors should be systematically assessed at least annually in all patients with diabetes. This assessment is directed at the prevention and management of atherosclerotic cardiovascular disease and heart failure.74 “These risk factors include obesity/overweight, hypertension, dyslipidemia, smoking, a family history of premature coronary disease, chronic kidney disease, and the presence of albuminuria.”74 Some of these are discussed here.

Hypertension:

Identification and treatment of hypertension in patients who have diabetes can reduce the risk of cardiovascular events and microvascular complications.74 The American Diabetes Association recommends that blood pressure should be measured at every visit with a healthcare provider. If the blood pressure is ≥ 140/90 mmHg, multiple reading should be done, on

56 NurseCe4Less.com separate days, to confirm. If the patient has hypertension, a home blood pressure monitoring device should be used.74

Dyslipidemia:

The American Diabetes Association’s recommendations for lipid screening state that in diabetic patients who are not taking a statin or other lipid-lowering drug, consider measuring a lipid profile when the patient is first diagnosed.74 For patients under 40, this can be repeated every five years or as needed.74

A lipid profile should be obtained when lipid lowering therapy is started, 4-12 weeks after initiation or after a dose change, and every year thereafter.74

Lowering lipid levels can decrease the risk of developing atherosclerosis and heart disease. Deciding who to screen, when, and how often are decisions that are usually made by considering the cardiovascular disease risk profile of the patient. Vijan (2019) recommended that young adults who have never been screened for elevated lipids should have baseline testing done. Additionally, people who have a high risk for cardiovascular disease should be screened starting at age 25-30 for men, and age 30-35 for women.76

High risk for cardiovascular disease would be someone who has diabetes, hypertension, obesity, sedentary lifestyle, smoking, and/or a family history of premature heart disease. People who have a low risk for cardiovascular disease should have a screening at age 35 for men, and age 45 for women. Total cholesterol, high-density lipoprotein and low-density lipoprotein should be measured.76

The American Academy of Pediatrics recommends that children be screened for dyslipidemia by assessing risk factors and if needed, measuring lipid levels, starting at age four, several more times during childhood, and yearly from age 11 to 16.77 The USPSTF concluded that the “... current evidence is insufficient to assess the balance of benefits and harms of

57 NurseCe4Less.com screening for lipid disorders in children and adolescents 20 years or younger.”78

Cardiovascular Disease:

The American Diabetes Association does not recommend screening for patients who are asymptomatic for coronary artery disease so long as risk factors for atherosclerotic cardiovascular disease are treated.75

Chronic Kidney Disease:

Urinary albumin and estimated glomerular filtration rate (GFR) should be measured once a year for patients who have had type 1 diabetes for ≥ five years, in all patients who have type 2 diabetes, and in patients who have comorbid conditions. At least once a year, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and the estimated glomerular filtration rate in patients with type 1 diabetes with duration of ≥5 years, should be tested. All patients with type 2 diabetes and with comorbid hypertension should be tested at least annually.75

Components of Diabetes Care

Diabetic patients with proliferative diabetic retinopathy (PDR) or macular edema may be asymptomatic. This may be due to treatment. For these reasons, screening to detect diabetic retinopathy is recommended. Other conditions that should be screened include diabetic peripheral neuropathy, and diabetic foot ulcers.75

Diabetic Retinopathy:

Patients who have type 1 diabetes should have a comprehensive dilated eye examination within five years of the time of diagnosis. Patients who have type 2 diabetes should have a comprehensive dilated eye examination at the time of diagnosis. If there is no evidence of retinopathy after one-two examinations and blood sugar is well controlled, doing an examination every

58 NurseCe4Less.com one or two years can be considered. If these examinations show signs of retinopathy, annual examinations should be done and if retinopathy is present and progressing, more frequent examinations are required. Examinations, e.g., retinal camera images, can be evaluated remotely by an ophthalmologist or optometrist.75

Women who have type 1 or type 2 diabetes who are planning a pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Women who have type 1 or type 2 diabetes should have an eye examination done before pregnancy or in the first trimester and the patient should be monitored every trimester and for 1-year postpartum.75

Diabetic Neuropathy:

Patients who have type 1 diabetes should be screened for diabetic peripheral neuropathy five years after the time of diagnosis and then annually. Patients who have type 2 diabetes should be screened at the time of diagnosis.75

Assessment for distal symmetric polyneuropathy should include a history, and an assessment of temperature or pinprick sensation and vibration sensation using a 128-Hz tuning fork. Every patient should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. If the patient has microvascular complications, autonomic neuropathy should be ruled out.75

Diabetic Foot Ulcer:

A comprehensive foot evaluation should be done at least once a year. If the patient has signs and symptoms of sensory loss or of a previous ulcer, the feet should be evaluated at every visit. It should be determined if the patient has had an amputation, ulceration, Charcot foot, angioplasty or vascular surgery, renal disease, a history of smoking, retinopathy, or vascular disease.75

59 NurseCe4Less.com The examination should include pinprick, vibration, and temperature assessment, and 10-g monofilament testing, and assessment of the pulses in the feet and legs. Assess for signs and symptoms of neuropathy. If there are abnormalities on the vascular examination or the patient has signs/symptoms of claudication, an ankle-brachial index test should be done, and the patient should be referred for further assessment of vascular function.

Patients who have structural abnormalities or complications of the lower extremities, smokes, peripheral arterial disease, or loss of protective sensation, should be referred to a foot care specialist.

Research: Exercise and Metabolic Disorders

Metabolic disorders have serious deleterious effects on the health and quality of life of those who are affected. The authors of this research study reported on lifestyle strategies to prevent and treat metabolic diseases.71 They focused on exercise in addition to diet and weight control as a combined recommended treatment to avoid the risk of a metabolic disorder and to promote recovery. The following are conditions they highlighted as targets for an effective treatment strategy.

Obesity:

While obesity can occur as a result of a person’s genetics and lifestyle, secondary obesity is caused by multiple endocrine and metabolic diseases. Exercise prescriptions for obesity include aerobic exercise and resistance exercise combined with HIIT. Long-term and moderate to high intensity aerobic exercise, including treadmill and stationary bicycle training, helps to improve body composition in obese individuals. Aerobic interval training (AIT) helps improve the microvascular endothelial dysfunction in obese patients.

Resistance exercise combined with HIIT in sedentary, overweight, middle-aged individuals leads to weight loss, and resistance exercise combined with HIIT has been shown to be superior to resistance training alone. Exercise methods typically have positive results and aerobic exercise is the common for treating or preventing obesity.

60 NurseCe4Less.com Type 2 Diabetes:

Type 2 diabetes carries high morbidity and mortality, and is a significant health problem worldwide. There is a global increase in the prevalence and incidence of type 2 diabetes over the past several decades.

The authors report a worldwide estimate of 371 million people with diabetes with an anticipated total of 552 million diabetics by 2030. They stated that “Diet therapy, drug therapy, psychotherapy, and self-care monitoring are commonly used intervention methods. Exercise therapy is also a key treatment for patients with T2D and is considered a cornerstone of treatment for T2D, alongside diet and drug treatments.”71

Some of the exercise forms for diabetes type 2 reportedly include aerobic exercise, resistance exercise, and HIIT. The treadmill and stationary bicycle were recommended exercise routines. The benefit of long-term exercise training for people with diabetic complications primarily involves resistance exercise at moderate and high intensity because in type 2 diabetics (notably older people) this approach can “significantly decrease glucose, insulin, and homeostatic model assessment-insulin resistance levels.”71

Low-volume HIIT on a cycle ergometer was tried in type 2 diabetics and was found to have immunomodulatory and potential anti-inflammatory effects. The authors reported that the most common exercises to treat type 2 diabetes included aerobic exercise and resistance exercise, and that long- term, moderate intensity exercise had positive health effects in type 2 diabetic patients.

Type 1 Diabetes

Type 1 diabetes involves a complex relationship between genetic and environmental factors and involves ongoing research to determine the exact pathogenesis. The authors identified that insulin therapy, psychotherapy, and exercise therapy are effective treatments for type 1 diabetes.

61 NurseCe4Less.com With regard to exercise, “HIIT and speed endurance training were the exercise methods used to treat T1D. Cycle sprint training was used as a common speed endurance training method. In the HIIT protocol, cycle sprints with acute interval training carried out on cycle ergometers with high intensity showed a positive effect in that the intervention rapidly decreased patients’ perception of subsequent hypoglycemia and reduced their cognitive dysfunction caused by hypoglycemia.”71 The authors concluded that long-term speed endurance training at high intensity is able to improve type 1 diabetes outcomes.

Nonalcoholic fatty liver disease (NAFLD)

Nonalcoholic fatty liver disease is reportedly “the most common chronic liver disease in the world.”71 The authors reported that NAFLD is predicted to be the primary reason for liver transplantation by 2030 with a diverse range of liver conditions, such as simple steatosis (nonalcoholic fatty liver), nonalcoholic steatohepatitis, and liver cirrhosis, which place a person at risk of developing hepatocellular carcinoma.

The American Association for the Study of Liver Diseases reportedly had proposed that hepatic steatosis can be reduced in patients with NAFLD through a routine of exercise. Exercise prescriptions included aerobic exercise as a main intervention for NAFLD at moderate to high intensity, both long-term and short-term programs. Aerobic exercise has also been found to reduce the overall risk of developing NAFLD with some benefit of intrahepatic triglyceride.

A one-year program of moderate aerobic exerise for obese individuals with NAFLD was found to significantly lower intrahepatic triglyceride levels and decreased abdominal obesity and blood pressure. The authors reported that positive effects could be obtained through moderate intensity aerobic exercise to prevent and to treat NAFLD.

Discussion:71

The use of exercise to prevent and to treat many diseases is a common medical wisdom based upon numerous prior studies. The authors of this case

62 NurseCe4Less.com study encouraged clinicians to validate the benefit of exercise interventions to their patients. They stated that “Compared with the huge cost of drugs, exercise intervention is an economic and safe way to prevent and treat diseases, and has few side effects, which reduces the economic burden on families and society.”71

Exercise therapy cannot improve all diseases and sometimes it can only be used as an adjuvant treatment for major illness. At present, the types of exercise interventions used as treatments are mainly aerobic exercise, resistance exercise, and HIIT. Different types of training methods have their own characteristics. For instance, resistance exercise primarily enhances muscle strength and increases basal metabolic rate. The authors of this research study focused on combined recommended treatment of varied exercise regimes in addition to diet and weight control lower metabolic risk and as treatment.

Obesity

Obesity and being overweight can have serious health consequences like the development of cardiovascular disease, diabetes, bone and joint disorders, and morbidities associated with essentially every organ system. Being overweight in adults is defined as a body mass index (BMI) of 25 to 29.9 kg/m2. For children, being overweight is having a BMI between the 85th and 95th percentile for the child’s age and sex.79

Specifically, obesity is defined as a BMI ≥30 kg/m2. For children, obesity is defined as a BMI ≥95th percentile for age and sex. Severe obesity is defined as a BMI ≥40 kg/m2 (or ≥35 kg/m2 if the patient has comorbidities).79

Obesity and being overweight are common in American adults, children and adolescents. More than 20% of American adults are obese, and approximately one-third of children and adolescents are overweight or obese.80 In certain ethnic groups, e.g., non-Hispanic blacks, the prevalence of obesity is >39%.79 The USPSTF advises that adults age 18 and older be screened by using body mass index (BMI) and anyone with a BMI ≥30 kg/m2 “… should be offered or referred to intensive, multicomponent behavioral

63 NurseCe4Less.com interventions.”21 Additionally, “Screening combined with interventions can improve glucose tolerance and decrease risk factors for cardiovascular disease and the harms of this approach are considered to be small.”21

For some adults, particularly those of Asian descent, waist circumference should also be measured if the patient has a BMI of 25 kg/m2 to 30 kg/m2 as failing to do so may not detect patients at risk for weight- associated morbidities.81 The USPSTF recommends obesity screening for all children and adolescents > age six.82

Research: Obesity Risk in Youth

The following study was conducted in Canada and focused on healthy young people in British Columbia (BC) who reported multiple stressful life events and who the authors identified as more likely to have obesity in the short term, more so for young men than young women. Study findings added to previous work supporting the need to consider addressing young people's experiences of stressful life events in future obesity prevention strategies. The authors suggested that additional gender-sensitive health research should investigate the behavioural and biological mechanisms linking stressful life events with obesity risk.83

By considering stressful life events relative to levels of obesity in a group of ethnically diverse youth in a specific geographic region, both static and dynamic risk factors are identified, such as gender and history of trauma or current environmental triggers to stress. These become an important part of clinical assessment during an encounter with a youth and parents concerned about obesity and the health risks associated with obesity.

In this study, 905 BC adolescents (13–17 years of age) self-reported on stressful life events. Gender-specific predicted average probabilities of developing obesity that was associated with a greater frequency of stressful life events was evaluated. The authors reported that young men reporting one stressful life event had an estimated 50% more chance of having obesity at 6-month follow-up and those reporting multiple stressful life events had twice

64 NurseCe4Less.com the chance of developing obesity at 6-month follow-up than young men who reported no stressful life events over the prior year. Young women reporting multiple events demonstrated a higher chance of developing obesity than young women reporting no life events at the end of the study.

The authors concluded that the “frequency of major life events may be an important social stressor associated with obesity in adolescents, particularly for young men. However, findings should be replicated in larger samples using measured anthropometry to inform future obesity prevention strategies.”83 Because adolescent obesity has grown into a worldwide concern, the authors wanted to investigate how stress-related weight gain could impact a youth’s overall development. They opined that it was important to understand social stressors, specifically adverse life events, in youth and the role of stress in adolescent obesity so that preventive health interventions could be developed to improve health outcomes. The authors highlighted the following considerations:83

● Young people experience a unique period of developmental vulnerability relative to major life events. ● Social stressors can permanently impact a young person’s brain development and metabolic systems, thereby negatively impacting physical functioning and emotional regulation later on in life. ● Young people are more vulnerable to the health impact of stress and have less control over stressful life events. ● Independent stressors in youth reportedly vary: - more common everyday life events (25%), i.e., parental divorce, peer conflict, - more extreme but less common life events (6.2%), i.e., death of a parent or being a victim of violence. ● An estimated quarter of young people by the age of 16 encounter at least one high-magnitude stressor. ● Young people are more emotionally vulnerable to social stressors because they have higher hypothalamic–pituitary–adrenal (HPA) activity and heightened biological stress reactivity, which impacts cortisol levels effects on central adiposity.

65 NurseCe4Less.com When social stressors impact the brain of a youth it could lead to negative metabolic consequences. The youth could turn to food as a means of calming by consuming highly desirable foods (such as those rich in sugar and fat). The authors stated that “energy-dense foods triggers the brain's reward pathway and becomes a reinforcing behaviour in the same way as that of drug use in young people, underpinned by the principles of reward and reinforcement.”83 Also, sex hormones differ in HPA activation and stress reactivity so it is important to understand how stressful life events can affect weight-related outcomes for both young women and young men. During times of social stress, young people may not only have poor quality diets but may appear sedentary, not exercising and sleeping less, and consuming illegal substances, i.e., tobacco and alcohol. These behaviors have all been associated with obesity. Other factors could add to the risk of obesity such as sleep deprivation related to changes in sleep–wake cycles and effects on leptin (satiety hormone) regulation and emotional regulation. These factors combined lead to behavioral changes in youth, as well as the formation of lifestyle habits contributing to obesity.

Sex chromosomes reportedly regulate habit formation and the sleep deprivation impacting metabolic processes is said to be greater in young women than in young men. Few studies exist that include a gender-based analysis focused on the differences between male and female exposures to stressful life events and the varied vulnerability of male and female youth to the metabolic effects of stressful life events. The authors “hypothesized that greater levels of stressful life events would be associated with higher obesity at follow-up and that the associations would show gender-specific patterning.”83

Discussion83

The authors concluded there was longitudinal data that showed how stressful life events in young and adult populations were positively associated with obesity. They also reported on potential gender differences, as young women reporting two or more events showed higher obesity rates. In children a greater exposure to stressful life events were found to correlate with a 12%

66 NurseCe4Less.com greater likelihood of overweight status with some gender differences in young children. They stated, “It is difficult to directly compare our results with those of previous works, as the literature uses heterogeneous nomenclature and operationalization of both stressful life events and obesity status, lacks a focus on this vulnerable age group of mid-to late-puberty and is silent on potential gender differences.”83

Factors highlighted by the authors that explained how stressful life events corresponded with obesity rates included:83 ● Chronic stress increases overall activation of the HPA axis, negatively affecting hormonal regulation of metabolic activities. ● Elevated cortisol levels are associated with increased leptin levels and central adiposity. Disrupted leptin levels may result in inhibited satiety, and increase food consumption. ● Stressful life events correspond with unhealthy behavioral responses, poor coping mechanisms, which further contribute to obesity risk through psychosocial effects and sedentary behaviour.

Metabolic dysregulation and unhealthy behaviors combined have known sex- and gender-based differences that underlie stressful life events and obesity among adolescent males. During exposure to a stressful event, young males reportedly have higher cortisol and autonomic nervous system reactivity than young females. The sex-based difference in HPA response patterns in mid-adolescence has been found to be similar to those in adults. Female sex hormone cycles involving post-ovulation luteal phase and circadian rhythms can effect HPA responsiveness to perceived stress.

Canadian studies have shown that the social roles and norms of young females suggest they have a wider social network and support system to help them cope with stressful life events thereby avoiding negative metabolic outcomes due to stressful life events. It was also suggested that young women carry thin body ideals that explain why stressful life events tend to not be correlated with obesity.

67 NurseCe4Less.com The authors stated that a key strength of the study pertained to its representation of a regions broader adolescent population, including youth ethnicity, pubertal stage and socioeconomic status. They were able to observe that independent stressful life events (versus perceived psychological stress) incorporated identified risk factors for future interventions to target during treatment. Also, this study focused on youth aged 13–17 years during a “unique developmental period putting them at particularly high risk of negative metabolic consequences from major life events.”83 Gender played a critical role relative to the relationship between stressful life events and obesity in the teen group that was monitored in this Canadian study.

Osteoporosis

Osteoporosis is defined as reduced bone strength that increases the risk for fractures, and it is a very common disease.84 Approximately 10 million American have osteoporosis, and osteoporosis is the cause of about 2 million fractures each year in the United States.84

Osteoarthritis is also a degenerative bone disease affecting the elderly. After age 50 the number of people who have osteoarthritis increases and in the United States, at least 20% of men and women over the age of 50 have had one or more osteoporotic fractures. Women suffer disproportionately from osteoarthritis.84-86

Risk factors for osteoporosis include advanced age, caucasian race, excessive alcohol use, family history, female gender, long-term treatment with a glucocorticoid, low body weight, and smoking.87 The USPSTF recommends that all women 65 years of age and older be screened for osteoporosis; post-menopausal women < age 65 years who have an increased risk for osteoporotic fracture should be screened.88 There is not enough evidence to determine if screening men for osteoporosis is beneficial.

Wu (2018) noted that some professional organizations, the National Osteoporosis Foundation (NOF), the International Society for Clinical Densitometry (ISCD), the Endocrine Society, the American College of

68 NurseCe4Less.com Preventive Medicine, and the American College of Physicians (ACP) recommends that men 65 years of age and older be screened for osteoporosis.87 The USPSTF has determined that osteoporosis screening may reduce hip fractures in women; however, the review by Wu (2018) concluded that the evidence for the effectiveness of osteoporosis screening was mixed.87,88 Dual-energy x-ray absorptiometry (DXA) is the most commonly used method of osteoporosis screening.87

Research: Vitamin D Deficiency and Osteoporosis

The authors of this case study focused on Vitamin D deficiency as the most common nutritional deficiency for all age groups worldwide. They reported on a 51-year-old woman who dressed routinely in a religious garment with almost no exposure to sunlight for years, and she developed slowly progressing weakness over a two year period involving the proximal limb muscles, extreme fatigue, chest and lower spine pain, paresthesia, depression, difficulties in walking and waddling gait.89

The patient had a health history that was negative for metabolic syndrome. She was hospitalised and treated for fibromyalgia with the use of NSAIDs, but without improvement of her clinical symptoms. Her social history included married status with two healthy children and one child deceased from leukemia.

On physical examination, the patient was found to have demineralisation of teeth and an unstable gait. Laboratory testing reports showed her serum vitamin D3 level was extremely low at 3 ng/mL and parathyroid hormone level was found to be very high at 423 pg/mL. The patient was diagnosed with severe Vitamin D deficiency.

Other diagnostic testing included inflammation markers and thyroid hormones, which were normal. Antibodies for celiac disease returned negative, and the patient’s renal and hepatic functions were normal. electrocardiography (ECG) was normal. A whole-body bone scintigraphy showed diffuse metabolic changes (chest ribs and knees bones), and a dual-

69 NurseCe4Less.com energy X-ray absorptiometry scan (DXA) showed low body mass density and severe osteoporosis in both femur region and L-spine. Lumbosacral radiograph revealed biconcave vertebral bodies (fish vertebrae) indicating osteomalacia, and upper anterior fracture of the 5th lumbar vertebra. A gastroesophagoscopy was done and biopsies were done that showed the patient had chronic gastroduodenitis. Thyroid and parathyroid disease was ruled out by ultrasound, and the patient reported no signs or symptoms of cardiovascular disease.

In summary, the patient was diagnosed with a severe deficiency of 25(OH) vitamin D, high PTH, low calcium and high alkaline phosphatase. Follow up of treatment was over a six month period. Treatment considered “malabsorption of vitamin D due to gastrointestinal lymphoplasmacytic inflammatory infiltrates.”89 The authors reported that cholecalciferol (vitamin D3) 300,000 IU intramuscularly was administered followed by vitamin D3 50,000 IU orally every week, along with calcium 1000 mg daily. She was provided dairy products for one month and this was followed with 25,000 IU orally every week for another two months. Appropriate sun exposure in daily bases was recommended and other necessary treatment. Last three months, appropriate doses of Vitamin D were ordered in oral tablets.

The patient gained 3 kg and significant improvement in her walking, and she denied pain and paresthesia, and depression. A DXA revealed normal values on follow up. Treatment with the use of high doses of vitamin D and calcium replacement led to improvement of osteomalacia and the patient’s overall muscle/bone performance and gait improved with reduced pain level continued following vitamin D treatment.

The authors stated that cases for osteomalacia in individuals wearing a religious garment and with insufficient exposure to sunlight have been reported. In such cases, laboratory studies should include 25 (OH) vitamin D, parathyroid hormone (PTH) level, calcium and alkaline phosphatase levels, and DXA performance should be done, however, frequently these measures are not done and vitamin D deficiency and corresponding complications go

70 NurseCe4Less.com undiagnosed. Women who wear concealing clothing are likely at increased risk of vitamin D deficiency, poor bone status and muscle function.

Discussion89

Malabsorption, inadequate exposure to sunlight, environmental factors such as institutionalization can lead to vitamin D deficiency. Osteomalacia, decreased mineralisation of newly formed osteoid (areas of bone turnover), can be associated with symptoms of diffuse body aches and pain. The authors raised the following health concerns related to vitamin D deficiency:89 ● Nearly 30-50% of all age groups are Vitamin D deficient worldwide. ● Secondary hyperparathyroidism and osteomalacia can occur due to severe, long-standing vitamin D deficiency. ● Muscles weakness with difficulty in walking, and proximal myopathy.

The Institute of Medicine (IOM) has defined vitamin D deficiency as 25(OH) vitamin D less than 20 ng/mL. As mentioned, secondary hyperparathyroidism and osteomalacia can develop due to prolonged, severe vitamin D deficiency. Clinicians should be aware of factors causing vitamin D deficiency, such as poor sunlight exposure, and prolonged use of anticonvulsants and corticoids, and nutritional deficiency. Intestinal inflammation, celiac disease or gastric surgery can lead to malabsorption of dietary nutrients.

The authors stated that vitamin D is important to immune system function, cardiovascular health, oncogenesis, and cognitive functioning. They referred to earlier studies that had reported a connection between hypovitaminosis and poor muscle function in people, emphasizing the importance of vitamin D to proper blood levels of calcium, phosphorus and bone metabolism. When there is a chronically low 25(OH) or vitamin D status, intestinal calcium and phosphorus absorption becomes reduced and the body starts to increase secretion of parathyroid hormone. In secondary hyperparathyroidism bone tissue becomes depleted of calcium, and also there is increased phosphorus wasting affecting the kidneys. High increases of parathyroid hormone and osteoclastic activity resulting from inadequate

71 NurseCe4Less.com calcium-phosphorus levels can lead to decreased bone mineral density (BMD), osteopenia and osteoporosis. Other abnormal laboratory test findings can include elevation of alkaline phosphatase (ALP) levels in the setting of secondary hyperparathyroidism due to osteomalacia.

In children, vitamin D deficiency and an increased serum PTH level can lead to soft bones (rickets), whereas in in adults bone turnover and bone loss results in osteomalacia. Muscles weakness corresponds with difficulty walking, increased falling and bone fracture risk. Generally, a vitamin D level below 30 nmol/l is associated with decreased muscle strength.

In the case of this female patient diagnosed with osteomalacia the authors reported that vitamin D has an important role in muscle growth, strength and gait, and low vitamin D “is always associated with a decrease in muscle function and performance and an increase in disability. Progressive difficulties in changing the body position, or rising from a chair followed with diffuse muscle pain are all symptoms of myopathy from osteomalacia.”89 The active form of vitamin D, calcitriol or 1, 25-dihydroxy vitamin D3 reportedly has an effect on the muscle tissue that involves rapid influx of calcium into the cell.

Osteomalacia should be considered in a population of people wearing religious garments, and in those with poor sunlight exposure. Laboratory evaluations should involve 25(OH) vitamin D, PTH, calcium, alkaline phosphatase and DXA testing to diagnose a potential vitamin D deficiency. Vitamin D supplementation is needed for women who wear concealing clothes to maintain a healthy vitamin D status and to avoid osteomalacia. In these cases, treatment with high doses of vitamin D and calcium supplements is recommended to avoid osteomalacia and myopathy.

Hepatitis B and Hepatitis C

This section addresses viral hepatitis, which affects people worldwide and leads to a short-term condition or may develop into a chronic infection,

72 NurseCe4Less.com which may be life-threatening. Common features of hepatitis B and hepatitis C are discussed.

Hepatitis B

Hepatitis B is a viral infection of the liver. Hepatitis B is transmitted primarily by contact with infected blood, and it can also be transmitted through other body fluids, by sexual contact, and from mother to child. The Centers for Disease Control and Prevention (CDC) estimated that in 2016 approximately 862,000 Americans were chronically infected with the hepatitis B virus.90 Factors that increase the risk of being infected with hepatitis B are close, household contact with an infected person, healthcare workers who are exposed to blood or blood-contaminated fluids, hemodialysis, infants of mothers infected with hepatitis B, injection drug use, men who have sex with men, and sexual contact with an infected person.90

People who have a chronic hepatitis B infection are typically asymptomatic.91 A study (2019) found that 33.9% of Americans infected with hepatitis B were unaware they had the virus.90

Early identification of hepatitis B can reduce the risk for virus transmission and liver damage, and the CDC recommends screening the following groups for hepatitis B by testing for the presence of hepatitis B surface antigen (HBsAg), antibody to HBsAg [anti-HBs], and antibody to hepatitis B core antigen:90 ● Persons born in countries with 2% or higher HBV prevalence ● Men who have sex with men ● Persons who inject drugs ● HIV-positive persons ● Household and sexual contacts of HBV-infected persons ● Persons requiring immunosuppressive therapy ● Persons with end-stage renal disease (including hemodialysis patients) ● Blood and tissue donors ● Persons with elevated alanine aminotransferase levels (>19 IU/L for women and >30 IU/L for men)

73 NurseCe4Less.com ● Pregnant women (HBsAg only is recommended) ● Infants born to HBV-infected mothers (HBsAg and anti-HBs are only recommended)

Hepatitis B screening accurately identifies pregnant women who are infected and can prevent mother-to-child transmission.91 The USPSTF recommends that at the first prenatal visit all pregnant women be screened for hepatitis B.92 The vaccine for hepatitis is very effective, and the CDC recommends hepatitis B vaccination in these groups/stuations.90 ● All infants ● Unvaccinated children aged <19 years ● People at risk for infection by sexual exposure o Sex partners of hepatitis B surface antigen (HBsAg)–positive persons o Sexually active people who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months) o People seeking evaluation or treatment for a sexually transmitted infection o Men who have sex with men ● People at risk for infection by percutaneous or mucosal exposure to blood o Current or recent injection-drug users o Household contacts of people who are HBsAg-positive o Residents and staff of facilities for developmentally disabled people o Health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids o Hemodialysis patients and predialysis, peritoneal dialysis, and home dialysis patients o People with diabetes aged 19–59 years; persons with diabetes aged ≥60 years at the discretion of the treating clinician ● International travelers to countries with high or intermediate levels of endemic hepatitis B virus (HBV) infection (HBsAg prevalence of ≥2%) ● People with hepatitis C virus infection

74 NurseCe4Less.com ● People with chronic liver disease (including, but not limited to, persons with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal) ● People with HIV infection ● People who are incarcerated ● All other people seeking protection from HBV infection

Hepatitis C

Hepatitis C is a viral disease of the liver. Hepatitis C is transmitted by contact with infected blood or body fluids, and there is a small risk of transmission by sexual contact.93 As with hepatitis B, patients who have chronic hepatitis C infection are almost always asymptmatic.93

The CDC estimated that in 2017 there were 44,300 new cases of hepatitis C and that there are approximately 2.4 million Americans who are chronically infected with hepatitis C.91 Risk factors for hepatitis C include:93 Blood transfusion or organ transplantation before 1992, hemodialysis, HIV infection, infants born to infected mothers, injection drug use (current and former), transfusion of clotting factors made prior to 1987, needle stick that was contaminated with hepatitis C.

Some people exposed to hepatitis C will spontaneously clear the virus but in 75-85% of acute infections, the hepatitis C infection becomes chronic.93 The CDC recommendations for hepatitis C screening include those listed here:93 ● Anyone born from 1945 to 1965 ● Anyone who was transfused with clotting factors made before 1987 ● Anyone who received a blood transfusion or organ transplantation before 1992 ● Anyone ● Chronic hemodialysis patients ● Current and former IV drug users ● Exposure to hepatitis C, e.g., a needle stick injury

75 NurseCe4Less.com

Hepatitis screening consists of blood tests for hepatitis C antibodies, hepatitis C RNA, and hepatitis C viral load.93 Pregnant women should be screened for hepatitis C during the first prenatal visit.94

Screening and early detection of hepatitis C reduces the risk of liver damage and complications.95 There is no hepatitis C vaccine.

Research: Hepatitis C in MSM

In the following PubMed study the authors discussed the case of a 47- year-old Caucasian male with a history of HCV infection (genotype 3A), hypertension and renal failure.96

The patient was reportedly admitted with symptoms of shortness of breath, dyspnea on exertion, lower extremity edema, abdominal distention, and decreased urine output over a period of two months. His physical examination revealed an elevated jugular venous pulse to 8-10 cm of water, bibasilar crackles, an S3 gallop, bilateral lower extremity edema, and hepatosplenomegaly. He was hypertensive and had a blood pressure of 183/111 mmHg. Laboratory tests revealed pancytopenia, hypoalbuminemia, hypocomplementemia, cryoglobulinemia, elevated HCV PCR levels, an elevated creatinine level, and an elevated rheumatoid factor level. Urine microscopy revealed dysmorphic red blood cells (RBC) in addition to white blood cell (WBC) and RBC casts. He was also found to have nephrotic range proteinuria (9.5 g in 24 hours).

Retroperitoneal ultrasound only showed a small volume of ascites, 14 cm and 12 cm sized kidneys with no hydronephrosis. HCV-induced cryoglobulinemia was suspected and a kidney biopsy was performed. The renal biopsy revealed cryoglobulinemic glomerulonephritis with monoclonal light chain (mCGN). Hepatosplenomegaly associated with retroperitoneal para-aortic lymph node enlargement was detected by computed tomography (CT) and a bone survey did not show lytic or blastic lesions. The patient’s bone marrow however was biopsied and the results were consistent with low-grade

76 NurseCe4Less.com lymphoma, Marginal Zone Lymphoma. Immunohistochemistry studies were conducted and identified lymphoid cells as mostly PAX-5 and CD20 positive B cells. A diagnosis of marginal zone lymphoma was made, and the patient started on a rituximab/dexamethasone-based regimen with improvement of his renal function.

During the course of his hospitalization, hematology and infectious disease were consulted and planned a trial of direct acting antivirals at a later stage. At the most recent follow-up, patient reportedly was continued on the abovementioned therapy and was monitored by oncology closely.

Discussion:96

Hepatitis C virus infection-associated cryoglobulinemia is reportedly a common disease, and affects the kidney by causing polyclonal cryoglobulinemic glomerulonephritis (pCGN). The HCV-infected patient in this case report was diagnosed with renal failure and underwent a renal biopsy that revealed cryoglobulinemic glomerulonephritis with monoclonal light chain restriction (mCGN).

The incidence of monoclonal cryoglobulinemic glomerulonephritis (mCGN) was reviewed in this research study, which also highlighted the importance of detecting monoclonality in the renal biopsies obtained from HCV-infected patients. Monoclonal (type I) cryoglobulinemia accounts for about 10-15% of total cryoglobulinemia cases. Also, mCGN is a very rare diagnosis, and there are fewer than 50 cases reported so far in the literature.

The importance of this case is that it raises awareness regarding the “possibility of monoclonality in the biopsy of HCV-infected patients, especially because polyclonality is the routine finding in these patients.”96 The incidence of mCGN among HCV patients may be higher than previously thought since monoclonality can be overlooked in the biopsies. This emphasises the importance of looking for mCGN on a renal biopsy to help make an early diagnosis so that more effective treatment and management of the disease may be implemented. This will help contribute to a better patient outcome.

77 NurseCe4Less.com Human Immunodeficiency Virus

The human immunodeficiency virus (HIV) is primarily transmitted by sexual contact and contact with contaminated blood. After the initial HIV infection, approximately 5-6% of untreated patients each year progress to autoimmune deficiency syndrome (AIDs) and for patients who do not, there is a dormant period of up to 15 years.97 At that point viral replication increases rapidly, HIV begins to cause serious, irreversible damage to the immune system, and patients succumb to a wide variety of opportunistic infections and/or cancer.

The CDC estimates that at the end of 2016 (The last time that accurate statistics were available) 1.1 million Americans were infected with HIV and approximately 14% did not know they were infected.98 Screening for HIV is recommended for everyone between the ages of 13 and 65.99 Anyone who has had contact with blood contaminated with HIV, e.g., a healthcare worker who has a needle stick injury, should be tested for HIV.100 Also, anyone who has recently had exposure - or a possible exposure – to HIV, e.g., unprotected sex with someone who is infected with HIV should be tested.

People who are at high risk for HIV infection should be screened annually.99 High risk would include IV drug users, anyone who has had unprotected sex with someone who is infected with HIV, men who have sex with men, anyone who has had sex with more than one person since the last HIV test, anyone who has sex in exchange for drugs or money, people who are infected with hepatitis or tuberculosis or were treated for these diseases, and anyone who has been diagnosed with or treated for a sexually transmitted disease.99,101

Screening for HIV is critically important. It decreases the risk for transmission, especially given that many people are unaware they are infected, and it allows for early treatment of HIV infection. Testing for HIV after an acute exposure like a needle stick injury is critical because prompt use of post-exposure prophylaxis (PEP) can significantly decrease the risk of developing an HIV infection after an acute exposure.102 Screening for HIV is

78 NurseCe4Less.com typically done using a combination antibody-antigen test.101 There is no HIV vaccine.

Research: HIV and Biomedical Advances

This study focused on recent biomedical advances aimed at ending the HIV epidemic through prevention strategies.103 The authors considered a “status-neutral” strategy for both people living with HIV and those at risk with a high priority on engagement regardless of a person’s HIV status.

The program starts with HIV testing and “two divergent paths depending on the results.”103 The authors stated that the paths end at a “common final state.”103 They use the example of New York City men who have sex with men, which is a population with high HIV incidence and prevalence, to illustrate use of epidemic-ending technology. The authors stated that HIV continues to spread, with new HIV diagnoses being added to the staggering number of cases already reported. New models for prevention and treatment are urgent, especially in an era of prevention where viral load suppression affects both individual and public health, and “where pre-exposure prophylaxis (PrEP) represents a viable, highly effective biomedical intervention for HIV prevention.”103

Discussion:103

The authors of this research study introduced a new approach they called “status neutral,” because it incorporated people living with HIV and people at risk of HIV. This approach begins with an HIV test and proposes two different paths of care depending on the patient’s test results: a patient testing negative is placed in the group for “HIV Primary Prevention Engagement;” and, a patient testing positive is placed in the group for “HIV Treatment Engagement.”103 Both paths end at a common final state: patients “engaged in clinical care, with either sustained viral load suppression (VLS) or taking daily PrEP, reflecting that the risk of either HIV transmission or acquisition is negligible in this state.”103 This approach is described as “HIV status- neutral.”103 Care is provided regardless of the patient’s HIV status, and

79 NurseCe4Less.com continuous care services is provided as the patient and provider remain engaged in preventive care or treatment.

Key outcomes of this approach are that HIV testing is the ultimate gateway to prevention and care, the same approaches used for achieving viral load suppression for treatment are necessary and useful for HIV prevention, and people receiving prophylactic care are not distinguishable from people receiving treatment for HIV. The authors stated that “Normalizing both treatment and prevention serves to destigmatize both.”103 The authors maintain further that using a “status-neutral continuum” will help accomplish the ultimate goal of eliminating new HIV infections.103

Illicit Drug and Prescription Drug Use

Use of illicit drugs, prescription medications, and alcohol is a growing problem in the United States. The Substance Abuse and Mental Health Services Administration estimated that in 2018 7.8% of all Americans, 19.3 million, had a substance use disorder.104 In 2016 almost 63,000 Americans died from a drug overdose.105 The number of deaths in the United States from acute overdose of opioids increased by 345% from 2001 to 2017.106

The USPSTF states that “... the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or non-medical pharmaceutical use in children and adolescents.”21 Saitz (2018) recommends the use of a single questioning screening to detect drug use, stating that single question screening is as well validated for use in primary care as longer, more involved questionnaires, and the author advised clinicians ask patients: “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”107

Research: Opioid Use in an Era of Medical Marijuana Dispensaries

The authors of this research reported on 2004 to 2014 U.S. National Survey data, which focused on nonmedical prescription opioid use and the

80 NurseCe4Less.com change in prescription opioid use disorder (POUD) among users after medical marijuana law enactment.108 They raised an interesting question: Could the introduction of medicinal marijuana as a treatment for chronic pain reduce the need for opioid use and prescriptions? If the answer to this question is yes, medicinal marijuna could be a partial solution to the opioid crisis in the United States.

The dates of enactment vary from state to state with the first state, California, enacting a medical marijuana law in 1996. Rates of opioid use disorder (OUD) have increased and in 2016, 2 million Americans met the criteria for OUD. There has also been an alarming increase in opioid overdose deaths between 1999 and 2017 in the United States, as reported by the authors: “An estimated 25 million US individuals aged 12 years and older initiated nonmedical use of prescription opioids (NMUPO) between 2002 and 2011.”108

Research has partially attributed increases in POUD and opioid-related deaths to increases in prescription opioids dispensed for chronic, noncancer pain. Opioid prescribing increased from 1999 to 2010 and then decreased each year through 2015. However, opioid prescriptions remain approximately 3 times higher than in 1999. This spike in prescription opioids has contributed to 400,000 opioid overdose deaths in the United States between 1999 and 2017.”108

Marijuana provides possible pain relief, which is viewed as an alternative to prescription opioids, possibly lowering opioid use, nonmedical use, and serious outcomes of opioid use disorder and mortality. The authors reported that there is some evidence that medical marijuana laws (MMLs) may reduce certain opioid-related outcomes. The MML status and prevalence of NMUPO at a state-wide level was shown in some studies to correspond with a decreasing trend in POUD treatment following the opening of state-wide medical marijuana dispensaries. There was a significant limitation with these statistics since individual data was not included. Without individualized data, the authors stated, there was no direct proof that an individual’s reduction in opioid use was due to marijuana use.

81 NurseCe4Less.com There could be other factors leading to the decline in POUD treatment. This study found that there was not adequate support for the hypothesis that individual NMUPO and POUD are lower in states with MMLs.108

Discussion108

The authors acknowledged that further studies were needed to answer the important question of how medical marijuana laws and rise of dispensaries influenced opioid use for pain control. If their results were confirmed, this could suggest that medical marijuana laws may not be sufficient to reduce “individual-level opioid outcomes.”108 The better approach may be opioid- specific interventions. There was also no discussion regarding whether marijuana users may be more likely than nonusers to misuse prescription opioids and develop prescription opioid use disorder.

Glaucoma

Glaucoma is the second leading causes of blindness.109 Approximately 3 million Americans have glaucoma110 and about 50% have not been diagnosed.110 There several types of glaucoma and the most common, open angle glaucoma, is a progressive disease. Patients typically have no symptoms until the disease is quite advanced and glaucoma is discovered during an eye examination. Risk factors for developing glaucoma include age, African American ethnicity, diabetes, elevated intraocular pressure, family history, hypertension, and lipid disorders.109,110

Vision loss from glaucoma can be prevented with early detection and treatment.111 Periodic eye examinations can help slow vision loss, but there is no universal agreement on who should be screened and how often.109,112 The 2014 USPSTF guidelines concluded that there was no conclusive evidence for or against routine glaucoma screening.21 However, Zhao, et al. (2018) concluded that that the USPSTF guidelines were based in part on studies with insufficient patient follow up.111

82 NurseCe4Less.com Jacobs (2019) and the American Academy of Ophthalmology provided recommendations for individuals with and without risk factors. For individuals without risk factors, a comprehensive eye examination should be done every 5-10 years for patients < 40, every two to four years for patients 40-54 years of age, every one to three years for patients 55 to 64 years of age, and every one to two years for patients ≥ 65 years of age.109,112

Where risk factors exist, a comprehensive eye examination should be done every 1 to 2 years in patients < 40 and ≥ 55 years of age, and every 1 to 3 years in patients aged 40 to 54 years.109 The American Academy of Ophthalmology (2016) has stated that a comprehensive eye examination should be done every one to two years in patients < 40 and ≥ 55 years of age, every one to three years in patients aged 40 to 54 years, every one to two years in patients aged 55-64, and every one to two years in patients ≥ 65 years of age.112

Diabetes:

For individuals diagnosed with type 1 diabetes, a comprehensive eye examination should be done at five years from the time of diagnosis and then annually. For type 2 diabetes, a comprehensive eye examination at the time of diabetes should be done, and then annually.111

Research: Open-angle Glaucoma Case Study

The authors in this case study presented a 65-year-old phakic patient with open-angle glaucoma and no previous filtration surgery.113 They reported that patients with an intraocular lens (phakic) treated with high-intensity focused ultrasound (HIFU) might be at risk of pupil ovalization with accommodation loss.

The patient was treated in both eyes with HIFU. After intervention, the patient presented with mild uveitis for 10 days, which remitted with the application of topical cycloplegic and corticosteroid treatment. After that, he

83 NurseCe4Less.com reported a loss of near vision and examination showed pupil ovalization. It persisted 6 months later, with an accommodation loss of one diopter.

High-intensity focused ultrasound treatment applied in this study consisted in the sequential activation of 6 miniaturized piezoelectric transducers, activated for 8 seconds. The complications following the procedure were accommodation loss and pupillary ovalization.

Discussion:113

The authors stated that the complications observed in this patient had not been previously described in any literature. The authors concluded that the key factor that explained the accommodation loss and pupillary ovalization was the characteristic as a phakic patient. Because of the risk that phakic patients treated with HIFU might be at risk of pupil ovalization with accommodation loss, the authors recommended that this complication be included in the informed consent for patients with glaucoma who are offered HIFU as a treatment option.

Hearing Impairment

Hearing loss or hearing impairment is common in older adults, and advancing age is one of the primary risk factors for decreased hearing ability.114 Other risk factors for hearing loss are diabetes, genetic susceptibility, exposure to loud noise, exposure to ototoxic drugs, and recurrent ear infections.114,115

The USPSTF does not recommend routine screening for hearing loss in asymptomatic adults 50 years and older, noting that there is no convincing evidence to determine the benefits and harms of screening in this population.21

Hearing loss in newborns and children is relatively common; 1-2 per 1000 newborns and 2 of 1000 children have some form of hearing loss.116 Common causes or risk factors for childhood hearing loss may include

84 NurseCe4Less.com congenital anomalies, infection, trauma, and the use of ototoxic drugs like aminoglycosides and platinum antineoplastics.116 Hearing loss in the first few years of life can cause delays in cognitive, language, and speech development, so early identification of hearing impairment is critical.117

Hearing testing for newborns is mandatory in all 50 states.118 Specific guidelines for newborn hearing screening for each state can be viewed on link from the American Academy of Pediatrics.118

Research

The authors presented a case study of a 26-year-old man who was referred to an ear, nose and throat (ENT) clinic for hearing loss pain in the right ear.119

The patient stated that his hearing normal prior to a wasp sting to his ear. Hearing loss followed about 8 to 10 hours later. The patient had been taken to an emergency department about 29 days earlier because of the incident. At that time, the patient complained that he sensed the presence of a foreign object in his right ear. After inspection by the emergency department personnel, a foreign body was removed from the right ear that turned out to be a wasp, or Vespula vulgaris.

Inspection of the ear canal at the time of the patient’s evaluation at the ENT clinic revealed “erythema above the right tympanic membrane and what initially appeared to be a small perforation in the left upper quadrant of the right tympanic membrane.”119 Testing was performed confirming sudden sensorineural hearing loss (SSNHL). The reaction to the wasp’s Hymenoptera venom is believed to be an immunoglobulin E (IgE)-mediated allergy, or IgE- mediated mechanism. The patient was prescribed oral steroids.

The patient was asked to schedule a follow-up evaluation within 14 days but did not return for an evaluation until 42 days later. The patient advised the ENT team that his condition had not improved.

85 NurseCe4Less.com Testing revealed moderate hearing loss with a slight improvement in the higher frequencies when compared with the previous tests. An “intratympanic dexamethasone injection was tried. Topical phenol was applied to the right tympanic membrane and 0.5 mL dexamethasone (4 mg/mL) was injected through the anesthetized area.”119

At the patient’s follow-up visit 7 days later, the patient reported that his hearing had returned. Upon evaluation, the ENT team observed “a pinhole perforation to the right ear in the location of the intratympanic injection, but the previously described perforation/monomeric/dimeric area in the left upper quadrant had resolved.”119

Discussion119

The exact mechanism for the patient’s SSNHL following the wasp sting was not determined. The authors surmised it was possible that there was a connection between the IgE levels (associated with the allergic reaction induced by the Hymenoptera venom) and the development of SSNHL but further studies are needed to confirm this association. Sudden sensorineural hearing loss can have a number of causes. The most common cause is an idiopathic (an unknown) mechanism. Regardless of the mechanism, treatment involves the use of oral and intratympanic steroid injections. One possible cause is an insect sting, as in this case but a thorough history should be taken to rule out other causes.

Genitourinary Infections and Sexually Transmitted Diseases

Genitourinary infections and sexually transmitted diseases discussed in this section are asymptomatic bacteriuria, chlamydial infection, gonorrhea, and syphilis.

86 NurseCe4Less.com Asymptomatic Bacteriuria

Asymptomatic bacteriuria is defined as the presence of at least 105 colony forming units of bacteria per 1 mL of urine.120 Asymptomatic bacteriuria has been reported to occur in 2%-7% of pregnant women.121 It can cause pyelonephritis, low birth weight, preterm birth, and increased infant mortality.121,122

The USPSTF has published a draft statement about screening for asymptomatic bacteriuria, and it recommends that all pregnant women should be screened for asymptomatic bacteriuria with the use of a urine culture.123

Chlamydial Infection

Chlamydia trachomatis is bacteria that can cause many types of infections, but it is most often a sexually transmitted disease.124 Chlamydia is the most common sexually transmitted disease in the United States,and it can be transmitted by anal, oral and vaginal sex. Most cases of sexually transmitted chlamydia infections occur in adults aged 18-24.124,125 Twice as many women as men develop chlamydia infections, and these infections can cause chronic pelvic pain and infertility.125 Men infected with chlamydia can develop urethritis, epididymitis, prostatitis.124 Chlamydia can also be transmitted from mother child, and C. trachomatis infection in an infant can cause conjunctivitis and/or pneumonia.126

Signs and symptoms of a sexually transmitted chlamydial infection may include vaginal discharge and pain when urinating. However, chlamydial infections may not cause signs and symptoms and given the consequences of chlamydial infection, screening is recommended.21 Screening is done by testing a urine sample or testing fluid obtained by swabbing an infected area. The CDC recommendations for chlamydia screening include:127

● Sexually active women < 25 years of age. Sexually active women 25 years of age and older if there is increased risk: women who have a new sex partner, more than one sex partner, a sex partner who has concurrent

87 NurseCe4Less.com partners, or a sex partner who has a sexually transmitted infection. Re- test patients at three months post-treatment.

● Pregnant women < 25 years of age. Pregnant women who are sexually active, 25 years of age and older, and who have an increased risk. Retest during the 3rd trimester for women under 25 years of age or who have increased risk.

● Consider screening young men if there is high prevalence of infection or if they are in a risk group, e.g., men who have sex with men. Men who have sex with men should be tested at least once a year, and all possible infection sites should be tested. If the patient has increased risk, test every three to six months.

● People who have HIV infection should be tested at the time of diagnosis and at least once a year after that. More frequent testing should be done if the patient has increased risk.

The USPSTF recommendations for chlamydia screening state that sexually active women who are < 24 years and younger and older women who are risk for chlamydial infection should be screened.21

Gonorrhea

Gonorrhea is a common sexually transmitted disease caused by infection with Neisseria gonorrhoeae bacterium. Gonorrhea infections can occur after anal, oral, or vaginal intercourse, and the infection can be transmitted from a pregnant woman to her child. In 2017 there were 555,608 reported cases of gonorrhea in the United States.128 Gonorrhea is more common in men than in women, most cases occur in adolescents and young adults.128 Gonorrhea is more likely to occur in people who have multiple sex partners, ethnic minorities, people who are substance abusers, and in people who have had a gonococcal infection.129

88 NurseCe4Less.com Gonorrhea can cause chronic pelvic pain, ectopic pregnancy, pelvic inflammatory disease, and tubal infertility.128 In men, gonorrhea can cause epididymitis and urethritis.129 In addition, a gonococcal infection may increase the risk of HIV transmission.128

Many people who have gonorrhea are asymptomatic and given that transmission of the bacterium is very effective, screening is essential. Screening is done by testing a urine sample or testing fluid obtained by swabbing an infected area. The CDC recommendations for gonorrhea screening include the following groups of people.127

● Sexually active women under 25 years of age. Re-test patients at three months post-treatment.

● Sexually active women 25 years of age and older if they are at increased risk. Increased risk is: A new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI. Additional risk factors for gonorrhea include inconsistent condom use among persons who are not in mutually monogamous relationships, previous or coexisting sexually transmitted infections, and exchanging sex for money or drugs.

● All pregnant women < 25 years of age, and older pregnant women if they are at increased risk.

● Men who have sex with men should be screened at least once a year, and testing should be done at all body sites of sexual activity. Men who have sex with men and have an increased risk should be tested every three to six months.

● People who have HIV infection should be tested at the time of diagnosis and at least once a year after that. More frequent screening should be considered based on the patient’s risk factors and the burden of HIV infection in the area.

89 NurseCe4Less.com The USPSTF recommendations for gonorrhea screening in women state that sexually active women who are < 24 years and younger and older women who are risk for gonococcal infection should be screened.21

Syphilis

Syphilis is a sexually transmitted disease caused by the Treponema pallidum bacterium. Syphilis can be transmitted by anal, oral, or vaginal intercourse, and less often by blood transfusion and organ transplantation, nonsexual personal contact, and in utero transmission.130

In its early stages a syphilis infection does not cause dramatic or highly specific signs or symptoms – primarily genital lesions and non-specific signs and symptoms - but a late stage syphilis infection may cause severe neurological complications.130 Vertical transmission can cause congenital syphilis, and this has been associated with severe developmental, musculoskeletal, and neurological morbidities and fetal death.131,132

There were 30,644 cases of syphilis in 2017, and most cases occurred in men and in men who have sex with men. The CDC recommendations for screening for syphilis state that the following groups should be screened:133

● All pregnant women should be screened for syphilis at the first prenatal visit.

● If the patient has a high risk for syphilis, re-test early in the third trimester and again at delivery.

● Men who have sex with men should be screened at least once a year and screened every three to six months if they are high risk.

● People who have HIV infection should be tested at the time of diagnosis and at least once a year after that. More frequent screening should be considered based on the patient’s risk factors and the burden of HIV infection in the area.

90 NurseCe4Less.com Research: Rates and Trends on Syphilis

The authors of this study reported that the rates and trends of syphilis vary by populations, and review the current rates of syphilis in the United States.134 They examined P&S syphilis trends in key subgroups and considered how national and county trends differ.

Syphilis varies among subgroups of people, for example, “men who have sex with men (MSM), rates of primary and secondary (P&S) syphilis are high throughout the United States (228.8 per 100,000 in 2013). P&S syphilis among women is much less common (0.9 per 100,000 in 2013) and occurs in isolated outbreaks plus in a few counties with persistent low levels of infection. Congenital syphilis trends closely follow P&S trends among women.”134 Varying trends of syphilis impacts health prevention practices. For example, tertiary syphilis can be prevented among MSH with routine screening, however the infection rates reportedly continue to increase among MSM and “will soon approach those last seen in 1982 (estimate: 340.7 per 100,000).”134 In women, the control of syphilis is important because of the risk of congenital syphilis associated with untreated syphilis during pregnancy. Intensive screening and partner notification continues to be a hallmark of syphilis prevention and treatment.

The authors reported the following trends in syphilis prevention and treatment in the United States:134 ● In 2012, syphilis cases reached a 13-year high in adults and an all-time low in newborns. ● Primary and secondary (P&S) syphilis case reports in adults have increased annually (2000 and 2012) from 5,979 to 15,667. ● Congenital syphilis reports (2000 and 2012) decreased from 580 to 322, the lowest number of reported cases since 1988 when the case definition changed. ● Divergent trends in adult and congenital syphilis reveal the complex epidemiology of syphilis. ● P&S syphilis among MSM were rising prior to the syphilis elimination plan (1999), but trends among MSM were difficult to detect. National syphilis

91 NurseCe4Less.com case report data did not include sex-of-sex-partner information until 2005, which continues to be incompletely reported in certain areas.

The authors suggested that because of the very large number of syphilis cases among MSM, the trends in syphilis occurring in the heterosexual population are now hidden and easily missed. Trends in syphilis cases within a certain region can be hidden when combined in one trend. Diagnosing, treating, and preventing syphilis involve decisions based on the local epidemiology. The authors analyzed P&S syphilis case data reported to the Centers for Disease Control and Prevention during 1963–2013, and congenital syphilis case data reported during 1995–2012. Since 1963, the reports have included the sex of cases, and both the sex and age of cases have been reported since 1983. Cases of syphilis based on the person’s county of residence has been available in reports since 2003. The epidemiology of U.S. cases of syphilis over the past 10 years and earlier were reviewed among MSM populations.

Syphilis is diagnosed according to stage and typically trended according to cases involving primary and secondary stages (P&S), which the authors stated “most accurately reflect recent infection and are less susceptible to changes in screening rates because (presumably) cases are detected due to signs and symptoms.”134 There are no signs or symptoms in people with latent syphilis and this stage tends to be reported as early latent and occurring within the year before diagnosis, and as late latent without evidence of when the infection was contracted. The authors reported that P&S represents an estimated one-quarter of syphilis cases, and limited their enquiry to P&S syphilis case reports (recently acquired infections).

Epidemiological facts of congenital syphilis raised in the study are included below:134 ● The risk of congenital syphilis is very high in women diagnosed with syphilis. ● On average, there is one case of congenital syphilis for every 4.5 women with P&S syphilis (since 1995).

92 NurseCe4Less.com ● P&S syphilis among women decreased from 7,779 cases (1995) to 1,458 cases (2012); at the same time, the number of congenital syphilis cases fell from 1,863 to 322. ● Congenital syphilis is more difficult to diagnose; maternal antibody crosses the placenta, and infants with antibody may not be infected. ● The risk of over-treatment is small compared to under-treatment in congenital syphilis infection due to its debilitating outcomes. ● Surveillance case definition was changed to be highly-sensitive (1988), not specific, to not miss cases. ● Congenital syphilis exists if there is inadequate syphilis treatment in the mother at delivery, or if syphilis is evident in the newborn. ● Congenital syphilis trends are similar to the trends in P&S among women.

Epidemiological facts of syphilis among adults raised in the study are included below:134 ● Sex-of-sex-partner information was not included in the national data until 2005 with varying completion of case reports between regions making syphilis among MSM difficult to monitor; however, MSM syphilis cases are reportedly on the rise in the U.S. ● The male:female rate ratio has been rapidly increasing since 2000 with the highest level recorded in 2013. ● The estimated percent of MSM cases was 25.1 in 2000, 78.2 in 2008, and 89.7 in 2013. ● P&S syphilis rates for MSM (per 100,000 MSM) was 15.8 in 2000, 146.5 in 2008, and 228.8 in 2013. ● The rate for MSM was 243 times the rate for women (0.94 per 100,000 women) and 214 times the rate for heterosexual men (1.07 per 100,000 heterosexual men) in 2013. ● During 1963–2013, MSM syphilis cases peaked at 15,820 in 1982. ● The rate of infection was 340.7 per 100,000 or about 1.5 times the rate in 2013 (228.8 per 100,000) in MSM cases. ● During the early years of the AIDS epidemic there were dramatic decreases of MSM syphilis attributed to behavior change among MSM and deaths in men at highest risk for syphilis.

93 NurseCe4Less.com ● Rates in MSM syphilis will soon surpass the peak that occurred in 1982 if trends go unchecked. ● Multiple investigators have collected information on sex-of-sex-partners of persons with syphilis, and current estimated rates of syphillis between studies are similar.

The authors of this study estimated that “78.2% of all male P&S syphilis cases were MSM for the entire United States in 2008. Analysis of data from 39 states and Washington DC in 2008, found sex partner information was available for 86.5% and estimated that the rate of syphilis (per 100,000) was 154 for MSM and 2.2 for other men. A study from New York City in 2008, estimated rates for 18–64 year-old MSM to be 707 per 100,000 MSM, 147 times the rate for MSW (4.8).”134 For 15–54 year old men in the U.S., the authors estimated 255.5 for MSM and 2.9 for heterosexual men. By 2013 these estimated rates had changed to 404.7 for MSM and 1.9 for heterosexual men.

The rates of syphilis among HIV-infected MSM have been high, and the authors reported that MSM with syphilis not already infected with HIV carried a very high chance of being infected. ● Between 2002–2006, 52.7% of MSM diagnosed with P&S syphilis had HIV co-infection in California. ● An estimated 4% of HIV-infected MSM acquired syphilis (2011) in Seattle. ● Men with P&S syphilis diagnosed in Atlanta, San Francisco, and Los Angeles were tested for evidence of recent seroconversion in one study, and an estimated 10.5% of MSM with P&S syphilis had recently acquired HIV. ● Men diagnosed with early syphilis in Florida (2003) had an estimated 21.5% diagnosed with new HIV infection at the end of 2011 in one study. ● Some MSM acquire syphilis repeatedly. In California, 300 (10%) of 3,000 MSM with P&S reported between 2002 and 2006 had a repeat early syphilis infection reported within 2 years. ● In South Florida in 2008, 10% of all persons diagnosed with early syphilis had a previous syphilis diagnosis between 2000 and 2008.17 In San Diego, between 2004 and 2007, 11.7% of MSM with early syphilis had another syphilis diagnosis within 2 years.

94 NurseCe4Less.com The occurrences of MSM syphilis and HIV could be increasing according to the authors. Their analysis did not consider repeat infections, and the identification of repeated syphilis infections may help in the monitoring and prevention of transmission in at risk populations.

The U.S., rates of syphilis cases were calculated by the authors using “data for all ages combined because national syphilis data were not available by both age and sex until 1983.”134 The authors restricted their analysis to men aged 15 and older, and the rates (per 100,000 MSM) were 20.6 in 2000, 180.9 in 2008, and 282.2 in 2013. By further restricting their analysis to men ages 15–54, the rates for MSM were 23.0 in 2000, 255.5 in 2008, and 404.7 in 2013.

Rates of P&S syphilis vary according to geographic region. Every state, including the District of Columbia, showed an increase in cases involving men between 2003 and 2013, and there was a slight increase among women in 31 areas. Different counties reported differences in P&S syphilis rates. The authors stated that “Of 3142 counties in the US, 2123 (67.6%) reported no P&S syphilis in 2012. Half of reported P&S syphilis in the US came from 27 counties, which contained 19.6% of the U.S. population in 2012. Among US counties, 436 (13.9%) averaged at least 2 cases of P&S per year for the 10- year period ending in 2012, and only 47 counties (1.5%) averaged at least 1 case per week during that time.”134

Four counties (Los Angeles, Cook, New York, and San Francisco) reported the most P&S syphilis cases between 2003 and 2013, which varied between the four counties and from national trends. All four counties reported large increases P&S syphilis rates among MSM, with relatively lower syphilis rates among women. San Francisco rates of MSM syphilis decreased between 2005–2007 then increased, while in Los Angeles an opposite trend reportedly occurred. Later increases in syphilis among MSM were reported in other counties. Some counties reported high rates of P&S syphilis among women, for example, “Jefferson County, TX, where there was no reported P&S syphilis among women in 2003 or 2004, 140 cases during 2008–2009, and 2 cases in

95 NurseCe4Less.com 2013.”134 Some counties reported heterosexual epidemics alongside increases in the MSM population.

The rates of syphilis for other subgroups of MSM were reportedly higher. Although the authors did not estimate MSM syphilis accounting for race, syphilis rates “have been increasing the most among all young black men. Between 2004 and 2008, syphilis diagnoses increased among young black men in 70% of large metropolitan areas and HIV among black MSM increased in 85% of areas. Using reported data from 27 states in 2008, the rate for MSM aged 25–34 was 1.8 times the rate of all MSM (over age 12), and the rate for black MSM was estimated to be 2.3 times the rate for all MSM in the US. In New York City, the rate of P&S for 18–64 year old MSM was 0.7% but the rate for MSM aged 18–29 was 1.4% and the rate for black MSM was 2.4%.”134

The authors identified a significant challenge in controlling MSM syphilis. They pointed to a paucity of literature on interventions to lower MSM syphilis rates. While gay-friendly services were raised in the 1970s to decrease stigma, with a provision of screening in gay bars and bathhouses where infections were found, investigators found that “the population is very large, and our efforts must be viewed more as surveillance than as control programs.”134 Early investigators had reported that screening may help to limit syphilis and advocated for monthly syphilis screening in high risk MSM, but provided no data on the numbers of men tested. Stigma has decreased since the 1970’s, however, is an ongoing concern. Therefore, HIV-infected MSM should be tested for syphilis as a form of routine screening and prevention. The authors noted that HIV clinics have not routinely tested patients for syphilis, and screening rates are low. In San Francisco, 37.5% of high-risk MSM (2012) reported being screened within the previous 3 to 6 months.

While the rates of syphilis are occurring among the MSM population, the more serious complications of infection are linked to congenital syphilis. With antibiotic treatment, the U.S., death rate has significantly reduced since the 1930’s (death rate 16 per 100,000). Today, syphilis rarely causes death in an adult. As high as 1–2% may develop symptomatic early neurosyphilis. Whereas, syphilis transmission during pregnancy and the damaging

96 NurseCe4Less.com consequences of congenital infection remain unchanged; an estimated “66.5% of women with untreated syphilis will have an adverse outcome of pregnancy, including 25.6% who will have a stillbirth. Thus, compared with disease in adults, the relative importance of congenital infection is higher than in the past.”134 The authors concluded that “universal screening can detect and cure many, but not all, infections because some women acquire infection after the initial test, some who are detected are not treated, and some women do not seek care until late in pregnancy.”134

Discussion:134

With regard to congenital syphilis, the authors stated that in regions where the risk for congenital syphilis is high, serologic testing and a sexual history should be obtained at 28 weeks’ gestation and at the time of birth. Health providers should know when the risk is high. They reported that in areas where three syphilis tests were required by law, there was still only 9% of pregnant women tested three times despite the known fact that the “most effective way to prevent transmission during pregnancy is to prevent infection in women.”134 Although congenital syphilis is less common than ever, its effects are devastating. The authors concluded that “the most effective way to prevent congenital syphilis is to prevent syphilis among women.”134 Heterosexual outbreaks of syphilis have been better controlled by prevention interventions. Nonetheless, a consequence of heterosexual syphilis is congenital syphilis with a high concern that greater efforts need to occur to further reduce rates of congenital syphilis by intensifying prevention interventions among women.

The authors reported that syphilis is on the rise in certain subgroups of the U.S. population with most cases being among MSM. They stated that screening can identify most syphilis infections before tertiary syphilis develops, preventing most complications. Syphilis testing added to HIV viral load testing is recommended for clinics and the authors suggested that this combined screening has led to a greater number of infections being identified. In the MSM population, the authors suggested additional approaches to

97 NurseCe4Less.com screening and prevention of syphilis is needed. The syphilis epidemic (1967– 1982) suggests the MSM increasing rates of infection may continue.

Iron Deficiency Anemia and Pregnancy

Anemia during pregnancy is defined as a hemoglobin level < 11 g/dL in the first and third trimester and < 10.5 g/dL in the second trimester.135 Anemia during pregnancy is very common; the prevalence depends on the population that has been studied and in economically distressed areas up to 90% of pregnant women have been found to be anemic.136 Iron deficiency anemia accounts for 95% of all cases of anemia during pregnancy.137 When undetected and uncorrected, iron deficiency anemia has been associated with low birth weight, premature labor, developmental issues and other morbidities.138,139

Iron deficiency anemia during pregnancy is caused by increased maternal iron requirements for red blood cell production, inadequate intake, and growth of the fetus and placenta.139 Iron deficiency anemia during pregnancy is easily treated, but it often goes undetected.139 However, screening is a somewhat controversial topic.140,-142

The USPSTF and the International Federation of Gynecology and Obstetrics (FIGO) state that the current evidence is insufficient to determine whether the benefits of screening for iron deficiency in pregnant women outweigh the harm associated with screening.140,141 The USPSTF specifically stated that “... the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes.”141 The International Federation of Gynecology and Obstetrics also noted: “Although iron deficiency in pregnancy is, in principle, identifiable, treatable, and possibly preventable, there is uncertainty about its significance as a clinical and public health problem, and whether systematic screening and treatment for iron deficiency and iron deficiency anemia in pregnancy would improve maternal and infant outcomes.”140

98 NurseCe4Less.com Some practitioners recommend screening but even supporters of screening for iron deficiency anemia admit that “... the data do not definitively demonstrate a cause-and-effect relationship between iron deficiency and adverse outcomes or between iron supplementation and improved outcomes.”142

Research: Intravenous Iron for Iron Deficiency Anemia

The authors of this study located through a PubMed search focus on the use of intravenous infusions of iron to treat iron deficiency anemia during pregnancy.143

The incidence of iron deficiency anemia is reportedly common and associated with adverse maternal and fetal health, especially in South Asia. Maternal mortality, preterm labor and low birth weight are amongst the health risks associated with iron deficiency anemia during pregnancy. The authors stated that screening for anemia “is not sufficient to diagnose iron deficiency. Iron deficiency in neonates is associated with a statistically significant increment in cognitive and behavioral abnormalities which persist after iron repletion. Oral iron is the frontline standard but is associated with an unacceptably high incidence of gastrointestinal adverse events leading to poor adherence.”143

Neonatal iron deficiency occurs at an estimated rate as high as 45% despite oral iron supplementation. Oral iron ingestion is associated with poor absorption and efficacy. Intravenous iron has been reported as safe and effective during the second and third trimesters of pregnancy, and is the preferred route for an intolerance of oral iron or in situations where oral iron is ineffective or harmful. For severe anemia (< 8 g/dL) in the second or third trimester, intravenous iron is preferred when iron quantities delivered to the fetus is believed to suffer, as iron requirements increase during every trimester of a woman’s pregnancy.

The authors stated that the guidelines for maternal and neonatal screening and treatment lack consistency and differ between the United States

99 NurseCe4Less.com and Europe. Intravenous iron is “underutilized in pregnancy and guidelines suggesting there is insufficient evidence to recommend the routine screening and treatment of iron deficiency in gravidas should be revisited.”143 The authors suggested that in low-income countries there could be a trial to test the “efficacy, safety, cost and feasibility of the administration of intravenous iron to anemic and/or iron-deficient women.”143

Anemia during pregnancy varies between 8% and 20%, depending on the economic status of a worldwide region. The authors stated that in India and Pakistan there were some regions reporting up to 90% incidence rate. In some of these areas, hemoglobin levels of 8 mg/dl in an estimated 10% of pregnant women exists although oral iron and vitamin preparations are reportedly available.

Iron deficiency can lead to significant serious health outcomes in maternal and fetal health. During pregnancy there is a reported two-fold increase incidence of preterm labor and a three-fold increase in the incidence of low birth weight in pregnancy cases involving iron deficiency. Screening for anemia alone is “not sufficient to diagnose iron deficiency. If iron deficiency and heavy vaginal bleeding are present at the beginning of pregnancy, the incidence of preterm labor is increased five-fold. Iron deficient mothers, irrespective of anemia, are at risk of delivering iron deficient neonates.”143 The authors stated that the current data suggests that iron deficient neonates showed delayed growth and development, and cognitive and behavioral abnormalities that continued even after iron repletion.

Oral iron therapy is the current standard treatment for iron deficiency anemia, although it is often not optimal as treatment in pregnancy. Intravenous iron is “safe, effective and should be considered early in the treatment paradigm for iron deficient gravidas, irrespective of the presence or absence of anemia.”143 The authors stated that the Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG) and the United States Preventive Service Task Force (USPSTF) all recommend routine screening for anemia during pregnancy; additionally, the CDC and ACOG has recommended low-dose iron supplementation for all

100 NurseCe4Less.com pregnant women. A recent USPSTF publication supported these guidelines, however noted that “there is insufficient evidence that routine prenatal screening and supplementation for iron deficiency anemia improves maternal or infant clinical health outcomes, but supplementation may improve maternal hematologic indices.”143 Although there is a lack of published outcome data, published evidence suggests more work needs to be done on the existing recommendations.

More could be said about the value of iron administration to prevent serious health outcomes in iron deficient pregnant women. The Cochrane Collaboration reported that “a paucity of quality trials assessing clinical maternal and neonatal effects of iron administration in pregnant women with anemia.”143 While studies are absent that validate the health benefits of routine iron deficiency screening and iron supplementation, the authors point to current medical research opinion suggesting that the USPSTF statements be revisited. They stated that the current USPSTF recommendations will also miss identifying women with iron deficiency without anemia.

Pregnant women are not typically screened for iron deficiency unless reportedly anemic with a low hemoglobin concentration. Half of iron deficient pregnant women may be missed by clinicians when iron measures are not added to the screening laboratory profiles. Clinicians need to be aware that iron deficiency during pregnancy will occur prior to the development of anemia. Significant morbidity from iron deficiency has been reported, which may happen in the absence of anemia. Fetal sequelae include neonatal and childhood brain growth, developmental abnormalities with adverse effects on myelination, neurotransmitters and brain programming, and there is a two- fold increased incidence of preterm birth, a three-fold increase in low birth weight, and small for gestational age could occur. Maternal low serum ferritin concentrations correspond with neonatal iron deficiency with both cognitive and behavioral abnormalities reported up to 19 years of age.

Maternal iron deficiency anemia is also associated with “increased risk for caesarean section, increases in transfusion, perinatal bleeding, pre- eclampsia, placental abruption, abnormal maternal thyroid status, impaired

101 NurseCe4Less.com wound healing, cardiac failure and death.”143 The replacement of iron through proper supplementation has been shown to decrease morbidity in women with “heavy uterine bleeding, inflammatory bowel disease, chronic kidney disease, cancer and chemotherapy induced anemia, heart failure, hereditary hemorrhagic telangiectasia, bariatric surgery, the pre-, peri- and post- operative periods and in critically ill patients.”143 The authors concluded that it is reasonable to expect that “in the absence of harm, a similar benefit to iron deficient gravidas would be observed leading to the credible conclusion that, given the absence of quality prospective outcomes data, we should err on the side of repletion until such data are available.”143 They reference a study of 2400 urban Chinese women that reported up to 45% of infants were iron deficient despite oral supplementation.

Because iron requirements significantly increase during pregnancy, this becomes significant in the setting of the need to perform a caesarean section. Daily iron requirements reportedly increase from 0.8, 4–5 to 6 mg/day in the first second and third trimesters respectively. Iron requirements in pregnancy “may exceed 1000 mg, with 500 mg required for red cell expansion, 300–350 mg for the developing fetus and placenta, with variable losses at delivery.”143 The World Health Organization (WHO) estimated anemia of pregnancy approaches 50% worldwide. The WHO defines anemia of pregnancy “as a hemoglobin level of less than 11 g/dL, or hematocrit < 33%, at any time during pregnancy with the CDC defining anemia of pregnancy as Hb < 11 g/dL, or hematocrit < 33% during the first and third trimesters and less than 10.5 g/dL, or a hematocrit < 32% in the second trimester.”143 ron deficiency treatment is oral iron administered as two to three 325 mg tablets containing approximately 50–65 mg elemental iron daily.

Although the oral form of iron is inexpensive and readily available, >70% of people taking it will complain of significant gastrointestinal disturbances, including metallic taste, gastric irritation, and worsening constipation, which leads to poor adherence. During pregnancy, rapidly increasing progesterone levels slow bowel transit, and the growing fetus leads to pressure on the bowel/recturm. Also, hepcidin (hepatic synthesized iron regulatory protein) decreases iron absorption through the intestinal

102 NurseCe4Less.com epithelium. During pregnancy, the need for iron absorption is more important for maternal and fetal health making effective iron repletion a preventive health priority.

Gastric acid (for conjugation of the iron to amino acids), sugars and vitamin C are important to protect the elemental iron from conversion to (unabsorbable) ferric hydroxide in the proximal duodenum. This becomes a significant health concern for pregnant women who have undergone bariatric surgery (roux-en-Y or biliopancreatic bypass procedures). Other iron formulations are needed, such as heme polypeptide, enteric coated and timed release iron, which increased tolerability and with equivalent efficacy to ferrous sulfate.

There are research reports showing that a ferritin level less than 15 ng/ml in a pregnant woman compromises growing fetal brain development that is critical from week 34 throughout the remainder of the mother’s pregnancy. Screening for iron deficiency in newborns is currently not recommended in any of the worldwide guidelines. Along with the deficiencies identified in existing prenatal screening practices, the authors suggest that oral iron therapy (in moderately to severely anemic pregnant women) should be considered for replacement with the parenteral route as a preferred treatment. Intravenous iron has been shown “to be nearly uniformly safe and effective, with serious adverse events extremely rare…”143

The authors stated that the 2008 ACOG Practice Bulletin recommended intravenous iron in the “rare patient who cannot tolerate or will not take modest doses of oral iron.”143 The ACOG also stated that women with severe malabsorption may benefit from parenteral iron. The United Kingdom guidelines (2012) stated that “parenteral iron should be considered from the second trimester onwards and during the postpartum period for women with confirmed iron deficiency who fail to respond to or are intolerant of oral iron.”143 The treatment of anemia in pregnancy was addressed in a recent review by Achebe and Gafter-Gvili who recommended that intravenous iron be considered in 2nd and 3rd trimester patients intolerant to oral iron, 2nd

103 NurseCe4Less.com trimester gravidas with hemoglobin concentrations < 10.5 g/dL and in all in the third trimester with iron deficiency anemia.

Successful use of intravenous iron during pregnancy is not novel according to the authors. Studies of intravenous iron for iron deficiency during pregnancy have been reported since the 1960s, and the safety and efficacy of complete replacement dosing with iron dextran has been published. Intravenous iron administration during pregnancy continues to be studied in iron intolerant women, including during second and third trimesters where oral iron intolerance exists.

Discussion:143

Published evidence on intravenous iron administration during pregnancy has been discussed, and the available studies are growing. There is published data suggesting that intravenous iron administration for pregnant women is safe and effective in correcting iron deficiency. The authors stated that a “consistent finding in virtually all published evidence is the absence of serious adverse events.”143

Clinicians are slow to include intravenous iron into the screening and prevention treatment for iron deficiency during pregnancy. The authors submit a reason for this clinical gap in clinical practice may be due to the fact that “no intravenous iron formulation has been assigned the highest safety rating from FDA…”143 They suggest the lack of FDA endorsement may actually be a discouragement to obstetricians who possibly struggle in a litigious environment. Minor infusion reactions in the case studies may also further delay the use of parenteral iron formulations despite the fact most are very safe.

The authors discussed the cost of intravenous iron formulations for poorer countries, which would negate its use. Nonetheless, the authors recommended that clinicians revisit the current international guidelines for the screening and treatment of anemia during pregnancy, and provided the following suggested steps:143

104 NurseCe4Less.com ● All newly diagnosed gravidas, irrespective of hemoglobin level at presentation to their obstetricians, midwives or other providers, be screened for iron deficiency to include serum iron, total iron binding capacity, percent transferrin saturation and serum ferritin. ● If iron deficiency is present in the first trimester one ferrous sulfate tablet every other day should be taken. We acknowledge these recommendations may not be practical for much of the world’s pregnant woman with limited health care budgets, however the potential improved outcomes may prove cost effective. ● If iron deficiency is diagnosed in the second trimester, the hemoglobin is greater than 8 g/dL and the mother’s serum ferritin is greater than 15 ng/ml, one ferrous sulfate tablet every other day should be taken with a rapid switch to intravenous iron if the therapy proves ineffective or is poorly tolerated. If the hemoglobin level is less than 8 g/dL or the mother’s serum ferritin is less than 15 ng/ml, the intravenous route is preferable. ● Neonates at risk for iron deficiency should be screened at birth. These include preterm infants, infants of diabetic mothers, infants born to anemic or iron deficient mothers, those with parasitic infestation or malaria, HIV, and those who had chronic hypoxia in utero (infants of smokers). ● In low income countries, a trial or demonstration project to test efficacy, safety, cost and feasibility of the routine administration of intravenous iron appears prudent. ● Intravenous iron is the preferred route of replacement if required, in the third trimester. ● A prospective comparison of oral to intravenous iron with screening of neonates appears prudent.

Major Depression

Major depression is the most common psychiatric disorder.144 The lifetime prevalence of depression has been estimated to be between 6.8 to 8.7%.145 In 2017, an estimated 17.3 million American adults and 3.2 million adolescents reportedly had a major depressive disorder.146 Risk factors for depression may include adverse life experiences, family history of depression,

105 NurseCe4Less.com female gender, major illness, certain medications, and substance abuse.147,148 Depression is the most important risk factor for suicide.149

The diagnostic criteria for major or depressive disorder include that five or more of the following symptoms have been present during a two-week period, are a significant change from the patient’s previous mood and functioning, at least one of the symptoms is depressed mood or loss of pleasure or interest, and the symptoms are not caused by a medical condition. The criteria include those outlined here.148

● Depressed mood most of the day, nearly every day. The depressed mood can be subjective (for example, the patient reports feeling sad, hopeless) or can be observed by others. In children or adolescents, irritation is often present. ● Markedly diminished interest or pleasure in daily activities. This happens nearly every day and is reported by the patient or by others. ● Significant weight loss (>5% of body weight) when not dieting or a decrease or increase in appetite nearly every day. (In children, consider failure to make expected weight gain.) ● Insomnia or hypersomnia nearly every day. ● Psychomotor agitation or retardation nearly every day: this should be observable by others and not just the patient’s feelings of restlessness or feeling lethargic. ● Fatigue or loss of energy nearly every day. ● Feelings of worthlessness or excessive or inappropriate guilt nearly every day. ● Diminished ability to think or concentrate, or indecisiveness, nearly every day, reported by the patient or observed by others. ● Recurrent thoughts of death; recurrent suicidal ideation without a specific plan; a suicide attempt or a specific plan for committing suicide.

The symptoms are generally known to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Further, major depression is suspected when the episode is not attributable to a substance or another medical condition, the occurrence of

106 NurseCe4Less.com the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders and there has never been a manic episode or a hypomanic episode.

Many people who have major depression are not identified.144 Screening can identify people who are depressed, and screening and there is evidence that early treatment can improve the response rate to treatment and improve outcomes.144,150

The USPSTF recommendations for depression screening state that depression screening should be done in the general population, including pregnant and postpartum women. Depression screening should be done with adequate systems in place “... to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”150

There is evidence that screening improves identification of people who are depressed, and identification and use of therapies for depression improves clinical outcomes and decreases clinical morbidity. The optimal timing and optimal interval for screening for depression is not known. Short depression screening questionnaires that have been validated and have good sensitivity and specificity are available:144,150 the Beck Depression Inventory for Primary Care (BDI-PC), the Patient Health Questionnaires (PHQ-2 and PHQ-9), the World Health Organization Well-Being Index (WHO-5). There is no significant difference between these questionnaires in terms of performance.144

The prevalence of depression in children ages 3 to 5 has been estimated to be 0.5%; in children aged 6 to 11 1.4%, and in adolescents aged 12 to 17, 3.5%.151 The USPSTF recommends screening for major depressive disorder in adolescents aged 12 to 18 years.151 Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.152

107 NurseCe4Less.com PHQ-9 Screening Tool Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things. 2. Feeling down, depressed, or hopeless. 3. Trouble falling or staying asleep or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating. 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching television. 8. Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way.

The possible answers and their respective scores are: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

Depression score ranges: 5 to 9: Mild 10 to 14: Moderate 15 to 19: Moderately severe 20 to 27: Severe

Research: Comorbid Major Depression and PTSD

The authors of this case study reported on an unusual case of a 36- year-old female with major depression and a history of post-traumatic stress disorder (PTSD) who had a remission of symptoms following treatment.153 The patient also had co-occurring adrenal insufficiency diagnosed by an insulin tolerance test (ITT). The authors reported that the patient experienced remission PTSD symptoms following a hypoglycemic episode with intravenous short-acting insulin.

108 NurseCe4Less.com The patient’s social status was married, with no children. She had completed university and worked as a lawyer. Her primary psychiatric symptoms included depression, low motivation, insomnia, and feelings of worthlessness. She was diagnosed with major depressive disorder (MDD) and was started on escitalopram 20 mg daily.

After 5 weeks of treatment the patient showed no signs of improvement. Paroxetine 60 mg daily was started for depressed mood and trazodone 150 mg at bedtime for insomnia, which led to a marked improvement of the patient’s symptoms after 6 weeks; however, the patient continued to have difficulty starting activities.

Later, the patient was diagnosed with Hashimoto autoimmune thyroiditis. Levothyroxine 75 mg daily was believed to help with remission of depressive symptoms and the patient was diagnosed with mood disorder secondary to hypothyroidism with a major depressive-like episode.

In the following year the patient became pregnant. Multiple birth defects of the fetus were diagnosed by ultrasound, and fetal demise transpired in week 16 of the pregnancy. The patient developed psychiatric symptoms of intense fear and helplessness, and eventually sought help for unremitting depression, poor motivation, insomnia, and feelings of worthlessness. The patient began to have dreams of the trauma related to losing her child and the perception that the event was recurring; however, she had poor memory of details related to the trauma. When efforts were made to discuss the loss of her child, the patient became withdrawn and defiant. She had symptoms of irritability, angry outbursts, difficulty concentrating, and hypervigilance. She was unable to function socially at home or work. Major depression in the context of acute PTSD was diagnosed.

Paroxetine 20 mg daily and trazodone 75 mg at bedtime were prescribed since they had worked for depression in the past and were also indicated for PTSD. After 5 weeks of treatment there was not much improvement. Paroxetine was increased up to 60 mg/day and trazodone increased up to 150 mg daily at bedtime. Sleep dysfunction was described as delayed onset of

109 NurseCe4Less.com sleep at nighttime, frequent waking periods during the night, and the patient reportedly showed high irritability, as well as multiple outbursts of anger and anxiety. Trazodone was increased to 200 mg at bedtime and diazepam 5 mg twice daily was added.

Medically, the patient lost 10% of her initial body weight over a month, and had a body mass index (BMI) 19 kg/m2. Physical symptoms were described as general weakness, dizziness and fainting, episodes of hyperventilation and paresthesia. She experienced dehydration and hypotension of 100/60 mmHg at rest with orthostatic hypotension. Serum adrenocorticotropin (ACTH) and cortisol levels drawn in the morning as an outpatient showed slightly decreased levels (ACTH = 6.00 pg/ml; cortisol = 4.90 ng/ml), and the patient was diagnosed with suspected adrenal insufficiency.

A physical examination determined the patient had a correct circadian rhythm with serum cortisol (6:00, 5.60 µg/dl; 8:00, 11.30 µg/dl; 20:00, 4.40 µg/dl; 24:00, 4.20 µg/dl), and correct levels of the hormone in a 24-h sample of urine: 28.2 µg/24. The ACTH concentration in the daily profile of the serum was correct (6:00, 6.12 pg/ml; 8:00, 10.20 pg/ml; 20:00, <5.40 pg/ml; 24:00, 7.07 pg/ml). Thyrotropin concentration (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) were all within normal range; however, the patient had elevated anti-thyroid peroxidase (TPO) antibodies, 253 IU/ml (reference range < 35 IU/ml). The authors stated that “In order to assess the ACTH/cortisol axis for detecting secondary adrenal insufficiency, a standard ITT was performed.”153 The authors stated that symptomatic hypoglycemia, blood glucose values < 40 mg/dl to evoke a reliable central stress response with activation of the hypothalamic–pituitary–adrenal (HPA) axis was initiated with the use of insulin 0.1 units/kg; 6j aspart insulin intravenously. The patient developed symptomatic hypoglycemia with blood glucose 29 mg/dl within 30 minutes, and experienced mild palpitations, severe hot flushes, and sweating, which disappeared within several minutes of the procedure. Abnormalities of the ACTH/cortisol and growth hormone secretion were excluded from testing.

110 NurseCe4Less.com Psychiatry consultation followed the patient’s treatment, and the psychiatrist reported a marked improvement of the patient’s mental status. The patient showed less PTSD symptoms, “arousal diminished, sleep was normalized, and bouts of anxiety became much less frequent and less severe.” Memory improved for the patient and she was able to recall traumatic events, and recurrent distressing dreams since the trauma event reportedly disappeared. The symptoms of MDD continued, including depressed mood, decreased interest, and feelings of worthlessness. Diazepam was tapered over 10 days and stopped.

The patient’s MDD symptoms continued to gradually lessen. Trazodone was lowered to 100 mg at bedtime (from 200 mg at bedtime), and paroxetine reduced to 40 mg daily from 60 mg daily. Within 14 months following the insulin tolerance test, the patient remained in remission from depressive symptoms and was planning a pregnancy.

Discussion:153

A review of the literature included statistics showing that an estimated 52% of patients diagnosed with PTSD develop a co-occurring condition of major depressive disorder (MDD). Symptoms can include cognitive impairment, resistance to antidepressant medications, and increased risk of suicide in comparison to individuals diagnosed with PTSD alone.

Differences between people with PTSD and MDD and those with PTSD alone have been determined through the use of neuroimaging studies:153 ● Medial prefrontal cortex and amygdala activation by threatening stimuli are lower in the PTSD/MDD group than in those diagnosed with PTSD alone. ● People with PTSD/MDD exhibit a lower functional connectivity between the insula and hippocampus when compared to those with PTSD alone. ● It may be hypothesized that PTSD and MDD comorbidity can represent a subtype of PTSD. ● There is an approximate 60% response rate of PTSD symptoms to FDA approved pharmacological treatment.

111 NurseCe4Less.com ● Prognosis PTSD and MDD co-occurrence in people is less than for those diagnosed with MDD or PTSD alone. ● Treatment dropout rates for people diagnosed with PTSD/MDD are more common. Therefore, optimal drug therapy is necessary to ensure patient retention and treatment success.

The authors reported on a case of insulin tolerance testing that resulted in hypoglycemia, and consequently resolution of the patient’s PTSD symptoms. Mention was made of Manfred Sakel, an Austrian psychiatrist, who used insulin to help decrease anxiety and agitation in patients during opioid withdrawal. Insulin shock therapy was originally used to treat schizophrenia and later it was used for depressive disorders. This procedure had not been scientifically determined. The authors postulated that the patient’s symptoms of depression were a result of metabolic issues that improved with intravenous insulin-induced hypoglycemia. The patient was able to experience excitation due to the “effect of insulin on the central nervous system, the impact of hypoglycemia on the release of aspartate and glutamate, and transiently GABA.”153 Lower GABA levels seen in PTSD has typically been treated with benzodiazepines.

The HPA response axis in patients with PTSD/MDD are similar to those with PTSD alone. Patients with PTSD/MDD typically have lower peripheral cortisol levels with enhanced glucocorticoid receptor (GR) sensitivity, whereas patients with PTSD “have an exaggerated cortisol suppression response to dexamethasone (DEX), which indicates that the negative-feedback system of the HPA axis is overly sensitive.”153 Intranasal insulin prior to a psychosocial stressor reportedly can diminish saliva and plasma cortisol in healthy people without affecting heart rate or blood pressure stress, which indicates that insulin blunts the stress-induced HPA axis response. In this case report, an induced hypoglycemic episode with intravenous short-acting insulin corresponded with improvement of PTSD symptoms in a female with PTSD and MDD comorbidity. The authors highlighted the mutual dependencies between the endocrine and nervous systems that is an ongoing area of research by neuroendocrinologists.

112 NurseCe4Less.com Screening for Newborns, Children and Adolescents

This section focuses on key areas of screening and treatment of youth in the prevention literature, including congenital hypothyroidism, obesity, phenylketonuria, sickle cell disease and visual impairment.

Congenital Hypothyroidism

Normal functioning of the thyroid gland is essential for cognitive, neurological, and physical development.154 Congenital hypothyroidism occurs in 1:2000 to 1:4000 births, and undetected, untreated congenital hypothyroidism can lead to growth deficiency as well as severe mental retardation.154-156 It is one of the most common preventable causes of intellectual disability, and there is an inverse level between time of initiation of treatment and intelligence quotient.156

Congenital hypothyroidism is primarily caused by a disruption in the development of the thyroid gland, and it is easily detected and treated.154-156 Screening for congenital hypothyroidism is mandatory in the United States. The infant’s blood is tested one to two days after birth.156 The blood is tested for T3, T4, thyroid stimulating hormone (TSH) levels. Different approaches to the use of these tests have recommended and the decision as to which to use should be done on a case by case basis.156 False negative and positive results can occur, and clinicians should be aware of any situation that can affect the accuracy and sensitivity of screening.156

Obesity

The prevalence of obesity in children and adolescents in the United States has been estimated to be 18.5%/13.7 million children and adolescents.157 More than one-third of children and adolescents are overweight.158

The adverse health effects of obesity in adults are well known, and obese children have a high risk and an increased risk of developing dyslipidemia,

113 NurseCe4Less.com hypertension, non-alcoholic fatty liver disease, obstructive sleep apnea, type 2 diabetes, and other diseases.159,160

The USPSTF recommendations are obesity screening in children and adolescents state that children 6 years of age and older should be screened for obesity using measurement of BMI. The USPSTF concluded that screening and interventions can improve weight status.158

Phenylketonuria

Phenylketonuria is a rare genetic disease that causes an inability, in varying degrees, to metabolize the amino acid phenylalanine.161,162 Elevated phenylalanine levels can cause serious neurological and psychiatric morbidities like attention deficits, anxiety, irreversible intellectual disability, mood disorders, and seizures.161,162 The incidence of phenylketonuria has been estimated to be 1 in 10,000 live births.161

All infants should be screened for PKU.161 In all 50 states, PKU screening is mandatory and is done by measuring serum phenylalanine level, usually by tandem mass spectrometry.162

Sickle Cell Disease

Sickle cell disease is an inherited hematologic disorder. People who have sickle cell disease have an abnormal, inherited hemoglobin called hemoglobin S. When hemoglobin S binds to oxygen, red blood cells form an abnormal shape (the sickle shape) and result in hemolysis. Hemolysis causes an anemia that deprives the tissues of oxygen and blocks blood vessels.163,164 Sickle cell disease primarily affects African Americans, and approximately 1 in every 365 African Americans has the disease.164

All newborns should be screened for sickle cell disease.163 Screening provides early recognition of the disease and early intervention, and the latter can reduce morbidities and decrease mortality rate.166

114 NurseCe4Less.com Research: Sickle Cell Disease

It was difficult to find infant cases of sickle cell disease in a review of the current literature; however, a PubMed search provided this case study of a 20-year-old African American female with a history of sickle cell disease. The authors reported the patient had multiple hospital admissions for vaso- occlusive crisis (VOC) and severe pain throughout her body.167

The patient in this case was admitted to the hospital in severe distress. Vital sign measures showed a blood pressure 155/101 mmHg, pulse 117 beats per minute, temperature 37.6 C, respiratory rate 25 breaths per minute, and oxygen saturation 98% on room air. On physical examination, the patient had poor bilateral air entry due to splinting (on auscultation) and an audible aortic systolic murmur. There was mild-to-moderate tenderness felt on palpation over her extremities. The neurological examination was normal.

Laboratory testing revealed leukocytosis, 12,800 with 53% neutrophil, 32% lymphocyte, and 1% band, hemoglobin 7.5 gm/dL, hematocrit 22.3%, platelet 181,000/dL, reticulocyte count 13%, lactate dehydrogenase 1144 IU/L, normal blood urea nitrogen, creatinine, and serum electrolyte studies. Liver function tests showed a total bilirubin level of 16.2 mg/dL but was otherwise unremarkable. The chest X-ray was negative.

Initial treatment included intravenous hydration, and analgesia with the use of intravenous narcotics. Within 24 hours of being admitted to the hospital, the patient reportedly became unresponsive suddenly, and naloxone was administered without effect to improve her mental status. A CT scan of the head was performed urgently and revealed a large right-sided frontoparietal epidural hematoma with midline shift, and herniation.

Laboratory data was repeated and showed a platelet of 45,000/dL, prothrombin time 19.7 Seconds, INR 1.7, activated partial thromboplastin time 43 seconds, and a fibrinogen level of 96 mg/dL, consistent with a diagnosis of disseminated intravascular coagulation (DIC). Surgery was arranged on an emergency basis to evacuate the hematoma. The patient

115 NurseCe4Less.com continued to deteriorate during surgery and became hypotensive and, despite emergency medications and interventions, she eventually died from disseminated intravascular coagulation (DIC) 24 hours after surgery.

Discussion167

The authors reported that most cases of sickle cell disease comprised males (80%). The age ranges were between 2–35 years (males) and 7– 19 years (females). Of the total cases 84% had sickle cell disease.

Symptoms varied in the reported cases. Headache was reported for 37% of those admitted to hospital, whereas symptoms consistent with VOC, such as pain crisis, were the initial physical symptom in 40% of cases. Other symptoms included eye swelling, proptosis, seizure, and coma.

Patients who reported having a headache also were found to have EDH on admission (82% of the time). Also, patients who presented with VOC, reportedly progressed to have EDH within 6–120 hours after hospital admission. The authors also provided the following findings and opinions from reported cases:

● Unilateral EDH was more common (65% of cases). ● Subgaleal hemorrhage was concurrently present (30% of cases) and associated with bone infarction (78% of cases). ● 48% of patients with EDH showed evidence of overlying bony infarction. ● Overall mortality among the reported cases was 23%. ● Patients with evidence of overlying bone infarction had a survival of 100% and patients with DIC had a mortality of 100%. ● Most common cause of EDH is trauma causing injury to the middle meningeal artery, middle meningeal vein, the diploic vein, or the dural venous sinuses. ● Spontaneous non-traumatic EDH is a rare manifestation of SCD and variant sickle cell syndromes. ● The pathophysiology of this rare occurrence is not completely understood.

116 NurseCe4Less.com Most cases in the literature involved males but whether there is true gender specific etiology remains unknown. Risk factors for stroke in SCD include low steady-state hemoglobin and high leukocyte count. It remains unclear whether this is true for EDH. Hemorrhagic strokes are reportedly more prevalent in adult SCD patients between the ages of 20–30 years. In adolescents, EDH is believed to be more prevalent. The authors reported three causes of rare entity: “1) Vaso-occlusion of the hematopoietically active calvarial diploic bone resulting in bone infarction and subsequent leaking of blood and proteinaceous material in the subperiosteal, epidural, or subgaleal space. 2) Acute rapid expansion of hematopoiesis with resultant microfracture of already thinned inner cortex and extravasation of blood and hematopoietic tissue. 3) Sludging of sickle cells in the diploic veins hampering venous drainage and oozing of blood due to vascular injury and elevated back pressure. A combination of different mechanisms could also be responsible. Presence of coagulopathy or platelet dysfunction worsens hematoma expansion and portends a dire clinical outcome.”167

The authors stated that patients admitted with VOC developed EDH in an average of 24 hours. They stated that early deterioration is expected in this patient population. There are difficulties associated with the diagnosis of bone infarction, and MRI was reportedly the most sensitive tool. In the acute phase of the disease, CT scan had low yield. The authors opined that “patients without any obvious bony disruption and infarction, most likely suffer from microfracture of the inner table and extrusion of blood and hematopoietic cells in the epidural space due to rapid expansion of hematopoiesis.”167 Coagulopathy as occurs in cases of DIC worsens bleeding. The authors reported 100% mortality in patients diagnosed with spontaneous EDH and DIC.

Visual Impairment in Children Ages 3 to 5: Amblyopia

Amblyopia is defined as a functional reduction in visual acuity that is caused by abnormal visual development during childhood.168,169 Amblyopia is the most common cause of monocular visual impairment in children,168 with a reported prevalence of 1%-4%.169,170 Amblyopia develops during a critical

117 NurseCe4Less.com period of three months to eight years when the vision is maturing. Risk factors for amblyopia include having a first-degree relative with amblyopia, neurodevelopmental delay, premature birth, and small size in relation to gestational age, strabismus, and anisometropia.169-171 Amblyopia affects boys and girls equally.169

Screening for amblyopia is recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and the USPSTF.169,171 Early detection of amblyopia and early treatment improves the chances of normal visual development and can reduce the severity of amblyopia.169,171 Untreated amblyopia is not likely to resolve spontaneously, 149 and amblyopia can increase the risk of vision abnormalities and/or vision loss in the unaffected eye.171

The USPSTF recommendations for amblyopia screening state that children from 3 to 5 years old should be screened for amblyopia and amblyopia risk factors at least once.171

Children who are preverbal are screened by using the fixation reflex test or the objection to occlusion test.171 Children who are three years of age or older can have their visual acuity checked by using the Snellen chart (the classic eye chart with letters and numbers, viewed from 20 feet away) or by using Allen figure cards.171

In the fixation reflex test one eye is occluded, the examiner moves an object back and forth across the child’s visual space, and the child’s ability to maintain contact - to fixate - is assessed. During the occlusion test the examiner watches the child’s response as each eye is alternately occluded. Children who have amblyopia will usually become upset when the good eye is occluded.

118 NurseCe4Less.com Research: Amblyopia in Children

The authors of this study reported that amblyopia (blunted sight) is a common condition affecting 2-3% of the population, and involves a unilateral or bilateral decrease in vision where no cause exists.172

People affected by amblyopia experience reduced visual acuity, the phenomenon of crowding, presence of a central suppression scotoma, and impairment of binocular vision. The authors stated that first-line treatment involves “correction of any existing significant refractive error for at least 18 weeks (refractive adaptation) but full resolution only occurs in about 30%.” If amblyopia persists, treatment will include patching, or more recently, penalisation. Wearing patches can be uncomfortable and compliance tends to vary. There have been reports of bullying against children who wear patches.

The normal eye is covered up to help improve the vision in the amblyopic eye; however, it can also lead to reduced vision in the patched eye. The authors reported on an alternative treatment using a strategy based on dichoptic stimulation. They defined dichoptic stimulation as “the ability to present different images to each eye independently. For example, one could present the sprite (a sprite is a computer graphic which may be moved on- screen and otherwise manipulated as a single entity and here refers to a gaming object of interest) to one eye and objects to collect to the other eye thereby forcing both eyes to work together in order to successfully play the game.”172

A number of early devices had been developed to treat amblyopia: 1) Priestly-Smith’s fusion tubes, 2) Worth’s amblyoscope, and 3) Maddox developed the major amblyoscope, or synoptophore (in the 1930s). The synoptophore was developed with the notion of dichoptic stimulation for therapeutic benefit. However, the interest of participants typically did not last more than a few minutes and little therapeutic effect was realized.

Currently, rapid advances in stereo-viewing technology has led to easily adapted dichoptic stimulation. This new technology involves a virtual reality-

119 NurseCe4Less.com based system to treat amblyopia using dichoptic stimulation, either playing special video games or watching DVDs (Interactive Binocular Treatment or I- BIT). The authors stated that the I-BiT™ system “can improve the visual acuity in amblyopic patients. The most recent of these pilot studies using shutter- glasses technology showed that all patients who completed their planned treatment (nine of the 10 patients) showed a mean improvement in visual acuity of 0.18 LogMAR.”172

The I-BiT™ system was originally designed for treating patients under supervision in a hospital-based setting. The authors reported on an I-BiT system for home use combined with an eye-tracker. This method allows for dichoptic stimulation and harmonious retinal presentation with the use of visual material that engages a child long enough for treatment. Their target study participants included children ages 3.5 to 12 years with anisometropic, mixed and strabismic amblyopia. They aimed to report on dichoptic stimulation as an effective treatment for amblyopia, building upon previous studies. They introduced the I-BiT system with the following improvements:172

● Home-based system: simple use and safe. The system switches off if it is left idle for 15 minutes and can be used without supervision ● Range of games and videos (not just one game and one video) ● Allow image off-setting for strabismic and mixed amblyopia ● Simple psychophysical tests incorporated ● Monitor activities undertaken and treatment time. A treatment session longer than 1 hour or more than 2 hour in a day is not permitted. ● A face verification system to ensure the person using the system is the intended participant

Mention was made that a major cause of treatment failure with patching is poor compliance; however, engaging video games also has unique compliance issues. This revised I-BiT included eight programmed games for reasonable choice and around 40 hours of videos aimed to appeal to the 3.5– 6 years of age group.

120 NurseCe4Less.com In strabismic and mixed amblyopia, “only the fovea can support normal visual acuity and so it seems an important requirement that the dichoptic images are presented harmoniously. The revised I-BiT has this capability to off-set images by a required amount and it can measure the distance of the participant from the screen in real time to ensure that the angle of off-set can change with distance such that the degree of off-set as measured in prism dioptres is kept constant.”172

Study participants included those whose only treatment was prescription glasses, not patching. All participants must have undergone at least 12 weeks of refractive adaptation, which can occur over 30 weeks and standard practice is to allow 18 weeks of refractive adaptation prior to initiating patching or penalisation.

The tests described are standard, however variation exists in practice, especially with children. Practice variation involved clinicians’ perceived failures in concentration by the child. Other variations centered on patient diagnosis, for example, “patients with anisometropic amblyopia are required not to have had previous patching or penalisation whereas this is permissible for those with strabismic amblyopia.”172 Age of presentation was described as a determining factor; most patients with strabismic amblyopia were less than 3.5 years of age and considered too young to engage use of I-BiT. On the other hand, patients with anisometropic amblyopia usually presented at 3.5 years of age, making I-BiT more feasible.

Data was collected for cost-utility analysis in the pediatric population, which posed a problem of accuracy. No instrument existed for children under the age of six. There were two questionnaires used to calculate Quality- adjusted Life Years (QALYs): 1) the CHU-9D22 and 2) the EQ-5D-Y23. The CHU-9D22 was validated for ages 7–11 years and the EQ-5D-Y23 for age 8 years. For ages 6–7 years the CHU-9D performed better than the EQ-5D-Y and so the authors chose it. It also had a proxy form whereby a guardian could respond on behalf of the child. The authors also used a modified CAT-QoL “which is a treatment-specific tool as a disease-specific measure.”172

121 NurseCe4Less.com The authors stated that the “revised I-BiT does have the ability to perform simple psychophysical testing. The participants in this study will be monitored clinically but the efficacy of this automated testing will be separately assessed as it may be possible, in the future, to monitor progress remotely and without the need for hospital visits.”172 The I-BiT approach was described as having the ability to transform how patients with amblyopia are treated.

Discussion:172

Amblyopia or lazy eye affects a significant percentage of children in the U.S., and worldwide. The condition has been studied in numerous worldwide studies. The authors of this case study reported on the traditional eye patch treatment as it compared to the I-BiT system - stereo technology. The eye patch treatment involves having the child wear a patch over his or her good eye for a number of hours daily, over several months. The I-BiT system - stereo technology uses shutter glasses designed to treat amblyopia with dichoptic stimulation. It is designed with home use application and eye- tracking capability.

This study was sponsored by the Department of Research and Innovation at Nottingham University Hospital Trust. In 2018, research subjects were being recruited and the study is currently underway to determine how the I-BiT system will help in the treatment of amblyopia, as well as patient engagement and compliance of all age groups recruited.

Interpersonal Violence: Intimate Partner & Elder

The CDC defines intimate partner violence (IPV) as “... physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.”173 The CDC lists four behaviors as being part of IPV:173 ● Physical violence: Someone hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.

122 NurseCe4Less.com ● Sexual violence: Forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent. ● Stalking: Repeated, unwanted attention and contact by a partner that causes fear or concern for one’s safety or the safety of someone close to the victim. ● Psychological aggression: Verbal and non-verbal communication with the intent to harm another person mentally or emotionally and/or exert control over another person.

Approximately 1 in 4 women and 1 in 10 men have experienced IPV, and psychological aggression is particularly common: More than 43 million women and 38 million men have experienced psychological aggression by an intimate partner at least once in their lives.173

Risk factors for IPV are community, personal, relationship, and societal, e.g., poverty, poor community support, low self-esteem, alcohol and drug use, jealousy and possessiveness in the intimate relationship, and economic inequality.173 The consequences of IPV may include physical harm and death, psychological conditions like depression, post-traumatic stress disorder (PTSD), sexually transmitted disease, substance use disorder, suicide, unwanted pregnancy, and pre-term birth.174

Screening can detect IPV inflicted on women but there is no conclusive evidence that screening decreases the incidence of IPV. There is no data on screening men for IPV.174

The USPSTF recommendations for screening for IPV state that women of reproductive age should be screened for IPV and if appropriate, provide support service or refer to support services.174 There is no evidence about the appropriate intervals for IPV screening. These screening instruments have been shown to accurately IPV in adult women that has occurred in the past year: Humiliation, Afraid, Rape, Kick (HARK), Hurt, Insult, Threaten, Scream (HITS), Extended–Hurt, Insult, Threaten, Scream (E-HITS), Partner Violence Screen (PVS), and Woman Abuse Screening Tool (WAST).

123 NurseCe4Less.com WOMEN ABUSE SCREEN TOOL

1. In general, how would you describe your relationship? A lot of tension/some tension/no tension 2. Do you and your partner work out arguments with: Great difficulty/some difficulty/no difficulty? 3. Do arguments ever result in you feeling down or bad about yourself? Often/sometimes/never 4. Do arguments ever result in hitting, kicking or pushing? Often/sometimes/never 5. Do you ever feel frightened by what your partner says or does? Often/sometimes/never 6. Has your partner ever abused you physically? Often/sometimes/never 7. Has your partner ever abused you emotionally? Often/sometimes/never 8. Has your partner ever abused you sexually? Often/sometimes/never

Elder Abuse

The CDC defines elder abuse “... as an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.”175 Elder abuse includes emotional/psychological abuse, financial exploitation, neglect, and sexual abuse, and the perpetrators can be family members and healthcare workers.176 The consequences of elder abuse may include emotional and psychological distress, physical harm, and death.174

Risk factors for elder abuse are community, personal, relationship, and societal, e.g., alcohol and drug use, inadequate support services, and poverty.175 The National Council on Aging notes that approximately 1 in 10 million Americans 60 years of age or older has suffered some type of elder abuse, and that only 1 out of 14 cases are reported.176

The American Medical Association, the American Academy of Neurology, and the US Medicare program recommend screening for elder abuse.177 The USPSTF concluded that there is insufficient evidence to determine the balance of benefits and harms of screening for elder abuse.174 The Brief Abuse Screen

124 NurseCe4Less.com for the Elderly (BASE) and the Elder Assessment Instrument (EAI) have been validated and are simple and fast to use.177

Research: Interdisciplinary Team and Elder Care

The authors of this case study reported on an 85-year-old widowed, Caucasian male who received healthcare through the Department of Veterans Affairs. He carried diagnoses of left-sided cerebrovascular accident with hemiparesis but without significant language impairment.178

The patient was in need of extended care; he had no in-home assistance since his wife died and he had no other family support. His health history included hypertension, arteriosclerotic heart disease, sleep apnea (treated with a continuous positive airway pressure [CPAP] device), age-related macular degeneration (early stage), and chronic back pain (adequately controlled). Laboratory testing was unremarkable. A brain magnetic resonance imaging (MRI) prior to his stroke had revealed mild to moderate chronic small vessel disease. His mental health history included a diagnosis of posttraumatic stress disorder related to his military service (asymptomatic at the time of his long-term care placement) and bereavement related to the loss of his spouse.

Prior to his stroke the patient had lived independently at home with his spouse at the time of her unexpected death. He developed difficulty managing his independent needs, and reportedly becoming less organized and increasingly depressed living alone at home. Following the stroke, he underwent a period of rehabilitation and was diagnosed with Alzheimer’s disease. It was determined the patient was in need of a legal guardian; however, the patient strongly opposed having one appointed. His personal lawyer reportedly felt concern for his protection, and petitioned the county court for joint guardianship and conservatorship. The patient’s diagnosis of Alzheimer’s disease was highlighted as a reason for the need of “a permanent plenary guardian and conservator.”178 A cousin who was familiar with the patient was appointed guardian and conservator by the court.

125 NurseCe4Less.com The patient did not progress much with rehabilitation efforts and was transitioned into long-term care. The guardian proceeded to sell the patient’s house; however, the sale of his property and home items were not the patient’s wishes. The authors identified relevant statutes pertaining to this case. In this case, state statute allowed for:178 ● Any person to petition the court for the appointment of a conservator for a proposed ward, with specific reasons why one is believed to be needed. ● A court may then appoint a conservator upon finding that it is in “the best interest of the proposed ward.” ● The court could classify the adult as an “incompetent person” defined as “an individual who, for reasons other than being a minor, is unable unassisted to properly manage and take care of himself or his property as a result of the medical conditions of advanced age, physical disability, disease, the use of alcohol or controlled substances, mental illness, mental deficiency or intellectual disability.” ● Many states have moved away from relying on global determinations of incapacity in favor of more limited and specific determinations making for guardians or conservators with limited authorities. ● Decisional abilities are not specifically addressed as part of the guardianship and conservatorship statutes, but may be found in statutes related to health care decisions. ● “Capacity” (in this case) is defined as “the ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision.”

The authors reported that the patient remained in the long-term care facility and continued as an active participant in his healthcare, in the facility where he stayed, and in community activities. An interdisciplinary health team were part of his treatment planning and consisted of an advanced nurse practitioner, nurse manager, registered nurse, social worker, psychologist, chaplain, physical therapist, occupational therapist, recreational therapist, dentist, and dietician.

Members of the interdisciplinary team met weekly to discuss the patient’s treatment plan. A formal treatment team session, which included the

126 NurseCe4Less.com patient, met on a quarterly basis to discuss his long-term care status. The patient was actively engaged with his social worker and nurse practitioner and made several requests related to his medical decisions and finances. His major concern related to regaining control over his finances. The patient made his own low risk medical decisions such as agreeing to start or discontinue medications, and consenting to special procedures such as laboratory blood draws, the seasonal flu shot, and other treatments.

Veteran benefits were included in the patient’s finances. He received a monthly check from the federal government (disability from his wartime service). The guardianship was considered a related evaluation, and was done to “capture diagnostic impressions and to evaluate the patient’s capacity to manage his own finances.”178 Interdisciplinary health team members generally agreed the patient did not appear to have a major neurocognitive disorder; however, the patient was evaluated as perseverative, making repetitive requests and showing a defect of memory. The patient also was observed to have a decline in his decisional capacity, i.e., donating large sums of money to a suspicious charity. The health team noticed a male visitor taking the patient out for meals but always made the patient pay the cost. After some of these meal outings, the patient suddenly wanted to donate approximately $50,000 to a children’s charity run by this same person. Although the patient had fired his lawyer the lawyer had investigated previous court cases involving this male visitor and discovered a history of financial exploitation of vulnerable people. The lawyer’s discovery aligned with the treatment team’s observations that the patient lacked decisional capacity.

The patient was provided information regarding his evaluation and the recommendation for continuance of the conservatorship. He was informed that the evaluation would focus on his financial abilities, and that evaluation of medical decision-making capacity would require another evaluation. The patient appeared to understand and provided informed consent. The guardian provided consent for the evaluation.

The patient’s general physical functioning, cognitive abilities, and perceptions of impressionability were considered. The guardian was consulted

127 NurseCe4Less.com for specific information related to the patient’s health history, financial management skills, and with regard to his finances, and legal counsel was consulted for the financial portion.

The authors noted that an interview was completed and based on the American Psychological Association (APA)/American Bar Association (ABA) Assessment of Capacity in Older Adults handbook). Brief neurocognitive testing was administered to determine the patient’s specific cognitive strengths and weaknesses, and his cognitive performance was found to be in the average range, although this may have declined from a prior baseline.

The patient’s hemiparesis was considered the main concern of the interdisciplinary health team. Tasks that were challenging due to his hemiparesis included writing a check, balancing a checkbook, and using a calculator, however basic financial knowledge of his own resources remained intact.

The treatment team believed that the patient was susceptible to potential elder abuse, such as the influence of the representative from the children’s charity. The guardian opined that the patient was “very impressionable” and required protection; his large donation to the children’s charity was concerning to the team. Ultimately, the patient was found incapable of managing his day-to-day financial affairs, and the team proposed limited conservatorship “to balance the patient’s autonomy and need for assistance.”178 Recommendations made included providing assistance with the physical demands of financial management (writing checks, paperwork, etc.), and with the management of stocks, investments, and more difficult financial operations.

The patient needed both physical assistance following his stroke and oversight for his limitations with problem-solving. Specific recommendations were made for the team to provide effective communication when working with an older person, such as speaking at a slower pace, facing the person directly, and being mindful of professional jargon.

128 NurseCe4Less.com The patient’s lawyer and guardian had access to the patient’s report. The patient shared the report with his lawyer who provided it to the court. The authors stated that “the impact of medical and mental health conditions, and the prognosis of both must be weighed in determinations of capacity. In a related vein, the presence of neurocognitive impairments or disorders are essential to consider as they may affect decision-making abilities in various ways.”178

The treatment team had concerns about the patient’s safety and vulnerability to elder abuse; however, they were also careful to discuss all of their concerns and findings with him. Mention was made that “legal clarification on the state statutes relevant to the case provided further education to team members when patient autonomy could be curtailed by safety concerns.”178

Discussion:178

This case study showed how interdisciplinary team members engaged an older person with physical and cognitive disabilities, and the effort made to assist the patient with his needs and keep him safe. The authors recommended that interdisciplinary health team members make an effort to “elicit input up front from relevant stakeholders (e.g., the physician if the question pertains to medical decision-making, occupational therapy if there are questions about independent living).”178 These interprofessional interactions were described as “a prime opportunity to provide informal education about capacity evaluations.”178

Each health team member may have a different perspective regarding how to balance a patient’s safety over the patient’s autonomy. These different perspectives may conflict. To resolve this conflict, each team member should attempt to understand where the other member is coming as the team seeks to balance the patient’s safety and his need for autonomy.178 Providers should be interacting with a local or regional counsel or hospital attorney regarding local laws and practices that might be relevant to an assessment.178

129 NurseCe4Less.com Hospital policies and procedures are important to know. If necessary, a provider should step back and evaluate a situation. In this case, the patient had experienced delirium therefore no immediate decision was made until the patient could stabilize before evaluating for competency and a fitness to proceed with an evaluation.

Conducting capacity assessments are often challenging and may feel intimidating. Working as a team of health professionals will support all members of the health team as well as the patient and family members to consult and progress to act as advocates for the patient.

Prevention and Personal Health Counseling

Counseling is a vital component of preventive medicine. Screening tests detect health problems and identify people at risk. But screening tests should be followed by counseling and patient education if the patient has, or is at risk for a specific disease or disorder.

The USPSTF recommends that when appropriate, adult patients should be counseled about the following health concerns.21 ● Alcohol misuse ● Breastfeeding ● Falls ● Healthful diet and physical activity ● Motor vehicle occupant restraints ● Obesity ● Sexually transmitted infections ● Skin cancer ● Tobacco use

Children and adolescents should be counseled, when appropriate, about the following health concerns.21 ● Alcohol misuse ● Illicit drug use ● Motor vehicle occupant restraints

130 NurseCe4Less.com ● Obesity ● Sexually transmitted infections ● Skin cancer

Vaccinations

Vaccinations are a critically important part of preventive medicine. The Centers for Disease Control and Prevention has published recommendations for vaccination schedules, and these are available to the general public online at https://www.cdc.gov/vaccines/schedules/index.html.179

Summary

Screening is an effective method for detecting and preventing acute and chronic diseases. Health clinicians need to know the recommended screening tests or practice tools that may lead to early detection or prevention of medical problems that cause morbidity and mortality if left undiagnosed and untreated.

Screening tests include the recommendations contained in the U.S. Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services 2014, and recommendations on screening by applicable organizations such as the National Center on Elder Abuse, the National Academy of Sciences, the American Academy of Neurology and the American Medical Association.

Other public health concerns that have been raised in the above sections are currently being developed within interdisciplinary health teams that carry an interest in the development for improved standardized screening tools to help identify high risk health issues and guide patient education, such as those related to smoking cessation and exposure to second-hand smoke and varied other health and public safety hazards related to disease recognition and prevention.

Health clinicians who are informed on the evolving area of preventive health medicine, and of the many resources available to educate patients and

131 NurseCe4Less.com their families, are pivotal in guiding patients to make better health choices that help them to avoid illness. In addition to finding ways to reduce morbidity and mortality rates, such as through earlier disease detection, the above sections highlighted the many research trials validating the importance of screening for disease prevention and the role of health clinicians to continuously promote prevention education and the best available evidence on health prevention, and on the treatment and recovery of common diseases.

132 NurseCe4Less.com Self-Assessment of Knowledge Post-Test:

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.

1. One of the limitations of screening tests is

a. screening guidelines are often changed and updated. b. these tests rarely provide a high degree of specificity or sensitivity. c. the guidelines differ for children and adults. d. the benefits seldom outweigh the risks.

2. Screening tests must be used with the understanding that

a. they are seldom able to detect diseases. b. most of them are associated with harmful side effects. c. they are not diagnostic. d. they cannot be used for children.

3. Adults should be screened for alcohol misuse

a. unless the patient is pregnant. b. only if they use illicit drugs. c. only if they engage in risky drinking behavior. d. in all cases.

4. Breast cancer is

a. more common in women < 50 years of age. b. the most common cancer in women. c. primarily caused by cigarette smoking. d. not detectable without a biopsy.

5. What is the recommendation of the U.S. Preventive Services Task Force (USPSTF) regarding the use of mammograms to screen for breast cancer in women age 75 or older?

a. They should have a mammogram annually. b. The USPSTF recommends against a mammogram in all cases. c. They should have a biennial mammogram. d. There is no recommendation.

133 NurseCe4Less.com 6. Screening for cervical cancer

a. decreases mortality from the disease. b. should begin during adolescence. c. has no effect on mortality in women. d. is only recommended for women with a genetic disposition for cervical cancer.

7. Risk factors for colorectal cancer include

a. lower levels of low-density lipoprotein. b. a sedentary lifestyle. c. Leriches syndrome. d. perforation and bleeding.

8. Screening adolescents ages 12 to 18 for major depressive disorder should be implemented

a. on a case-by-case basis. b. if the clinician is comfortable talking about depression. c. with follow-up care. d. if depression symptoms have lasted 12 months or longer.

9. True or False: Diabetes is a major contributing factor to blindness, heart disease and kidney failure.

a. True b. False

10. Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in

a. all adults of any age. b. adults with a risk factor for diabetes and who are overweight. c. women who were pregnant. d. adults who are overweight or obese.

11. Screening for Hepatitis B is recommended for

a. people who misuse alcohol and people > age 50. b. infants born to HBV-infected mothers. c. patients with renal disease. d. anyone born between 1945 and 1965.

134 NurseCe4Less.com 12. Screening for Hepatitis C is recommended for

a. people who misuse alcohol and people > age 50. b. all persons who have diabetes. c. pregnant women and adolescents. d. anyone born from 1945 to 1965.

13. Screening for HIV is recommended for people

a. who are infected with hepatitis or tuberculosis. b. as part of routine screening for all patients. c. who misuse alcohol. d. with hypertension and diabetes.

14. True or False: The USPSTF recommends that all adults should be screened for hypertension.

a. True b. False

15. The Centers for Disease Control and Prevention (CDC) includes ______as one of the behaviors constituting intimate partner violence.

a. anger b. sexting c. theft d. All of the above

16. A patient who has comorbidities is considered severely obese if the patient has a body mass index (BMI)

a. of 25 to 29.9 kg/m2. b. ≥30 kg/m2 c. ≥25 kg/m2 d. ≥35 kg/m2

17. Osteoporosis is most common in

a. African American males. b. men age 50 or older. c. elderly white females. d. people of average or above average weight.

135 NurseCe4Less.com 18. The Centers for Disease Control and Prevention (CDC) recommendations for chlamydia screening include

a. all pregnant women. b. pregnant women < 25 years of age. c. all women of childbearing age. d. men who are sexually active.

19. True or False: The benefits of prostate cancer screening far outweigh the risks.

a. True b. False

20. All newborns should be screened for

a. lipid disorders. b. iron deficiency anemia. c. phenylketonuria. d. liver disease.

21. All pregnant women under the age of 25, regardless of risk, should be screened for

a. gonorrhea. b. trichomonas. c. HSV infection. d. Hepatitis C.

22. All newborns should be screened for

a. sickle cell disease. b. elevated cholesterol. c. Hepatitis C. d. All of the above

23. True or False: Screening infants for hearing impairment is mandatory.

a. True b. False

136 NurseCe4Less.com 24. All newborns should be screened for

a. HIV. b. diabetes. c. Hepatitis B. d. congenital hypothyroidism.

25. Which of the following is the leading cause of preventable deaths in the United States?

a. Diabetes b. Alcohol c. Tobacco d. HIV

26. Which of the following is NOT true regarding cigarette smoking in the United States?

a. Sidestream smoke is more toxic than second-hand smoke. b. Multi-residential living arrangements can expose non-smokers to second-hand smoke. c. There is a safe level of second-hand smoke. d. Sidestream smoke enters a person’s lungs more easily than second- hand smoke.

27. Health effects of secondhand smoke include

a. sudden infant death syndrome (SIDS). b. ear infections. c. pneumonia. d. All of the above.

28. Which of the following is a drug approved by the Food and Administration (FDA) for assisting patients with smoking cessation?

a. Tamoxifen b. Disulfiram c. Varenicline d. Raloxifene

137 NurseCe4Less.com 29. Sidestream smoke is smoke that is

a. produced when a person exhales cigarette smoke. b. emitted from the burning end of a cigarette or cigar. c. produced by inhaling tobacco smoke. d. less toxic than second-hand smoke.

30. True or False: Intimate partner violence may include stalking.

a. True b. False

31. Risk factors for non-melanoma and melanoma skin cancer include

a. smoking tobacco. b. absence of ephelides on the skin. c. alcohol consumption. d. the presence of multiple nevi.

32. Risk factors for developing oral cancer include

a. a tuberculosis infection. b. infection with hepatitis C. c. contracting syphilis. d. infection with the human papillomavirus HPV-16.

33. Congenital syphilis that is untreated can cause ______in or to a mothers’ unborn baby.

a. spontaneous sequelae b. phenylketonuria c. death d. All of the above

34. Which of the following is a modifiable risk factor for coronary heart disease?

a. diabetes. b. family history of coronary heart disease. c. gender. d. age.

138 NurseCe4Less.com 35. True or False: The AUDIT and the Audit-C screening tools are accurate and widely accepted and have been used in primary care settings for assessment of an alcohol use disorder.

a. True b. False

36. The USPSTF recommends that women aged 21-29 be screened for cervical cancer

a. if they are in a high risk category. b. every three years. c. only if they have a history of cervical cancer. d. once a year.

37. The USPSTF recommends that women ______do not need to be screened for cervical cancer.

a. women with a prior, negative screening b. women aged 21-29 c. women < 21 d. All of the above

38. Squamous cell carcinoma is a form of ______skin cancer.

a. basal cell b. non-melanoma c. malignant melanoma d. melanoma

39. In its early stages, a syphilis infection will cause

a. dramatic symptoms. b. severe neurological complications c. primarily genital lesions and non-specific signs and symptoms. d. HIV infection.

40. True or False: The USPSTF recommends routine screening for skin cancer.

a. True b. False

139 NurseCe4Less.com 41. The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present

a. with no causal event. b. on one or more occasions. c. using ambulatory blood pressure monitoring. d. on several occasions.

42. Blood pressure measurement is an important predictor of cardiovascular complications in people with

a. diabetes. b. colorectal cancer. c. iron deficiency anemia. d. lipid disorders.

43. People who have sickle cell disease have an abnormal, inherited hemoglobin called

a. hemoglobin C. b. hemoglobin A. c. hemoglobin A2. d. hemoglobin S.

44. Screening for ______should continue until age 75.

a. skin cancer. b. prostate cancer c. colorectal cancer d. sickle cell anemia

45. True or False: Because of the increased use of sunscreens, incidences of malignant melanoma, and deaths from this cancer, have been decreasing for years.

a. True b. False

140 NurseCe4Less.com 46. The USPSTF stated that the evidence related to screening for iron deficiency anemia in pregnant women leads to the following position:

a. all women should be screened for iron deficiency anemia. b. it is unclear whether the benefits of screening outweigh the harm. c. the benefits of screening outweigh the harm. d. maternal health and birth outcomes are greatly improved by screening.

47. Iron deficiency anemia during pregnancy is caused by

a. a mother’s increased iron needs for red blood cell production. b. inadequate iron intake. c. the growth of the fetus and placenta. d. All of the above

48. Anemia during pregnancy can cause, or has been associated with

a. premature labor. b. high birth weight. c. delayed labor and late birth. d. breast cancer.

49. Malignant melanoma can metastasize to any organ but in most cases it will metastasize to the skin and the

a. lymph nodes. b. lungs. c. pancreas. d. liver.

50. Amblyopia is defined as a functional reduction in

a. hearing ability. b. mental development. c. visual acuity. d. a sense of smell.

141 NurseCe4Less.com CORRECT ANSWERS:

1. One of the limitations of screening tests is a. screening guidelines are often changed and updated.

“Annual health screening is an effective method for detecting and preventing poor health habits that cause acute and chronic diseases. Although broad screening guidelines are often a helpful start to discussing personal health choices, in a heterogeneous population the use of screening guidelines are not likely to detect all cases of disease. Screening guidelines are continuously evolving and being updated, so screening on a case-by-case basis is recommended.”

2. Screening tests must be used with the understanding that c. they are not diagnostic.

“Screening tests are not considered diagnostic but they are used to identify a group of the population who should be tested to determine the presence or absence of disease.”

3. Adults should be screened for alcohol misuse d. in all cases.

“... the U.S. Preventive Services Task Force (USPSTF) recommendations are to screen for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women.”

4. Breast cancer is b. the most common cancer in women.

“Breast cancer is the most common cancer in women.”

5. What is the recommendation of the U.S. Preventive Services Task Force (USPSTF) regarding the use of mammograms to screen for breast cancer in women age 75 or older? d. There is no recommendation.

“The USPSTF does not recommend the use of mammograms in women age 75 or older.”

142 NurseCe4Less.com 6. Screening for cervical cancer a. decreases mortality from the disease.

“Cervical cancer screening decreases the incidence and mortality of cervical cancer.”

7. Risk factors for colorectal cancer include b. a sedentary lifestyle.

“Risk factors for colorectal cancer include alcohol use, obesity, smoking, a diet that is high in red meat, sedentary lifestyle, a family or personal history of the disease, inflammatory bowel disease, age > 50, type 2 diabetes, and African American ethnicity.”

8. Screening adolescents ages 12 to 18 for major depressive disorder should be implemented c. with follow-up care.

“The USPSTF recommends screening for major depressive disorder in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”

9. True or False: Diabetes is a major contributing factor to blindness, heart disease and kidney failure. a. True

“The prevalence of diabetes is increasing, and diabetes is the primary cause of, or a major contributing factor in the development of many serious diseases such as blindness, heart disease, and kidney failure.”

143 NurseCe4Less.com 10. Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in b. adults with a risk factor for diabetes and who are overweight.

“Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in all adults of any age who are overweight or obese … and who have one or more other risk factors for diabetes. For people age 45 years and older, testing should begin regardless of risk…. Women who have had gestational diabetes should have lifelong testing done.”

11. Screening for Hepatitis B is recommended for b. infants born to HBV-infected mothers.

“... the CDC recommends screening the following groups for hepatitis B by testing for the presence of hepatitis B surface antigen (HBsAg), antibody to HBsAg [anti-HBs], and antibody to hepatitis B core antigen: … Infants born to HBV-infected mothers ….”

12. Screening for Hepatitis C is recommended for d. anyone born from 1945 to 1965.

“The CDC recommendations for hepatitis C screening include those listed here: Anyone born from 1945 to 1965.”

13. Screening for HIV is recommended for people a. who are infected with hepatitis or tuberculosis.

“People who are at high risk for HIV infection should be screened annually. High risk would include IV drug users, anyone who has had unprotected sex with someone who is infected with HIV, men who have sex with men, anyone who has had sex with more than one person since the last HIV test, anyone who has sex in exchange for drugs or money, people who are infected with hepatitis or tuberculosis or were treated for these diseases, and anyone who has been diagnosed with or treated for a sexually transmitted disease.”

144 NurseCe4Less.com 14. True or False: The USPSTF recommends that all adults should be screened for hypertension. a. True

“The USPSTF screening recommendations, … Adults 18 years of age and older be screened for hypertension.”

15. The Centers for Disease Control and Prevention (CDC) includes ______as one of the behaviors constituting intimate partner violence. b. sexting

“The CDC lists four behaviors as being part of IPV: Physical violence: Someone hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force. Sexual violence: Forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent. Stalking: Repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim. Psychological aggression: Verbal and non-verbal communication with the intent to harm another person mentally or emotionally and/or exert control over another person.”

16. A patient who has comorbidities is considered severely obese if the patient has a body mass index (BMI) d. ≥35 kg/m2.

“Specifically, obesity is defined as a BMI ≥30 kg/m2. For children, obesity is defined as a BMI ≥95th percentile for age and sex. Severe obesity is defined as a BMI ≥40 kg/m2 (or ≥35 kg/m2 if the patient has comorbidities).”

17. Osteoporosis is most common in c. elderly white females.

“Risk factors for osteoporosis include advanced age, caucasian race, excessive alcohol use, family history, female gender, long-term treatment with a glucocorticoid, low body weight, and smoking.”

145 NurseCe4Less.com 18. The Centers for Disease Control and Prevention (CDC) recommendations for chlamydia screening include b. pregnant women < 25 years of age.

“The CDC recommendations for chlamydia screening include: Pregnant women < 25 years of age. Pregnant women who are sexually active, 25 years of age and older, and who have an increased risk.”

19. True or False: The benefits of prostate cancer screening far outweigh the risks. b. False

“Screening for prostate cancer does not have a large positive effect on reducing mortality from the disease. Many of the cancers detected by prostate cancer screening do not require treatment and aggressive treatment that may be initiated based on a prostate screening result can have many adverse effects.”

20. All newborns should be screened for c. phenylketonuria.

“All infants should be screened for PKU. In all 50 states, PKU screening is mandatory and is done by measuring serum phenylalanine level, usually by tandem mass spectrometry.”

21. All pregnant women under the age of 25, regardless of risk, should be screened for a. gonorrhea.

“The CDC recommendations for gonorrhea screening include the following groups of people…. All pregnant women < 25 years of age, and older pregnant women if they are at increased risk.”

22. All newborns should be screened for a. sickle cell disease.

“All newborns should be screened for sickle cell disease.”

146 NurseCe4Less.com 23. True or False: Screening infants for hearing impairment is mandatory. a. True

“Hearing testing for newborns is mandatory in all 50 states.”

24. All newborns should be screened for d. congenital hypothyroidism.

“Screening for congenital hypothyroidism is mandatory in the United States. The infant’s blood is tested one to two days after birth.”

25. Which of the following is the leading cause of preventable deaths in the United States? c. Tobacco

“Tobacco use is an enormous public health concern. It is the leading cause of preventable death in the United States.”

26. Which of the following is NOT true regarding cigarette smoking in the United State? c. There is a safe level of second-hand smoke.

“Secondhand smoke is smoke that is produced from burning tobacco or smoke that is exhaled by someone smoking tobacco. There is no safe level of second-hand smoke. Sidestream smoke is the smoke that emits from the burning end of a cigarette or cigar. It contains higher levels of toxic chemicals and smaller particles that may more easily enter a person’s lungs.”

27. Health effects of second-hand smoke include a. sudden infant death syndrome (SIDS). b. ear infections. c. pneumonia. d. All of the above [Correct Answer]

“The health effects of secondhand smoke include asthma attacks, bronchitis, chronic obstructive pulmonary disease (COPD), ear infections, heart disease, lung cancer, pneumonia, stroke, and sudden infant death syndrome (SIDS).”

147 NurseCe4Less.com 28. Which of the following is a drug approved by the Food and Administration (FDA) for assisting patients with smoking cessation?

c. Varenicline

“There are three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation: bupropion, nicotine replacement therapy (NRT), and varenicline. These drugs have been proven to be very effective for smoking cessation.”

29. Sidestream smoke is smoke that is

b. emitted from the burning end of a cigarette or cigar.

“Sidestream smoke is the smoke that emits from the burning end of a cigarette or cigar. It contains higher levels of toxic chemicals and smaller particles that may more easily enter a person’s lungs.”

30. True or False: Intimate partner violence may include stalking.

a. True

“The CDC lists four behaviors as being part of IPV: … Stalking: Repeated, unwanted attention and contact by a partner that causes fear or concern for one’s safety or the safety of someone close to the victim.”

31. Risk factors for non-melanoma and melanoma skin cancer include

d. the presence of multiple nevi.

“Risk factors for nonmelanoma and melanoma skin cancer include Caucasian ethnicity, fair skin, the presence of multiple nevi, and family history of melanoma.”

32. Risk factors for developing oral cancer include

d. infection with the human papillomavirus HPV-16.

“Risk factors for developing oral cancer are smoking and tobacco use, alcohol use, and infection with the human papillomavirus HPV-16.”

148 NurseCe4Less.com 33. Congenital syphilis that is untreated can cause ______in or to a mothers’ unborn baby. c. death

“In its early stages a syphilis infection does not cause dramatic or highly specific signs or symptoms – primarily genital lesions and non-specific signs and symptoms - but a late stage syphilis infection may cause severe neurological complications. Vertical transmission can cause congenital syphilis, and this has been associated with severe developmental, musculoskeletal, and neurological morbidities and fetal death.”

34. Which of the following is a modifiable risk factor for coronary heart disease? a. diabetes.

“Modifiable risk factors include cigarette smoking, diabetes, diet, elevated serum lipids and cholesterol, hypertension, obesity, and sedentary lifestyle. Non-modifiable risk factors are age, gender, and family history of coronary heart disease.”

35. True or False: The AUDIT and the Audit-C screening tools are accurate and widely accepted and have been used in primary care settings for assessment of an alcohol use disorder. a. True

“The AUDIT and the Audit-C screening tools are accurate and widely accepted and have been used in primary care settings for assessment of an alcohol use disorder.”

36. The USPSTF recommends that women aged 21-29 be screened for cervical cancer b. every three years.

“The USPSTF recommendations for cervical cancer screening are noted as follows: Women aged 21-29: Screen three years with a Pap smear. Women aged 30-65: Screen every three years with a Pap smear, every five years with HPV testing alone, or every five years with a Pap smear and HPV testing or a Pap smear and HPV testing.”

149 NurseCe4Less.com 37. The USPSTF recommends that women ______do not need to be screened for cervical cancer.

c. women < 21

“Women < 21 years: Do not screen.”

38. Squamous cell carcinoma is a form of ______skin cancer.

b. non-melanoma

“Skin cancer is divided into two categories: non-melanoma and melanoma. Basal cell carcinoma and squamous cell carcinoma are the two non- melanoma skin cancers.”

39. In its early stages, a syphilis infection will cause

c. primarily genital lesions and non-specific signs and symptoms.

“In its early stages a syphilis infection does not cause dramatic or highly specific signs or symptoms – primarily genital lesions and non-specific signs and symptoms - but a late stage syphilis infection may cause severe neurological complications. Vertical transmission can cause congenital syphilis, and this has been associated with severe developmental, musculoskeletal, and neurological morbidities and fetal death.”

40. True or False: The USPSTF recommends routine screening for skin cancer.

b. False

“There does not seem to be any benefit from universal screening for skin cancer: the USPSTF concluded that ‘... the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults.’”

41. The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present

d. on several occasions.

“The diagnosis of hypertension cannot be confirmed until an elevated blood pressure is present on several occasions.”

150 NurseCe4Less.com 42. Blood pressure measurement is an important predictor of cardiovascular complications in people with

a. diabetes.

“Identification and treatment of hypertension in patients who have diabetes can reduce the risk of cardiovascular events ….”

43. People who have sickle cell disease have an abnormal, inherited hemoglobin called

d. hemoglobin S.

“People who have sickle cell disease have an abnormal, inherited hemoglobin called hemoglobin S. When hemoglobin S binds to oxygen, red blood cells form an abnormal shape (the sickle shape) and result in hemolysis.”

44. Screening for ______should continue until age 75.

c. colorectal cancer

“Colorectal Cancer … Screening should continue until age 75. From age 76 to 85, screening should be done on a case by case basis. There is no recommendation to screen for colorectal cancer after age 85.”

45. True or False: Because of the increased use of sunscreens, incidences of malignant melanoma, and deaths from this cancer, have been decreasing for years.

b. False

“The incidence of malignant melanoma has been increasing for years.”

46. The USPSTF stated that the evidence related to screening for iron deficiency anemia in pregnant women leads to the following position:

b. it is unclear whether the benefits of screening outweigh the harm.

“The USPSTF and the International Federation of Gynecology and Obstetrics (FIGO) state that the current evidence is insufficient to determine whether the benefits of screening for iron deficiency in pregnant women outweigh the harm associated with screening.’”

151 NurseCe4Less.com 47. Iron deficiency anemia during pregnancy is caused by

a. a mother’s increased iron needs for red blood cell production. b. inadequate iron intake. c. the growth of the fetus and placenta. d. All of the above [correct answer]

“Iron deficiency anemia during pregnancy is caused by increased maternal iron requirements for red blood cell production, inadequate intake, and growth of the fetus and placenta.”

48. Anemia during pregnancy can cause, or has been associated with

a. premature labor.

“When undetected and uncorrected, iron deficiency anemia has been associated with low birth weight, premature labor, developmental issues and other morbidities.”

49. Malignant melanoma can metastasize to any organ but in most cases it will metastasize to the skin and

a. lymph nodes.

“Malignant melanoma can metastasize to any organ but in most cases it will metastasize to the skin and lymph nodes.”

50. Amblyopia is defined as a functional reduction in

c. visual acuity.

“Amblyopia is defined as a functional reduction in visual acuity that is caused by abnormal visual development during childhood.”

152 NurseCe4Less.com Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for further reading.

1. Johns Hopkins Medicine. Screening Tests for Common Diseases. 2019. Retrieved from: https://www.hopkinsmedicine.org/health/treatment- tests-and-therapies/screening-tests-for-common-diseases 2. Booth, F., Roberts, C., and Laye, M. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012;2(2):1143–1211. 3. Tetrault, JM and O’Connor, PG. Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/risky-drinking-and-alcohol-use- disorder-epidemiology-pathogenesis-clinical-manifestations-course- assessment-and- diagnosis?search=alcohol%20abuse&source=search_result&selectedTit le=2~150&usage_type=default&display_rank=2#H1137604420. 4. U.S. Preventive Services Task Force. Final Recommendation Statement. Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions. 2018. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/Reco mmendationStatementFinal/unhealthy-alcohol-use-in-adolescents- and-adults-screening-and-behavioral-counseling-interventions. 5. Saitz, R (2018). Screening for unhealthy use of alcohol and other drugs in primary care. UpToDate. Retrieved from https://www.uptodate.com/contents/screening-for-unhealthy-use-of- alcohol-and-other-drugs-in-primary- care?search=audit%20c&source=search_result&selectedTitle=1~54&u sage_type=default&display_rank=1. 6. Bruguera, P, Barrio, P, Oliveras, C, et al. Effectiveness of a specialized brief intervention for at-risk drinkers in an emergency department: Short-term results of a randomized controlled trial. Acad Emerg Med. 2018;25(5):517-525. 7. Carneiro, LP and Battistella, LR. Two innovative Brazilian programs relating to road safety prevention. A case study. Sao Paulo J. 2019;137, Suppl:2-7. doi:10.1590/1516-3180.2019.137150319lpc. 8. Centers for Disease Control and Prevention. Burden of Tobacco Use in the United States. 2019. Retrieved from https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette- smoking-in-united-states.html. 9. Mirbolouk, M, Charkhchi, P, Kianoush, S, et al. Prevalence and distribution of e-cigarette use among U.S. adults: Behavioral risk

153 NurseCe4Less.com factor surveillance system, 2016. Ann Intern Med. 2018;169(7):429- 438. 10. Office of the Surgeon General. E-cigarette Use among Youth and Young Adults: A Report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/e- cigarettes/pdfs/2016_sgr_entire_report_508.pdf. 11. Centers for Disease Control and Prevention. Secondhand Smoke (SHS) Facts. CDC. 2018. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_ smoke/general_facts/index.htm. 12. Samet, JM. Secondhand smoke exposure: Effects in adults. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/secondhand-smoke-exposure- effects-in- adults?source=autocomplete&index=0~1&search=secondhand#H11. 13. Park, ER. Behavioral approaches to smoking cessation. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/behavioral- approaches-to-smoking- cessation?search=smoking%20cessation&source=search_result&select edTitle=4~150&usage_type=default&display_rank=4#H15300106. 14. Rigotti, NA. Overview of smoking cessation management in adults. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/overview-of-smoking-cessation- management-in- adults?search=smoking%20cessation%20acupuncture&source=search _result&selectedTitle=1~150&usage_type=default&display_rank=1#H 1124333798 15. [No authors listed]. Drugs for smoking cessation. Med Lett Drugs Ther. 2019;61(1576):105-110. 16. Worku, D and Worku, E. A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool. SAGE Open Med. 2019;7:2050312119871405. 17. Marler, JD, Fujii, CA, Utley, DS, Tesfamariam, LJ, Galanko, JA, Patrick, H. Initial assessment of a comprehensive digital smoking cessation program that incorporates a mobile app, breath sensor, and coaching: Cohort study. JMIR Mhealth Uhealth. 2019;7(2) e12609. 18. Meghea, C, et al. A couples-focused intervention for smoking cessation during pregnancy: The study protocol of the Quit Together pilot randomized controlled trial. Tob Prev Cessat. 2018;4:17. 19. Deffebach, ME and Humphrey, L. Screening for lung cancer. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/screening-for-lung-

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