Prevention of Injuries & Violence

Injuries & Violence :

Injuries remain the most important cause of loss of potential years of life before age 65. Homicide and motor vehicle accidents are a major cause of injury-related deaths among young adults, and accidental falls are the most common cause of injury-related death in the elderly. Other causes of injury-related deaths include suicide and accidental exposure to smoke, fire, and flames.

Although there has been a steady decline in motor vehicle accident deaths per miles driven, road traffic injuries remain the tenth leading cause of death and the ninth leading cause of the burden of disease. Although seat belt use protects against serious injury and death in motor vehicle accidents, at least one-fourth of adults and one-third of teenagers do not use seat belts routinely. Air bags are protective for adults but not for small children.

Each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home.

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

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

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

Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse—in particular, routine assessment of women for risk of domestic violence. In a trial, the 12-month prevalence of intimate partner violence ranged from 4% to 18% depending on the screening method, instrument, and health care setting. Rates of current domestic violence on exit questionnaire were 21% in suburban emergency department and 26% in urban emergency department settings. Inclusion of a single question about domestic violence in the medical history—"At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?"—can increase identification of this common problem. Another screen consists of three questions: (1) "Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?" (2) "Do you feel safe in your current relationship?" (3) "Is there a partner from a previous relationship who is making you feel unsafe now?" Women seem to prefer written, self-completed screening questionnaires to face-to-face questioning. Alternatively, computer prompts to clinicians may serve as useful reminders to inquiry. Assessment for abuse and offering of referrals to community resources creates potential to interrupt and prevent recurrence of domestic violence and associated trauma. Screening patients in emergency departments for intimate partner violence appears to have no adverse effects related to screening and may lead to increased patient contact with community resources.

Cancer Prevention

Prevention of cancer :

Primary Prevention:

Mortality rates of cancer have begun to decrease in the past 2 years; part of this decrease results from reductions in tobacco use, since cigarette smoking is the most important preventable cause of cancer. Preventive health examinations and preventive gynecologic examinations are among the most common reasons for ambulatory care visits, although the use and content of these types of visits remains controversial. Primary prevention of skin cancer consists of restricting exposure to ultraviolet light by wearing appropriate clothing and use of sunscreens. In the past 2 decades, there has been a threefold increase in the incidence of squamous cell carcinoma and a fourfold increase in melanoma in the United States. Persons who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemoprevention has been widely studied for primary cancer prevention (see above Chemoprevention section and Chapter 39: Cancer). Use of tamoxifen, raloxifene, and aromatase inhibitors for breast cancer prevention is discussed in Chapter 17: Breast Disorders and Chapter 39: Cancer. Hepatitis B vaccination can prevent hepatocellular carcinoma (HCC), and screening and vaccination programs may be cost-effective and useful in preventing HCC in high-risk groups such as Asians and Pacific Islanders. The use of HPV vaccine to prevent cervical cancer is discussed above in the Prevention of Infectious Disease section.

Screening & Early Detection:

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

Cancer screening recommendations for average-risk adults.

Test ACS1   CTF2   USPSTF3     Breast self-examination (BSE) An option for women over age 20. Fair evidence that BSE should not be used.  Insufficient evidence to recommend for or against.   Clinical breast examination Every 3 years age 20–40 and annually thereafter. Good evidence for annual screening women aged 50-69 by clinical examination and mammography. Insufficient evidence to recommend for or against.   Mammography Annually age 40 and older. Current evidence does not support the recommendation that screening mammography be included in or excluded from the periodic health examination of women aged 40–49. Recommended every 1–2 years for women aged 40 and over (B).   Papanicolaou test Annually beginning within 3 years after first vaginal intercourse or no later than age 21. Screening may be done every 2 years with the liquid-based Pap test. Annually at age of first intercourse or by age 18; can move to every-2-year screening after two normal results to age 69. Every 3 years beginning at onset of sexual activity or age 21 (A).     After age 30, women with three normal tests may be screened every 2–3 years or every 3 years by Pap test plus the HPV DNA test.          Women may choose to stop screening after age 70 if they have had three normal (and no abnormal) results within the last 10 years.   Recommends against routinely screening women older than age 65 if they have had adequate recent screening with normal Pap tests and are not otherwise at high risk for cervical cancer (D).   Annual stool test for occult blood4 or fecal immunochemical test (FIT)   Screening recommended, with the combination of fecal occult blood test or fecal immunochemical test (FIT) and sigmoidoscopy preferred over stool test or sigmoidoscopy alone. Double-contrast barium enema and colonoscopy also considered reasonable alternatives. Good evidence for screening every 1–2 years over age 50. Screening strongly recommended (A), but insufficient evidence to determine best test.   Sigmoidoscopy (every 5 years) Fair evidence for screening over age 50 (insufficient evidence about combining stool test and sigmoidoscopy).   Double-contrast barium enema (every 5 years) Not addressed.   Colonoscopy (every 10 years) Insufficient evidence for or against use in screening.   Prostate-specific antigen (PSA) blood test PSA and DRE should be offered annually to men age 50 and older who have at least a 10-year life expectancy. Men at high risk (African American men and men with a strong family history) should begin at age 45. Information should be provided to men about the benefits and risks, and they should be allowed to participate in the decision. Men without a clear preference should be screened. Fair evidence against including in routine care.  Insufficient evidence to recommend for or against.   Digital Rectal Examination (DRE) Insufficient evidence for or against including in routine care. Insufficient evidence to recommend for or against.   Cancer-related checkup For people aged 20 or older having periodic health exams, a cancer-related checkup should include counseling and perhaps oral cavity, thyroid, lymph node, or testicular examinations. Not assessed. Not assessed.

Home test with three samples Recommendation A: The USPSTF strongly recommends that clinicians routinely provide the service to eligible patients. (The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.) Recommendation B: The USPSTF recommends that clinicians routinely provide the service to eligible patients. (The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.) Recommendation D: The USPSTF recommends against routinely providing the service to asymptomatic patients. (The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.) The appropriate form and frequency of screening for breast cancer is controversial. A large randomized trial of breast self-examination conducted among factory workers in Shanghai found no benefit. A systematic review performed for the United States Preventive Services Task Force found that mammography was moderately effective in reducing breast cancer mortality for women 40–74 years of age. The absolute benefit was greater for older women, and the risk of false-positive results was high for all women. Digital mammography is more sensitive in women with dense breasts and younger women; however, studies exploring outcomes are lacking. Several organizations, including the American Cancer Society and the National Cancer Institute, recommend routine mammography screening, and changes in screening guidelines appear to impact women's beliefs about how frequently they should obtain screening. Although delays to following up an abnormal mammogram exist, the use of patient navigation programs to reduce such delays appears beneficial, especially among poor and minority populations. The use of MRI is not currently recommended for general screening, although the American Cancer Society does recommend screening MRI for women at high risk ( 20–25%), including those with a strong family history of breast or ovarian cancer. A recent systematic review reported that screening with both MRI and mammography might be superior to mammography alone in ruling out cancerous lesions in women with an inherited predisposition to breast cancer. All current recommendations call for cervical and colorectal cancer screening. Prostate cancer screening, however, is controversial, as no completed studies have answered the question whether early detection and treatment after screen detection produce sufficient benefits to outweigh harms of treatment. A 2008 USPSTF review of current evidence on benefits and harm of screening asymptomatic men for prostate cancer with prostate-specific antigen (PSA) testing revealed that PSA screening is associated with increased psychological harm with uncertain potential benefits. Providers and patients are advised to discuss how to proceed in light of this uncertainty. Whether early detection through screening and subsequent treatment alters the natural course of the disease remains to be seen. There are still no data on the morbidity and mortality benefits of screening. Unlike the American College of Physicians, the American Cancer Society recommends that providers offer annual PSA testing for men over age 50. Screening is not recommended by any group for men who have estimated life expectancies of less than 10 years. Decision aids have been developed to help men weigh the arguments for and against PSA screening. Annual or biennial fecal occult blood testing reduces mortality from colorectal cancer by 16–33%. The risk of death from colon cancer among patients undergoing at least one sigmoidoscopic examination is reduced by 60–80% compared with that among those not having sigmoidoscopy. Colonoscopy has also been advocated as a screening examination. It is more accurate than flexible sigmoidoscopy for detecting cancer and polyps, but its value in reducing colon cancer mortality has not been studied directly. Recent studies have shown that CT colography (virtual colonoscopy) is also able to detect cancers and polyps with reasonable accuracy. Screening for cervical cancer with a Papanicolaou smear is indicated in sexually active adolescents and in adult women every 1–3 years. Screening for vaginal cancer with a Papanicolaou smear is not indicated in women who have undergone hysterectomies for benign disease with removal of the cervix—except in diethylstilbestrol (DES)-exposed women (see Chapter 18: Gynecologic Disorders). Women over age 70 who have had normal results on three or more previous Papanicolaou smears may elect to stop screening. Screening for lung cancer with spiral CT can detect early stage disease; however, its efficacy in reducing lung cancer mortality has not been evaluated in a randomized trial, although a recent study of survival in asymptomatic patients at risk for lung cancer who were screened annually with spiral CT revealed that such screening detected lung cancer at a curable stage.