USPSTF

USPSTF is the United States Preventative Services Task Force.

Here: https://www.uspreventiveservicestaskforce.org/.

This is a site I often use and frequently show to patients. For further reading….that is, if they want to know more about a topic. There is a nice two minute video about the Task Force right now, saying that it’s a volunteer organization that started 30 years ago, to review research about preventative care, agree on a recommendation and publish that recommendation.

Before they publish or update a recommendation, they ask for public comments and expert comments.

I have great respect for the USPSTF. Let’s take breast cancer screening. The current recommendation is here: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening1. There was a big furor when this came out, because the recommendation is for biennial mammograms. Every other year, not every year. The USPSTF went through reams of data and papers and said that they could discern no difference between yearly and every other year screens in normal risk patients. The screening recommendations are different for people with abnormal BRCA1 and BRCA2 genes.

So who yelled about that recommendation? Radiologists for one. Now, there is a financial incentive on their part to have women get the mammograms yearly. The American Cancer Society was annoyed and the Susan B. Komen Foundation too. But the USPSTF stand their ground. The guidelines get updated in a 5-10 year cycle.

Reasons that I like the guidelines:

1. They are online. My patients can look at them too.
2. They make recommendations for screening by age groups.
3. They rate their recommendation: A, B or C level evidence or I for Insufficient Evidence.
4. You can read the fine print. They put the article with all the detail and all the references on the website. The weight of evidence is apparent.
5. They say “We don’t know.” when there is insufficient evidence.
6. The site is pretty easy to use.

I have to weigh evidence in medicine. A functional medicine “study” that is not a randomized double blind clinical trial and that only has 20 patients is really more of a case report. Hey, we tried this supplement and they liked it. The recent study about alcohol from Europe with 599,912 patients has a lot more weight. The Women’s Health Initiative had 28,000 women in the estrogen/progesterone arm, and 21,000 in the estrogen only/had a hysterectomy arm. Length of study, design, all of these are important.

There is a recent headline about a study saying that coronary calcium scores have now had one study where they were useful. That is a study. The guideline from the USPSTF is here: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cardiovascular-disease-screening-using-nontraditional-risk-assessment. The guideline says “insufficient evidence” and that’s what I tell patients who ask for it. I offer referral to a cardiologist to discuss it, but I am reluctant to do a test where I really don’t know what to do with the results. I pay very close attention to the guidelines and they are always changing. They have the strongest and least biased (by money and greed) evidence that I can find. And patients can read them too, which is wonderful.

Even though the USPSTF says that there is insufficient evidence for mammograms after age 75, we can still do them. That is, medicare will keep covering them. Some people keep doing them, some don’t. I discuss guidelines, but I will support the person continuing the care if that is what they want and they are informed. People are infinitely variable in their choices and logic.

Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm