HEALTH MAINTENANCE

Note--the following are random notes, not meant to be a complete list of evidence-based health maintenance interventions.

Please click on links for details

• Adult Screening--Collated Recommendations from Various Organizations
• Pediatric Screening & Prevention

• Abdominal Aortic Aneurysm Screening
• Breast Cancer Prevention with Tamoxifen and other drugs for high-risk patients 
• Breast Cancer Mortality Prevention with mammography screening 
• Cancer Prevention with antioxidants 
• Coronary Disease Prevention 
• Diabetes Mellitus Prevention
• Diarrheal Illness Prevention in infants with probiotics
• Diet
  • Low saturated fats (CAD)
  • High fiber (CAD, DM)
  • Low simple sugars after age 40 (type 2 DM)
  • Avoid fish high in methylmercury (shark, swordfish, king mackerel, tilefish, tuna except for canned tuna) in women who might become pregnant (FDA 2001)
  • Overall low fat diet--Benefit may be slim
    • In a study in 48,835 postmenopausal women participating in the Women's Health Initiative randomized to a "regular diet" or a low-fat diet (< 20% of calories from fat, fruit/veg 5 servings/day, grain 6 servings/day), over mean 8y f/u, there was no sig. diff. in incidence of breast Ca, colorectal Ca, coronary events, or CVA (JAMA 295:629, 643, and 655, 2006--JW)
• Douching in women may predispose to ectopic pregnancies (Am. J. Obs. Gyn. 176:991, 1997)
• High oral fluid intake may reduce the risk of Bladder Cancer
• Hip Protectors  in Elderly for hip fracture prevention
  • In a study in 1,801 nursing home patients > 70yo (all ambulatory but with at least one risk factor for hip fx, including prior fall or fx, impaired balance or mobility, use of a walking aid, cognitive impairment, impaired vision, poor nutrition, or a disease or medication known to predispose to falls), of whom 1,148 refused the hip protector (i.e. not a randomized study), use of hip protector was associated with sig. reduced incidence of hip fracture (RR 0.46) (NEJM 343:1506, 2000--AFP)
  • 561 elderly pts (mean age 85yo) with low bone mineral density randomized to hip protectors or no hip protectors x 70wks.  In intention-to-treat analysis, no diff. in fx incidence (JAMA 289:1957, 2003--JW)

• Immunization
• Iron Deficiency Anemia Screening and Prevention 
• Lung Cancer Screening
• Multivitamins and Antioxidants for general health
  • In a study in 158 pts > 45yo randomized to a daily multivitamin vs. a placebo (the placebo contained Ca, Mg, and vitamin B2), over 12mos, the incidence of infectious illnesses was sig. lower in the treatment group (43% vs. 73%) but there were no sig. diffs., in quality of life (Ann. Int. Med. 138:365, 2003--AFP)
  • In a meta-analysis of 47 randomized trials of beta-carotene, vitamin A, and vitamin E, all were associated with sig. increased mortality risk (RR 1.05, 1.16, and 1.04 respectively); no sig. diff. with vitamin C and selenium (JAMA 297:842, 2007--JW)
  • See section on Prostate Cancer regarding potential risks of folic acid supplementation in men
• Neural Tube Defect Prevention-- Folic acid in women who may become pregnant 
• Nosocomial Infection Prevention
• For elderly patients at risk of falls or fractures"
  • Osteoporosis prevention with Calcium, Vitamin D, and Folic Acid + Vitamin B12 but consider potential cardiovascular risks of supplemental Calcium (see link for detail)
  • Vitamin D for prevention of falls in the Elderly
  • If regularly engage in outside activities, avoid  bifocals/multifocals when out and about!  Use of single-lens distance glasses, compared with multi-focals, was associated with a sig. reduction in fall risk (RR 0.6) in a 13mo randomized study in 606 elderly pts who wore multifocals and had risk factors for falling (BMJ 340:c2265, 2010-JW)
• Ovarian Neoplasm Screening
• Pediatric Immunization
• Pediatric Safety Issues
• Prenatal Care-Click to see info on Preventive Issues
• Prevention of Dementia
• Premature Rupture of Membranes Prevention--Vitamin C may help 
• Respiratory Syncytial Virus Prevention for high-risk infants and children
• Thyroid Disease Screening
• Ask adults about Varicella history so as to identify candidates for adult vaccination.

Ramipril for reduction of cardiovascular events in at-risk patients:

The Heart Outcomes Prevention Evaluation ("HOPE") Study:

• 9297 pts > 55yo with h/o CAD, CVA, PVD, or (DM plus at least one other CV risk factor (HTN, high tot. chol., high LDL, smoking, or microalbuminuria)) randomized to Ramipril titrated up to 10mg QD vs. placebo. None had a known h/o CHF or LVEF < 40%. A sample of 496 pts were chosen to undergo echocardiogaphy at study onset, only 2.6% had LVEF < 40%. Over median 4.5y f/u, incidence of all-cause mortality was sig. less in ramipril group (10.4% vs. 12.2%); also sig. less risk for CV death (6.1% vs. 8.1%), CHF dx (9.0% vs. 11.5%), and primary endpoint of MI, CVA, or CV death (14% vs. 17.8%). On subgroup analysis, reduction in risk for primary outcome remained sig. for pts with no HTN and in both male & female subgroups. Note that among the subgroup with no CV disease at onset (i.e. whose "qualifying" diagnosis was DM), the risk reduction for the primary outcome was not significant (NEJM 342:145, 2000)
• In another paper analyzing the subgroup with DM: 3577 diabetics > 55yo with previous CV event or at least 1 other CV risk factor (TC > 5.2 mmol/L, HDL < 1.0 mmol/l, HTN, microalbuminuria, or smoking) but no overt proteinuria or CHF, not on ACEI's, randomized to Ramipril 10mg/d vs. placebo. Study stopped early (after 4.5y) b/c of sig. improvement with Ramipril--RR for primary outcome (MI, CVA, or cardiovascular death) was 0.75 with Ramipril (sig.; persisted after controlling for effects on BP); RR of total mortality was 0.76 (sig.). (Lancet 355:253, 2000--AFP; abst)
• In another paper reporting CVA incidence in the same cohort, rampipril recipients had RR 0.68 for any CVA and RR 0.39 for fatal CVA (BMJ 324:699, 2002--JW)
• A follow-up study on the same cohort ("HOPE-TOO") examined the effect of vitamin E vs. placebo on incidence of Ca and carrdiovascular events; click link for details
• In a cohort study of 18,453 MI survivors > 65yo, of whom 41% had used ACE Inhibitors for at least 1y after their MI's, 1y incidence of mortality was sig. lower in pts who received ramipril c/w enalapril, captopril, fosinopril, or quinapril (HR 0.59-0.71) (Ann. Int. Med. 141:102, 2004)