Increasing Cancer Screening Rates in Primary Care
Screening for cancer has contributed to substantial reductions in death from several cancers and is one of the most cost-effective preventive interventions in all of health care. In the United States, primary care clinicians, their clinical teams, and the systems in which they work are primarily responsible for ensuring that screening occurs. In order to achieve the highest possible population-wide screening rates, primary care clinicians must embrace the responsibility to screen their entire enrolled patient population, institute several overarching general approaches to screening, and implement a combination of evidence-...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Richard Wender, Andrew M.D. Wolf Source Type: research

Screening for Breast Cancer
Among women, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death in the world. The purpose of this article is to review the evidence regarding breast cancer screening for average-risk women. The review primarily focuses on mammographic screening but also reviews clinical breast examinations, emerging screening technologies, and opportunities to build consensus. Wherever possible, the review relies on published systematic reviews, meta-analyses, and guidelines from three major societies (US Preventive Services Task Force, American College of Radiology, and the American Cancer So...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Anand K. Narayan, Christoph I. Lee, Constance D. Lehman Source Type: research

Screening for Colorectal Cancer
Colorectal cancer screening is essential to detect and remove premalignant lesions to prevent the development of colorectal cancer. Multiple screening modalities are available, including colonoscopy and stool-based testing. Colonoscopy remains the gold standard for detection and removal of premalignant colorectal lesions. Screening guidelines by the American Cancer Society now recommend initiating screening for all average-risk adults at 45  years old. Family history of colorectal cancer, other cancers, and advanced colon polyps are strong risk factors that must be considered in order to implement earlier testing. Epi...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Eric M. Montminy, Albert Jang, Michael Conner, Jordan J. Karlitz Source Type: research

Screening for Cervical Cancer
The most effective strategy for cervical cancer prevention involves vaccination to prevent human papillomavirus (HPV) infections during adolescence followed by screening to detect HPV infections during adulthood. HPV vaccination before sexual debut can prevent HPV infections, precancers, and cancers. HPV vaccination of sexually active populations does not prevent cancer. Screening with HPV testing is the most effective method of detecting precancers and cancers between ages 25 and 65. Ensuring adequate screening around the age of menopause may be the key to preventing cervical cancer among elderly women. Most cervical canc...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Terresa J. Eun, Rebecca B. Perkins Source Type: research

The Development of Cancer Screening Guidelines
Clinicians and the public have always depended on expert advice to guide clinical practice. However, since the 1970s, a growing emphasis on evidence-based medicine has led to clinical practice guidelines being less expert based and increasingly evidence based and judgments about the balance between the two. Because the existence of standards for guidelines development is no guarantee that a guideline will be trustworthy, tools and instruments have been developed to measure the degree to which a guideline has been developed with rigorous adherence to methodology, and has not been influenced by conflicts of interest. (Source...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Robert A. Smith Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Source Type: research

Cancer Screening in Primary Care: So Much Progress, So Much Left to Do
In this update on cancer screening, it is sobering to realize that the first comprehensive evaluation of cancer screening guidelines took place 40 years ago when the American Cancer Society (ACS) commissioned Dr David Eddy and his colleagues to apply the principles of evidence-based medicine to the ACS ’ recommendations for the early detection of cancer.1 Shortly thereafter in 1984, the US Preventive Services Task Force was commissioned and charged with bringing evidence-based medicine to the evaluation of common interventions in the primary care setting, and 5 years later, issued its first repo rt on 169 preventive ...
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Robert A. Smith, Kevin C. Oeffinger Tags: Preface Source Type: research

Update in Cancer Screening
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Authors: Robert A. Smith, Kevin C. Oeffinger Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Source Type: research

Forthcoming Issues
Common Symptoms in Outpatient Practice (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Source Type: research

Contents
Jack Ende (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - October 22, 2020 Category: Primary Care Source Type: research

The Evaluation of Cancer Screening
Cancer screening uses many investigative procedures, and different screening programs and methods have different objectives. For example, mammography aims to detect breast cancer at an earlier stage when successful treatment is more likely, whereas colonoscopy is aimed primarily at detecting adenomas in the colon and removing them, thus preventing them from progressing to cancer at all. Evaluation has different objectives, including proof of principle, checking that screening services are delivering the desired clinical outcome, technical quality control of the investigation procedures. All necessitate a range of tools for...
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Stephen W. Duffy, Robert A. Smith Source Type: research

Cancer Screening in Older Adults
Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered mor...
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Ashwin A. Kotwal, Louise C. Walter Source Type: research

Screening for Lung Cancer
Lung cancer screening with low-dose computed tomography provides an opportunity to save lives by early detection of the deadliest cancer in the United States. Uptake of lung cancer screening has been quite low but may be improving. Clinician and patient education, integration of lung cancer screening protocols into electronic medical records, support for shared decision making and tobacco cessation, and improved communication between referral centers and clinicians are all important areas for improvement for lung cancer screening to reach its potential in improving morbidity and mortality from lung cancer. (Source: Medical...
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Thomas Houston Source Type: research

Screening for Prostate Cancer
This article gives an overview of the current state of the evidence for prostate cancer early detection with prostate-specific antigen (PSA) and summarizes current recommendations from guideline groups. The article reviews the global public health burden and risk factors for prostate cancer with clinical implications as screening tools. Screening studies, novel biomarkers, and MRI are discussed. The article outlines 7 key practice points for primary care physicians and provides a simple schema for facilitating shared decision-making conversations. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Sigrid V. Carlsson, Andrew J. Vickers Source Type: research

The Importance of Cancer Screening
The burden of cancer in the United States is substantial, providing important opportunity and obligation for primary care clinicians to promote cancer prevention and early detection. Without a system of organized screening to support reminders and follow-up of cancer screening, primary care clinicians face challenges in addressing risk assessment, informed/shared decision making, reminders for screening, and tracking adherence to screening recommendations. Tools exist for collecting information about family history, tracking screening adherence, and reminding patients when they are due for screening, and strategies exist f...
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Robert A. Smith, Kevin C. Oeffinger Source Type: research

Cancer Screening: Finding the Path Forward
Nothing should be more straightforward than screening for cancer, or so one might think. After all, is not early detection of cancer consistently associated with better outcomes? Are not serologic, endoscopic, and radiologic tests always objective and accurate. Decisions for cancer screening should be straightforward, but, of course, they are not. Why not? (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - September 15, 2020 Category: Primary Care Authors: Jack Ende Tags: Foreword Source Type: research

Thoughtful Prescribing and Deprescribing
Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Vassiliki Pravodelov Source Type: research

Identifying Goals of Care
Goals of care conversations are important but complex for clinicians caring for older adults. Although clinicians tend to focus on specific medical interventions, these conversations are more successful if they begin with gaining a shared understanding of the medical conditions and possible outcomes, followed by discussion of values and goals. Although training in the medical setting is incomplete, there are many published and online resources that can help clinicians gain these valuable skills. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Amber Comer, Lyle Fettig, Alexia M. Torke Source Type: research

Overview of High Yield Geriatrics Assessment for Clinic and Hospital
Geriatric assessment is a comprehensive, multifaceted, and interdisciplinary evaluation of medical, socioeconomic, environmental, and functional concerns unique to older adults; it can be focused or broadened according to the needs of the patient and the concerns of clinical providers. Herein, the authors present a high-yield framework that can be used to assess older adult patients across a variety of settings. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Mariana R. Gonzalez, Rachel K. Miller, Alyson R. Michener Source Type: research

Cognitive Impairment Evaluation and Management
Clinicians should use a systematic approach to evaluating patients presenting with a concern for cognitive impairment. This approach includes interviewing a knowledgeable informant and performing a thorough mental status examination in order to determine the presence of functional impairments and the domains of cognition that are impaired. The results of this interview and examination determine the next steps of the diagnostic work-up. The pattern of cognitive impairment shapes the differential diagnosis. Treatment should address symptoms, and environmental, psychological, and behavioral interventions are essential. (Sourc...
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Lauren McCollum, Jason Karlawish Source Type: research

Evaluation and Management of Difficult Symptoms in Older Adults in Primary Care
This article reviews the evaluation of 4 vexing symptoms for elderly patients in primary care: leg cramps, dizziness, insomnia, and weight loss. For each, ideal evaluations are proposed. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Chitra Hamilton, Colleen Christmas Source Type: research

Common Urinary and Bowel Disorders in the Geriatric Population
This article summarizes the current literature regarding the occurrence and implications of lower urinary tract and bowel symptoms in the geriatric population. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Zara Manuelyan, Keila Siomara Mu ├▒iz, Ellen Stein Source Type: research

Perioperative Care Strategy for Older Adults
Geriatric patients are not just older adult patients. Aging brings about unique physiologic, psychological, and sociologic changes within individuals. Recognition of these unique characteristics and measuring for their impact; instituting mitigating strategies; using age-specific anesthetic measures; and performing a systematic, algorithmic care model in the postoperative period overseen by a multidisciplinary team brings about enhanced outcomes and improved quality of care for this expanding group of patients. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Teresa S. Jones, John T. Moore, Thomas N. Robinson Source Type: research

Caring for Older Adults
The planning for this issue of Medical Clinics of North America started in 2019, long before “coronavirus,” “shelter at home,” and “social distancing” became part of our everyday discourse. It feels like a long time since we have been able to routinely see our patients in clinic and meet in person with interdisciplinary teams. Many of the topics covered in this issue are necessa rily “high touch” practices. It is unclear when we will be able to partake in some of these practices regularly and consistently again. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Danelle Cayea Tags: Preface Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Source Type: research

Geriatrics
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Authors: Danelle Cayea Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Source Type: research

Forthcoming Issues
Cancer Prevention and Screening (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Source Type: research

Contents
Jack Ende (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - August 13, 2020 Category: Primary Care Source Type: research

Sadness and Worry in Older Adults
Older adults experience greater emotional well-being in late life. However, older adults may be vulnerable to certain physiologic risk factors, including less physiologic resilience to prolonged stress. Depression and anxiety can be difficult to diagnose in late life owing to differences in self-reported symptoms from younger adults and unclear distinctions between normative and non-normative emotional experiences. We discuss age differences in the presentations of depression and anxiety, and normative and non-normative late life developmental trajectories around bereavement and grief, social isolation and loneliness, and ...
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Julie Lutz, Kimberly A. Van Orden Source Type: research

Musculoskeletal Pain in Older Adults
This article reviews the current understanding of persistent pain in older adults and suggests a general approach to its assessment and management, followed by specific considerations for musculoskeletal pain conditions commonly seen in older adults. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Travis P. Welsh, Ailing E. Yang, Una E. Makris Source Type: research

The Intersection of Falls and Dementia in Primary Care
This article explores the relationship between falls and dementia, including the importance of rehabilitation strategies for reducing fall risk in these individuals. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Colleen M. Casey, Jamie Caulley, Elizabeth A. Phelan Source Type: research

Osteoporosis in Older Adults
Osteoporosis and osteoporosis-related fractures are common causes of morbidity and mortality in older adults. Healthy adults should be counseled about measures to prevent osteoporosis. Women should be screened for osteoporosis beginning at age 65. Screening for osteoporosis in men should be considered when risk factors are present. Appropriate screening intervals are controversial. Women and men with osteoporosis should be offered pharmacologic therapy. Choice of therapy should be based on safety, cost, convenience, and other patient-related factors. Bisphosphonates are a first-line therapy for many patients with osteoporo...
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Catherine Bree Johnston, Meenakshi Dagar Source Type: research

Challenges Related to Safety and Independence
Advancing age is associated with increasing risk of activities important for independence, such as driving and living alone. Cognitive impairment is more common with older age; financial resources and social support may dwindle. Risk, cognitive impairment, and decisional capacity each change over time. Transparent decision making and harm reduction help balance risk and safety. When a patient lacks decisional capacity, an option that considers the patient ’s preferences and shows respect for the person is favored. Vulnerable patients making choices that are high risk, and patients for whom others are making such choi...
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Hannah Ward, Thomas E. Finucane, Mattan Schuchman Source Type: research

Knowledge, Wisdom, and the Practice of Geriatrics
I wish I knew who actually said, “Knowledge is knowing which way to look when crossing a one-way street; wisdom is looking both ways, nonetheless.” I have used that quote so many times, especially on rounds. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - July 14, 2020 Category: Primary Care Authors: Jack Ende Tags: Foreword Source Type: research

Recent Advances in the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a chronic, irreversible obstructive lung disease that results from exposure to noxious stimuli. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) usually result from viral or bacterial respiratory infections, but may also result from exposure to environmental pollution. AECOPD are associated with functional decline, increased risk of subsequent exacerbations, and death. Despite the poor prognosis of AECOPD, patients are empowered through self-management programs in their battle against this lethal disease. Morbidity and mortality of chronic obstructive pulmonary ...
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Stacey-Ann Whittaker Brown, Sidney Braman Source Type: research

Alcohol and the Hospitalized Patient
Alcohol use is a common social and recreational activity in our society. Misuse of alcohol can lead to significant medical comorbidities that can affect essentially every organ system and lead to high health care costs and utilization. Heavy alcohol use across the spectrum from binge drinking and intoxication to chronic alcohol use disorder can lead to high morbidity and mortality both in the long and short term. Recognizing and treating common neurologic, gastrointestinal, and hematological manifestations of excess alcohol intake are essential for those who care for hospitalized patients. Withdrawal is among the most comm...
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Svetlana Chernyavsky, Patricia Dharapak, Jennifer Hui, Violetta Laskova, Eve Merrill, Kamana Pillay, Evan Siau, Dahlia Rizk Source Type: research

Using Bedside Rounds to Change Culture
Although not suitable for every patient encounter, rounding at the beside provides an opportunity to teach and augment the attitudes essential for optimal medical care. It also provides an opportunity to establish and grow the team ’s culture as well as the culture for each patient encounter. Finally, it provides the attending physician with an opportunity to assess learners’ position on the supervision-to-autonomy spectrum, thereby ensuring appropriate supervision while enabling the autonomy necessary for optimal learner growth. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Abigail Bryne, Jeff Wiese Source Type: research

Acute Liver Injury and Decompensated Cirrhosis
Hospitalists often care for patients with liver disease, including those with acute liver injury and failure and patients with complications of decompensated cirrhosis. Acute liver failure is a true emergency, requiring intensive care and oftentimes transfer of the patient to a liver transplant center. Patients with decompensated cirrhosis have complications of portal hypertension, including variceal hemorrhage, ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy. These complications increase the risk of mortality among patients with decompensated cirrhosis. Comanagement by the hospitalist with gastroent...
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: James F. Crismale, Scott L. Friedman Source Type: research

Advances in the Management of Acute Decompensated Heart Failure
Patients hospitalized for heart failure pose a considerable clinical and financial burden on the health care system. Early recognition and deep phenotyping of heart failure for reduced and preserved ejection fraction syndromes facilitate the introduction of appropriate guideline-directed therapy and decongestion strategies to help improve heart failure morbidity and mortality. Robust and safe transitions of care programs are needed to deliver adequate care and improve overall survival. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Sumeet S. Mitter, Sean P. Pinney Source Type: research

Treatment of Acute Venous Thromboembolism
“Acute venous thromboembolism is a common disease seen by nearly all hospitalists. The advent of low molecular weight heparin (LMWH) several decades ago ushered in the era of early hospital discharge and home treatment. More recently, the direct oral anticoagulants (DOACs) have further simplified outpatient treatment and some offer treatment without parenteral therapy. Use of DOACs for cancer-associated venous thromboembolism is emerging and is a welcome evolution of care to spare oncologic patients the burden of daily LMWH injections.” (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Sashi Nair, Nina Garza, Matt George, Scott Kaatz Source Type: research

Realizing the Potential of Hospitalist Medicine
The bar to break even is high, and the goal is not to break even. Hospital medicine has been the fastest growing field in medicine due to multiple factors; none of which are a proven net benefit over the traditional model when the posthospitalization period is considered. A traditional model, which can also be called “historic” in recognition of its current impracticality and rarity, here refers to a primary care physician (PCP) who sees a patient longitudinally over years, provides care as the attending of record while the patient is hospitalized, and seamlessly resumes outpatient care promptly after discha rg...
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Andrew S. Dunn Tags: Preface Source Type: research

CME Accreditation Page
(Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Source Type: research

Update in Hospital Medicine
MEDICAL CLINICS OF NORTH AMERICA (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Authors: Andrew S. Dunn Source Type: research

Copyright
ELSEVIER (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Source Type: research

Medical Clinics of North America
Geriatrics (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Source Type: research

Contributors
JACK ENDE, MD, MACP (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - June 4, 2020 Category: Primary Care Source Type: research