TOPIC

 REC

        NOTES

A
Abdominal Aortic Aneurysm

 B

Recommend one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.
Good evidence on benefit &  harms. Harms = increased surgical and psychological morbidity.   Conclusion:  moderated benefit outweighs harms for male smokers, age 65-75.

B
Bacterial Vaginosis in Pregnancy

 I

 Good studies, conflicting results. Many studies showed benefit, largest did not.
For women with history of pre-term delivery, screening may be option, but the optimal screening has not been determined.

Bacteriuria

 A

 Good evidence that screening pregnant women for asymptomatic bacteriuria with urine culture significantly reduces symptomatic urinary tract infections, low birth weight, and preterm delivery. Not true for non-pregnant women or men.

Bladder Cancer

 D

 Fair evidence that screening with available tests can detect bladder cancer in asymptomatic individuals. Potential benefit of screening would be small for the following reasons: fair evidence that many of the cancers detected by screening have low tendency to progress to invasive disease; relatively low overall prevalence of asymptomatic bladder cancer that would eventually lead to important clinical consequences; limited evidence that early treatment of bladder cancer detected through screening improves long-term health outcomes. 

Blood Pressure

 A

 Good evidence that blood pressure measurement can identify adults at increased risk for cardiovascular disease due to high blood pressure, and good evidence that treatment of high blood pressure substantially decreases the incidence of cardiovascular disease and causes few major harms.

Breast Cancer:

 B

 Fair evidence that mammography screening every 12-33 months significantly reduces mortality from breast cancer. Evidence is strongest for women aged 50-69. For women aged 40-49, the evidence that screening mammography reduces mortality from breast cancer is weaker, and the absolute benefit of mammography is smaller, than it is for older women. Most, but not all, studies indicate a mortality benefit for women undergoing mammography at ages 40-49, but the delay in observed benefit in women younger than 50 makes it difficult to determine the incremental benefit of beginning screening at age 40 rather than at age 50.

Breastfeeding:

 B

 Fair evidence that structured education and counseling programs can promote increased rates of breastfeeding. Insufficient evidence that brief counseling by primary care physician, peer counselors or written materials promote increase.

C
Carotid Artery Stenosis

 I

 Insufficient evidence to recommend for or against screening asymptomatic persons for carotid artery stenosis using physical examination or carotid ultrasound. For selected high-risk patients, a recommendation to discuss the potential benefits of screening and carotid endarterectomy may be made on other grounds.
All persons should be screened for hypertension, and clinicians should provide counseling about smoking cessation.

Cervical Cancer

 A

 Good evidence from multiple observational studies that screening with Pap smears reduces incidence of and mortality from cervical cancer. Evidence to determine the optimal starting and stopping age and interval for screening is limited. Indirect evidence suggests most of the benefit can be obtained by beginning screening within 3 years of onset of sexual activity or age 21 (whichever comes first) and screening at least every 3 years. Consider stopping screening > 65 y/o if women has had adequate screening with 3 negative findings in past and no abnormal Pap tests in 10 yrs. Be alert to screen any women who has not had adequate screening in past.

Chlamydial Infection

 A

 Good evidence that screening women at risk for chlamydial infection reduces the incidence of pelvic inflammatory disease and fair evidence that community-based screening reduces prevalence of chlamydial infection. Routinely screen all sexually active women aged 25 years and younger (including those pregnant), and other asymptomatic women at increased risk for chlamydial infection.

Colorectal Cancer

 A

 Strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer.
Fair to good evidence that several screening methods are effective in reducing mortality from colorectal cancer. Benefits from screening substantially outweigh potential harms, but the quality of evidence, magnitude of benefit, and potential harms vary with each method  (FOB testing, flex sig, colonoscopy).
Initiate screening at 50 years of age for men and women at average risk for colorectal cancer.
 In persons at higher risk (for example, those with a first-degree relative who receives a diagnosis with colorectal cancer before 60 years of age), initiating screening at an earlier age is reasonable.

Coronary Heart Disease

 D,I

 Recommends against routine screening with resting ECG, exercise testing (ETT), or scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.
Found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium in adults at increased risk for CHD events.

D
Dementia

 I

 Evidence is insufficient to recommend for or against routine screening for dementia in older adults.

Dental Caries in Preschool Children

 I

 Evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease.
Recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride

Depression

 B

 Good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity. Insufficient evidence to recommend screening for adolescents and children.

Diabetes Mellitus

 I, B

 The evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose. 
Good evidence to screen patients with hyperlipidemia, and those with hypertension, since lowering blood pressure to below conventional target ranges is deemed beneficial in diabetic hypertensives..

Diet

 B,I

 Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
Insufficient evidence to determine the significance and magnitude of the benefit of routine counseling to promote a healthy diet in adults

Down Syndrome

 B,B

 The offering of amniocentesis or chorionic villus sampling (CVS) for chromosome studies is recommended by the USPSTF for pregnant women at high risk for Down syndrome.
The offering of screening for Down syndrome by serum multiple-marker testing is recommended for:

·          All low-risk pregnant women.

·          As an alternative to amniocentesis and CVS for high-risk women.

Drug Abuse

 I

 There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescent and adult patients may be recommended on other grounds.All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus.Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment facilities where available.

F
Family Violence:

 I

 Found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death.
The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been suspected and assessed.

G
Gestational Diabetes

 I

•  Fair to good evidence that screening combined with diet and insulin therapy can reduce the rate of fetal macrosomia in women with gestational diabetes mellitus (GDM). The USPSTF found insufficient evidence, however, that screening for GDM substantially reduces important adverse health outcomes for mothers or their infants (for example, cesarean delivery, birth injury, or neonatal morbidity or mortality).
• Risk factors for GDM include maternal obesity (usually defined as a body mass index [BMI] of 25 or more), older age (usually defined as older than 25 years), family or personal history of diabetes, or a history of GDM in a prior pregnancy. Expert groups have also identified certain ethnic groups as being at increased risk for GDM (such as Hispanic, African American, American Indian, and South or East Asian). Using all the above criteria, however, would identify 90 percent of all pregnant women as being at increased risk for GDM.

The optimal approach to screening and diagnosis is uncertain. Expert panels in the United States recommend a 50-g 1-hour glucose challenge test (GCT) at 24 to 28 weeks' gestation, followed by a 100-g 3-hour oral glucose tolerance test (OGTT) for women who screen positive on the GCT.

Glaucoma

 I

 Good evidence that screening can detect increased intraocular pressure (IOP) and early primary open-angle glaucoma (POAG) in adults. The USPSTF also found good evidence that early treatment of adults with increased IOP detected by screening reduces the number of persons who develop small, visual field defects, and that early treatment of those with early, asymptomatic POAG decreases the number of those whose visual field defects progress. The evidence, however, is insufficient to determine the extent to which screening—leading to the earlier detection and treatment of people with IOP or POAG—would reduce impairment in vision-related function or quality of life

Gonorrhea

 B

 Fair evidence that screening tests can accurately detect gonorrhea infection and good evidence that antibiotics can cure gonorrhea infection. There is fair evidence that screening pregnant women at high risk for gonorrhea, including women at high risk because of younger age, may prevent other complications associated with gonococcal infection during pregnancy, such as preterm delivery and chorioamnionitis.
Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use.

Gynecologic Cancers

 I

 There is insufficient evidence to recommend for or against routine counseling of women about measures for the primary prevention of gynecologic cancers.

H
Hearing Impairment

 B

 Screening for older adults for hearing impairment is recommended through:

• Periodically questioning them about their hearing.
• Counseling them about the availability of hearing aid devices.
• Making referrals for abnormalities when appropriate.

Hearing, Newborn

 I

 Good evidence that newborn hearing screening leads to earlier identification and treatment of infants with hearing loss. However, evidence to determine whether earlier treatment resulting from screening leads to clinically important improvement in speech and language skills at age 3 years or beyond is inconclusive because of the design limitations in existing studies.
The USPSTF found good evidence that the prevalence of hearing loss in infants in the newborn intensive care unit (NICU) and those with other specific risk factors  is 10 to 20 times higher than the prevalence of hearing loss in the general population of newborns. Both the yield of screening and the proportion of true positive results will be substantially higher when screening is targeted at these high-risk infants.
Evidence that early identification and intervention for hearing loss improves speech, language, or auditory outcomes in high-risk populations is also limited.

Hemoglobinopathies

 B,I

 Neonatal screening for sickle hemoglobinopathies is recommended to identify infants who may benefit from antibiotic prophylaxis to prevent sepsis.
Whether screening should be universal or targeted to high-risk groups will depend on:

• The proportion of high-risk individuals in the screening area.
• The accuracy and efficiency with which infants at risk can be identified.
• Other characteristics of the screening program.

Offering screening for hemoglobinopathies to pregnant women at the first prenatal visit is recommended, especially for those at high risk.

There is insufficient evidence to recommend for or against routine screening for hemoglobinopathies in high-risk adolescents and young adults, but recommendations to offer such testing may be made on other grounds.

All screening efforts must be accompanied by comprehensive counseling and treatment services.

Hepatitis B Virus Infection

 A,D

 Good evidence that universal prenatal screening for HBV infection using HBsAg substantially reduces prenatal transmission of HBV and the subsequent development of chronic HBV infection. The current practice of vaccinating all infants against HBV infection and postexposure prophylaxis with hepatitis B immune globulin administered at birth to infants of HBV-infected mothers substantially reduces the risk for acquiring HBV infection.

No evidence that screening the general population for HBV infection improves long-term health outcomes such as cirrhosis, hepatocellular carcinoma, or mortality. The prevalence of HBV infection is low; the majority of infected individuals do not develop chronic infection, cirrhosis, or HBV-related liver disease.

Hepatitis C Virus Infection

 D,I

 Good evidence that screening with available tests can detect HCV infection in the general population. The prevalence of HCV infection in the general population is low, and most who are infected do not develop cirrhosis or other major negative health outcomes. There is no evidence that screening for HCV infection leads to improved long-term health outcomes, such as decreased cirrhosis, hepatocellular cancer, or mortality.
No evidence that screening for HCV infection in adults at high risk leads to improved long-term health outcomes, although the yield of screening would be substantially higher in a high-risk population than in an average-risk population and there is good evidence that anti-viral therapy improves intermediate outcomes, such as viremia. There is, as yet, no evidence that newer treatment regimens for HCV infection, such as pegylated interferon plus ribavirin, improve long-term health outcomes.

Herpes Simplex, Genital

 D

 Fair evidence that screening asymptomatic pregnant women using serological screening tests for HSV antibody does not reduce transmission of HSV to newborn infants. Women who develop primary HSV infection during pregnancy have the highest risk for transmitting HSV infection to their infants. Because these women are initially seronegative, serological screening tests for HSV (enzyme-linked immunosorbent assay [ELISA], immunoblot, and western blot assay [WBA]) do not accurately detect those at highest risk.

No evidence that screening asymptomatic adolescents and adults with serological tests for HSV antibody improves health outcomes or symptoms or reduces transmission of disease.

Home Uterine Activity Monitoring

 There is insufficient evidence to recommend for or against home uterine activity monitoring (HUAM) in high-risk pregnancies as a screening test for preterm labor, but recommendations against its use may be made on other grounds.

Hormone Replacement Therapy

 D

 Good evidence that the use of combined estrogen and progestin results in both benefits and harms. Benefits include reduced risk for fracture (good evidence) and colorectal cancer (fair evidence). Combined estrogen and progestin has no beneficial effect on coronary heart disease and may even pose an increased risk (good evidence). Other harms include increased risk for breast cancer (good evidence), venous thromboembolism (good evidence), stroke (fair evidence), cholecystitis (fair evidence), dementia (fair evidence), and lower global cognitive function (fair evidence).

Household and Recreational Injuries

 Periodic counseling of the parents of children on measures to reduce the risk of unintentional household and recreational injuries is recommended.

Counseling to prevent household and recreational injuries is also recommended for adolescents and adults based on the proven efficacy of risk reduction, although the effectiveness of counseling these patients to prevent injuries has not been adequately evaluated.

Persons with alcohol or drug problems should be identified, counseled and monitored. Those who use alcohol or illicit drugs should be warned against engaging in potentially dangerous activities while intoxicated.

Counseling elderly patients on specific measures to prevent falls is recommended based on fair evidence that these measures reduce the risk of falls, although the effectiveness of counseling elders to prevent falls has not been adequately evaluated.

More intensive individualized multi-factorial intervention is recommended for high-risk elderly patients in settings where adequate resources to deliver such services are available. There is insufficient evidence to recommend for or against the use of external hip protectors to prevent fall injuries.

Human Immunodeficiency Virus (HIV) Infection

 A

 Good evidence that rapid screening tests accurately detect HIV infection. The USPSTF also found good evidence that appropriately timed interventions, particularly highly active antiretroviral therapy (HAART), lead to improved health outcomes for many of those screened, including reduced risk for clinical progression and reduced mortality. Since false-positive test results are rare, harms associated with HIV screening are minimal. Potential harms of true-positive test results include increased anxiety, labeling, and effects on close relationships. Most adverse events associated with HAART, including metabolic disturbances associated with an increased risk for cardiovascular events, may be ameliorated by changes in regimen or appropriate treatment. The USPSTF concluded that the benefits of screening individuals at increased risk substantially outweigh potential harms.

Hypothyroidism, Congenital

 A

 Screening for congenital hypothyroidism with thyroid function tests on dried-blood spot specimens is recommended for all newborns in the first week of life.

I
Immunizations, Adult

Immunizations, Childhood

Intrapartum Electronic Fetal Monitoring

 D,I

 Routine electronic fetal monitoring for low-risk women in labor is not recommended.

There is insufficient evidence to recommend for or against intrapartum electronic fetal monitoring for high-risk pregnant women.

L
Lead Levels in Childhood and Pregnancy

 Screening for elevated lead levels by measuring blood lead at least once at age 12 months is recommended for:

• All children at increased risk of lead exposure.
• All children with identifiable risk factors.
• All children living in communities in which the prevalence of blood lead levels requiring individual intervention, including residential lead hazard control or chelation therapy, is high or is undefined.

Lipid Disorders

 A,B

 Good evidence that lipid measurement can identify asymptomatic middle-aged people (men > 35, women > 45) at increased risk of coronary heart disease and good evidence that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in such people with abnormal lipids and causes few major harms.
Recommends that clinicians routinely screen younger adults (men aged 20 to 35 and women aged 20 to 45) for lipid disorders if they have other risk factors for coronary heart disease.

Lung Cancer

 I

 Evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests

Motor Vehicle Injuries

 The following counseling to all patients, and the parents of young patients, is recommended:

• Use occupant restraints (lap/shoulder safety belts and child safety seats).
• Wear helmets when riding motorcycles.
• Refrain from driving while under the influence of alcohol or other drugs.

N Neural Tube Defects

Screening for neural tube defects during pregnancy is currently considered part of standard prenatal care

O
Overweight in Children and Adolescents

 I

 Approximately 15 percent of children and adolescents aged 6 to 19 years are overweight and are at risk for diabetes, elevated blood lipids, increased blood pressure and their sequelae, as well as slipped capital femoral epiphysis, steatohepatitis, sleep apnea, and psychosocial problems. The USPSTF found fair evidence that body mass index (BMI) is a reasonable measure for identifying children and adolescents who are overweight or are at risk for becoming overweight. There is fair evidence that overweight adolescents and children aged 8 years and older are at increased risk for becoming obese adults.

The USPSTF found insufficient evidence for the effectiveness of behavioral counseling or other preventive interventions with overweight children and adolescents that can be conducted in primary care settings or to which primary care clinicians can make referrals. There is insufficient evidence to ascertain the magnitude of the potential harms of screening or prevention and treatment interventions. The USPSTF was, therefore, unable to determine the balance between potential benefits and harms for the routine screening of children and adolescents for overweight.

Obesity in Adults

 I

 Found good evidence that body mass index (BMI) is reliable and valid for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. There is fair to good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese (as defined by BMI > 30 kg/m²). Although the USPSTF did not find direct evidence that behavioral interventions lower mortality or morbidity from obesity, the USPSTF concluded that changes in intermediate outcomes, such as improved glucose metabolism, lipid levels, and blood pressure, from modest weight loss provide indirect evidence of health benefits

Oral Cancer

 I

 No good-quality evidence that screening for oral cancer leads to improved health outcomes for either high-risk adults (i.e., those over the age of 50 who use tobacco) or for average-risk adults in the general population.

Osteoporosis

 B,C

 Recommends that women aged 65 and older be screened routinely for osteoporosis.

No recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.

Ovarian Cancer

 D

 Fair evidence that screening with serum CA-125 level or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening; however, the USPSTF found fair evidence that earlier detection would likely have a small effect, at best, on mortality from ovarian cancer. Because of the low prevale e of ovarian cancer and the invasive nature of diagnostic testing after a positive screening test, there is fair evidence that screening could likely lead to important harms.

P
Pancreatic Cancer:

 D

 No evidence that screening for pancreatic cancer is effective in reducing mortality. There is a potential for significant harm due to the very low prevalence of pancreatic cancer, limited accuracy of available screening tests, the invasive nature of diagnostic tests, and the poor outcomes of treatment

Peripheral Arterial Disease

 D

 Fair evidence that screening with ankle brachial index can detect adults with asymptomatic PAD. The evidence is also fair that screening for PAD among asymptomatic adults in the general population would have few or no benefits because the prevalence of PAD in this group is low and because there is little evidence that treatment of PAD at this asymptomatic stage of disease, beyond treatment based on standard cardiovascular risk assessment, improves health outcomes.

Phenylketonuria

 A

 Screening for phenylketonuria (PKU) by measurment of phenylalanine level on a dried-blood spot specimen is recommended for all newborns prior to discharge from the nursery. Infants who are tested before 24 hours of age should receive a repeat screening test by 2 weeks of age.

Physical Activity

 I

 Insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients. Controlled trials of physical activity counseling in adult primary care patients were of variable quality and had mixed results. There were no completed trials with children or adolescents that compared counseling with usual care practices.
The USPSTF reviewed only the literature on the effectiveness of primary care counseling to promote physical activity. It did not review the evidence for the effectiveness of physical activity to reduce chronic disease morbidity and mortality, which has been well documented in other recent reviews, or review evidence of counseling in other settings.

Postexposure Prophylaxis for Selected Infectious Diseases

 Postexposure prophylaxis should be provided to selected persons with exposure or possible exposure to:

• Haemophilus influenzae type b.
• Hepatitis A.
• Hepatitis B.
• Meningococcal pathogens.
• Rabies pathogens
• Tetanus pathogens

Preeclampsia

 B

 Screening for preeclampsia with blood pressure measurement is recommended for all pregnant women at the first prenatal visit and periodically throughout the remainder of the pregnancy.

Prostate Cancer:

 I

 Good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health.

R
Rh Incompatibility

 A,B

 Good evidence that Rh (D) blood typing, anti-Rh (D) antibody testing, and intervention with Rh (D) immunoglobulin, as appropriate, prevents maternal sensitization and improves outcomes for newborns. The benefits substantially outweigh any potential harms.

Fair evidence that repeated antibody testing for unsensitized Rh (D)-negative women (unless the father is also known to be Rh [D]-negative) and intervention with Rh (D) immunoglobulin, as appropriate, provides additional benefit over a single test at the first prenatal visit in preventing maternal sensitization and improving outcomes for newborns.

Rubella

 Routine screening for rubella susceptibility by history of vaccination or by serology is recommended for all women of childbearing age at their first clinical encounter. Susceptible non-pregnant women should be offered rubella vaccination; susceptible pregnant women should be vaccinated immediately after delivery.

An equally acceptable alternative for non-pregnant women of childbearing age is to offer vaccination against rubella without screening.

S
Skin Cancer:

 I

 Evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer.

Also insufficient evidence to determine whether clinician counseling is effective in changing patient behaviors to reduce skin cancer risk.  Counseling parents may increase the use of sunscreen for children, but there is little evidence to determine the effects of counseling on other preventive behaviors (such as wearing protective clothing, reducing excessive sun exposure, avoiding sun lamps/tanning beds, or practicing skin self-examination) and little evidence on potential harms.

Suicide Risk

 I

 No evidence that screening for suicide risk reduces suicide attempts or mortality. There is limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk.
There is insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality.

Syphilis

 A

 Strongly recommends that clinicians screen persons at increased risk for syphilis infection.

Observational evidence that the universal screening of pregnant women decreases the proportion of infants with clinical manifestations of syphilis infection and those with positive serologies. 

T
Testicular Cancer

 D

 No new evidence that screening with clinical examination or testicular self-examination is effective in reducing mortality from testicular cancer. Even in the absence of screening, the current treatment interventions provide very favorable health outcomes. Given the low prevalence of testicular cancer, limited accuracy of screening tests, and no evidence for the incremental benefits of screening, the USPSTF concluded that the harms of screening exceed any potential benefits.

Thyroid Disease

 I

 Fair evidence that the thyroid stimulating hormone (TSH) test can detect sub-clinical thyroid disease in people without symptoms of thyroid dysfunction, but poor evidence that treatment improves clinically important outcomes in adults with screen-detected thyroid disease. Although the yield of screening is greater in certain high-risk groups (e.g., postpartum women, people with Down syndrome, and the elderly), the USPSTF found poor evidence that screening these groups leads to clinically important benefits.

Thyroid Cancer

 D, C

 Routine screening for thyroid cancer using neck palpation or ultrasonography is not recommended for asymptomatic children or adults.

There is insufficient evidence to recommend for or against screening persons with a history of external head and neck irradiation in infancy or childhood, but recommendations for such screening may be made on other grounds.

Tobacco Use

 A

 Good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year.

Recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke.

Tuberculous Infection

 A

 Screening for tuberculous infection with tuberculin skin testing is recommended for asymptomatic high-risk persons.

Bacille Calmette-Guerin (BCG) vaccination should be considered only for selected high-risk individuals.

U
Ultrasonography in Pregnancy

Routine third-trimester ultrasound examination of the fetus is not recommendeed. There is insufficient evidence to recommend for or against routine ultrasound examination in the second trimester in low-risk pregnant women. Despite the lack of evidence on its positive impact on health outcomes and the 1996 USPSTF recommendation against its routine use, ultrasonography in pregnancy has become common practice in the U.S. Based on currently available evidence, the USPSTF believes there would be limited potential impact on clinical practice in updating the 1996 recommendation. The USPSTF will not update its 1996 recommendation.

Unintended Pregnancy

Periodic counseling about effective contraceptive methods is recommended for all women and men at risk for unintended pregnancy. Counseling should be based on information from a careful sexual history and should take into account the individual preferences, abilities, and risks of each patient. Sexually active patients should also receive information on measures to prevent sexually transmitted diseases. 

V
Visual Impairment

 Vision screening to detect amblyopia and strabismus is recommended once for all children before entering school, preferably between the ages of 3 and 4. Clinicians should be alert for signs of ocular misalignment when examining infants and children.

Screening for diminished visual acuity with the Snellen visual acuity chart is recommended for elderly persons. There is insufficient evidence to recommend for or against screening for diminished visual acuity among other asymptomatic persons, but recommendations against routine screening may be made on other grounds.

Visual Impairment in Children Ages 0-5

 B

 The USPSTF found no direct evidence that screening for visual impairment in children leads to improved visual acuity. However, the USPSTF found fair evidence that screening tests have reasonable accuracy in identifying strabismus, amblyopia, and refractive error in children with these conditions; that more intensive screening compared with usual screening leads to improved visual acuity; and that treatment of strabismus and amblyopia can improve visual acuity and reduce long-term amblyopia.

Vitamin Supplementation to Prevent Cancer and Coronary Heart Disease

 I

 Evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.
 

Y
Youth Violence

 There is insufficient evidence to recommend for or against clinician counseling of asymptomatic adolescents and adults to prevent morbidity and mortality from youth violence.

Adolescent and adult patients should be screened for problem drinking.

Clinicians should also be alert for symptoms and signs of drug abuse and dependence, the various presentations of family violence, and suicidal ideation in persons with established risk factors.