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a LANGE medical book

2021
CURRENT
Medical Diagnosis
& Treatment
SIXTIETH EDITION

Edited by

Maxine A. Papadakis, MD
Professor of Medicine, Emeritus
Department of Medicine
University of California, San Francisco

Stephen J. McPhee, MD
Professor of Medicine, Emeritus
Division of General Internal Medicine
Department of Medicine
University of California, San Francisco

Associate Editor

Michael W. Rabow, MD
Professor of Medicine and Urology
Division of Palliative Medicine
Department of Medicine
University of California, San Francisco

With Associate Authors

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 Contents
Authors v 13. Blood Disorders 512
Preface xiii
Lloyd E. Damon, MD, & Charalambos Babis
1. Disease Prevention & Health Promotion 1 Andreadis, MD, MSCE

Michael Pignone, MD, MPH, & Rene Salazar, MD
2. Common Symptoms
Paul L. Nadler, MD, & Ralph Gonzales, MD, MSPH
14. Disorders of Hemostasis, Thrombosis, &
Antithrombotic Therapy 558
16
Andrew D. Leavitt, MD, Erika Leemann Price, MD,
MPH, & Tracy Minichiello, MD

3. Preoperative Evaluation & Perioperative 15. Gastrointestinal Disorders 592

Management 44
Kenneth R. McQuaid, MD
Hugo Q. Cheng, MD
16. Liver, Biliary Tract, & Pancreas
4. Geriatric Disorders 54 Disorders 693
G. Michael Harper, MD, C. Bree Johnston, Lawrence S. Friedman, MD
MD, MPH, & C. Seth Landefeld, MD
17. Breast Disorders 758
5. Palliative Care & Pain Management 70
Armando E. Giuliano, MD, FACS, FRCSEd, &
Michael 1/1/. Rabow, MD, Steven Z. Pantilat, MD, Sara A. Hurvitz, MD, FACP
Ann Cai Shah, MD, Lawrence Poree, MD, MPH, PhD,
& Scott Steiger, MD 18. Gynecologic Disorders 785

6. Dermatologic Disorders 102 Jason Woo, MD, MPH, FACOG, &

Jill Long, MD, MPH, MHS, FACOG
Kanade Shinkai, MD, PhD, & Lindy P. Fox, MD
19. Obstetrics & Obstetric Disorders 820
7. Disorders of the Eyes & Lids 173
Vanessa L. Rogers, MD, & Scott W. Roberts, MD
Jacque L. Duncan, MD, Neeti B. Parikh, MD, &
Gerami D. Seitzman, MD 20. Rheumatologic, Immunologic,
& Allergic Disorders 849
8. Ear, Nose, & Throat Disorders 210
Jinoos Yazdany, MD, MPH, Rebecca Manno, MD,
Lawrence R. Lustig, MD, & Joshua S. Schindler, MD MHS, David B. Hellmann, MD, MACP, &John B.
Imboden Jr., MD
9. Pulmonary Disorders 251
Asha N. Chesnutt, MD, Mark S. Chesnutt, MD, 21. Electrolyte & Acid-Base Disorders 909
Niall T. Prendergast, MD, & Nayan Arora, MD, &J. Ashley Jefferson, MD
Thomas J. Prendergast, MD
22. Kidney Disease 938
10. Heart Disease 334
Tonja C. Dirkx, MD, & Tyler B. Woodell, MD, MCR
Thomas M. Bashore, MD, Christopher B. Granger,
MD, Kevin P. Jackson, MD, & Manesh R. Patel, MD 23. Urologic Disorders 980
11. Systemic Hypertension 453 Mathew Sorensen, MD, MS, FACS, Thomas J. Walsh,
MD, MS, & Kevin A. Ostrowski, MD
Michael Sutters, MD, MRCP (UK)
24. Nervous System Disorders 1005
12. Blood Vessel & Lymphatic Disorders 485
Vanja C. Douglas, MD, &
Warren J. Gasper, MD, James C. lannuzzi, MD, MPH, Michael J. Aminoff, MD, DSc, FRCP
& Meshell D. Johnson, MD

iii
 iv CMDT2021 CONTENTS

25. Psychiatric Disorders 1082 39. Cancer 1654

Kristin S. Raj, MD, Nolan Williams, MD, & Sunny Wang, MD, Tiffany 0. Dea, PharmD, BCOP,
Charles DeBattista, DMH, MD Patricio A. Cornett, MD, Lawrence S. Friedman, MD,
Carling Ursem, MD, Kenneth R. McQuaid, MD, &
26. Endocrine Disorders 1138 George R. Schade, MD
Paul A. Fitzgerald, MD
40. Genetic & Genomic Disorders 1721
27. Diabetes Mellitus & Hypoglycemia 1242 Reed E. Pyeritz, MD, PhD
Umesh Moshorani, MB, BS, MRCP (UK)
41. Sports Medicine & Outpatient
Orthopedics 1730
28. Lipid Disorders 1288
Anthony Luke, MD, MPH, &C. Benjamin Mo, MD
Michael J. Blaha, MD, MPH
42. Sexual & Gender Minority Health 1765
29. Nutritional Disorders 1299
Juno Obedln-Mallver, MD, MPH, MAS,
Katherine H. Sounders, MD, &
Patricio A. Robertson, MD, Kevin L. Arc/, MD, MPH,
Leon I. lgel, MD, FACP, FTOS Kenneth H. Moyer, MD, &Madeline B. Deutsch,
MD, MPH
30. Common Problems in lnfedious
Diseases & Antimicrobial Therapy 1320 e1. Anti-lnfedive Chemotherapeutic &
Peter V. Chin-Hong, MD, & Antibiotic Agents Online*
B. Joseph Guglielmo, PharmD Katherine Gruenberg, PharmD, &
B. Joseph Guglielmo, PhormD
31. HIV Infection & AIDS 1361
Mitchell H. Katz, MD e2. Diagnostic Testing & Medical
Decision Making Online*
32. Viral & Rickettsial Infections 1403 Chuonyi Mark Lu, MD
Eva Clark. MD, PhD, & Wayne X. Shandera, MD
e3. Information Technology in Patient
33. Baderlal& Chlamydlallnfectlons 1490 Care Online*
Bryn A. Boslett, MD, & Brion S. Schwartz, MD Russ Cue/no, MD, MS

34. Spirochetal Infections 1535 e4. Integrative Medicine Online*

Susan S. Philip, MD, MPH Dorshon Mehta, MD, MPH

35. Protozoal& Helminthic Infections 1552 e5. Podiatric Disorders Online*

Philip J. Rosenthal, MD Monara Dlnl, DPM, & Charles B. Parks, DPM

36. Mycotic Infections 1593 e6. Women's Health Issues Online*

Stacey R. Rose, MD, & Richard J. Hamill, MD Brigid Dolan, MD, MEd, & Judith Walsh, MD, MPH

37. Disorders Related to Environmental e7. Appendix: Therapeutic Drug Monitoring,

Emergencies 1608 Laboratory Reference Intervals, &
Pharmacogenetic Tests Online*
Jacqueline A. Nemer, MD, FACEP, &
Marianne A. Juarez. MD Chuanyi Mark Lu, MD

Index 1787
38. Poisoning 1624
Craig Smollin, MD, & Kent R. Olson, MD

"Free access to online chapters at www.accessmedicine.com/cmdt

 Preface
Current Medical Diagnosis & Treatment 2021 (CMDT 2021) is the 60th edition of this single-source reference for
practitioners in both hospital and ambulatory settings. The book emphasizes the practical features of clinical diagnosis and
patient management in all fields of internal medicine and in specialties of interest to primary care practitioners and to
subspecialists who provide general care.
Our students have inspired us to look at issues of race and justice, which surely impact peoples health. We have therefore
reviewed the content of our work to ensure that it contains the dignity and equality that every patient deserves.

INTENDED AUDIENCE FOR CMDT

House officers, medical students, and all other health professions students will find the descriptions of diagnostic and
therapeutic modalities, with citations to the current literature, of everyday usefulness in patient care.
Internists, family physicians, hospitalists, nurse practitioners, physician assistants, and all primary care providers will
appreciate CMDT as a ready reference and refresher text. Physicians in other specialties, pharmacists, and dentists will find
the book a useful basic medical reference text. Nurses, nurse practitioners, and physician assistants will welcome the format
and scope of the book as a means of quickly referencing medical diagnosis and treatment modalities.
Patients and their family members who seek information about the nature of specific diseases and their diagnosis and
treatment may also find this book to be a valuable resource.

NEW IN THIS EDITION OF CMDT

• INNOVATIVE TABLE highlighting the “Year in Review: Key Clinical Updates in CMDT 2021,” individually listed with
page numbers and reference citations, for easy access to significant changes in this edition
• New section on SARS-CoV-2 virus and COVID-19 infection
• Extensive revision of the Viral & Rickettsial Infections chapter, including new section on acute flaccid myelitis as well
as updates on measles, mumps, and Zika virus
• 140 NEW online images in the Heart Disease, Gastrointestinal Disorders, and Cancer chapters
• Addition of the 2019 European guidelines for treating pulmonary embolism
• New table outlining agents to consider for reversing anticoagulant effect during life-threatening bleeding based on the
Anticoagulation Forum and American Society of Hematology 2019 guidelines
• Bedaquiline considered first-line medication for multidrug-resistant tuberculosis
• Lefamulin, a new commercially available medication for treating community-acquired bacterial pneumonia
• New information on the combination of emtricitabine/tenofovir alafenamide as antiretroviral treatment for preexposure
prophylaxis among men
• A two-drug regimen, dolutegravir plus lamivudine, included in the top recommended HIV antiretroviral regimens
• Recommendation from the Advisory Committee on Immunization Practices for shared clinical decision-making
regarding HPV vaccination for adults aged 26-45 years
• Substantial revision of the Sexual & Gender Minority Health chapter
• Bempedoic acid, a new FDA-approved pharmacologic option for lowering LDL cholesterol in patients who cannot toler­
ate statins
• FDA approval of various closed loop systems that adjust basal insulin delivery for diabetic patients
• Eculizumab, a newly FDA-approved medication for both myasthenia gravis and neuromyelitis optica
• FDA approval of lasmiditan, a new pharmacologic option that can safely be given to migraine sufferers with cardiovas­
cular risk factors
• The sodium-glucose linked transporter (SGLT) inhibitors slow progression of early diabetic nephropathy in addition to
their having cardioprotective effects
• The US Preventive Services Task Force recommendation for hepatitis C screening of asymptomatic adults between ages
18 and 79 years

xiii
 XIV CMDT 2021 PREFACE

• FDA approval of adjuvant trastuzumab emtansine for patients with HER2-positive breast cancer with residual disease
after standard trastuzumab-containing neoadjuvant therapy
• Data from HER2CLIMB, a phase III trial, expected to lead to FDA approval of a new therapy for breast cancer patients
with pretreated HER2-positive advanced disease
• Promising results from phase 3 clinical trials of gene therapy for hemophilia A and B
• Information on bremelanotide, a second FDA-approved medication for hypoactive sexual desire disorder in premeno­
pausal women
• Mepolizumab, newly FDA approved for the treatment of eosinophilic granulomatosis with polyangiitis

OUTSTANDING FEATURES OF CMDT

• Medical advances up to time of annual publication
• Detailed presentation of internal medicine disciplines, plus primary care topics in gynecology, obstetrics, dermatology,
ophthalmology, otolaryngology, psychiatry, neurology, toxicology, urology, geriatrics, orthopedics, womens health,
sexual and gender minority health, preventive medicine, and palliative care
• Concise format, facilitating efficient use in any practice setting
• More than 1000 diseases and disorders
• Annual update on HIV/AIDS and other newly emerging infections
• Specific disease prevention information
• Easy access to medication dosages, with trade names indexed and costs updated in each edition
• Recent references, with unique identifiers (PubMed, PMID numbers) for rapid downloading of article abstracts and, in
some instances, full-text reference articles

E-CHAPTERS, CMDT ONLINE, & AVAILABLE APPS

Seven e-chapters listed in the Table of Contents can be accessed at www.AccessMedicine.com/CMDT. These online-only
chapters (available without need for subscription) include
• Anti-Infective Chemotherapeutic & Antibiotic Agents
• Diagnostic Testing & Medical Decision Making
• Information Technology in Patient Care
• Integrative Medicine
• Podiatric Disorders
• Womens Health Issues
• Appendix: Therapeutic Drug Monitoring, Laboratory Reference Intervals, & Pharmacogenetic Tests
Institutional or individual subscriptions to AccessMedicine also have full electronic access to CMDT 2021.
Subscribers to CMDT Online receive full electronic access to CMDT 2021 as well as
• An expanded, dedicated media gallery
• Quick Medical Diagnosis & Treatment (QMDT)—a concise, bulleted version of CMDT 2021
• Guide to Diagnostic Tests—for quick reference to the selection and interpretation of commonly used diagnostic tests
• CURRENT Practice Guidelines in Primary Care—delivering concise summaries of the most relevant guidelines in
primary care
• Diagnosaurus—consisting of 1000+ differential diagnoses
CMDT 2021, QMDT, Guide to Diagnostic Tests, and Diagnosaurus are also available as individual apps for your smartphone
or tablet and can be found in the Apple App Store and Google Play.

Disease Prevention &
Health Promotion
Michael Pignone, MD, MPH1
Rene Salazar, MD
GENERAL APPROACH TO THE PATIENT
The medical interview serves several functions. It is used to
collect information to assist in diagnosis (the “history” of
the present illness), to understand patient values, to assess
and communicate prognosis, to establish a therapeutic
relationship, and to reach agreement with the patient about
further diagnostic procedures and therapeutic options. It
also serves as an opportunity to influence patient behavior,
such as in motivational discussions about smoking cessa­
tion or medication adherence. Interviewing techniques
that avoid domination by the clinician increase patient
involvement in care and patient satisfaction. Effective
clinician-patient communication and increased patient
involvement can improve health outcomes.
Patient Adherence
For many illnesses, su ccessfu l prevention and treatment
depends on difficu lt fu ndamental behavioral changes,
including altering diet, taking up exercise, giving up smok­
ing, cu tting down drinking, and adhering to medication
regimens that are often complex. Adherence is a problem in
every practice; up to 50% of patients fail to achieve full
adherence, and one-third never take their medicines. Many
patients with medical problems, even those with access
to care, do not seek appropriate care or may drop out of
care prematu rely. Adherence rates for short-term, self­
administered therapies are higher than for long-term
therapies and are inversely correlated with the number of
interventions, their complexity and cost, and the patients
perception of overmedication.
As an example, in HIV-infected patients, adherence to
antiretroviral therapy is a crucial determinant of treatment
success. Studies have unequivocally demonstrated a close
relationship between patient adherence and plasma HIV
RNA levels, CD4 cell counts, and mortality. Adherence
levels of more than 95% are needed to maintain virologic
suppression. However, studies show that over 60% of
1Dr. Pignone is a former member of the US Preventive Services
Task Force (USPSTF). The views expressed in this chapter are
his and Dr. Salazar's and not necessarily those of the USPSTF.
CMDT 2021
patients are less than 90% adherent and that adherence
tends to decrease over time.
Patient reasons for suboptimal adherence include sim­
ple forgetfulness, being away from home, being busy, and
changing daily routine. Other reasons include psychiatric
disorders (depression or substance misuse), uncertainty
about the effectiveness of treatment, lack of knowledge
about the consequences of poor adherence, regimen com­
plexity, and treatment side effects. The rising costs of medi­
cations, including generic drugs, and the increase in
patient cost-sharing burden, has made adherence even
more difficult, particularly for those with lower incomes.
Patients seem better able to take prescribed medications
than to adhere to recommendations to change their diet,
exercise habits, or alcohol intake or to perform various self-
care activities (such as monitoring blood glucose levels at
home). For short-term regimens, adherence to medications
can be improved by giving clear instructions. Writing out
advice to patients, including changes in medication, may
be helpful. Because low functional health literacy is com­
mon (almost half of English-speaking US patients are
unable to read and understand standard health education
materials), other forms of communication—such as illus­
trated simple text, videotapes, or oral instructions—may be
more effective. For non-English-speaking patients, clini­
cians and health care delivery systems can work to provide
culturally and linguistically appropriate health services.
To help improve adherence to long-term regimens, cli­
nicians can work with patients to reach agreement on the
goals for therapy, provide information about the regimen,
ensure understanding by using the “teach-back” method,
counsel about the importance of adherence and how to
organize medication-taking, reinforce self-monitoring,
provide more convenient care, prescribe a simple dosage
regimen for all medications (preferably one or two doses
daily), suggest ways to help in remembering to take doses
(time of day, mealtime, alarms) and to keep appointments,
and provide ways to simplify dosing (medication boxes).
Single-unit doses supplied in foil wrappers can increase
adherence but should be avoided for patients who have dif­
ficulty opening them. Medication boxes with compart­
ments (eg, Medisets) that are filled weekly are useful.
Microelectronic devices can provide feedback to show
 CMDT 2021 CHAPTER 1
patients whether they have taken doses as scheduled or to
notify patients within a day if doses are skipped. Reminders,
including cell phone text messages, are another effective
means of encouraging adherence. The clinician can also
enlist social support from family and friends, recruit an
adherence monitor, provide a more convenient care envi­
ronment, and provide rewards and recognition for the
patients efforts to follow the regimen. Collaborative pro­
grams in which pharmacists help ensure adherence are also
effective. Motivational interviewing techniques can be
helpful when patients are ambivalent about their therapy.
Adherence is also improved when a trusting doctor­
patient relationship has been established and when patients
actively participate in their care. Clinicians can improve
patient adherence by inquiring specifically about the behav­
iors in question. When asked, many patients admit to
incomplete adherence with medication regimens, with
advice about giving up cigarettes, or with engaging only in
“safer sex” practices. Although difficult, sufficient time must
be made available for communication of health messages.
Medication adherence can be assessed generally with a
single question: “In the past month, how often did you take
your medications as the doctor prescribed?” Other ways of
assessing medication adherence include pill counts and
refill records; monitoring serum, urine, or saliva levels of
drugs or metabolites; watching for appointment nonatten­
dance and treatment nonresponse; and assessing predict­
able drug effects, such as weight changes with diuretics or
bradycardia from beta-blockers. In some conditions, even
partial adherence, as with drug treatment of hypertension
and diabetes mellitus, improves outcomes compared with
nonadherence; in other cases, such as HIV antiretroviral
therapy or tuberculosis treatment, partial adherence may
be worse than complete nonadherence.
Guiding Principles of Care
Ethical decisions are often called for in medical practice, at
both the “micro” level of the individual patient-clinician
relationship and at the “macro” level of the allocation of
resources. Ethical principles that guide the successful
approach to diagnosis and treatment are honesty, benefi­
cence, justice, avoidance of conflict of interest, and the
pledge to do no harm. Increasingly, Western medicine
involves patients in important decisions about medical
care, eg, which colorectal screening test to obtain or which
modality of therapy for breast cancer or how far to proceed
with treatment of patients who have terminal illnesses (see
Chapter 5).
The clinician’s role does not end with diagnosis and
treatment. The importance of the empathic clinician in
helping patients and their families bear the burden of seri­
ous illness and death cannot be overemphasized. “To cure
sometimes, to relieve often, and to comfort always” is a
French saying as apt today as it was five centuries ago—as
is Francis Peabody’s admonition: “The secret of the care of
the patient is in caring for the patient.” Training to improve
mindfulness and enhance patient-centered communica­
tion increases patient satisfaction and may also improve
clinician satisfaction.
Cutler RL et al. Economic impact of medication non-adherence
by disease groups: a systematic review. BMJ Open. 2018 Jan
21;8(l):e016982. [PMID: 29358417]
Kini V et al. Interventions to improve medication adherence:
a review. JAMA. 2018 Dec 18;320(23):2461-73. [PMID:
30561486]
HEALTH MAINTENANCE & DISEASE
PREVENTION
Preventive medicine can be categorized as primary, sec­
ondary, or tertiary. Primary prevention aims to remove or
reduce disease risk factors (eg, immunization, giving up or
not starting smoking). Secondary prevention techniques
promote early detection of disease or precursor states (eg,
routine cervical Papanicolaou screening to detect carci­
noma or dysplasia of the cervix). Tertiary prevention mea­
sures are aimed at limiting the impact of established
disease (eg, partial mastectomy and radiation therapy to
remove and control localized breast cancer).
Tables 1-1 and 1-2 give leading causes of death in the
United States and estimates of deaths from preventable
causes. Recent data suggest increased mortality rates,
driven by increases in suicide and substance misuse and its
sequelae. Unintentional injuries, including deaths from
opioid-related overdoses, have become the third leading
cause of death in the United States. Non-Hispanic whites
with a high school education or less have suffered
disproportionately.
Many effective preventive services are underutilized,
and few adults receive all of the most strongly recom­
mended services. Several methods, including the use of
provider or patient reminder systems (including interac­
tive patient health records), reorganization of care environ­
ments, and possibly provision of financial incentives to
Table 1-1. Leading causes of death in the United States,
2017.
Category Estimate
All causes 2,179,857
1. Diseases of the heart 647,457
2. Malignant neoplasms 599,108
3. Unintentional injuries 169,936
4. Chronic lower respiratory 160,201
diseases
5. Cerebrovascular diseases 146,383
6. Alzheimer disease 121,404
7. Diabetes mellitus 83,564
8. Influenza and pneumonia 55,672
9. Nephritis, nephrotic syndrome, 50,633
and nephrosis
10. Intentional self-harm (suicide) 47,173
Data from National Center for Health Statistics 2019.
 DISEASE PREVENTION & HEALTH PROMOTION CMDT2021

the United States (eg, regional epidemics) highlight the need

Table 1-2. Leading preventable causes of death in the to understand the association of vaccine refusal and disease
United States, 2017. epidemiology.
Evidence suggests annual influenza vaccination is safe
Category Estimate
and effective with potential benefit in all age groups, and
Dietary risks 503,390 the Advisory Committee on Immunization Practices
High systolic blood pressure 454,346 (ACIP) recommends routine influenza vaccination for all
persons aged 6 months and older, including all adults.
Tobacco 437,706
When vaccine supply is limited, certain groups should be
High fasting plasma glucose 420,192 given priority, such as adults 50 years and older, individuals
High BMI 408,831 with chronic illness or immunosuppression, and pregnant
women. An alternative high-dose inactivated vaccine is
High LDL cholesterol 221,557
available for adults 65 years and older. Adults 65 years and
Impaired kidney function 173,378 older can receive either the standard-dose or high-dose
Air pollution 107,506 vaccine, whereas those younger than 65 years should
Alcohol use 104,536 receive a standard-dose preparation.
The ACIP recommends two doses of measles, mumps,
Drug use 104,440
and rubella (MMR) vaccine in adults at high risk for expo­
Low physical activity 70,844 sure and transmission (eg, college students, health care
Occupational risks 63,580 workers). Otherwise, one dose is recommended for adults
aged 18 years and older. Physician documentation of dis­
BMI, body mass index; LDL, low-density lipoprotein. ease is not acceptable evidence of MMR immunity.
Data from the US Burden of Disease Collaborators, 2019. Routine use of 13-valent pneumococcal conjugate
vaccine (PCV13) is recommended among adults aged 65
clinicians (though this remains controversial), can increase and older. Individuals 65 years of age or older who have
utilization of preventive services, but such methods have never received a pneumococcal vaccine should first receive
not been widely adopted. PCV13 followed by a dose of 23-valent pneumococcal
polysaccharide vaccine (PPSV23) 6-12 months later.
Borsky A et al. Few Americans receive all high-priority, appro­ Individuals who have received more than one dose of
priate clinical preventive services. Health Aff. (Millwood). PPSV23 should receive a dose of PCV13 more than 1 year
2018 Jun;37(6):925-8. [PMID: 29863918] after the last dose of PPSV23 was administered.
Heron M. Deaths: leading causes for 2017. Natl Vital Stat Rep.
The ACIP recommends routine use of a single dose of
2019 Jun 24;68(6)l-77. https://www.cdc.gov/nchs/data/nvsr/
nvsr68/nvsr68_06-508.pdf
tetanus, diphtheria, and five-component acellular pertussis
Levine DM et al. Quality and experience of outpatient care in the vaccine (Tdap) for adults aged 19-64 years to replace the
United States for adults with or without primary care. JAMA next booster dose of tetanus and diphtheria toxoids
Intern Med. 2019 Mar l;179(3):363-72. Erratum in: JAMA vaccine (Td). Due to increasing reports of pertussis in the
Intern Med. 2019 Jun 1;179(6):854. [PMID: 30688977] United States, clinicians may choose to give Tdap to per­
US Burden of Disease Collaborators. The state of US health,
sons aged 65 years and older (particularly to those who
1990-2016: burden of diseases, injuries, and risk factors
among US states. JAMA. 2018 Apr 10;319(14):1444-72.
might risk transmission to at-risk infants who are most
[PMID: 29634829] susceptible to complications, including death), despite lim­
Woolf SH et al. Life expectancy and mortality rates in the United ited published data on the safety and efficacy of the vaccine
States, 1959-2017. JAMA. 2019 Nov 26;322(20):1996-2016. in this age group.
[PMID: 31769830] Both hepatitis A vaccine and immune globulin pro­
vide protection against hepatitis A; however, administra­
PREVENTION OF INFECTIOUS DISEASES tion of immune globulin may provide a modest benefit
over vaccination in some settings. Hepatitis B vaccine
Much of the decline in the incidence and fatality rates of administered as a three-dose series is recommended for all
infectious diseases is attributable to public health children aged 0-18 years and high-risk individuals (ie,
measures—especially immunization, improved sanitation, health care workers, injection drug users, people with end­
and better nutrition. stage renal disease). Adults with diabetes are also at
Immunization remains the best means of preventing increased risk for hepatitis B infection. The ACIP recom­
many infectious diseases. Recommended immunization mends vaccination for hepatitis B in diabetic patients
schedules for children and adolescents can be found online at aged 19-59 years. The hepatitis B vaccine should also be
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent. considered in diabetic persons age 60 and older.
html, and the schedule for adults is at http://www.cdc.gov/ Human papillomavirus (HPV) virus-like particle
vaccines/schedules/hcp/adult.html (see also Chapter 30). (VLP) vaccines have demonstrated effectiveness in pre­
Substantial morbidity and mortality from vaccine-preventable venting persistent HPV infections and thus may impact
diseases, such as hepatitis A, hepatitis B, influenza, and pneu­ the rate of cervical intraepithelial neoplasia (CIN) II—III.
mococcal infections, continue to occur among adults. The ACIP recommends routine HPV vaccination for
Increases in the number of vaccine-preventable diseases in children and adults aged 9-26 years. Though routinely
 CMDT 2021 CHAPTER 1
recommended at age 11 or 12 years, vaccination can be
given starting at 9 years of age. Catch-up HPV vaccination
is recommended for all persons not adequately vaccinated
through age 26 years. Catch-up vaccination is not recom­
mended for all adults older than 26 years. Shared clinical
decision-making regarding HPV vaccination is recom­
mended for some individuals between 27 and 45 years of
age (vaccine is not licensed for adults older than 45 years).
Persons traveling to countries where infections are
endemic should take the precautions described in Chapter 30
and at https://wwwnc.cdc.gov/travel/destinations/list.
Immunization registries—confidential, population-based,
computerized information systems that collect vaccination
data about all residents of a geographic area—can be used
to increase and sustain high vaccination coverage.
The US Preventive Services Task Force (USPSTF) rec­
ommends behavioral counseling for adolescents and adults
who are sexually active and at increased risk for sexually
transmitted infections. Sexually active women aged
24 years or younger and older women who are at increased
risk for infection should be screened for chlamydia and
gonorrhea. Screening HIV-positive men or men who have
sex with men for syphilis every 3 months is associated with
improved syphilis detection.
HIV infection remains a major infectious disease prob­
lem in the world. The CDC recommends universal HIV
screening of all patients aged 13-64, and the USPSTF rec­
ommends that clinicians screen adolescents and adults
aged 15-65 years. Clinicians should integrate biomedical
and behavioral approaches for HIV prevention. In addition
to reducing sexual transmission of HIV, initiation of anti­
retroviral therapy reduces the risk for AIDS-defining
events and death among patients with less immunologi­
cally advanced disease.
Daily preexposure prophylaxis (PrEP) with the fixed-
dose combination of tenofovir disoproxil 300 mg and
emtricitabine 200 mg (Truvada) should be considered for
people who are HIV-negative but at substantial risk for
HIV infection. Studies of men who have sex with men sug­
gest that PrEP is very effective in reducing the risk of
contracting HIV. Patients taking PrEP should be encour­
aged to use other prevention strategies, such as consistent
condom use and choosing less risky sexual behaviors (eg,
oral sex), to maximally reduce their risk. Postexposure
prophylaxis (PEP) with combinations of antiretroviral
drugs is widely used after occupational and nonoccupa-
tional contact, and may reduce the risk of transmission
by approximately 80%. PEP should be initiated within
72 hours of exposure.
In immunocompromised patients, live vaccines are
contraindicated, but many killed or component vaccines
are safe and recommended. Asymptomatic HIV-infected
patients have not shown adverse consequences when given
live MMR and influenza vaccinations as well as tetanus,
hepatitis B, Haemophilus influenzae type b, and pneumo­
coccal vaccinations—all should be given. However, if
poliomyelitis immunization is required, the inactivated
poliomyelitis vaccine is indicated. In symptomatic HIV-
infected patients, live-virus vaccines, such as MMR, should
generally be avoided, but annual influenza vaccination is
safe.
Herpes zoster, caused by reactivation from previous
varicella zoster virus infection, affects many older adults
and people with immune system dysfunction. It can cause
postherpetic neuralgia, a potentially debilitating chronic
pain syndrome. The ACIP recommends the herpes zoster
subunit vaccine (HZ/su; Shingrix) be used for the preven­
tion of herpes zoster and related complications in immu­
nocompetent adults age 50 and older and in individuals
who previously received Zostavax.
Zika virus spreads to people primarily through mos­
quito bites but can also spread during sex by a person
infected with Zika to his or her partner. Although clinical
disease is usually mild, Zika virus infections in women
infected during pregnancy have been linked to fetal micro­
cephaly and loss, and newborn and infant blindness and
other neurologic problems (see Chapter 32). Pregnant
women should consider postponing travel to areas where
Zika virus transmission is ongoing.
Blackstock OJ et al. A cross-sectional online survey of HIV pre­
exposure prophylaxis adoption among primary care physicians.
J Gen Intern Med. 2017 Jan;32(l):62-70. [PMID: 27778215]
Centers for Disease Control and Prevention (CDC). HIV/AIDS,
2019. https://www.cdc.gov/hiv/basics/index.html
Centers for Disease Control and Prevention (CDC). PEP
(postexposure prophylaxis), 2018. https://www.cdc.gov/hiv/
risk/pep/index.html
Centers for Disease Control and Prevention (CDC). PrEP
(preexposure prophylaxis), 2019. https://www.cdc.gov/hiv/
basics/prep.html
Centers for Disease Control and Prevention (CDC). Recom­
mended Adult Immunization Schedules: United States, 2019.
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
Centers for Disease Control and Prevention (CDC). Zika virus,
2019. https://www.cdc.gov/zika/index.html
Meites E et al. Human papillomavirus vaccination for adults:
updated recommendations of the Advisory Committee on
Immunization Practices. MMWR Morb Mortal Wkly Rep.
2019 Aug 16;68(32):698-702. [PMID: 31415491]
Riddell J 4th et al. HIV preexposure prophylaxis: a review. JAMA.
2018 Mar 27;319(12):1261-8. [PMID: 29584848]
Short MD et al. Which patients should receive the herpes zoster
vaccine? JAAPA. 2019 Sep;32(9):18-20. [PMID: 31460969]
PREVENTION OF CARDIOVASCULAR DISEASE
Cardiovascular diseases (CVDs), including coronary heart
disease (CHD) and stroke, represent two of the most
important causes of morbidity and mortality in developed
countries. Several risk factors increase the risk for coronary
disease and stroke. These risk factors can be divided into
those that are modifiable (eg, lipid disorders, hypertension,
cigarette smoking) and those that are not (eg, age, sex, fam­
ily history of early coronary disease). Impressive declines
in age-specific mortality rates from heart disease and
stroke have been achieved in all age groups in North
America during the past two decades, in large part through
improvement of modifiable risk factors: reductions in ciga­
rette smoking, improvements in lipid levels, and more
aggressive detection and treatment of hypertension. This
section considers the role of screening for cardiovascular
risk and the use of effective therapies to reduce such risk.
Key recommendations for cardiovascular prevention
are shown in Table 1-3. Guidelines encourage regular
 DISEASE PREVENTION & HEALTH PROMOTION CMDT2021

Table 1-3. Expert recommendations for cardiovascular risk prevention methods: US Preventive Services Task Force
(USPSTF).1

Prevention Method Recommendation/[Year Issued]

Screening for Recommends one-time screening for AAA by ultrasonography in men aged 65-75 years who have ever smoked. (B)
abdominal aortic Selectively offer screening for AAA in men aged 65-75 years who have never smoked. (C)
aneurysm (AAA) Current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women aged
65-75 years who have ever smoked or have a family history of AAA. (1)
Recommends against routine screening for AAA in women who have never smoked and have no family history of
AAA. (D)
[2019]
Aspirin use Recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and
colorectal cancer (CRC) in adults aged 50-59 years who have a 10% or greater 10-year CVD risk, are not at increased
risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least
10 years. (B)
The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60-69 years
who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for
bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least
10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential
harms may choose to initiate low-dose aspirin. (C)
The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the
primary prevention of CVD and CRC in adults younger than 50 years or older than age 70. (I)
[2016]
Blood pressure The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF
screening recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting
treatment. (A)
[2015]
Serum lipid screening The USPSTF recommends that adults without a history of CVD use a low- to moderate-dose statin for the prevention
and use of statins of CVD events and mortality when all of the following criteria are met: (1) they are aged 40-75 years; (2) they have
for prevention one or more CVD risk factors (ie, dyslipidemia, diabetes mellitus, hypertension, or smoking); and (3) they have a
calculated 10-year risk of a cardiovascular event of 10% or greater.
Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults
aged 40-75 years. See the "Clinical Considerations" section of the USPSTF recommendations1 for more information
on lipids screening and the assessment of cardiovascular risk. (B)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiat­
ing statin use for the primary prevention of CVD events and mortality in adults aged 76 years and older without a
history of heart attack or stroke. (I)
[2016]
Counseling about Recommends offering or referring adults who are overweight or obese and have additional CVD risk factors to inten­
healthful diet and sive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. (B)
physical activity for [2014]
CVD prevention Recommends that primary care professionals individualize the decision to offer or refer adults without obesity who
do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to
promote a healthful diet and physical activity. (C)
[2017]
Screening for Recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged
diabetes mellitus 40-70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose
to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (B)
[2015]
Screening for smoking Recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide
and counseling to behavioral interventionsand US Food and Drug Administration (FDA)-approved pharmacotherapy for cessation
promote cessation to adults who use tobacco. (A)
[2015]

1US Preventive Services Task Force recommendations available at http://www.uspreventiveservicestaskforce.org/BrowseRec/lndex/browse-

recommendations.
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 C: The USPSTF makes no recommendation for or against routine provision of the service.
Recommendation D: The USPSTF recommends against routinely p roviding the service to asymp tomatic p atients. (The USPSTF found at
least fair evidence that the service is ineffective or that harms outweigh benefits.)
Recommendation I: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service.
 CMDT 2021 CHAPTER 1
assessment of global cardiovascular risk in adults
40-79 years of age without known CVD, using standard
cardiovascular risk factors. The role of nontraditional risk
factors for improving risk estimation remains unclear.
Lin JS et al. Nontraditional risk factors in cardiovascular disease
risk assessment: a systematic evidence report for the US
Preventive Services Task Force [Internet]. Rockville, MD:
Agency for Healthcare Research and Quality (US); 2018 Jul.
https://www.ncbi.nlm.nih.gov/books/NBK525925/ [PMID:
30234933]
Wall HK et al. Vital signs: prevalence of key cardiovascular
disease risk factors for Million Hearts 2022—United States,
2011-2016. MMWR Morb Mortal Wkly Rep. 2018 Sep 7;
67(35):983-91. [PMID: 30188885]
Yadlowsky S et al. Clinical implications of revised pooled cohort
equations for estimating atherosclerotic cardiovascular
disease risk. Ann Intern Med. 2018 Jul 3; 169( 1 ):20—9. [PMID:
29868850]
Abdominal Aortic Aneurysm
One-time screening for abdominal aortic aneurysm (AAA)
by ultrasonography is recommended by the USPSTF
(B recommendation) in men aged 65-75 years who have
ever smoked. One-time screening for AAA is associated
with a relative reduction in odds of AAA-related mortality
over 12-15 years (odds ratio [OR] 0.65 [95% confidence
interval [CI] 0.57-0.74]) and a similar reduction in AAA-
related ruptures (OR 0.62 [95% CI 0.55-0.70]). Women
who have never smoked and who have no family history
of AAA do not appear to benefit from such screening (D
recommendation); the current evidence for women who
have ever smoked or who have a family history of AAA is
insufficient to assess the balance of risks versus benefits (I
recommendation) (Table 1-3).
Guirguis-Blake JM et al. Primary care screening for abdominal
aortic aneurysm: updated evidence report and systematic
review for the US Preventive Services Task Force. JAMA. 2019
Dec 10;322(22):2219-38. [PMID: 31821436]
US Preventive Services Task Force, Owens DK et al. Screening
for abdominal aortic aneurysm: US Preventive Services Task
Force Recommendation Statement. JAMA. 2019 Dec
10;322(22):2211—8. [PMID: 31821437]
Ying AJ et al. Abdominal aortic aneurysm screening: a system­
atic review and meta-analysis of efficacy and cost. Ann Vase
Surg. 2019 Jan;54:298-303.e3. [PMID: 30081169]
Cigarette Smoking
Cigarette smoking remains the most important cause of
preventable morbidity and early mortality. In 2015, there
were an estimated 6.4 million premature deaths in the
world attributable to smoking and tobacco use; smoking is
the second leading cause of disability-adjusted life-years
lost. Cigarettes are responsible for one in every five deaths
in the United States, or over 480,000 deaths annually.
Annual cost of smoking-related health care is approxi­
mately $130 billion in the United States, with another $150
billion in productivity losses. Fortunately, US smoking
rates have been declining; in 2015,15.1% of US adults were
smokers, and by 2018, 13.7% were smokers. Global direct
health care costs from smoking in 2012 were estimated at
$422 billion, with total costs of over $1.4 trillion.
Over 41,000 deaths per year in the United States are
attributable to environmental tobacco smoke.
Smoking cessation reduces the risks of death and of
myocardial infarction in people with coronary artery
disease; reduces the rate of death and acute myocardial
infarction in patients who have undergone percutaneous
coronary revascularization; lessens the risk of stroke; and is
associated with improvement of chronic obstructive pul­
monary disease symptoms. On average, women smokers
who quit smoking by age 35 add about 3 years to their life
expectancy, and men add more than 2 years to theirs.
Smoking cessation can increase life expectancy even for
those who stop after the age of 65.
Although tobacco use constitutes the most serious
common medical problem, it is undertreated. Almost 40%
of smokers attempt to quit each year, but only 4% are suc­
cessful. Persons whose clinicians advise them to quit are
1.6 times as likely to attempt quitting. Over 70% of smokers
see a physician each year, but only 20% of them receive any
medical quitting advice or assistance.
Factors associated with successful cessation include
having a rule against smoking in the home, being older,
and having greater education. Several effective clinical
interventions are available to promote smoking cessation,
including counseling, pharmacotherapy, and combinations
of the two.
Helpful counseling strategies are shown in Table 1-4.
Additionally, a system should be implemented to identify
smokers, and advice to quit should be tailored to the
patients level of readiness to change. All patients trying to
quit should be offered pharmacotherapy (Table 1-5) except
those with medical contraindications, women who are
pregnant or breast-feeding, and adolescents. Weight gain
occurs in most patients (80%) following smoking cessa­
tion. Average weight gain is 2 kg, but for some (10-15%),
major weight gain—over 13 kg—may occur. Planning for
the possibility of weight gain, and means of mitigating it,
may help with maintenance of cessation.
Several pharmacologic therapies shown to be effective
in promoting cessation are summarized in Table 1-5. Nico­
tine replacement therapy doubles the chance of successful
quitting. The nicotine patch, gum, and lozenges are avail­
able over the counter and nicotine nasal spray and inhalers
by prescription. The sustained-release antidepressant drug
bupropion (150-300 mg/day orally) is an effective smoking
cessation agent and is associated with minimal weight gain,
although seizures are a contraindication. It acts by boosting
brain levels of dopamine and norepinephrine, mimicking
the effect of nicotine. Varenicline, a partial nicotinic acetyl -
choline-receptor agonist, has been shown to improve ces­
sation rates; however, its adverse effects, particularly its
effects on mood, are not completely understood and war­
rant careful consideration. No single pharmacotherapy is
clearly more effective than others, so patient preferences
and data on adverse effects should be taken into account in
selecting a treatment. Combination therapy is more effec­
tive than a single pharmacologic modality. The efficacy of
 DISEASE PREVENTION & HEALTH PROMOTION CMDT2021

Table 1-4. Inquiries to help in support of smoking cessation.

Component Helpful Clinician Statements and Inquiries

Communicate your caring and concern
Encourage the patient to talk about the
quitting process
Provide basic information about smoking
(eg, its addictive nature) and successful
quitting (eg, nature and time course of
withdrawal)
Encourage the patient to make a quit attempt
"1 am concerned about the effects of smoking on your health...
• and want you to know that 1 am willing to help you to quit."
• and so how do you feel about quitting?"
• do you have any fears or ambivalent feelings about quitting?"
"Tell me...
• why do you want to quit smoking?"
• when you tried quitting smoking in the past, what sort of difficulties did you
encounter?"
• were you able to succeed at all, even for a while?"
• what concerns or worries do you have about quitting now?"
"Did you know that...
• the nicotine in cigarette smoke is highly addictive?"
• within a day of stopping, you will notice nicotine withdrawal symptoms, such as
irritability and craving?"
• after you quit, any smoking (even a single puff) makes it likely that you will fully
relapse into smoking again?"
"1 want you to reassure you that...
• as your clinician, 1 believe you are going to be able to quit."
• there are now available many effective smoking cessation treatments."
• more than half the people who have ever smoked have now successfully quit."

e-cigarettes in smoking cessation has not been well evalu­

ated, and some users may find them addictive. Recent
reports of “vaping-related” lung disease should prompt
additional caution in the use of unregulated nicotine deliv­
ery devices for smoking cessation (see Chapter 9).
Clinicians should not show disapproval of patients who
fail to stop smoking or who are not ready to make a quit
attempt. Thoughtful advice that emphasizes the benefits of
cessation and recognizes common barriers to success can
increase motivation to quit and quit rates. An upcoming
medical procedure or intercurrent illness or hospitalization
may motivate even the most addicted smoker to quit.
Individualized or group counseling is very cost effec­
tive, even more so than treating hypertension. Smoking
cessation counseling by telephone (“quitlines”) and text
messaging-based interventions have both proved effective.
An additional strategy is to recommend that any smoking
take place outdoors to limit the effects of passive smoke on
housemates and coworkers. This can lead to smoking
reduction and quitting.
Public policies, including higher cigarette taxes and
more restrictive public smoking laws, have also been
shown to encourage cessation, as have financial incentives
directed to patients.
Anonymous. Drugs for smoking cessation. Med Lett Drugs
Ther. 2019 Jul 15;61(1576): 105-10. [PMID: 31381546]
Centers for Disease Control and Prevention (CDC). Current
cigarette smoking among adults in the United States in 2017.2019
November 18. https://www.cdc.gov/tobacco/data_statistics/
fact_sheets/adult_data/cig_smoking/index.htm
Goodchild M et al. Global economic cost of smoking-attributable
diseases. Tob Control. 2018 Jan;27(l):58-64. [PMID:
28138063]
Hollands GJ et al. Interventions to increase adherence to medi­
cations for tobacco dependence. Cochrane Database Syst Rev.
2019 Aug 16;8:CD009164. [PMID: 31425618]
Ma J et al. Smoking-attributable mortality by state in 2014, U.S.
Am J Prev Med. 2018 May;54(5):661-70. [PMID: 29551325]
Tibuakuu M et al. National trends in cessation counseling,
prescription medication use, and associated costs among US
adult cigarette smokers. JAMA Netw Open. 2019 May 3;
2(5):el94585. [PMID: 31125108]
Lipid Disorders
Higher low-density lipoprotein (LDL) cholesterol concen­
trations and lower high-density lipoprotein (HDL) levels are
associated with an increased risk of CHD (see Chapter 28).
Measurement of total and high-density lipoprotein choles­
terol levels can help assess the degree of CHD risk. The best
age to start screening is controversial, as is its frequency.
Cholesterol-lowering therapy reduces the relative risk of
CHD events, with the degree of reduction proportional to
the reduction in LDL cholesterol achieved, at least at LDL
levels greater than 100 mg/dL. The absolute benefits of
screening for—and treating—abnormal lipid levels depend
on the presence and level of other cardiovascular risk fac­
tors, including hypertension, diabetes mellitus, smoking,
age, and sex. If other risk factors are present, atherosclerotic
CVD risk is higher and the potential benefits of therapy are
greater. Patients with known CVD are at higher risk and
have larger benefits from reduction in LDL cholesterol. The
optimal risk threshold for initiating statins for primary pre­
vention remains somewhat controversial, although most
guidelines now suggest statin therapy when the 10-year
atherosclerotic cardiovascular risk is greater than 10%.
Evidence for the effectiveness of statin-type drugs is
better than for the other classes of lipid-lowering agents
 CMDT 2021 CHAPTER 1

Table 1-5. Medications for tobacco dependence and smoking cessation.

Cost3
Drug Some Formulations Usual Adult Dosage1,2 30 days

Nicotine Replacement Therapies (NRTs]

Nicotine transdermal patch4 - generic 7,14,21 mg/24 hr patches 1 patch/day5 $54.90
(NicoDerm CQ)
Nicotine polacrilex gum4 - generic 2,4 mg/pieces 8-24 pieces/day5,6,7 $70.40
(Nicorette gum)
Nicotine polacrilex lozenge4,8 - generic 2,4 mg/lozenges 8-20 lozenges/day5,6,9 $81.47
(Nicorette Lozenge)

Nicotine oral inhaler - Nicotrol 10 mg cartridges10 4-16 cartridges/day5 $524.87

Nicotine nasal spray - Nicotrol NS 200 sprays/10 mL bottles (0.5 mg/spray) 2 sprays 8-40x/day (max 10 sprays/hr)4 $551.11
(4-bottle
package)
Dopaminergic-Noradrenergic Reuptake Inhibitor
Bupropion SR - generic 100,150,200 mg SR tablets11 150 mg orally once daily x 3 days, then $116.00
150 mg orally twice daily
Nicotinic Receptor Partial Agonist
Varenicline tartrate - Chantix 0.5,1 mg tablets 0.5 mg orally once daily x 3 days, then $568.80
0.5 mg twice daily on days 4-7, then
1 mg twice daily

SR, sustained-release.
1 Dosage reductions may be needed for liver or kidney impairment.

2Patients should receive a minimum of 3-6 months of effective therap y. In general, the dosage of NRTs can be tap ered at the end of

treatment; bup rop ion SR and varenicline can usually be stop p ed without a gradual dosage reduction, but some clinicians recommend
a taper.
3Cost for 30 days treatment.

4Available over-the-counter for persons >18 years old.

5See expanded table for dosage titration instructions, available at: medicalletter.org/TML-article-1576c.

6Eating or drinking within 15 minutes of using a gum or lozenge should be avoided.

7 A second piece of gum can be used within 1 hour. Continuously chewing one piece after another is not recommended.

8Also available in a mini-lozenge.

9Maximum of 5 lozenges in 6 hours or 20 lozenges/day. Use of more than 1 lozenge at a time or continuously using one after another is

not recommended.
10Each cartridge delivers 4 mg of nicotine.

11Only the generic 150-mg SR tablets are FDA-approved as a smoking cessation aid.

Modified, with permission, from Drugs for smoking cessation. Med L ett Drugs Ther. 2019 Jul 15;61 (1576): 105-10. http://www.medicalletter
•org.

or dietary changes specifically for improving lipid levels.
Multiple large, randomized, placebo-controlled trials
have demonstrated important reductions in total mortal­
ity, major coronary events, and strokes with lowering
levels of LDL cholesterol by statin therapy for patients
with known CVD. Statins also reduce cardiovascular
events for patients with diabetes mellitus. For patients
with no previous history of cardiovascular events or dia­
betes, meta-analyses have shown important reductions of
cardiovascular events.
Newer antilipidemic monoclonal antibody agents (eg,
evolocumab and alirocumab) lower LDL cholesterol by
50-60% by binding proprotein convertase subtilisin kexin
type 9 (PCSK9), which decreases the degradation of LDL
receptors. PCSK9 inhibitors also decrease Lp(a) levels. These
newer agents are very expensive so are often used mainly in
high-risk patients when statin therapy does not reduce the
LDL cholesterol sufficiently at maximally tolerated doses
or when patients are intolerant of statins. So far, few side
effects have been reported with PCSK9 inhibitor use.
Guidelines for statin and PCSK9 therapy are discussed
in Chapter 28.
Navarese EP et al. Association between baseline LDL-C level and
total and cardiovascular mortality after LDL-C lowering: a
systematic review and meta-analysis. JAMA. 2018 Apr
17;319(15):1566-79. [PMID: 29677301]
Pagidipati NJ et al. Comparison of recommended eligibility for
primary prevention statin therapy based on the US Preventive
Services Task Force Recommendations vs the ACC/AHA
Guidelines. JAMA. 2017 Apr 18;317(15):1563-7. [PMID:
28418481]
 DISEASE PREVENTION & HEALTH PROMOTION
US Preventive Services Task Force. Statin use for the primary
prevention of cardiovascular disease in adults: US Preventive
Services Task Force Recommendation Statement. JAMA.
2016 Nov 15;316( 19): 1997-2007. [PMID: 27838723]
Hypertension
Over 67 million adults in the United States have hyperten­
sion, representing 29% of the adult US population (see
Chapter 11). Hypertension in nearly half of these adults is
not controlled (ie, less than 140/90 mm Hg). Among those
whose hypertension is not well controlled, nearly 40% are
not aware of their elevated blood pressure; almost 16% are
aware but not being treated; and 45% are being treated but
the hypertension is not controlled. In every adult age group,
higher values of systolic and diastolic blood pressure carry
greater risks of stroke and heart failure. Systolic blood pres­
sure is a better predictor of morbid events than diastolic
blood pressure. Home monitoring is better correlated with
target organ damage than clinic-based values. Clinicians
can apply specific blood pressure criteria, such as those of
the Joint National Committee or American Heart Associa­
tion guidelines, along with consideration of the patients
cardiovascular risk and personal values, to decide at what
levels treatment should be considered in individual cases.
Primary prevention of hypertension can be accom­
plished by strategies aimed at both the general population
and special high-risk populations. The latter include per­
sons with high-normal blood pressure or a family history
of hypertension, blacks, and individuals with various
behavioral risk factors, such as physical inactivity; exces­
sive consumption of salt, alcohol, or calories; and deficient
intake of potassium. Effective interventions for primary
prevention of hypertension include reduced sodium and
alcohol consumption, weight loss, and regular exercise.
Potassium supplementation lowers blood pressure mod­
estly, and a diet high in fresh fruits and vegetables and low
in fat, red meats, and sugar-containing beverages also
reduces blood pressure. Interventions of unproven efficacy
include pill supplementation of potassium, calcium, mag­
nesium, fish oil, or fiber; macronutrient alteration; and
stress management.
Improved identification and treatment of hypertension
is a major cause of the recent decline in stroke deaths as
well as the reduction in incidence of heart failure-related
hospitalizations. Because hypertension is usually asymp­
tomatic, screening is strongly recommended to identify
patients for treatment. Elevated office readings should be
confirmed with repeated measurements, ideally from
ambulatory monitoring or home measurements. Despite
strong recommendations in favor of screening and treat­
ment, hypertension control remains suboptimal. An inter­
vention that included both patient and provider education
was more effective than provider education alone in
achieving control of hypertension, suggesting the benefits
of patient participation; another trial found that home
monitoring combined with telephone-based nurse support
was more effective than home monitoring alone for blood
pressure control. Pharmacologic management of hyperten­
sion is discussed in Chapter 11.
CMDT2021
Bundy JD et al. Comparison of the 2017 ACC/AH A Hyperten­
sion Guideline with earlier guidelines on estimated reduc­
tions in cardiovascular disease. Curr Hypertens Rep. 2019
Aug 31;21(10):76. [PMID: 31473837]
Fryar CD et al. Hypertension prevalence and control among
adults: United States, 2015-2016. NCHS Data Brief. 2017
Oct;(289):l-8. [PMID: 29155682]
Weiss J et al. Benefits and harms of intensive blood pressure
treatment in adults aged 60 years or older: a systematic review
and meta-analysis. Ann Intern Med. 2017 Mar 21;166(6):
419-29. [PMID: 28114673]
Whelton PK et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/
ASH/ASPC/NMA/PCNA guideline for the prevention, detec­
tion, evaluation, and management of high blood pressure in
adults: a report of the American College of Cardiology/
American Heart Association Task Force on Clinical Practice
Guidelines. Hypertension. 2018 Jun;71(6):1269-324. [PMID:
29133354]
Chemoprevention
Regular use of low-dose aspirin (81-325 mg) can reduce
cardiovascular events but increases gastrointestinal bleed­
ing. Aspirin may also reduce the risk of death from several
common types of cancer (colorectal, esophageal, gastric,
breast, prostate, and possibly lung). The potential benefits
of aspirin may exceed the possible adverse effects among
middle-aged adults who are at increased cardiovascular
risk, which can be defined as a 10-year risk of greater than
10%, and who do not have an increased risk of bleeding. A
newer trial in older healthy adults did not find clear benefit
from aspirin for reduction of cardiovascular events and
saw an increase in all-cause mortality with aspirin. There­
fore, aspirin should not be routinely initiated in healthy
adults over age 70.
Nonsteroidal anti-inflammatory drugs may reduce the
incidence of colorectal adenomas and polyps but may also
increase heart disease and gastrointestinal bleeding, and
thus are not recommended for colon cancer prevention in
average-risk patients.
Antioxidant vitamin (vitamin E, vitamin C, and
beta-carotene) supplementation produced no significant
reductions in the 5-year incidence of—or mortality from—
vascular disease, cancer, or other major outcomes in high-
risk individuals with coronary artery disease, other
occlusive arterial disease, or diabetes mellitus.
Gaziano JM. Aspirin for primary prevention: clinical consider­
ations in 2019. JAMA. 2019 Jan 22;321(3):253-55. [PMID:
30667488]
Huang WY et al. Frequency of intracranial hemorrhage with low-
dose aspirin in individuals without symptomatic cardiovascular
disease: a systematic review and meta-analysis. JAMA Neurol.
2019 May 13. [Epub ahead of print] [PMID: 31081871]
McNeil JJ et al; ASPREE Investigator Group. Effect of aspirin on
cardiovascular events and bleeding in the healthy elderly.
N Engl J Med. 2018 Oct 18;379( 16): 1509-18. [PMID: 30221597]
Patrono C et al. Role of aspirin in primary prevention of cardio­
vascular disease. Nat Rev Cardiol. 2019 Nov;16(ll):675-86.
[PMID: 31243390]
Zheng SL et al. Association of aspirin use for primary prevention
with cardiovascular events and bleeding events: a systematic
review and meta-analysis. JAMA. 2019 Jan 22;321 (3):277-87.
[PMID: 30667501]
 1 CMDT 2021 CHAPTER 1
PREVENTION OF OSTEOPOROSIS
See Chapter 26.
Osteoporosis, characterized by low bone mineral den­
sity, is common and associated with an increased risk of
fracture. The lifetime risk of an osteoporotic fracture is
approximately 50% for women and 30% for men. Osteopo­
rotic fractures can cause significant pain and disability. As
such, research has focused on means of preventing osteo­
porosis and related fractures. Primary prevention strategies
include calcium supplementation, vitamin D supplementa­
tion, and exercise programs. The effectiveness of calcium
and vitamin D for fracture prevention remain controver­
sial, particularly in noninstitutionalized individuals.
Screening for osteoporosis on the basis of low bone
mineral density is recommended for women over age 65,
based on indirect evidence that screening can identify
women with low bone mineral density and that treatment
of women with low bone density with bisphosphonates is
effective in reducing fractures. However, real-world adher­
ence to pharmacologic therapy for osteoporosis is low:
one-third to one-half of patients do not take their medica­
tion as directed. Screening for osteoporosis is also recom­
mended in younger women who are at increased risk. The
effectiveness of screening in men has not been established.
Concern has been raised that bisphosphonates may
increase the risk of certain uncommon atypical types of
femoral fractures and rare osteonecrosis of the jaw, making
consideration of the benefits and risks of therapy impor­
tant when considering osteoporosis screening.
US Preventive Services Task Force. Screening for osteoporosis to
prevent fractures: US Preventive Services Task Force recom­
mendation statement. JAMA. 2018 Jun 26;319(24):2521-31.
[PMID: 29946735]
US Preventive Services Task Force. Vitamin D, calcium, or com­
bined supplementation for the primary prevention of frac­
tures in community-dwelling adults: US Preventive Services
Task Force recommendation statement. JAMA. 2018 Apr
17;319(15):1592-9. [PMID: 29677309]
Yedavally-Yellayi S et al. Update on osteoporosis. Prim Care.
2019 Mar;46(l):175-90. [PMID: 30704657]
PREVENTION OF PHYSICAL INACTIVITY
Lack of sufficient physical activity is the second most
important contributor to preventable deaths, trailing only
tobacco use. The US Department of Health and Human
Services and the CDC recommend that adults (including
older adults) engage in 150 minutes of moderate-intensity
(such as brisk walking) or 75 minutes of vigorous-intensity
(such as jogging or running) aerobic activity or an equiva­
lent mix of moderate- and vigorous-intensity aerobic activ­
ity each week. In addition to activity recommendations, the
CDC recommends activities to strengthen all major muscle
groups (abdomen, arms, back, chest, hips, legs, and shoul­
ders) at least twice a week.
Patients who engage in regular moderate to vigorous
exercise have a lower risk of myocardial infarction, stroke,
hypertension, hyperlipidemia, type 2 diabetes mellitus,
diverticular disease, and osteoporosis. Evidence supports
the recommended guidelines of 30 minutes of moderate
physical activity on most days of the week in both the pri­
mary and secondary prevention of CHD.
In longitudinal cohort studies, individuals who report
higher levels of leisure-time physical activity are less likely
to gain weight. Conversely, individuals who are overweight
are less likely to stay active. However, at least 60 minutes of
daily moderate-intensity physical activity may be necessary
to maximize weight loss and prevent significant weight
regain. Moreover, adequate levels of physical activity
appear to be important for the prevention of weight gain
and the development of obesity. Physical activity also
appears to have an independent effect on health-related
outcomes, such as development of type 2 diabetes mellitus
in patients with impaired glucose tolerance when com­
pared with body weight, suggesting that adequate levels of
activity may counteract the negative influence of body
weight on health outcomes. Compared to individuals with­
out CVD, those with CVD may benefit from physical activ­
ity to a greater extent.
Physical activity can be incorporated into any person’s
daily routine. For example, the clinician can advise a
patient to take the stairs instead of the elevator, to walk or
bike instead of driving, to do housework or yard work, to
get off the bus one or two stops earlier and walk the rest of
the way, to park at the far end of the parking lot, or to walk
during the lunch hour. The basic message should be the
more the better, and anything is better than nothing.
To be more effective in counseling about exercise, clini­
cians can also incorporate motivational interviewing tech­
niques, adopt a whole-practice approach (eg, use practice
nurses to assist), and establish linkages with community
agencies. Clinicians can incorporate the “5 As” approach:
1. Ask (identify those who can benefit).
2. Assess (current activity level).
3. Advise (individualize plan).
4. Assist (provide a written exercise prescription and sup­
port material).
5. Arrange (appropriate referral and follow-up).
Such interventions have a moderate effect on self­
reported physical activity and cardiorespiratory fitness,
even if they do not always help patients achieve a predeter­
mined level of physical activity. In their counseling, clini­
cians should advise patients about both the benefits and
risks of exercise, prescribe an exercise program appropriate
for each patient, and provide advice to help prevent injuries
and cardiovascular complications.
Although primary care providers regularly ask patients
about physical activity and advise them with verbal coun­
seling, few providers provide written prescriptions or per­
form fitness assessments. Tailored interventions may
potentially help increase physical activity in individuals.
Exercise counseling with a prescription, eg, for walking at
either a hard intensity or a moderate intensity with a high
frequency, can produce significant long-term improve­
ments in cardiorespiratory fitness. To be effective, exercise
prescriptions must include recommendations on type, fre­
quency, intensity, time, and progression of exercise and
 DISEASE PREVENTION & HEALTH PROMOTION
must follow disease-specific guidelines. Several factors
influence physical activity behavior, including personal,
social (eg, family and work), and environmental (eg, access
to exercise facilities and well-lit parks) factors. Walkable
neighborhoods around workplaces support physical activ­
ity such as walking and bicycling. A community-based
volunteer intervention resulted in increased walking activ­
ity among older women, who were at elevated risk for both
inactivity and adverse health outcomes.
Broad-based interventions targeting various factors are
often the most successful, and interventions to promote
physical activity are more effective when health agencies
work with community partners, such as schools, businesses,
and health care organizations. Enhanced community
awareness through mass media campaigns, school-based
strategies, and policy approaches are proven strategies to
increase physical activity.
Giroir BP et al. Physical activity guidelines for health and pros­
perity in the United States [Viewpoint]. JAMA. 2018 Nov
20;320(19): 1971-2. [PMID: 30418473]
Jeong SW et al. Mortality reduction with physical activity in
patients with and without cardiovascular disease. Eur Heart J.
2019 Nov 14;40(43):3547-55. [PMID: 31504416]
Kennedy AB et al. Tools clinicians can use to help get patients
active. Curr Sports Med Rep. 2018 Aug;17(8):271-6. [PMID:
30095547]
Piercy KL et al. The physical activity guidelines for Americans.
JAMA. 2018 Nov 20;320(19):2020-8. [PMID: 30418471]
PREVENTION OF OVERWEIGHT & OBESITY
Obesity is now a true epidemic and public health crisis that
both clinicians and patients must face. Normal body
weight is defined as a body mass index (BMI), calculated as
the weight in kilograms divided by the height in meters
squared, of less than 25; overweight is defined as a BMI =
25.0-29.9, and obesity as a BMI greater than 30. BMI is
often miscategorized as overweight, when it is in fact in the
obese range.
Risk assessment of the overweight and obese patient
begins with determination of BMI, waist circumference for
those with a BMI of 35 or less, presence of comorbid condi­
tions, and a fasting blood glucose and lipid panel. Obesity
is clearly associated with type 2 diabetes mellitus, hyper­
tension, hyperlipidemia, cancer, osteoarthritis, cardiovas­
cular disease, obstructive sleep apnea, and asthma.
Obesity is associated with a higher all-cause mortality
rate. Data suggest an increase among those with grades 2
and 3 obesity (BMI more than 35); however, the impact on
all-cause mortality among overweight (BMI 25-30) and
grade 1 obesity (BMI 30-35) is questionable. Persons with
a BMI of 40 or higher have death rates from cancers that
are 52% higher for men and 62% higher for women than
the rates in men and women of normal weight.
Prevention of overweight and obesity involves both
increasing physical activity and dietary modification to
reduce caloric intake. Adequate levels of physical activity
appear to be important for the prevention of weight gain
and the development of obesity. Physical activity programs
consistent with public health recommendations may
CMDT 2021
promote modest weight loss (~2 kg); however, the amount
of weight loss for any one individual is highly variable.
Clinicians can help guide patients to develop personal­
ized eating plans to reduce energy intake, particularly by
recognizing the contributions of fat, concentrated carbohy­
drates, and large portion sizes (see Chapter 29). Patients
typically underestimate caloric content, especially when
consuming food away from home. Providing patients with
caloric and nutritional information may help address the
current obesity epidemic. To prevent the long-term chronic
disease sequelae of overweight and obesity, clinicians must
work with patients to modify other risk factors, eg, by
smoking cessation (see previous section on cigarette smok­
ing) and strict blood pressure and glycemic control (see
Chapters 11 and 27).
Lifestyle modification, including diet, physical activity,
and behavior therapy, has been shown to induce clinically
significant weight loss. Other treatment options for obesity
include pharmacotherapy and surgery (see Chapter 29).
Counseling interventions or pharmacotherapy can produce
modest (3-5 kg) sustained weight loss over 6-12 months.
Counseling appears to be most effective when intensive
and combined with behavioral therapy. Pharmacotherapy
appears safe in the short term; long-term safety is still not
established.
Commercial weight loss programs are effective in pro­
moting weight loss and weight loss management. A ran­
domized controlled trial of over 400 overweight or obese
women demonstrated the effectiveness of a free prepared
meal and incentivized structured weight loss program
compared with usual care.
Weight loss strategies using dietary, physical activity, or
behavioral interventions can produce significant improve­
ments in weight among persons with prediabetes and a
significant decrease in diabetes incidence. Lifestyle inter­
ventions including diet combined with physical activity are
effective in achieving weight loss and reducing cardiometa-
bolic risk factors among patients with severe obesity.
Bariatric surgical procedures, eg, adjustable gastric
band, sleeve gastrectomy, and Roux-en-Y gastric bypass,
are reserved for patients with morbid obesity whose BMI
exceeds 40, or for less severely obese patients (with BMIs
between 35 and 40) with high-risk comorbid conditions
such as life-threatening cardiopulmonary problems (eg,
severe sleep apnea, Pickwickian syndrome, and obesity-
related cardiomyopathy) or severe diabetes mellitus. In
selected patients, surgery can produce substantial weight
loss (10-159 kg) over 1-5 years, with rare but sometimes
severe complications. Nutritional deficiencies are one com­
plication of bariatric surgical procedures and close moni­
toring of a patients metabolic and nutritional status is
essential.
Finally, clinicians seem to share a general perception
that almost no one succeeds in long-term maintenance of
weight loss. However, research demonstrates that approxi­
mately 20% of overweight individuals are successful at long­
term weight loss (defined as losing 10% or more of initial
body weight and maintaining the loss for 1 year or longer).
Clinicians must work to identify and provide the best
prevention and treatment strategies for patients who are
 CMDT 2021 CHAPTER 1
overweight and obese. Clinician advice on weight loss can
have a significant impact on patient attempts to adjust
weight-related behaviors. Unfortunately, many clinicians
are poorly prepared to address obesity. Clinicians are more
likely to give advice as BMI increases, missing opportuni­
ties to discuss weight with overweight patients. Clinician
bias and lack of training in behavior-change strategies
impair the care of obese patients. Strategies to address
these issues should be incorporated into innovative treat­
ment and care-delivery strategies (see Chapter 29).
Ryan DH et al. Guideline recommendations for obesity manage­
ment. Med Clin North Am. 2018 Jan;102(l):49-63. [PMID:
29156187]
Walsh K et al. Health advice and education given to overweight
patients by primary care doctors and nurses: a scoping
literature review. Prev Med Rep. 2019 Jan 25;14:100812.
[PMID: 30805277]
CANCER PREVENTION
Primary Prevention
Cancer mortality rates continue to decrease in the United
States; part of this decrease results from reductions in
tobacco use, since cigarette smoking is the most important
preventable cause of cancer. Primary prevention of skin
cancer consists of restricting exposure to ultraviolet light
by wearing appropriate clothing, and use of sunscreens.
Persons who engage in regular physical exercise and avoid
obesity have lower rates of breast and colon cancer. Preven­
tion of occupationally induced cancers involves minimiz­
ing exposure to carcinogenic substances, such as asbestos,
ionizing radiation, and benzene compounds. Chemopre­
vention has been widely studied for primary cancer pre­
vention (see earlier Chemoprevention section and Chapter
39). Use of tamoxifen, raloxifene, and aromatase inhibitors
for breast cancer prevention is discussed in Chapters 17
and 39. Hepatitis B vaccination can prevent hepatocellular
carcinoma (HCC), and screening and vaccination pro­
grams may be cost effective and useful in preventing HCC
in high-risk groups, such as Asians and Pacific Islanders.
Screening and treatment of hepatitis C is another strategy
to prevent HCC (see Chapter 16). The use of HPV vaccine
to prevent cervical and possibly anal cancer is discussed
earlier in this chapter. HPV vaccines may also have a role
in the prevention of HPV-related head and neck cancers.
The USPSTF recommends genetic counseling and, if indi­
cated after counseling, genetic testing for women whose
family or personal history is associated with an increased
risk of harmful mutations in the BRCA 1/2 gene. Guide­
lines for optimal cancer screening in adults over the age of
75 are unsettled; thus, an individualized approach that
considers differences in disease risk rather than chrono­
logical age alone is recommended.
US Preventive Services Task Force; Owens DK et al. Risk assess­
ment, genetic counseling, and genetic testing for BRCA-
related cancer: US Preventive Services Task Force
Recommendation Statement. JAMA. 2019 Aug 20;322(7):
652-65. [PMID: 31429903]
Wernli KJ et al. Screening for skin cancer in adults: updated
evidence report and systematic review for the US Preventive
Services Task Force. JAMA. 2016 Jul 26;316(4):436-47.
[PMID: 27458949]
Screening & Early Detection
Screening prevents death from cancers of the breast, colon,
and cervix. Current cancer screening recommendations
from the USPSTF are available online at https://www.
uspreventiveservicestaskforce.org/BrowseRec/Index/
browse-recommendations. Despite an increase in rates of
screening for breast, cervical, and colon cancer over the last
decade, overall screening for these cancers is suboptimal.
Interventions effective in promoting recommended cancer
screening include group education, one-on-one education,
patient reminders, reduction of structural barriers, reduc­
tion of out-of-pocket costs, and provider assessment and
feedback.
Though breast cancer mortality is generally reduced
with mammography screening, evidence from randomized
trials suggests that screening mammography has both ben­
efits and downsides. Clinicians should discuss the risks and
benefits with each patient and consider individual patient
preferences when deciding when to begin screening (see
Chapters 17 and e6).
Digital mammography is more sensitive in women with
dense breasts and in younger women; however, studies
exploring outcomes are lacking. MRI is not currently rec­
ommended for general screening, and its impact on breast
cancer mortality is uncertain; nevertheless, the American
Cancer Society recommends it for women at high risk
(20-25% or more), including those with a strong family
history of breast or ovarian cancer. Screening with both
MRI and mammography might be superior to mammogra­
phy alone in ruling out cancerous lesions in women with
an inherited predisposition to breast cancer. Digital breast
tomosynthesis (three-dimensional mammography) inte­
grated with digital mammography increases cancer detec­
tion rates compared to digital mammography alone;
however, the extent of improved detection and impact on
assessment outcomes need further exploration.
All current recommendations call for cervical and
colorectal cancer screening. Screening for testicular can­
cers among asymptomatic adolescent or adult males is not
recommended by the USPSTF. Prostate cancer screening
remains controversial, since no completed trials have
answered the question of whether early detection and
treatment after screen detection produce sufficient benefits
to outweigh harms of treatment. For men between the ages
of 55 and 69, the decision to screen should be individual­
ized and include a discussion of its risks and benefits with
a clinician. The USPSTF recommends against PSA-based
prostate cancer screening for men older than age 70 years
(grade D recommendation).
Annual or biennial fecal occult blood testing reduces
mortality from colorectal cancer. Fecal immunochemical
tests (FIT) are superior to guaiac-based fecal occult blood
tests (gFOBT) in detecting advanced adenomatous polyps
and colorectal cancer, and patients are more likely to favor
 DISEASE PREVENTION & HEALTH PROMOTION
FIT over gFOBT. Randomized trials using sigmoidoscopy
as the screening method found 20-30% reductions in mor­
tality from colorectal cancer. Colonoscopy has also been
advocated as a screening examination. It is more accurate
than flexible sigmoidoscopy for detecting cancer and pol­
yps, but its value in reducing colon cancer mortality has
not been studied directly. CT coIonography (virtual colo­
noscopy) is a noninvasive option in screening for colorectal
cancer. It has been shown to have a high safety profile and
performance similar to colonoscopy.
The USPSTF recommends screening for cervical cancer
in women aged 21-65 years with a Papanicolaou smear
(cytology) every 3 years or, for women aged 30-65 years
who desire longer intervals, screening with cytology and
HPV testing every 5 years. The USPSTF recommends
against screening in women younger than 21 years of age
and average-risk women over 65 with adequate negative
prior screenings. Receipt of HPV vaccination has no
impact on screening intervals.
Women whose cervical specimen HPV tests are positive
but cytology results are otherwise negative should repeat
co-testing in 12 months (option 1) or undergo HPV-
genotype-specific testing for types 16 or 16/18 (option 2).
Colposcopy is recommended in women who test positive
for types 16 or 16/18. Women with atypical squamous cells
of undetermined significance (ASCUS) on cytology and a
negative HPV test result should continue routine screening
as per age-specific guidelines.
In a randomized, controlled trial, transvaginal ultra­
sound combined with serum cancer antigen 125 (CA-125)
as screening tools to detect ovarian cancer did not reduce
mortality. Furthermore, complications were associated with
diagnostic evaluations to follow up false-positive screening
test results. Thus, screening for ovarian cancer with trans­
vaginal ultrasound and CA-125 is not recommended.
The USPSTF recommends offering annual lung cancer
screening with low-dose CT to current smokers aged 55 to
80 years with a 30-pack-year smoking history or to smokers
who quit within the past 15 years. Screening should stop
once a person has not smoked for 15 years or a health prob­
lem that significantly limits life expectancy has developed.
Screening should not be viewed as an alternative to smok­
ing cessation but rather as a complementary approach.
Geneve N et al. Colorectal cancer screening. Prim Care. 2019
Mar;46(l):135-48. [PMID: 30704654]
Li T et al. Digital breast tomosynthesis (3D mammography) for
breast cancer screening and for assessment of screen-recalled
findings: review of the evidence. Expert Rev Anticancer Ther.
2018 Aug;18(8):785-91. [PMID: 29847744]
Qaseem A et al. Screening for breast cancer in average-risk
women: a guidance statement from the American College of
Physicians. Ann Intern Med. 2019 Apr 16;170(8):547-60.
[PMID: 30959525]
Qaseem A et al. Screening for colorectal cancer in asymptomatic
average-risk adults: a guidance statement from the American
College of Physicians. Ann Intern Med. 2019 Nov 5;171 (9):
643-54. [PMID: 31683290]
US Preventive Services Task Force; Grossman DC et al. Screening
for ovarian cancer: US Preventive Services Task Force recom­
mendation statement. JAMA. 2018 Feb 13;319(6):588-94.
[PMID: 29450531]
CMDT 2021 3
US Preventive Services Task Force; Grossman DC et al. Screening
for prostate cancer: US Preventive Services Task Force recom­
mendation statement. JAMA. 2018 May 8;319(18):1901-13.
Erratum in: JAMA. 2018 Jun 19;319(23):2443. [PMID: 29801017]
US Preventive Services Task Force; Curry SJ et al. Screening for
cervical cancer: US Preventive Services Task Force recommen­
dation statement. JAMA. 2018 Aug 21;320(7):674-86. [PMID:
30140884]
PREVENTION OF INJURIES & VIOLENCE
Injuries remain the most important cause of loss of poten­
tial 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 older adults. Approxi­
mately one-third of all injury deaths include a diagnosis of
traumatic brain injury, which has been associated with an
increased risk of suicide.
Although motor vehicle accident deaths per miles driven
have declined in the United States, there has been an increase
in motor vehicle accidents related to distracted driving (using
a cell phone, texting, eating). Evidence also suggests that
motorists’ use of sleeping medications (such as zolpidem)
almost doubles the risk of motor vehicle accidents. Clinicians
should discuss this risk when selecting a sleeping medication.
For 16- and 17-year-old drivers, the risk of fatal crashes
increases with the number of passengers.
Men ages 16-35 are at especially high risk for serious
injury and death from accidents and violence, with blacks
and Latinos at greatest risk. Deaths from firearms have
reached epidemic levels in the United States. Having a gun
in the home increases the likelihood of homicide nearly
threefold and of suicide fivefold. Educating clinicians to
recognize and treat depression as well as restricting access
to lethal methods have been found to reduce suicide rates.
In addition, clinicians should try to educate their patients
about always wearing seat belts and safety helmets, about the
risks of using cellular telephones or texting while driving and
of drinking and driving—or of using other intoxicants
(including marijuana) or long-acting benzodiazepines and
then driving—and about the risks of having guns in the home.
Clinicians have a critical role in the detection, preven­
tion, and management of intimate partner violence (see
Chapter e6). The USPSTF recommends screening women
of childbearing age for intimate partner violence and pro­
viding or referring women to intervention services when
needed. Inclusion of a single question 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. Assessment for
abuse and offering of referrals to community resources cre­
ate the potential to interrupt and prevent recurrence of
domestic violence and associated trauma. Clinicians
should take an active role in following up with patients
whenever possible, since intimate partner violence screen­
ing with passive referrals to services may not be adequate.
Evaluation of services available to patients after identifica­
tion of intimate partner violence should be a priority.
Physical and psychological abuse, exploitation, and
neglect of older adults are serious, underrecognized
 CMDT 2021 CHAPTER 1

problems; they may occur in up to 10% of elders. Risk fac­
tors for elder abuse include a culture of violence in the
family; a demented, debilitated, or depressed and socially
isolated victim; and a perpetrator profile of mental illness,
alcohol or drug abuse, or emotional and/or financial
dependence on the victim. Clues to elder mistreatment
include the patient’s ill-kempt appearance, recurrent
urgent-care visits, missed appointments, suspicious physi­
cal findings, and implausible explanations for injuries.
Feltner C et al. Screening for intimate partner violence, elder
abuse, and abuse of vulnerable adults: evidence report and
systematic review for the US Preventive Services Task Force.
JAMA. 2018 Oct 23;320(16):1688—701. [PMID: 30357304]
Jin J. JAMA Patient Page. Screening for intimate partner vio­
lence, elder abuse, and abuse of vulnerable adults. JAMA.
2018 Oct 23;320(16):1718. [PMID: 30357300]
Lutgendorf MA. Intimate partner violence and women's health.
Obstet Gynecol. 2019 Sep;134(3):470-80. [PMID: 31403968]
PREVENTION OF SUBSTANCE USE DISORDER:
ALCOHOL & ILLICIT DRUGS
Unhealthy alcohol use is a major public health problem in
the United States, where approximately 51% of adults
18 years and older are current regular drinkers (at least 12
drinks in the past year). The 2015-2020 US Dietary Guide­
lines for Americans recommends that if alcohol is con­
sumed, it should be consumed in moderation—up to one
drink per day for women and two drinks per day for men—
and only by adults of legal drinking age. The spectrum of
alcohol use disorders includes alcohol dependence, harm­
ful pattern use of alcohol, and entities such as alcohol
intoxication, alcohol withdrawal, and several alcohol-
induced mental disorders. The ICD-11 includes a new
category: hazardous alcohol use. Categorized as a risk fac­
tor, hazardous alcohol use is a pattern of alcohol use that
appreciably increases the risk of physical or mental health
harmful consequence to the user.
Underdiagnosis and undertreatment of alcohol misuse
is substantial, both because of patient denial and lack of
detection of clinical clues.
As with cigarette use, clinician identification and
counseling about unhealthy alcohol use are essential. The
USPSTF recommends screening adults aged 18 years and
older for unhealthy alcohol use.
The Alcohol Use Disorder Identification Test (AUDIT)
consists of questions on the quantity and frequency of alco­
hol consumption, on alcohol dependence symptoms, and
on alcohol-related problems (Table 1-6). The AUDIT
questionnaire is a cost-effective and efficient diagnostic

Table 1-6. Screening for alcohol abuse using the Alcohol Use Disorder Identification Test (AUDIT).
(Scores for response categories are given in parentheses. Scores range from 0 to 40, with a cutoff score of 5 or more indicating
hazardous drinking, harmful drinking, or alcohol dependence.)
1. How often do you have a drink containing alcohol?
(0) Never (1) Monthly or less (2) Two to four times a month (3) Two or three times a week (4) Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
(0)1 or 2 (1)3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been
drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
9. Have you or has someone else been injured as a result of your drinking?
(0) No (2) Yes, but not in the past year (4) Yes, during the past year
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
(0) No (2) Yes, but not in the past year (4) Yes, during the past year

Adapted, with permission, from BaborTF, Higgins-Biddle JC, Saunders JB, Montiero MG. AUDIT. The Alcohol Use Disorders Identification Test.
Guidelines for Use in Primary Health Care, 2nd ed. Geneva, Switzerland: World Health Organization; 2001.
Another random document with
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avenging angels entering and could find no sign that she had been
stricken, she stuck to her guns.
“Well,” she said, “I just don’t believe it.”
“Mary!” said Mrs. Carter. “Go home and pray!”
So my sister went home, but I do not think that she prayed. Mrs.
Carter and the Preacher called that afternoon and told my father and
mother what had been said and done that day in God’s house, and
there was a considerable to-do about it, both Mrs. Carter and the
Preacher dropping to their knees and praying, and insisting, that my
sister pray also for forgiveness. But my father and mother took the
attitude that since my sister did not know what she was talking
about, she probably had not sinned to any great extent. But it was a
good many years before she again had courage to express a doubt
as to the Virgin Birth. And if she goes to Heaven she will probably
find that Mrs. Carter and the Preacher have instructed St. Peter to
catechize her about it, and not to admit her until she has atoned fully
for her heinous offense at the age of ten.

3
Some of our families in which there was an unfortunate excess of
girls permitted them to have callers on Sunday afternoon, but such
affairs were conducted in a prim and prissy manner. Holiness was
the motif. The boy, if he had been a good lad all week and had done
nothing to affront God or the Preacher, was dressed in his Sunday
suit, and the young lady wore the frock that was kept in reserve for
weddings, funerals and baptizings, and those cannibalistic exercises
called the Lord’s Supper. And it was definitely understood that if a
boy called on a girl on a Sunday, he was courting her, and intended
to propose marriage. They could not talk; they must converse, and
their conversation must be on subjects both inspiring and uplifting.
These bons mots that are now known as wise cracks were frowned
upon, and a repetition of them resulted in the young gentleman being
shown the door.
The piano and the phonograph, in those houses which possessed
such wonders, were under lock and key and covered over with
draperies to hide them, for it was God’s day and God wanted no
foolishness. The girl’s father sat in various strategic places about the
house, moving from one to another as his suspicions of the boy’s
intentions arose and subsided, and her mother moved solemnly to
and fro in her best crinkly silk dress. There was nothing of joy in the
hearts of a boy and girl who underwent the torture of the Sunday-
afternoon call; to paraphrase the immortal song of Casey, God had
struck them out.
The first, and almost the last, young lady upon whom I called on a
Sunday afternoon lived near the waterworks, and her father and
mother, rocking solemnly upon the front porch and doubtless
reflecting gloomily upon the wickedness of the race, presented such
a forbidding spectacle that I walked four times around the block
before venturing in. But at length I did, and the then idol of my heart
greeted me at the front door. Ordinarily she would have seen me
coming, and she would have poked her head out of the window and
yelled: “Hey! I’ll be out in a minute.” Then we would have piled side
by side into the lawn swing and begun swapping trade-lasts, and the
air would have been thick with appreciative squeals and “he saids”
and “she saids.” But this was Sunday, a day given over to the glory
that is religion, and so she met me at the door with a prim and pretty
curtsy. Her father gave me a gentle but suspicious greeting, because
to the religious parent every boy thinks of a girl only in terms of
seduction, and her mother stopped her rocking chair long enough to
inquire:
“Did you go to Sunday school to-day, Herbie?”
“Yes, ma’am.”
“What was the Golden Text?” she demanded, suspiciously.
I told her and she asked:
“Did you stay to church?”
“Yes, ma’am.”
“Brother Jenkins preached such a beautiful sermon.”
“Yes, ma’am.”
And then she smiled a gentle smile, sighed a dolefully religious sigh
and told her daughter that she could take me into the parlor, that holy
of holies which was darkened and unused during the week, but
opened on Sundays for callers and on other special occasions such
as funerals and weddings. The room was extraordinarily gloomy,
because the curtains were never raised enough to let in a great deal
of light, and it smelled musty from being closed all week. And
invariably the gloom was added to by a crayon portrait of the head of
the house, a goggle-eyed enlargement of a very ordinary photograph
by Trappe, which stood on an easel in a corner.
I had considered this call an occasion, and with the aid of my elder
sister who was visiting us from Memphis, I had made an elaborate
toilet and had been permitted to wear my Sunday suit. But I did not
have a good time; I had known this girl a long time and admired her
intensely, but she seemed suddenly to have changed. She sat stiffly
on one side of the room near a window, hands folded demurely in
her lap, and I sat as stiffly on the other. We inquired coldly
concerning each other’s health, and I had prepared in my mind a
suitable and, indeed, quite holy comment on certain aspects of our
school life and was about to deliver it when her mother called gently
from the porch:
“Don’t play the piano, dear: it’s Sunday.”
My observation went unuttered, and we sat for some little time in an
embarrassed silence broken only by the crunch of her mother’s
rocking chair and the crooning melody of a hymn, each wishing to
Heaven that the other was elsewhere. I yearned to hear the piano,
but this instrument, with its delightful tinkle and its capacity for
producing ragtime, was generally regarded as a hellish contraption;
in fact, any sort of fast music was considered more or less sinful. If
there had been an organ in the house, the young lady would have
been permitted to play it, and we could have sung from the family
hymn book, provided we did so in proper humility. But there was only
a piano, and it was taboo. Presently the mother spoke again:
“Don’t play the phonograph, dear; it’s Sunday.”
This admonition was modified later by permission to play an organ
record of the hymn, “Face to Face,” and we played it over five times
before the mother got tired of hearing it. She said, “You’d better stop
now, dear; it’s Sunday.” Then she suggested that we turn to other
means of entertainment.
“Perhaps Herbie would like to look at the album, dear. Would you,
Herbie?”
“Yes, ma’am,” I said.
So we looked at the album, stiffly and in silence, the sacred book
held on our knees, but we were very careful that our knees did not
touch. We dared not giggle at the sight of the bushy-whiskered
members of the young lady’s family, and made no comment on their
raiment, which we rightly considered outlandish. We turned the
pages and stared, and the girl explained.
“That’s Uncle Martin.”
“Taken when he went to Niagara Falls on his honeymoon, dear,” said
her mother. “Uncle Martin was a great traveler.”
“Yes, ma’am,” I said, feeling that comment was expected.
“Wouldn’t you like to travel, Herbie?”
“Yes, ma’am.”
“Well, be a good boy and read your Bible and maybe some day God
will make you a great traveler.”
“Yes, ma’am.”
“But don’t travel on Sunday, Herbie.”
“No, ma’am.”
And crunch went the rocker and we turned another page, to find
Aunt Ella smiling gently at us through a mass of glorious flounces
and trains and switches. We learned from the mother that Aunt Ella
had been converted, at an extraordinarily early age, during a revival
near Hazel Run, and had lived a singularly devout and godly life.
Then we looked through the stereopticon at various places of
interest, murmuring our awe when the mother swished gently into
the room and pointed out, in a view of Niagara Falls, the exact spot
where Uncle Martin had stood. It was, she explained, one of God’s
rocks.
To my knowledge this family had some very comical stereopticon
views, scenes depicting the life of an unfortunate tramp who was
kicked heartily and effectively at every place he applied for
nourishment, but we did not see them on Sunday afternoon. They
were Saturday-night stuff. Saturday night was nigger night in
Farmington, and the whole town let down the bars somewhat. That
was the night when those who drank got tight, and when those who
bathed got wet, and when those who had amorous intentions did
their best to carry them out. Had I called on Saturday night I should
have been permitted to enjoy the adventures of the unfortunate
tramp, but not on Sunday. They had been put away, under lock and
key in the writing desk, and would not be brought out until Monday.
They were not calculated to promulgate a proper respect for the
Lord’s Day; they were considered downright wicked one day a week
and funny the other six.
Even in my infatuated condition an hour or so of this was quite
enough. Ordinarily this girl and I had much in common; at that time I
ranked her high among the beautiful flowers of God, and had I
stopped at her house on a week day we would have had gleeful and
uproarious converse, although even then we would have been liable
to religious instruction and catechism from every snooping Brother
and Sister who saw us. But the taboos that this Christian family had
raised on its holy day stood between us and could not be broken
down; we were horribly uncomfortable in each other’s presence, and
we never got over it. She was never afterward the same girl. And
when I took myself and my Sunday suit into the sunlight of the porch
her mother stopped rocking and crooning hymns long enough to
demand.
“Are you going to church to-night, Herbie?”
“Yes, ma’am,” I replied. “I got to.”
And so I went out of the gate and away from there.
This sort of thing in the homes of Farmington drove all of the boys to
more or less open revolt as rapidly as they reached an age at which
they felt able to defy parental and churchly authority. By the time I
left the town the Sunday-afternoon callers, except those who made
unavoidable duty calls, were to be found only in the homes of the
ungodly, where there was music and pleasure and gayety, where the
parlor was wide open seven days a week and the phonograph blared
and the piano tinkled whenever anyone wanted to hear them. To
these houses also went the girls from the devout families for
clandestine meetings with their sweethearts; they could not entertain
anyone in the dismal mausoleums into which their fathers and
mothers had transformed their homes. Many a small-town romance
has been blighted by the Sunday-afternoon call.
 AGENTS OF GOD
1
In Farmington we had not only those Preachers who had been
ordained to the ministry and so licensed to preach by both God and
man, but the town was overrun with volunteers, Brothers and Sisters
who shouted the word of God whenever they could find an audience,
who gave the testimony at the camp meetings, the protracted
meetings, and at those orgies conducted by the professional
evangelist who chased the Devil from any town that would guarantee
him a fat fee. These Preachers and their allies controlled Farmington
to a very large extent, and when they were defeated, at elections or
otherwise, they raised their voices in howls of denunciation and
called upon God to punish the guilty. It was many years before I
learned that a candidate endorsed by a Preacher was not
necessarily called by God to assume the office.
It was essential for any man who wanted to hold public office to
profess religion and be seen at church, and usually the more noise
he made in religious gatherings, the greater his chances of success
at the polls. If any candidate dared to hold views contrary to those of
the godly, a vile whispering campaign was started against him, and
his personal life was raked over and bared with many gloating
references to the Christian duty of the people to punish this upstart.
Occasionally the ungodly or anti-religious element elected a mayor
or what not, but generally religion triumphed and thanks were offered
to God, and then throughout his term the office-holder was harassed
by pious hypocrites seeking favors and special privilege. My father,
as county surveyor and city clerk, was constantly being checked up
to determine if he remained steadfast in the faith.
I do not think that my father was regarded as a first-class Christian in
Farmington; I am sure that in many quarters it was felt that he was
more or less disgracing his ancestry because he did not bound to his
feet at camp meetings and similar gatherings and make a holy show
of himself with hypocritical testimony. He went to church, and until I
was old enough to do pretty much as I pleased, he saw to it that I
went also, and to Sunday school and Epworth League and other
places where the Methodist God could take a peek at my soul. But
he was only passively religious; he showed no tremendous
enthusiasm for the Wesleyan Deity, and he never made a particularly
active effort to keep me in the path that, according to some, leads to
spiritual glory.
In a religious sense I was annoyed much less by my father and my
mother than I was by the busybodies who seemed to be appointed
by the Lord to take care of everybody’s business but their own. Most
of the religious instruction that I received came from volunteers,
either relatives of my parents, or Brothers and Sisters whom I
encountered during my pathetic efforts to have a good time. And, of
course, from the Preacher. To many of these I put questions; I asked
them to explain certain things in the Bible and in the church service
that I did not understand, and which seemed to conflict with the little
definite knowledge that I had of life and human beings. Invariably I
was told that the Bible needed no explaining; I was merely to believe
it and have faith.
I was afraid of the Preachers in Farmington, and of the Brothers and
Sisters, desperately afraid of them, because they filled my mind with
horrible pictures of Hell and the roaring fires of old Nick; their object
in talking religion to small boys seemed to be to frighten them into
being good. And I think that most of the other boys were afraid of
them, too, except such brave souls as my cousin, Barney Blue, who
was a “bad boy” and afraid of neither God nor Devil. One of my great
moments was when I heard Barney tell a prying old Brother to go to
hell. And curiously enough, and incomprehensibly to many of the
good old people of Farmington, Barney is to-day exceedingly
prosperous and well thought of in his community.
But there were very few like Barney; most of us trembled in our
boots, even the red-topped ones we were so proud of, when a
Preacher or a Brother or Sister came snooping about, head bowed
under its burden of religious horror, and demanded information as to
our conduct and the condition of our souls. In the cities the cry of the
youngsters was “Cheese it, the cop,” but in Farmington it was “Look
out, there’s a Preacher!” We could not start a game of marbles
anywhere in town but one of them, or else a Brother or Sister, did not
pounce upon us and demand to know if we were playing “for keeps.”
And since we invariably were, and did not know enough to tell the
Preacher what was politely called a fib, the game stopped then and
there while we absorbed a little religion and learned that God
abhorred little boys who played for keeps.
We were told that God had His eye on us when we did such things,
and that our Guardian Angels put black marks in their little books
every time we shot a marble.
“You must give your heart to Jesus,” we were told. “He will not let
you dwell in the Heavenly Mansions if you persist in this sinful
practice.”
We used to play marbles in a vacant lot behind the Christian church,
and it was a very fine playground, with a level stretch on which the
marbles rolled beautifully. But we had to give it up, because the lot
was near the home of a Sister, who spent most of her waking hours
in front of her window, staring out through the curtains in a constant
search for sin and scandal. We had no more than drawn the ring and
legged for first shot than she came out on her porch and shouted:
“Are you boys playing for keeps?”
And we answered in unison, politely, as we had been taught:
“Yes, ma’am.”
She stopped the game, swooping down upon us with the glint of the
Heaven-born fanatic in her eye. She told us that we were wicked and
sinful and blasphemous and Heaven knows what else besides to
play for keeps in the very shadow of a House of God. She invariably
threatened us with punishment ranging from spanking to everlasting
torment in Hell, and if we dared to say anything to her other than the
conventional “Yes, ma’am,” she said we were saucy and threatened
to telephone our mothers. Occasionally she did so, and a marble
game behind the Christian church was then followed by the wails of
little boys being led into the woodshed. She performed her war
dance many times, and finally we went to play near the livery stable.
The atmosphere there was not so uplifting, but at least we were in
peace, for the hostlers had no interest at all in our immortal souls,
although they were very much interested in who won the marbles.

2
The livery stables in Farmington were a sort of symbol of the
heretical element of the town. The big Mayberry & Byington barn,
down the block from Braun’s Hotel and Saloon, was a particularly
delightful place to loaf; it was infested by sinners, abandoned
wretches who swore horrible oaths, smoked cigarettes, and drank
whisky and gin out of big bottles. The politicians loafed there at such
times as they felt they would not be seen by the more godly part of
our citizenry.
Two of our most celebrated darkies, Uncle Louis Burks and Uncle
Mose Bridges, spent most of their time at the Mayberry barn, and we
considered them quite fascinating, especially Uncle Louis. He
regaled us with tales of the days when, in the South before the Civil
War, he had no duties except be the father of as many children as
possible; that was his job. He estimated the number of his progeny
anywhere from fifty to five hundred, according to the amount of liquor
he had consumed before counting, and we generally gave him the
benefit of the doubt and called it five hundred. We ranked him with
the great fathers of the Bible, and I recall that it seemed to me
somewhat strange that the preachers did not offer Uncle Louis’s
achievements as proof of the truth of certain portions of the Book.
Uncle Mose’s principal claim to our attention was his dog, a sad-
eyed little mongrel that trotted at the end of a string everywhere
Uncle Mose went. We were permitted to play with the dog
occasionally, much to the disgust of our parents, as we invariably
went home scratching. Both Uncle Louis and Uncle Mose were
regarded as sinners, partly on account of their color. It was not
believed that a black man could enter the Kingdom of Heaven,
although the deluded creatures had churches and prayed to God.
And then their domestic arrangements were somewhat haphazard,
and Uncle Louis frequently boasted that he did not marry all the
mothers of his children before the War. Both he and Uncle Mose
were familiar figures around Farmington for many years; they did
odd jobs at the homes of the godly, and for their pay received part
cash and part religious lectures and prayers. They thrived on the
cash, and apparently the prayers did not hurt them.
It was at the livery stable, also, that the drummers from St. Louis,
waiting for rigs to take them to the towns of the lead-mining district
around Bonne Terre, Flat River and Elvins, left their stocks of stories.
The coming of a drummer was an event with us; it meant that we
should hear things that were not meant for our little ears, and that for
a little while at least we could revel in the sight of a man given over
to sin and seemingly enjoying it. He used to assure us solemnly that
playing marbles for keeps was not a sin anywhere in the world but in
Farmington, and tell stories, which we regarded as fanciful untruths,
of towns in which little boys did not have to go to Sunday school.
The drummer came in on the herdic from De Lassus before the
interurban railroad was built, and he was generally a gorgeous
spectacle. He was not welcomed in our best homes, and even his
presence in church was not considered a good omen for the forces
of righteousness, so he could usually be found loafing in front of the
livery stable or dozing in a chair tilted against the wall of the St.
Francis Hotel. He brought with him not only the latest stories, but the
most advanced raiment; the first peg-top trousers ever seen in
Farmington adorned the legs of a shoe drummer traveling out of St.
Louis, and they created a furor and established a style. Soon our
most stylish dressers had them.
Besides being the abode of wickedness and the lair of Satan, and
therefore an extraordinarily fascinating place, the livery stable was
also the principal loafing place of a darky who had fits. He was one
of our town characters, and was regarded by myself and the other
boys as a person of remarkable accomplishments. We felt that to be
able to have fits set him above us; we gloated enormously when he
suddenly shrieked, fell to the ground and began foaming at the
mouth. Our attitude toward him was respectful, and he appreciated
it. He was, it seemed to me, proud of his fits. I have known him to
rise, finally, brush himself off and ask, simply:
“Was it a good one?”
Generally we thought it was. This darky became such an attraction
for us that for a long time, when a group of us could find nothing
interesting to do, and when there was for the moment no one in sight
to remind us of our duty to God and the church, it was the custom for
one of us to say:
“Let’s go over to the livery stable and see Tod have a fit.”
We thereupon trooped solemnly to the big barn and gathered in a
circle about the darky, who was generally sitting against the side of
the building whittling on a stick. We watched him silently for a while,
and then someone mustered up courage enough to say:
“Going to have a fit to-day, Tod?”
With the instinct of the true artist, Tod ignored us for a time, intent
upon his whittling. Finally he gave us brief attention.
“Maybe,” he said, and returned to his task.
And then suddenly he uttered a blood-curdling shriek and tumbled
headlong from his chair. We watched, fascinated, uttering little
murmurs of “ah!” as he writhed and moaned, and when it was all
over we settled back with a little sigh of satisfaction. We felt that we
had seen a first-rate performance, and when the darky had a fit in
front of the Post Office, or in the yard of the courthouse, his audience
was increased by as many boys and men as were downtown,
shopkeepers leaving their wares to run across and watch.
There was nothing of callousness in our attitude toward the darky.
My own feeling in the matter was that Tod was having fits for our
benefit, and because he enjoyed it, but at length I came to learn that
he could not help it, that the poor fellow was ill. Then I was sorry for
him, and one day I asked one of our most prominent Brothers why
Tod had fits. He immediately seized upon the question to give me
some religious instruction.
“He has sinned,” said the Brother, “and God is punishing him.”
He elaborated his statement, explaining that Tod had probably
neglected to attend Sunday school, or had not read his Bible, and
that he had thus become a blasphemous sinner and was being
properly dealt with. He pointed out that I, too, might grow up and
have fits if I was not a good boy. Now, I did not want to have fits, and
neither did I want to be a good boy. I wanted to have some fun; I
wanted to run about, and play marbles, and go swimming, and put
tick-tacks against people’s window on Halloween night. I wanted to
do all sorts of things that good boys did not do, yet I most certainly
did not want to have fits.
“But, Uncle Si,” I said, “how do you know that God is making him
have fits? And why does God do it?”
“Herbie!” He was shocked. “You are blasphemous! You must not
question the wisdom of the Almighty. I have faith, and I believe in
God and the holiness of His acts. I know that this man must have
sinned, or God would not punish him so.”
I was not prepared to confound this faulty logic; it was not then the
business of small boys to question anything their elders told them,
but to accept without comment the pearls of wisdom that fell from
bewhiskered lips. But it seemed to me small business for God to be
engaged upon. Yet it did not cause me great surprise, for I had long
known that the God who pressed so heavily upon Farmington was a
conception of unutterable cruelty, an omnipotent Being whose
greatest joy lay in singling out the weak and lowly and inflicting
horrible tortures upon them, to the vast and gloating satisfaction of
the Brothers and their kind.
Some time afterward, because I was worried over this torturing and
punishment of the darky whose writhings had now become less an
amusing exhibit than a terrible manifestation of the Almighty, I asked
another Brother how he knew that God had a hand in it. But neither
he nor Uncle Si ever told me. None of them were ever able to tell me
how they knew so well what God wanted and what God did not want;
they merely left with me the impression that on occasion they walked
with God and that God spoke to them and asked their advice on the
conduct of the human race. But the source of their information I
could not determine.
I have never found anyone who could satisfy my curiosity on this
point; I never then, or later, found a religious enthusiast who would
admit that he was offering merely his personal interpretation of the
utterances that other men had credited to the Almighty. But there
was nothing that entered the mind of God that the Preachers and the
Brothers and Sisters of Farmington did not know and that they could
not explain and apply to local affairs. They knew precisely what was
a sin and what was not, and it was curious that the sins were
invariably things from which they received no pleasure. Nor was
anything which paid a profit a sin. They knew very well that God
considered it a sin to play cards or dance, but that He thought it only
good business practice to raise the price of beans or swindle a fellow
citizen in the matter of town lots, or refuse credit to the poor and
suffering.

3
As I grew older, and began to be skeptical of what I was told, I
became increasingly annoyed not only by the mental mannerisms of
these people, but by their physical mannerisms as well. Not only did
they walk as if their soles were greased, sliding and slipping about,
but they talked as if their tongues were greased also. Their language
was oily; they poured out their words unctuously, with much
roundabout phrasing and unnecessary language. If they wanted to
tell about a man going across the street from the Court House to the
Post Office they would take him up the hill past the Masonic
cemetery, with side trips to Jerusalem and other Jewish centers. If I
went downtown and met a man like Sheriff Rariden, who will always
have a place in my affections because he permitted his son Linn and
myself to roam the jail yard and stare through the bars at the nigger
prisoners, he would say:
“How’re you, Herbie? How’re your folks?”
But if I met a Preacher the greeting was this:
“Good afternoon, Herbert. And how are your dear father and
mother?”
And then he patted me on the head, pinched my arm, and padded
away, sliding greasily along the pavement, his eagle eye alert for
little boys playing marbles or for other signs of sin. He might have
been skinny and pitifully in need of food, but nevertheless I thought
of him as greasy. He had about him an unwholesome atmosphere; I
could not be comfortable in his presence. I felt that he had to be
watched, and when I became old enough to understand some of the
looks that he bestowed upon the young and feminine members of his
flock I realized that he should have been.
I had not lived very many years before I learned to look upon
Preachers, and their familiars, the Brothers and Sisters, as useless
incumbrances upon an otherwise fair enough earth. But while I hated
all of them, with a few natural exceptions, the one I always hated
most was the current pastor of our Southern Methodist church. He
was my spiritual father, the guardian of my soul and the director of
my life in the hereafter, and he tried to see to it that I went into the
hereafter with proper respect for him and a proper respect for his
God. I had to call him Brother and be very meek and gentle in his
presence, and stand without moving while he patted me on the head,
asked me fool questions, and told me how much God loved little
boys and girls. He called me a “manly little fellow,” which annoyed
me exceedingly, and I have the word of my young nephew that small
boys are still annoyed by it.
But he made it quite clear, out of his profound knowledge of the
wishes of the Almighty, that God did not want little boys and girls to
have a good time. Quite the contrary. God wanted them to do exactly
what the Preacher told them to do; He wanted them to accept the
Preacher as their guide and their philosopher and to believe
everything they were told, without fretting him with unanswerable
and therefore blasphemous questions. He wanted the little boys and
girls to spend most of their time praying to Him to “gimme this and
gimme that,” and the rest of it being little gentlemen and little ladies,
solemn and subdued, speaking only when spoken to and answering
promptly when called. God told the Preacher, who relayed the
message on to me very impressively, that it was a sin to play
marbles on Sunday, or to play for keeps at any time; that it was a sin
to roll hoops on the sidewalk in front of the church or rattle a stick
against the picket fence in front of the parsonage. Everything that I
wanted to do, everything that seemed to hold any promise of fun or
excitement, was a sin.
But it was not a sin to saw wood for the Preacher, or to carry huge
armfuls of sticks and fill his kitchen bin, and it was not a sin to mow
his lawn or rake the trash in his back yard. The children of the godly
were permitted to do these things because of the profound love
which the Preacher bore for them; his motto was “Suffer little
children to come unto me, and I will put them to work.” And since by
his own admission the Preacher was a Man of God, we were
permitted to perform these labors for nothing. A boy was paid
twenty-five to fifty cents, enormous and gratifying sums in those
days, if he mowed the lawn or raked the trash for a family given over
to sin, but if he did the job for a Preacher or a devout Brother, he
received nothing but a pat on the back and a prayer, or he could
listen to a verse from the Bible and a lecture on his duty to serve the
Lord and, incidentally, the self-appointed ambassadors of the Lord.
Once when I was about twelve years old our pastor telephoned my
mother and asked that I be sent to his house to help him perform
certain tasks which should have been done by the darky men of all
work about town. But our family did not wish to offend the Preacher,
so I did the work. And it was hard work. I toiled all morning cleaning
out the Preacher’s woodshed and stacking split stove wood in neat
piles, and then I carried in enough to fill two big wooden boxes in the
kitchen. During this time the Preacher sat in his study, holding
communion with God, and I presume, reading the Scriptures.
Occasionally he came out to the woodshed to superintend my work,
ordering me to do this and do that and scolding me because I did not
work faster, but he did none of the work himself. And when I was
through he told me to come into his study and receive payment. I
hurried after him, very weary, but with pleasant visions of a quarter
floating before my eyes. I believed that was the least I should
receive, and to me it was a great deal of money; properly expended
at McKinney’s or Otto Rottger’s, it would keep me in jawbreakers for
more than a week, and there might be enough left to buy a bag of
peewees or an agate.
But I did not receive the twenty-five cents. The Preacher closed the
door when we got into his study, and then he commanded me to
kneel. He put a hand on my shoulder, and he said:
“My dear boy, I am going to pray for you. I am going to ask the Lord
Jesus to enter your heart and make you a good boy.”
And then he knelt and prayed somewhat in this fashion: “O Lord
Jesus, bless this little boy who has this day performed labor in Thy
behalf,” etc.
It was all very confusing. I went home somewhat in doubt as to
whether the Preacher or God owned the woodshed.
But labor of little boys was not all that the Preachers got for nothing.
They were inveterate beggars, and all of them had fine, highly
developed noses for chickens and other dainties; it was seldom that
a family could have a chicken or turkey dinner without the Preacher
dropping in. It is true that their salaries were not large, but they had
free use of the parsonage, and they were not in dire circumstances
at all. Yet they always had their hands out, grasping; they were
ecclesiastical tramps begging for a donation. In our town we used to
give showers for them; many families made periodical donations to
the Pastor, and sometimes there were surprise parties, when the
Preacher and his wife were led into a room and shown piles of old
clothing, food and discarded furniture, all of which was sent next day
to the parsonage. The Preacher was always pathetically grateful for
these things; he would kneel in the midst of them and offer a prayer
for the souls of the good people who had thus given him the
clutterings of their cellars and attics, which they had no further use
for. He seldom had enough self-respect to refuse them.

4
The notion was prevalent in Farmington, among the Brothers and
Sisters, that the Preachers were their servants and should peddle
God to them 365 days a year. It was felt also that their wives should
be constantly at the Lord’s work; that they should be at home at all
times, available for consultation and prayer meetings, and that when
they went abroad they should dress soberly and walk with due
humility. The wife of Brother Court, one of our Methodist pastors,
was severely criticized for her departure from this formula of
conduct. Apparently the Courts had means other than the salary paid
them by the church, and they kept a maid, which in itself was enough
to arouse suspicion that Mrs. Court was not a true servant of the
Lord.
But the straw that broke the religious back of the Courts and
hastened the end of Brother Court’s ministry was the fact that Mrs.
Court took a nap each afternoon. This was considered nothing less
than scandalous, and for a long time our Brothers and Sisters
refused to believe that the wife of a man of God should so far forget
herself as to lie abed when she might be praying or sitting at her
front window looking through the curtains for a sin to happen. But the
story persisted, and was broadcast by a discharged servant who
swore that with her own eyes she had seen Mrs. Court sound asleep
at three o’clock in the afternoon. Finally two Sisters appointed
themselves a committee of investigation. They rang the bell at the
parsonage one afternoon, and told the maid that they had called to
join Mrs. Court in afternoon prayer, and, although they did not say it,
backbiting gossip.
“Mrs. Court,” said the maid, “is asleep and cannot be disturbed. Can
you call later?”
They could not. They had barely strength enough to get home, but
after prayer they revived sufficiently to sally forth and carry the awful
news throughout the town. There could no longer be any doubt. The
wife of the Pastor of the Southern Methodist church took a nap in the
afternoon. The Sisters had called, and had been so informed by the
maid, and while a few chronic doubters remained, the vast majority
realized that in a matter involving such serious consequences to
Mrs. Court’s spiritual welfare, a matter that directly affected and
almost destroyed her chances of going to Heaven, the Sisters could
not tell a lie.
So Brother Court soon resigned and accepted a call to a town where
members of his family could sleep when they felt like it, and could
even snore without jeopardizing their immortal souls. Nor did his
successor last very long. He was an Englishman, and spoke in a
high nasal voice, pronouncing his words very distinctly, syllable by
syllable. He was criticized for several reasons. One was that his
favorite phrase was “and an-gels can do no more,” and it was felt
that it was somewhat blasphemous to mention angels so often
before mixed company. And then he spoke from notes, whereas it
was a custom of our Pastors to preach solely out of divine inspiration
at the moment of delivery.
There was much talk about the new Preacher’s notes, and it was felt
that, somehow, he was lacking in devotion to God; many Brothers
and Sisters argued that if he were really a Man of God he would not
have to use notes, but would be inspired and filled with words as he
rose in the pulpit. His finish came the Sunday morning that the wind
blew through an opened window and scattered his notes, so that he
had to leave the pulpit and chase the scraps up and down the aisle
before he could proceed with his discourse. This was regarded as
direct evidence that God had deserted him, and he left town soon
afterward.

5
The personalities of the preachers of my home town, impressed as
they were upon my growing, plastic mind, probably will remain with
me always, but I am thankful that for the most part their names elude
me. I remember clearly, however, Brother Jenkins and Brother
Fontaine, of our Southern Methodist church; Brother Nations, of the
so-called Christian church; Brother Hickok, of the Presbyterian
church, and, clearest of all, Brother Lincoln McConnell, the
professional itinerant evangelist who “converted” me with the aid of
half a dozen strong-armed and strong-lunged Brothers and Sisters
who dragged and pushed me down the aisle of the church to the
mourners’ bench, where I was surrounded and overwhelmed by
“workers for the Lord.”
Brother Jenkins I recall as a meek, thin little man with a sad smile
and a classical appetite for fried chicken. At the time I was very
much in awe of him, and listened to his every utterance with the
most profound respect. I thought him saintly, and concluded that he
and God were the closest sort of friends, and that the Deity would
not dare launch upon a plan for a new universe or start a new war
without consulting Brother Jenkins. But in truth he was probably only
under-nourished. Brother Jenkins was a demon quoter of platitudes
and Biblical passages; nothing happened that it did not remind him
of a quotation from the Bible.
Brother Fontaine was a plump man who would have been jovial and
possibly likable—that is giving him the benefit of a great doubt—if he
had not been so burdened by the troubles of God and if he had not
been so frightfully aware of the responsibilities of his position as a
recipient and promulgator of Heavenly wisdom and commands. He
officiated at the wedding of my sister, principally because our family
belonged to his church and the presence of another preacher at the
wedding would have deprived Brother Fontaine of a goodly fee and
made an enemy of him for life. Christian charity does not function
well when it hits the pocketbook. I think my sister would have
preferred Brother Hickok, but she yielded to public opinion and
Brother Fontaine got the job. He arrived at the house chewing
tobacco, a habit of his which he disliked intensely in other men, but
for which he found justification for himself in the belief that he walked
with the Lord and that it was tacitly understood he was to have a little
leeway.
He was excessively sanctimonious; and so was his wife. We have
never forgiven her for her attitude at the wedding. I recall that she
looked suspiciously from time to time at the groom, and watched the
whole proceeding with an air that said there must of a necessity be
something wrong somewhere; for one thing, there was quite a deal
of laughter in our house that day, and that in itself was a sign that the
Lord was not hovering over the housetop. Immediately after the
ceremony Sister Fontaine paraded up front and began waving her