resume_recommandatio..

GUIDE DE L’EXAMEN MÉDICAL
PÉRIODIQUE
Adolescent - Adulte
NOVEMBRE 2004
Mise à jour : janvier 2010
Préparé par
Dre Guylène Thériault
UMF de Gatineau
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Pour chaque thème il y a la recommandation du Groupe d’étude canadien sur les
soins de santé préventifs et/ou celle de son équivalent américain.
Les recommandations de groupes de travail ou d’associations qui semblaient
pertinentes ont aussi été retranscrites. Pour assurer la fiabilité de la retranscription
la langue d’origine a été conservée.
L’immunisation n’a pas été abordée dans son ensemble. Le PIQ étant selon moi
une excellente référence (souvent mise à jour et fiable).
Les problématiques liées à la grossesse ou aux problèmes dentaires ne sont pas
couvertes.
Dans les feuilles synthèses, les recommandations qui datent de plus de 15 ans
seront considérées comme non actives et représentées par un *.
Un * souligne la nécessité de consulter ce guide. Soit qu’il existe une
recommandation d’un autre organisme ou que la seule recommandation date
de plus de 15 ans.
Remerciements à
Dre Cléo Mavriplis pour sa participationà la version originale de 2004.
Dr Gilles Brousseau pour les feuilles sommaires et son aide précieuse au fil des ans.
Dre Guylaine Proulx, Dre Marie-Claude Dupras, Dre Helène Bureau et Dre Louise
Guay pour leurs commentaires.
Dr Isabelle Gagnon et Dr Zineb El-Merzouar pour leurs commentaires sur la feuille
sommaire plus de 70 ans
Patricia Rhéaume, Irène Veilleux, Suzanne Lessard et Pierre Lebrun pour leur
soutien technique.
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Table des matières
MALADIES MÉTABOLIQUES ET NUTRITIONNELLES ..................................................................................... 9
GLYCEMIE (DEPISTAGE DU DIABETE) ........................................................................................................................ 9
CHOLESTÉROL ........................................................................................................................................................ 10
TENSION ARTÉRIELLE .............................................................................................................................................. 12
OSTEOPOROSE ....................................................................................................................................................... 13
TSH ......................................................................................................................................................................... 14
HÉMOCHROMATOSE ................................................................................................................................................ 15
CANCERS .................................................................................................................................................................. 17
CANCER DU SEIN ..................................................................................................................................................... 17
CANCER DU COLON (RECHERCHE DE SANG OCCULTE DANS LES SELLES) ............................................................ 19
CANCER DU COL DE L’UTÉRUS ................................................................................................................................ 21
CANCER DE LA PROSTATE....................................................................................................................................... 22
CANCER DES TESTICULES ....................................................................................................................................... 24
CANCER DU POUMON .............................................................................................................................................. 25
VESSIE..................................................................................................................................................................... 26
OVAIRES .................................................................................................................................................................. 26
PANCRÉAS............................................................................................................................................................... 26
ORAL ....................................................................................................................................................................... 26
PEAU ....................................................................................................................................................................... 27
THYROÏDE ................................................................................................................................................................ 27
MALADIES INFECTIEUSES ................................................................................................................................... 29
ITSS (COUNSELLING) ............................................................................................................................................. 29
CHLAMYDIA.............................................................................................................................................................. 29
GONORRHÉE ........................................................................................................................................................... 31
SYPHILIS .................................................................................................................................................................. 32
HIV .......................................................................................................................................................................... 33
HÉPATITES .............................................................................................................................................................. 34
HERPES ................................................................................................................................................................... 35
HUMAN PAPILLOMA VIRUS INFECTION ..................................................................................................................... 36
RUBÉOLE ................................................................................................................................................................. 36
TUBERCULOSE ........................................................................................................................................................ 36
BACTÉRIURIE ........................................................................................................................................................... 37
VARICELLE............................................................................................................................................................... 37
HABITUDES DE VIE ................................................................................................................................................ 39
TABAC...................................................................................................................................................................... 39
ALCOOL ................................................................................................................................................................... 39
ACTIVITÉ PHYSIQUE................................................................................................................................................. 39
DIÈTE ....................................................................................................................................................................... 40
OBÉSITÉ .................................................................................................................................................................. 40
PRÉVENTION DES ACCIDENTS .......................................................................................................................... 43
PERSONNES ÂGÉES ................................................................................................................................................ 44
MCAS ..................................................................................................................................................................... 45
ASPIRINE PREVENTION PRIMAIRE............................................................................................................................ 45
ASPIRINE PRÉVENTION SECONDAIRE ...................................................................................................................... 46
DIABETES ................................................................................................................................................................ 46
HYPERTENSION ....................................................................................................................................................... 47
DÉPISTAGE MCAS.................................................................................................................................................. 48
VITAMINE E.............................................................................................................................................................. 48
MALADIES VASCULAIRES ................................................................................................................................... 49
ANÉVRYSME DE L’AORTE ABDOMINALE ................................................................................................................... 49
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STÉNOSE CAROTIDIENNE ........................................................................................................................................ 49
MVAS ..................................................................................................................................................................... 49
TROUBLES DE LA VISION OU DE L’AUDITION............................................................................................... 50
VISION ..................................................................................................................................................................... 50
GLAUCOME .............................................................................................................................................................. 50
SURDITÉ .................................................................................................................................................................. 51
SANTÉ MENTALE .................................................................................................................................................... 51
DROGUES ................................................................................................................................................................ 51
DÉPRESSION IN ADULTS .......................................................................................................................................... 51
DÉPRESSION IN ADOLESCENTS............................................................................................................................... 52
DÉMENCE ................................................................................................................................................................ 52
VIOLENCE FAMILIALE ............................................................................................................................................... 53
MALADIES CHRONIQUES ..................................................................................................................................... 53
MPOC ..................................................................................................................................................................... 53
SANTÉ DE LA FEMME ........................................................................................................................................... 55
CONTRACEPTION..................................................................................................................................................... 55
ACIDE FOLIQUE EN PRECONCEPTION ...................................................................................................................... 55
CHIMIOPROPHYLAXIE CONTRE LE CANCER DU SEIN ............................................................................................... 55
HORMONOTHÉRAPIE ............................................................................................................................................... 55
ANNEXE 1.................................................................................................................................................................. 59
FEUILLES SYNTHESE DES RECOMMANDATIONS ...................................................................................................... 59
ANNEXE 2.................................................................................................................................................................. 61
SUGGESTION DE FEUILLES DE PRISE DE DONNEES POUR L’EXAMEN PERIODIQUE ADOLESCENT-ADULTE ............ 61
ANNEXE 3.................................................................................................................................................................. 63
SUGGESTION DE FEUILLES SOMMAIRES ................................................................................................................. 63
ANNEXE 4.................................................................................................................................................................. 65
CRITERES POUR LES RECOMMANDATIONS DES DIVERS GROUPES ........................................................................ 65
ANNEXE 5.................................................................................................................................................................. 71
SCORE................................................................................................................................................................... 71
ORAI ....................................................................................................................................................................... 71
TABLEAU DU GUIDE DE DÉPISTAGE DES ITSS ............................................................................................ 73
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Recommandations
Maladies métaboliques et nutritionnelles
Prévention des accidents
Glycémie (dépistage du diabète)
Cholestérol
Tension artérielle
Ostéoporose
TSH
Hémochromatose
MCAS
Maladies vasculaires
Cancers
Sein
Côlon (recherche de sang dans les selles)
Col utérin
Prostate
Testicules
Poumon
Vessie
Ovaires
Pancréas
Oral
Peau
Thyroïde
Maladies infectieuses
Chlamydia
Gonorrhée
Syphilis
HIV
Hepatites (B et C)
Herpes
Human papilloma virus
Rubéole
Tuberculose
Bactériurie
Varicelle
Habitudes de vie
Tabac
Alcool
Diète
Obésité
Activité physique
Aspirine (prévention primaire)
Dépistage
Vitamine E
Anévrysme de l’aorte abdominale
Sténose carotidienne
MVAS
Troubles de la vision ou de l’audition
Vision
Glaucome
Surdité
Santé mentale
Drogues
Depression
Démence
Maladies chroniques
MPOC
Santé de la femme
Contraception
Acide folique préconception
Chimioprophylaxie pour le cancer du sein
Hormonothérapie
ANNEXES
Annexe 1
Feuilles synthèse des recommandations par sexe
et groupe d’âge
Annexe 2
Suggestions de feuilles de prise de données pour
l’examen périodique adulte
Annexe 3
Feuilles sommaires
Annexe 4
Critères pour les recommandations des différents
groupes
Annexe 5
SCORE, ORAI
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MALADIES MÉTABOLIQUES ET NUTRITIONNELLES
Glycémie (dépistage du diabète)
CANADA
1) CTFPHC
2005: There is fair evidence to recommend screening adults with hypertension or hyperlipidemia
for type 2 diabetes mellitus to prevent cardiovascular events and death
(Recommandation B) There is good evidence to recommend lifedtyle interventions for
overweight individuals (BMI>25 or >22 if on asian descent) with impaired glucose tolerance to
reduce the incidence of progression to diabetes (Recommandation B) There is fair evidence to
recommend acarbose treatment for overweight individuals (as above) with impaired glucose
tolerance to prevent cardiovascular events and hypertension (Recommandation B) There is
insufficient evidence to recommend metformin or acarbose treatment for overweight individuals
with impaired glucose tolerance to prevent diabetes progression (Recommandation I)
1993 : Good evidence to include dipstick screening for protein in the PHE of adults with IDDM.
(Recommandation A)
2) Association canadienne du diabète 2008
All individuals should be evaluated annually for type 2 diabetes risk on the basis of demographic
and clinical criteria ( Grade D Consensus) Screening for diabetes using an FPG should be
performed every 3 years in individuals ≥ 40 years of age (Grade D Consensus) More frequent
and/or earlier testing with either an FPG or a 2hPG in a 75-g OGTT should be considered in
people with additionnal risk factors for diabetes (Grade D Consensus) These risk factors include :
first degree relative with type 2 diabetes, member of high risk population (e.g. people of
Aboriginal, Hispanic, Asian, South-Asian or African descent), history of IGT or IFG, presence of
complications associated with diabetes, vascular disease (coronary, cerebrovascular or
peripheral), history of gestationnal diabetes mellitus, History of delivery of a macrosomic infant,
hypertension, dyslipidemia, overweight, abdominal obesity, polycystic ovary syndrome,
acanthosis nigricans, schizophrénia and others
ÉTATS-UNIS
1) USPSTF 2008
The USPSTF recommands screening for type 2 diabetes in asymptomatic adults with sustained
blood pressure (either treated or untreated) greater than 135/80 mm Hg (Recommandation B)
The USPSTF concludes than the current evidence is insufficient to assess the balance of benefits
and harms of screening for type-2 diabetes in asymptomatic adults with blood pressure of 135/80
mmHg or lower (Recommandation I) Screening may be considered on an individual basis if
knowledge of diabetes status would help inform decisions about coronary heart disease (CHD)
prevention strategies, including assessment of CHD risk and subsequent consideration of lipidlowering agents or aspirin.The optimal screening interval is not known.
Guide de l’examen médical périodique – révision janvier 2010 | 9
2) American diabetes association 2010
Criteria for testing for diabetes in asymptomatic individuals
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m 2*) and have
additional risk factors: physical inactivity, first-degree relative with diabetes, members of a highrisk ethnic population (e.g., African American, Latino, Native American, Asian American,
Pacific Islander), women who delivered a baby weighing >9 lb or were diagnosed with GDM,
hypertension (≥140/90 mmHg or on therapy for hypertension), HDL cholesterol level <35 mg/dl
(0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l), women with polycystic ovary
syndrome, A1C ≥5.7%, IGT, or IFG on previous testing, other clinical conditions associated with
insulin resistance (e.g., severe obesity, acanthosis nigricans), history of CVD.
In the absence of the above criteria, testing diabetes should begin at age 45 years. If results are
normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent
testing depending on initial results and risk status. At-risk BMI may be lower in some ethnic groups
3) AACE 2007
Annually screen all individuals 30 years or older who are at risk of developing T2DM. Family
history of dabetes, cardiovascular disease, overweight or obese state, sedentary lifestyle,
Latino/Hispanic, Non-hispanic black, Asian american, Native american or pacific Islander
ethnicity, previously impaired glucose tolerance or impaired fasting glucose, hypertension,
increased level of triiiglycerides, low concentration of high density lipoprotein cholesterol or
both, history of gestationnal diabetes, history of delivery of an infant with a birth weight > 9
pounds, polycystic ovarian disease, psychiatric illness.
Cholestérol
CANADA
1) CTFPHC 1994
(recommendation qui date de PLUS DE 15 ANS)
Screening should be considered in all men aged 30 to 59 years; individual clinical judgement
should be exercised in all other cases (Recommandation C) For men 30 to 59 years old with a
mean total cholesterol level of more than 6.85 mmol/L or an LDL-C level of more than 4.50
mmol/L treatment is efficacious in reducing incidence of CHD. (Recommandation B) For all
other asymptomatic individuals the value of treatment has not been demonstrated.
(Recommandation C)
2) Canadian cardiovascular society 2009
Patients whose plasma lipid profile should be screened
• Men ≥40 years of age, and women ≥50 years of age or postmenopausal
• All patients with the following conditions, regardless of age:
Diabetes, Hypertension, Current cigarette smoking, Obesity (Obesity Canada guidelines), Family
history of premature CAD (<60 years in first-degree relatives), Inflammatory diseases* (systemic
lupus erythematosis, rheumatoid arthritis, psoriasis), Chronic renal diseases (eGFR <60
mL/min/1.73 m2), Evidence of atherosclerosis, HIV infection treated with highly active
antiretroviral therapy, Clinical manifestations of hyperlipidemias (xanthomas,
xanthelasmas,premature arcus cornealis), Erectile dysfunction
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3) Association canadienne du diabète 2008
A fasting lipid profile (total cholesterol [TC], HDL-C,TG and calculated LDL-C) should
therefore be conducted at the time of diagnosis of diabetes, and then every 1 to 3 years, as
clinically indicated. More frequent testing should be conducted if treatment for dyslipidemia is
initiated.
ÉTATS-UNIS
1) USPSTF 2008
The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged
35 and older for lipid disorders (Recommandation A) The USPSTF recommends screening men
aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.
(Recommandation B) The USPSTF strongly recommends screening women aged 45 and older
for lipid disorders if they are at increased risk for coronary heart disease. (Recommandation A)
The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at
increased risk for coronary heart disease. (Recommandation B) The USPSTF makes no
recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in
women aged 20 and older who are not at increased risk for coronary heart disease
(Recommandation C) The optimal interval for screening is uncertain. On the basis of other
guidelines and expert opinion, reasonable options include every 5 years, shorter intervals for
people who have lipid levels close to those warranting therapy, and longer intervals for those not
at increased risk who have had repeatedly normal lipid levels. An age to stop screening has not
been established. Screening may be appropriate in older people who have never been screened;
repeated screening is less important in older people because lipid levels are less likely to increase
after age 65.
2) NCEP III 2001
NCEP: National cholesterol education program (USA) In all adults aged 20 years or older, a
fasting lipoprotein profile should be obtained once every five years (rien de nouveau sur
dépistage dans update 2004)
The American Heart Association has the same recommendation
3) AACE 2002 (American association of clinical endocrinologists)
Screening for dyslipidemia is warranted for all adults up to 75 years of age regardless of CAD
risk status and for adults more than 75 years old who have multiple CAD risk factors (if they
have good quality of life and no other major life-limiting disease). For adult more than 20 years
of age with no CAD risk factors the screening should be done every 5 years. (more often if CAD
risk factors exist)
4) American diabetes association 2010
In most adult patients, measure fasting lipid profile at least annually. In adults with low-risk lipid
values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl),
lipid assessments may be repeated every 2 years. (E)
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Tension artérielle
CANADA
1) CTFPHC 1994 (recommandation qui date de PLUS DE 15 ANS)
Measurement of blood pressure (BP) level. Although not evaluated for its effectiveness, casefinding should be considered in all persons aged 21 to 64 years; Fair evidence to include in
periodic health examination . (Recommandation B)
Hypertension in the elderly: Screening for this condition can be confidently recommanded in
those aged 65 to 84 years.(Recommandation B) Efficacy in treatment in treatment has not been
demonstrated in those above 80. While definitive evidence for treatment of hypertension in those
over 85 is lacking, it seems unlikely that judicious treatment will be detrimental
2) Canadian hypertension society 2009
The blood pressure (BP) of all adult patients should be assessed at all appropriate visits for
determination of cardiovascular risk and monitoring of antihypertensive treatment by health care
professionals who have been specifically trained to measure blood pressure accurately (Grade D).
3) Canadian diabetes association 2008
People with diabetes should be regularly screened (i.e. at every diabetes-related clinic visit) for
the presence of hypertension, and those with elevated BP should be aggressively treated.
ÉTATS-UNIS
1) USPSTF
2006: The U.S. Preventive Services Task Force (USPSTF) recommends screening for high
blood pressure in adults aged 18 and older (Recommandation A)
Evidence is lacking to recommend an optimal interval for screening adults for hypertension.
2) JNC VII
(Joint national committee on prevention, detection, evaluation and treatment of high blood pressure)
2003: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) recommends screening every 2 years in persons
with blood pressure less than 120/80 mm Hg and every year with systolic blood pressure of 120
to 139 mm Hg or diastolic blood pressure of 80 to 90 mm Hg.
3) American diabetes association 2010
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic
blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should have blood pressure
confirmed on a separate day. Repeat systolic blood pressure ≥130 mmHg or diastolic blood
pressure ≥80 mmHg confirms a diagnosis of hypertension. (C)
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Ostéoporose
CANADA
1) CTFPHC 2004
Screening all postmenopausal women with a history of previous fracture, or who are 65 years or
older, or have a ORAI score of 9 or a SCORE score of 6 with BMD by DEXA to prevent fragility
fractures. (Recommandation B).For women without documented osteoporosis, there is fair
evidence that calcium and vitamin D supplementation alone prevents osteoporotic fractures
(Recommandation B)
2) Osteoporosis society of Canada 2002
Screening of all postmenopausal women or all men over age 50 is not justified according to
available data. However, measuring bone density in men and women after the age of 65,
recognizing that after this age fracture risk increases, is justifiable (level 3).
Evidence for the use of bone measurement in men and in non-Caucasian women is meager.
Existing data do not contradict the inferences already made (consensus). Targeted case-finding
strategies for those at increased risk (at least one major or 2 minor risk factors) are recommended,
and BMD measurement with central DXA at age 65 is recommended (Grade A). Daily intake of
calcium : Femme 19-50 ans 1000mg/jr (Grade A) Femme >50 ans 1500 mg/jr (Grade A)
Homme 19-50 ans 1000 mg/jr (Grade C) Homme >50 ans 1500 mg/jr (Grade C).
Daily intake of vitamin D : Femme 19-50 ans 400UI (Grade D) Femme >50 ans 800UI (Grade
A) Homme 19-50 ans 400UI (Grade D) Homme >50 ans 800UI (Grade A) Eviter >4 tasses
café/jr (Grade B).
ÉTATS-UNIS
1) USPSTF 2002
The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older
be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at
age 60 for women at increased risk for osteoporotic fractures (Recommandation B)
(Lower body weight (weight < 70 kg ) is the single best predictor of low bone mineral
density.There is less evidence to support the use of other individual risk factors (for example,
smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low
calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65 . The
best validated instruments include the 3-item ORAI and the 6-item Simple Calculated
Osteoporosis Risk Estimation tool (SCORE))
(voir annexe de la version papier ou SCORE http://www.geocities.com/HotSprings/8741/score2.html et
ORAI http://www.cmaj.ca/cgi/content/full/162/9/1289/T414)
The USPSTF makes no recommendation for or against routine osteoporosis screening in
postmenopausal women who are younger than 60 or in women aged 60-64 who are not at
increased risk for osteoporotic fractures (Recommandation C)
No studies have evaluated the optimal intervals for repeated screening. Because of limitations in the precision of
testing, a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer
intervals may be adequate for repeated screening to identify new cases of osteoporosis. Yield of repeated screening
will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture
There are no data to determine the appropriate age to stop screening and few data on osteoporosis treatment in
women older than 85.
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2) National osteoporosis foundation 2008
All postmenopausal women and men age 50 and older should be evaluated clinically for
osteoporosis risk in order to determine the need for BMD testing. In general, the more risk factors
that are present, the greater the risk of fracture. Since the majority of osteoporosis-related
fractures result from falls, it is also important to evaluate risk factors for falling. NOF
recommends testing of all women age 65 and older and men age 70 and older regardless of their
risk factors, younger postmenopausal women and men age 50 to 69 about whom you have
concern based on their clinical risk factor profile, women in the menopausal transition if there is a
specific risk factor associated with increased fracture risk such as low body weight, prior lowtrauma fracture or high risk medication, adults who have a fracture after age 50, Adults with a
condition (e.g., rheumatoid arthritis) or taking a medication(e.g.,glucocorticoids in a daily dose ≥
5 mg prednisone or equivalent for ≥three months) associated with low bone mass or bone loss,
anyone being considered for pharmacologic therapy for osteoporosis.
NOF supports the National Academy of Sciences (NAS) recommendation that women older than
age 50 consume at least 1,200 mg per day of elemental calcium. Intakes in excess of 1,200 to
1,500 mg per day have limited potential for benefit and may increase the risk of developing
kidney stones or cardiovascular disease. Calcium supplements should be used when an adequate
dietary intake cannot be achieved. NOF recommends an intake of 800 to1,000 international units
(IU) of vitamin D per day for adults age 50 and older.
TSH
CANADA
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Poor evidence for either inclusion or exclusion of TSH screening (Recommandation C); due to
the high prevalence of thyroid disorders in peri-menopausal women, physicians should maintain a
high index of clinical suspicion.
ÉTATS-UNIS
USPSTF 2004
The USPSTF concludes the evidence is insufficient to recommend for or against routine
screening for thyroid disease in adults (Recommandation I)
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Hémochromatose
ETATS-UNIS
USPSTF 2006
The U.S. Preventive Services Task Force (USPSTF) recommends against routine genetic
screening for hereditary hemochromatosis in the asymptomatic general population.
(Recommandation D)
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CANCERS
Cancer du sein
CANADA
1) CTFPHC
1998: There is good evidence for screening women aged 50-69 years by clinical examination
and mammography (Recommandation A). The best available data support screening every 1-2
years. 2001: Current evidence does not support the recommendation that screening
mammography be included in or excluded from the periodic health examination of women aged
40-49 at average risk of breast cancer (Recommandation C) Upon reaching the age of 40,
Canadian women should be informed of the potential benefits and risks of screening
mammography and assisting in deciding at what age they wish to initiate it. Comparison of RCT
results suggests that, if done, frequent screening may be required (Mammography every 12-18
months) 2001: Because there is fair evidence of no benefit, and good evidence of harm, there is
fair evidence to recommend that routine teaching of BSE be excluded from the periodic health
examination of women aged 40–69 (Recommandation D)
2) Société canadienne du cancer
Si vous êtes âgée de 50 à 69 ans, passez une mammographie tous les 2 ans. Si vous avez entre 40
et 49 ans, discutez avec votre médecin de votre risque personnel de cancer du sein ainsi que des
avantages et inconvénients de la mammographie. Si vous avez 70 ans ou plus, demandez à votre
médecin ce qu’il vous conseille en matière de dépistage. Si vous avez plus de 40 ans, passez un
examen clinique des seins, effectué par un professionnel de la santé compétent, au moins une fois
tous les 2 ans.
ÉTATS-UNIS
1) USPSTF 2005
The USPSTF recommends that women whose family history is associated with an increased risk
for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counselling and
evaluation for BRCA testing (Recommandation B) For non-Ashkenazi Jewish women, these
patterns include 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at
age 50 years or younger; a combination of 3 or more first- or second-degree relatives with breast
cancer regardless of age at diagnosis; a combination of both breast and ovarian cancer among
first- and second-degree relatives; a first-degree relative with bilateral breast cancer; a
combination of 2 or more first- or second-degree relatives with ovarian cancer regardless of age
at diagnosis; a first- or second-degree relative with both breast and ovarian cancer at any age; and
a history of breast cancer in a male relative. For women of Ashkenazi Jewish heritage, an
increased-risk family history includes any first-degree relative (or 2 second-degree relatives on
the same side of the family) with breast or ovarian cancer.
Guide de l’examen médical périodique – révision janvier 2010 | 17
2) USPSTF 2009
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
(Recommandation B)
The decision to start regular, biennial screening mammography before the age of 50 years should
be an individual one and take patient context into account, including the patient's values
regarding specific benefits and harms. (Recommandation C)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits
and harms of screening mammography in women 75 years or older.
(Recommandation I)
The USPSTF recommends against teaching breast self-examination (BSE).
(Recommandation D)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits
and harms of clinical breast examination (CBE) beyond screening mammography in women 40
years or older. (Recommandation I)
3) ACOG 2003
The following recommandations are based on limited and inconsistent scientific evidence (Level
B) : Women aged 40-49 years should have screening mammography every 1-2 years. Women
aged 50 years and older should have annual mammography. The following recommandations are
based primarly on consensus and expert opinion (level C) : Despite a lack of definitive data for or
against breast self examination, breast self examination has the potential to detect palpable breast
cancer and can be recommanded. All women should have clinical breast examination annually as
part of the physical examination.
4) American geriatrics society 2005
For women in average to better health, with a life expectancy of 5 or more years, it is appropriate
to offer screening mammography every one to two years to age 85. The recommandation should
include an individualized review of the potential benefits and harms of screening and patients
personnal preferences. Mammography screening beyond the age of 85 should be reserve for those
women more likely to benefit by virtue of execellent health and fonctionnal status, and for those
who feel strongly that they will benefit from such screening, either in peace of mind or improved
quality of life. Clinical breat examination should be performed periodically.
COCHRANE 2006
Sreening likely reduces breast cancer mortality. Based on all trials, the reduction is 20%, but as
the effect is lower in the highest quality trials, a more reasonable estimate is a 15% relative risk
reduction. Based on the risk level of women in these trials, the absolute risk reduction was
0.05%. Screening also leads to overdiagnosis and overtreatment, with an estimated 30% increase,
or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening
throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would
not have been diagnosed if there had not been screening, will be diagnosed as breast cancer
patients and will be treated unnecessarily. It is thus not clear whether screening does more good
than harm. Women invited to screening should be fully informed of both benefits and harms.
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Cancer du colon (Recherche de sang occulte
dans les selles)
CANADA
1) CTFPHC 2001
Good evidence to include screening with annual or biennial Hemoccult test in the periodic health
examination (PHE) of patients >50 (Recommandation A)
2) Canadian association of gastroenterologists 2004
Average risk: FOBT every two years. The AGA guidelines recommand screening yearly using a
guaiac-test with dietary restrictions or a immunochemical test for heme without restrictions. The
Canadian expert panel commissioned by Health Canada recommanded occult blood testing every
two years. Although yearly occult blood testing does increase the detection of cancer, it was not
felt that this justified the resulting considerable increase in work load
Above average risk: 1) One first degree relative with cancer or adenomatous polyp at age< 60 or
two or more first degree relatives with polyp or colon cancer at any age: colonoscopy every five
years. Begin at age 40 or ten years earlier than the youngest diagnosis of polyp or cancer in the
family which ever comes first. 2) One first degree relative with cancer or adenomatous polyp
affected at age >60 or two or more second degree relatives with polyps or cancer: average risk
screening but begin at age forty
3) National committee on colorectal cancer sreening (Health Canada 2002)
Screening should be offered to adults 50-74 years old using FOBT. Individuals should be
screened at least every two years recognising that annual screening would have slight
improvement in mortality reduction but require increased resources.
ÉTATS-UNIS
1) USPSTF
2008 The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood
testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until
age 75 years. The risks and benefits of these screening methods vary (Recommandation A) The
USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years.
There may be considerations that support colorectal cancer screening in an individual patient
(Recommandation C) The USPSTF recommends against screening for colorectal cancer in
adults older than age 85 years (Recommandation D) The USPSTF concludes that the evidence is
insufficient to assess the benefits and harms of computed tomographic colonography and fecal
DNA testing as screening modalities for colorectal cancer (Recommandation I)
2002 The USPSTF found good evidence that periodic fecal occult blood testing (FOBT)
reduces mortality from colorectal cancer. 2007 The USPSTF recommends against the routine use
Guide de l’examen médical périodique – révision janvier 2010 | 19
of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in
individuals at average risk for colorectal cancer.(Recommandation D)
2) American Gastroenterological Association 2008
The following options are acceptable choices for colorectal cancer screening in average-risk
adults beginning at age 50 years. Since each of the following tests hasinherent characteristics
related to prevention potential, accuracy, costs, and potential harms, individuals should have an
opportunity to make an informed decision when choosing one of the following options. Tests that
are designed to detect both early cancer and adenomatous polyps (like sigmoidoscopy q 5 years,
colonoscopie q 10 ans, barium enema q 5 ans, colono virtuelle q 5 ans) should be encouraged if
resources are available and patients are willing to undergo an invasive test.
Annual screening with high-sensitivity gFOBT (such as Hemoccult SENSA) that have been
shown in the published, peer-reviewed literature to detect a majority of prevalent CRC in an
asymptomatic population is an acceptable option for colorectal screening in average-risk adults
aged 50 years and older. Any positive test should be followed up with colonoscopy.
Familial history : 1) histoire de cancer du colon ou de polype adénomateux chez un parent de 1 er
degré de moins de 60 ans OU 2 parents de 1er degre peu importe l’âge : colonoscopie aux 5 ans
débutant à 40 ans ou 10 ans avant le cas le plus jeune. 2) histoire de cancer du colon ou de polype
adénomateux chez un parent du premier degré de plus de 60 ans OU cancer du colon chez 2
parents du 2eme degré : dépistage comme pour la personne de risque moyen mais débutant à 40
ans.
COCHRANE 2007
Benefits of screening include a modest reduction in colorectal cancer mortality, a possible
reduction in cancer incidence through the detection and removal of colorectal adenomas, and
potentially, the less invasive surgery that earlier treatment of colorectal cancers may involve.
Harmful effects of screening include the psycho-social consequences of receiving a false-positive
result, the potentially significant complications of colonoscopy or a false-negative result, the
possibility of overdiagnosis (leading to unnecessary investigations or treatment) and the
complications associated with treatment.
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Cancer du col de l’utérus
CANADA
CTFPHC 1992 (recommandation qui date de PLUS DE 15 ANS)
Pap: Fair evidence to include in periodic health examination of sexually active women.
(Recommandation B) Annual screening is recommended following initiation of sexual activity
or age 18; after 2 normal smears, screen every 3 years to age 69. Consider increasing frequency
for women with risk factors: age of first sexual intercourse < 18 yrs, many sexual partners or
consort with many partners, smoking or low socioeconomic status.
SOGC 2007
No Quebec guidelines but national guidelines as above. There is no indication for cervical
screening before initiation of sexual activity, regardless of age. Women who have undergone total
hysterectomy for benign conditions, do not have a history of cervical dysplasia, and have a
negative and adequate prior screening history do not require screening after their hysterectomy.
INSPQ 2009
Le dépistage devrait débuter à 21 ans, à moins de circonstances exceptionnelles (âge très précoce
des premières relations sexuelles, abus sexuel, immunosuppression ou infection par le VIH). Les
tests de dépistage seraient espacés aux 2 ans, lorsque les résultats sont normaux. Le dépistage
pourrait être cessé à 69 ans chez les femmes ayant au moins un test négatif au cours
des 10 dernières années.
ÉTATS-UNIS
1) USPSTF 2003
The USPSTF strongly recommends screening for cervical cancer in women who have been
sexually active and have a cervix. (Recommandation A) Indirect evidence suggests most of the
benefit can be obtained by beginning screening within 3 years of onset of sexual activity or age
21 (which ever comes first) and screening at least every 3 years. The USPSTF found no direct
evidence that annual screening achieves better outcomes than screening every 3 years. The
American Cancer Society guidelines suggest waiting until age 30 before lengthening the
screening interval.
Although there is little value in screening women who have never been sexually active, many
U.S. organizations recommend routine screening by age 18 or 21 for all women, based on the
generally high prevalence of sexual activity by that age in the U.S. and concerns that clinicians
may not always obtain accurate sexual histories
The USPSTF recommends against routinely
screening women older than age 65 for cervical cancer if they have had adequate recent screening
with normal Pap smears and are not otherwise at high risk for cervical cancer (Recommandation
D). The USPSTF recommends against routine Pap smear screening in women who have had a
total hysterectomy for benign disease. (Recommandation D) The USPSTF concludes that the
evidence is insufficient to recommend for or against the routine use of new technologies to screen
for cervical cancer. (Recommandation I) Newer Food and Drug Administration (FDA)approved technologies, such as the liquid-based cytology (e.g., ThinPrep®), may have improved
sensitivity over conventional Pap smear screening, but at a considerably higher cost and possibly
with lower specificity.
Guide de l’examen médical périodique – révision janvier 2010 | 21
2) ACOG 2009
Begin screening at age 21. Screen every 2 years between age of 21 and 29. After age 30 screen
every 2 years unless 3 consecutive tests where negative than screen every 3 years.Stop screening
around age 65-70 if there was 3 negative tests in the last 10 years. No screening for patients that
had hysterectomy for benign reasons.
Women with certain risk factors may need more frequent screening, including those who have
HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and have been
treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.
3) American geriatrics society 2000
Regular pap smear screening at 1 to 3 year intervals until at least the age of 70 seems reasonable.
Beyond age 70, there is little evidence for or against screening women who have been regularly
screened in previous years. An older woman of any age who has never had a pap smear may be
screened with at least two negative pap smears 1 year apart.
Cancer de la prostate
CANADA
1) CTFPHC 1994 (recommandation qui date de PLUS DE 15 ANS)
Digital Rectal Examination (DRE) : Poor evidence to include or exclude DRE from the periodic
health examination (PHE) for men over 50 years of age (Recommandation C)
Prostate specific antigen (PSA) : Exclusion is recommended on the basis of low positive
predictive value and the known risk of adverse affects associated with therapies of unproven
effectiveness. Fair evidence to exclude routine screening with PSA from the periodic health
examination of asymptomatic men over 50 years of age. (Recommandation D)
2) Collège des medecins du Quebec 1998
Il n’est pas recommandé d’utiliser systématiquement le dosage de l’APS et/ou le toucher rectal
seuls ou combinés comme méthode de dépistage du cancer de la prostate, quel que soit l’âge du
patient (catégorie D) Le patient qui manifeste un intérêt ou des craintes relativement au cancer de
la prostate devrait rcevoir du counselling pour lui permettre de faire un choix éclairé.
De fait, une incertitude persiste quant aux avantages et aux inconvénients de dépistage chez les
individus appartenant à l’un des groupes suivants ▪ les hommes agés de 50à 69 ans et jouissant
d’une espérance de vie supérieur à 10 ans ▪ les hommes agés de 40 ans et plus d’origine afroaméricaine ou les hommes de 40 ans et plus dont au moins un parent de premier degré a souffert
d’un cancer de la prostate et qui jouissent d’une espérance de vie supérieure à 10 ans. Cependant
les données actuelles ne permettent pas d’affirmer que le dépistage est plus efficace dans de telles
circonstances (catégorie C).
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ÉTATS-UNIS
1) USPSTF 2008
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of prostate cancer screening in men younger than age 75 years. (Recommandation I)
The USPSTF recommends against screening for prostate cancer in men age 75 years or older
(Recommandation D)
*(In men younger than age 75 years, the USPSTF found inadequate evidence to determine
whether treatment for prostate cancer detected by screening improves health outcomes compared
with treatment after clinical detection. The USPSTF found convincing evidence that treatment for
prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile
dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially
important because some men with prostate cancer who are treated would never have developed
symptoms related to cancer during their lifetime.There is also adequate evidence that the
screening process produces at least small harms, including pain and discomfort associated with
prostate biopsy and psychological effects of false-positive test results. Older men, AfricanAmerican men, and men with a family history of prostate cancer are at increased risk for
diagnosis of and death from prostate cancer.1 Unfortunately, the previously described gaps in the
evidence regarding potential benefits of screening also apply to these men.) If screening were to
reduce deaths, PSA screening as infrequently as every 4 years could yield as much of a
benefit as annual screening.
Given the uncertainties and controversy surrounding prostate cancer screening in men younger
than age 75 years, a clinician should not order the PSA test without first discussing with the
patient the potential but uncertain benefits and the known harms of prostate cancer screening and
treatment. Men should be informed of the gaps in the evidence and should be assisted in
considering their personal preferences before deciding whether to be tested.
2) American urological association 2009
Patients need to be informed of the risks and benefits of testingbefore it is undertaken. The risks
of overdetection and overtreatment should be included in thisdiscussion. Because there is now
evidence from a randomized, controlled trial regarding a mortality decrease associated with PSA
screening, the AUA is recommending PSA screening, for well-informed men who wish to pursue
early diagnosis. (Baseline PSA age 40 years with anticipated lifespan of 10 or more years: PSA AND
DRE)
Cochrane 2006
Given that only two randomised controlled trials were included, and the high risk of bias of both
trials, there is insufficient evidence to either support or refute the routine use of mass, selective or
opportunistic screening compared to no screening for reducing prostate cancer mortality.
Currently, no robust evidence from randomised controlled trials is available regarding the impact
of screening on quality of life, harms of screening, or its economic value. Results from two
ongoing large scale multicentre randomised controlled trials that will be available in the next
several years are required to make evidence-based decisions regarding prostate cancer screening.
Guide de l’examen médical périodique – révision janvier 2010 | 23
Cancer des testicules
CANADA
CTFPHC 1994 (recommendation qui date de PLUS DE 15 ANS)
Insufficient evidence to include or exclude routine examination of testes either by physician or by
patient self-examination from the periodic examination. (Recommandation C)
ÉTATS-UNIS
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for
testicular cancer in asymptomatic adolescent and adult males. (Recommandation D)
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Cancer du poumon
CANADA
CTFPH 2003
The CTFPHC concludes that there still is fair evidence to recommend against screening with
chest X-ray asymptomatic people for lung cancer using chest radiographic examination
(Recommandation D)
The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a
recommendation as to whether spiral CT scanning should be used for screening asymptomatic
people for lung cancer; however other factors may influence decision-making
(Recommandation I )
ÉTATS-UNIS
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to
recommend for or against screening asymptomatic persons for lung cancer with either low dose
computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of
these tests. (Recommandation I)
The USPSTF found fair evidence that screening with LDCT, CXR, or sputum cytology can
detect lung cancer at an earlier stage than lung cancer would be detected in an unscreened
population; however, the USPSTF found poor evidence that any screening strategy for lung
cancer decreases mortality. Because of the invasive nature of diagnostic testing and the
possibility of a high number of false-positive tests in certain populations, there is potential for
significant harms from screening. Therefore, the USPSTF could not determine the balance
between the benefits and harms of screening for lung cancer.
Cochrane 2003
The current evidence does not support screening for lung cancer with chest radiography or
sputum cytology. Frequent chest x-ray screening might be harmful. Further, methodologically
rigorous trials are required.
Guide de l’examen médical périodique – révision janvier 2010 | 25
Autres cancers
Vessie
CTFPHC 1993
(recommandation qui date de PLUS DE 15 ANS)
Urine dipstick or microscopy for hematuria : Fair evidence to exclude from Periodic Health
Examination (PHE) for general population (Recommandation D); poor evidence to include or
exclude from the PHE for persons at high risk.* (Recommandation C )
(* High-risk groups are Males > 60 years of age who smoke or have smoked, and were employed in a trade that may
have exposed them to aromatic amines. )
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for
bladder cancer in adults. (Recommandation D)
Ovaires
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Fair evidence to exclude screening for ovarian cancer by any means (ultrasound, pelvic exam,
serum markers) for pre- and post-menopausal women. (Recommandation D)
For High-Risk Women with >1 First-degree Relative with Ovarian Cancer : Insufficient evidence
to recommend for or against screening. (Recommandation C)
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for
ovarian cancer.(Recommandation D)
Pancréas
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
There is fair evidence that routine screening should be excluded from the periodic health
examination. (Recommandation D)
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for
pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or
serologic markers. (Recommandation D)
Oral
CTFPHC 1999
Insufficient insufficient evidence to recommend inclusion or exclusion of screening for oral
cancer by clinical examination of asymptomatic patients (Recommandation C) For high risk
patients, annual examination by physician or dentist should be considered. Major risk factors
include a history of tobacco use and excessive alcohol consumption
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USPSTF 2004
the evidence is insufficient to recommend for or against routinely screening adults for oral
cancer. (Recommandation I)
Peau
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Total body skin examination : There is poor evidence to include or exclude from the periodic
health examination (PHE) of the general population (Recommandation C ); there is fair
evidence for the inclusion of total body skin examination for a very select sub-group of
individuals. (Recommandation B)
(For individuals at significantly increased risk (i.e. family melanoma syndrome (MM) first degree
relative with melanoma) it is prudent to undertake regular examinations (dermatologists may be
more accurate assessors).)
Self-Exam : There is poor evidence to include or exclude in the periodic health examination.
(Recommandation C )
Avoidance of sun exposure and protective clothing : On the basis of epidemiologic data and casecontrol studies, and prudence, there is fair evidence to include in the periodic health examination.
(Recommandation B )
Sunscreens (for prevention of squamous cell and basal cell carcinoma; and malignant
melanoma) : There is poor evidence for the inclusion or exclusion of advice on sunscreen use in
the PHE to prevent squamous cell carcinoma, basal cell carcinoma and malignant melanoma.
(Recommandation C)
USPSTF
2009 : The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of using a whole-body skin examination by a primary care clinician or patient
skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or
squamous cell skin cancer in the adult general population. (Recommandation I)
2003 : The U.S. Preventive Services Task Force concludes that the evidence is insufficient to
recommend for or against routine counselling by primary care clinicians to prevent skin cancer.
(Recommandation I)
AUTRES
The American Cancer Society recommends cancer check-up including skin examination every 3
years for those aged 20-39 and annually after age 40. The American Academy of Dermatology
recommends annual screening for all patients.
Thyroïde
USPSTF 1996
Routine screening for thyroid cancer using neck palpation or ultrasonography is not
recommended for asymptomatic children or adults.(Recommandation D)
Guide de l’examen médical périodique – révision janvier 2010 | 27
There is insufficient evidence to recommend for or against screening persons with a history of
external head and neck irradiation in infancy or childhood, but recommendations for such
screening may be made on other grounds.(Recommandation C)
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MALADIES INFECTIEUSES
ITSS (Counselling)
ÉTATS-UNIS
USPSTF 2008
The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted
infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.
(Recommandation B)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of behavioral counseling to prevent STIs in non-sexually-active adolescents and in
adults not at increased risk for STIs. (Recommandation I)
Risk assessment: All sexually active adolescents are at increased risk for STIs and should be
offered counseling. Adults with current STIs or infections within the past year are at increased
risk for future STIs. In addition, adults who have multiple current sexual partners should be
considered at increased risk and offered counseling to prevent STIs. Married adolescents may be
considered for counseling if they meet the criteria described for adults. Clinicians should also
consider the communities they serve. If the practice's population has a high rate of STIs, all
sexually active patients in nonmonogamous relationships may be considered to be at increased
risk. Among the studies reviewed, successful high-intensity interventions were delivered through
multiple sessions, most often in groups, with total durations from 3 to 9 hours. Little evidence
suggests that single-session interventions or interventions lasting less than 30 minutes were
effective in reducing STIs.
CANADA
Chlamydia
1) CTFPHC 1996
Fair evidence to support annual screening of high-risk groups (Recommandation B)
(*High-risk groups are sexually active women less than 25 years of age, women with new sexual
partners, women or men with multiple sexual partners during the previous year, women who use
nonbarrier contraceptive methods and women who have symptoms of chlamydial infection
(cervical friability, mucopurulent cervical discharge or intermenstrual bleeding).)
Fair evidence to exclude routine screening of the general population (Recommandation D)
2) Lignes directrices canadiennes sur le ITSS 2006
Personne les plus touchées : jeunes femmes agées de 15 à 24 ans, jeunes hommes agés de 20 à
29 ans
Facteurs de risque : un contact sexuel ave une personne infectée, un nouveau partenaire sexuel ou
plus de deux partenaires sexuel au cours de l’années précédente, des antécédents d’ITSS, les
Guide de l’examen médical périodique – révision janvier 2010 | 29
populations vulnérables, comme les utilisateurs de drogues injectables,
incarcérées, les travailleurs de l’industrie du sexe et les jeunes de la rue.
les personnes
3) Guide québecois de dépistage des ITSS 2006
Depistage pour la ▪personne de 25 ans et moins ayant eu un nouveau partenaire sexuel, sans
autre facteur de risque ▪personne de 25 ans et moins ayant eu deux partenaires sexuels durant la
dernière année ▪personne de 25 ans ou moins ayant contracté une ITSS au cours de l’année
précédente ▪ femme demandant une interuuption de grosesse ▪personne ayant eu plus de deux
partenaires sexuels au cours des deux derniers mois ou plus de cinq partenaires au cours de la
dernière année ▪jeune de la rue ▪utilisateur de drogue, par injection ou non ▪homme ayant des
relations sexuelles avec d’autres hommes ▪personne ayant eu une relation sexuelle avec un
nouveau partenaire revenant d’un séjour dans une région où les ITS ou le VIH sont endémiques
▪personne ayant eu une relation sexuelle avec un partenaire originaire d’un pays où les ITS ou le
VIH sont endémiques ▪travailleur(se) du sexe ▪personne demandant un dépisatge, même en
l’absence de facteur de risque avoué après un counselling pré-test ▪femme enceinte Dépistage à
envisager : ▪nouveau-né dont l’un des parents a une ITSS ou est à risque (*voir tableau en
annexe ou http://www.masexualite.ca/professionnels/its-4.aspx )
ÉTATS-UNIS
1) USPSTF 2007
The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial
infection for all sexually active non-pregnant young women aged 24 and younger and for older
non-pregnant women who are at increased risk . (Recommandation A)The USPSTF
recommends screening for chlamydial infection for all pregnant women aged 24 and younger and
for older pregnant women who are at increased risk . (Recommandation B)
Intervalle : Screening for pregnant women who are at increased risk for chlamydial infection is
recommended at the first prenatal visit. For pregnant women who remain at increased risk and for
those who acquire a new risk factor, such as a new sexual partner, a screening should be
conducted during the third trimester. The optimal interval for screening for nonpregnant women
is unknown. The CDC recommends at least annual screening for women at increased risk
Risque accru: All sexually active women 24 years of age or younger, including adolescents, are
at increased risk for chlamydial infection. In addition to sexual activity and age, other risk factors
for chlamydial infection include a history of chlamydial or other sexually transmitted infection,
new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or
drugs. Risk factors for pregnant women are the same as for nonpregnant women.
The USPSTF recommends against routinely providing screening for chlamydial infection for women aged 25 and
older, whether or not they are pregnant, if they are not at increased risk . (Recommandation C) The USPSTF
concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for
chlamydial infection for men . (Recommandation I)
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2) ACPM 2003
Assessment of risk factors for infection with Chlamydia trachomatis should be performed during
every routine healthcare contact of sexually active women. Sexually active women with risk
factors should be screened annually. Risk factors include age < 25 years, a new male sex partner
or two or more partners during the preceding year, inconsistent use of barrier contraception,
history of a prior STD, African-american race and cervival ectopy. All partners of women with
positive test should be tested for chlamydia.
Gonorrhée
CANADA
1) CTFPHC 1994 (recommandation qui date de PLUS DE 15 ANS)
Gonorrhee : Fair evidence to provide counselling to prevent spread of gonorrhea.
(Recommandation B)
good evidence to screen those at high-risk.* (Recommandation A) *High-risk groups include:
individuals under age 30 years with at least 2 sexual partners in the previous year or age 16
years at first intercourse, prostitutes, sexual contacts of individuals known to have a sexually
transmitted disease.
2) Lignes directrices canadiennes sur les ITSS 2006
Personnes les plus touchées : jeunes hommes agés de 20 à 29 ans (les hommes représentent 2/3
des cas signalés, augmentation Chez les HARSAH), jeunes femmes agées de 15 à 24 ans.
Facteurs de risque : les individus ayant des contacts avec une personne atteinte d’une infection
confirmée ou d’un syndrome compatible, les individus qui ont eu des relations sexuelles non
protégées avec une personne provenant d’une région du monde où la maladie est endémique (il
existe également un risque de résistance plus élevé chez la population de ces régions), les
voyageurs qui séjournent dans des régions du monde où la maladie est endémique et qui ont des
rapports sexuels non protégés avec une personne habitant une telle région (il existe également un
risque de résistance plus élevé chez la population de ces régions), les travailleurs de l’industrie
du sexe et leurs partenaires sexuels, les jeunes âgés de moins de 25 ans, actifs sexuellement et
ayant plusieurs partenaires, les jeunes de la rue, les hommes ayant des relations sexuelles non
protégées avec d’autres hommes, les personnes ayant des antécédents de gonorrhée et d’autres
ITS.Dans une étude passive de surveillance canadienne, la réinfection a été rapportée d’être au
moins 2% par année
3) Guide québecois de dépisatge des ITSS 2006
Dépistage pour ▪personne ayant eu plus de deux partenaires sexuels au cours des deux derniers
mois ou plus de cinq partenaires au cours de la dernière année ▪jeune de la rue ▪utilisateur de
drogue, par injection ou non ▪homme ayant des relations sexuelles avec d’autres hommes
▪personne ayant eu une relation sexuelle avec un nouveau partenaire revenant d’un séjour dans
une région où les ITS ou le VIH sont endémiques ▪personne ayant eu une relation sexuelle avec
un partenaire originaire d’un pays où les ITS ou le VIH sont endémiques ▪travailleur(se) du sexe
Guide de l’examen médical périodique – révision janvier 2010 | 31
▪personne demandant un dépisatge, même en l’absence de facteur de risque avoué après un
counselling pré-test ▪femme enceinte.
Dépistage à envisager : ▪personne de 25 ans et moins ayant eu deux partenaires sexuels durant la
dernière année ▪personne de 25 ans ou moins ayant contracté une ITSS au cours de l’année
précédente ▪ femme demandant une interuuption de grosesse ▪nouveau-né dont l’un des parents a
une ITSS ou est à risque.
(*voir tableau en annexe ou http://www.masexualite.ca/professionnels/its-4.aspx ).
ÉTATS-UNIS
USPSTF 1996
Routine screening for Neisseria gonorrhoeae is recommended for: Asymptomatic women at high
risk of infection. (Recommandation B) High-risk groups include commercial sex workers,
persons with a history of repeated episodes of gonorrhea and young women(under age 25) with
two or more sex partners in the last year.(actual risk depends on local epidemiology).
Syphilis
CANADA
1) Lignes directrices canadiennes sur les ITSS 2006
Personnes les plus touchées : HARSAH (VIH+ et VIH-) âgés de 30 à 39 ans, Travailleurs de
l’industrie du sexe et leurs clients, Acquisition dans les régions endémiques
2) Guide québecois de dépisatge des ITSS 2006
Dépistage pour ▪personne ayant eu plus de deux partenaires sexuels au cours des deux derniers
mois ou plus de cinq partenaires au cours de la dernière année ▪jeune de la rue ▪utilisateur de
drogue, par injection ou non ▪homme ayant des relations sexuelles avec d’autres hommes
▪personne ayant eu une relation sexuelle avec un nouveau partenaire revenant d’un séjour dans
une région où les ITS ou le VIH sont endémiques ▪personne ayant eu une relation sexuelle avec
un partenaire originaire d’un pays où les ITS ou le VIH sont endémiques ▪travailleur(se) du sexe
▪personne demandant un dépistage, même en l’absence de facteur de risque avoué après un
counselling pré-test ▪femme enceinte. Dépistage à envisager : ▪personne de 25 ans et moins
ayant eu deux partenaires sexuels durant la dernière année ▪personne de 25 ans ou moins ayant
contracté une ITSS au cours de l’année précédente ▪ femme demandant une interruption de
grossesse ▪nouveau-né dont l’un des parents a une ITSS ou est à risque (*voir tableau en annexe
ou http://www.masexualite.ca/professionnels/its-4.aspx)
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ÉTATS-UNIS
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen
persons at increased risk for syphilis infection. (Recommendation A)
Populations at increased risk for syphilis infection (as determined by incident rates) include men
who have sex with men and engage in high-risk sexual behavior, commercial sex workers,
persons who exchange sex for drugs, and those in adult correctional facilities. There is no
evidence to support an optimal screening frequency in this population. Persons diagnosed with
other sexually transmitted diseases (STDs) (i.e., chlamydia, gonorrhoea, genital herpes simplex,
human papilloma virus, and HIV) may be more likely than others to engage in high-risk behavior,
placing them at increased risk for syphilis; however, there is no evidence that supports the routine
screening of individuals diagnosed with other STDs for syphilis infection. Clinicians should use
clinical judgment to individualize screening for syphilis infection based on local prevalence and
other risk factors.
HIV
CANADA
1) CTFPHC 1991 (recommandation qui date de PLUS DE 15 ANS)
Voluntary HIV testing : Good evidence to include offer of screening in PHE of asymptomatic
people at high risk. (Recommandation A)
2) Lignes directrices canadiennes sur les ITSS 2006
Personnes les plus touchées : HARSAH, Acquisition dans les régions endémiques, Utilisateurs
de drogues injectables, Jeunes femmes âgées de 15 à 19 ans
3) Guide québécois de dépistage des ITSS 2006
Dépistage pour ▪personne ayant eu plus de deux partenaires sexuels au cours des deux derniers
mois ou plus de cinq partenaires au cours de la dernière année ▪jeune de la rue ▪utilisateur de
drogue, par injection ou non ▪homme ayant des relations sexuelles avec d’autres hommes
▪personne ayant eu une relation sexuelle avec un nouveau partenaire revenant d’un séjour dans
une région où les ITS ou le VIH sont endémiques ▪personne ayant eu une relation sexuelle avec
un partenaire originaire d’un pays où les ITS ou le VIH sont endémiques ▪travailleur(se) du sexe
▪personne demandant un dépistage, même en l’absence de facteur de risque avoué après un
counselling pré-test ▪femme enceinte ▪possibilité d’exposition sanguine accidentelle (tatouage
ou perçage dans des conditions non-steriles, exposition en milieu de travail) ▪transfusion de sang
ou de produits sanguins, greffe de tissus ou d’organe Dépistage à envisager : ▪personne de 25 ans
et moins ayant eu deux partenaires sexuels durant la dernière année ▪personne de 25 ans ou
moins ayant contracté une ITSS au cours de l’année précédente ▪ femme demandant une
interruption de grosesse ▪nouveau-né dont l’un des parents a une ITSS ou est à risque (*voir
tableau en annexe ou http://www.masexualite.ca/professionnels/its-4.aspx)
Guide de l’examen médical périodique – révision janvier 2010 | 33
ÉTATS-UNIS
USPSTF 2005
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen
for human immunodeficiency virus all adolescents and adults at increased risk for HIV infection
(Recommandation A) The USPSTF makes no recommendation for or against routinely
screening for HIV adolescents and adults who are not at increased risk for HIV infection
(Recommandation C) The USPSTF recommends that clinicians screen all pregnant women for
HIV (Recommandation A)
Risk factors : men who have had sex with men after 1975; men and women having unprotected
sex with multiple partners; past or present injection drug users; men and women who exchange
sex for money or drugs or have sex partners who do; individuals whose past or present sex
partners were HIV-infected, bisexual, or injection drug users; persons being treated for sexually
transmitted diseases (STDs); and persons with a history of blood transfusion between 1978 and
1985,persons who request an HIV test despite reporting no individual risk factors, persons who
report no individual risk factors but are seen in high-risk or high-prevalence clinical settings.
High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis
clinics, clinics serving men who have sex with men, and adolescent health clinics.
Hépatites
CANADA
HEPATITE B
1) Lignes directrices canadiennes sur les ITSS 2006
Personne les plus touchées : Nourrissons dont la mère est positive pour l’antigène HBs,
Utilisateurs de drogues injectables qui partagent leur matériel, Personnes ayant plusieurs
partenaires sexuels, Acquisition dans les régions endémiques , Contacts sexuels ou personnes
vivant sous le même toit d’un cas aigus ou chronique
2) Guide québecois de dépistage des ITSS 2006
Dépistage pour ▪personne ayant eu plus de deux partenaires sexuels au cours des deux derniers
mois ou plus de cinq partenaires au cours de la dernière année ▪jeune de la rue ▪utilisateur de
drogue, par injection ou non ▪homme ayant des relations sexuelles avec d’autres hommes
▪personne ayant eu une relation sexuelle avec un nouveau partenaire revenant d’un séjour dans
une région où les ITS ou le VIH sont endémiques ▪personne ayant eu une relation sexuelle avec
un partenaire originaire d’un pays où les ITS ou le VIH sont endémiques ▪travailleur (se) du sexe
▪personne demandant un dépistage, même en l’absence de facteur de risque avoué après un
counselling pré-test ▪femme enceinte ▪possibilité d’exposition sanguine accidentelle (tatouage
ou perçage dans des conditions non-steriles, exposition en milieu de travail) ▪transfusion de sang
ou de produits sanguins, greffe de tissus ou d’organe Dépistage à envisager : ▪personne de 25
ans et moins ayant eu deux partenaires sexuels durant la dernière année ▪personne de 25 ans ou
moins ayant contracté une ITSS au cours de l’année précédente ▪ femme demandant une
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interruption de grossesse ▪nouveau-né dont l’un des parents a une ITSS ou est à risque (*voir
tableau en annexe ou http://www.masexualite.ca/professionnels/its-4.aspx)
HEPATITE C
Guide québécois de dépistage des ITSS 2006
Dépistage pour : ▪utilisateur de drogue, par injection ou non ▪possibilité d’exposition sanguine
accidentelle (tatouage ou perçage dans des conditions non-steriles, exposition en milieu de
travail) ▪transfusion de sang ou de produits sanguins, greffe de tissus ou d’organe ▪personne
demandant un dépistage, même en l’absence de facteur de risque avoué après un counselling prétest Dépistage à envisager : pour ▪personne ayant eu plus de deux partenaires sexuels au cours
des deux derniers mois ou plus de cinq partenaires au cours de la dernière année ▪personne de
25 ans ou moins ayant contracté une ITSS au cours de l’année précédente ▪homme ayant des
relations sexuelles avec d’autres hommes ▪femme enceinte ▪nouveau-né dont l’un des parents a
une ITSS ou est à risque (*voir tableau en annexe ou http://www.masexualite.ca/professionnels/its-4.aspx)
ÉTATS-UNIS
USPSTF 2004
Recommends against routinely screening the general asymptomatic population for chronic
hepatitis B virus infection (Recommandation D)
Recommends against routine screening for hepatitis C virus (HCV) infection in asymptomatic
adults who are not at increased risk (general population) for infection. (Recommandation D)
Insufficient evidence to recommend for or against routine screening for HCV infection in adults
at high risk for infection (Recommandation I)
Herpes
Lignes directrices canadiennes sur les ITSS 2006
Personnes les plus touchées: Très fréquent chez les adolescents et les adultes, hommes ou
femmes, Les femmes sont plus touchées que les hommes
USPSTF 2005
Recommends against routine serological screening for HSV in asymptomatic adolescents and
adults (Recommandation D)
Guide de l’examen médical périodique – révision janvier 2010 | 35
Human papilloma virus infection
Lignes directrices canadiennes sur les ITSS 2006
Personnes les plus touchées : Hommes et femmes, adolescents ou jeunes adultes (il frappe aussi
bien les hommes que les femmes, et ce, quel que soit leur âge).
CTFPHC 1995
HPV screening (beyond Papanicolaou testing for cervical cancer) : Fair evidence to exclude from
periodic health examination. (Recommandation D)
Rubéole
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Screening for immunization status (serology or proof of vaccination) and immunization of
women at risk. Fair evidence to include in the periodic health examination of women of childbearing age. (Recommandation B)
USPSTF 1996
Routine screening for rubella susceptibility by history of vaccination or by serology is
recommended for all women of childbearing age at their first clinical
encounter.(Recommandation B) Susceptible nonpregnant women should be offered rubella
vaccination; susceptible pregnant women should be vaccinated immediately after delivery.
(Recommandation B)
Tuberculose
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Tuberculose : Good evidence to support screening individuals at high-risk* (Recommandation
A) Good evidence to recommend INH prophylaxis to household contacts and skin test converters
and persons with underlying medical conditions like HIV that increase the risk of reactivation of
infection (Recommandation A);
*High-risk groups include immigrants from endemic areas (Africa, Asia, Central America and
certain countries in South America and the Caribbean), Canadian-born aboriginals, close contacts
of active cases, persons with abnormal chest radiographs consistent with healed tuberculosis, and
persons with underlying medical conditions which increase their likelihood of reactivation of
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tuberculosis if infected (those with silicosis, jejunoilial by-pass, hemodialysis, gastrectomy,
malnutrition, intravenous drug users, alcohol abusers and especially those with known or
suspected infection with HIV).
USPSTF 1996
Screening for tuberculous infection with tuberculin skin testing is recommended for all persons at
increased risk of developping tuberculosis (Recommandation A)
Persons infected with HIV, close contacts of personswith known or suspected TB, persons with
medical risk factors associated with TB, immigrants from countries with high TB prevalence,
medically underserved low-income populations, alcoholics, injection drug users, residents of
long-term care facility.
Bactériurie
USPSTF 2008
The USPSTF recommends against screening for asymptomatic bacteriuria in men and
nonpregnant women. (Recommandation D)
Varicelle
CTFPHC 2001
Immunization of susceptible adolescents and adults with varicella vaccine is effective in
preventing varicella infection and secondary cases in household contacts
(Recommandation B)
Guide de l’examen médical périodique – révision janvier 2010 | 37
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HABITUDES DE VIE
Tabac
CTFPHC 1994
Good evidence to support smoking cessation counselling (Recommandation A); nicotine
replacement therapy may be offered as an adjunct. (Recommandation A)
USPSTF 2009
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco
cessation interventions for those who use tobacco products. (Recommandation A) AAFP has
same recommandation
Alcool
CTFPHC 1994
Fair evidence to include routine detection and counselling in periodic health examination.
(Recommandation B) by standardized questionnaire and/or patient inquiry
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral
counselling interventions to reduce alcohol misuse by adults, including pregnant women, in
primary care settings. (Recommandation B)
the evidence is insufficient to recommend for or against screening and behavioral counselling
interventions to prevent or reduce alcohol misuse by adolescents in primary care settings.
(Recommandation I)
Activité physique
CANADA
CTFPHC 1994
Evidence for or against a recommendation to include physical activity counselling in the PHE is
lacking. (Recommandation C)
There is fair evidence to recommend that individuals engage in the regular practice of moderate
intensity physical activity. (Recommandation B)
There is good evidence to recommend lifestyle interventions for overweight individuals (body
mass index > 25 kg/m2, or > 22 kg/m2 if of Asian descent) with impaired glucose tolerance to
reduce the incidence of progression to diabetes (Recommendation B).
ÉTATS-UNIS
USPSTF 2002
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to
recommend for or against behavioral counselling in primary care settings to promote physical
activity. (Recommandation I)
Guide de l’examen médical périodique – révision janvier 2010 | 39
AAFP
The AAFP recognizes that regular physical activity is desirable. The effectiveness of physician's
advice and counselling in this area is uncertain.
Diète
CTFPHC 1994
Fair evidence to provide general dietary advice (Recommandation B) There is good evidence to
recommend lifestyle interventions for overweight individuals (body mass index > 25 kg/m2, or >
22 kg/m2 if of Asian descent) with impaired glucose tolerance to reduce the incidence of
progression to diabetes (Recommandation B)
USPSTF 2003
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to
recommend for or against routine behavioral counselling to promote a healthy diet in unselected
patients in primary care settings. (Recommandation I). The USPSTF recommends intensive
behavioral dietary counselling for adult patients with hyperlipidemia and other known risk factors
for cardiovascular and diet-related chronic disease. Intensive counselling can be delivered by
primary care clinicians or by referral to other specialists, such as nutritionists or dietitians
(Recommandation B)
Obésité
CANADA
CTFPHC 1998
Because of lack of evidence supporting long-term effectiveness of weight-reduction
interventions, there is insufficient evidence to recommend for or against BMI measurement in the
periodic health examination of the general population (Recommandation C )
There is fair evidence to recommend BMI measurement in the periodic health examination of
obese adults with obesity-related disease (Recommandation B )
There is insufficient evidence to recommend for or against weight-reduction therapy in obese
adults without obesity-related disease (Recommandation C )
There is fair evidence to recommend weight-reduction therapy in obese adults with obesityrelated disease (Recommandation B)
CTFPHC 2005
There is good evidence to recommend lifestyle interventions for overweight individuals (body
mass index > 25 kg/m2, or > 22 kg/m2 if of Asian descent) with impaired glucose tolerance to
reduce the incidence of progression to diabetes (Recommandation B)
There is fair evidence to recommend acarbose treatment for overweight individuals (as described
above) with impaired glucose tolerance to prevent cardiovascular events and hypertension
(Recommandation B). There is insufficient evidence to recommend metformin or acarbose
treatment for overweight individuals (as described above) with impaired glucose tolerance to
prevent diabetes progression (Recommandation I)
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ÉTATS-UNIS
USPSTF 2005
The evidence is insufficient to recommend for or against routine screening for
overweight in children and adolescents as a means to prevent adverse health
outcomes(Recommandation I)
USPSTF 2003
The USPSTF recommends that clinicians screen all adult patients for obesity
and offer intensive counselling and behavioral interventions to promote sustained weight loss for
obese adults.(Recommandation B)
AAFP
The AAFP recommends screening for obesity by measuring height and weight
periodically for all patients
Guide de l’examen médical périodique – révision janvier 2010 | 41
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PRÉVENTION DES ACCIDENTS
CTFPHC 1993
Individual counselling for :
Don’t drink and drive (Grade C)
Use helmets when riding bicycles on roadway (Grade C)
In the home, make guns inaccessible ; keep ammunition and gun separately (GradeC)
Use of seatbelt and/or child restraints (Grade B )
Use of helmet when riding motorcycle or all-terrain vehicles (Grade C)
In elderly
Monitor elderly patients for medical impairment (balance, medication, gait abnormalities) (Grade C)
Counselling regarding use of safety aid in hazardous areas such as stairs, bathtubs (Grade C)
USPSTF
2007: The USPSTF concludes that the current evidence is insufficient to assess the incremental benefit,
beyond the efficacy of legislation and community-based interventions, of counseling in the primary care
setting, in improving rates of proper use of motor vehicle occupant restraints (child safety seats, booster
seats, and lap-and-shoulder belts). (Recommandation I)
1996: Periodic counselling of the parents of children on measures to reduce the risk of unintentional
household and recreational injuries is recommended. (Grade B) ; Measures to reduce the risk of
unintentional injuries from residential fires and hot tap water, drowning, poisoning, bicycling, firearms
and falls is recommended
Counselling to prevent household and recreational injuries is also recommended for adolescents and adults
based on the proven efficacy of risk reduction, although the effectiveness of counselling these patients to
prevent injuries has not been adequately evaluated. (Grade C)
Persons with alcohol or drug problems should be identified, counselled and monitored. Those who use
alcohol or illicit drugs should be warned against engaging in potentially dangerous activities while
intoxicated.(Grade B)
Counselling elderly patients on specific measures to prevent falls is recommended based on fair evidence
that these measures reduce the risk of falls (Grade B) although the effectiveness of counselling elders to
prevent falls has not been adequately evaluated. (Grade C)
More intensive individualized multi-factorial intervention is recommended for high-risk elderly patients in
settings where adequate resources to deliver such services are available.(Grade B)
There is insufficient evidence to recommend for or against the use of external hip protectors to prevent fall
injuries.
The following counselling to all patients, and the parents of young patients, is recommended:
 Use occupant restraints (lap/shoulder safety belts and child safety seats). (Grade B)
 Wear helmets when riding motorcycles. (Grade C)
 Refrain from driving while under the influence of alcohol or other drugs (Grade C)
There is currently insufficient evidence to recommend for or against counselling to prevent pedestrian
injuries (Grade C)
Guide de l’examen médical périodique – révision janvier 2010 | 43
AAFP
The AAFP recommends counselling all parents and patients more than 2 years old regarding accidental
injury prevention including, as appropriate: child safety seats lap and shoulder belt use, bicycle safety,
motorcycle helmet use, smoke detectors, poison control center number, and driving while intoxicated.
Personnes âgées
American geriatrics society 2001
Routine Care of Older Persons (not presenting after a fall)
 Clinicians caring for older persons should ask about fall history annually
 Those patients who report a single fall should undergo a balance and gait screening. This is done
by observing the ability to stand up from a chair without using arms, walk several paces and
return. ( i.e. the "get up and go test")
 Those having difficulty require further assessment and appropriate intervention such as referral to
physical and or occupational therapy.
Evaluation of Older Persons Presenting with One or More Falls or Having Abnormalities Gait and or
Balance or who report Recurrent Falls:
 History of the fall circumstances, medications (prescribed and over the counter), acute or chronic
medical problems, and mobility levels
 An examination of vision, muscle strength, gait, balance, and neurological function including
lower extremity peripheral nerves, proprioception, reflexes,cortical and extrapyramidal and
cerebellar functions should be done. An assessment of cognitive function and a basic
cardiovascular evaluation including heart rate and rhythm, orthostatic pulse and blood pressure
should be done.,
Single interventions:
 Exercise:












Although exercise has many proven benefits, the optimum type, duration and intensity to
prevent falls remains unclear (B).
Physical therapy, exercise and balance training should be offered to older persons who
have recurrent falls (B).
Tai Chi C'uan is said to improve balance, it requires further evaluation before before it
can be recommended (C).
Environmental Modification:
Older persons at increased risk for falls should have an environmental assessment done of
their home by an OT or other qualified professional (B).
Medications:
Patients, who have fallen, should have their medications reviewed especially those on
more than four prescribed meds or those taking psychotropic meds (C). (There is no clear
difference in risk for falls between long term and short-term benzodiazepines).
Assistive devices:
There is no clear evidence that use of assistive devices alone such as bed alarms, canes,
and walkers have demonstrated benefits in preventing falls. While assistive devices may
be effective elements of a multifactorial intervention program, their isolated use without
attention to other risk factors cannot be recommended (C).
Hip protectors do not appear to reduce the risk of falls (Class I), but have been shown to
be effective in preventing fractures in high-risk individuals.
Behavioral and Educational Programs:
When used as an isolated intervention, health and behavioral education does not reduce
falls (B).
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Other Potential Interventions:
 Visual/sensory loss: deficits in sight and sensation have been linked to a higher incidence of falls
resulting in hip fractures. Identification of these deficits and appropriate intervention may be
preventative.
 Footwear interventions: there are no experimental studies of footwear examining falls as an
outcome. There are, however trials looking at intermediate outcomes such as balance and sway
from specific footwear interventions. For women, use of walking shoes was better than barefoot.
For men, stability was best with high mid-sole hardness and low mid-sole thickness.
MCAS
Aspirine prévention primaire
CTFPHC 1994
(recommandation qui date de PLUS DE 15 ANS)
Weak evidence to use or not to use routine ASA therapy for the primary prevention of
cardiovascular disease in asymptomatic men and women (Recommandation C)
USPSTF 2009
The USPSTF recommends the use of aspirin for men age 45 to 79 years
when the potential benefit due to a reduction in myocardial infarctions outweighs the potential
harm due to an increase in gastrointestinal hemorrhage. (Recommandation A)
Decisions about aspirin therapy should consider the overall risks for coronary heart disease and
gastrointestinal bleeding. Available tools provide estimations of coronary heart disease risk (such
as the calculator available at http://hp2010.nhlbihin.net/atpiii/calculator.asp).
Estimated myocardial infarctions (MIs) prevented and estimated harms of using aspirin for
10 years in a hypothetical cohort of 1000 men
http://www.ahrq.gov/clinic/uspstf09/aspirincvd/aspcvdrsf2.htm
The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential
benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in
gastrointestinal hemorrhage. (Recommandation A)
Decisions about aspirin therapy should consider the overall risk for stroke and gastrointestinal
bleeding. Tools for estimation of stroke risk are available (such as the calculator available at
http://www.westernstroke.org/PersonalStrokeRisk1.xls).
Estimated number of strokes prevented and estimated harms of using aspirin for 10 years
in a hypothetical cohort of 1000 women on the basis of age and 10-year stroke risk.
http://www.ahrq.gov/clinic/uspstf09/aspirincvd/aspcvdrsf4.htm
Guide de l’examen médical périodique – révision janvier 2010 | 45
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.
(Recommandation I)
The net benefit of aspirin use in persons older than 80 years is probably best in those without risk
factors for gastrointestinal bleeding (other than older age) and in those who could tolerate a
gastrointestinal bleeding episode (for example, those with normal hemoglobin levels, good
kidney function, and easy access to emergency care).
The USPSTF recommends against the use of aspirin for stroke prevention in women younger
than 55 years and for myocardial infarction prevention in men younger than 45 years.
(Recommandation D)
The optimum dose of aspirin for preventing cardiovascular disease events is not known. Primary
prevention trials have demonstrated benefits with various regimens, including dosages of 75 and
100 mg/d and 100 and 325 mg every other day. A dosage of approximately 75 mg/d seems as
effective as higher dosages. The risk for gastrointestinal bleeding may increase with dose.
Aspirine prévention secondaire
Diabètes
Association canadienne du diabètes 2003
Unless contraindicated, low-dose ASA therapy (80 to 325 mg/day) is recommended in all
patients with diabetes with evidence of CVD, as well as for those individuals with atherosclerotic
risk factors that increase their likelihood of CV events (Grade A)
American diabetes association 2009
In patients with known CVA aspirin (if nor contraindicated) should be used to reduce the risk of
cardiovascular events (Grade A) Use aspirin therapy (75–162 mg/day) as a primary prevention
strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk , including those
who are > 40 years of age or who have additional risk factors (family history of CVD,
hypertension, smoking, dyslipidemia, or albuminuria (Grade C) Aspirin therapy is not
recommended in people under 30 years of age and is contraindicated in people under the age of
21. (Grade E).
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Hypertension
Canadian hypertension society 2009
Strong consideration should be given to the addition of low dose ASA therapy in hypertensive
patients (Grade A in patients older than 50 years). Caution should be exercised if blood pressure
is not controlled (Grade C).
Cochrane 2004
For primary prevention in patients with elevated blood pressure, anti-platelet therapy with ASA
cannot be recommended since the magnitude of benefit, a reduction in myocardial infarction, is
negated by a harm of similar magnitude, an increase in major haemorrhage. For secondary
prevention in patients with elevated blood pressure (ATC meta-analysis: APTC 1994) antiplatelet
therapy is recommended because the magnitude of the absolute benefit is many times greater.
Warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure
cannot be recommended because of lack of demonstrated benefit. Glycoprotein IIb/IIIa inhibitors
as well as ticlopidine and clopidogrel have not been sufficiently evaluated in patients with
elevated blood pressure.
Further trials of antithrombotic therapy with complete documentation of all benefits and harms
are required in patients with elevated blood pressure.
Guide de l’examen médical périodique – révision janvier 2010 | 47
Dépistage MCAS
USPSTF 2004
The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening with
resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized
tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary
artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low
risk for CHD events. (Recommandation D)
The USPSTF found insufficient evidence to recommend for or against routine screening with
ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the
prediction of CHD events in adults at increased risk for CHD events.
(Recommandation I)
USPSTF 2009
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to
assess the balance of benefits and harms of using the nontraditional risk factors discussed in this
statement to screen asymptomatic men and women with no history of CHD to prevent CHD
events (Recommandation I)
The nontraditional risk factors included in this recommendation are high-sensitivity C-reactive
protein (hs-CRP), ankle–brachial index (ABI), leukocyte count, fasting blood glucose level,
periodontal disease, carotid intima–media thickness (carotid IMT), coronary artery calcification
(CAC) score on electron-beam computed tomography (EBCT), homocysteine level, and
lipoprotein(a) level.
Vitamine E
CTFPHC 2003
Primary prevention of CVD : The CTF concludes that there is insufficient evidence to
recommend for or against the use of routine vitamin E supplementation for the primary
prevention of CVD events in the general population and in male smokers
( Recommandation I).
Secondary prevention of CVD in patients with established CVD or risk factors for CVD : The
CTF concludes that there is good evidence to recommend against the use of vitamin E for the
secondary prevention of CVD in patients with established CVD or risk factors for CVD
(Recommandation D)
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MALADIES VASCULAIRES
Anévrysme de l’aorte abdominale
CTFPHC 1994
Palpation abdominale ou échographie : Poor evidence to include or exclude in periodic health
examination of asymptomatic individuals (Recommandation C) but screening may be
considered for individuals at high risk. (males over the age of 60 who are smokers with hypertension,
claudication, evidence of other vascular disease or a positive family history of AAA)
La société canadienne de chirurgie vasculaire 2008
Recommande que les hommes agés de 65 à 75 ans soient soumis au dépistage de l’AAA dans un
programme de dépistage universel. Que les personnes à risque élevé d’AAA soient soumises à un
dépistage sélectif individuel, à savoir: a) les femmes de plus de 65 ans à risque élevé en raisons
d’antécédents de tabagisme ou de maladie cérébrovasculaire ou d’une histoire familiale b) les
hommes de moins de 65 ans dont l’histoire familiale révèle des cas d’AAA.
USPSTF 2005
Recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in
men aged 65 to 75 who have ever smoked. (Recommandation B)
Makes no recommendation for or against screening for AAA in men aged 65 to 75 who have
never smoked. (Recommandation C)
Recommends against routine screening for AAA in women (Recommandation D)
Sténose carotidienne
CTFPHC 1994
Neck auscultation : Fair evidence not to include in periodic health examination of asymptomatic
individuals. (Recommandation D)
USPSTF 2007
The U.S. Preventive Services Task Force (USPSTF) recommends against screening for
asymptomatic carotid artery stenosis (CAS) in the general adult population. (Recommandation D)
MVAS
USPSTF 1996
Routine screening for peripheral arterial disease in asymptomatic persons is not recommended
(Recommandation D)
Clinicians should be alert to symptoms of peripheral arterial disease in persons at increased risk,
and should evaluate patients who have clinical evidence of vascular disease.
Guide de l’examen médical périodique – révision janvier 2010 | 49
TROUBLES DE LA VISION OU DE L’AUDITION
Vision
CTFPHC 1995
Snellen in elderly : Fair evidence to include in the periodic health examination (PHE)
(Recommandation B)
USPSTF 2009
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of screening for visual acuity for the improvement of outcomes in older adults.
(Recommandation I)
AAFP
The AAFP recommends screening for visual difficulties in elderly adults by performing Snellen
acuity testing.
Glaucome
CTFPHC 1995
Screening in elderly:
(Recommandation C)
Insufficient evidence to include in or exclude from the PHE
USPSTF 2005
There is insufficient evidence to recommend for or against screening adults for glaucoma
(Recommandation I) The uncertainty of the magnitude of benefit from early treatment and
given the known harms of screening and early treatment, the USPSTF could not determine the
balance between the benefits and harms of screening for glaucoma.
AUTRES
The American Academy of Ophthalmology 2006
recommended frequency of eye examinations for the general population, based on age and
presence of risk factors for glaucomatous optic neuropathy.
The
TABLE 1 Recommended Frequency of Comprehensive Adult Medical Eye Evaluation
Age (years)
With Risk Factors for Glaucoma
No Known Risk Factors
>65
6-12 months[A:III]
1-2 years1 [A:II]
55-64
1-2 years[A:III]
1-3 years[A:III]
40-54
1-3 years[A:III]
2-4 years[A:III]
[A:III]
Under 40
2-4 years
5-10
years[A:III]
The overall likelihood of developing glaucomatous optic neuropathy increases with the number
and strength of risk factors, which include the following: Elevated IOP measurement, Older age,
Family history of glaucoma, Thinner central corneal thickness, African or Hispanic/Latino
descent, Increased cup-to-disc ratio. In addition, migraine headache and peripheral vasospasm
have been identified in some studies as risk factors for progressing to glaucomatous optic nerve
damage. The association between factors such as concurrent cardiovascular disease, systemic
hypertension, and myopia and the development of glaucomatous optic nerve damage has not been
demonstrated consistently. The relationship between diabetes mellitus and progression to
glaucomatous optic neuropathy is unclear.
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In 2007 they wrote: We are requesting a reevaluation of the USPSTF recommendation at this
time, because of new evidence regarding screening for and treatment of glaucoma not available
at the time of the USPSTF report and because of significant concerns regarding the scope and
applicability of the USPSTF recommendation.
Surdité
CTFPHC 1994
Fair evidence to screen the elderly for hearing impairment. (Recommandation B)
USPSTF 1996
Screening for older adults for hearing impairment is recommended through:
 Periodically questioning them about their hearing. (Recommandation B)
 Counselling them about the availability of hearing aid devices.
 Making referrals for abnormalities when appropriate.
There is insufficient evidence to recommend for or against routinely screening asymptomatic
working-age adults for hearing impairment. Recommendations against such screening, except for
those exposed to excessive occupational noise levels, may be made on other ground.
SANTÉ MENTALE
Drogues
USPSTF 2008
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of screening adolescents, adults, and pregnant women for illicit drug use
(Recommandation I)
Dépression in adults
CTFPHC 2005
There is fair evidence to recommend screening adults in the general population for depression in
primary care settings that have integrated programs for feedback to patients and access to case
management or mental health care (Recommandation B)
There is insufficient evidence to recommend for or against screening adults in the general
population for depression in primary care settings where effective follow-up and treatment are
not available (Recommandation I)
Guide de l’examen médical périodique – révision janvier 2010 | 51
USPSTF-2009
The USPSTF recommends screening adults for depression when staff-assisted depression care
supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
(Recommandation B). Asking 2 simple questions about mood and anhedonia ("Over the past 2
weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt
little interest or pleasure in doing things?") may be as effective as using more formal instruments.
The optimum interval for screening for depression is unknown. Recurrent screening may be most
productive in patients with a history of depression, unexplained somatic symptoms, comorbid
psychological conditions (for example, panic disorder or generalized anxiety), substance abuse,
or chronic pain. The USPTF recommends against routinely screening adults for depression when
staff-assisted depression care supports are not in place. There may be considerations that support
screening for depression in an individual patient. (Recommandation C)
Dépression in adolescents
USPSTF-2009
The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive
disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy
(cognitive-behavioral or interpersonal), and follow-up. (Recommandation B)
Démence
CTFPHC 2001
There is insufficient evidence to recommend for, or against, screening for cognitive impairment
in the absence of dementia, (Recommandation C)
Memory complaints should be evaluated and the individual followed to assess progression
(Recommandation B)
When caregivers or informants describe cognitive decline in an individual, these observations
should be taken very seriously: cognitive assessment and careful follow-up are indicated
(Recommandation A)
USPSTF 2003
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to
recommend for or against routine screening for dementia in older adults.
(Recommandation I)
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Violence familiale
USPSTF 2004
insufficient evidence to recommend for or against routine screening of parents or guardians for
the physical abuse or neglect of children, of women for intimate partner violence, or of older
adults or their caregivers for elder abuse (Recommandation I)
SOGC-2005
Les fournisseurs de soins de santé devraient inclure des questions au sujet de la violence dans le
cadre de l’évaluation de la santé comportementale de leurs nouvelles patientes, à l’occasion des
consultations préventives annuelles, dans le cadre des soins prénatals, ainsi qu’en réaction à des
symptômes ou à des états pathologiques associés à la violence. (B)
MALADIES CHRONIQUES
MPOC
USPSTF 2008
The USPSTF recommends against screening adults for chronic obstructive pulmonary disease
(COPD) using spirometry (Recommandation D)
Guide de l’examen médical périodique – révision janvier 2010 | 53
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SANTÉ DE LA FEMME (divers)
Contraception
CTFPHC 1994
Physicians who see adolescents should advise those who are sexually active about the correct use
of appropriate contraception (Recommandation B) (Révision en cours )
Oral contraceptive has been identified as the method of choice for adolescents in combination with a condom to
protect against sexually transmitted diseases
USPSTF 1996
Periodic counselling about effective contraceptive methods is recommended for all women and
men at risk for unintended pregnancy. (Recommandation B) Counselling should be based on
information from a careful sexual history and should take into account the individual preferences, abilities, and risks
of each patient. Sexually active patients should also receive information on measures to prevent sexually transmitted
diseases
Acide folique en préconception
CTFPHC 1994
Good evidence to advise all women capable of becoming pregnant to increase their consumption
of folic acid to 0.4 mg/day. Supplementation appears to be the most effective and practical way to
achieve this goal. (Recommandation A)
USPSTF 2009
The USPSTF recommends that all women planning or capable of pregnancy take a daily
supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (Recommandation A)
Chimioprophylaxie contre le cancer du sein
CTFPHC 2001
There is fair evidence to recommend counselling high risk women about the potential benefits
and risks of using tamoxifen to reduce the likelihood of breast cancer, and hence support
individual choice. (Recommandation B) (High Risk Women (e.g. 1.66% or more on Gail Index)
Screening using the Gail Index has not been evaluated for general use
National Cancer Institute: The model is applicable to women 40 years or older who receive
regular mammography. (possible de calculer le risque à http://bcra.nci.nih.gov/brc/ )
USPSTF 2002
The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for
breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform
patients of the potential benefits and harms of chemoprevention(Recommandation B)
Hormonothérapie
CTFPHC 2004
Recommends against the use of combined estrogen-progestin therapy and estrogen-only therapy
for the primary prevention of chronic disease in menopausal women (Recommandation D) For
women who wish to alleviate menopausal symptoms using hormone replacement therapy (HRT), a discussion
between the woman and her physician about the potential benefits and risks of HRT is warranted. (Voir aussi le
site de la SOGC : www.sogc.org)
USPSTF 2005
Guide de l’examen médical périodique – révision janvier 2010 | 55
The U.S. Preventive Services Task Force (USPSTF) recommends against the routine use of
combined estrogen and progestin for the prevention of chronic conditions in postmenopausal
women (Recommandation D) The USPSTF recommends against the routine use of unopposed
estrogen for the prevention of chronic conditions in postmenopausal women who have had a
hysterectomy (Recommandation D) (Voir aussi le site du WHI : www.whi.org)
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Liste des sites web
EMP général
Canadian task force
Site: http://www.ctfphc.org/
Livre de 1994: http://www.hc-sc.gc.ca/hppb/soinsdesante/pdf/soins98/s7c50f.pdf US task force
http://www.ahrq.gov/clinic/uspstfix.htm
American college of preventive medicine:
http://www.acpm.org/pol_practice.htm
Glycémie
Association canadienne du diabète
http://www.diabetes.ca/cpgfrancais/default.aspx
American diabetes association
http://care.diabetesjournals.org/content/vol29/suppl_1/
American association of clinical endocrinologists
http://www.aace.com/pub/pdf/guidelines/DMGuidelines2007.pdf
Cholestérol
Canadian cardiovascular society
http://www.ccs.ca/download/position_statements/lipids.pdf
NCEPP III
http://www.nhlbi.nih.gov/guidelines/cholesterol/
American heart association
http://www.americanheart.org/presenter.jhtml?identifier=548
American association of clinical endocrinologists: http://www.aace.com/clin/guidelines/lipids.pdf
Hypertension
Canadian hypertension society
www.hypertension.ca/chep/recommandations2006/CHEP_06_BookletFullText_vf.pdf
Société québécoise d’hypertension artérielle
http://www.hypertension.qc.ca/docs/guide_SQHTA_2002.pdf
JNC 7
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
http://hyper.ahajournals.org/cgi/reprint/42/6/1206
Ostéoporose
Osteoporosis society of Canada (guidelines 2002)
http://www.cmaj.ca/content/vol167/10_suppl/index.shtml
National osteoporosis foundation 2003 http://www.nof.org/physguide/table_of_contents.htm
Cancer du sein
Société canadienne du cancer
http://www.cancer.ca/ccs/internet/standard/0,3182,3172_10175_74567690_langId-fr,00.html
National cancer institute
http://www.cancer.gov/newscenter/mammstatement31jan02
ACOG
ACOG Practice Bulletin. Obstetrics and Gynecology. Avril 2003 vol 101 pp821-32
American geriatrics society
http://www.americangeriatrics.org/education/cp_index.shtml
Guide de l’examen médical périodique – révision janvier 2010 | 57
Cancer du côlon
Canadian association of gastroenterologists
http://www.cag-acg.org/guidelines/pdf/Colorectal%20cancer%20screening%202004.pdf
National committee on colorectal cancer sreening
http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ncccs-cndcc/pdf/ccstechrep_e.pdf
American Gastroenterological Association
http://www2.us.elsevierhealth.com/inst/serve?action=searchDB&searchDBfor=art&artType=abs
&id=agast1240544&nav=abs&special=hilite&query=[articletitle](colorectal+cancer+screening,su
rveillance,)
Cancer du col utérin
American cancer society
http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.
asp?sitearea=PED
ACOG (American college of obstetricians and gynecologists)
ACOG Practice Bulletin. Obstetrics and Gynecology aout 2003 vol 102. pp417-27
American geriatrics society
http://www.americangeriatrics.org/products/positionpapers/cer_carc_2000.shtml
Cancer de la prostate
Canadian urological association
http://www.cua.org/
http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Genitourinary/Prostate/PSAScre
ening/PositionsofOtherMedicalOrganizationsonScreeningforProstateCancerwithPSA.htm
American urological association
http:www.urologyhealth.org/adult/index.cfm?cat=09&topic=250
http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Genitourinary/Prostate/PSAScre
ening/PositionsofOtherMedicalOrganizationsonScreeningforProstateCancerwithPSA.htm
Prevention des accidents
American geriatrics society
http://www.americangeriatrics.org/products/positionpapers/abstract.shtml
Maladies infectieuses
Guide québecois de dépistage des ITSS 2006
http://www.masexualite.ca/professionnels/its-4.aspx
Lignes directrices canadiennes pour les MTS 1998
http://www.phac-aspc.gc.ca/publicat/std-mts98/index_f.html
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ANNEXE 1
Feuilles synthèse des recommandations
Par sexe et groupe d’âge
Les recommandations A ou B du Canada et/ou des Etats-Unis qui s’adressait à une population générale
adulte ont été incluses.
Toutefois si une recommandation d’un organisme autre semblait pertinente et importante la
manœuvre a quand même été incluse dans la liste.
Chaque item est suivi des recommandations canadienne et américaine. La première valeur est
celle du CTFPHC. Elle est suivie de celle du USPSTF.
Lorsque qu’il n’y a pas de recommandation un * apparaît. Pour les recommandations des autres
associations se référer au document de base.
Adolescent
20-35 ans
35-50 ans
50-70 ans
> 70 ans
Ces feuilles sont disponibles sur notre site : http://medecinefamiliale.com/umf/emp
Guide de l’examen médical périodique – révision janvier 2010 | 59
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ANNEXE 2
Suggestion de feuilles de prise de données pour
l’examen périodique adolescent-adulte
Adolescents
20-35 ans
35-50 ans
50-70 ans
> 70 ans
Ces feuilles sont disponibles sur notre site :
http://medecinefamiliale.com/umf/emp
Guide de l’examen médical périodique – révision janvier 2010 | 61
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ANNEXE 3
Suggestion de feuilles sommaires
Ces feuilles sont disponibles sur notre site :
http://medecinefamiliale.com/umf/emp
Guide de l’examen médical périodique – révision janvier 2010 | 63
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ANNEXE 4
Critères pour les recommandations des divers
groupes
Guide de l’examen médical périodique – révision janvier 2010 | 65
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Recommandations des différents groupes
CTFPHC
(Canadian Task force on preventive health care)
Grade A:
good evidence to recommend the clinical preventive action.
Grade B:
fair evidence to recommend the clinical preventive action.
Grade C:
the existing evidence is conflicting and does not allow making a
recommendation for or against use of the clinical preventive action, however other factors may
influence decision-making
Grade D:
fair evidence to recommend against the clinical preventive action.
Grade E:
good evidence to recommend against the clinical preventive action.
Grade I:
insufficient evidence (in quantity and/or quality) to make a recommendation,
however other factors may influence decision-making
I: Evidence from randomized controlled trial(s)
II-1: Evidence from controlled trial(s) without randomization
II-2: Evidence from cohort or case-control analytic studies, preferably from more than one
centre or research group
II-3: Evidence from comparisons between times or places with or without the intervention;
dramatic results in uncontrolled experiments could be included here
III: Opinions of respected authorities, based on clinical experience; descriptive studies or
reports of expert committees
USPSTF
(US preventive services task force)
A.— The USPSTF strongly recommends that clinicians 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.
B.— The USPSTF recommends that clinicians provide [this service] to eligible patients. The
USPSTF found at least fair evidence that [the service] improves important health outcomes and
concludes that benefits outweigh harms.
C.— The USPSTF makes no recommendation for or against routine provision of [the service].
The USPSTF found at least fair evidence that [the service] can improve health outcomes but
concludes that the balance of benefits and harms is too close to justify a general recommendation.
D.— The USPSTF recommends against routinely providing [the service] to asymptomatic
patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms
outweigh benefits.
I.— The USPSTF concludes that the evidence is insufficient to recommend for or against
routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor
quality, or conflicting and the balance of benefits and harms cannot be determined
Guide de l’examen médical périodique – révision janvier 2010 | 67
American diabetes association
A Clear evidence from well-conducted, generalizable, randomized controlled trials that are
adequately powered, including:

Evidence from a well-conducted multicenter trial

Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling nonexperimental evidence, i.e., "all or none" rule developed by the Centre for
Evidence-Based Medicine at Oxford
Supportive evidence from well-conducted randomized controlled trials that are adequately
powered, including:

Evidence from a well-conducted trial at one or more institutions

Evidence from a meta-analysis that incorporated quality ratings in the analysis
B Supportive evidence from well-conducted cohort studies, including:

Evidence from a well-conducted prospective cohort study or registry

Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C Supportive evidence from poorly controlled or uncontrolled studies, including:

Evidence from randomized clinical trials with one or more major or three or more
minor methodological flaws that could invalidate the results

Evidence from observational studies with high potential for bias (such as case series
with comparison with historical controls)

Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience
Association canadienne du diabète et La société de l’ostéoporose du Canada
Catégorie A: Les meilleures données probantes étaient de niveau 1
Catégorie B : Les meilleures données probantes étaient de niveau 2
Catégorie C : Les meilleures données probantes étaient de niveau 3
Catégorie D : Les meilleures données probantes étaient de niveau 4 ou il y a eu consensus
Pour le diagnostic
Niveau 1 : études répondent à 5 critères prédéfinis sur 5
Niveau 2 : études répondent à 4 critères
Niveau 3 : études répondent à 3 critères
Niveau 4 : études répondent à 1 ou 2 critères
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Recommandations des différents groupes
SOGC
Tableau 1 Critères d’évaluation des résultats et classification des recommandations
Niveaux des résultats* Catégories de recommandations†
I: Résultats obtenus dans le cadre d’au moins un essai comparatif convenablement randomisé.
II-1: Résultats obtenus dans le cadre d’essais comparatifs non randomisés bien conçus.
II-2: Résultats obtenus dans le cadre d’études de cohortes (prospectives ou rétrospectives) ou
d’études analytiques cas-témoins bien conçues, réalisées de préférence dans plus d’un centre ou
par plus d’un groupe de recherche.
II-3: Résultats découlant de comparaisons entre différents moments ou différents lieux, ou selon
qu’on a ou non recours à une intervention. Des résultats de première importance obtenus dans le
cadre d’études non comparatives (par exemple, les résultats du traitement à la pénicilline, dans
les années 1940) pourraient en outre figurer dans cette catégorie.
III: Opinions exprimées par des sommités dans le domaine, fondées sur l’expérience clinique,
études descriptives ou rapports de comités d’experts.
A. On dispose de données suffisantes pour appuyer la recommandation selon laquelle il faudrait
s’intéresser expressément à cette affection dans le cadre d’un examen médical périodique.
B. On dispose de données acceptables pour appuyer la recommandation selon laquelle il faudrait
s’intéresser expressément à cette affection dans le cadre d’un examen médical périodique.
C. On dispose de données insuffisantes pour appuyer l’inclusion ou l’exclusion de cette affection
dans le cadre d’un examen médical périodique, mais les recommandations peuvent reposer sur
d’autres fondements.
D. On dispose de données acceptables pour appuyer la recommandation de ne pas s’intéresser à
cette affection dans le cadre d’un examen médical périodique.
E. On dispose de données suffisantes pour appuyer la recommandation de ne pas s’intéresser à
cette affection dans le cadre d’un examen médical périodique.
*La qualité des résultats signalés dans les présentes directives cliniques a été établie
conformément aux critères d’évaluation des résultats présentés dans le Rapport du groupe de
travail canadien sur l’examen médical périodique.
†Les recommandations que comprennent les présentes directives cliniques ont été classées
conformément à la méthode de classification décrite dans le Rapport du groupe de travail
canadien sur l’examen médical périodique.
Guide de l’examen médical périodique – révision janvier 2010 | 69
American geriatrics society
Class I: Evidence from At least one randomized controlled trial or meta-analysis of randomized
controlled trials.
Class II: Evidence from at least one controlled study without randomization or evidence or
evidence from at least one other type of quasi experimental study.
Class III: Evidence from non-experimental studies, such as comparative studies, correlation
studies and case-controlled studies.
Class IV: Evidence from expert committee reports or opinions and/or clinical experience of
respected authorities.
The strength of the recommendations is classified as follows:
A.
Directly based on Class I evidence.
B.
Directly based on Class II evidence or extrapolated recommendation from Class I
evidence.
C.
Directly based on Class III evidence or extrapolated recommendation from Class I or II
evidence.
D.
Directly based on Class IV evidence or extrapolated recommendation from Class I, II, or
III evidence.
AAFP: American Academy of Family Physicians
SR: Strongly Recommend: Good quality evidence exists which demonstrates substantial net
benefit over harm; the intervention is perceived to be cost effective and acceptable to nearly all
patients.
R:
Recommend: Although evidence exists which demonstrates net benefit, either the benefit
is only moderate in magnitude or the evidence supporting a substantial benefit is only fair. The
intervention is perceived to be cost effective and acceptable to most patients.
NR: No Recommendation Either For or Against: Either good or fair evidence exist of at least a
small net benefit. Cost-effectiveness may not be known or patients may be divided about
acceptability of the intervention.
RA:
Recommend Against: Good or fair evidence which demonstrates no net benefit over harm.
I : Insufficient Evidence to Recommend Either for or Against: No evidence of even fair quality
exists or the existing evidence is conflicting.
I-HB: Healthy Behavior is identified as desirable but the effectiveness of physician's advice and
counselling is uncertain.
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ANNEXE 5
SCORE
ORAI
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TABLEAU DU GUIDE DE DÉPISTAGE DES ITSS
Copié du guide québécois de dépistage des ITSS 2006
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