synposis of AFP's "Evaluation of Fever in Infants and Young Children"

This is a synposis of  Evaluation of Fever in Infants and Young Children

JENNIFER L. HAMILTON, MD, PhD, FAAFP, Drexel University College of Medicine, Philadelphia, Pennsylvania

SONY P. JOHN, MD, Chester County Hospital, West Chester, Pennsylvania

Am Fam Physician. 2013 Feb 15;87(4):254-260.

     A sick kid is always a big concern. With the progress of vaccinations, infections which were once common killers, such as S. pneumoniae and H. influenzae, are now rare. The two most common causes of fever in children under 3 years old these days are UTIs and pneumonia. It is important to remember that UTIs are more common in boys than girls at this age.
     The most accurate way to determine a fever in children under 3 is with a rectal temperature of at least 100.4'F (38'C). Other areas of measurement are not as reliable.  Physical exam is another important part of the diagnosis. Changes in the child's behavior, circulation, breathing, rash, seizures, skin elasticity, parental concerns, as well as the physician's own instinct are important factors in the assessment. Even if the child is afebrile when you check, and the mom says it was high at home, the patient still must treated as urgent.
     According to this article, the WBC and absolute neutrophil counts are something worth paying attention to. The test is important for patients less than a month old, but for those older, the usefulness is questionable. Bacteremia is not that common a cause of fever comparatively .  It is still recommended in current guidelines, thus it still should be done. Inflammatory markers, such as CRP and procalcitonin, have a better sensitivity and specificity than the WBC count, although the cost and availability may prohibit the usage.
     Lumbar puncture is a test that was once very common, but is now used less due to the effectiveness of vaccinations against meningitis. it is not recommended for patients older than 3 months unless there are also neurological signs. Some signs are nuchal rigidity and petechiae.
     Chest x ray is another test that should be considered if the patient is older than 1 month old, has a fever greater than 102.2'F, and a WBC count above 20,000 per mm3, (good thing you went ahead with the WBC count, huh). Respiratory signs wouldn't hurt either.
     Diarrhea would trigger a stool culture and fecal WBC count.
     Treatment depends a lot on antibiotic resistance patterns in the area. Neonates can be treated with ampicillin and gentamicin. A third generation cephalosporin can be substituted for ampicillin if E.coli resistance is a concern. If the patient is older than 1 month with urinary findings, Cefotaxime or cefixime may be used. If the patient is older than 3 months and pneumonia is suspected, you can try amoxicillin or azithromycin.
   

Choosing Wisely Link (Five Things Physicians and Patients Should Question

  Below is a link to all the "Five Things Physicians and Patients Should Question " from each society. I think there are 90 total. Have fun.

http://www.choosingwisely.org/doctor-patient-lists/

A Brief Synopsis of AFP's "Guillian-Barre Syndrome"

this is a brief synopsis of

Guillain-Barré Syndrome

ANNE D. WALLING, MD, ChB, and GRETCHEN DICKSON, MD, MBA, University of Kansas School of Medicine, Wichita, Kansas

Am Fam Physician. 2013 Feb 1;87(3):191-197.

     GBS is a very rare disease, and although most people recover completely,  up to 3% can die from it. The common clinical symptoms are symmetric ascending weakness, or absent reflexes. Complete areflexia has also been seen in GBS. Other less common, but very important symptoms are arrhythmia, orthostasis, blood pressure instability, cranial nerve involvement, urinary retention, or GI issues.
     Basically, GBS occurs about 3 weeks after a GI or respiratory illness. Common infections are from C. jejuni, M. pneumoniae, H. influenzae,  CMV, EBV, as well as triggering events like stress and surgeries. It occurs through cross-reactivity between the bacterial cell wall and gangliosides, which causes the antibodies to attack our nerves.
     The initial presentation is numbness, weakness, tingling, and pain in the limbs. It is symetrical. The symptoms peak within 2-4 weeks, followed by resolution, often spontaneously, with or withjout some residual diability.
     The CSF can be tested for increase protein levels with a normal WBC count. Electrodiagnostic studies can also be done to test for slowing of nerve conduction.
    Patients should be kept in the hospital during the disease process to monitor respiratory changes, which can precipitate the need for rapid intubation, tracheotomy and/or respiratory support if the ascending paralysis affects breathing. A swallowing eval should be ordered if patients present with cranial nerve dysfunction due to GBS. Other autonomic functions should be monitored as well, such as cardiac rhythm and blood pressure. Patients may need anticoagulation and compression stockings.  Pain is best controlled with gabapentin, or carbamazepine over opiods. PT and strength training has been helpful for patients to regain function and mobility.
     Plasma exchange has been shown to shorten the course of the disease, especially if given within 7 days. This is considered first line therapy. Patients may see benefit even  if treated up to 30 days after onset. IVIG has had similar success if given within 2 weeks, especially in non ambulatory patients. Giving patients both of these has not shown any benefit over monotherapy.

Get Your Girl a PAP SMEAR for Valentines Day!

    I guess it is just ironic that I was looking up pap smears today. It is very confusing to say the least. The 2001 Bethesda System explains what the acronyms mean, so i'm not going to get into it. So, after you get your pap smear, 3 things can happen; they can test the fluid for HPV, they can recommend a colposcopy  or they could  just schedule a repeat visit.  If the pap results are HSIL, LSIL, ASC-H (which just means "we can't rule out HSIL) or AIS, they are going to need a colposcopy regardless of the HPV results. If the pap comes back negative or ASC-US, then the HPV becomes important. If the pap is ASCUS and the HPV is positive, they get a colposcopy. If it is negative, the pap gets repeated in a year. If the pap is negative and the HPV is negative, the pap gets repeated in 3 years, if the HPV is positive, both the pap and HPV is repeated in 6 months to a year. And then the cycle continues....
     So what happens after the colposcopy  Well, if it comes back CIN 2 or 3, you send the patient for ablation and diagnostic excision. If it comes back AIS (high glandular lesion), the patient gets a hysterectomy. If the sample comes back CIN 1 , then it depends on what the pap originally was. If the pap was ASC-US, ASC-H, or LSIL, then the patient has cytology repeated at 6 and 12 months OR an HPV DNA at 12 months. If the pap was HSIL or AGC-NOS, then the patient gets a diagnostic excision, OR another colposcopy with cytology at 6 and 12 months. If the patient keeps going through this cycle with a positive CIN 1 for 2 years, then the patient can be referred for excision and ablation.
     Keep in mind that the rules are different in the pregnant and adolescent.

Resources

http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937807009337.pdf

http://www.asccp.org/Portals/9/docs/pdfs/Consensus%20Guidelines/algorithms_hist_07.pdf

http://www.aafp.org/afp/2009/0715/p147.html

http://www.aafp.org/afp/2003/1115/p1992.html

A Synopsis of AFP's Outpatient Diagnosis of Acute Chest Pain in Adults" by McConaghy and Oza

This is a quuick review of:

Outpatient Diagnosis of Acute Chest Pain in Adults

JOHN R. McCONAGHY, MD, CPE, and RUPAL S. OZA, MD, MPH, The Ohio State University, Columbus, Ohio

Am Fam Physician. 2013 Feb 1;87(3):177-182.

     According to this article, 1% of  outpatient office visits is for chest pain, and 1.5% of these patients will have angina or an MI.  The other will have diagnosis such as chest wall pain (20%), reflux (13%) and costrochondritis (13%). One of the most important jobs of a physician is to tweeze out the serious problems with the non urgent ones.
     The first thing you want to do is to determine of the pain is coronary ischemia(ACS) and to decide if the patient need to be referred for troponins, a stress test, or an angiogram. Important characteristics that should worry you are, if the patient is a male, over 60 years old, is diaphoretic, if the chest pain is pleuritic, sharp, stabbing, not reproducible by palpation, worse with exercise,radiating down one or both arms, a third heart sound, or a past medical history of angina/ known vascular disease. If a patient had several of these, then you should consider referring this patient. Patients may also use words like "discomfort, tightness, squeezing, or indigestion" instead of "pain".
     Patients who are over 40 and have comorbidities should also be considered.
     Any patient with chest pain should get an ECG. Typical red flags on ECG are ST changes, new onset left bundle branch blocks, Q waves, and T wave inversions.
     If you do not think the patient is having a life threatening condition, it is important to know the common signs and symptoms of the other diseases in the differential of chest pain.

Chest Wall Pain- localized pain, stinging pain, reproducible by palpation, and an absense of cough.
GERD- burning retrosternal pain, acid regurgitation, and a sour, bitter taste in the mouth.
Costochondritis- pain reproducible by palpation to the costochondral joints.
Panic/ Anxiety- can be determined through specialized questionnaires, or a past history of panic attacks
Pericarditis- pleuritic chest pain, friction rub, ST-T changes, PR depression, Pin worse with inspiration and better with leaning forward.

     Other less common diseases in the differential are  pneumonia, heart failure, PE (see well criteria) or aortic dissection.

A Blurb on B12 and Neurology

     Ok so real quick, pernicious anemia is due to a decrease production of intrinsic factor, decreased B12 absorption in the terminal ilium, or decreased dietary intake of B12. The symptoms are known as the "5 P's" (pancytopenia, peripheral neuropathy, posterior spinal column neuropathy, pyramidal tract signs, ans papillary (tongue) atrophy).  B12 has two functions in the body. First, is works with nucleic acid synthesis through the regeneration of tetrahydrofolate. What's even cooler is that it is also a co-factor of methylmalonyl COA mutase. This enzyme breaks down branched and odd carbon fatty acids. If this fatty acid breakdown does not occur, then the fat gets incorporated into the myelin sheets and causes neuropathy. That's why when you treat a patient with folate, the hematologic symptoms get resolved but not the neurological. Whatever, I thought that was cool.

Football Saved my Life! A Synopsis of "Hereditary Hemochromatosis" from American Family Physician

Hereditary Hemochromatosis

BRIAN K. CROWNOVER, MD, and CARLTON J. COVEY, MD, Nellis Family Medicine Residency, Nellis Air Force Base, Nevada

Am Fam Physician. 2013 Feb 1;87(3):183-190.

P.S I hope you enjoy my little football side note I heard on TV while waiting for the Super Bowl to start last year. 

     Hemochromatosis is the accumulation of iron in the body. This is due to an autosomal recessive disorder of the HFE gene, which regulates hepicidin through the C282Y protein  Normally, when there is too much iron in the body, the liver secretes hepicidin, which lowers iron absorption in the intestine and decreases iron release from macrophages. Only 10% of homozygous patients are symptomatic.
     The classic triad for the disease is cirrhosis, diabetes, and bronze skin. Common symptoms are weakness, lethargy, impotence, and arthralgia. These are very general features,  Once lab work is done, an abnormal liver function test should prompt an evaluation hemochromatosis if the hisotry and physical did not tip you off. A serum ferritin and transferrin saturation should be ordered. If the transferrin saturation is greater than 45% or the serum ferritin level is greater than 300 ng/mL in men or 200 ng/mL in women, further testing for the HFE gene should be done. At this point the patient may be referred to a gastroenterologist if the patient is heterozygous for the gene or if the ferritin level is greater than 1000 ng/mL.
     First line treatment for hemochromatosis is phlebotomy. Each donation of 500 ml whole blood removes 200-250 mg of iron and lowers serum ferritin by 30 ng/ml. (this reminds me of a story I heard about a Packers fan who would donate his blood every month, for decades,  to pay for his season tickets. He later found out he had hemochromatosis, so the Packers really saved his life!). Phlebotomy should be withheld if the hemoglobin is at or below 12.5 g/L. Most of the signs and symptoms should resolve from the treatment. Chelation therapy could be done as a second line treatment. Dietary restriction is not necessary and iron supplementation (as well as vitamin C) is not recommended.
     Iron avidity is a desire or craving of iron, which is a complication of phlebotomy, and due to overcorrection of the iron overload. According to the lab work, serum ferritin will be low/normal, and the transferrin saturation will be elevated. Oddly, this is treated with iron supplementation (when there was elevated transferrin saturation in hemochromatosis, we tried to reduce the iron, and now we supplement the iron with the same lab value?!?!) Iron avidity could be due to a GI bleed causing anemia, or the avidity may resolve spontaneously.
    If a patient is found to have hemochromatosis and cirrhosis, a screening ultrasound should be performed 1-2 times a year. If a lesion less than 1 cm is found, increase the screening to every 3 -6 months. If it is larger than 1 cm, refer to a gastroenterologist for CT and biopsy.