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AAFP: Review January 15, 2011 Emory Family Medicine

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Title: AAFP: Review January 15, 2011 Emory Family Medicine


1
AAFP Review January 15, 2011
Emory Family Medicine
  • Susan Schayes M.D., M.P.H.
  • Assistant Professor-CT
  • Family Medicine, Emory University School of
    Medicine

2
Learning objectives
  • Review January 15, 2011AAFP highlights
  • RSV infection in Children
  • Cat-scratch Disease
  • Evaluation and Management of Intestinal
    Obstruction
  • Special Nutrition Support

3
Respiratory Syncytial Virus infection in Children
  • RSV peak Nov-April
  • Cough, coryza, wheezing
  • Treatment is supportive with maintaining
    hydration and oxygenation
  • Bronchodilator trial is ok
  • For wheezing, but should
  • Have prompt response.
  • Children at high risk may have
  • Palivizumab prophylaxis

4
Respiratory Syncytial Virus infection in Children
  • RSV causes resp tract infections in
    children-bronchiolitis is the most common lower
    resp tract infection in children under 2.
  • RSV enveloped, nonsegmented, dble stranded RNA
    virus- subtype A B
  • Incubation 2-8 days
  • Shedding 3-8 days-but
  • Can continue for up to 4 wks

5
RSV clinical manifestations
  • Vary depending on the patients age and previous
    health status
  • Infants and young children with a primary
    infection usually present with LRI such as
    bronchiolitis or pneumonia- cough 98, fever 75,
    rhinorrhea, wheezing 65-78, labored respirations
  • 73-95
  • Severe disease- grunting, nasal flaring,
  • intercostal retractions

6
Risk factors for Severe RSV
  • Chronic Lung disease eg bpd
  • Current weight less than 11 lbs
  • Cyanotic congenital HD
  • Immune compromise
  • IU exposure to tobacco smoke
  • Low socio-economic status
  • Neuromuscular disease
  • Premature birth before 35 wks

7
Respiratory Syncytial Virus infection in Children
8
Candidates for Palivizumab (Synagis)
  • Infants eligible for a maximum of 5 doses
  • Infants with chronic lung disease, younger than
    24 months, who require medical therapy (i.e.,
    supplemental oxygen, bronchodilator or diuretic
    use, or corticosteroid use within the past six
    months)
  • Infants with congenital heart disease, younger
    than 24 months, who require medical therapy
    (i.e., medication to control congestive heart
    failure, those with moderate to severe pulmonary
    hypertension, or infants with cyanotic disease)
  • Premature infants born at less than 31 weeks, six
    days of gestation
  • Certain infants with neuromuscular disease or
    congenital abnormalities of the airways
  • Infants eligible for a maximum of 3 doses
  • Premature infants with a gestational age of 32
    weeks, 0 days to 34 weeks, 6 days with one risk
    factor and born three months before or during RSV
    season

9
Clinical Recommnedation
  • SORT KEY RECOMMENDATIONS FOR PRACTICE
  • The diagnosis of an RSV infection is based on
    patient history and physical examination. C
  • Routine laboratory and radiologic studies should
    not be used in making the diagnosis of RSV
    infection. C
  • Routine use of bronchodilators is not recommended
    for the treatment of bronchiolitis, although they
    may be considered if there is a prompt favorable
    response to an initial treatment. B
  • Routine use of corticosteroids or ribavirin
    (Virazole) is not recommended in children with
    RSV. B
  • Hand decontamination is important in
    preventing the spread of RSV. Hands should be
    washed before and after contact with a patient or
    inanimate object in direct vicinity of the
    patient. B

10
Palivizumab (Synagis)
  • Primary benefit of prophylaxis is a reduced rate
    of RSV associated hospitalizations
  • No effect on mortality has been proven
  • The use of palivizumab (Synagis), a humanized
    murine monoclonal antibody directed against RSV,
    is indicated for select children in high-risk
    groups as a preventive measure against RSV
    infection.
  • Three groups of children qualify for
    immunization
  • (1) infants born before 35 weeks of gestation,
  • (2) infants with chronic lung disease, and
  • (3) infants born with hemodynamically significant
    congenital heart disease. Palivizumab is given in
    five monthly intramuscular injections (15 mg per
    kg) beginning usually on November 1. Fewer
    injections may be appropriate for some children,
    but never more than five

11
AAFP question
  • Respiratory Syncytial Virus Infection in Children
  • 1. Which one of the following statements about
    the use of palivizumab (Synagis) to prevent
    respiratory syncytial virus (RSV) infection is
    correct?  (check one)
  • A. It is recommended for infants born before 35
    weeks of gestation.
  • B. It has been shown to reduce mortality in
    vulnerable groups.
  • C. It is recommended for all infants born before
    38 weeks of gestation.
  • D. It is given as a single injection at one year
    of age.

12
AAFP questions
  • 2. Which one of the following statements about
    drug therapy for bronchiolitis caused by RSV
    infection is correct?  (check one)
  • A. Antibiotics are recommended for children
    hospitalized with severe RSV infection.
    B. Corticosteroids are recommended for most
    children with RSV to reduce inflammation and
    speed recovery. C. Ribavirin (Virazole) is
    recommended for immunocompetent and
    immunodeficient children. D. Antibiotics,
    corticosteroids, and ribavirin are not routinely
    recommended for children with RSV infection.

13
AAFP questions
  • 3. Which of the following are routinely
    recommended for children with RSV bronchiolitis?
     (check one)
  • A. Chest radiography.
  • B. White blood cell count.
  • C. Oxygen supplementation if oxygen saturation is
    less than 90 percent.
  • D. Rapid antigen testing.

14
.break
15
Cat Scratch Disease
  • http//youtu.be/EikujS53hvg

16
Cat-Scratch Disease
  • Common infection that presents as tender
    unilaterally lymphadenopathy
  • Asymptomatic, bacteremic cats with Bartonella
    henselae in their saliva serve as vectors by
    biting and clawing the skin
  • Causitive agent is difficult to culture
  • Diagnosis arrived by history and titers
  • greater than 1256 of IGG AB to Bartonella

17
Cat Scratch Disease
  • Bartonella is found in feline erythrocytes and
    fleas which contaminate the saliva
  • The cat flea Cternocephalides felis is the vector
    responsible for horizontal transmission
  • Tick bits can also transmit the bacterium to
    humans
  • 50 of cats harbor Bartonella

18
Cat Scratch Disease
  • After contact with an infected cat- develop a
    primary skin vesicle at innoculation site,
    regional lymphadenopathy develops 1-2 weeks later
    and is usually ipsilateral. These nodes are
    swollen, tender and may eventually suppurate.
  • 75 of patient develop aching, malaise, anorexia
  • 9 develop fever
  • In immunocompromised can develop
  • bacillary angiomatosis- red-purple papules

19
From cat scratch disease to endocarditis, the
possible natural history of Bartonella henselae
infection. BMC Infect Dis. 2007 7 30.
20
Cat Scratch Disease
  • SORT KEY RECOMMENDATIONS FOR PRACTICE Clinical
    recommendation Evidence rating References
    Cat-scratch disease should be included in the
    differential diagnosis in any patient with
    lymphadenopathy. C
  • The diagnosis of cat-scratch disease is usually
    confirmed by a history of cat exposure and
    antibodies to Bartonella henselae. C
  • Most cases of cat-scratch disease are
    self-limited and do not require antibiotic
    therapy. B
  • If an antibiotic is chosen to treat cat-scratch
    disease, azithromycin (Zithromax) appears to be
    effective at reducing the duration of
    lymphadenopathy. B

21
AAFP question
  • Cat-scratch Disease
  • 4. Which one of the following is the most common
    site for lymphadenopathy in patients with
    cat-scratch disease?  (check one)
  • A. Chest.
  • B. Upper extremity.
  • C. Groin.
  • D. Neck and jaw.

22
AAFP question
  • 5. Which one of the following is the best
    initial test for patients suspected of having
    cat-scratch disease?  (check one)
  • A. Culture.
  • B. Polymerase chain reaction.
  • C. Serology.
  • D. Lymph node biopsy

23
AAFP question
  • 6. Which of the following are complications
    of Bartonella henselae infection?
     (check all that apply)
  • A. Bacillary angiomatosis.
  • B. Bacillary peliosis.
  • C. Neuroretinitis.
  • D. Encephalopathy.

24
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25
Intestinal Obstruction
  • The most common causes of intestinal obstruction
    include adhesions, neoplasms, and herniation .
    Adhesions resulting from prior abdominal surgery
    are the predominant cause of small bowel
    obstruction, accounting for approximately 60 of
    cases.
  • Other causes of obstruction include
  • intestinal intussusception, volvulus,
  • intra-abdominal abscesses, gallstones,
  • foreign bodies.

26
Intestinal Obstruction
CAUSES OF INTESTINAL OBSTRUCTION

Adhesive disease (60 percent)
Neoplasm (20 percent)
Herniation (10 percent)
Inflammatory bowel disease (5 percent)
Intussusception (lt 5 percent)
Volvulus (lt 5 percent)
Other (lt 5 percent)
27
DDx of Abdominal pain, distension, nausea and
cessation of flatus and bowel movements
DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN,
DISTENSION, NAUSEA, AND CESSATION OF FLATUS AND
BOWEL MOVEMENTS
Alternate diagnosis Clues
Ascites Acute liver failure, history of hepatitis or alcoholism
Medications (e.g., tricyclic antidepressants, narcotics) Review of medications diagnosis of exclusion
Mesenteric ischemia History of peripheral vascular disease, hypercoagulable state, or postprandial abdominal angina recent use of vasopressors
Perforated viscus/intra-abdominal sepsis Fever, leukocytosis, acute abdomen, free air on imaging
Postoperative paralytic ileus Recent abdominal surgery with no postoperative flatus or bowel movement
Pseudo-obstruction (Ogilvie syndrome) Acutely dilated large intestine, history of intestinal dysmotility, diabetes mellitus, scleroderma

28
Intestinal Obstruction
29
Intestinal Obstruction
30
Intestinal Obstruction
  • Axial computed tomography scan showing dilated,
    contrast-filled loops of bowel on the patient's
    left (yellow arrows), with decompressed distal
    small bowel on the patient's right (red arrows).
    The cause of obstruction, an incarcerated
    umbilical hernia, can also be seen (green arrow),
    with proximally dilated bowel entering the hernia
    and decompressed bowel exiting the hernia

31
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32
Intestinal Obstruction
  • SORT KEY RECOMMENDATIONS FOR PRACTICE
  • Abdominal radiography is an effective initial
    examination in patients with suspected intestinal
    obstruction. C
  • ( Radiography has greater sensitivity in
    high-grade obstruction than in partial
    obstruction.)
  • Computed tomography is warranted when radiography
    indicates high-grade intestinal obstruction or is
    inconclusive. C
  • (Computed tomography can reliably determine
    the cause of obstruction, and whether serious
    complications are present, in most patients with
    high-grade obstructions.)
  • Upper gastrointestinal fluoroscopy with small
    bowel follow-through can determine the need for
    surgical intervention in patients with partial
    obstruction. C
  • Contrast material that passes into the cecum
    within four hours of oral administration is
    highly predictive of successful nonoperative
    management.

33
Intestinal Obstruction
  • SORT KEY RECOMMENDATIONS FOR PRACTICE
  • Antibiotics can protect against bacterial
    translocation and subsequent bacteremia in
    patients with intestinal obstruction. C
  • Clinically stable patients can be treated
    conservatively with bowel rest, intubation and
    decompression, and intravenous fluid
    resuscitation. C
  • Surgery is warranted in patients with intestinal
    obstruction that does not resolve within 48 hours
    after conservative therapy is initiated. C

34
AAFP question
  • Evaluation and Management of Intestinal
    Obstruction
  • 7. Which one of the following statements about
    proximal intestinal obstruction is correct?
     (check one)
  • A. Vomiting is a common early symptom.
    B. Abdominal distension is a prominent early
    symptom.
  • C. Most patients are asymptomatic.
  • D. Abdominal tympany is usually heard on
    examination.

35
AAFP question
  • 8. Which of the following statements about
    typical complications of intestinal obstruction
    are correct?  (check all that apply)
  • A. Patients with severe vomiting may develop
    metabolic alkalosis.
  • B. Antibiotics are recommended to treat
    intestinal overgrowth of bacteria and
    translocation across the bowel wall.
  • C. Oral hydration is recommended.
  • D. Intravenous hydration is recommended.

36
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37
Specialized Nutrition Support
  • In normal baseline nutrition- any condition that
    precludes food intake consider in adults 5-7
    days , 3-5 days in children, 1-3 days in infants
  • Precise indications for nutrition support
    controversial- Consensus impaired bowel
    function, severe protein-calorie malnutrition and
    a treatable disease, and those requiring
  • prolonged therapeutic bowel rest

38
Specialized Nutrition Support
  • In adults, the average nutritional requirement is
    25-35 kcal per kg per day
  • For children older than 5 years, the suggested
    requirement is 1500 kcal for the first 20 kg plus
    25 kcal for each additional kg per day

39
Special Nutritional Support
  • Enteral nutrition can be divided into two
    basic categories polymeric or elemental.
  • Disease specific
  • Immune modulated
  • Modular
  • Pulmonary
  • Renal

40
Complications of Enteral Nutrition
  • Aspiration pneumonia
  • Prevent elevate head of bed 30 degrees
  • Diarrhea
  • Metabolic complications- fluid and electrolyte
    complications, hyperglycemia, vit K deficiency,
    hypertonic dehydration

41
Complications of Enteral Nutrition
  • Complications related to feeding tube
  • -nasopharyngeal erosions, sinusitis, otitis
    media, gagging, esophagititis, GERD,
    tracheoesophageal fistulas, rupture of esophageal
    varices, knotting or kinking of feeding tubes,
    mechanical obstruction
  • Pericutaneous tubes can leak, cause local wound
    infections, dislodge to an interperitoneal
    position,
  • and cause occlusion

42
Specialized Nutrition Support
  • T

43
Subjective GlobalAssessment
44
Clinical Recommnedation
  • SORT KEY RECOMMENDATIONS FOR PRACTICE
  • Enteral nutrition is preferred over parenteral
    nutrition because it has been shown to be more
    cost-effective and may decrease the rate of
    infections. A
  • Specialized nutrition support is not obligatory
    at the end of life. Enteral nutrition is unlikely
    to be helpful in patients with advanced dementia,
    and may be harmful. C

45
Clinical Recommnedation
  • SORT KEY RECOMMENDATIONS FOR PRACTICE
  • Nutritional assessment should be based on the
    patient history and physical data, including
    weight loss and dietary intake before admission
    disease severity comorbid conditions and
    function of the gastrointestinal tract (e.g.,
    Subjective Global Assessment). Serum markers
    (e.g., albumin, prealbumin, retinol binding
    protein, transferrin) alone are not adequate. C
  • The decision to administer specialized nutrition
    support should consider the patient's preexisting
    nutritional status, the impact of the disease
    process on nutritional intake, and the likelihood
    that specialized nutrition support will improve
    patient outcome or quality of life. B

46
AAFP question
  • Specialized Nutrition Support
  • 9. Which one of the following patients would be a
    candidate for specialized nutrition support?
     (check one)
  • A. A 50-year-old man who is unable to eat four
    days after gallbladder surgery.
  • B. An infant who is unable to eat three days
    after surgery to repair an intussusception.
  • C. A 10-year-old child who is unable to eat two
    days after surgery for appendicitis.
  • D. A patient with low serum albumin levels and
    abnormal retinol binding protein levels, but who
    is able to eat some food

47
AAFP question
  • 10. Which one of the following statements about
    specialized nutrition support at the end of life
    is correct?  (check one)
  • A. Nutrition support is almost always needed at
    the end of life.
  • B. Enteral nutrition improves quality of life in
    older patients with dementia.
  • C. Nutrition support may be withheld based on
    patient preference.
  • D. Enteral and parenteral nutrition are well
    tolerated with a low risk of complications

48
AAFP question
  • 11. Which of the following statements about
    nutritional requirements are correct?
     (check all that apply)
  • A. Children and infants have lower protein
    requirements than adults.
  • B. In adults, 25 to 35 kcal per kg per day is
    typically required.
  • C. Linoleic acid supplementation is needed for
    infants and children receiving specialized
    nutrition support, but not for adults.
  • D. Patients with enteropathy or acute nephritic
    syndrome have higher protein requirements.

49
The End
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