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American Family Physician Review of June 1 st and June 15 th editions

Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program. American Family Physician Review of June 1 st and June 15 th editions. AFP June 1 st , 2008 Topics. Unfractionated heparin vs LMWH for Rx of DVT – JAMA 2006 article Chronic Pelvic Pain in women

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American Family Physician Review of June 1 st and June 15 th editions

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  1. Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program American Family PhysicianReview of June 1st and June 15th editions

  2. AFP June 1st, 2008 Topics • Unfractionated heparin vs LMWH for Rx of DVT – JAMA 2006 article • Chronic Pelvic Pain in women • Immunization Update • Reducing Cancer Risk • Photo Quiz • Practice Guidelines

  3. Unfractionated Heparin • Is unfractionated heparin equivalent to LMWH for VTE? • Yes…in one study. • Something to watch over the next 1-2 years as we attempt to decrease the cost of health care in America. Kearon C, Ginsberg JS, Julian JA, et al., for the Fixed-Dose Heparin (FIDO) Investigators. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006;296(8):935-942.

  4. Chronic Pelvic Pain in Women • Definition – pain lasting > 6 months • 61% of women – no definitive diagnosis • Four most common Dx include’ • Endometriosis • Adhesions • IBS • Interstitial cystitis • Consider non-GYN sources as well

  5. Selected Differential Diagnoses of Chronic Pelvic Pain by Organ System System • Gastrointestinal • Celiac disease, colitis, colon cancer, inflammatory bowel disease, irritable bowel syndrome • Gynecologic • Adhesions, adenomyosis, adnexal cysts, chronic endometritis, dysmenorrhea, endometriosis, gynecologic malignancies, leiomyomata pelvic congestion syndrome, pelvic inflammatory disease • Musculoskeletal • Degenerative disk disease, fibromyalgia, levatorani syndrome, myofascial pain, peripartum pelvic pain syndrome, stress fractures • Psychiatric/neurologic • Abdominal epilepsy, abdominal migraines, depression, nerve entrapment, neurologic dysfunction, sleep disturbances, somatization • Urologic • Bladder malignancy, chronic urinary tract infection, interstitial cystitis, radiation cystitis, urolithiasis • Other • Familial Mediterranean fever, herpes zoster, porphyria

  6. Occam’s razor…perhaps • As many as 40% of women who present with chronic pelvic pain in primary care practices have more than one diagnosis William of Occam

  7. What women want…

  8. What women want from their physicians • To receive personalized care • To be taken seriously • To receive an explanation for their condition (more so than a cure) • To be reassured

  9. History, Physical Exam, and Diagnostic Testing

  10. History • Hematochezia • Gastrointestinal malignancy/bleeding • History of pelvic surgery, pelvic infections, or use of intrauterine device • Adhesions • Nonhormonal pain fluctuation • Adhesions, interstitial cystitis, irritable bowel syndrome, musculoskeletal causes • Pain fluctuates with menstrual cycle • Adenomyosis or endometriosis • Perimenopausal or postmenopausal irregular vaginal bleeding • Endometrial cancer • Postcoital bleeding • Cervical cancer or cervicitis (e.g., chlamydia or gonorrhea) • Unexplained weight loss • Systemic illness or malignancy

  11. Physical Examination • Lack of uterus mobility on bimanual examination • Endometriosis, pelvic adhesions • Nodularity or masses on abdominal, bimanual pelvic and/or rectal examination • Adenomyosis, endometriosis, hernias, malignancy, tumors • Pain on palpation of outer back and outer pelvis • Abdominal/pelvic wall source of pain, trigger points • Point tenderness of vagina, vulva, or bladder • Adhesions, endometriosis, nerve entrapment, trigger points, vulvarvestibulitis • Positive Carnett's sign • Myofascial or abdominal wall cause of pain

  12. Diagnostic Studies • Abnormal urinalysis or urine culture • Bladder malignancy, infection • Complete blood count abnormalities • Infection, systemic illness, or malignancy (elevated/decreased white blood cell count or anemia) • Elevated erythrocyte sedimentation rate • Infection, malignancy, systemic illness • Positive gonorrhea or chlamydia testing • Pelvic inflammatory disease • Transvaginal ultrasound abnormalities • Adenomyosis, endometriosis/endometrioma, malignancy

  13. Treatment • Combined oral contraceptives • Evidence supports use in patients with dysmenorrhea • No quality studies show benefit in patients with chronic pelvic pain • Oral medroxyprogesterone acetate (Provera), 50 mg daily • Only medication with evidence showing some benefit in most patients with chronic pelvic pain (excluding those with endometriosis, primary dysmenorrhea, chronic active pelvic inflammatory disease, and irritable bowel syndrome)4 • Depot medroxyprogesterone (Depo-Provera), 150 mg IM every three months • Studies only show benefit in patients with chronic pelvic pain related to endometriosis

  14. Treatment • NSAIDs • No studies show benefit specifically for treatment of chronic pelvic pain; recommendation from expert/consensus opinions only • GnRH agonists (i.e., goserelin [Zoladex]) • Goserelin effective for pelvic congestion and has longer duration of effect than medroxyprogesterone; monitor patient for bone density loss • Levonorgestrel intrauterine system (Mirena) • One study supports benefit in patients with chronic pelvic pain related to endometriosis • Danazol • Use for six months only; associated with a high incidence of side effects

  15. Other treatment options for CPP • Vitamin B1 and magnesium • Only proven effective in dysmenorrhea, not CPP • Neurontin (gabapentin) alone or in combination with Elavil(amitriptylline) • Provides relief of pain in one 2005 study • Surgery for LOA (lysis of adhesions) • Nerve blocks/nerve stimulation • Referral

  16. Update on Immunizations in Children and Adolescents • Influenza • Hepatitis A • Rotavirus • Varicella • Tdap • Menigococcus • HPV

  17. Influenza • http://www.aafp.org/afp/20080601/1561.html • Key points • Two vaccines currently available • Trivalent (inactivated) influenza vaccine (TIV; Fluzone) • Live, attenuated influenza vaccine (LAIV; Flumist)

  18. Fluzone (IM shot) for kids • Children ages 6 months to 18 years • Contraindications – allergy to eggs, active illness w/ or w/o fever, h/o Guillian-Barre • Dosing • 0.25 mL (6 – 36 months) • 0.5 mL (older than 3 years) • Give two doses between ages of 6 months and 8 years at first dose or if child did not receive two doses previously • At least 4 weeks between two doses • Give between October and March

  19. Flumist – inhaled flu vaccine • Children ages 2 – 18 years • Contraindications – same at Fluzone • In addition, do not give to any child with an active respiratory condition or altered immune status • Dosing – one half a vial in each nostril • Give two doses between ages of 2 and 8 years at first dose or if child did not receive two doses previously • At least 4 weeks between two doses • Give between October and March, possibly as early as July

  20. Flumist • Of note, Flumist is a live, attenuated vaccine. • Do not give it to immunocompromised patients or anyone regularly comes in contact with them. • Flumist is approved for patients 2 – 49 years of age.

  21. Hepatitis A • Immunize all children at 12 months (12 – 15 month WBC) and again 6 -12 months later. • Minimum of 6 months between doses. • Vaccinate all children, including those not previously vaccinated up to age 18 (or older if indicated).

  22. Rotavirus • Most common cause of gastroenteritis-related hospitalization. • Peaks in winter months. • Most severe symptoms in children 3 – 35 months of age. • In the first five years of life: • 4 out of five have symptoms • 1 in seven requires an ER visit • 1 in 70 requires hospitalization

  23. Rotavirus • Initial vaccine, Rotashield, associated with intussusception

  24. Rotavirus – key points • Start before 12 weeks of life (3 months) • Dosing – start between 6 and 12 weeks • 2 months • 4 months • 6 months • Series must be completed before 32 weeks of age • Minimum interval 4 weeks • Unnecessary to repeat if infant spits up dose • Contraindications – severe illness, previous intussusception, current gastroenteritis

  25. Varicella • Routinely give two doses • First at 12 months • Second at 4-6 years old • After one dose, 97% children 12 months to 12 years old are antibody seropositive. • After two doses, 99% children aged 13 and older are antibody seropositive.

  26. Varicella • Varivax – varicella by itself • Proquad – varicella with MMR • Of note, these are all four live-attenuated vaccines • For children younger than 13 years old who need a second booster, give it three months after the initial vaccination. • All adolescents 13 years old or older without prior evidence of varicella need the two shot series with the second dose 28 days or more after the first dose.

  27. Varicella • Contraindications • Pregnancy • Immunocompromised state

  28. Tdap • Effectiveness of DTaP = 95% (Antibody +) with diphtheria and tetanus. • Pertussis Ab(+) = 50-90% and wanes over time • Routinely immunize at 11-12 years old with Tdap x 1 dose, then Td every 10 years.

  29. Meningococcus • Case fatality rate is 9-12%, with 11-19% of survivors having serious sequelae. • At risk: • Functional or anatomic asplenia (Sickle cell pts) • Terminal complement deficiency • Military recruits • Travel to and residence in Sub-Saharan Africa • Microbiologists exposed to isolates, if the CDC happens to be in your town.

  30. Meningococcus • Current recommendation is to use Menactra/ MCV4 – one dose does the trick • Use in at risk children ages 2 – 10 years old • Use in all others aged 11 – 55 years old • At the 11 – 12 year old check, give MCV4. • Give MCV4 to unvaccinated children entering high school. • Give MCV4 to college freshmen living in dormitories and to military recruits.

  31. Human Papillomavirus • Given at ages 11 – 12 years old • Age range 9 – 26 years old • Three dose schedule • Initial dose • Two months – second dose • Six months – third dose • Most effective if given before the onset of sexual activity.

  32. Human Papillomavirus • Protects against HPV 6, 11, 16, and 18. • These cause 70% cervical cancer • And they cause 90% genital warts • Is almost 100% effective. • Can be given to women already infected with one HPV type in order to prevent other types.

  33. Immunization Summary • Vaccines work • Many parents have never seen a case of a vaccine-preventable illness. • Use this as a basis to start a discussion to encourage parents to get their children immunized. • Dr. Jeff Cooper example, ambulatory peds rotation.

  34. Lifestyle Interventions to Reduce Cancer Risk and Improve Outcomes • Maintain a healthy weight • Stay physically active throughout life • At least 30 minutes per day • At least five days per week • Consume a healthy diet • Plant-based high in fruits, vegetables, and whole grains – eat color • Low in saturated fats and red meat • Looks like a Mediterranean diet • Moderate alcohol consumption, if at all.

  35. Photo Quiz 54 year old diabetic woman presents with AMS. Had headache, sinus pain, and dental extraction 10 days ago. WBC = 28K, Glucose = 588, pH = 7.21 She develops proptosis, worsens, and eventually succumbs (dies). What is the diagnosis? • Bacterial orbital cellulitis. • Cavernous sinus thrombosis. • Central nervous system aspergillosis. • Ecthyma gangrenosum. • Rhinocerebral mucormycosis.

  36. Practice guidelines for LBP • They are there and provide a good review for what we do every day in clinic.

  37. AFP June 15th, 2008 Topics • Food allergies: Detection and Management • Disability Evaluation • GI issues with diabetes • VTE during pregnancy

  38. Food Allergies • Food allergies affect 4 – 5% of children and 2 – 3% of adults. • 70% of kids who have an egg allergy and 85% with milk allergy will outgrow it by 5 years of age. • Only 20% of children outgrow peanut allergy • Conversely, adults with food allergies remain allergic.

  39. Common Food Allergies Children • Egg • Milk • Soy • Wheat • Peanut Adults • Crustaceans • Tree nuts • Peanut • Fish

  40. Food allergies • Suspicion of food allergy begins with symptoms that are temporally related to food ingestion. • Consider taking a food diary. • Allergist referral indicated for: • H/o anaphylactic reaction • Need for skin-prick testing or food challenge testing • No improvement with primary care interventions

  41. Food allergies • Account for 30% of acute urticaria • Account for 3 – 4% chronic urticaria • About 35% of children with atopic dermatitis have a food allergy.

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