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American Family Physician Journal Review February 1,2011 issue

American Family Physician Journal Review February 1,2011 issue. Samantha Brown-Parks, MD, MPH Assistant Professor, Department of Family & Preventive Medicine. Topics covered. Osteochondrosis : Common Causes of Pain in Growing Bones Alfred Atanda et al Recurrent Venous Thromboembolism

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American Family Physician Journal Review February 1,2011 issue

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  1. American Family PhysicianJournal ReviewFebruary 1,2011 issue Samantha Brown-Parks, MD, MPH Assistant Professor, Department of Family & Preventive Medicine

  2. Topics covered • Osteochondrosis: Common Causes of Pain in Growing Bones Alfred Atanda et al • Recurrent Venous Thromboembolism Nicholas Galioto et al • Treatment of Acute Migraine Headache Benjamin Gilmore et al

  3. Treatment of Acute Migraine Headaches:The Problem • Common but debilitating • 18% of US Women, 6% of US Men • Recurrent headaches with similar sx, 1/3 with aura

  4. Diagnosis • International Headache Society diagnostic criteria (Table 1) • Thorough H&P • Rule out other causes (Table 2) • POUND mnemonic • Pulsatile quality of Headache • One day duration (4-72 h) • Unilateral • Nausea (or vomiting) • Disabling intensity In Primary Care Setting: 4 or more= 92% probability 3/5= 64% 1-2/5=17%

  5.  IHS:Diagnostic Criteria for Migraine Headache With and Without Aura Migraine without aura Migraine with aura Recurrent disorder manifesting in headaches of reversible focal neurologic symptoms that usually develop gradually over five to 20 minutes and last for less than 60 minutes Headache with the features of migraine without aura usually follows the aura symptoms Less commonly, headache lacks migrainous features or is completely absent Diagnostic criteria: Aura consisting of at least one of the following, but no motor weakness: Fully reversible dysphasic speech disturbance Sensory symptoms that are fully reversible, including positive features (pins and needles) and/or negative features (numbness) Visual symptoms that are fully reversible, including positive features (flickering lights, spots, lines) and/or negative features (loss of vision) At least two of the following: Homonymous visual symptoms and/or unilateral sensory symptoms At least one aura symptom develops gradually over five minutes or different aura symptoms occur in succession over five minutes Each symptom lasts at least five minutes, but no longer than 60 minutes Headache fulfilling criteria for migraine without aura begins during the aura or within 60 min Not attributed to another disorder Hx of at least two attacks fulfilling above criteria Diagnostic criteria: Headache lasts four to 72 hours (untreated or unsuccessfully treated) Headache has at least two of the following: Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs) Moderate or severe pain intensityPulsating qualityUnilateral location During headache, at least one of the following: Nausea and/or vomitingPhotophobia and phonophobia Not attributed to another disorderHistory of at least five attacks fulfilling above criteria

  6. Differential Dx (see table 2) • Acute Glaucoma-blurred vision, N/V, halos • Subdural Hematoma-Antecedent trauma, Altered consciousness, neuro deficit • Severe HTN- BP elevation, confusion, irritable • Pseudotumor Cerebri- abrupt onset, N/V, dizziness, blurred vision, papilledema • CO poisoning- insidious, +/- dyspnea, common in colder months • Cluster headache- uncommon, sudden onset, min-hrs, unilat lacrimation, nasal congestion, severe unilat and periorbital pain, men>women, pt is restless • Encephalitis- neuro abnmlties, confusion, AMS • Frontal sinusitis- worse lying down, nasal congestion, tenderness over sinus • Intracranial neoplasm- worse on waking, progressive, aggravated by cough, strain • Med-induced headache- daily, hormone tx common, analgesic rebound • Meningitis- fever, meningeal signs • Tension HA- Common, lasts 30-7hr, bilateral, nonpulsating, mild to mod without limit on activity, no nausea/vomiting

  7. General Treatment Principles • No set algorithm only a general strategy • >50% treat with OTCs • OTC NSAIDs/combo analgesics +/- Caffeine first line for mild-mod or severe that have previously responded • Triptans first line for mod to severe or mild that have not responded to OTCs in past • Ergotamines may also be used in this group • Avoid Opiates and Barbituates

  8. First Line Therapies • NSAIDs OTC dose (200, 400 ibuprofen) good for short term relief 24h relief = placebo • Combination Analgesics Acet/ASA/Caff (excedrin) Effective, cheap, OTC Similar to 50mg of Imitrex • Triptans Migraine specific Binds serotonergic sites 7 diff meds available None preferred over others Different rxns with diff pts Increase mg- increased relief Vasoconstrictive- not for Ischemic Heart Disease, stroke, uncontrolled HTN Contraindicated in MAOis Caution with SSRIs Can be combined with NSAIDs

  9. Other Effective Therapies • Antiemetics IV Reglan in EDs /Alternative to Opiates Possible benefit other than antinausea effects • Dexamethasone IV adjunct in EDs added to standard Tx to decrease recurrence • Isometheptene combo Midrin- sympathomimetic + muscle relaxant = LD triptan • Intranasal Lidocaine- rapid, but short acting • Ergotamines Migraine specific- 5HT site Lots of side effects with oral form Improved when combined with caffeine (Cafergot) Nasal slightly less effective than sumitriptan, but better tolerated Given in ED IV with antiemetics In general inferior to Triptans

  10. Special Populations • Pregnancy • Acetominophen, NSAIDs (until 3rd Trimester), limited caffeine • Avoid Triptans, ergotamines • Metoclopromide + Opiates if severe • Menstrual • Long acting Triptans in days before menses • Abortive Tx with sumatriptan, rizatriptan, Mefenamic acid (Ponstel) • Children • Limited info • Nasal triptans effective, not FDA approved • NSAIDs and Acetominophen safe

  11. Clinical Recommendations • Triptans are effective and safe for treatment of acute migraine. A • Abortive therapy should be used as early as possible in the course of a migraine. B • Combination analgesics containing aspirin, caffeine, and acetaminophen are an effective first-line abortive treatment for migraine. A • Ibuprofen at standard doses is effective for acute migraine treatment. A • Intravenous metoclopramide (Reglan) is effective for acute migraine treatment. B • Parenteral dexamethasone is useful as an adjunctive treatment in the emergency department to help prevent short-term headache recurrence. A • Opiates and barbiturate-containing compounds should not be routinely used for abortive treatment of migraine. C A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

  12. Recurrent Venous Thromboembolism

  13. VTEs • Annual incidence 1-2:1000 • Recurrent Thrombosis common • Idiopathic 1st VTE more likely to recur • Provoked VTEs do not require workup

  14. Risk Factors for VTE

  15. Compared Risk of Recurrence

  16. Risk factors suggesting Thrombophilia • Age younger than 50 years at onset of first thrombosis • Atypical site of thrombosis (e.g., hepatic, mesenteric, or cerebral veins) • History of thrombosis • No identifiable provoking risk factors • Positive family history for venous thromboembolism • Recurrent pregnancy loss • Repeated pregnancies with evidence of intrauterine growth retardation

  17. Testing for Thrombophilias • No consensus on who should be tested • Questions of cost-effectiveness in idiopathic VTEs? • Routine testing not shown to predict recurrence, duration of treatment, or need for long term prophylaxis • ACCP guidelines focus on location of VTE rather than testing for underlying abnormality

  18. Other lab tests for VTE Patients

  19. Other Testing • VTE at atypical sites should be evaluated for hematologic disorders and malignancy • Hepatic, mesenteric, cerebral veins • Arterial thrombi • D-dimer values • Elevated 1 mo after stopping anticoagulant tx associated with increased risk of recurrence • At 3 mo: 3.5% (neg)vs. 8.9% (elevated) • Functional Assay testing should be postponed until 3-4 wks after stopping anticoagulant tx

  20. Evaluation of Malignancy • VTE may be the first manifestation of CA • 10% of unprovoked VTEs dx’d CA within 1 yr • Most common with VTE: • Pancreatic, lung, GI • Limited vs. Extensive Screening? • 50% with limited, 67% with extensive • Cost Effective? • Improve survival?

  21. Duration of Therapy • ACCP guides NOT to test for thrombophilia to direct therapy • Based on location of initial clot, recurrence?, and presence of transient risk factors.

  22. SORT Key Recommendations

  23. Osteochondrosis: Common Causes of Pain in Growing Bones Alfred Atanda, Jr , et al.

  24. Osteochondrosis • A group of disorders affecting growing bones • From abnormal growth, injury or overuse • Only in immature skeleton. • boys> girls, ages 10-14 • Pain/disability • Hip • Knee • Foot • Elbow • Back

  25. Osteochondrosis vs. Osteochondritis Osteochondrosis Osteochondritis dissecans Inflammatory condition of bone/cartilage in mature and immature skeletons Activity-related pain Joint catching, locking May or may not resolve with nonoperative treatment • Inflammation due to abnl growth, trauma, overuse of IMMATURE skeletons • Activity-related pain • No locking of joints • Resolves when growth plates close

  26. Hip Pain Legg-Calve-Perthes disease • Partial interruption of blood supply to immature femoral head joint deformity • 4-8yo, boys 4-5x>girls • Low birth wt, low SES, high birth order • Hip painreferred to knee atraumatic limp • PE: limited hip abduction, internal rotation, leg-length discrepancies • A-P and Frog-leg views: fragmentation, flattening, and sclerosis of proximal femur growth center with joint space widening • Early tx- better prognosis • Worse with age >6, extent of deformity, ROM • No change in outcome with PT, bracing in age <6 yo. • Surgery= reconstruction of hip conguity

  27. Knee Pain Osgood-Schlatter Disease Sinding-Larsen-Johansson Anterior pain from inferior pole of patella 10-13yo, often in athletics Worsening by jumping and direct pressure over inferior pole of patella Point tenderness over inf pole Clinical Dx, xray to r/o fx and see soft tissue swelling and calcification of an avulsed portion of patella Self-limited, NSAIDs, Tylenol, decrease activity, stretching • Anterior knee pain from repetitive traction of patellar tendon on tibial tubercle or apophysis • 10-14 yo, 30% bilat • 50% pts- regular atheletics • Worsening by jumping and direct pressure (kneel) • Mod TTP, swelling over tibial tubercle • Clinical DX, Xray to r/o fx and see soft tissue swell and fragmentation of tibial tubercle • Self-limited, NSAIDs, Tylenol, decrease activity, stretching

  28. Foot Pain Sever Disease • Calcanealapophysitis from Achilles tendon forces • In Young athletes/ Soccer • Worse in beginning of season, during a growth spurt • Wt-bearing and shoes (cleats) aggravate sx • Point tenderness at Achilles insertion, tight heel cords, and heel pain with medial-lateral compression • Xray- normal

  29. Foot Pain, cont’d Freiberg Disease Kohler Bone Disease Mid-foot pain and limp from navicular bone sclerosis 2-8 yo boys>girls Point tenderness over navicular bones +/- mild swelling and warmth over dorsal midfoot Clinical diagnosis, xray may demonstrate navicular sclerosis, flattening, and fragmentation Self-limited, short cast may accelerate resolution • Pain in forefoot typically characterized by disordered ossification of 2nd metatarsal head • Adolescent girls in Ballet and dance, bilateral <10% • Worse with wt-bearing, athletics • Point tender and swelling over affected head • Xray- sclerosis and flattening of articular surface • Tx- activity modification, metatarsal pads, padded shoes

  30. Elbow Pain Medial EpicondyleApophysitis Panner Disease Abnl ossification, necrosis, and degeneration of the capitellum Most common cause of lateral elbow pain in <10 yo +/- Athletics Vague pain without point tenderness Xray- frag and fissuring of entire distal humeral ossification center (capitellum) Self-limited Tx with rest, NSAIDs, Tylenol • Repetitive stress at medial epicondyle growth plate in throwing athletes • Localized pain over Medial Epicondyle- mild TTP early, severe if avulsion • Must examine shoulder to r/o pathology • Xray may show fragmentation • Prevention is Best (pitch limits, no curve, no sliders) • Tx with ice, rest, NSAIDs & surgery reserved for avulsion fx

  31. Back Pain Scheuermann Disease • Common Back Pain with rigid kyphosis or humpback deformity • Caused by disturbance of vertebral end plates  anterior vertebral body wedging during growth spurt • 10-12 yo onset, unknown etiology • PE: rigid humpback that does not correct with back extension (“postural roundback” corrects), nerve compression rare • Xray: >5* wedging in 3 adjacent vertebrae (with possible disk space narrowing, end plate irregularity, and scoliosis) • Progression not severe after maturity. Bracing for immature skeletons with increasing curve. • Surgery for mature spines with curve > 75*, pain, rigid deformity and unacceptable appearance

  32. When to Refer? • Refer to Ortho only if non-operative therapies have failed • Mature skeletons and disabling sx refer • Osgood-Schlatter • Sinding –Larsen-Johannson • Freiberg and PannerDz with loose fragments • Kohler, Panner or Med EpicondyleApophysisitis with recent trauma, continued pain  refer to r/o occult fracture • Any pt with Legg-Calve-Perthes or ScheuermannDz

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