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may 15 th 2009 issue n.
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  1. MAY 15th 2009 Issue AAFP JOURNAL REVIEW

  2. AAFP JOURNAL REVIEW • Resistant hypertension • SIDS • Latent TB infection • High Quality Review articles

  3. MCQ 1. Which of the following is/are true with regard to high quality review articles? • A. The review may have included German and Chinese language articles • B. Usually authored by renowned experts in the field • C. Local studies and unpublished studies are included • D. Review articles with an evidence table listing recommendations are best

  4. High Quality Review articles • Validity of the research design leads to the level of evidence assignment • Relevance of the study with regard to patient oriented outcomes determines strength of recommendation • Beware of Experts. Increasing expertise of the author is correlated with lower methodologic quality of the review

  5. High Quality Review articles

  6. High Quality review articles

  7. High Quality review articles • CONCLUSION: • use sources that use the SORT system

  8. Resistant Hypertension • DEFINITION: BP not at target despite adherence to 3 or more optimally dosed medications of different classes, incl. diuretic. • 65million Americans have HTN • 40million BP not at target • Prevalence of true resistant HTN unclear • “Resistant HTN” is subset of “difficult-to-control HTN ”

  9. Difficult to Control HTN • Most common cause: suboptimal treatment • Patient factors: non-adherence • Physician factors: inertia; acceptance above goal; not knowing “true” BP • Assess adherence to TLC and medications • R/O white coat HTN (home BP, consider confirmation with 24h ambulatory BP) • Average 24h BP > 130/80, or average daytime>135/85 → intensify therapy

  10. Resistant HTN

  11. Resistant HTN

  12. Measurement issues • Cuff too small • Severe arteriosclerosis : pseudo-HTN • Suspect pseudo HTN if: • radial pulse palpable with cuff fully inflated, • dizziness/weakness in elderly following anti-HTN meds

  13. Adherence issues • DASH + low Na, equally effective as 1 drug • Importance of weight loss • Daily aerobic exercise • Moderate etoh • Non judgmental inquiry into drug adherence • Factors: economic, health literacy, language, side-effects • Fixed dose combination/once daily may improve adherence (but beware of ↑ cost) • Simplest regimen: diuretic/Ace-combo + a 3rd once-daily agent (eg long-acting CCB)

  14. Associated factors • Isolated systolic HTN in elderly: it is OKAY to lower diastolic to 70mmHg • Octogenarian on anti-HTN meds have reduced morbidity and mortality • Obesity:  Na/fluid retention, RAAS-stimulation • Obesity treatment: - 1kg Wt reduction = 1-2.4mmHg BP - diet, orlistat, bariatric surgery • Reduce etoh intake

  15. Causes of Resistant HTN • CKD • OSA • Hyperaldosteronism • Common factor in the above: fluid retention • Obesity • Etoh • High dietary sodium • Interfering drugs, eg NSAIDS (incl COX2), OCP, bupropion, sudafed, cocaine, appetite suppressants, amphetamines, herbals(Ginseng)

  16. Truly Drug-Resistent HTN • Volume overload (eg CKD, ↑ NA-intake, obesity, OSA, hyperaldosteronism) • Ensure adequate diuretic therapy (chlorthalidone rather than HCTZ) • If cr >1.5-1.8, or GFR<30 switch to loop diuretic • Give short acting loop diuretic BID

  17. Secondary HTN • CKD. Na-restriction!, Diuretic, ACE/ARB Check K, cr 2 wks after start of ACE/ARB 30% rise in cr, K up to 5.5 are acceptable • Hyperaldosteronism. 20% of referred patients. K can be normal. AM aldosterone/renin ratio < 20 rules out. Ratio>20 or aldosterone>15 → refer to endocrinology or HTN specialist. • Primary hyperaldosteronism– treat with spironolactone, eplerenone(Inspra) or amiloride(Midamor). Monitor cr., K.

  18. Secondary HTN • OSA. Difficult to control HTN can be the only sign. Unexpectedly found in 83% of patients in 1 study of DTC-HTN

  19. Pharmocologic options • Spironolactone (up to 20/10mmHg reduction) • α- blocker(terazosin) • α/β blocker(labetalol, carvedilol) • Clonidine, reserpine or hydralazine • Combine a non-dihydropyridine + dihydropyridine CCB • Minoxidil • Avoid ACE/ARB combo → improves proteinuria, but worsens major renal outcomes

  20. Resistant HTN

  21. Resistant HTN

  22. Resistant HTN

  23. Resistant HTN

  24. Resistant HTN

  25. MCQ 1. Which one of the following is a cause of truly drug-resistant hypertension? • A. Volume overload. • B. Physician inertia in prescribing. • C. Costly or complex medication regimens. • D. Pseudohypertension.

  26. MCQ 7. Which of the following is/are causes of apparently difficult-to-control hypertension? (check all that apply) • A. Nonadherence to therapy. • B. Obstructive sleep apnea. • C. White-coat hypertension. • D. Severe arteriosclerosis.

  27. MCQ 8. Which of the following is/are treatment options for drug-resistant hypertension? • A. Optimizing diuretic dose and adding spironolactone (Aldactone). • B. Assessing for and treating obstructive sleep apnea. • C. Giving both an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker. • D. Adding a combined alpha-beta blocker.

  28. SIDS Definition • DEFINITION (1991): sudden death of an infant < 1yo, that remains unexplained after thorough case investigation, including complete autopsy, death scene examination and clinical history review.

  29. SIDS • Leading cause of death under healthy infants • 0.57/1000, 2200/year • Modifiable RFs: sleeping position, cigarette smoke exposure • ALTE does NOT increase risk of SIDS • Home apnea monitoring does NOT reduce SIDS

  30. SIDS Risk Factors Infant factors Maternal factors Low socioeconomics Smoking Illicit drug use Poor prenatal care Young age Single parent Unemployed Crowded household • Low birth weight • Low apgar scores • Recent viral illness • Native American • African American • Male sex

  31. SIDS prevention • Back to Sleep → decreased SIDS cases, but prone sleeping remains presumptive cause. • AA babies more often placed in prone position • Firm mattress • Avoid soft objects, loose bedding • Avoid overheating • Pacifier . Wait till >1month old for breastfed babies

  32. Pathophysiology • 3 common autopsy findings: unclotted blood in heart, intrathoracicpetechiae, fluid filled heavier organs • “Apnea theory” discredited • “Triple-risk model”: + underlying vulnerability (unidentified) + exogenous stress (eg prone sleeping) + critical developmental period (< 1yo)

  33. SIDS research topics • Ion channel abnormalities causing QT prolongation. 5-10% of SIDS cases? • Autonomic nervous system disturbance 2/2 gene mutations. Arousal mechanism defects. 15% of cases? • Pre- & postnatal nicotine effects on developing brain. Nicotine metabolizing gene defects? Exposure a/w SIDS, prematurity, autonomic dysfunction, LBW, spontaneous abortion,

  34. SIDS prevention/counseling • 92% of cases in prone sleeping, bed sharing, sleeping in other location than crib • Back to Sleep campaign  50-70% reduction • Bedsharing – discouraged by AAP 2005 • Bedsharing (50% of cases) – increased risk in LBW infant, smoking, etoh, drugs. • Bedsharing > 4 months old: no  risk • Infant never to sleep with other children, with adult on couch or armchair • Infant to sleep in separate crib near mom’s bed

  35. Deformational plagiocephaly • Flattening of the occiput • 50% of supine sleepers • Give supervised “tummy time” • Alternate rotation during sleep times • Do not use car seat unless in car • Minimize devices with pressure to back of head (swing, bouncy seat) • If DP present: do not sleep on flat side, PT if torticollis, NEU-surgeval PRN in no improvement with head positioning s

  36. Immunizations • Some case control studies : lower SIDS rate among fully immunized. • Confounders: socioeconomic status? Other risk factors?

  37. Apnea • No  risk of SIDS • Home apnea monitor  no  risk of SIDS • Pacifier at bedtime  does  risk of SIDS (AAP 2005) • Delay pacifier to 1 month of age for breastfed babies

  38. ALTE-s • Apparent Life Threatening Event • s in skin color (cyanosis, pallor, erythema) s in muscle tone & choking or gasping • 1:400 infants • “ near-miss-SIDS” - incorrect term • SIDS campaign has not reduced ALTE incidence • common RF for SIDS & ALTE: prenatal smoking, single parenthood

  39. ALTE risk factors • H/O apnea, cyanosis, pallor • H/O feeding difficulties • Single parenthood • F/H of infant death • Maternal smoking in pregnancy

  40. ALTE etiology • Etiology determined in 50% • Diagnosis by H&P • Potentially useful tests: reflux testing, UA, Neu imaging, CXR, WBC • GI/ GERD most common • Respiratory infections • Minority of cases: valvular disease, arrhythmia, cardiomyopathy • Rare: NEU cause: tumor, structural brain abnormailities, Sz D/O • Recurrent ALTEs- high incidence of Munchausen by proxy

  41. SIDS differential diagnosis • Infection, electrolyte abnormalities, inborn errors of metabolism, abuse • Investigation: death scene evaluation – infant’s position, bedding, bed, body temp, room temp, rigor?, type of heating/cooling, caregiver response • Intentional suffocation estimated 1-5% of cases

  42. SIDS differential diagnosis • Suspicion of intentional suffocation if lone caretaker, infant death > 6 months, unexplained death of siblings, simultaneous death of twins, previous death of child under care of same person

  43. SIDS support & counseling • Empathy/compassion • Support through process of death investigation • Guide through ending lactation, funeral planning • Grief counseling • SIDS support groups • Risk of future children dying from SIDS not 

  44. SIDS

  45. SIDS

  46. SIDS

  47. SIDS

  48. MCQ 3. The parents of a newborn ask about risks associated with their infant sleeping in bed with them. Which one of the following statements is correct? (check one) • A. Infants who bed share with smokers have about the same risk of sudden infant death syndrome (SIDS) as infants who bed share with nonsmokers. • B. The risk of SIDS is not increased in a low–birth-weight infant who bed shares. • C. The American Academy of Pediatrics recommends against bed sharing. • D. Infants older than four months who bed share appear to be at greater risk of SIDS than younger infants.

  49. MCQ 2. A two-month-old boy is rushed to the emergency department because he briefly turned pale, choked, and went limp. Which one of the following evaluations is most likely to lead to a diagnosis? (check one) • A. History and physical examination. • B. Testing for gastroesophageal reflux. • C. Neuroimaging. • D. Urinalysis.

  50. MCQ 9. Which of the following practices is/are or may be protective against sudden infant death syndrome? • A. Keeping immunizations up-to-date. • B. Pacifier use. • C. Ante-partum smoking cessation. • D. Postpartum smoking cessation.