may 15 th 2009 issue l.
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MAY 15 th 2009 Issue. AAFP JOURNAL REVIEW. AAFP JOURNAL REVIEW. Resistant hypertension SIDS Latent TB infection High Quality Review articles. MCQ. 1. Which of the following is/are true with regard to high quality review articles?

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aafp journal review
  • Resistant hypertension
  • SIDS
  • Latent TB infection
  • High Quality Review articles

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  • C. Local studies and unpublished studies are included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
high quality review articles
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
high quality review articles7
High Quality review articles
  • use sources that use the SORT system
resistant hypertension
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 ”

difficult to control htn
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
measurement issues
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
adherence issues
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)
associated factors
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
causes of resistant htn
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)
truly drug resistent htn
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
secondary htn
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.
secondary htn18
Secondary HTN
  • OSA. Difficult to control HTN can be the only sign. Unexpectedly found in 83% of patients in 1 study of DTC-HTN
pharmocologic options
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

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.

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.

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.
sids definition
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.
  • 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
sids risk factors
SIDS Risk Factors

Infant factors

Maternal factors

Low socioeconomics


Illicit drug use

Poor prenatal care

Young age

Single parent


Crowded household

  • Low birth weight
  • Low apgar scores
  • Recent viral illness
  • Native American
  • African American
  • Male sex
sids prevention
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
  • 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)

sids research topics
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,
sids prevention counseling
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
deformational plagiocephaly
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
  • Some case control studies : lower SIDS rate among fully immunized.
  • Confounders: socioeconomic status? Other risk factors?
  • 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
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
alte risk factors
ALTE risk factors
  • H/O apnea, cyanosis, pallor
  • H/O feeding difficulties
  • Single parenthood
  • F/H of infant death
  • Maternal smoking in pregnancy
alte etiology
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
sids differential diagnosis
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
sids differential diagnosis42
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
sids support counseling
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 

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.

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.

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.
ltbi latent tb infection
LTBI – latent TB infection
  • DEFINITION: LTBI is a condition in which the person is infected with Mycobacterium tuberculosis, but does not currently have active tuberculosis disease.
ltbi tb epidemiology
LTBI / TB - Epidemiology
  • 1.7 -2 million deaths per year (2 million HIV deaths in 2007, diarrhea 10.6 million)
  • 2 billion worldwide infected (30%)
  • 10-15 million with LTBI in USA
  • 26.000 new cases of active TB in US in 1992
  • 13.000 new cases of active TB in US in 2007
  • 60% in foreign born
  • Progression to active disease 10% lifetime risk (2-23%).
  • TB in HIV: 10% annual risk of progression
epidemiology cdc fact sheet
Epidemiology (CDC fact sheet)
  • American Indians or Alaska Natives: 7.4 cases per 100,000 persons
  • Asians: 25.6 cases per 100,000 persons
  • Blacks: 10.2 cases per 100,000 persons
  • Native Hawaiians and other Pacific Islanders: 13.6 cases per 100,000 persons
  • Hispanics or Latinos: 9.2 cases per 100,000 persons
  • Whites: 1.2 cases per 100,000 persons
  • Foreign born 10x more likely than US-born
increased risk for ltbi
Increased risk for LTBI
  • < 18 yo in close contact w/ high risk adults
  • Residents/employees of healthcare/LTC facilities
  • Immigrants from high prevalence countries
  • High risk minorities, defined locally
  • Close contact with known or suspected case
  • Resident/employee at congregate living facility
  • Underserved, low income populations
increased risk of progression
Increased risk of progression
  • < 4 yo
  • HIV
  • infected with TB in past 2 yrs
  • illicit drug abuse
  • tobacco/etoh
  • H/O inadequately treated TB
  • long-term immunosuppressant medications
  • Wt 10% under ideal
  • ESRD
  • DM
  • gastrectomy, intestinal bypass
  • malignancy
  • silicosis
  • Screening means decision to treat
  • Useful if high risk for contracting Mycobacterium TB or high risk for progression from LTBI to active TB
  • TST (Mantoux), IGRA’s
  • Read TST in 48-72 hrs (unreliable after >72h)
tst technique
TST technique
  • 0.1ml intradermal injection = 5 tuberculin units
  • Initial 6-10mm wheal
  • Read in 48-72 hrs
  • Pt return>72hrs
  • = unreliable result
  • Measure induration in
  • transverse direction
tst reaction
TST reaction
  • Delayed Type Hypersensitivity (DHT)
  • Detectable 2-12wks after infection
  • Criteria for positive test depend on health status and risk factors
  • False neg rate 10-20% in proven TB infection

without immunocompromise

  • Anergy testing no longer recommended
2 step tst
2- step TST
  • booster phenomenon
  • reactivity after BCG &/or old TB infection wanes
  • 2-step testing at baseline for people who will be tested annually
  • initial TST negative
  • repeat TST within 1-3 weeks of a negative result
  • 2nd step shows baseline reactivity
  • W/O 2 step, next annual TST could wrongly suggest recent infection
  • 2 step TST not appropiate in contact investigation
criteria for positive tst 5mm
Criteria for positive TST ≥ 5mm
  • CXR s c/w previous TB
  • HIV infection
  • Organ transplant recipients
  • Immunosuppressant medications (incl prednisone > 15mg Qday)
  • Recent contact with active TB
criteria for positive tst 10mm
Criteria for positive TST ≥ 10mm
  • Children < 4yo
  • < 18 yo exposed to high risk adult
  • high risk minorities, defined locally
  • Immigrants, arrived from high prevalence country in past 5 yrs
  • Illicit drug use
  • Mycobacteriology personnel
  • Note: with annual testing, the increase of induration from baseline is what counts. Increase >10mm over 2 yrs means conversion
criteria for positive tst 10mm64
Criteria for positive TST ≥ 10mm

Patient condition



Nursing homes



Some medically inderserved low income populations

  • Wt 10% under ideal
  • DM
  • s/p gastrectomy, GI bypass
  • malignancy, silicosis
criteria for positive tst 15mm
Criteria for positive TST ≥ 15mm
  • Patients with no risk factors for tuberculosis
  • These populations should actually not be screened
  • High false positive rate
igra interferon release assay
IGRA – interferon--release-assay
  • positive test does not distinguish between BCG
  • T-lymphocyte response to MTB-specific antigens
  • These proteins are absent from BCG & other common mycobacteria
  • CDC 2005: Quantiferon –TB Gold can be used instead of TST



Not generally available

12h time limit blooddraw to lab

Determination of Sens/spec has not been completes

Risk stratified cut-offs lacking

  • Distinguishes MTB from BCG & other mycobacteria
  • Obviates 2 step testing
  • Cost/benefit favors IGRA over TST in health care, prisons, shelters


  • Both negative TST & IGRA don’t R/O TB infection
inh treatment
INH treatment
  • Adult tx w/ INH : at least 6, preferably 9 months
  • < 18 yo, HIV: 9 months
  • pregnant: 6-9 month course may be delayed till post partum, unless high risk of progression/ placental infection
inh side effects
INH side effects
  • Hepatotoxity
  • asymptomatic LFT elevation in 10-20%, D/C if LFT > 3x in symptomatic, > 5x in asympt.
  • Baseline LFTs if person at increased risk of liver disease (hepatitis, etoh, cirrhosis, HIV, pregnant up to 3 months postpartum)
  • F/U Q month, LFTs if signs or sx of liver dz

(N, V, jaundice, dark urine, abd pain)

  • Abstain from alcohol
inh side effects72
INH side effects
  • Peripheral neuropathy 2/2 pyridoxine metabolism intrerference
  • Pyridoxin 10-50mg Qday for pt with condition where neuropathy is common (DM, HIV, etoh, malnutrition)
inh contra indications interactions
INH contra indications/interactions
  • Contraindication: active hepatitis, ESLD
  • Phenytoin  increases serum concentration of both meds
  • 4 month treatment
  • if contact with INH resitant TB
  • In children not tolerating INH
  • Side effects: GI, skin rash, thrombocytopenia, orange urine/body fluids, contact lense discoloration
  • Interaction: increases metabolism of hepaticaly cleared drugs (eg. OCPs)
  • Interacts with HIV meds, Rifabutin is alternative
inh rifampin
INH + Rifampin
  • 3 month treatment: as effective with regard to preventing active Tb/mortality, no increased severe side effects
  • Rifampin + pyrazinamide no longer recommended for LTBI 2/2 severe side effects in people w/o HIV
ltbi regimens
LTBI regimens
  • Treatment completion based on total number of administered doses
  • Minor interruptions OKAY
  • Interruption> 2 months: start over & R/O development of active TB
  • No RCTs have assessed effectiveness of LTBI treatment after MDR-TB exposure. Risk/benefit of treatment unclear

4. Which one of the following is the treatment of choice for adults with latent tuberculosis infection?

  • A. Isoniazid (INH) plus rifampin (Rifadin) for one year.
  • B. INH for nine months.
  • C. Rifampin plus pyrazinamide for two months.
  • D. INH plus pyrazinamide for four months.

10. Routine screening for tuberculosis is recommended for which of the following groups of patients?

  • A. Persons with human immunodeficiency virus infection.
  • B. All immigrants to the United States.
  • C. Persons taking long-term immunosuppressant medications.
  • D. Children in close contact with high-risk adults.
latent tb
Latent TB

Increased LTBI risk


5. Which one of the following statements about preeclampsia is correct?

  • A. Anti-platelet medications are ineffective for prevention.
  • B. Calcium supplementation is beneficial for prevention.
  • C. Epidural analgesia is contraindicated in patients with severe preeclampsia.
  • D. Patients with preeclampsia have improved outcomes if put on bed rest in the hospital.

6. Based on recommendations from the U.S. Preventive Services Task Force (USPSTF), which of the following statements about iron deficiency anemia is/are correct?

  • A. Asymptomatic pregnant women should not be screened for iron deficiency anemia.
  • B. Iron deficiency anemia is more common than iron deficiency.
  • C. Hemoglobin measurement is a specific test for iron deficiency anemia.
  • D. There is no evidence that universal screening for iron deficiency anemia in asymptomatic children results in improved health outcomes.
  • E. The prevalence of iron deficiency anemia in the general U.S. population continues to increase.