AFP Journal Review

1. AFP Journal Review February 15, 2010 Issue Faiqa Mahmud PGY-2 Emory Family Medicine

2. Articles Reviewed • Primary Care for Children with Autism • Severe Asymptomatic Hypertension • Sexual Assault of Women • Hawthorn : Health Effects

3. Primary Care for Children with Autism

4. Autism Spectrum Disorders • ASDs are a group of developmental disabilities that can cause significant delay in social interaction, communication and behavioral challenges. ASDs begin before the age of 3 and last throughout a person's life, although symptoms may improve over time. • 3 subtypes of ASD are; 1. Autistic disorder 2. Pervasive developmental disorder PDD-NOS 3. Asperger’s syndrome AD and PDD- NOS collectively called Autism. Children's with Asperger syndrome have relatively normal expressive language and cognitive skills.

5. ASD prevalence is 6-7/1000 kids in US. • Steady increase by 57% between 2002-2006 • 4 times more common in boys • Diagnostic criteria is available for AD and AS. PDD is a sub threshold term for those who don’t meet criteria for either condition.

6. Etiology • Genetics: Incidence rate is 10 folds higher in autistic siblings. Increase concordance in monozygotic twins. • Environmental factors: Unclear role of pre and postnatal exposure. No association with thimerosal in vaccines.

7. Surveillance and Screening • Early treatment is beneficial so early diagnosis is critical. • Surveillance: Ask parents about behavioral or developmental concerns at every well child visit. • Observe for early signs of autism • Family hx of autism

8. Screening: AAP recommends Autism specific screening test to all children at 18 and 24 month visit. • M-CHAT (modified checklist for autism in toddlers) tool has picked kids missed by surveillance alone.

11. Areas of Concern Delayed Social Skills Milestones; Earliest, most specific sign of autism. Includes joint attention, social orienting and pretend play. Language Impairment; Less specific. Absent babbling at 9 months and speech delay at 18-24 months. Trouble with simple commands and identifying body parts. Echolalia

12. Restricted Interests; Repetitive behaviors.

15. Referral and Diagnosis Prompt referral to audiologist, autism team, EIP for age <3 yr, special education program of local school district for age >3 yrs or interdisciplinary assessment team to evaluate per DSM IV criteria.

17. Long Term Care • Goal is to increase independent functioning • Provide support to child and family • Important to be knowledgeable about ASD and community resources

18. Treatment • Behavioral Therapy; Aggressive therapy (25 hr/ wk ) improves cognitive, language and adaptive skills outcome.

20. Management of Associated Conditions

23. Prognosis • Adults with average or near average cognitive ability can achieve high level of independence in work and home life. • Poor cognitive function and psychiatric conditions leads to encounters with law enforcement. • Early diagnosis and intervention can improve overall prognosis

24. Q- The earliest and most specific sign of autism is delayed social interaction, which includes an assessment of which of the following milestones? ( check all that apply) • Joint attention • Pretend play • Spoken language • Social orienting

25. A 24 month old child is identified as being at risk of autism by an autism specific screening tool. Which of the following responses are appropriate? (check all that apply) • Refer to a multidisciplinary autism team • Refer to an audiologist • Reassure the family or caregiver, and follow up at the next well-child visit. • Refer to an early intervention program.

26. Evaluation and Treatment of Severe Asymptomatic Hypertension

27. Hypertension JNC 7 Defines; • Normal BP <120/80 mm Hg • Pre HTN 120-139/80-89 mm Hg • Stage 1 HTN 140-159/90-99 mm Hg • Stage 2 HTN >=160/>=100 mm Hg • Definition and classification of severely elevated BP is based on clinical recommendations for practice and is BP > 180/110 mm Hg.

28. Classification of Severely Elevated BP Severe Asymptomatic HTN; • Hypertensive Urgency: Risk factors for progressive end organ damage present • Severe Uncontrolled HTN: Absence of risk factors for EOD, other than HTN Hypertensive Emergency; Signs /symptoms of EOD are present

31. Pathophysiology Elevation in BP and severity of EOD is caused by failure of normal auto regulatory function and increase in systemic vascular resistance. Endovascular injury, ischemia, vasoactive substances released, further failure of auto regulation and a right shift on auto regulation graph.

32. Based on that, if BP lowered more than 20-25 %, hypoperfusion and ischemia of major organs can occur.

33. Evaluation of severe asymptomatic HTN • According to 2007 European guidelines, determine CV risk factors. Risk stratification categorized as low, mod, high or very high. • Risk stratification is dynamic. Pt with low BP and multiple risk factors may have a similar prognosis to pt with poorly controlled BP and no risk factors.

35. Further Evaluation • History and Physical Recheck BP Look for secondary causes Assess for s/s of EOD Compliance, ? new meds Orthostatic vitals

36. Labs; No labs indicated for severe asymptomatic HTN. Clinical judgment. Preliminary labs if new diagnosis. If low risk on CV risk profile check UA, UDS if indicated Mod- High CV risk, check UA, BMP If CV symptoms check EKG, CXR No CT/MRI recd for Isolated HA

38. Treatment • Office management. • Rapid lowering of BP harmful. • Trials shows no significant diff in BP with and without loading dose of anti HTN in office at 24 hr and 1 wk. • VALUE trial (valsartan anti hypertensive long term use evaluation) concludes that BP goals should be reached within 3-6 months to reduce cardiac events in high risk pts. • Pt education

40. Hypertensive Urgency Rx • Initiate / adjust meds if already on them. F/u in 24-48 hrs. • If BP > 200/120, give a loading dose before discharge. • If f/u is uncertain or many risk factors for CV disease, consider hospitalization.

41. Severe Uncontrolled HTN Rx • Initiate/ adjust meds. F/u in 1-7 days. • Loading dose if BP > 200/120, before discharge. • Treatment Table

42. Q-Which of the following statements about severe asymptomatic hypertension are correct? (check all that apply) • Patients typically have had hypertension for months or years before they present to the ER or physician’s office • Rapid reduction in blood pressure may be harmful. • Some patients have evidence of end organ damage. • Severe asymptomatic hypertension can be classified as hypertensive urgency or severe uncontrolled hypertension

43. Q-Which of the following statements about diagnostic testing in patients with severe asymptomatic hypertension are correct? (check all that apply) • Any patient with headache should be evaluated with CT scan or MRI • Evaluation of hemoglobin levels is recommended for all patients • EKG is recommended in patients with signs or symptoms of CV disease • An estimate of GFR is helpful is assessing CV risk.

44. Sexual Assault Of Women

45. Affects 1/3 women during their life time. • Under reported. 12-20% seek medical care, 20-30% report in community surveys, less than ¼ report to police. • Vulnerable groups are adolescents, survivors of childhood sexual/ physical abuse, disabled, substance abusers, sex workers, homeless, persons living in prisons, institutions or military conflict areas.

46. Care of Sexual Assault Survivor • Legal, medical and psychosocial aspect of care • FP office less intimidating than ED • Determine if FP office well equipped for an assault victim evaluation. • Rape kit availability and physician experience with immediate assault cases is important.

47. Medical Treatment • Detailed history in pt’s own words • Obtain consent with each step of physical exam • Body diagrams for injuries/photographs • Treatment of injuries. Nongenital > genital injuries. • Major injury takes priority over forensic collection

50. Prevention of pregnancy and STI should be offered.