AAFP: Review January 15, 2011 Emory Family Medicine

1. AAFP: Review January 15, 2011 Emory Family Medicine Susan Schayes M.D., M.P.H. Assistant Professor-CT Family Medicine, Emory University School of Medicine

2. Learning objectives • Review January 15, 2011AAFP highlights • RSV infection in Children • Cat-scratch Disease • Evaluation and Management of Intestinal Obstruction • Special Nutrition Support

3. Respiratory Syncytial Virus infection in Children • RSV peak Nov-April • Cough, coryza, wheezing • Treatment is supportive with maintaining hydration and oxygenation Bronchodilator trial is ok For wheezing, but should Have prompt response. Children at high risk may have Palivizumab prophylaxis

4. Respiratory Syncytial Virus infection in Children • RSV causes resp tract infections in children-bronchiolitis is the most common lower resp tract infection in children under 2. • RSV enveloped, nonsegmented, dble stranded RNA virus- subtype A & B Incubation 2-8 days Shedding 3-8 days-but Can continue for up to 4 wks

5. RSV clinical manifestations • Vary depending on the patient’s age and previous health status • Infants and young children with a primary infection usually present with LRI such as bronchiolitis or pneumonia- cough 98%, fever 75%, rhinorrhea, wheezing 65-78%, labored respirations 73-95% • Severe disease- grunting, nasal flaring, intercostal retractions

6. Risk factors for Severe RSV • Chronic Lung disease eg bpd • Current weight less than 11 lbs • Cyanotic congenital HD • Immune compromise • IU exposure to tobacco smoke • Low socio-economic status • Neuromuscular disease • Premature birth before 35 wks

7. Respiratory Syncytial Virus infection in Children

8. Candidates for Palivizumab (Synagis) Infants eligible for a maximum of 5 doses • Infants with chronic lung disease, younger than 24 months, who require medical therapy (i.e., supplemental oxygen, bronchodilator or diuretic use, or corticosteroid use within the past six months) • Infants with congenital heart disease, younger than 24 months, who require medical therapy (i.e., medication to control congestive heart failure, those with moderate to severe pulmonary hypertension, or infants with cyanotic disease) • Premature infants born at less than 31 weeks, six days of gestation • Certain infants with neuromuscular disease or congenital abnormalities of the airways Infants eligible for a maximum of 3 doses • Premature infants with a gestational age of 32 weeks, 0 days to 34 weeks, 6 days with one risk factor and born three months before or during RSV season

9. Clinical Recommnedation • SORT: KEY RECOMMENDATIONS FOR PRACTICE • The diagnosis of an RSV infection is based on patient history and physical examination. C • Routine laboratory and radiologic studies should not be used in making the diagnosis of RSV infection. C • Routine use of bronchodilators is not recommended for the treatment of bronchiolitis, although they may be considered if there is a prompt favorable response to an initial treatment. B Routine use of corticosteroids or ribavirin (Virazole) is not recommended in children with RSV. B Hand decontamination is important in preventing the spread of RSV. Hands should be washed before and after contact with a patient or inanimate object in direct vicinity of the patient. B

10. Palivizumab (Synagis) • Primary benefit of prophylaxis is a reduced rate of RSV associated hospitalizations • No effect on mortality has been proven The use of palivizumab (Synagis), a humanized murine monoclonal antibody directed against RSV, is indicated for select children in high-risk groups as a preventive measure against RSV infection. Three groups of children qualify for immunization: (1) infants born before 35 weeks of gestation, (2) infants with chronic lung disease, and (3) infants born with hemodynamically significant congenital heart disease. Palivizumab is given in five monthly intramuscular injections (15 mg per kg) beginning usually on November 1. Fewer injections may be appropriate for some children, but never more than five

11. AAFP question Respiratory Syncytial Virus Infection in Children • 1. Which one of the following statements about the use of palivizumab (Synagis) to prevent respiratory syncytial virus (RSV) infection is correct?  (check one) • A. It is recommended for infants born before 35 weeks of gestation. • B. It has been shown to reduce mortality in vulnerable groups. • C. It is recommended for all infants born before 38 weeks of gestation. • D. It is given as a single injection at one year of age.

12. AAFP questions • 2. Which one of the following statements about drug therapy for bronchiolitis caused by RSV infection is correct?  (check one) • A. Antibiotics are recommended for children hospitalized with severe RSV infection. B. Corticosteroids are recommended for most children with RSV to reduce inflammation and speed recovery. C. Ribavirin (Virazole) is recommended for immunocompetent and immunodeficient children. D. Antibiotics, corticosteroids, and ribavirin are not routinely recommended for children with RSV infection.

13. AAFP questions 3. Which of the following are routinely recommended for children with RSV bronchiolitis?  (check one) • A. Chest radiography. • B. White blood cell count. • C. Oxygen supplementation if oxygen saturation is less than 90 percent. • D. Rapid antigen testing.

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15. Cat Scratch Disease http://youtu.be/EikujS53hvg

16. Cat-Scratch Disease • Common infection that presents as tender unilaterally lymphadenopathy • Asymptomatic, bacteremic cats with Bartonella henselae in their saliva serve as vectors by biting and clawing the skin • Causitive agent is difficult to culture • Diagnosis arrived by history and titers greater than 1:256 of IGG AB to Bartonella

17. Cat Scratch Disease • Bartonella is found in feline erythrocytes and fleas which contaminate the saliva • The cat flea Cternocephalides felis is the vector responsible for horizontal transmission • Tick bits can also transmit the bacterium to humans • 50% of cats harbor Bartonella

18. Cat Scratch Disease • After contact with an infected cat- develop a primary skin vesicle at innoculation site, regional lymphadenopathy develops 1-2 weeks later and is usually ipsilateral. These nodes are swollen, tender and may eventually suppurate. • 75% of patient develop aching, malaise, anorexia • 9% develop fever • In immunocompromised can develop bacillary angiomatosis- red-purple papules

19. From cat scratch disease to endocarditis, the possible natural history of Bartonella henselae infection. BMC Infect Dis. 2007; 7: 30.

20. Cat Scratch Disease • SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Cat-scratch disease should be included in the differential diagnosis in any patient with lymphadenopathy. C • The diagnosis of cat-scratch disease is usually confirmed by a history of cat exposure and antibodies to Bartonella henselae. C • Most cases of cat-scratch disease are self-limited and do not require antibiotic therapy. B • If an antibiotic is chosen to treat cat-scratch disease, azithromycin (Zithromax) appears to be effective at reducing the duration of lymphadenopathy. B

21. AAFP question Cat-scratch Disease • 4. Which one of the following is the most common site for lymphadenopathy in patients with cat-scratch disease?  (check one) • A. Chest. • B. Upper extremity. • C. Groin. • D. Neck and jaw.

22. AAFP question • 5. Which one of the following is the best initial test for patients suspected of having cat-scratch disease?  (check one) • A. Culture. • B. Polymerase chain reaction. • C. Serology. • D. Lymph node biopsy

23. AAFP question 6. Which of the following are complications of Bartonella henselae infection?  (check all that apply) • A. Bacillary angiomatosis. • B. Bacillary peliosis. • C. Neuroretinitis. • D. Encephalopathy.

25. Intestinal Obstruction • The most common causes of intestinal obstruction include adhesions, neoplasms, and herniation . Adhesions resulting from prior abdominal surgery are the predominant cause of small bowel obstruction, accounting for approximately 60% of cases. • Other causes of obstruction include: intestinal intussusception, volvulus, intra-abdominal abscesses, gallstones, foreign bodies.

26. CAUSES OF INTESTINAL OBSTRUCTION Intestinal Obstruction

27. DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN, DISTENSION, NAUSEA, AND CESSATION OF FLATUS AND BOWEL MOVEMENTS DDx of Abdominal pain, distension, nausea and cessation of flatus and bowel movements

28. Intestinal Obstruction

29. Intestinal Obstruction

30. Intestinal Obstruction • Axial computed tomography scan showing dilated, contrast-filled loops of bowel on the patient's left (yellow arrows), with decompressed distal small bowel on the patient's right (red arrows). The cause of obstruction, an incarcerated umbilical hernia, can also be seen (green arrow), with proximally dilated bowel entering the hernia and decompressed bowel exiting the hernia

32. Intestinal Obstruction • SORT: KEY RECOMMENDATIONS FOR PRACTICE • Abdominal radiography is an effective initial examination in patients with suspected intestinal obstruction. C ( Radiography has greater sensitivity in high-grade obstruction than in partial obstruction.) • Computed tomography is warranted when radiography indicates high-grade intestinal obstruction or is inconclusive. C (Computed tomography can reliably determine the cause of obstruction, and whether serious complications are present, in most patients with high-grade obstructions.) • Upper gastrointestinal fluoroscopy with small bowel follow-through can determine the need for surgical intervention in patients with partial obstruction. C • Contrast material that passes into the cecum within four hours of oral administration is highly predictive of successful nonoperative management.

33. Intestinal Obstruction • SORT: KEY RECOMMENDATIONS FOR PRACTICE • Antibiotics can protect against bacterial translocation and subsequent bacteremia in patients with intestinal obstruction. C • Clinically stable patients can be treated conservatively with bowel rest, intubation and decompression, and intravenous fluid resuscitation. C • Surgery is warranted in patients with intestinal obstruction that does not resolve within 48 hours after conservative therapy is initiated. C

34. AAFP question • Evaluation and Management of Intestinal Obstruction • 7. Which one of the following statements about proximal intestinal obstruction is correct?  (check one) • A. Vomiting is a common early symptom. B. Abdominal distension is a prominent early symptom. • C. Most patients are asymptomatic. • D. Abdominal tympany is usually heard on examination.

35. AAFP question • 8. Which of the following statements about typical complications of intestinal obstruction are correct?  (check all that apply) • A. Patients with severe vomiting may develop metabolic alkalosis. • B. Antibiotics are recommended to treat intestinal overgrowth of bacteria and translocation across the bowel wall. • C. Oral hydration is recommended. • D. Intravenous hydration is recommended.

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37. Specialized Nutrition Support • In normal baseline nutrition- any condition that precludes food intake: consider in adults 5-7 days , 3-5 days in children, 1-3 days in infants • Precise indications for nutrition support controversial- Consensus: impaired bowel function, severe protein-calorie malnutrition and a treatable disease, and those requiring prolonged therapeutic bowel rest

38. Specialized Nutrition Support • In adults, the average nutritional requirement is 25-35 kcal per kg per day • For children older than 5 years, the suggested requirement is 1500 kcal for the first 20 kg plus 25 kcal for each additional kg per day

39. Special Nutritional Support Enteral nutrition can be divided into two basic categories: polymeric or elemental. • Disease specific • Immune modulated • Modular • Pulmonary • Renal

40. Complications of Enteral Nutrition • Aspiration pneumonia Prevent: elevate head of bed 30 degrees • Diarrhea • Metabolic complications- fluid and electrolyte complications, hyperglycemia, vit K deficiency, hypertonic dehydration

41. Complications of Enteral Nutrition • Complications related to feeding tube • -nasopharyngeal erosions, sinusitis, otitis media, gagging, esophagititis, GERD, tracheoesophageal fistulas, rupture of esophageal varices, knotting or kinking of feeding tubes, mechanical obstruction • Pericutaneous tubes can leak, cause local wound infections, dislodge to an interperitoneal position, and cause occlusion

42. Specialized Nutrition Support • T

43. Subjective GlobalAssessment

44. Clinical Recommnedation • SORT: KEY RECOMMENDATIONS FOR PRACTICE • Enteral nutrition is preferred over parenteral nutrition because it has been shown to be more cost-effective and may decrease the rate of infections. A • Specialized nutrition support is not obligatory at the end of life. Enteral nutrition is unlikely to be helpful in patients with advanced dementia, and may be harmful. C

45. Clinical Recommnedation • SORT: KEY RECOMMENDATIONS FOR PRACTICE • Nutritional assessment should be based on the patient history and physical data, including weight loss and dietary intake before admission; disease severity; comorbid conditions; and function of the gastrointestinal tract (e.g., Subjective Global Assessment). Serum markers (e.g., albumin, prealbumin, retinol binding protein, transferrin) alone are not adequate. C • The decision to administer specialized nutrition support should consider the patient's preexisting nutritional status, the impact of the disease process on nutritional intake, and the likelihood that specialized nutrition support will improve patient outcome or quality of life. B

46. AAFP question • Specialized Nutrition Support • 9. Which one of the following patients would be a candidate for specialized nutrition support?  (check one) • A. A 50-year-old man who is unable to eat four days after gallbladder surgery. • B. An infant who is unable to eat three days after surgery to repair an intussusception. • C. A 10-year-old child who is unable to eat two days after surgery for appendicitis. • D. A patient with low serum albumin levels and abnormal retinol binding protein levels, but who is able to eat some food

47. AAFP question • 10. Which one of the following statements about specialized nutrition support at the end of life is correct?  (check one) • A. Nutrition support is almost always needed at the end of life. • B. Enteral nutrition improves quality of life in older patients with dementia. • C. Nutrition support may be withheld based on patient preference. • D. Enteral and parenteral nutrition are well tolerated with a low risk of complications

48. AAFP question 11. Which of the following statements about nutritional requirements are correct?  (check all that apply) • A. Children and infants have lower protein requirements than adults. • B. In adults, 25 to 35 kcal per kg per day is typically required. • C. Linoleic acid supplementation is needed for infants and children receiving specialized nutrition support, but not for adults. • D. Patients with enteropathy or acute nephritic syndrome have higher protein requirements.

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