AFP Journal Review

1. AFP Journal Review Leena Mane PGY2 Resident Emory Family Medicine

2. Agenda Introduction Discussion Questions

3. Low Back Pain Prevalence- lifetime prevalence is 60-70% Affects- 5.6% US adults each day In last month -18% report having back pain Only 25- 30% seek medical care

4. Definition Acute low back pain- as pain that occurs posterior in region between the lower rib margin and proximal thighs and that is of less than six week’s duration. Sciatica- is the pain radiates down posterior or lateral leg beyond knee

5. History Red Flags- 1.Age > 50 yrs 2.Fever, Chills, recent UTI, or skin infection 3. Significant Trauma 4.Unrelenting night pain or rest pain 5.Progressive motor or sensory deficit 6.Saddle anesthesia, bilateral sciatica or leg weakness, difficulty urinating, fecal incontinence

6. Red Flags ctd 7.Unexpained weight loss 8.H/O cancer or strong suspicion for current cancer 9. H/O Osteoporosis 10.Immunosuppresion 11.Chronic steroid use 12. IV drug abuse 13.Failure to improve after six week of conservative therapy

7. History & Physical Goal of Physical exam is to identify patient who require immediate surgical evaluation and those whose symptoms suggest a more serious condition such as malignancy or infection.

8. Physical exam 1. Straight leg raise 2. Crossed straight leg raise 3. Testing of strength and reflexes in lower extremities 4. Exam according to ROS

10. Imaging & Laboratory evaluation 1. In absence of red flag findings, four to six weeks of conservative care is safe & appropriate. 2.Timing of first and second line evaluation is guided by patient’s symptoms & strength of clinical suspicion. 3.If clinical suspicion is high it may be necessary to proceed to directly to advance imaging like MRI

11. Asymtomatic patient & imaging MRI findings- Herniated disks- 9 to 76 % Bulging disks-20 to 81% Degenerative disks- 46 to 93% Annular tears-14 to 56% Imaging should be carefully selected & interpreted with appropriate clinical co- relation.

12. Treatment Oral NSAIDs- strong evidence that NSAIDs significantly improve pain. Conflicting evidence about whether NSAIDs are superior to acetaminophen. Opioids are considered second or third line analgesics & should be used for short period.

13. Treatment Muscle relaxant -strong evidence that muscle relaxant are helpful in nonspecific low pain. Muscle relaxant are most beneficial in first or two weeks of treatment. Corticostroids - Epidural injections may be helpful in patients with radicular symptoms that do not respond to 6 wks of conservative therapy. It causes short term improvement but no long term improvement in pain & disability.

14. Treatment Bed Rest- no benefit who have acute low back pain with or without sciatica. Patient education- may speed recovery & prevent chronic low back pain Exercise therapy- not helpful. Massage- insufficient evidence to make a reliable recommendation.

15. Treatment Acupuncture- limited evidence about the use of acupuncture. Heat or Ice-minimal evidence regarding use of ice. Heat therapy helpful in reducing pain & increasing function. Manipulation-Some evidence that spinal manipulation results in short term improvement. Physiotherapy- heterogeneous studies. Indivisualised education helps Traction does not lead to improvement for patients with or without sciatica.

16. Prevention USPSTF-concluded that there is insufficient evidence to recommend for or against routine use of exercise European guidelines recommend exercise. Lumbar support do not prevent low back pain.

17. Psychosocial factors associated with Chronic LBP 1. Disputed compensation claims 2.Fear avoidance - exaggerated pain or fear that causes permanent damage. 3.Job dissatisfaction 4.Pending or past litigation 5.Psychosocial distress & depression 6. Somatization.

18. Late Pregnancy Bleeding Late pregnancy ( late second trimester & third trimester) bleeding is associated with significant maternal & fetal morbidity Maternal morbidity may be caused by acute hemorrhage & operative delivery & fetus might be compromised by uteroplacental insufficiency.

19. Initial assessment Differentiate between minor from serious bleeding History / Physical exam- Sterile speculum exam.Digital exam should not be performed unless placenta previa is excluded. Ultrasonography for placental location- to r/o placenta previa Brief period of observation.

20. Vaginal Bleeding Causes- Bloody show during normal labor After sexual intercourse After digital vaginal exam Cervicitis Cervical ectropion Cervical polyp Cervical cancer

21. Management of Ante partum Hemorrhage Initial management of significant bleeding is similar regardless of etiology Assess the hemodynamic stability If unstable- IV access, Fluid resuscitation, and use of blood products as needed. Baseline labs- H/H, platelet counts, fibrinogen level, coagulation studies, blood type & antibody screen Rhogam - to Rh negative woman, Kleihauer - Betke test should be performed for adequate dosage

22. Management Continuous fetal monitoring Decelerations or loss of variability may resolve with adequate maternal resuscitation. Persistently nonreassuring fetal heart rate tracing may require urgent cesarean delivery.

23. Placenta Previa Placenta previa- is placental implantation that overlies or is within 2 cms of the internal cervical os. Complete previa- when placenta covers the os Marginal previa- when edge lies within 2 cm of os. Low lying placenta-when edge lies within 2 to 3.5 cm.

24. Risk factors for major causes of vaginal bleeding 1.Placenta Previa- chronic hypertension, multiparty, multiple gestations, older age, previous c- section, tobacco use, uterine curettage 2.Placental Abruption- chronic hypertension, multiparty, preeclampsia, previous abruption, short umbilical cord, sudden decompression of an over distended uterus, thrombophilias, Tobacco, cocaine, or methamphetamine use, Trauma- blunt or sudden deceleration, uterine fibroids 3.Vasa Previa- In vitro fertilization, low lying & second trimester placenta previa, marginal cord insertion, multiple gestatation, succenturriate - lobed & bilobed placenta.

25. Clinical Presentation Placenta Previa – common incidental finding on second trimester ultrasonagraphy. 4% - of ultrasound studies @ 20- 24 wks 0.4% - of term pregnancies Transvaginal ultrasonography is more accurate than transabdominal ultrasound. Migration of placenta away from lower segment is caused by growth of placental trophoblast towards fundus & development of lower uterine segment.

26. Symptoms Vaginal bleeding in late second or third trimester often after sexual intercourse. Bleeding is typically painless unless labor or placental abruption occurs.

27. Management

28. Outpatient management Is appropriate for selected patients who do not have active bleeding & who can rapidly access a hospital with operative labor & delivery services. Cervical cerclage has decreased the risk of premature birth before 34 wks. Additional studies needed before this clinical practice is introduced.

29. Likelihood of placenta previa persisting to term.

30. Placenta Previa & Previous C/S Woman with h/o previous C/S and who present with placenta previa Placenta is located at the site of previous c- section. These patients should be valuated with color flow Doppler for Placenta accreta, increata, or percreta.

31. Few definitions Placenta accreta- when placenta attaches to deeply to uterine wall, it does not penetrate the uterine wall Placenta increta - when placenta attaches to deeper into uterine wall and does penetrate uterine wall Placenta percreta- when placenta penetrate through uterine wall and attaches to other organ like bladder. MRI of pelvis may help confirm the diagnosis of invasive placenta & delineate organ involvement.

32. Placenta Percreta Placenta Percreta -

33. Placental abruption Placental abruption is the separation of placenta from uterine wall before delivery. Most common cause of serious vaginal bleeding Neonatal death occurs in 10 to 30 % cases. Risk factors- tobacco or cocaine use, chronic hypertension, preeclampsia, abdominal trauma.

34. Placental abruption Abruption

35. Clinical Presentation Vaginal bleeding (bright red, dark or mixed with amniotic fluid), uterine tenderness or back pain and evidence of fetal distress. Preterm labor, growth restriction & intrauterine fetal death Fundus is often tender & pain occurs between contractions Manifestations of DIC Chronic form- vaginal bleeding, with episodic pain & ctx.

36. Management Rapid stabilization of maternal cardiopulmonary status Assessment of fetal well being Definitive management of should not be delayed for ultrasound confirmation. Tocolysis is generally contraindicated except in mild abruption before 34 wks.

37. Management A non reassuring fetal heart tracing necessitates rapid usually cesarean delivery. Decision to delivery interval of 20 mins or less resulted in improved neonatal outcomes in case control studies of abruption. When fetal death occurs due to abruption, vaginal delivery should be goal.

38. Prevention Incidence can be decreased by cessation of tobacco, cocaine, amphetamines, and appropriate care for hypertensive disorders of pregnancy. One study demonstrated a reduction in incidence of abruption with intrapartum treatment of preeclampsia with magnesium sulphate.

39. Vasa Previa Vasa previa is the velamentous insertion of umbilical cord into membrane in lower uterine segment resulting in presence of fetal vessels between cervix and presenting part. Incidence- 1 in 2500 births Mortality- 33 to 100%

40. Symptoms- Onset of hemorrhage at the time of amniotomy or spontaneous rupture of membrane. Hemorrhage is fetal blood and exsanguinations can occur rapidly because average blood volume of term fetus is 250 ml.

41. Management If fetal heart tone are reassuring, blood sample from vault may be checked for fetal blood cells or fetal Hgb. Apt test is used very commonly. Delivery should not be deferred for confirmation of fetal blood.

42. Prevention No strategies for primary prevention of vasa previa. Screening is carried out with transvaginal color flow Doppler to identify the presence of vessels in fetal membrane. Although screening is recommended in high risk patients ( in vitro fertilization, placenta previa, bilobed& succenturiate - lobed placenta ), no evidence of screening general population changes outcomes.

43. Noninvasive Cardiac imaging Can be used for diagnostic & prognostic assessment of patients with suspected or known CAD Central in treatment of patient with MI, CAD, ACS with or without angina Radionuclide cardiac imaging , echocardiography, and cardiac MRI play important role.

44. Initial evaluation History- presence of cardiac risk factors, including age , sex, hypertension, diabetes, smoking, physical inactivity, obesity, abnormal lipid profile, positive family history CP- 7 points of HPI Framingham risk score

45. Framingham score

46. Algorithm for stress testing in patients with CAD

47. Cardiac Radionuclide Imaging- Recommended uses- 1. In patients with intermediate likelihood or clinical suspicion of CAD when standard exercise testing is likely to non diagnostics ( resting ST- T wave changes ,bundle branch blocks.) 2.In ER with patients with suspected ACS & nondignostic ECG and biomarkers. Diagnosis of chronic CAD relating to diagnosis of symptomatic and select asymptomatic patients with ischemia.

48. Uses continued 4. Prognosis & risk therapy assessment after ST elevation acute MI, assessment of resting right ventricular & left ventricular function. Determination of initial LV & RV function in heart failure.

49. SPECT myocardial perfusion imaging Stress perfusion imaging with single – photon emission computed tomography uses radioactive tracer to provide info about regional flow, coronary artery perfusion &ventricular function.

50. Nuclear stress imaging-

51. Poor prognostic factors 1. Relative to number of vascular territories involved 2. Extent & severity of defect size 3.Degree of reversibility 4.Poststress EF < 45% 5.End systolic volume > 70 ml 6.Transient ischemic dilation 7.Increased lung uptake of Thallium 201

52. Echocardiography & Stress Echocardiography Indications- 1. Diagnosis of underlying cardiac disease in patient with chest pain & clinical evidence of valvular, pericardial or primary myocardial disease. 2.Assessment of LV function to guide therapy in patients with known CAD

53. Indications continued 3.Evaluation of CP in patient with suspected aortic dissection. Evaluation of Cp in patients with acute MI when baseline ECG is nondiagnostic & when study can be obtained during CP & soon after its abatement Assessment of infarct size or extent of jeopardized myocardium.

54. Stress Echo Sensitivity-81% Specificity-86% Overall accuracy- 84% Stress Echocardiography with exercise or dobutamine is effective and highly accurate noninvasive means of detecting CAD in symptomatic patients with intermediate to high pretest likelihood of CAD.

55. Cardiac CT: cardiac calcium scoring & noninvasive coronary angiography Cardiac CT detect and quantifies the amount of coronary calcium using either electron beam tomography or multidetector CT Coronary calcium scores approximates the total atherosclerotic plaque burden & strongly predicts future cardiac event.

56. Coronary artery calcium scoring

57. CAC in Men

58. CAC scoring Low score- 1 - 100 Moderate score- 101 to 400 Higher score- > 400 Low scores are associated with twice the risk Higher scores are associated with higher relative risk of events.( 15 % year) It does not tell anything about actual luminal narrowing.

59. Cardiac CT Provides quantitative measures of calcified and noncalcified coronary plaques Positive scan indicates CAD but no significant stenosis AHA endorses the use of calcium testing as screening procedure in selected patient. CAC has incremental and independent value when added to clinical and historical data in estimation of death & nonfatal MI.

60. Testing of patient at risk of CAD *

61. Cardiac MRI Cardiac MRI is noninvasive techniques for evaluating right & left ventricular function, cardiac masses, congenital heart disease & suspected arrythmogenic right ventricular dysplasia Cardiac MRI angiography is standard technique for imaging aorta & large vessel of the chest & abdomen.

62. Cardiac MRI ctd Dobutamine atropine MRI is used in risk assessment & prognostication of patients with suspected known CAD. CAD predictors- inducible ischemia , LVEF < 40 % Cardiac MRI perfusion imaging have demonstrated ability detect high grade coronary stenosis & severity of valvular disease.

63. Conclusions- Cardiac imaging using contempary techniques of stress echocardiography or ECG gated SPECT imaging provide accurate imaging. Asymptomatic men & women with significant subclinical CAD should be treated to secondary prevention goal. Research continues to improve existing techniques & application in areas of cardiac CT & cardiac MRI Local expertise & availability should guide technique selection.