Title: AAFP Journal Review
1AAFP Journal Review
2Health Maintenance in School-aged Children
History, Physical Examination, Screening, and
Immunizations
- The aim of the well-child examination in
school-aged children is to promote health and
prevent future health problems. - Lack of time limits provision on preventive care.
- This section focuses on history, physical
examination and screening for health maintenance
in school-aged children
3SORT KEY RECOMMENDATIONS FOR PRACTICE
4History
- A complete well-child examination history
includes multiple screening questions. - Social history, living situation and lifestyle
habits, can be particularly important in this age
group - Important to inquire about safety habits and the
presence of firearms in the home. - Consider giving a questionnaire to the family to
complete before the visit.
5Physical Examination
- A full physical examination should be performed
during any health maintenance visit. - Abnormality found in less than 4 percent of
patients, and most of these abnormalities are not
clinically significant. - More than 1 million abused children are
identified annually in the United States.
6Screening Recommendations for School-aged
Children and Adolescents
7Supplements
- VITAMIN D
- Inadequate vitamin D levels are associated with a
wide range of conditions - Studies have shown that up to 50 percent of
children are vitamin D deficient - The AAP recommends 400 IU of vitamin D daily for
all - There are no clear guidelines for screening for
vitamin D deficiency in children.
8Supplements
- Children six months to 16 years of age living in
areas with inadequate fluoride in the water
supply should be counseled on fluoride
supplementation.
9Immunizations
- Two sets of immunizations recommended for
school-aged children. - In addition to these primary vaccines, the
influenza virus vaccine is recommended annually
for all children older than six months. - Certain high-risk groups may need additional
vaccines. At every well-child visit, the
immunization record should be reviewed to ensure
that catch-up immunizations are not needed. - Nationally, there is a high level of vaccine
completion for the four- to six-year-old
vaccines. - Completion rates for vaccines recommended in
early adolescence are significantly less, - Less than 20 percent completing the human
papillomavirus vaccine series. - physicians should adopt strategies to increase
immunization completion in their patients.
10Health Maintenance in School-aged Children
Counseling Recommendations
- Anticipatory guidance is appropriate at all ages,
but it is particularly important in school-aged
children - Focus on counseling recommendations
- There is little evidence to suggest the best
methods for health counseling in school-aged
children - School aged children are concrete thinkers
- Discuss high risk behaviours
11SORT KEY RECOMMENDATIONS FOR PRACTICE
12Screening and Counseling Recommendations for
School-aged Children and Adolescents
13Screening and Counseling Recommendations for
School-aged Children and Adolescents
14Counseling
- Well-child visits for school-aged children are
typically conducted with a parent present. - Discussions about sensitive issues, such as
substance use and sexual activity, should occur
without the parent in the room.
15DIETARY COUNSELING
- Poor definitive evidence on how to best advise
patients and families. - The most effective are comprehensive behavioral
interventions - Most experts recommend providing some dietary
counseling to children and their families at the
well-child examination focusing - Families should also be advised to limit sugary
beverages, fast food, and highly processed foods,
and be educated on appropriate portion sizes.
16Dietary Counseling Recommendations for
School-aged Children
17NIH Recommendations for Physical Activity in
School-aged Children
- At least 60 minutes of physical activity per day
- Moderate-intensity aerobic activity, such as
walking, running, skipping, playing on the
playground, playing basketball, and biking, on
most days - Vigorous-intensity aerobic activity, such as
running, doing jumping jacks, and swimming fast,
at least three days per week - Muscle-strengthening activities, such as climbing
trees, playing tug-of-war, and doing push-ups and
pull-ups, at least three days per week - Bone-strengthening activities, such as hopping,
skipping, doing jumping jacks, playing
volleyball, and working with resistance bands, at
least three
18Screen Time
- The average child spends 7.5 hours per day in
front of a screen - Obesity rates are lowest in children who have
less than one hour of screen time daily, and are
highest in those who have greater than four hours
of screen time daily. - Screen time may also negatively affect body image
and school performance, and promote violent
behavior. - Physicians should counsel families to limit
screen time, and encourage children to replace
screen time with physical activity. - The AAP recommends limiting screen time to no
more than one to two hours of quality programming
daily.
19High-Risk Behaviors
- Tobacco, alcohol, and illicit drug use may begin
in early adolescence. - According to a 2007 survey of youth in the United
States, 24 percent of those younger than 13 years
had had their first drink of alcohol, 15 percent
had smoked an entire cigarette, and 8 percent had
tried marijuana. - The effectiveness of physician counseling in this
area is unknown. - The AAP recommends asking adolescents directly
about tobacco alcohol, and drug use annually
beginning at 11 years of age. - If the patient reports substance use, additional
questioning on duration, amount, and frequency is
appropriate
20High Risk Behavior
- The CRAFFT (car, relax, alone, forget, friends,
trouble) questionnaire is one brief screening
tool that has been validated in the primary care
setting to identify substance abuse in
adolescents - Have you ever ridden in a car driven by someone
who was high or had been using alcohol or
drugs? - Do you ever use alcohol or drugs to relax, feel
better about yourself, or fit in? - Do you ever use alcohol or drugs when you are by
yourself? - Do you ever forget things you did while you were
using alcohol or drugs? - Do your family or friends ever tell you that you
should cut down on your drinking or drug use? - Have you ever gotten into trouble while you were
using alcohol or drugs? - Physicians would give one point for each yes
answer to the previous questions. A score of 2 or
more should prompt concern for substance abuse or
dependence
21Differentiation and Diagnosis of Tremor
- Tremor is an involuntary, rhythmic, oscillatory
movement of a body part. - It is the most common movement disorder
encountered in clinical practice. - There is no diagnostic standard to distinguish
among common types of tremor - History and physical examination can provide a
great deal of certainty in diagnosis. - The most common tremor in patients presenting to
primary care physicians is enhanced physiologic
tremor, followed by essential tremor and
parkinsonian tremor. - All tremors are more common in older age
22SORT KEY RECOMMENDATIONS FOR PRACTICE
23Broad Classification of Tremor
- Action -Occurs with voluntary contraction of
muscle. Includes postural, isometric, and kinetic
tremors - Postural - Occurs when the body part is
voluntarily maintained against gravity. Includes
essential, physiologic, cerebellar, dystonic, and
drug-induced tremors - Kinetic- Occurs with any form of voluntary
movement. Includes classic essential, cerebellar,
dystonic, and drug-induced tremors - Intention-Subtype of kinetic tremor amplified as
the target is reached.Presence of this type of
tremor implies that there is a disturbance of the
cerebellum or its pathways - Rest- Occurs in a body part that is relaxed and
completely supported against gravity. Most
commonly caused by parkinsonism, but may also
occur in severe essential tremor
24Tremors
- http//www.youtube.com/watch?vxVRKO-Sz0x4
- http//www.youtube.com/watch?vGQm8klm6ub8
- http//www.youtube.com/watch?vDaIN2zRQn8w
25ESSENTIAL TREMOR
- The most common pathologic tremor is essential
tremor. - In one-half of cases, it is transmitted in an
autosomal dominant fashion, and it affects 0.4 to
6 percent of the population. - Careful history reveals that patients with
essential tremor have it in early adulthood (or
sooner), but most patients do not seek help for
it until 70 years - Despite being sometimes called benign essential
tremor, essential tremor often causes severe
social embarrassment, and up to 25 percent of
those afflicted retire early or modify their
career path - Essential tremor is an action tremor, usually
postural, but kinetic and even sporadic rest
tremors have also been described. It is most
obvious in the wrists and hands when patients
hold their arms out - It is generally bilateral, is present with a
variety of tasks, and interferes with activities
of daily living.
26DRUG- AND METABOLIC-INDUCED TREMORS
- Dozens of medications can cause or exacerbate
tremor - Patients with new-onset tremor should have a
comprehensive medication review with specific
attention to medications prescribed and
over-the-counter - Medications particularly prone to inducing or
exacerbating tremor are those that stimulate the
sympathetic nervous system (e.g., amphetamines,
terbutaline, pseudoephedrine) and psychoactive
medications (e.g., tricyclic antidepressants,
haloperidol, fluoxetine Prozac). - Metabolic causes of tremor are varied.8 Initial
workup of tremor may include blood testing for
hepatic encephalopathy, hypocalcemia,
hypoglycemia, hyponatremia, hypomagnesemia,
hyperthyroidism, hyperparathyroidism, and vitamin
B12 deficiency
27Selected Medications and Substances That May
Exacerbate Tremor
- Amphetamines
- Atorvastatin (Lipitor)
- Beta-adrenergic agonists (e.g., albuterol)
- Caffeine
- Carbamazepine (Tegretol)
- Corticosteroids
- Cyclosporine (Sandimmune)
- Epinephrine
- Fluoxetine (Prozac)
- Haloperidol
- Hypoglycemic agents
- Lithium
- Metoclopramide (Reglan)
- Methylphenidate (Ritalin)
- Pseudoephedrine
- Terbutaline
- Theophylline
28PSYCHOGENIC TREMOR
- Differentiation of organic from psychogenic
tremor can be difficult. - Features consistent with psychogenic tremor are
abrupt onset, spontaneous remission, changing
tremor characteristics, and extinction with
distraction. - Often, there is an associated stressful life
event. - Based on clinical experience, the prevalence of
psychogenic tremor is thought to be high, but
there are no precise estimates.
29Physiological Tremor
- A physiologic tremor is present in all persons
- It is a low-amplitude, high-frequency tremor at
rest and during action that is not reported as
symptomatic. - This tremor can be enhanced by anxiety, stress,
and certain medications and metabolic conditions. - Patients with a tremor that comes and goes with
anxiety, medication use, caffeine intake, or
fatigue do not need further testing.
30Diagnostic Approach
31Diagnosis of Tremor with an Organic Cause
32Diagnostic Approach
- The diagnosis of tremor is based on clinical
information obtained from a thorough history and
physical examination. Although there is overlap
and variability among the individual tremor
syndromes, the intrinsic features of the tremor
usually provide key diagnostic clues - The first step in the evaluation of a patient
with tremor is to categorize the tremor based on
its activation condition, topographic
distribution, and frequency. The activation
condition should be described as rest, kinetic
(or intention), postural, or isometric - The examiner can have the patients sit with their
hands in their laps to check for rest tremor. A
sequential test for postural and kinetic tremors
can be done by having the patient stretch his or
her arms and hands out, followed by a simple
finger-to-nose test. - A rest tremor is virtually synonymous with
parkinsonism, whereas an intention tremor often
indicates a cerebellar lesion. - Several historical clues can play important roles
in the differentiation of tremors Tremor in older
patients is more likely to be parkinsonian or
essential tremor. Patients with sudden onset of
tremor should be evaluated to determine if the
tremor is caused by medications, toxins, a brain
tumor, or a psychogenic cause. Patients with a
gradual onset of tremor should prompt questions
about Parkinson disease.
33Features of Common Tremor Syndromes
34Transfusion of Blood and Blood Products
Indications and Complications
- Blood transfusion can be a lifesaving procedure,
but it has risks, including infectious and
noninfectious complications. There is debate in
the medical literature concerning the appropriate
use of blood and blood products. Clinical trials
investigating their use suggest that waiting to
transfuse at lower hemoglobin levels is
beneficial.1,2 This review will consider the
indications for transfusion of blood and blood
products, and will discuss common noninfectious
complications associated with transfusion
35SORT KEY RECOMMENDATIONS FOR PRACTICE
36Red Blood Cells
- Packed red blood cells (RBCs) are prepared from
whole blood by removing approximately 250 mL of
plasma. One unit of packed RBCs should increase
levels of hemoglobin by 1 g per dL (10 g per L)
and hematocrit by 3 percent. In most areas,
packed RBC units are filtered to reduce
leukocytes before storage, which limits febrile
nonhemolytic transfusion reactions (FNHTRs), and
are considered cytomegalovirus safe - RBC transfusions are used to treat hemorrhage and
to improve oxygen delivery to tissues.
Transfusion of RBCs should be based on the
patient's clinical condition.4 Indications for
RBC transfusion include acute sickle cell crisis
(for stroke prevention), or acute blood loss of
greater than 1,500 mL or 30 percent of blood
volume.4 Patients with symptomatic anemia should
be transfused if they cannot function without
treating the anemia.4 Symptoms of anemia may
include fatigue, weakness, dizziness, reduced
exercise tolerance, shortness of breath, changes
in mental status, muscle cramps, and angina or
severe congestive heart failure. The 10/30
ruletransfusion when a patient has a hemoglobin
level less than or equal to 10 g per dL (100 g
per L) and a hematocrit level less than or equal
to 30 percentwas used until the 1980s as the
trigger to transfuse, regardless of the patient's
clinical presentation.4,5 - In 1999, a randomized, multicenter, controlled
clinical trial evaluated a restrictive
transfusion trigger (hemoglobin level of 7 to 9 g
per dL 70 to 90 g per L) versus a liberal
transfusion trigger (hemoglobin level of 10 to 12
g per dL 100 to 120 g per L) in patients who
were critically ill.1 Restrictive transfusion
practices resulted in a 54 percent relative
decrease in the number of units transfused and a
reduction in the 30-day mortality rate. The
authors recommended transfusion when hemoglobin
is less than 7 g per dL, and maintenance of a
hemoglobin level between 7 to 9 g per dL.1 A
recently updated Cochrane review supports the use
of restrictive transfusion triggers in patients
who do not have cardiac disease.6
37Red Blood Cells
- similar study was carried out in critically ill
children.2 The restrictive transfusion trigger
was a hemoglobin level of 7 g per dL, with a
target level of 8.5 to 9.5 g per dL (85 to 95 g
per L). The liberal transfusion trigger was a
hemoglobin level of 9.5 g per dL, with a target
level of 11 to 12 g per dL (110 to 120 g per L).
Patients in the restrictive group received 44
percent fewer blood transfusions, with no
difference in rates of multiple organ dysfunction
syndrome or death. The restrictive transfusion
strategy is useful for children who are stable
patients in intensive care. It should not be used
in preterm neonates or in children with severe
hypoxemia, active blood loss, hemodynamic
instability, or cyanotic heart disease.2
38Plasma
- Plasma products available in the United States
include fresh frozen plasma and thawed plasma
that may be stored at 33.8 to 42.8F (1 to 6C)
for up to five days. Plasma contains all of the
coagulation factors. Fresh frozen plasma infusion
can be used for reversal of anticoagulant
effects. Thawed plasma has lower levels of
factors V and VIII and is not indicated in
patients with consumption coagulopathy (diffuse
intravascular coagulation). - Plasma transfusion is recommended in patients
with active bleeding and an International
Normalized Ratio (INR) greater than 1.6, or
before an invasive procedure or surgery if a
patient has been anticoagulated.7,8 Plasma is
often inappropriately transfused for correction
of a high INR when there is no bleeding.
Supportive care can decrease high-normal to
slightly elevated INRs (1.3 to 1.6) without
transfusion of plasma. Table 1 gives indications
for plasma transfusion
39(No Transcript)
40Platelets
- Platelet transfusion may be indicated to prevent
hemorrhage in patients with thrombocytopenia or
platelet function defects. - Contraindications to platelet transfusion include
thrombotic thrombocytopenic purpura and
heparin-induced thrombocytopenia - Transfusion of platelets in these conditions can
result in further thrombosis.10,11 One unit of
apheresis platelets should increase the platelet
count in adults by 30 to 60 103 per µL (30 to
60 109 per L).3 In neonates, transfusing 5 to
10 mL per kg of platelets should increase the
platelet count by 50 to 100 103 per µL (50 to
100 109 per L).12 One apheresis platelet
collection is equivalent to six pooled random
donor platelet concentrates
41Indications for Transfusion of Platelets in Adults
42Cryoprecipitate
- Cryoprecipitate is prepared by thawing fresh
frozen plasma and collecting the precipitate.
Cryoprecipitate contains high concentrations of
factor VIII and fibrinogen. Cryoprecipitate is
used in cases of hypofibrinogenemia, which most
often occurs in the setting of massive hemorrhage
or consumptive coagulopathy. - Each unit will raise the fibrinogen level by 5 to
10 mg per dL with the goal of maintaining a
fibrinogen level of at least 100 mg per dL. The
usual dose in adults is 10 units of pooled
cryoprecipitate.
43Indications for Transfusion of Cryoprecipitate
44Infectious Complications of Blood Transfusions
45Transfusion Complications
- Transfusion-related complications can be
categorized as acute or delayed, which can be
divided further into the categories of
noninfectious and infectious. - Acute complications occur within minutes to 24
hours of the transfusion, whereas delayed
complications may develop days, months, or even
years later. - Transfusion-related infections are less common
because of advances in the blood screening
process the risk of contracting an infection
from transfusion has decreased 10,000-fold since
the 1980s. - Noninfectious serious hazards of transfusion are
up to 1,000 times more likely than an infectious
complication. However, there has been no progress
in preventing noninfectious serious hazards of
transfusion, despite improvements in blood
screening tests and other related medical
advances. Therefore, patients are far more likely
to experience a noninfectious serious hazard of
transfusion than an infectious complication.
46Noninfectious Serious Hazards of Transfusion
47- Hemolytic transfusion reactions are caused by
immune destruction of transfused RBCs, which are
attacked by the recipient's antibodies. The
antibodies to the antigens of the ABO blood group
or alloantibodies to other RBC antigens are
produced after immunization through a previous
transfusion or pregnancy. There are two
categories of hemolytic transfusion reactions
acute and delayed. Nonimmune causes of acute
reactions include bacterial overgrowth, improper
storing, infusion with incompatible medications,
and infusion of blood through lines containing
hypotonic solutions or small-bore intravenous
tubes.16,18,19 - In acute hemolytic transfusion reactions, there
is a destruction of the donor's RBCs within 24
hours of transfusion. Hemolysis may be
intravascular or extravascular. The most common
type is extravascular hemolysis, which occurs
when donor RBCs coated with immunoglobulin G
(IgG) or complement are attacked in the liver or
spleen.17 Intravascular hemolysis is a severe
form of hemolysis caused by ABO antibodies.
Symptoms of acute hemolytic transfusion reactions
include fever, chills, rigors, nausea, vomiting,
dyspnea, hypotension, diffuse bleeding,
hemoglobinuria, oliguria, anuria, pain at the
infusion site and chest, back, and abdominal
pain.19 Associated complications are clinically
significant anemia, acute or exacerbated renal
failure, disseminated intravascular coagulation,
need for dialysis, and death secondary to
complications.18 - The incidence of acute hemolytic reactions is
approximately one to five per 50,000
transfusions.19 From 1996 to 2007, there were 213
ABO-incompatible RBC transfusions with 24
deaths.17 Systems using bar codes for blood and
patient identification have decreased errors.17
48ALLERGIC REACTIONS
- Allergic reactions range from mild (urticarial)
to life threatening (anaphylactic). Urticarial
allergic reactions are defined by hives or
pruritus.20 Patients experiencing allergic
transfusion reactions have been sensitized to the
antigens in the donor unit. These antigens are
soluble, and the associated reaction is
dose-dependent. Allergic transfusion reactions
occur in 1 to 3 percent of transfusions.16 - Patients with anaphylactic transfusion reactions,
like those with urticarial reactions, may present
with hives, but they are distinct in that they
also develop hypotension, bronchospasm, stridor,
and gastrointestinal symptoms.16 Anaphylaxis
occurs in response to a recipient's
presensitization to a variety of proteins in
donor plasma. For example, anaphylaxis occurs
because of donor IgA being infused into a
recipient who is IgA deficient and has
preexisting circulating anti-IgA.17 In addition,
antihuman leukocyte antigen (HLA) antibodies and
anticomplement antibodies have been linked to
anaphylactic reactions, which are estimated to
occur in one in 20,000 to 50,000 transfusions - Prevention of anaphylactic transfusion reactions
includes avoiding plasma transfusions with IgA in
patients known to be IgA deficient. Cellular
products (e.g., RBCs, platelets) may be washed to
remove plasma in patients with an IgA
deficiency.16 The best precaution is observation
of the patient during the initial 15 minutes of
transfusion.
49FEBRILE NONHEMOLYTIC TRANSFUSION REACTIONS
- An FNHTR is defined as a rise in body temperature
of at least 1.8F (1C) above 98.6F (37C)
within 24 hours after a transfusion it may
involve rigors, chills, and discomfort.10 The
fever occurs more often in patients who have been
transfused repeatedly and in patients who have
been pregnant.25 Leukoreduction, which is the
removal or filtration of white blood cells from
donor blood, has decreased FNHTR rates.26 FNHTRs
are caused by platelet transfusions more often
than RBC transfusions and have an incidence that
ranges from less than 1 percent to more than 35
percent. - Two mechanisms have been proposed to explain
FNHTRs a release of antibody-mediated endogenous
pyrogen, and a release of cytokines. Common
cytokines that may be associated with FNHTRs
include interleukin-1, interleukin-6,
interleukin-8, and tumor necrosis factor.25 FNHTR
is a diagnosis of exclusion that can be made only
after ruling out other causes of fever (e.g.,
hemolysis, sepsis).
50TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD
- Transfusion-associated circulatory overload is
the result of a rapid transfusion of a blood
volume that is more than what the recipient's
circulatory system can handle. It is not
associated with an antibody-mediated reaction.
Those at highest risk are recipients with
underlying cardiopulmonary compromise, renal
failure, or chronic anemia, and infants or older
patients.17 Signs and symptoms include
tachycardia, cough, dyspnea, hypertension,
elevated central venous pressure, elevated
pulmonary wedge pressure, and widened pulse
pressure. Cardiomegaly and pulmonary edema are
often seen on chest radiography - The diagnosis is made clinically, but may be
assisted by measuring brain natriuretic peptide
levels, which are elevated in response to an
increase in filling pressure.28 A study comparing
patients who have transfusion-associated
circulatory overload with patients who have TRALI
found significantly greater levels of brain
natriuretic peptide in those with
transfusion-associated circulatory overload.28
Transfusion of lower volumes or at a slower rate
may help prevent it.16 The treatment is diuresis
to decrease volume overload.