AFP Journal Review April 15, 2011

1. AFP Journal ReviewApril 15, 2011 Faiqa Mahmud PGY-3 Emory Family Medicine

2. Articles Reviewed • Carpal Tunnel Syndrome • Update on Subclinical Hyperthyroidism • House Calls • Neonatal Resuscitation-An Update

3. Carpal Tunnel Syndrome

4. Carpal Tunnel Syndrome • Most common entrapment neuropathy • 3-6% of adults affected • An accurate history and physical examination are essential to establishing the diagnosis • Rule out other conditions that may present as CTS.

6. Etiology • Repetitive maneuvers • Obesity • Pregnancy • Arthritis • Hypothyroidism • Diabetes mellitus • Trauma • Mass lesions • Amyloidosis • Sarcoidosis • Multiple myeloma • Leukemia

7. Symptoms/Signs • Hand Symptom Diagram; Classic pattern Probable pattern Possible pattern Unlikely pattern • Classic or probable pattern has sensitivity of 64% and specificity of 73%

8. Classic, probable, unlikely patterns

9. Shaking the hand or flicking the wrist in an attempt to alleviate the discomfort- the flick sign • Square wrist sign-The ratio of the wrist thickness to the wrist width is greater than 0.7. • hypalgesia (diminished ability to perceive painful stimuli) along the palmar aspect of the index finger compared with the ipsilateral little finger of the affected hand. • Thenar atrophy

10. Phalen sign • Tinel sign • Weak thumb abduction • Abnormal 2 point discrimination-Inability to discriminate points less than 6 mm apart is considered abnormal

12. Adjunctive Tests Nerve conduction studies and electromyography • Used for confirmation of diagnosis in patients with an intermediate pretest probability • Atypical presentation • Quantify and stratify disease severity • NCS has sensitivity of 56-85 % and a specificity of 94 % for carpal tunnel syndrome • U/S, CT and MRI are not helpful.

13. Treatment • Based on disease severity • Mild disease- Six weeks to three months of conservative treatment . Cock-up and neutral wrist splints and oral corticosteroids are considered first-line therapies. Local corticosteroid injections used for refractory symptoms. • Moderate to severe disease Refer for surgical evaluation

15. Conservative Management • Lifestyle modification; Avoiding repetitive motions, using ergonomic equipment , taking breaks, using keyboard and alternating job functions. • Oral Medications; Oral steroids first line, effective for 1 month. NSAIDS, diuretics, and pyridoxine (vitamin B6) are no more effective than placebo.

16. Splinting; with neutral or cock-up wrist splints. Similar symptom relief outcomes with both styles. Use for 6-8 wks. • Local steroid injection; Good for short term treatment. Particularly useful for patients wanting to delay surgical treatment

17. Surgical Management • Open and endoscopic surgical approaches have similar five-year outcomes. • On average, postsurgical patients were able to return to driving in nine days, to ADL in 13 days, and to work in 17 days, with a satisfaction rate of more than 90 percent.

18. Update on Subclinical Hyperthyroidism

19. Subclinical Hyperthyroidism • TSH levels are low (0.1 to 0.4 mIU per L) or undetectable (less than 0.1 mIU per L), with normal free T4 and T3 levels. • Rate of progression to overt hyperthyroidism is higher in persons who have suppressed TSH levels compared with those who have low but detectable levels • Prevalence has been reported to be as high as 15% in persons older than 70 years in iodine-deficient regions (thyroid autonomy/iatrogenic)

20. Etiology • Increased endogenous production of thyroid hormone . (Graves disease, autonomous functioning thyroid adenoma, toxic MNG, subacute and post partum thyroiditis) • Intentional administration to suppress thyroid malignancy • Unintentional excessive therapy in hypothyroidism

21. Secondary causes of TSH Suppression • Unrelated to subclinical hyperthyroidism. • TSH suppression caused by glucocoticoids, TRH deficiency, euthyroid sick syndrome, affective psychiatric disorders.

22. Clinical Significance • Subclinical hyperthyroidism is associated with an increased risk of Afib in older adults • Associated with decreased BMD in postmenopausal women • Lesser-quality evidence suggests an association with cardiovascular effects (increase HR, LVH) • Controvertial association with cognition, and increased mortality rates .

25. Evidence based association with Afib • In a retrospective, population-based study of adults > 65 years on average, the prevalence of afib in persons with TSH levels less than 0.4 mIU per L was 12.7 percent, compared with 2.3 percent in those with normal TSH levels. • 2 large cohorts of adults > 60 to 65 years found that subclinical hyperthyroidism is associated with an increased relative risk of developing atrial fibrillation over at least 10 years.

26. Evidence based association with BMD • Increased bone turnover caused by imbalance between bone reabsorption and formation. • In a crosssectional study of women with endogenous subclinical hyperthyroidism (TSH levels of 0.01 to 0.1 mIU per L), postmenopausal women had significantly lower BMD at the level of the femur and lumbar regions, whereas premenopausal women had only a modest decrease in BMD in the femur area.

28. Screening Guidelines • No consensus regarding screening for subclinical hyperthyroidism in the general population • Randomized controlled trials are needed to address the effects of early treatment on potential morbidities to help determine whether screening should be recommended in the asymptomatic general population. • Effectiveness of treatment in preventing these conditions is unknown • Physicians should use their best clinical judgment in the context of the recommendations for screening in individual patients.

29. House Calls

30. House calls involving multidisciplinary teams may reduce hospital readmissions and long-term care facility stays • In 1930, 40 percent of patient encounters occurred in the patient's home • By 1980, only about 1 percent of patient encounters were house calls • Renewed interest in house calls based on medicare’s new reimburstment increments. • By 2030, 70 million U.S. citizens will be older than 65 years and requiring home visits.

32. Evidence of Effectiveness • The VA Home Based Primary Care program, which uses a multidisciplinary care team to serve frail older persons in the home, has demonstrated fewer hospital admissions, shorter lengths of stay, reduction in readmission rates, and reduction in long-term care facility stays. • Preliminary analysis suggests the experience of the multidisciplinary team and inclusion of a physician and nurse practitioner are important factors to reduce inpatient days

33. Rationale and Type of House Call

35. Conducting a House Call • Advance planning is necessary to develop the anticipated agenda of a house call • The INHOMESSS mnemonic (impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services) addresses the components of a comprehensive house call

39. Team approach • To enhance communication and improve efficiency of care, physicians should coordinate house calls with other health care professionals. Examples of health care professionals whose visits can be arranged through a home health agency include the following: dietitian, home health aide, licensed practical nurse, occupational therapist, physical therapist, psychiatric nurse, registered nurse, social worker, speech therapist, and wound care nurse. • House calls can be an important component of the patient-centered medical home • Documented as an outpatient clinical visit, but the chief complaint must include justification of the reason for the visit to occur in the home

40. Neonatal Resuscitation- An Update

41. Nearly 10 % of newborns in the USA annually need some assistance to begin breathing at birth • Approximately 1 percent needing extensive resuscitation • About 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy • NRP made major updates in 2006 and 2010 to neonatal resuscitation guidelines

42. Updates • Do not intervene with endotracheal suctioning in vigorous infants born through meconium-stained amniotic fluid • Endotracheal suctioning may be appropriate in nonvigorous infants • Provide positive pressure ventilation with one of three devices when necessary. (self-inflating bag, flow-inflating bag, or T-piece device) • To begin resuscitation of term infants using room air or blended oxygen • To have a pulse oximeter readily available in the delivery room.

43. Updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine • Do not use sodium bicarbonate or naloxone during resuscitation • Confirming endotracheal tube placement using an exhaled carbon dioxide detector • Using less than 100 % oxygen and adequate thermal support to resuscitate preterm infants

44. Using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy

45. Preparation • Once the neonatal resuscitation team is summoned to the delivery room, it is important to obtain a pertinent history; assign roles to each team member; check that all equipment is available and functional, including a pulse oximeter and an air/oxygen blender; optimize room temperature for the infant; and turn on the warmer, light, oxygen, and suction

47. Recommendations • When using assisted ventilation initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a HR of 100 bpm. • Ventilation rates of 40 to 60 breaths per minute are recommended • Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful

48. It is recommended to begin resuscitation with 21 % oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low Preterm: • PIP 20-25 cm H2O should be used • An initial oxygen concentration of more than 21 percent (30 to 40 percent), but less than 100 percent should be used

49. If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine (1:10,000 solution) should be given intravenously • Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room • the use of sodium bicarbonate in the delivery room did not improve survival • Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia

50. It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. Hyperthermia should be avoided • When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation