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CPC’s

CPC’s. Why I like them… audience participation… Why I don’t like them… audience participation. Case 1 June 1995. HPI: 54 yo wm. NP visit to establish care. No active concerns. He wants a “physical”. What to do now?!.

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CPC’s

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  1. CPC’s • Why I like them… • audience participation… • Why I don’t like them… • audience participation

  2. Case 1June 1995 • HPI:54 yo wm. NP visit to establish care. No active concerns. He wants a “physical”. • What to do now?!

  3. Periodic Health ExamAges 25-64 (General Population)US Preventive Services Task Force, 1996 • Screening • Blood pressure • Height and weight • Total blood cholesterol (men 35-65, women 45-65) • Pap smear (women who are or have been sexually active and who have a cervix: q >/ 3 y) • Fecal occult blood test (annually) and or sigmoidoscopy (age >/ 50) • Mammogram +/ clinical breast exam (women 50-69 y; mammogram q 1-2 y, or mammogram q 1-2 y with annual clinical breast exam)

  4. Periodic Health ExamAges 25-64 (General Population)US Preventive Services Task Force, 1996 • Screening (cont.) • Assess for problem drinking • Rubella serology or vaccination hx (women of childbearing age; serologic testing, documented vaccination history, and routine vaccination - preferably MMR - are equally acceptable) • Counseling • Substance Use • Tobacco Cessation • Avoid alcohol use while driving, swimming, boating, etc.

  5. Periodic Health ExamAges 25-64 (General Population)US Preventive Services Task Force, 1996 • Counseling (cont.) • Diet and exercise • Limit fat and cholesterol; maintain caloric balance; emphasize grains, fruit, vegetables • Adequate calcium intake (women) • Regular physical activity • Injury prevention • Lap/shoulder belts • Motorcycle/bicycle/ATV helmets • Smoke detector • Safe storage/removal of firearms

  6. Periodic Health ExamAges 25-64 (General Population)US Preventive Services Task Force, 1996 • Counseling (cont.) • Sexual Behavior • STD prevention: avoid high-risk behavior; condoms/female barrier with spermicide • Unintended pregnancy: contraception • Dental Health • Regular visits to dental care provider • Floss, brush with fluoride toothpaste daily

  7. Periodic Health ExamAges 25-64 (General Population)US Preventive Services Task Force, 1996 • Immunizations • Td boosters • Rubella (women of childbearing age; serologic testing, documented vaccination history, and routine vaccination - preferably MMR - are equally acceptable) • Chemoprophylaxis • MVI with folic acid (women planning or capable of pregnancy) • Discuss hormone prophylaxis (peri- and postmenopausal women)

  8. Periodic Health ExamConditions for Which Clinicians Should Remain Alert (Adults)US Preventive Services Task Force, 1996 • Symptoms of peripheral arterial disease (elderly, smokers, diabetics) • Skin lesions with malignant features • Symptoms and signs of oral cancer and premalignancy (smokers, drinkers) • Subtle or nonspecific symptoms and signs of thyroid dysfunction (elderly, postpartum women, Down’s) • Changes in functional performance (elderly) • Depression (adolescents, young adults, risk factors) • Suicide (persons with established risk) • Family violence (general population) • Drug abuse (general population) • Tooth decay, gingivitis, loose teeth, halitosis (general population)

  9. Screening for Iron Deficiency Anemia • USPSTF (1996) • Pregnant women and high risk infants • encourage breast-feeding and iron-enriched foods for infants and young children • CDC (1998) • Ages 0-5 yrs • high risk (low income, migrant, refugee) • Ages 5-12 and Boys 12-18 • prior hx of IDA; special needs; low intake

  10. Screening for Iron Deficiency Anemia • CDC (1998), cont. • Girls 12-18, Nonpregnant women of childbearing age • screen every 5-10 yrs • yearly if risk factors (heavy menses, low iron intake, prior dx of IDA) • Pregnant women • screen at first prenatal visit • Postpartum women • at 4-6 wks if risk factors (anemia through 3rd trimester, excess blood loss during delivery, multiple birth) • Men (>/ 18) and Postmenopausal women • no routine screening

  11. Screening for Diabetes • USPSTF (1996) • Insufficient evidence to recommend for or against routine screening in asymptomatic adults • Insufficient evidence to recommend for or against universal screening for gestational diabetes • “Although the benefit of early detection has not been established for any group, clinicians may decide to screen selected persons at high risk of diabetes…”

  12. Screening for Diabetes • American Diabetes Association (1999) • “Based on the lack of high-quality cost-benefit studies, it is premature to recommend screening all high-risk individuals. Thus, the decision to screen for diabetes should ultimately be based on clinical judgment and patient preference. On the basis of expert-opinion, screening of high-risk individuals should be considered at 3-year intervals.” • fasting plasma glucose is recommended screening test (>/ 126 is indication for re-testing)

  13. Screening for Diabetes • American Diabetes Association (1999) • Major Risk Factors for Diabetes • Family Hx (parents, siblings) • Obesity (>/ 20% over desired body wt or BMI >/ 27) • Race (African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, Pacific Islanders) • Age >/ 45 • Prior impaired glucose tolerance • HTN (>/ 140/90) • HDL cholesterol </ 35 and/or TG >/ 250 • Hx of GDM or delivery of babies over 9 lb.

  14. Case 1 (cont.) • PMH: • HTN: mild; ran out of BP meds 3 mos. ago • Rt eye injury 1971 resulting in blindness • Toenail surgery • Meds:none (Atenolol? Until 3 mos. ago) • Allergies:NKDA • SH:Married > 30 y; 2 children; 2 grandchildren; cigarette machine operator; never smoked; rare alcohol; walks occasionally for exercise • FH:negative for colon CA, prostate CA, DM, HTN, early CAD, hyperlipidemia • ROS: “all negative”

  15. Case 1 (cont.) • PE: 97.1 140/95 212 lbs. 6”1” • appears healthy, exam normal except R eye abnormality • Labs? • CBC: Hb 13.5, MCV 78, WBC 6.8k, Plt 226k • SMAC: normal • FLP: chol 152, HDL 40, LDL 93, TG 95 • PSA 0.93 • What next?

  16. Anemia • Definition • arbitrary • WHO frequently used: • men: < 13 g/dL (< 14 g/dL in various hematology texts) • women: < 12 g/dL • pregnant women: < 11 g/dL • Remember - not a diagnosis! • Indication of underlying pathology for which a specific cause should be sought

  17. Approach to Anemia Rice WY. Anemia. In: Ling FW, ed. Primary Care In Gynecology. 1996: 421-440.

  18. Evaluation of Microcytosis Rice WY. Anemia. In: Ling FW, ed. Primary Care In Gynecology. 1996: 421-440.

  19. Diagnosis of Iron Deficiency • Bone marrow is gold standard • Non-invasive lab tests preferred….. • Serum iron • increases with each meal • increases with infections and inflammation • diurnal variation (rises a.m., falls p.m.) • TIBC • increases with oral contraceptives, pregnancy • decreases with inflammation, chronic infection, malignancies, liver disease, nephrotic syndrome, malnutrition • Transferrin sat = (serum iron/TIBC) x 100 • Ferritin • represents storage form of iron • has been shown to be best test …

  20. Diagnosis of IDAGuyatt GH, et al. Am J Med 1990;88:205-209. • Prospective study of 259 consecutive anemic (Hb < 12, men; < 11 women) inpatients and outpatients at two Canadian community hospitals • all pts > 65 yrs old • all underwent BM bx and blood tests • 36% prevalence of iron deficiency; 44% ACD • ferritin best test for distinguishing IDA • above 100 reduces probability of IDA to < 10% • below 18 increases probability of IDA to > 95% • up to 45 increases likelihood of IDA; > 45 decreases likelihood of IDA

  21. ROC Curve - FerritinGuyatt, et al, Am J Med 1990; 88: 205-209 AUC: Ferritin 0.91 Trans. Sat. 0.79 MCV 0.78

  22. Diagnosis of IDA - ROC CurvesMetanalysis of 55 ArticlesGuyatt, et al, J Gen Intern Med 1992; 7: 145-153 AUC: ferritin 0.95 red cell prot. 0.77 MCV 0.76 Trans. Sat. 0.74 RDW 0.62

  23. Serum Transferrin Receptor TfR = serum transferrin receptor TfR-F Index = TfR/log ferritin ratio Punnonen, et al, Blood 1997: 89; 1052-1057

  24. Diagnosis of IDA:Likelihood Ratios Guyatt, et al, Am J Med 1990; 88: 205-209

  25. IDA - Pretest ProbabilityGuyatt, et al, Am J Med 1990;88:205-209 Prevalence of IDA = 94/259 = 36%

  26. Ferritin is an Acute Phase Reactant -Is it Still Helpful? Guyatt, et al, J Gen Intern Med 1992; 7: 145-153

  27. Likelihood Ratios:How Do They Work? ---- inflammatory dz population ___ general population (no inflammatory conditions) Ex:ferritin 30 general population: LR 2; post 50% inflammatory dz pop: LR 4; post 70% pre-test prob 36% (36% prevalence of IDA in Guyatt study)

  28. Iron Deficiency Anemia • Most common type of anemia in US • 3 ways: • inadequate intake (rare in US) • malabsorption (rare in US) • XS loss (bleeding); most common • Prevalence: • adult men 1-2% • premenopausal women 3-5% • postmenopausal women 2% • avg daily intake 10-20 mg; 1 mg absorbed (max 4 mg) • iron loss: • normal: 1 mg/d • menstruating women: 2 mg/day (30 mg per cycle) • pregnant women: up to 5 mg/day (extra 3 mg/d; 3rd trimester)

  29. HannahTwo Years Old!

  30. Allie, Julie, Katy1 Year

  31. Baby Girl Rice #5!20 weeks

  32. Body Iron Supply and Storage(Scientific American Medicine, 1999)

  33. Stages of Iron Deficiency 1. Depletion of stores 2. Iron Deficiency Erythropoiesis 3. Iron Deficiency Anemia

  34. Case 1 (cont.) • Iron profile: • iron 189 (40-160) • TIBC 405 (230-500) • sat = 189/405 = 47% (20-50%) • ferritin 13 (30-300) • What next? • GI tract evaluation... • Lower? • Upper? • Which first? • Both?

  35. Do Symptoms Predict Lesion Sites?(McIntyre, et al, Gut 1993; 34:1102-1107) LGI Lesion + - + LGI Symptoms - Sensitivity = 8/18 = 44% Specificity = 74/93 = 80% PPV = 8/27 = 30% NPV = 74/84 = 88%

  36. Do Lower GI Symptoms Predict Lower GI Lesions in Evaluation of IDA? Rockey NEJM, 1993 McIntyre Gut, 1993 Cook BMJ, 1986 Sensitivity Specificity PPV NPV

  37. Do Symptoms Predict Lesion Sites?(McIntyre, et al, Gut 1993; 34:1102-1107) UGI Lesion + - + UGI Symptoms - Sensitivity = 32/64 = 50% Specificity = 39/47 = 83% PPV = 32/40 = 80% NPV = 39/71 = 55%

  38. Do Upper GI Symptoms Predict Upper GI Lesions in Evaluation of IDA? Rockey NEJM, 1993 McIntyre Gut, 1993 Cook BMJ, 1986 Sensitivity Specificity PPV NPV

  39. UGI Findings in Evaluation of IDAAverage of 5 Prospective StudiesN = 446

  40. LGI Findings in Evaluation of IDAAverage of 5 Prospective StudiesN = 446

  41. Malignant Findings in Evaluation of IDAAverage of 5 Prospective StudiesN = 446 (3 pts) ( 1 pt) * Note: benign dual UGI/LGI lesions in 10%

  42. GI Evaluation of IDA • approach controversial; need to consider: • symptoms (poor correlation with lesions) • if asymptomatic, seems prudent to begin with LGI • age • studies in elderly suggest colonic evaluation necessary even with UGI lesions • dual malignant lesions are rare - • if initial study shows lesion clearly consistent with bleeding, further eval may not be necessary; clinical judgment should guide • if first site normal, other site should be studied • premenopausal women - • role of GI tract evaluation undefined • consider trial of iron unless suspect possible GI blood loss

  43. Case 1 (cont.) • Colonoscopy - internal hemorrhoids • UGI - small hiatal hernia • What next?

  44. When LGI and UGI studies are unrevealing -When should we study the small bowel? • Rockey, et al (1993, NEJM) - 100 patients • enteroclysis in 26 of 38 pts with normal endoscopic studies; normal in all 26 • McIntyre, et al (1993, Gut) - 111 patients • cause for small bowel blood loss was an “infrequent finding” (methods unclear) • one case each of ileal Crohn’s, ileal vascular malformation, Ehlers-Danlos syndrome • Cook, et al (1986, BMJ) - 100 patients • small bowel radiography in 13 patients (“only when clinically indicated” - definition?) • two cases of Crohn’s; both clinically suspected • Hardwick, et al (1997, Br J Surg) - 89 patients • small bowel enema in 14 pts (methods?) • jejunal carcinoma (2); ileal Crohn’s (1) • ileal carcinoid (1) - by colonoscopy

  45. Small Bowel InvestigationRecommendationRockey, NEJM 1999; 341:38-46 • Data do not support routine use of enteroscopy or enteroclysis in initial evaluation of all patients with IDA • reserved for pts with negative studies of the LGI and UGI tracts if: • persistent GI sxs • failed short course of iron therapy • role of routine bx of small intestine to investigate possibility of celiac disease is controversial • reasonable in high-risk groups • Back to our patient …. • Small bowel study? • Trial of iron? • Other history?

  46. Iron-Deficiency Anemia in Blood Donors Finch, et al, Blood 1977;50:441-447

  47. Treatment of IDA • Two goals: (1) ID and rx source; (2) replace iron • oral preferred • parenteral if poor absorption or if poor tolerance of oral preparations • ferrous (vs. ferric) preps. best absorbed and preferred • ferrous sulfate least expensive and most commonly used • most recommend 150-250 mg elemental iron daily (I.e. ferrous sulfate 325 mg tid; 65 mg elemental iron per dose) • GI side effects common • can reduce with food, but may decrease absorption • can decrease dose to bid or qd; may take longer to replenish • enteric coated expensive and ineffective • iron must dissolve in stomach for duodenal absorption

  48. Treatment of IDAResponse to Therapy • Reticulocytosis begins within 3-5 days; peaks 8-10 days • Hb increases by approx 2 g/dL within 1-3 wks; may take 2-4 months to normalize • a practical approach for response is to repeat Hb in 3-4 wks • if inadequate response, consider: • poor compliance • inadequate dosage • malabsorption (gastrectomy, celiac dz, Crohn’s) • concurrent antacid rx (can inhibit absorption) • ongoing blood loss • coexisting infx, inflammation, malignancy • mixed anemia (I.e. IDA and B12 def) • IDA incorrect dx.

  49. Case 1 (cont.) • Prescribed Ferrous sulfate 325 mg bid • 3 months later: • Hb 15.0 (from 13.5) • MCV 89 (from 78) • Ferritin 32 (from 13) • How long should he continue to take iron?

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