The Journal of the Oklahoma State Medical Association最新文献

Neonatal abstinence syndrome from opioids (NAS-O) is a multisystem disorder resulting in neurological and gastrointestinal symptoms from the abrupt discontinuation of chronic fetal exposure to opioids. Increasing opioid use during pregnancy has led to a five-fold increase in NAS-O nationally over the past decade. Several knowledge gaps in our experiences with opioid-exposed neonates have been identified: 1) universal maternal screening; 2) diagnostic tools for newborn abstinence syndrome; 3) optimal treatment protocols; and 4) long-term neurodevelopmental effects of fetal opioid exposure. This review article gives a broad overview of the issues associated with screening, diagnosis, and management of opioid exposure in newborns as well as the issues with collecting accurate outcomes data to monitor efforts aimed at curbing opioid exposure in children and NAS-O. Data specific to Oklahoma is provided, when available.

Background: Reach Out and Read is an evidence based early literacy program used in primary care practices. In 2014, the program expanded to County Health Departments in Oklahoma.

Objective: To evaluate how implementation of the program in Health Departments affects access for at risk children.

Methods: Oklahoma program sites were classified as either Health Department or practice, geocoded, and mapped to census tract, census block group, and county subdivision maps. Sites were classified as rural or urban, and census data was used to classify sites as high or low poverty prevalence and education level. Sites were compared to determine their accessibility to at risk children as defined by living in rural areas, high poverty, and low educational level.

Results: There were 18 Health Department and 67 practice sites. Health Department sites were more likely to be in rural areas: 13 of 18 sites versus 16 of 67 practices (p<0.001). They were less likely to be in areas of high poverty: 10 of 18 versus 61 of 67 practices (p<0.001), and they were not more likely to be in areas of lower education, with 8 of 18 sites in low education areas versus 34 of 67 practices (p=0.8342).

Conclusions: Implementation of Reach Out and Read in Health Departments in Oklahoma increased the number of rural program sites. Health Department locations were less likely to be in areas of poverty and lower education. Use of the program in Health Departments is an effective way to expand the program to serve rural children.

Importance: Nonalcoholic fatty liver disease (NAFLD) is rapidly evolving into one of the most common pediatric liver diseases and currently is the most common cause for liver transplantation in young adults. Therefore, early recognition of risk factors, disease prevention, and diagnosis during childhood is paramount for effective management.

Objective: The primary objective of this review is to discuss updated recommendations for screening, diagnosis and management of NAFLD. The secondary objective is to review the extent and impact of pediatric NAFLD in Oklahoma through our center's participation in a multi-center prospective study.

Evidence review: We reviewed updated guidelines from the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), the approach used in our clinic and data from a multi-center collaboration on NAFLD, known as TARGET-NASH.

Findings: Our review highlights that obese and Hispanic children are at greatest risk for developing NAFLD. Screening with ALT should be considered between ages 9-11 years for children with BMI more than the 95^th percentile. Liver biopsy is the gold standard for diagnosis of NAFLD and currently lifestyle modification is the only effective therapy for management of NAFLD.

Conclusion and relevance: All obese children, especially those who are Hispanics or have a family history of NAFLD should be considered for screening with serum ALT between the ages of 9 and 11 years. Children with ALT values that are elevated more than twice the upper limit of normal for more than 3 months must be referred to pediatric hepatology for timely evaluation.

Clinical question: In adults with osteoarthritis of the knee, do conservative management methods such as weight reduction, physical therapy, Tai Chi, non-steroidal anti-inflammatory drugs (NSAIDs), and others provide more and longer pain relief and functionality of the knee, as well as overall well-being, when compared to corticosteroid knee injections?

Answer: Yes. Although there are limited head-to-head trials directly comparing each alternative method to corticosteroid injections, overall evidence appears to indicate conservative methods as being more effective than injections, especially when considering long-term pain relief and functionality.

Delivery occurs before 37 weeks in up to 12.7 percent of all births in the United States with many more pregnant women experiencing preterm labor.¹ Current therapy includes corticosteroids to hasten fetal lung development administered from 24 to 34 weeks of gestation, tocolysis, antibiotics for infections, and Group B streptococcus prophylaxis when indicated. Further study has been completed to determine risks and benefits of repeated doses of corticosteroids for women who have previously been treated but are still at risk for preterm delivery after 7 days. Research has shown decreased mortality for neonates after delivery and no long term impairments when comparing repeated to single courses.

While screening for dementia in patients without symptoms is not recommended by the United States Preventative Services Task Force (USPSTF), screening in those presenting with symptoms may help patients and caregivers prepare for the future. When selecting which screening tool to use in a primary care office, one needs to consider practicality, feasibility, applicability, and psychometric properties. The MIS, MiniCog, PhotoTest, and GPCOG have been found to have short administration times, good accuracy, and applicability for a broad range of patient education and backgrounds. The BAS, MiniCog, PhotoTest and MAT have been found to be the most accurate tests. However, the evidence is limited and more studies need to be done to accurately answer the presented question.

Clinical question: In menopausal women who experience regular hot flashes, does treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) reduce the frequency and/or severity of hot flashes?

Answer: Yes. Review of the literature suggests that treatment with SSRIs or SNRIs reduces the frequency and severity of hot flashes in menopausal and post-menopausal women. Studies demonstrated that paroxetine (Paxil), citalopram (Celexa) and escitolapram (Lexapro) were the most effective SSRIs, and venlafaxine (Effexor) was the most effective first line SNRI, with desvenlafaxine as a second option. The most common side effects reported for both SSRIs and SNRIs are nausea and constipation, with most resolving within the first week of treatment. SNRIs have been associated with increased blood pressure in some patients and should be used with caution in women with hypertension. Women with a history of breast cancer and taking tamoxifen should avoid SSRIs, which have been shown to interfere with tamoxifen metabolism. SNRIs are the safest drugs for this population. Treatment choice should be patient-specific and begin with the lowest dose available.

Level of evidence for the answer: A.

Search terms: SSRI, SNRI, hot flashes, vasomotor symptoms, menopause.

Search conducted: August 2014, February 2016 and August 2016.

Inclusion criteria: menopausal, perimenopausal or postmenopausal women 18 years of age or older with frequent and/or severe vasomotor symptoms, meta-analyses, systematic reviews, randomized controlled trials, cohort studies.

Exclusion criteria: pre-menopause, anxiety, depression, panic disorder, bipolar disorder, co-morbid conditions.

ANSWER: Insufficient evidence. DATE ANSWER WAS DETERMINED: June 28, 2016. PROGRAM NAME: Great Plains Family Medicine Residency Program, Oklahoma City, OK.