COW Week 14

34 yo F presents for WH appt. Feels well, reports mild non-purulent vaginal discharge x2 months. Monogamous x4 years, no hx of STI. Speculum exam normal, wet mount/koh prep negative. Pap returns normal except rare trichomonas. What next?

1. Intravaginal metronidazole gel (0.75%) once daily for five days
2. Metronidazole 2g po xi
3. Metronidazole 500mg po BID x7d and treat partner
4. New specimen for Fungal and T. vaginalis Cultures -Correct Answer



This is a healthy patient with questionable symptoms (her discharge may also be physiologic).  She is not in a high risk group, and trichmononas, though a common disease, is an unlikely cause in this patient and is a surprising finding.  The most common vaginal discharges are BV, Trich and Candida.  Of the "bedside" tests, the Wet Mount has the best sensitivity (clue cells:sensitivity 98.2%, specificity 94.3%, positive predictive value 89.9%, negative predictive value 99.0%).  The Whiff Test is also relatively sensitive. BV is thus ruled out by the the findings.  Of note Intravaingal Metronidazole is a treatment only for BV, not TV.

KOH prep is not particularly sensitive 60% for vulvovaginal candidasisis (a more likely Dx than Trich in this patient).  If symptoms persist, it may be reasonable to send for gram stain/fungal culture in this patient to clarify the diagnosis. Also fungal culture is indicated if patient has failed Rx for candida to look for non-abicans species.

Wet mount is not particularly sensitive for T. vaginalis (40–70%), especially if there is time lag in sample transport.  Trich is likely under diagnosed as a result, and further investigation is warranted, especially in patients treated for Candida or BV (without partner treatment-as males are almost always asymptomatic). The wet mount does have good specificity for Trich.  Patients with history of STIs should be investigated for T. vaginalis (along with CT/GC) if they have any symptoms of discharge. Any patient that is diagnosed with T. Vaginalis should have partner treatment as well to reduce risk of re-infection, and barrier methods should be used until treatment is complete.

However, in this case we have the opposite situation. We doubt the diagnosis of TV as it did not show up on bedside tests and the patient is not high risk.  The specificity of cytology for trich is such that in an endemic area or high risk population, treatment can be based upon a positive result, but not in low risk/low endemic area. In this case, it's reasonable for us to use a more sensitive and specific test for trichomonas: either culture or PCR to confirm diagnosis. In addition, fungal culture would help rule out candidaisis. 

 Sherrard J, Donders G, White D, Jensen JS; European IUSTI. European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011. Int J STD AIDS. 2011 Aug;22(8):421-9.

COW Week 13

A 58 yo American female presents to establish care. She has a history of exercise induced asthma and HTN but is otherwise healthy without bad habits. What test should be part of your health maintenance screening?


a. DEXA
b. Hep C- Correct Answer
c. Zoster Vaccine
d. TSH

The Centers for Disease Control and Prevention (CDC) now recommends screening for all persons in the United States born between 1945 and 1965. This is a new recommendation as of 2012. This was based on a mathematical model that showed theapproach of 1-time screening for hepatitis C in this birth cohort followed by treatment was cost-effective. 

Annals of Internal Medicine February 2012

Dexa scan is recommended in females >65: The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. The patient has no additional risk factors so should NOT be screened

USPSTF- Osteoporosis Screening

Zoster Vaccine in recommended by the CDC in patients without contraindications. This patient does not meet criteria based on age.

Shingles

There is insufficient evidence for thyroid screening in asymptomatic adults

USPSTF- TSH

COW Week 12

64 yo M presents to establish care. Has CAD, HTN, DM-II.  He feels well, had recent negative stress test with his cardiologist, has good exercise tolerance.  Meds are metofromin/glipizide, metoprolol, ASA, lisinopril, fish oil and atorvastatin. Labs: Cr 1.1, A1c 7.1, HDL 30, LDL 68, U protein/CR Ratio 450mg/day.  Echo shows EF 40%.

What should you do:

Add Niacin

Change MTP to Coreg

Add Losartan- Correct Answer

Change glipizide to insulin basal/bolus

This patient's CAD is well controlled and though he has a low EF he does not have clinical evidence of CHF. The patient's EF does not necessitate a change to carvedilol .  The landmark Comet Trial compared long-acting Metoprolol (Toprol XL) to Carvedilol (Coreg) in NYHA Class II-V CHF with EF 35% or less. The results showed improvement in these patients with Carvedilol.   This patient does not have symptomatic CHF and his EF is 40% so he does not meet inclusion criteria for this trial and thus does not have in indication for a change in Beta Blocker Therapy.
 
 The patient's LDL is a at goal, and he is on fish oil, however he has low HDL.  Currently there are limited effective therapy to raise HDL other than statins and fish oil.  Niacin is controversial.

The patient's A1c is at/near goal, there is no indication to change his hypoglycemics to insulin at this time.  However, the patient has evidence of nephropathy, and his proteinuria is not controlled by his ACE-I.  Thus he requires dual RAAS inhibition, which will confer now additional anti-hypertensive benefit but will decrease his proteiuria,.

Adding an ARB is currently not recommended in patients with CHF on an ACEi + BB but still symptomatic. A Cochrane review of outcomes of ARB plus ACE inhibitor therapy to ACE inhibitor therapy alone in patients with HF was dominated by the Val-HeFT and CHARM-Added results [3,12,13]. There were no statistically significant differences in total mortality (RR 0.98, 0.90-1.06), cardiovascular mortality, or non-cardiovascular mortality between combined ARB plus ACE inhibitor and ACE inhibitor monotherapy. Combination therapy reduced hospitalization for HF compared to ACE inhibitor therapy (RR 0.81, 95% CI .074, 0.89) but did not reduce total hospitalizations. Withdrawals due to adverse effects were more frequent with combination therapy

Poole-Wilson  PA  et al Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial.
Lancet. 2003 Jul 5;362(9377):7-13.

Cohen DL, and Townsend RR Is There Added Value to Adding ARB to ACE Inhibitors in the Management of CKD?JASN August 1, 2009 vol. 20 no. 8 1666-1668

COW Week 11

Your 60yo male patient has COPD (FEV1 50%, FEV1/FVC 60%). He is compliant with his Advair and prn Combivent (with good technique) and stopped smoking 2 years ago. He is enrolled in pulmonary rehab and has a normal resting and ambulatory oxygen saturation. He has had 4 exacerbations in the past year. His other medications include lisinopril and atorvastatin and he has no cardiac history. What should be your next step?

a. Azithromycin 250mg MWF
b. EKG
c. Lung Reduction Surgery
d. Oxygen

Acute exacerbations of COPD portend to further morbidity. Each exacerbation increases the rate of FEV1 decline by an additional 2ml or 7ml per year in non-smokers and smoker respectively. The cost to society is also high. Treatment of COPD includes smoking cessation, pulmonary rehab, anti-cholinergics, beta-agonists, and glucocorticoids. Some patients, despite maximal therapy, may still have uncontrolled disease. Macrolides have anti-inflammatory and immune-modultating effects and may decrease the production of cytokines in the lungs (Role of Macrolide therapy in COPD. Int J Chron Obstruc Pulmon Dis 2008;3:331-50). Thus, these have been studied in COPD.

NEJM published a study in 2011 showing daily use of azithromycin 250mg reduced the frequency of acute exacerbations of COPD (NEJM Article). The median time to the first acute exacerbation was increased by 92 days compared to the placebo group (266 days compared to 174 days). Quality of life was also improved per the St. George's Respiratory Questionnaire. There was no statistically significant difference in mortality. Similar results were found in a trial using erythromycin (Am J Respir Crit Care Med 2008; 178:1139-47).

Long-term use of azithromycin comes with many concerns including prolonged QT (greater than 450), ototoxicity, drug interactions, and possible antibiotic resistance. The risk of torsades is of great concern. It is because of these side-effecs that the GOLD report guidelines stated that despite it's proven efficacy azithromycin is "not recommended because of an unfavorable balance between benefits and side effects" (GOLD Report).

Many expert believe it is still safe and reasonable to add azithromycin if proper baseline screening is done.  Important baseline tests include heart-rate, QTc, audiography,  LFTs, and medicationreview. If the patient is taking a QTc prolonging agent, has a baseline QTc greater than 450, or has a significant cardiac history (CHF, hx of stroke) then azithromycin is not recommended. Additionally it is not recommended if the patient has an abnormal audiogram or LFTs greater then 3x the ULN. If these tests are normal then it is reasonable to start a trial of azithromycin, but only in those patients who continue to have frequent COPD exacerbations despite being on maximal therapy (~ 2 or more a year). Expert opinion favors three times a week dosing, despite the trials using a daily dose based on pharmacokinietics of the drug. This may also minimize the side effects. (NEMJ Clinical Therueptucis article). They also recommend repeating EKG, audiography, and labs every three months to monitor for side effects. Some experts suggest obtaining a baseline sputum culture to asses for nontuberculous mycobactermia as well.

Therefore, for this patient the answer is to obtain a baseline EKG and hearing test. If normal, it is reasonable to start azithromycin three times a week with monitoring of side effects.

This case is based on the following article: NEJM Clinical Therapeutics of COPD:

COW Week 10

29yF presents with fever, sore throat, tonsillar exudate, anterior cervical LAD, no cough. Rapid strep negative. What is the next step? Pt has no allergies?

1) PCN V
2) Send Home
3) Send Throat Culture, start PCN
4) Augmentin

The correct answer is 2, Send Home. 

The IDSA just came out with new guidelines on September 9th 2012 for management of strep throat. GAS is the most common bacterial cause of acute pharyngitis, responsible for 5%–15% of sore throat visits in adults and 20%–30% in children. The main reason to treat strep throat is to decrease the chance of rheumatic fever and suppurative complications of strep throat. However, in adults, the chance of developing rheumatic fever is very small. We've all heard about the Centor criteria to diagnose strep throat. The 4 criteria are: Reported fever, anterior cervical LAD, lack of cough, tonsillar exudate. If the patient has 0 or 1 of these criteria this has pretty good negative predictive value and you can stop there. Generally, adults do not need to be tested for strep throat if they have a cough, runny nose, hoarseness and mouth sores, which are strong signs of a viral throat infection. However, strep and non strep symptoms have such overlap that even if a patient meets all 4 of the Centor criteria, there is a positive predictive value of only 35-55% leading to significant over treatment with abx that the IDSA says is unacceptable.  Because of this, treatment for strep throat should only be given with a positive diagnostic test, with rapid recommended over culture. If culture is chosen, you should wait until the culture is positive before giving abx even though it may delay treatment a couple days. Lastly, given the low frequency of strep complications in adults, a negative rapid strep test, even in the setting of 4 centor criteria, is enough to send the patient home without any further diagnostic studies. Cultures do not need to be sent to confirm the diagnosis.

The take home points are:
1) Rapid antigen/culture should be performed to diagnose and treat GAS pharygitis. Negative rapid should not be followed with a culture in adults.
2) Clinical Criteria has good negative predictive value, however, it is not specific enough to make a diagnosis alone.
3) PCN or Amoxicillin x 10 days is the treatment of choice for nonallergic patients
4) If PCN allergic, 10 day course of 1st generation cephalosporin, clindamycin, clarithromycin or 5 days of azithromycin can be used.

Click on the link below to see the new guidelines:
IDSA GAS Pharyngitis 2012 Guidelines

COW Week 9

37yo male complains of left leg painful swelling. Ultrasound confirms popliteal DVT. There was no antecedent trauma, surgery, hospitalizations, or trips. Family history is negative and thrombophilia workup is negative. After three months of warfarin therapy, what is the next step?

1. Continue Warfarin for 1 year
2. Stop Warfarin
3. Countinue Warfarin indefinitely
4. Stop Warfarin and start aspirin
5. Further diagnostic testing

After an idiopathic thrombotic event, the 10-year risk of recurrence is about 30 percent. The risk of major bleeding while on warfarin therapy is approximately 2 percent per year when warfarin is well managed. Therefore, it can be helpful to to further risk stratify patients which can be done with D-Dimer testing or lower extremity doppler ultrasound.

The Prolong Trial assessed using D-Dimer testing to determine the duration of anticoagulation. This was a prospective trial that evaluated 600 people with idiopathic DVT after 3 months of therapy with warfarin. Their D-Dimer was checked one month after stopping warfarin and if it was abnormal the patients were randomized to further anticoagulation or no therapy. The risk of venous thrombosis if you had a positive D-Dimer and you were left off of warfarin therapy was approximately 10 percent per year. A negative D-Dimer predicted a risk of recurrence of about 3 percent per year

The DACUS trial looked at 250 patients who had on warfarin for at least 3 months and then assessed residual thrombus by ultrasound. If there was residual thrombus, then they randomized patients either to resume warfarin or to stop warfarin; if there was no residual thrombus then they simply stopped warfarin therapy. Patient's without evidence of thrombosis had a low risk of DVT recurrence suggesting continued warfarin therapy was unnecessary in this group past the three month window.

The take-home points for unprovoked deep vein thrombosis are that the risk of recurrence is relatively high. The risk of major bleeding while on warfarin therapy is approximately 2 percent per year when warfarin is well managed. Using risk stratification tools such as D-Dimer and a duplex ultrasound for residual vein thrombosis can help guide your management.

Prolong Trial:
DACUS Trial:

COW Week 8

A 60 yo male is admitted  for his 3rd episode of diverticular lower GI bleeding. Surgery evaluates him for hemicolectomy. He has ETOH cirrhosis and his last drink was 1 week ago. His Child-Pugh class is C and MELD score is 23. He denies chest pain or DOE. Exercise tolerance is 8 Mets and his ECHO shows an EF of 65%. You are asked for a preoperative evaluation.

Which of the following is the best recommendation for his elective surgery?
a. Delay surgery 7-10 days
b. Delay surgery indefinitely until risk improves
c. Proceed with surgery without further risk stratification
d. Recommend against elective surgery

While this patient has no active cardiac conditions and a fair-moderate exercise tolerance, he is still a poor surgical candiate in terms of his liver disease and elective surgery should be avoided. Child-Turcotte-Pugh class A, B, anc C have a 10%, 30%, and 80% postoperative mortality respectively. Patients with MELD score greater then15 are also considered to be at greater risk for postoperative mortality. Other risk factors in cirrhotic patients include age greater then 70yrs, obstructive jaundice,and  portal hypertension. Therefore, elective surgeries are avoided in these patients.

Risk Factors for Mortality After Surgery in Patients With Cirrhosis: Gastroenterology. 2007; 132(4):1261-1269