COW Week 20

A 42yo F is admitted for asthma exacerbation. She responds well to steroids, albuterol, and atrovent in the ED. What will you give her on the floor?

a. Albuterol, atrovent, steroid, azithro
b. Albuterol, atrovent, steroid
c. albuterol, steroid
d. albuterol, steroid, azithro

Practice guidelines recommend against antibiotics as most infections that trigger exacerbations are secondary to viral organisms, not bacterial.

The National Asthma Education and Prevention Program Expert Panel updated their guidelines in 2007. They recommend against inhaled anticholingerics in pure asthma patients during hospitalization. These agents are recommended as add-on therapy in the ER when a patient does not respond to a beta-agonist. Inhaled ipratropium should not be given as monotherapy in the ER because of it's slow onset of action. The combination of the two agents in the ER "has been shows to reduce rates of hospitalization by 25%" but no clear benefits have been shown for the combination once a patient has been admitted (Chest. 1996;110(3):611)

Article Showing Positive benefits of anticholingerics in Asthma
NEJM Review Article on Asthma

COW Week 19

Your 82yo M patient with ischemic CM (EF 40%) presents to clinic with DOE, 3 pillow orthopnea, and elevated JVP. His BNP is 550. He returns one week later after aggressive diuresis with 1 pillow orthopnea, reduced JVP, and less dyspnea. His BNP is 520. What do you do?

a. increase diuresis
b. admit the patient to CCU
c. decrease diuresis
d. refer for AICD



The purpose of this question is to emphasize that BNP is not a reliable indicator for clinical response to diuresis and CHF management in patient's over the age of 80. However, BNP can be useful in younger patients. This was demonstrated in the TIME-CHF trial. 499 patients with NYHA class II or greater, LVEF less then 45%, prior CHF hospitalization in the last year, and bnp greater the 2x the upper limit of normal were randomized to therapy aimed at improving clinical symptoms vs. improving clinical symptoms and reducing BNP. The study showed that “heart failure therapy guided by N-terminal BNP did not improve overall clinical outcomes or quality of life compared with symptom-guided treatment.”

In TIME-CHF, there was no significance in the primary outcomes of 18-month survival free from any hospitalization of quality of life for the total cohort for BNP-guided management vs. symptom-guided management. Given the lack of significance in the primary outcome, subgroup analyses need to be interpreted with caution. However, for patients less then 75 years, there was significant benefit for hospital free survival and overall survival. For patients greater then 75 years, there was no significant difference in hospital free survival or overall survival. 

There are other situations in which BNP is not as reliable besides age and these include obesity and renal failure. BNP levels are inversely related to BMI.


References for BNP and obesity:

Wang  T.J., Larson  M.G., Levy  D., Benjamin  E.J., Leip  E.P., Wilson  P.W., Vasan  R.S.;  Impact of obesity on plasma natriuretic peptide levels, Circulation 109 2004 594-600

Mehra  M.R., Uber  P.A., Park  M.H., Scott  R.L., Ventura  H.O., Harris  B.C., Frohlich  E.D.;  Obesity and suppressed B-type natriuretic peptide levels in heart failure, J Am Coll Cardiol 43 2004 1590-1595

McCord  J., Mundy  B.J., Hudson  M.P.;  et al.  Relationship between obesity and B-type natriuretic peptide levels, Arch Intern Med 164 2004 2247-2252

COW Week 18

43yo female comes to clinic with dysuria and frequency. Urine culture grows E. Coli ESBL. How do you treat her?
a. Ertapenem x 3 days
b. Ertapenem x 7 days
c. fosfomycin
d. cipro

This patient has an uncomplicated cystitis which generally warrants 3 days of treatment with antibiotics. Having an ESBL urine infection does not automatically qualify the infection as complicated, thus a 7-10 day course is unnecessary. Fosfomycin has been shown in studies to be an effective oral therapy for uncomplicated cystitis from ESBL. One study had antimicrobial susceptibility testing was carried out on  isolates of E.Coli ESBL in the outpatient setting. "Susceptibility rates indicate that fosfomycin (97%), nitrofurantoin (94%), and pivmecillinam (85%) could be considered important oral treatment options."

here are some articles on the subject
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2935012/
http://www.ncbi.nlm.nih.gov/pubmed/17189097
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2809%2970325-1/abstract

COW Week 17

61 yo patient with diabetes (HbA1c 7.2 on metformin) has been on Lipitor 80mg for over one year. His LDL is 146, HDL is 44, Tg are 118. How should you address his lipid profile?

a. add Zetia 10mg/day

b. change Lipitor to Crestor

c. add Niacin

d. add another statin

The first thing one should do is ensure the patient is taking the medication correctly and adhering to a strict diet and exercise regiment. The next step would be to try a more potent statin (Crestor).

Zetia has been show to decrease LDL by 14-17% when combined with a statin, however there is no evidence that addition of Zetia has any effect on mortality or cardiovascular outcomes.

The ENHANCE trial randomized patients to simvastatin 80mg with or without ezetimbide 10mg daily. Combination therapy provided a significant LDL decrease and HDL increase. However, there was no difference in primary outcome of carotid intima-media thickness or cardiovascular events.  The ARBITER 6-HALTs trial took patients with CHD or CHD equivalents who were already on statins and randomized them to niacin or ezetimibide. Addition of Niacin had better outcomes then addition of ezetimibide. We already know from the AIM-HIGH trial that niacin really provides no benefit in patients already on a statin. Thus, all this data seems to suggest that the addition of ezetimibe does not provide clinical benefit. Additionally, ezetimibe has some potential concerning side effects including a possible cancer link that was noted the SEAS trial.

In the absence of an indication other than prevention of CHD, do not treat patients with another lipid-lowering medication in combination with a statin even if the LDL-C is not at goal. There is a theory that the actual statin itself is more important than the LDL goal. Some advocate only adding on a second lipid lowering agent if the LDL is still greater then 160. 

The ATP 4 committee is actually discussing this issue right now and we asked our expert for insider information. Unfortunately, it is classified, so all we can advise is that it is a grade E recommendation (ie: expert opinion but little or no data to support it) to consider adding a second class of lipid lowering drugs in select patients. 

Statins are the only lipid lowering class of drugs to demonstrate clear improvements in overall mortality in primary and secondary prevention. It is reasonable to try a different statin as you may see better results and Crestor is more potent then lipitor.

COW week 16

40 yo F admitted for CAP, Has PCN allergy, no other PMHx. Febrile to 102.3, HR 105. BP 122/67. O2 is 96% on 2LNC. Patient is placed on levofloxacin. In addition to DVT Px, what other preventive measures should be considered?

Pepcid 20 mg po BID
Lactobacillus 1 cap Daily- Correct Answer
Protonix 40 mg daily
Pneumovax




Rationale:

This patient is healthy and has become ill with community acquired pneumonia.  Based on the question stub, there is no prior history of pneumonia or other recurrent infections. There is no data the pneumovax in indicated in patients presenting with CAP without other indications for Pneumovax

From the CDC  website- Adult indications 23-Valent Pneumococcal Polysaccharide Vaccine

• All adults 65 years of age and older.
• Anyone 2 through 64 years of age who has a long-term health problem such as: heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid or cochlear implant.
• Anyone 2 through 64 years of age who has a disease or condition that lowers the body’s resistance to infection, such as: Hodgkin’s disease; lymphoma or leukemia; kidney failure; multiple myeloma; nephrotic syndrome; HIV infection or AIDS; damaged spleen, or no spleen; organ transplant.
• Anyone 2 through 64 years of age who is taking a drug or treatment that lowers the body’s resistance to infection, such as: long-term steroids, certain cancer drugs, radiation therapy.
• Any adult 19 through 64 years of age who is a smoker or has asthma.
• Residents of nursing homes or long-term care facilities.

Given that this patient has 1 episode of CAP, she does not meet criteria for any of the above so should not have the testing.  Of note, the patient only has a 25% chance of having her CAP from Penumococcus to begin with:

Percentage of pathogens in CAP in inpatients NOT admitted to ICU:

S. pneumoniae 25% Respiratory viruses10% M. pneumoniae 6% H. influenzae 5% C. pneumoniae  3% Legionella species 3% Unknown 37%
	With regard to GI prophylaxis with PPI or H2 Blocker- the indications for Stess Ucler Prophylaxis are as follows: Coagulopathy (plts<50 inr="inr">1.5, ptt> 2x over control) Mechanical Ventilation > 48 hours Traumtic Brain or Spinal cord injury Severe Burns  2 or more of the following: Sepsis, ICU x7+days, GI bleed without a source >6 days, or equivalent prednisone dose 50 mg/day or more The patient meets none of these critera and has no hx of GERD or PUD so does not require acid suppression.  The addition of a PPI is associated with increased risk of C. Diff colitis The patient is on antibitiotics for her infection, and fluroquinolones are associated with risk of C. Diff Colitis.  A recent meta-analysis published online ahead of print in the Annals of Internal Medicine (www.annals.org) found that in 13 trials, patient on antibiotics who were given probiotics had a reduced the incidence of C. Diff associated diarrhea by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]).  Though there was variability of the type and dose of probiotic, the effect size was large.   Thus in this patient, probiotics (in this case lactobacillus caps) may be considered to reduced her risk of complications from her antibiotic therapy.

COW Week 15

39yM presents with left facial droop x 2days. No other neurologic symptoms. Given forehead muscle involvement, hyperacusis, you diagnose him with Bell's Palsy. What do you do now?

A) Valacyclovir x 7 days

B) Prednisone x 10 days

C) Prednsione and Valacyclovir

D) Observation  

 Answer: B (C is also acceptable)

Up to 30% of patients with Bell's Palsy fail to recover facial function completely. The disease is common, with an annual incidence of 20 per 100,000 leading to thousands of patients per year with facial weakness. In the updated guidelines from the American Academy of Neurology, oral steroids are recommended for new-onset Bell's palsy to improve recovery of facial function. In these guidelines, 9 studies were identified comparing steroids and antivirals to placebo for Bell's Palsy. Regarding oral steroids, 2 class 1 studies comparing oral prednisolone to placebo for 10 days showed a significant improvement in complete facial recovery translating to a Number Needed to Treat of 6-8 people to achieve one complete recovery.  Regarding antivirals, there was no evidence of any benefit however, the authors conclude that the statistical power was insufficient to exclude a small benefit or harm and some believe that antivirals carry an additional benefit when added to steroids. The academy says that antivirals may be offered in addition to steroids, but patients should be counseled that the benefit is unknown and likely modest at best. 

In Journal Watch Neurology, Robert T. Naismith comments: "The side-effect profile for oral glucocorticoids is relatively favorable, and a 10-day course can be recommended within 3 days after facial-weakness onset. If the patient is evaluated for treatment after 3 days, the benefit may be smaller, and treatment would be up to the judgment of the physician and patient."

Lastly, remember to consider other etiologies such as Lyme, VZV, HSV, rarely HIV, Sjorgren's, Sarcoid and others as some of these do require alternative treatments.

 American Academy of Neurology Updated Guidelines on Bell Palsy

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.