COW Week 23

66yo M on dialysis comes for follow up of recent shingles diagnosis, doing well. He was vaccinated for Pneumovax and TDAP at age 62, but not zoster. What vaccine does he need?

a. Pneumovax, Prevnar
b. Pneumovax, Prevnar, Zoster
c. Prevnar, Zoster
d. Pneumovax, Zoster, Tdap


Prevnar is the pneumococcal 13-valent conjugate vaccine (PCV 13). The CDC has updated the recommended adult immunization schedule for 2013. There are new recommendations that Prevnar should be given to patients older then 19years of age with immunocompromising conditions, CKD, nephrotic syndrome, functional or anatomic asplenia, CSF leaks, or cochlear implants. Those previously vaccinated with Pnemovax (pneumococcal polysacchardie, PPSV 23) should still get the PCV 13 vaccine one year or more after their pneumovax vaccine. If your patient has not been vaccinated against either Pneumovax or Prevnar, then they should receive a single dose of Prevnar (PCV 13) followed by a dose of Pneumovax (PPSV 23) 8 weeks later.

Pneumovax should be given to all patients greater then 65years. A single vaccine is sufficiencent. There are a a few conditions that warrant vaccination under the age of of 65 and these include chronic lung diseases, chronic cardiovascular diseases, diabetes, CKD, nephrotic syndrome, chronic liver disease/cirrhois, alcohlism, cochlear impalants, CSF leaks, asplenia, nursing home residents, cigarrete smokers, and immunocompromised conditions. A "booster" shot of Pneumovax (PPSV 23) is required 5 years after the first dose for patients 19 through 64 years of age with chronic renal failure, nephortic snydrome, asplenia, or immunocompromising conditions. Regardless of vaccination status or booster status, all patients over 65 should be revaccinated with Pneumovax as long as it is 5 years past their prior vaccination. This patient had his vaccine 4 years ago so he should wait one additional year prior to revaccination.

Zoster should be given to all patients older then age 60years regardless of whether they have had zoster.

Other Interesting Pearls: Tdap shold be given to pregnant women 27 - 26 weeks gestation regardless of number of years from prior Td and Tdap vaccine to confer better immunity to the infant. Also HPV is recommended for boys starting at age 11 up to age 21.

COW Week 22

34F with ASCUS on current Pap.  Reflex HPV is negative.  PMHX only for hx of 2 abnormal paps in early 20s, with negative colposcopy at that time, followed by normal paps since then until now.  Monogamous, with same partner last 5 years.  Next best step?


1. GYN referral now for colopscopy
2. Repeat both Pap and HPV now
3. Repeat Pap with reflex HPV in 6 months
4. Repeat Pap with reflex HPV in  12 months


Best answer is 4.

This patient has an abnormal pap smear revealing atypical squamous cells of uncertain significance.  Per American Society of Colposocopy and Cervical Pathology Guidelines, there are three pathways for ASCUS-> 1. Reflex High Risk HPV testing 2. Repeat cytology and 3. Colposcopy. 


"A program of DNA testing for high-risk(oncogenic) types of HPV, repeat cervical
cytologic testing, or colposcopy are all acceptable methods for managing women over the age of 20 years with ASC-US.  When liquid-based cytology  is used or when cocollection for HPV DNA testing can be done, “reflex” HPV DNA testing is the preferred approach. Women with ASC-US who are HPV
DNA negative can be followed up with repeat cytologic testing at 12 months." (1)

 "Women who are HPV DNA positive should be managed in the same fashion as women with LSIL and be referred for colposcopic evaluation.  Endocervical sampling is preferred for women in whom no lesions are identified and those with an unsatisfactory colposcopy  but is acceptable for women with a satisfactory colposcopy and a lesion identified in the transformation  zone. Acceptable postcolposcopy management options of women with ASC-US who are HPV positive, but in  whom CIN is not identified, are HPV DNA testing at 12 months or repeat cytological  testing at 6 and 12 months.   It is recommended that HPV DNA testing not be performed at intervals less than 12 months." (1)


Since once of these avenues has already been selected (HPV testing) and we know the result (negative), we do not need to chose the other two avenues. And can feel confident about the low likelyhood of high grade dysplasia/neoplasia.
 

"Human papillomavirus testing is a very effective method of triage for an ASC-US cytology result. With a negative HPV test result, the risk of a precancerous lesion is extremely low. In one large study, the risk of CIN 3 at enrollment in patients with ASC-US cytology and HPV negative co-testing results was 0.28% . In a longitudinal  follow-up study, the risk was 0.54% at 5 years. For comparison, the risk at 5 years was 0.36% for women with normal cytology results alone." (2)



HPV infection is often transient in young females so the patient's prior abnormal paps (with negative colpoloscopy) approx 10 years ago may have represented transient infection that that time.   At this time there is a low likelyhood of CIN-III or invasive cervical cancer so the patient can return wait 1 year (though some guidelines indicated q2 years is routine screening, this patient has now had 3 normal paps, so 12 months is probably appropriate).   Of note it is not recommended to repeat HPV testing within 1 year.

References:

1. Wright TC Jr et al   
2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Screening Tests

J Low Genit Tract Dis 2007 Oct;11(4):201-22.

2. ACOG Practice Bulletin Number 131: Screening for Cervical Cancer.

Obstet Gynecol. 2012 Nov;120(5):1222-38. doi: http://10.1097/AOG.0b013e318277c92a.

COW Week 21

58 yo female with DMII, HbA1C of 6.8, BP 138/80, on lisinopril 20mg, LDL of 70, not on a statin, presents for follow up. What do you do?

1. Increase lisinopril to 40mg
2. start a statin
3. do nothing
4. 1 and 2

A higher maximum systolic blood pressure target for diabetics is one of the most significant changes in the American Diabetes Association's 2013 Standards of Medical Care. The new goal is SBP less than 140 as opposed less then 130. The ACCORD Trial (Action to Control Cardiovascular Risk in Diabetes) assigned type 2 diabetics to intensive BP therapy (less then 120 systolic) and to less then 140 systolic. There were no significant differences in MI, stroke or death from cardiovascular causes or in annual all cause mortality. There were reductions in annual rates of total stroke thus certain patients do require a higher blood pressure goal if they are at high risk for stroke.

The new recommendations also contain changes regarding diabetes self-management education, screening and treatment of cardiovascular risk factors in prediabetes, and emphasizing statin therapy OVER specific low-density lipoprotein cholesterol goals. A summary of the revisions and an executive summary of the standards are online.

http://care.diabetesjournals.org/content/36/Supplement_1/S3.full

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.