Sample Clinical Cases 15

Sample Clinical Cases Version 15.2

Table of Contents

1. Adult Primary Care, Internal Medicine, and Family Medicine Cases Pages 4-6 You have a 70 year-old healthy man whose brother just died from a ruptured abdominal aortic aneurysm

(AAA). Should he be screened for AAA? What is the best treatment for a patient who has renal insufficiency and now presents with an acute gout

attack in his first metatarsal joint? How beneficial is Echinacea in treating and preventing colds?

2. Cardiology Cases Pages 7-9 You have a patient with New York Heart Association class II heart failure, and left ventricular ejection

fraction of 32 percent, and a QRS duration of 130 msec. Is this patient a candidate for cardiac resynchronization therapy (CRT)?

You have a 63 year-old woman who, after a stressful event, presented with what looked like an acute myocardial infarction causing hypotension. Angiography showed no critical lesion and she rapidly and completely recovered. Was this incident stress-induced cardiomyopathy? If so, is she at risk for recurrence?

A patient presents to the emergency department with chest pain. The initial ECG demonstrates two to three millimeters of ST elevation in leads V2 through V6. His heart rate is 80 beats per minute, blood pressure 136/84. Although short of breath, oxygen saturation is 96 percent on two liters via nasal cannula. He reports that his chest pain began approximately 2 hours ago. Your hospital does not have primary percutaneous coronary intervention (PCI) capability. Should you administer fibrinolytic therapy immediately, or arrange to transfer the patient for primary PCI?

3. Endocrinology Cases Pages 10-12 A 58 year-old postmenopausal woman is experiencing stress urinary incontinence that is interfering with

her quality of life. She is not having hot flashes, but she has heard that estrogen therapy is very effective for urinary incontinence. What advice do you give her?

A 55 year-old woman with primary adrenal insufficiency was recently told by a friend that she should start taking DHEA for libido. Is it effective? What dose should she use?

Is Denosumab an effective drug for osteoporosis? 4. Gastroenterology Cases 3-14 You performed an upper endoscopy with biopsies on a patient with longstanding heartburn. The

pathology report describes intestinal metaplasia with low grade dysplasia. What should be your next steps?

You are asked to see a 25 year-old Asian man with chronic hepatitis B who is HBsAg (+) and HBeAg (+) with serum HBV DNA of 700 million copies/mL. He has mild inflammation on biopsy. His serum ALT is 100 IU/L (upper limit of normal 40 IU/L). What is the appropriate treatment?

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5. Hematology and Oncology Cases Pages 15-17 You have an elderly patient who needs therapy for an advanced stage of the aggressive non-Hodgkin's

lymphoma diffuse large B-cell lymphoma (DLBCL). What is the recommended treatment? You have a patient with newly-diagnosed acute promyelocytic leukemia. What are the overall

recommendations for initial treatment, including remission induction, consolidation, monitoring for remission status, and maintenance therapy?

You have a patient with newly-diagnosed metastatic adenocarcinoma of the lung. The patient is a non-smoker. Should you add bevacizumab to the initial chemotherapy regimen?

6. Infectious Diseases Cases Pages 18-19 You are seeing an injection drug user in the emergency department who has symptoms consistent with

primary HIV infection. What tests should you order to confirm this diagnosis? You have just diagnosed a patient with chronic HIV infection and want to know which opportunistic

infections your patient is at risk of developing and what may be the appropriate therapy. The patient’s CD4 count is 75 cells.

7. Nephrology and Hypertension Cases Pages 20-21 Is adding the drug Cinacalcet to your usual therapy better than just traditional therapy to achieve

K/DOQI goals for bone metabolism in dialysis patients? You have a patient with IgA Nephropathy. What is the role of immunosuppressive therapy, and what is

the best regimen for a patient with relatively normal kidney function but persistent proteinuria despite appropriate dose of angiotensin inhibition?

8. Obstetrics, Gynecology and Women’s Health Cases Pages 22-24 A 42 year-old pre-menopausal woman comes in for her annual gynecological visit. Her history and

physical examination are unremarkable. However, her Pap smear report indicates the presence of benign endometrial cells. What is the next step?

A 28 year-old woman comes in with her 4th vaginal yeast infection this year. Because of the recurrent infections, a culture is taken which indicates Candida glabrata. How should this type of yeast infection be treated?

What is the recommended approach to treatment of gestational diabetes mellitus? 9. Pediatrics Cases Pages 25-26 It is 11 o'clock on a Friday morning and you are seeing an 18-month old child with mild symptoms of

classic croup. He has no retractions or stridor at rest but you are concerned that his symptoms may worsen in the evening hours. Should you prescribe dexamethasone?

You are seeing a four month old infant who was hospitalized at two months of age with culture-proven pertussis. Should she receive a pertussis containing vaccine at this visit?

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10. Pulmonary, Critical Care, and Sleep Medicine Cases Pages 27-28 A patient was admitted to the intensive care unit two days ago with septic shock. He was treated with

antibiotics, intravenous fluids, vasopressors, and hydrocortisone. His vasopressor requirement has not decreased. His serum cortisol increased 15 mcg/dL after high-dose ACTH stimulation. Should the hydrocortisone be discontinued?

How effective is long-term warfarin at preventing recurrent pulmonary embolism?

11. Rheumatology Cases Pages 29-30 What are some treatment options for an adult with dermatomyositis whose disease does not respond

adequately to prednisone and azathioprine? How is gouty arthritis prevented in a patient with renal failure?

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Adult Primary Care, Internal Medicine and Family Medicine Clinical Case #1

Question: A 70 year-old healthy man tells you that his brother just died from a ruptured abdominal aortic aneurysm (AAA). He wants to know if he should be screened for AAA and if he has increased risk? Answer: Type aaa

Select topic Screening for abdominal aortic aneurysm

Point out the author/date

Go to the outline

Click on section EPIDEMIOLOGY AND RISK FACTORS, which summarizes the risk with a positive

family history Click on reference 7 to show an abstract

Go to the outline

Click section SUMMARY AND RECOMMENDATIONS — ANSWER

o (7th bullet) Yes, he should be screened and is at increased risk. We recommend one-time screening

for AAA in men ages 65 to 75 who have never smoked but who have a first-degree relative who required repair of an AAA or died from a ruptured AAA.

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Question: What is the best treatment for a patient who has renal insufficiency and now presents with an acute gout attack in his first metatarsal joint? Answer:

Type gout Select topic Treatment of acute gout

Point out the author/date

Go to the outline

Under header SPECIAL CIRCUMSTANCE, click on Advanced renal failure — ANSWER

o (Last sentence, 1st paragraph) Such patients can be safely treated with intraarticular or oral

glucocorticoids as described above.

Scroll down to reference 17 to show an abstract

Scroll up to the section on GLUCOCORTICOIDS which discusses intraarticular (i.e. injection directly into joint) and systemic (i.e. oral) steroid regimens

Click on Colchicine to show drug information

Go to outline

Under GRAPHICS, click on Treatment of acute gout

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Question: How beneficial is Echinacea in treating and preventing colds? Answer: Type echin

Select echinacea

Select topic Clinical use of echinacea

Point out the authors/date

Go to the outline

Go to section SUMMARY AND RECOMMENDATIONS — ANSWER

o (1st bullet) Although echinacea may have some immune stimulating effects, the evidence to date does

not support its efficacy in treating or preventing the common cold and we recommend not using it for these purposes (Grade 1B).

Click on Grade 1B for a description of the meaning of the grade

o A Grade 1B recommendation is a strong recommendation, and applies to most patients. Clinicians

should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

To review the evidence supporting the recommendation, click on the link See “Treatment” above

Scroll down to reference 18 to show an abstract

Click on echinacea to show the drug database

Go to the outline

Under GRAPHICS, show a picture of Echinacea and show the Echinacea brand names table

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Cardiology Clinical Case #1

Question: You have a patient with New York Heart Association class II heart failure, and left ventricular ejection fraction of 32 percent, and a QRS duration of 130 msec. Is this patient a candidate for cardiac resynchronization therapy (CRT)? Answer: Type crt or Cardiac resynchronization therapy or Biventricular pacing or BiV pacing

Roll over the first topic, Cardiac resynchronization therapy (biventricular pacing) in heart failure

On the outline to the right, under header SPECIFIC ISSUES, click on Efficacy in NYHA class II HF —

ANSWER o The above trials largely consisted of patients with NYHA class III to IV HF (show table 1).

Limited data on NYHA class II HF were obtained in two ICD trials (VENTAK CHF/CONTAK CD and MIRACLE ICD II), which suggested both functional improvement and evidence of reverse ventricular remodeling.

o The potential value of CRT in this population was also assessed in an observational series of 50

patients. At six month follow-up, CRT resulted in improvements in clinical and hemodynamic parameters compared to baseline.

o The use of CRT in patients with NYHA class II HF, QRS prolongation, and LVEF ≤35 percent is

being addressed in the MADIT-CRT trial that initiated enrollment in April 2005. All such patients are candidates for an ICD for the primary prevention of sudden cardiac death.

Click on references 48, 56 to show abstracts

Go to the outline

Click on Interruption of CRT, thenclick on amiodarone to show the drug database

Go to the outline

Under GRAPHICS, click on any figure

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Question: You have a 63 year-old woman who, after a stressful event, presented with what looked like an acute myocardial infarction causing hypotension. Angiography showed no critical lesion and she rapidly and completely recovered. Was this incident stress-induced cardiomyopathy? If so, is she at risk for recurrence? Answer: Type stress induced cardiomyopathy or stress induced or takotsubo

Roll over the first topic, Stress-induced (takotsubo) cardiomyopathy

On the outline to the right, under header TREATMENT AND PROGNOSIS, click on Prognosis —

ANSWER

o (2nd bullet) Late sudden death and recurrent disease have occurred in occasional patients. In a report of 22 patients, all of whom survived the initial episode, two patients had a second similar episode triggered by psychologic stress at three and ten months.

Click on reference 4 to show an abstract

Click on aspirin to show the drug database

Go to the outline

Under GRAHICS, select any of the figures

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Question: A patient presents to the emergency department with chest pain. The initial ECG demonstrates two to three millimeters of ST elevation in leads V2 through V6. His heart rate is 80 beats per minute, blood pressure 136/84. Although short of breath, oxygen saturation is 96 percent on two liters via nasal cannula. He reports that his chest pain began approximately 2 hours ago. Your hospital does not have primary percutaneous coronary intervention (PCI) capability. Should you administer fibrinolytic therapy immediately, or arrange to transfer the patient for primary PCI? Answer: Type stemi reperfusion treatment

Roll over Selecting a reperfusion strategy for acute ST elevation (Q wave) myocardial infarction

On the outline to the right, under header SUMMARY AND RECOMMENDATIONS, click on the

subheading Presentation within three hours — ANSWER

o (2nd bullet) For patients who present ≤3 hours from symptom onset, we recommend primary PCI if PCI can be accomplished with a door-to-balloon time of 90 minutes and a PCI-related delay of 60 minutes; if both of these time criteria cannot be met, we recommend fibrinolytic therapy (Grade 1A).

Click on Grade 1 for a description of the meaning of the grade

o A Grade 1A recommendation is a strong recommendation, and applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

To review the evidence supporting the recommendation, click on See “Time from symptom onset to

presentation” above and on see “PCI-related delay” above Go to the outline and click on Early presentation under the heading FACILITIES WITHOUT ON-

SITE PCI for a discussion on the value of early reperfusion and the importance of minimizing transfer time Click on PCI-related delay and view reference 22 to show an abstract

Go to the outline

Click on ADJUNCTIVE THERAPIES and then on clopidogrel to show the drug database

Go to the outline

Under GRAPHICS, click on figure Time to reperfusion in MI to show a graph of the relationship

between time to reperfusion and mortality

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Endocrinology Clinical Case #1

Question: A 58 year-old postmenopausal woman is experiencing stress urinary incontinence that is interfering with her quality of life. She is not having hot flashes, but she has heard that estrogen therapy is very effective for urinary incontinence. What advice do you give her? Answer: Type estrogen for urinary incontinence in postmenopausal women

Roll over the second topic, Postmenopausal hormone therapy: Benefits and risks

On the outline to the right, under header OTHER POSSIBLE RISKS, click on Urinary incontinence —

ANSWER

o Although it had been thought that systemic estrogen therapy improved urinary incontinence, the best available evidence suggests that this is not the case. In the HERS trial, daily oral estrogen plus progestin increased the number of incontinent episodes when compared with placebo. Excess risk was seen for both stress and urge incontinence and occurred within four months of starting therapy.

o In a Cochrane review of randomized trials published in 2003, it was concluded that unopposed, but

not combined estrogen-progestin therapy was an effective treatment for urinary incontinence: approximately 50 percent of women treated with unopposed estrogen were cured or improved versus 25 percent of those taking placebo. The benefit was slightly greater in women with urge rather than stress incontinence.

o In the WHI, published after the Cochrane meta-analysis, women who were continent at baseline who

were treated with estrogen or combined estrogen-progestin (medroxyprogesterone acetate) had an increased risk of all types of urinary incontinence at one year. This increased risk was greatest for stress incontinence (relative risk [RR] 2.2 for combined therapy and RR 1.9 for unopposed estrogen); the risk of stress incontinence remained increased after three years of treatment. Women who were incontinent at baseline had worsening frequency and incontinence when treated with unopposed estrogen or combined estrogen-progestin therapy.


Click on conjugated estrogens to view the drug database

Click on See “Treatment of urinary incontinence” for additional information

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Question: A 55 year-old woman with primary adrenal insufficiency was recently told by a friend that she should start taking DHEA for libido. Is it effective? What dose should she use? Answer: Type DHEA for libido

Roll over the first topic, Dehydroepiandrosterone and its sulfate

On the outline to the right, under header CLINICAL USES OF DHEA, click on Adrenal insufficiency

to review all available studies on the efficacy of DHEA Click on reference 11 to show an abstract

Go to the outline

Click on SUMMARY AND RECOMMENDATIONS — ANSWER

o (1st bullet) In women with adrenal insufficiency, the benefits of DHEA therapy may outweigh its

risks. In these androgen-deficient women, we suggest DHEA 50 mg/day for androgen replacement. (Grade 2B).

Click on Grade 2B for a description of the meaning of the grade

o A Grade 2B recommendation is a weak recommendation; alternative approaches may be better for some patients under some circumstances

Scroll up and click on testosterone to view the drug database

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Question: Is Denosumab an effective drug for osteoporosis? Answer: Type denosumab and osteoporosis

Roll over the first topic, Overview of the management of osteoporosis in women

On the outline to the right, under header PHARMACOLOGIC THERAPY, click on Emerging

therapies See Denosumab (1st bullet) — ANSWER

o In a trial of 412 postmenopausal women with low bone mineral density (T score -1.8 to -4.0 at the

lumbar spine or -1.8 to -3.5 at the proximal femur) who were randomly assigned to receive denosumab, a humanized monoclonal antibody against RANKL (at a dose of 14, 60, 100, or 210 mg subcutaneously every three or six months), open-label alendronate (70 mg once weekly), or placebo for one year, the following results were seen:

Lumbar spine bone density increased by 3.0 to 6.7 percent with denosumab and 4.6 percent

with alendronate while it decreased by 0.8 percent in the placebo group. Bone density at the total hip increased by 1.9 to 3.6 percent with denosumab and 2.1 percent

with alendronate, with a decrease of 0.6 percent with placebo. Near-maximal reductions in mean serum C-telopeptide levels were seen three days after

denosumab administration.

Click on reference 83 to show an abstract Click on alendronate to show the drug database

Go to the outline

Show any of the images under GRAPHICS

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Gastroenterology Clinical Case #1

Question: You performed an upper endoscopy with biopsies on a patient with longstanding heartburn. The pathology report describes intestinal metaplasia with low grade dysplasia. What should be your next steps? Answer: Search on Barrett treatment

Select topic Management of Barrett's esophagus

Click on header AMERICAN COLLEGE OF GASTROENTEROLOGY AND AUTHOR'S

RECOMMENDATIONS — ANSWER

o (1st bullet) We suggest that patients with Barrett's esophagus have regular surveillance endoscopy to obtain esophageal biopsy specimens (Grade 2B). GERD should be treated prior to surveillance to minimize confusion caused by inflammation in the interpretation of dysplasia. For patients who have had two consecutive endoscopies that show no dysplasia, we suggest surveillance endoscopy at an interval of every three years (Grade 2B).

o For patients with verified low-grade dysplasia after extensive biopsy sampling, we suggest yearly

surveillance endoscopy (Grade 2B).

Click on Grade 2B for a description of the meaning of the grade o A Grade 2B recommendation is a weak recommendation; alternative approaches may be better for

some patients under some circumstances. Scroll up to the section on GUIDELINES and click on reference 1 to show an abstract

Scroll up to the section on CHEMOPREVENTION and click on aspirin to view the drug database

Go to the outline

Under GRAPHICS, click on the histologies

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Gastroenterology Clinical Case #2

Question: You are asked to see a 25 year-old Asian man with chronic hepatitis B who is HBsAg (+) and HBeAg (+) with serum HBV DNA of 700 million copies/mL. He has mild inflammation on biopsy. His serum ALT is 100 IU/L (upper limit of normal 40 IU/L). What is the appropriate treatment? Answer: Type hbv treatment

Select the second topic, Overview of the management of chronic hepatitis B and case examples

Point our author/date

Go to the outline

Under header WHO SHOULD BE TREATED AND HOW, click on Choosing among the available

options — ANSWER

o (1st paragraph) Treatment strategies for chronic HBV include interferon, lamivudine, adefovir dipivoxil, and entecavir. Many new treatments are undergoing testing. Thus, an approach to the care of patients with HBV is evolving rapidly.

Click on lamivudine to show the drug database

Go to the outline

Under GRAPHICS, click on a table

Scroll up to WHO SHOULD BE TESTED and click on reference 2, 3 to show abstracts

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Hematology and Oncology Clinical Case #1

Question: You have an elderly patient who needs therapy for an advanced stage of the aggressive non-Hodgkin's lymphoma diffuse large B-cell lymphoma (DLBCL). What is the recommended treatment? Answer: Type treatment for dlbcl

Roll over fourth topic, Treatment of aggressive non-Hodgkin's lymphoma

On the outline to the right, under header OLDER PATIENTS, click on Treatment approach —

ANSWER

o (1st paragraph) To date, no regimen has been shown to be superior to standard (full) dose CHOP for elderly patients with aggressive NHL. We therefore recommend standard dose CHOP, if tolerated, with growth factor support, to maintain the relative dose intensities of doxorubicin and cyclophosphamide, in combination with rituximab for CD20+ disease (ie, CHOP-R), as preferred therapy for elderly patients. In patients treated with CHOP-R, maintenance therapy with rituximab is not recommended.

o However, given the relatively poor prognosis with this treatment, patients should be encouraged to

enroll in a clinical trial specifically designed for elderly patients whenever possible.

Go to the outline Under header ADVANCED STAGE DISEASE, click on CHOP plus rituximab

Review the evidence supporting the recommendation


Click on rituximab to show the drug database

Scroll down to Treatment approach

Click on show table 8 and show table 3 to highlight the graphics and tables

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Question: You have a patient with newly-diagnosed acute promyelocytic leukemia. What are the overall recommendations for initial treatment, including remission induction, consolidation, monitoring for remission status, and maintenance therapy? Answer: Type treatment for apl

Select the first topic, Clinical features and treatment of acute promyelocytic leukemia in adults

Point out authors/date

Go to the outline

Under header SUMMARY AND RECOMMENDATIONS, click on Initial treatment — ANSWER

o We and others recommend that the treatment regimen for previously untreated APL requires the

combination of remission induction with ATRA plus chemotherapy, two to three cycles of consolidation chemotherapy, demonstration of molecular remission at the completion of consolidation chemotherapy, and maintenance therapy with ATRA (Grade 1A).

Click on Grade 1A for a description of the meaning of the grade:


To review the evidence supporting this recommendation, click on the link see “Remission induction,

consolidation, and maintenance” above Click on daunorubicin to show the drug database

Scroll down to Control of DIC


Go to the outline

Under GRAPHICS, under TABLES, show the table called Practice points APL

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Question: You have a patient with newly-diagnosed metastatic adenocarcinoma of the lung. The patient is a non-smoker. Should you add bevacizumab to the initial chemotherapy regimen? Answer: Type bevacizumab for metastatic lung cancer

Roll over first topic, Palliative chemotherapy for advanced non-small cell lung cancer

On the outline to the right, click on SUMMARY AND RECOMMENDATIONS — ANSWER

o (1st bullet) For good performance status patients with non-squamous NSCLC and without brain

metastases or a history of hemoptysis, we recommend the combination of bevacizumab and the carboplatin plus paclitaxel doublet (Grade 1B). There is no data available on the use of bevacizumab in combination with other platinum-based combinations.

Click on Grade 1B for a description of the meaning of the grade:

o A Grade 1B recommendation is a strong recommendation, and applies to most patients. Clinicians

should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

To review the evidence supporting this recommendation, click on the link See “Bevacizumab plus

carboplatin-paclitaxel” above

o (3rd paragraph) Based upon the phase II results, ECOG conducted a phase III trial (E4599) in 878 previously untreated patients with advanced, non-squamous NSCLC. Patients had a good PS (0 or 1, show table 2) and either stage IIIB (with a malignant pleural effusion) or stage IV disease. Patients with brain metastases or a history of hemoptysis were excluded to minimize the risk of pulmonary or intracerebral hemorrhage.

o (5th paragraph) As in the earlier phase II study, patients receiving chemotherapy plus bevacizumab

had a significantly increased objective response rate (35 versus 15 percent with paclitaxel plus carboplatin alone), median overall survival (12.3 versus 10.3 months, hazard ratio [HR] for death 0.79, 95% CI 0.67-0.92), and one-year and two-year survival rates (51 versus 44 and 23 versus 15 percent, respectively).

Click on reference 72 to show the abstract

Click on bevacizumab to show the drug database

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Infectious Diseases Clinical Case #1

Question: You are seeing an injection drug user in the emergency department who has symptoms consistent with primary HIV infection. What tests should you order to confirm this diagnosis? Answer: Type primary HIV

Select the first topic, Primary HIV-1 infection: Diagnosis and treatment


Go to outline

Under header ESTABLISHING THE DIAGNOSIS, click on Viral load — ANSWER

o Patients with acute HIV have a markedly elevated viral load, easily detectable with regular (as

opposed to ultrasensitive) viral load tests. In one study, for example, all patients with acute HIV had values >100,000 copies/mL [6]. An additional finding in this study was the occurrence of false-positive viral loads in 8 of 303 patients without HIV infection, for a false-positive rate of 2.6 percent.

o Importantly, all of the false-positives had <2000 copies/mL, making them easily distinguishable from

the true positives whose values were much higher. Furthermore, all of the false positives occurred with the bDNA rather than RT-PCR version of the test.


Click on See “Techniques and interpretation of HIV-1 RNA quantitation” to show link to another

topic Go to the outline

Click on Specimen collection

Click on heparin to show the drug database

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Infectious Diseases Clinical Case #2

Question: You have just diagnosed a patient with chronic HIV infection and want to know which opportunistic infections your patient is at risk of developing and what may be the appropriate therapy. The patient’s CD4 count is 75 cells. Answer: Type opportunistic

Select the first topic, Primary prevention of opportunistic infections in HIV-infected patient


Go to the outline

Under header RECOMMENDATIONS OF WHEN TO INITIATE PROPHYLAXIS, click on CD4

counts <100 cells/microL — ANSWER

o Patients with a CD4 count <100 cells/microL are at risk for developing pneumocystis infection. o Patients who are Toxoplasma seropositive are also at risk for reactivation of toxoplasmosis infection. o Patients who live in an endemic area for histoplasma, are at risk for histoplasmosis.

Click on show table 2 to show treatment options in table format For more detailed treatment recommendations, scroll down to RECOMMENDATIONS FOR

INDIVIDUAL PATHOGENS To show grading of evidence, click on Grade 1A under Pneumocystis

o Strong recommendations can apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Click on any of the drug names to show the drug database

Scroll up a little over RECOMMENDATIONS OF WHEN TO INITIATE PROPHYLAXIS


Go to the outline

Under GRAPHICS, select any of the tables

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Nephrology and Hypertension Clinical Case #1

Question: Is adding the drug Cinacalcet to your usual therapy better than just traditional therapy to achieve K/DOQI goals for bone metabolism in dialysis patients? Answer: Type cinacalcet

Select the first topic, Active vitamin D analogs and calcimimetics to control hyperparathyroidism in

chronic renal failure Point out authors/dates

Go to the outline

Under header THERAPEUTIC AGENTS, click on Calcimimetics — ANSWER

The 2nd paragraph discusses the benefits of using Cinacelcet: compared with placebo, using cinacelcet HL has

been beneficial in achieving K/DOQI target levels. o (2nd paragraph) Cinacalcet (Sensipar, AMG 073) is currently the only available calcimimetic.

Prospective phase 3 studies have found that the addition of cinacalcet to current treatment regimens increases the percentage of patients who are able to attain K/DOQI end-points related to PTH, calcium, and phosphate levels, and the Ca x P product. Further secondary analysis of these studies and a phase two study also found that, compared with placebo, cinacalcet reduced the risk of parathyroidectomy, fracture, and cardiovascular hospitalizations.

Click on reference 68-77 to show an abstract

Click on cinacalcet to show the drug database

Go to the outline

Under GRAPHICS, select the figure

21

Nephrology and Hypertension Clinical Case #2

Question: You have a patient with IgA Nephropathy. What is the role of immunosuppressive therapy, and what is the best regimen for a patient with relatively normal kidney function but persistent proteinuria despite appropriate dose of angiotensin inhibition? Answer: Type IgA neph

Select the fourth topic, Treatment and prognosis of IgA nephropathy


Go to the outline

Under header APPROACH TO THERAPY, select Patient selection — ANSWER

o (3rd bullet) Patients with more severe or rapidly progressive disease (e.g., nephrotic range proteinuria

or proteinuria persisting despite ACE inhibitor/ARB therapy, rising serum creatinine, and/or renal biopsy with more severe histologic findings, but no significant chronic changes) may benefit from immunosuppressive therapy in addition to nonimmunosuppressive interventions to slow disease progression.

Go to the outline

Under header SUMMARY AND RECOMMENDATIONS, select Treatment — ANSWER

o (6th bullet) For patients with progressive active disease (e.g., hematuria with increasing proteinuria

and/or increasing serum creatinine concentration) despite the use of ACE inhibitors and/or ARBs, we suggest initiating therapy with corticosteroids alone (Grade 2B).


o A Grade 2B recommendation is a weak recommendation; alternative approaches may be better for some patients under some circumstances.

Go to the outline

Under IMMUNOSUPPRESSIVE THERAPY, click on Corticosteroids to show the available evidence

backing the recommendation Click on reference 9,70 to link to an abstract

Click on corticosteroids to show the drug database

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Obstetrics, Gynecology, and Women’s Health Clinical Case #1

Question: A 42 year-old pre-menopausal woman comes in for her annual gynecological visit. Her history and physical examination are unremarkable. However, her Pap smear report indicates the presence of benign endometrial cells. What is the next step? Answer: Type benign endometrial cells

Click on the second topic, The cervical cytology report

Go to the outline

Under header INTERPRETATION, select Benign appearing endometrial cells — ANSWER

o (4th paragraph) If symptoms of endometrial cancer are present (abnormal uterine bleeding) or the

patient is at increased risk of endometrial cancer (e.g., postmenopausal; family or personal history of ovarian, breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation; obesity [20]; estrogen therapy; prior endometrial hyperplasia; diabetes) (show table 3), we suggest an endometrial biopsy be obtained to rule out endometrial cancer. In the absence of these factors, we elect to continue with routine gynecologic care as these women have not been proven to be at increased risk of endometrial cancer [17,21-24].

Click on show table 3 for a table showing the relative risk of endometrial cancer by risk factor

Click on reference 17, 21-24 to show an abstract

Click on tamoxifen to show the drug database

23


Question: A 28 year-old woman comes in with her 4th vaginal yeast infection this year. Because of the recurrent infections, a culture is taken which indicates Candida glabrata. How should this type of yeast infection be treated? Answer: Type candida glabrata vaginitis

Select the first topic, Candida vulvovaginitis

Go to the outline

Under header TREATMENT, click on C. glabrata — ANSWER

o Treatment failure with azoles is not uncommon (around 50 percent) in patients with C. glabrata vaginitis [15]. Moderate success (65 to 70 percent) in women infected with this organism can be achieved with intravaginal boric acid (600 mg capsule once daily at night for two weeks) [15]. Better results (>90 percent cure) have been achieved with intravaginal flucytosine cream (5 g nightly for two weeks); however, flucytosine cream is not readily available and must be made by a compounding pharmacy [38]. There are no good data regarding use of oral voriconazole for C. glabrata vaginitis. Anecdotal reports suggest poor response and rare if any success, and the potential for toxicity.


Click on flucytosine to show the drug database

Go to the outline

Under GRAPHICS, click on any of the graphics

24


Question: What is the recommended approach to treatment of gestational diabetes mellitus? Answer: Type treatment of gestational diabetes

Select the first topic, Treatment and course of gestational diabetes mellitus

Go to the outline

Select SUMMARY AND RECOMMENDATIONS — ANSWER

o We recommend that women with gestational diabetes mellitus receive treatment (Grade 1A). A

program of medical nutritional therapy, self monitoring of blood glucose levels, and insulin therapy, when needed, has been shown to improve perinatal outcome in randomized trials.

o Medical nutritional therapy is the initial approach.

o The calorie allotment is 12 to 40 kcal per kg current weight per day depending upon the degree current weight differs from ideal body weight.

o Calories are generally divided over three meals and three snacks and are composed of ²40

percent carbohydrate, 20 percent protein, and 40 percent fat. o Self blood glucose monitoring should be performed to evaluate the effectiveness of medical

nutritional therapy. Click on Grade 1A for a description of the meaning of the grade:


Click on the link See “Rationale for treatment” above to show data behind the recommendation


Go to the outline

Under GRAPHICS, click on any of the graphics

25

Pediatrics Clinical Case #1

Question: It is 11 o'clock on a Friday morning and you are seeing an 18-month old child with mild symptoms of classic croup. He has no retractions or stridor at rest but you are concerned that his symptoms may worsen in the evening hours. Should you prescribe dexamethasone? Answer: Type treatment croup dexamethasone

Select the first topic, Approach to the management of croup

Point out author/date

Go to the outline

Under header MILD CROUP, click on Outpatient treatment — ANSWER

o (2nd paragraph) We suggest that children with mild croup who are seen in the outpatient setting be

treated with a single dose of oral dexamethasone (0.6 mg/kg). Treatment of such children in the late morning or early afternoon hours may prevent worsening of symptoms as evening approaches. However, anticipatory guidance about potential worsening and when to seek care or return for follow-up also is reasonable.

Click on reference 10, 11 to show an abstract.

Click on dexamethasone to show the drug database.

Go to the outline

Click on SUMMARY AND RECOMMEDNATIONS to show the grading system

Go to the outline. Click on Information for patients to show patient information

26

Pediatrics Clinical Case #2

Question: You are seeing a four month old infant who was hospitalized at two months of age with culture-proven pertussis. Should she receive a pertussis containing vaccine at this visit? Answer: Type pertussis management

Select the first topic, Treatment and prevention of Bordetella pertussis infection in infants an children

Go to the outline

Under header OTHER PREVENTION MEASURES, click on Vaccination — ANSWER

o (4th paragraph) Well-documented pertussis infection (eg, a positive culture for B. pertussis or an

epidemiologic link to a culture-positive case) is likely to confer immunity against pertussis. However the duration of immunity is unknown. The AAP recommends that children who have had well documented pertussis disease complete the primary diphtheria-tetanus-pertussis vaccine series with at least the diphtheria and tetanus components of the vaccine. We suggest that such patients also receive the acellular component (ie, that they receive a full series of diphtheria-tetanus-acellular pertussis vaccine [DTaP]), provided there are no contraindications and the DTaP vaccine is available.

In preceding paragraph, click on diphtheria-tetanus toxoid to show the drug database.

In the second paragraph, click on reference 22 to show an abstract.

Go to the outline

Click on SUMMARY AND RECOMMENDATIONS to show a graded recommendation

Go to the outline

Under GRAPHICS, click on the table Pertussis Rx and prophylaxis, which summarizes recommendations

for antibiotic treatment and prevention of pertussis

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Pulmonary, Critical Care, and Sleep Medicine Clinical Case #1

Question: A patient was admitted to the intensive care unit two days ago with septic shock. He was treated with antibiotics, intravenous fluids, vasopressors, and hydrocortisone. His vasopressor requirement has not decreased. His serum cortisol increased 15 mcg/dL after high-dose ACTH stimulation. Should the hydrocortisone be discontinued? Answer: Type glucocorticoids in septic shock

Select the first topic, Glucocorticoid therapy in septic shock

Point our author/date

Go to the outline

Under header SUMMARY AND RECOMMENDATIONS, click Recommendations — ANSWER

o (3rd bullet) We suggest discontinuation of corticosteroids in patients who have a maximum serum

cortisol increase >9 mcg/dL following ACTH stimulation and no hemodynamic response to corticosteroid therapy (hemodynamic response defined as vasopressor withdrawal within 48 hours of starting corticosteroids) (show figure 5) (Grade 2B). We suggest continuing corticosteroids at full doses for seven days, regardless of the clinical response, if the maximum increase of serum cortisol is 9 mcg/dL after ACTH stimulation (Grade 2B).


o Recommendation is a weak recommendation; alternative approaches may be better for some patients under some circumstances.

Click on show figure 5 to view an algorithm for the use of corticosteroids in septic shock

To review the evidence supporting the recommendation, click on the link See “Clinical evidence” above

Scroll up to GLUCOCORTICOID THERAPY

Click on reference 71-73 to show an abstract

Click on glucocorticoids to show the drug database

Go to the outline

Under GRAPHICS, show any of the figures

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Pulmonary, Critical Care, and Sleep Medicine Clinical Case #2

Question: How effective is long-term warfarin at preventing recurrent pulmonary embolism? Answer: Type warfarin and PE

Select the second topic, Anticoagulation in acute pulmonary embolism


Go to outline

Under header WARFARIN, click on Clinical evidence — ANSWER

o Long-term treatment with warfarin is highly effective for preventing recurrent PE. This is best

illustrated by a meta-analysis of eight randomized, controlled trials (2994 patients) that demonstrated that patients with symptomatic PE had a decreased likelihood of recurrent PE or DVT when treated with long-term warfarin (odds ratio 0.18, 95% CI 0.13-0.26).


Click on warfarin to show the drug database

Go to the outline

Under GRAPHICS, select the figure or any of the tables

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Rheumatology Clinical Case #1

Question: What are some treatment options for an adult with dermatomyositis whose disease does not respond adequately to prednisone and azathioprine? Answer: Type treatment of dermatomyositis

Select the third topic, Treatment of recurrent and resistant dermatomyositis and polymyositis in

adults Go to the outline

Click on RESISTANT DISEASE

First paragraph — ANSWER

o Multiple options exist for treating patients who do not respond adequately to glucocorticoids plus

azathioprine or methotrexate. Evidence of clinically significant benefit is greatest with rituximab and intravenous immune globulin (IVIG). We suggest using rituximab first in this setting, and then trying IVIG if rituximab fails.


Click on rituximab to show the drug database

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Rheumatology Clinical Case #2

Question: In a patient with poor renal function, what is an appropriate starting dose of allopurinol? Answer: Type gout

Select the third topic, Treatment and prevention of recurrent gout

Point out author/date

Go to the outline

Click on ADVANCED RENAL FAILURE

Second bullet — ANSWER

o The half-life of allopurinol and its active metabolite oxipurinol are prolonged in renal failure. A

reduction in the starting dose is necessary depending upon the severity of the renal functional impairment (show table 1). If the desired serum urate level is not achieved, cautious titration of the dose is warranted, with careful observation for adverse effects.

Click on the link show table 2 to show a graphic and the appropriate reduced dose for a patient with renal

failure Click on allopurinol to show the drug database

Go back to text and click on reference 66 to show an abstract

Sample Clinical Cases 15

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Transcript of Sample Clinical Cases 15