Print Issue: June 27, 2008

MANAGING MULTIPLE CARDIAC PROBLEMS

How would you manage a 60-year-old patient with elevated BP, congestive heart failure (CHF), normal heart size, and left ventricular hypertrophy (LVH) and diastolic dysfunction confirmed on echocardiography?—Mohan L. Singhal, MD, Woodmere, N.Y. This pattern fits a common clinical scenario: CHF due to hypertension-induced LVH with LV diastolic dysfunction but normal heart size and normal…

RELIEVING POISON IVY

What is the standard therapy for contact dermatitis secondary to poison ivy and other allergens?—Joseph J. Umesi, MD, Mamers, N.C. For an acute allergic contact dermatitis, I prefer to treat aggressively since there can be a great amount of discomfort and pruritus. I generally treat with either a high-potency steroid or a three-week taper of…

WHY NOT USE LABETALOL IN PATIENTS WHO HAVE TAKEN COCAINE?

Since labetalol is used in patients with severe hypertension and chest pain, why is this agent considered dangerous in patients with cocaine-induced hypertensive emergency?—Jose T. Lorenzo, MD, Millersburg, Ky. The hypertension and coronary spasm induced by cocaine is at least partially mediated by stimulation of the sympathoadrenal system. In treating these effects, as in treatment…

TREATING ESOPHAGEAL VARICES

Which is the better treatment for esophageal varices—octreotide or vasopressin? Additionally, what is the adult dose for these medications?—Marangely Rodriguez, MD, Naguabo, P.R. Octreotide is preferable to vasopressin for the initial treatment of active variceal bleeding mostly because the side-effect profile of vasopressin limits its use. In addition to decreasing portal pressure by causing splanchnic…

HOW OFTEN TO CHECK ELECTROLYTES DURING ACE INHIBITOR THERAPY

When an ACE inhibitor or diuretic is initiated for hypertension, how soon and how often should electrolytes be checked?—Kiron Malhotra, MD, Palm Bay, Fla. This is an important question for which there is no dogmatic answer. Following initiation of a diuretic, the usual recommendation is to check electrolytes within a month. I tend to check…

PRE-VENIPUNCTURE TOPICAL NITRO

Could you comment on the use of nitroglycerin to dilate the veins prior to venipuncture?—Ana Soto Muniz, MD, Ponce, P.R. Theoretically, nitroglycerin might help in desperate circumstances, but there are many potential adverse effects. Difficulty with venous access often occurs in the elderly, in the presence of hypotension, or in situations of peripheral vasoconstriction (certain…

EVALUATING SUSPECTED PULMONARY EMBOLUS IN A PREGNANT PATIENT

What is the most appropriate diagnostic test when a pulmonary embolus (PE) is suspected in a pregnant patient?—Roberto Ramirez, MD, Chicago If a pregnant woman develops symptoms consistent with PE, the two most commonly used diagnostic procedures are ventilation-perfusion (V/Q) scan and spiral CT. Spiral CT is now the preferred diagnostic technique because it is…

CONFIRMING A FALSE-POSITIVE DRUG SCREEN

Can levalbuterol (Xopenex) cause urine to test positive for amphetamines?—William L. Powell, Orland, Calif. Drug screens falsely positive for amphetamines have been associated with use of the Vicks inhaler, but a search of the literature reveals no similar association with levalbuterol. However, given the serious consequences of a false-positive drug test, any suspect screening result—especially…

Combination infliximab plus azathioprine may be effective for Crohn’s disease

Level 2: Mid-level evidence An open-label randomized trial compared combination therapy for Crohn’s disease with conventional therapy in 133 newly diagnosed patients (mean duration of diagnosis two weeks) (Lancet. 2008;371:660-667). Participants ranged in age from 16 to 75 years (mean 30 years). Combination therapy consisted of infliximab 5 mg/kg infusions at weeks zero, two, and…

ADJUNCTIVE ACUPUNCTURE IMPROVES PREGNANCY RATES IN WOMEN HAVING IN VITRO FERTILIZATION

Level 1: Likely reliable evidence A systematic review of seven randomized trials evaluated needle acupuncture within one day of embryo transfer compared with sham acupuncture or no adjuvant treatment in 1,366 women having one round of in vitro fertilization (BMJ. 2008;336:545-549; full-text available online free of charge at: www.bmj.com/cgi/content/full/336/7643/545; accessed May 9, 2008). Comparing acupuncture…

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