Print Issue: March 18, 2008

WILL A HIGHER INR REDUCE RISK OF STROKE?

An elderly patient with prosthetic mitral and aortic valves has had two small, presumably cardioembolic strokes while anticoagulated (international normalized ratio [INR] 2.5-3.5). Would increasing his desired INR to between 3.5 and 4.5 decrease his chance of further strokes?—Michael Garrett, MD, Paradise Valley, Ariz. There are few data indicating any difference between the INRs you…

Check amiodarone level?

An 85-year-old woman with paroxysmal atrial fibrillation (AF) is now in normal sinus rhythm on 100 mg amiodarone. Should I be checking her amiodarone level?—Yushuang Xie, MD, Brooklyn, N.Y. The paroxysmal AF in this patient has apparently been successfully managed with low-dose amiodarone therapy. I would not worry about obtaining blood levels since the correlation…

A DIABETIC’S LOWER EXTREMITY

What mechanism would be responsible for nonpalpable, small, round purpuric eruptions on the ankles and feet of a diabetes patient with peripheral vascular disease? The patient wears no socks. He is taking pioglitazone (Actos), metformin, sitagliptin (Januvia), and clopidogrel (Plavix).—Duc Tran, DO, Westminster, Calif. Without seeing the eruption, it is difficult to be certain. However,…

HYPERTENSIVE THERAPY IN THE PATIENT WITH ALLERGIES

Which diuretic do you recommend for a hypertensive patient allergic to sulfonamides?—Roch P. Col, MD, Phoenix Spironolactone would be a first choice. Another alternative is the loop diuretic with the least cross-reactivity to the sulfonamides, ethacrynic acid. Bear in mind also that it is not clear that allergy to sulfonamides is associated with allergy specifically…

ARE WE OVERDOING CT SCANS?

Our radiologists are requesting that CT scans be ordered when chest x-rays done for unrelated symptoms show small benign-appearing nodules (≤5 mm). The recommendation is to repeat the CT in three months “to assure stability.” What are the guidelines for following incidentally found pulmonary nodules ≤5 mm in size?—James P. Cohen, MD, Westford, Mass. The…

MEDS IN THE POST-NEPHROPATHY PATIENT

Can gabapentin (Neurontin) and/or choline/magnesium trisalicylate (Trilisate) be prescribed to a patient who had a kidney transplant for diabetic nephropathy?—John D. Timothy, MD, Forest Hills, N.Y. Use of medications in the post-renal transplant patient must take into consideration concurrent use of immunosuppressive agents (drug-drug interactions) as well as the effects on renal function itself. Trilisate…

STUBBORN EUSTACHIAN-TUBE DYSFUNCTION

What treatment do you recommend for eustachian-tube dysfunction when all previously tried medications (i.e., antihistamines, decongestants, and sprays) have failed?—Joan E. Rigdon, NP, Pasadena, Calif. If you have not tried long-term intranasal corticosteroids, their use is appropriate in this patient. Exercising the eustachian tube by performing Valsalva maneuvers or “popping” the ear multiple times every…

NEW CHLAMYDIA TEST DETECTS INFECTIONS WITHIN 30 MINUTES

Level 1: Likely reliable evidence The Chlamydia Rapid Test uses a monoclonal antibody-coated test strip on vaginal swab samples, with results available in <30 minutes. This test is accurate for diagnosing or ruling out chlamydia genital infection in women, based on a diagnostic cohort study of 1,458 eligible patients aged 16-54 years who presented to…

Influenza vaccine associated with reduced hospitalizatino and mortality in elderly persons

Level 2: Mid-level evidence Influenza vaccination is associated with reduced rate of death or hospitalization for influenza or pneumonia in community-dwelling elderly persons, based on observational evidence (N Engl J Med. 2007;357:1373-1381). During 713,872 person-seasons of observation from 18 cohorts of patients older than 65 years in U.S. HMOs from 1990-2000, there were 4,599 hospitalizations…

CEFEPIME IS ASSOCIATED WITH INCREASED MORTALITY

Level 2: Mid-level evidence Mortality associated with cefepime (Maxipime) was evaluated in a systematic review and meta-analysis of 57 randomized trials comparing cefepime with another beta-lactam antibiotic; the review was limited by lack of complete mortality data from all of the trials (Lancet Infect Dis. 2007;7:338-348). An additional non-beta-lactam antibiotic was allowed if the same…

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