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Update in General Internal Medicine 2004. Laura Zakowski MD Christine Seibert MD Shobhina Chheda MD MPH No financial disclosures. Learning objectives. Utilize D-dimer for evaluation of possible DVT Consider fluconazole for suppression of vaginal yeast infection

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Update in General Internal Medicine 2004

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Update in General Internal Medicine2004

Laura Zakowski MD

Christine Seibert MD

Shobhina Chheda MD MPH

No financial disclosures


Learning objectives

  • Utilize D-dimer for evaluation of possible DVT

  • Consider fluconazole for suppression of vaginal yeast infection

  • Recognize alternative to colposcopy for young women with LSIL

  • Decrease antibiotic duration for older women with uncomplicated UTI

  • Consider topirimate for migraine prophylaxis


D-dimer to diagnose DVTFancer et al. BMJ. 2004;329:821-824

  • Systematic review of 12 studies

  • Studies reviewed used D-dimer andassessment of clinical probability

  • N = 5431 patients


Wells’ clinical criteria to diagnose DVT

  • Add 1 point for each:

    • Cancer

    • Immobilization

    • Recently bedridden > 3 d or surgery within 4 wks

    • Localized tenderness

    • Calf swelling > 3 cm

    • Pitting edema

    • Collateral superficial veins

  • Subtract 2 pointsif: alternative diagnosis as likely or greater


Wells’ clinical criteria to diagnose DVT

  • Low probability (3%):

    • 0 points

  • Intermediate probability (17%):

    • 1-2 points

  • High probability (75%):

    • 3 points


Results

  • SimpliRED

    • Sensitivity: 87.5%

    • Specificity: 76.9%

    • Likelihood ratio (-): 0.16

  • ELISA

    • Sensitivity: 97.7%

    • Specificity: 45.7%

    • Likelihood ratio (-): 0.05

Low probability

Intermediate

17%

3%

(-)

(-)

3%

0%

3%

17%

(-)

(-)

0%

1%


Bottom line

  • Highly sensitive D-dimer

    • If negative, rules out DVT in low or intermediate probability patients

    • Can potentially replace other tests performed in the clinical setting to rule out DVT or PE


Fluconazole for vaginitisSobel et al. NEJM. 2004;351:876-83

  • 12 month, double-blind RCT

  • Industry sponsored multicenter US sites

  • Age >18 with:

    • Active candida vaginitis

    • Positive culture

    • 4 episodes in last year

  • Exclusions: pregnancy, HIV, recent tx


Study design

  • Treatment with fluconazole q 72 hr x 3

  • Clinically cured patients randomized (N = 373)

  • Initial 6 months:

    • Weekly 150 mg fluconazole or placebo

    • Patients discontinued with recurrent infxn

  • Following 6 months:

    • Observation


Results

  • No development of candida resistance

  • Minimal adverse effects leading to discontinuation

%INFXN

MONTHS


Bottom line

  • Fluconazole effectively suppresses yeast vaginitis

  • No cure after discontinuation

  • No data about treatment beyond 6 months


Young women: Management of LSILMoscicki A-B at al. Lancet 2004; 364: 1678-83

  • Most observational studies of LSIL focus women mid-20’s to 40s

    • 50-60% spontaneously regress

    • 20-40% progress to HSIL

  • Hypothesis: Higher regression rates of LSIL in adolescent/younger women given transient nature of HPV infection


Study Design

  • 899 females age 13-22 years

  • Examined every 4 months

    • Cytology

    • Colposcopy

    • HPV DNA status

  • Both prevalent and incident LSIL included

    • 260 women eligible

    • 187 women included

  • Regression= three consecutive normal Pap results


Results

  • Median follow up 61 months

  • Sexually active for median 3.2 years

  • Probability for regression

    • 12 months:

      • 61% (95% CI 53-70)

    • 36 months:

      • 91% (95% CI 84-99)


Results

  • Regression less likely:

    • LSIL at baseline

    • multiple type HPV infection

  • No association:

    • sexual behavior

    • substance or cigarette use

    • incident sexually transmitted infection

    • contraceptive use


Bottom line

  • Immunocompetent young women with LSIL can be followed with serial cytology rather than routine colposcopy

    • Follow up recommended at 12 months

    • ? Use of HPV DNA testing at follow up


Optimal duration of antibiotic therapy for uncomplicated UTI in older womenVogel t et al. CMAJ. 2004 Feb 17;170:469-73.

  • N = 183 women in Quebec City area

  • Age at least 65 (mean 79yo)

  • UTI as defined by >100,000 pathogen on cx with 1 of 6 typical symptoms

  • Exclusions: DM, living in NH, pyelo sxs


Study Design

  • Randomly assigned to either

    • Cipro 250mg BID x 3 days (w/ 4 days placebo) OR Cipro 250mg BID x 7 days

  • Urine cx on days 5, 9, and at 6 wks

  • Primary outcomes:

    • antimicrobial efficacy 2 day after treatment

    • relapse/reinfection at 6 weeks


Results


Results

Percent of subjects reporting adverse events (day 9)


Bottom Line

  • 3 and 7 day courses of Cipro were equally effective for older community dwelling women with uncomplicated UTI

  • 3 day course tolerated significantly better


Topiramate for Migraine PreventionBrandes et al. JAMA. 2004;291:965-973

  • 26 week, double-blind RCT

  • N = 483 outpts from 52 US sites

  • Ages 12-65 (87% women) with

    • 6mo h/o migraine

    • 3-12 migraines/mo

    • not > 15 headache days/mo

  • Excluded: failed > 2 prophylactics, overused analgesics (>8 triptans or ergots/mo or >6 opioids/mo)


Study Design

  • 2 week washout of other prophylactics

  • 1 mo baseline (mean HA freq of 5.5)

  • Then randomized to 1of4 groups: placebo, 50mg/d, 100mg/d, 200mg/d in 2 divided doses.

  • All started at 25mg, then increased by 25mg/wk up to 8 wks

  • Followed for 26 wks


Results


Results

  • Almost half of all pts dropped out

    • rate similar in all groups

  • Side effects leading to discontinuation:

    • paresthesia (8%)

    • fatigue (8%)

  • Weight loss of 3-4% of TBW (11%)


Bottom Line

  • Topiramate at doses of 100-200mg/d issuperior to placebo

  • Efficacy seems similar to other prophylactics (beta blockers, TCAs and valproate)

  • Side effects are significant, though weight loss may be a plus


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