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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

Update in General Internal Medicine2004

Laura Zakowski MD

Christine Seibert MD

Shobhina Chheda MD MPH

No financial disclosures


Learning objectives
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 dvt fancer et al bmj 2004 329 821 824
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
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 dvt1
Wells’ clinical criteria to diagnose DVT

  • Low probability (3%):

    • 0 points

  • Intermediate probability (17%):

    • 1-2 points

  • High probability (75%):

    • 3 points


Results
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
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 vaginitis sobel et al nejm 2004 351 876 83
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
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


Results1
Results

  • No development of candida resistance

  • Minimal adverse effects leading to discontinuation

%INFXN

MONTHS


Bottom line1
Bottom line

  • Fluconazole effectively suppresses yeast vaginitis

  • No cure after discontinuation

  • No data about treatment beyond 6 months


Young women management of lsil moscicki a b at al lancet 2004 364 1678 83
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 design1
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


Results2
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)


Results3
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 line2
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 design2
Study Design in older women

  • 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


Results4
Results in older women


Results5
Results in older women

Percent of subjects reporting adverse events (day 9)


Bottom line3
Bottom Line in older women

  • 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 prevention brandes et al jama 2004 291 965 973
Topiramate for Migraine Prevention in older womenBrandes 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 design3
Study Design in older women

  • 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


Results6
Results in older women


Results7
Results in older women

  • 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 line4
Bottom Line in older women

  • 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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