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Update in General Internal Medicine 2004

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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  1. Update in General Internal Medicine2004 Laura Zakowski MD Christine Seibert MD Shobhina Chheda MD MPH No financial disclosures

  2. 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

  3. 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

  4. 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

  5. Wells’ clinical criteria to diagnose DVT • Low probability (3%): • 0 points • Intermediate probability (17%): • 1-2 points • High probability (75%): • 3 points

  6. 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%

  7. 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

  8. 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

  9. 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

  10. Results • No development of candida resistance • Minimal adverse effects leading to discontinuation %INFXN MONTHS

  11. Bottom line • Fluconazole effectively suppresses yeast vaginitis • No cure after discontinuation • No data about treatment beyond 6 months

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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

  17. 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

  18. 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

  19. Results

  20. Results Percent of subjects reporting adverse events (day 9)

  21. 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

  22. 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)

  23. 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

  24. Results

  25. 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%)

  26. 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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