AMBULATORY MEDICINE
| AMBULATORY MEDICINE: YEAR IN REVIEW —Jeffrey Kohlwes, MD, MPH, Associate Professor of Medicine, University
of California, San Francisco, School of Medicine, and Director, Veterans Affairs Medical Center PRIME Program,
San Francisco, CA
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| Asymptomatic hernia: >600,000 hernia repairs annually, most on asymptomatic patients; hernia complications—acute
incarceration; bowel obstruction; natural history—not well known; probably rare (3 per 1000 patients); risk increases
with age >70 yr
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 | Risks of herniorrhaphy: not benign procedure; recurrence (1%-3%); chronic groin pain (5%-20%; potentially incapacitating);
immediate complications—relatively rare, but include postoperative wound infection and ischemic orchitis
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| Watchful waiting vs immediate surgery: compared in study of 720 men with asymptomatic indirect hernias; average age
57 yr; results—no overall difference between groups; 84 in watchful waiting group (average age 65 yr) had increased
symptoms and surgery within mean of 2 yr, resulting in marked improvement in pain; incarceration or bowel accidents
occurred in patients >70 yr of age
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| Bottom line: “if it don’t hurt, don’t fix it”; delay surgery until hernia symptomatic (or bothers patient); recommendation
not generalizable to women, older men, or direct and femoral hernias; warn patients >70 yr of age about symptoms of
incarceration or bowel obstruction
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| Abdominal aortic aneurysm (AAA): classic location ≈1 cm infrarenal; defined as aortic width >3 cm in any plane circularly;
overall incidence ≈5%; incidence increases 6% per decade; 90% smokers or former smokers; seen in connective
tissue diseases, eg, Ehlers Danlos and Marfan’s syndromes; familial pattern (≈30% of men whose brothers have AAA;
6% of women whose brothers or sisters have AAA); risk of rupture—90% when occurs in hospital, worse outside;
≈9000 deaths per year; surgical repair problematic— operative mortality in centers of excellence 2% to 6%; ≈3000
deaths per year
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| Screening for AAA: ultrasonography (US) 95% sensitive and 99% specific; United States Preventive Services Task
Force recommendations—grade B (relatively strong) for male smokers or ex-smokers 65 to 75 yr of age (1-time US
if normal; same for family history, Ehlers-Danlos and Marfan’s syndromes; odds ratio for mortality reduced 43% in
screened population); grade C (no recommendation) for nonsmoking men; grade D (recommend no screening) for
women 65 to 75 yr of age (but based on 1 trial); approach at speaker’s institution—1-time US screening for patients
65 to 75 yr of age and male smokers or ex-smokers
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| Recommendations for managing AAA: US—if AAA 3 to 4 cm, annually; if AAA 4 to 4.5 cm, every 6 mo; if >4.5, every
6 mo and vascular surgery referral; when repair necessary—AAA 5.5 cm (without surgery, mortality 30% at 2 yr);
1-cm expansion in 12 mo; surgical options—intraoperative mortality 1.2% for new endovascular repair vs 4.6% for
standard open repair; at 30 days, mortality or severe complications 5% with endovascular repair vs ≈10% with open; at
2 yr, survival same for both procedures; possible reasons include that frail patients survive endovascular repair but die
of other causes in following months, or endovascular repair inferior to open; explanation depends on 5- and 10-yr data
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| Bottom line: screen male smokers 65 to 75 yr of age and men with family history of AAA or Marfan’s syndrome; follow
AAA as recommended; refer for repair at 5.5 cm; choice of surgical technique depends on capabilities of local referral
center; patients too frail for open repair are candidates for endovascular procedure
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| β-blockers and primary hypertension: Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7) recommendations for stage 2 hypertension—2-drug
combinations usually required; thiazide-type diuretic and angiotensin-converting enzyme (ACE) inhibitor or β-blocker
or calcium channel blocker; for stage 1—thiazide diuretics for most, but may consider ACE inhibitor, angiotensin II
receptor antagonist (ARB), β-blocker, calcium channel blocker, or combination
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| Strengths of β-blockers: used for 30 yr; mortality reduced 25% postmyocardial infarction (MI) and in congestive heart
failure (CHF); many guidelines use as first-line therapy; doubt raised—Losartan Intervention For Endpoint (LIFE)
trial found 20% mortality benefit for ARB vs atenolol in patients with left ventricular hypertrophy (LVH)
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| Atenolol vs placebo in meta-analysis: no difference in all-cause mortality, cardiovascular-specific mortality, or MI;
≈13% reduction in relative risk (RR) for stroke in patients on atenolol (not statistically significant)
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| Atenolol vs other classes of medications: while brachial artery blood pressure (BP) reduction equivalent, atenolol associated
with 13% increased RR for mortality; biologic plausibility for atenolol difference—less lipophilic; less effect
on central nervous system (CNS), which would reduce sympatholytic benefits; no effect on endothelial function; aortic
BP and brachial BP do not always match (new finding, means controlling brachial BP may not control central aortic
BP); β-blockers work primarily on heart and probably have no effect on aortic BP (responsible for MI and stroke);
LVH regression—occurs with other classes of medication, but atenolol has little effect (probably accounts for greater
mortality)
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| Class effect of β-blockers? conclusive data absent; meta-analysis of β-blockers in primary hypertension (involving
127,000 patients) found 26% increased RR for stroke with atenolol; for other β-blockers, numbers insufficient to draw
conclusions; significance of finding—unlike authors of study, speaker says data lacking to project atenolol results to
β-blockers as class
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| Diuretics drugs of choice: compared to calcium channel blockers, reduced CHF and decreased cardiovascular (CV)
events; compared to ACE inhibitors, reduced risk of CHF, CV events, and strokes; compared to β-blockers, reduced
risk of CV disease events
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| Bottom line: low-dose thiazide diuretics first-line therapy whenever possible (should be reference for future studies, not
atenolol); follow JNC-7 (watch for changes); where these data do not apply—to patients post-MI or with CHF ( β-
blockers should be used aggressively; however, use metoprolol rather than once-daily atenolol)
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| Pertussis: whooping cough reappearing, especially in adults (presents differently); Bordetella pertussis highly communicable
but preventable
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| Symptoms: incubation period 1 to 2 wk
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| Catarrhal phase: 7 to 10 days; coryza; conjunctivitis; slight cough
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| Paroxysmal phase: several weeks; characteristic inspiratory whoop in children (rare in adults); fever usually absent
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| Specific to adults: symptoms of upper respiratory tract infection (URI) followed by severe paroxysmal cough; posttussive
emesis in ≈50%; pulled or broken ribs in ≈10%; conjunctival hemorrhage
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| Convalescent phase: weeks to months; slow improvement
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| Myths about pertussis: only in children (but greater morbidity and mortality, especially in neonates); immunity lifelong
(wanes over years); adults asymptomatic (represents ≤20% of unexplained paroxysmal cough; underdiagnosed by internists)
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| Diagnostic tests: must be performed within 4 wk of symptom onset; direct fluorescent antibody (DFA)—not recommended;
bacterial culture—gold standard; nasopharyngeal aspirate; perform early and get to laboratory quickly (fastidious
bacteria); polymerase chain reaction (PCR)—many false positives due to other Bordetella species lining in
nasopharynx; acute and convalescent serum—preferable for diagnosis after 4 wk
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| Treatment: begin ≤4 wk after symptoms appear; some advocate continuing ≤6 wk to prevent contagion; macrolides
(erythromycin, clarithromycin, azithromycin) or sulfonamides (for 7 days); quinolones and ketolides (option for intolerance
to recommended drugs)
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| Prophylaxis: same as recommendations for treatment; treat close contacts at risk for infection; treat as long as index case
being treated
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| Prevention: booster vaccine (Boostrix) now being given to adults (not yet approved by Food and Drug Administration [FDA])
and adolescents; randomized trial found efficacy of antibody response 92% (370-450 cases per 100,000 person years;
would prevent ≤1 million cases per year in United States)
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| Bottom line: consider pertussis diagnosis (especially for cough symptoms); if early, treat; if late, prophylaxis for close
contacts; watch for new vaccine guidelines
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| Zoster vaccine: >90% of United States population has antibodies to herpesvirus 3 (varicella [chickenpox]); pathogenesis of
herpes zoster—at time of infection, herpesvirus 3 travels from sensory nerves to dorsal root ganglia; remains dormant until
T-cell immunity wanes with age, then reactivates as herpes zoster (shingles) in dermatomal pattern (lifetime risk 10%-
20%)
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| Treatment of zoster: goals—to speed healing, reduce pain, and prevent postherpetic neuralgia (pain >30 days major
problem); antiviral therapy—indicated within 72 hr of symptom onset to prevent postherpetic neuralgia; steroids—
provide immediate pain relief; improve symptoms; do not prevent postherpetic neuralgia
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| Childhood varicella vaccine: available since 1995; produced 90% reduction in 4 million annual cases and reduced deaths
66% (50 last year); breakthrough varicella demonstrates waning immunity
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| Live attenuated zoster vaccine (Zostavax): designed to reverse decline in T cells at 60 yr of age; clinical trial showed 61%
decline in RR and 66% reduction in postherpetic neuralgia
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| Nonoccupational postexposure prophylaxis (nPEP) for HIV
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| Risk for seroconversion: intravenous (IV) drug use (≈1 per 150); occupational needlestick (1 per 333); receptive anal intercourse
(1 per 200; with genital ulcer disease, 1 per 100); receptive vaginal intercourse (1 per 1000); risk additive, ie, increases
with repeated exposure to risk
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| Centers for Disease Control and Prevention (CDC) algorithm: substantial exposure risk—≤72 hr and source patient
known to be HIV positive, nPEP recommended; ≤72 hr and source patient HIV status unknown, case-by-case determination
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| First-line nPEP regimens: nonnucleoside reverse transcriptase inhibitor–based and protease-based options; side effects
(76% of health care workers had symptoms [nausea; fatigue; malaise]); caused only 1% to discontinue therapy; treat 28
days if source HIV-positive; stop treatment if source HIV test negative
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| Dark chocolate to reduce cardiac risk: contains antioxidants and flavonoids
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| Antioxidants: scavenge free radicals; prevent endothelial damage; reduce cardiovascular risk
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| Flavonoids: found in fruits, vegetables, tea, and red wine; high levels in dark chocolate; much lower in milk chocolate
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| Benefits attributed to: eicosanoid (aspirin-like) effect that blocks platelet aggregation, improves endothelial function
and nitric oxide metabolism, and reduces blood pressure; drawback—high in saturated fat
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| Meta-analysis: 21 studies evaluated consumption of 50 g of dark chocolate per day; found 10.5% reduction in RR for cardiac
disease mortality (≈50% as effective as statin); studies population-based with many confounders
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| Bottom line: eating dark chocolate may be beneficial; when asked, counsel patients to limit consumption to 2 oz per day
or avoid
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| Questions and answers: nonpharmacologic management of AAA—probably not effective; pertussis vaccine for
adults—“it’s a good idea”; trivalent acellular vaccine recommended (tetanus, diphtheria, and acellular pertussis [Tdap];
Adacel); pertussis treatment—in patients coughing for ≥2 mo, treat cough; no antibiotics; assess close contacts; new
human papillomavirus (HPV) vaccine—effective; controversy over recommendation for vaccine for sexually transmitted
disease may affect overall recommendation; obtaining culture for pertussis—necessary for Dacron swab to
reach posterior nasopharynx; diagnosing pertussis—screen patients with symptoms of URI lasting 2 wk and followed
by chronic cough; begin treatment within 1 mo; neurologic complications—mostly seizures; increased rate of febrile
seizures associated with pertussis vaccination in children, but no long-term sequelae; seizures in adults not related to pertussis
vaccine
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| WOMEN AND MAMMOGRAPHY: AN UPDATE —Judith M. Walsh, MD, MPH, Associate Professor of Clinical Medicine,
Women’s Health Clinical Research Center, University of California, San Francisco, School of Medicine
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| Breast cancer: most commonly detected cancer in women; second leading cause of cancer death; screening mammography
reduces mortality but controversial for women in forties (mortality benefit not shown; denser breasts decrease sensitivity)
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| Recommendations: United States Preventive Services Task Force—screening mammography every 1 to 2 yr, with or
without clinical breast examination, for women ≥40 yr of age; acknowledge weaker evidence for women in forties; for
women ≥70 yr of age, discuss screening based on comorbidities; American Cancer Society—begin at 40 yr of age; clinical
breast examination by physician at least every 3 yr for women 20 to 39 yr of age, annually for women ≥40 yr of age; breast
self-examination no longer recommended, based on lack of benefit in large study in China (recommend prompt reporting of
symptoms and review of technique in women already performing self-examination); discuss risks and benefits of routine
screening
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| Digital mammography: approved by FDA; large study comparing digital to film mammography found overall accuracy
similar; digital more accurate in women <50 yr of age, women with dense breasts, and pre- or perimenopausal women;
drawbacks to digital—expensive; may require multiple imaging in large breasts; more time to interpret; difficult to
compare with past film mammography
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| Conclusion: if digital mammography available, may be recommended to those women in whom technique more accurate
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Educational Objectives
| The goal of this program is to educate the listener about current thoughts and recent advances in ambulatory medicine. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Manage asymptomatic hernia.
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| 2. Screen for abdominal aortic aneurysm and refer for surgery when indicated.
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| 3. Evaluate the efficacy of β-blocker therapy for primary hypertension.
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| 4. Recognize and treat pertussis in adults.
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| 5. Implement recommendations for screening mammography for breast cancer in women.
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Discussed on This Program
Atenolol [Tenormin]
Azithromycin [Zithromax, Zmax]
Clarithromycin [Biaxin, Biaxin XL]
Erythromycin [several trade names]
Losartan potassium [Cozaar]
Metoprolol succinate [Lopressor, Metoprolol Tartrate, Toprol XL]
Zoster vaccine live (Oka/Merck) [Zostavax]
Suggested Reading
No authors listed: CDC releases detailed guidelines for PEP use. Agency focuses on nonoccupational exposure. AIDS
Alert 20:42, 2005; No authors listed: Screening mammography. Prescrire Int 15:192, 2006; Carlberg B et al: Atenolol in
hypertension: is it a wise choice? Lancet 364:1684, 2004; Ding EL et al: Chocolate and prevention of cardiovascular disease:
a systematic review. Nutr Metab (Lond) 3:2, 2006; Fleming C et al: Screening for abdominal aortic aneurysm: a
best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 142:203, 2005; Flum DR:
The asymptomatic hernia: “if it’s not broken, don’t fix it”. JAMA 295:328, 2006; Halperin SA: Pertussis—a disease and
vaccine for all ages. N Engl J Med 353:1615, 2005; Hewlett EL et al: Clinical practice. Pertussis—not just for kids. N
Engl J Med 352:1215, 2005; Lubsen J et al: The DREAM trial. Lancet 368:2050; Rosenberg RD et al: Performance
benchmarks for screening mammography. Radiology 241:55, 2006; Vazquez M et al: Varicella vaccine and infection with
varicella-zoster virus. N Engl J Med 352:439, 2005; Ward JI et al: Efficacy of an acellular pertussis vaccine among adolescents
and adults. N Engl J Med 353:1555, 2005; Yaffe MJ et al: Quality control for digital mammography: part II. Recommendations
from the ACRIN DMIST trial. Med Phys 33:737, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Kohlwes was recorded at 34th Annual Advances in Internal Medicine, June 19-23, 2006; Dr. Walsh at Primary
Care Medicine, October 25-27, 2006; both meetings sponsored by the University of California, San Francisco,
School of Medicine and held in San Francisco. The Audio-Digest Foundation thanks the speakers and the sponsor for
their cooperation in the production of this program.
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