Women's health
A 30-year-old woman was seen last week for a conventional screening, which included a Pap test. Her test results were normal, and she now presents to review her results and plan her cervical cancer screening schedule for the future. She has had Pap tests yearly since she was 21 years of age and is currently sexually active with a single partner. Five years ago she had an abnormal Pap test and was found to have human papillomavirus (HPV) infection. Cervical biopsies demonstrated no evidence of dysplasia and a repeat Pap test 6 months later no longer revealed HPV. She has had normal Pap tests since. She has no irregular bleeding between monthly menstrual cycles, but she still worries about her cervical cancer risk. Although recommendations vary somewhat among medical societies, which of the following screening schedules is most appropriate for this patient’s age and history?
a) Pap test should now be performed every 3 years, or pap plus HPV cotesting should be performed every 5 years.
b) Pap test screening should be continued yearly and she should receive the HPV vaccination series.
c) Pap test should be performed yearly until she reaches 35 years of age, then every 2-3 years.
d) Pap plus HPV co-testing should be continued yearly based on her history of HPV infetion
a) The incidence of cervical cancer has been decreasing since the introduction of the Pap smear and preventive measures. The most important risk factor for developing cervical cancer is HPV infection. A quadrivalent HPV vaccination series has been approved by the US Food and Drug Administration and is most effective when given before the onset of sexual activity. Even when women are fully vaccinated, Pap screening is still indicated. Recommendations vary among the American Academy of Family Physicians, US Preventive Services Task Force, American College of Obstetricians and Gynecologists, and American Cancer Society, but most recommend initiating screening at age 21 or 3 years after first sexual activity. The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. Early detection of cervical cancer through screening has consistently reduced associated morbidity and mortality. However, potential sources of harm from overly frequent screenings include unnecessary repeated tests and biopsies, psychological distress for women diagnosed with low-grade lesions that may not be clinically important, and potential adverse effects from unnecessary treatment.
References:
Smith, Robert A., et al. "Cancer screening in the United States, 2015: a review of current American Cancer Society guidelines and current issues in cancer screening." CA: a cancer journal for clinicians 65.1 (2015): 30-54.
Wright, Thomas C., et al. "Primary cervical cancer screening with human papillomavirus: end of study results from the ATHENA study using HPV as the first-line screening test." Gynecologic oncology 136.2 (2015): 189-197.
American Cancer Society. Cancer Facts & Figures 2015. Accessed January 20, 2015.
Guirguis-Blake J, et al. Preventive health care. In: Rakel RE, Rakel D. Textbook of Family Medicine. 8th ed, 2011:73-95.
Asymptomatic bacteriuria should be treated in patients with which of the following conditions?
a) pregnancy
b) influenza A
c) recent intestinal surgery
d) dementia
e) indwelling catheter
a)
The diagnosis of asymptomatic bacteriuria (ASB) is based on a clean catch voided specimen. A urine culture with greater than 100,000 colonies/mL of a single organism is consistent with ASB. Bacteriuria occurs in 2% to 7% of pregnancies (similar to nonpregnant women). The pathogenic organisms tend to be the same as in nonpregnant women. But the ureteral dilation seen in pregnancy may facilitate the ascent of bacteria from the bladder to the kidney, which may explain the greater propensity for bacteriuria to progress to pyelonephritis (up to 40%) in pregnant women.
For this reason, it is important to diagnose and treat ASB in pregnancy.
Escherichia coli is the organism responsible for most cases of ASB. Women can therefore be safely treated with nitrofurantoin, ampicillin, cephalosporins, and short-acting sulfa drugs. Sulfa compounds should be avoided near term, as they compete for bilirubin-binding sites on albumin in the fetus and newborn and therefore pose a risk for kernicterus. Nitrofurantoin should not be used in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD), as there is a risk for hemolytic crisis. Therapy for ASB should be continued for 7 days. A follow-up culture should be performed 1 to 2 weeks after discontinuing therapy.
Reference:
Asymptomatic Bacteriuria. Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed. 2012; Chapter 38 - Renal Disease
Accuracy of diagnostic tests to detect asymptomatic bacteriuria during pregnancy. Mignini L - Obstet Gynecol - 01-FEB-2009; 113(2 Pt 1): 346-52
One-day compared with 7-day nitrofurantoin for asymptomatic bacteriuria in pregnancy: a randomized controlled trial. Lumbiganon P - Obstet Gynecol - 01-FEB-2009; 113(2 Pt 1): 339-45
A 34-year-old woman who is not pregnant and was recently diagnosed with type 2 diabetes mellitus presents to you for a follow-up visit. Her initial therapy included encouragement to begin healthy eating with referral to a nutritionist, counseling with a diabetes educator, and increased physical activity.
Her glycated hemoglobin (HbA1C) level at the time of diagnosis was 7.8%, and metformin was started. Three months after lifestyle modifications and metformin treatment, her HbA1C level is 7.7%. Sitagliptin (Januvia) is added.
What is the mechanism of action of this medication?
a) Inhibit sodium-glucose cotransporter 2 (SGLT2)
b) Stimulate pancreatic beta islet cell insulin release
c) Activate glucagon-like peptide 1 (GLP1) receptor
d) Inhibit dipeptidyl peptidase 4 (DPP4)
e) Increase insulin sensitivity
d) Sitagliptin inhibits DPP4, which slows incretin metabolism, increases insulin synthesis and release, and decreases glucagon levels.
Explanation:
Sitagliptin belongs to a subclass of medications that is also known as DPP4 inhibitors. Other examples are saxagliptin, linagliptin, and alogliptin
Examples of GLP-1 agonists are exenatide (Byetta or Bydureon), dulaglutide (Trulicity), liraglutide (Victoza), and semaglutide (Ozempic).
Examples of SGLT2 inhibitors are dapagliflozin (Farxiga), canagliflozin (Invokana), and empagliflozin (Jardiance).
Examples of thiazolidinediones (TZD), which increase insulin sensitivity, include pioglitazone (Actos) and rosiglitazone (Avandia).
Examples of sulfonylureas, which stimulate pancreatic beta islet cell insulin release, are glimepiride (Amaryl), glipizide (Glucotrol), and glyburide.
Reference:
American Diabetes Association. Standards of medical care in diabetes – 2016 abridged for primary care providers. Diabetes Care. 2016;39(suppl):S3-S21.
Which of the following best describes the major advantage of using a male condom during intercourse?
A) Male condoms do not contain hormones.
B) Male condoms are more effective at preventing pregnancy than oral contraceptive pills (OCPs).
C) Male condoms can be reused with multiple acts of intercourse.
D) Male condoms are inexpensive and can be found worldwide
E) Male condoms protect against sexually transmitted infections.
Key Point:
E) Male condoms protect against sexually-transmitted infections, and should be used for this purpose even when other methods to prevent pregnancy are employed.
Explanation:
The major advantage to using a male condom is the added protection against sexually transmitted infections. The same is true for female condom use; however, this is not true for other forms of barrier contraceptive methods such as a diaphragm or cervical cap. Women using OCPs, the birth control patch, vaginal contraceptive ring, intrauterine contraception, permanent sterilization, or injectable methods are all at risk for contracting sexually transmitted infections without concurrent condom use. Although it is true that condoms do not contain hormones and are widely available, these do not describe the primary benefit. Condoms should not be reused and are less effective than OCPs in preventing pregnancy.
Reference:
Zieman M. Overview of contraception. In: Basow DS, ed. UpToDate. Accessed September 12, 2012.
A patient presents with chest pain associated with myocardial ischemia. The palpable anterior Chapman reflex point in this patient is most likely to be found
A. in the center of the manubrium
B. in the intercostal space between ribs 2-3 adjacent to the sternum
C. in the intercostal space between ribs 4-5 at the sternocostal junction
D. in the intercostal space between ribs 2-3 in the midclavicular line
E. in the intercostal space between ribs 4-5 in the midclavicular line
b) The anterior Chapman reflex point is located between the second and third intercostal space where the intercostal nerve emerges. The coinciding posterior Chapman reflex point is at the T2 transverse process.
A Chapman reflex point in the center of the manubrium can be related to the pylorus; it extends down thesternal body. A Chapman reflex point in the intercostal space between ribs 4-5 at the sternocostal junction.
This Chapman reflex point correlates with the lower lung. A Chapman reflex point in the intercostal space between ribs 2-3 in the mid clavicular line correlates with the sinuses. A Chapman reflex point in the intercostal space between ribs 4-5 in the mid clavicular line does not exist. It would likely be a pec minor or major tender point, and should be treated as such. It may still be in response to underlying rib dysfunction as a viscerosomatic reflex to myocardial injury.
Reference: Foundations for Osteopathic Medicine, 3rd ed., 2011; pg. 855
Somatic Dysfunction in Osteopathic Family Medicine, 2nd ed., 2015; pg. 54
Somatic Dysfunction in Osteopathic Family Medicine, 1st ed., 2007; Chapter 5; pg. 41
You are attempting to counsel a woman with severe vasomotor symptoms related to menopause about the possibility of treating her symptoms with hormone therapy (HT). Which of the following accurately represents current guidelines related to HT?
a) The U.S. Preventive Services Task Force recommends using HT for the primary prevention of osteoporosis.
b) The American Heart Association endorses the use of HT for the primary prevention of coronary heart disease.
c) The American College of Obstetrics and Gynecology (ACOG) recommend the use of either conventional hormonal menopausal therapy or compounded bioidentical hormones.
d) The American Society of Reproductive Medicine recommends HT for the secondary prevention of coronary heart disease.
e) The American College of Obstetrics and Gynecology (ACOG) endorses the use of HT for the treatment of symptomatic menopause in women who have become recently menopausal.
e)
HT is currently being advocated by several medical societies, including ACOG, the American Society of Reproductive Medicine, and the American Association of Clinical Endocrinologists, for the treatment of moderate to severe symptoms of menopause in a select group of patients who are recently menopausal. Treatment generally should be limited to 5 years or less and be limited to patients younger than 60 years of age, although the ACOG recognizes that some symptomatic women may require treatment of a longer duration. No organizations recommend the use of HT for the primary or secondary prevention of coronary heart disease, osteoporosis, or colon cancer. ACOG has recommended against the use of bioidentical hormones, stating that their efficacy and safety profiles have not been clearly demonstrated.
References:
Committee on Gynecologic Practice and the American Society for Reproductive Medicine Practice Committee. Committee opinion no. 532: compounded bioidentical menopausal hormone therapy. Obstet Gynecol. 2012;120(2 pt 1):411-415.
Pines A. Guidelines and recommendations on hormone therapy in the menopause. J Midlife Health. 2010;1:41-42.
Sterile (or seemingly sterile) pyuria is most commonly caused by:
a) inflammation of an adjacent organ
b) renal calculus
c) Chlamydial cystitis
d) anaerobic urinary tract infection (UTI)
a) Abdominal or pelvic infections or inflammation such as cervicitis with or without PID, appendicitis, diverticulitis, colitis, and bacterial vaginitis are the most common causes of sterile pyuria.
A recent literature analysis found that sterile pyuria is present in nearly 88% of patients with acute appendicitis and in nearly 73% of patients with acute diverticulitis. In both categories (appendicitis and diverticulitis), pyuria is significantly more common in females.
Less commonly, sterile pyuria can also be a sign of:
Anaerobic UTI typically will present with pyuria and positive nitrites, indicating infection.
References:
Goonewardene, Sanchia, and Raj Persad. “Sterile Pyuria: a Forgotten Entity.” Therapeutic Advances in Urology, SAGE Publications, Oct. 2015
“2015 Guidelines for Approach to Sterile Pyuria.” Therapeutic Advances in Urology, SAGE Publications, Oct. 2015
A 79-year-old, community-dwelling woman with mild dementia, osteoarthritis, hypertension, and type 2 diabetes mellitus controlled with diet and oral agents has been admitted to the hospital after an episode of lightheadedness, palpitations, and near syncope. Her blood sugar level measured in the emergency department was 45 mg/dL. This is the third episode of hypoglycemia in 2 months.
Which of the following antidiabetic medications should be excluded from her regimen?
a) glimepiride
b) metformin
c) sitagliptin
d) acarbose
e) pioglitazone
a)
One of the most common side effects of sulfonylureas (eg, glimepiride) is hypoglycemia; therefore, sulfonylureas should be avoided in patients prone to hypoglycemic episodes. Moreover, a patient with cognitive impairment can easily overdose on such drugs, causing severe hypoglycemia.
References:
Crandall J, Shamoon H. Diabetes mellitus. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016: 1527-1548.
Wright J, Tylee T.Pharmacologic therapy of type 2 diabetes.Med Clin North Am. 2016;100(4): 647-663.
Which of the following is the most appropriate instruction about missing one dose of a combined (estrogen and progestin) oral contraceptive during week two of active pills?
a) Take two pills today and start a new pack of pills tomorrow; there is no need for backup contraception.
b) Take the missed pill today and start a new pack of pills tomorrow; use backup contraception for 7 days.
c) Take the missed pill and today’s pill today; there is no need for backup contraception.
d) Take two pills today and two pills tomorrow; use backup contraception for 7 days.
Key Point
c) A single missed or late oral contraceptive dose does not require backup contraception, unless it occurs at the beginning or end of the pill pack.
Explanation
The 2013 US Selected Practice Recommendations for Contraceptive Use recommendation is to take the late pill as soon as possible and today’s pill as scheduled. This may mean taking the 2 pills simultaneously.
A late pill is defined as a pill taken within 24 hours of when it should have been taken. A dose is defined as missed if ≥24 hours have passed since the dose should have been taken. A late pill at any point in the cycle dose not result in a need for additional contraception. Additional contraception may need to be used for missed pills, but only if the pill is missed at the beginning or end of a packet of pills (not during the second week).
A new pack does not need to be started when the patient has missed only one pill. Taking two pills is not necessary to cover just one missed dose.
Reference:
US Selected Practice Recommendations for Contraceptive Use, 2013. Overview of the use of estrogen-progestin contraceptives. Accessed April 26th, 2017.
Where does the sympathetically mediated viscerosomatic reflex from the upper respiratory tract originate?
A. C1-C2
B. C3-C5
C. C6-C8
D. T1-T4
E. T5-T7
ANSWER: D
Sympathetic innervation to the head and neck stems from T1-T4. The upper respiratory tract is also from T1-T4. All other answer options exclude the right regions: C1-C2 are not sympathetic levels. C3-C5 are the phrenic nerve and are also not sympathetic levels. C6-C8 are not sympathetic levels. T5-T7 is sympathetic supply to the stomach, liver, spleen, and pancreas.
Reference: Foundations for Osteopathic Medicine, 3rd ed., 2010; pg. 141-146
A gravida 3 para 3 woman aged 42 years presents to you for an annual physical examination. Vital signs are: heart rate 73 beats/minute; blood pressure 138/88 mm Hg; respiratory rate 14 breaths/minute; temperature 98.6°F; oxygen saturation: 100% on room air. She has no complaints and the results from the physical examination are unremarkable. She denies tobacco use. Her medical history is significant for prehypertension, and she is currently taking oral contraceptives. Family history includes ovarian cancer in her paternal grandmother and hypertension in her mother and sibling. She desires guidance on appropriate cancer screening options based on her age, health status, and family history.
Which of the following factors is protective against the development of ovarian cancer?
a) being a carrier of the BRCA2 mutation
b) taking estrogen therapy after menopause
c) oral contraceptive use
d) having a second-degree relative with ovarian cancer
c ) Oral contraceptives are protective against the development of ovarian cancer, while hormone replacement therapy, family history, and BRCA2 mutation increase risk.
Explanation:
Ovarian cancer is the fifth leading cause of cancer-related deaths in women in the United States. Despite the fact that most women have nonlocalized disease at the time of diagnosis, no evidence indicates that screening reduces mortality from ovarian cancer. Risk factors for developing ovarian cancer include having any first- or second-degree relatives with ovarian cancer, being a carrier of the BRCA1/2 mutations, and hormone replacement therapy.
Both oral contraceptive use and parity have been demonstrated to have protective effects, thus reducing disease risk. Because of the relatively low incidence of ovarian cancer in the general population, screening tests such as the CA 125 blood test and transvaginal ultrasonography have proven to be ineffective due to high false-positive rates.
Although routine screening is not recommended by any medical society, women determined to be at increased risk should be closely monitored for early signs and symptoms of the disease.
References:
American Cancer Society. Cancer Facts & Figures 2015. Accessed January 20, 2015.
Eisenhauer EL, Salani Ritu, Copeland LJ. “Epithelial Ovarian Cancer.” Clinical Gyencologic Oncology 9th Ed., Elsevier 2018: 253-289.
All pregnant patients with pyelonephritis should be hospitalized for parental antibiotics. Appropriate choices for initial antibiotics include:
a) quinolones
b) Ceftriaxone
c) nitrofurantoin
d) vancomycin
e)levofloxacin
b) Levofloxacin is not appropriate for pregnant patients, nitrofurantoin is not efficacious for pyelonephritis, and vancomycin should not be used unless other antibiotics have failed and the organism is susceptible to vancomycin.
Diagnosis and Management of Acute Pyelonephritis in Adults, American Family Physician Vol 71 No. 5 March 1 2005
A 66-year-old man presents for a follow-up visit. He has a long history of diabetes mellitus and recently had a complete physical examination and laboratory investigations done, including a diabetic foot examination, urine microalbumin check, and lipid and glycated hemoglobin levels.
Prior to insulin management, the patient was not compliant with his oral antidiabetic drugs. Now, short- and long-acting insulin is used, and now he has well-maintained blood sugar levels.
His foot examination is unremarkable, but funduscopic examination reveals diffuse, opaque white spots throughout the fundus, with scattered hard exudates and multiple small microaneurysms.
Visual examination is 20/20 OS and 20/25 OD. The man denies any visual changes or defects such as blurred vision or diplopia.
Which of the following is the most likely cause of these visual changes?
a) nonproliferative diabetic retinopathy
b) proliferative diabetic retinopathy
c) macular edema
d) diabetic cataract
e) age-related ocular changes
a) Nonproliferative diabetic retinopathy is caused by small-vessel disease, which is a common complication of long-standing diabetes. Occlusion, dilation, and increased permeability of the small vessels result in the development of microaneurysms. Serous fluids and lipoprotein leak from damaged blood vessels and form hard exudates characteristic of diabetes mellitus. Small-vessel infarction leads to cotton-wool spots caused by the microinfarction of nerve fibers.
Exudates related to age tend to be soft and yellowish as opposed to hard and scattered.
Diabetic cataracts result in the opacification of the lens, leading to visual changes like diplopia and watering of the eyes.
Macular edema presents with permanent visual loss and is a well-established complication of diabetes mellitus.
Proliferative diabetic retinopathy is the ultimate outcome of diabetes due to long-standing ischemic changes that result in neovascularization that can disrupt the optic nerve and disc.
References:
Antonetti DA, Klein R, Gardner TW. Diabetic retinopathy. N Engl J Med. 2012;366(13):1227-1239.
Ferri FF. Diabetic retinopathy. In: Ferri FF. Ferri's Clinical Advisor 2017. 2017:379-380
Which of the following best describes the association between depot medroxyprogesterone acetate (DMPA) and bone mineral density (BMD) loss in adolescent girls?
A) Decline in bone mineral density (BMD) while on DMPA substantially reverses upon discontinuation of the drug.
B) Adolescent girls using DMPA should be advised to take calcium and vitamin D supplements because of the effect on bone mineral density (BMD).
C) A bone density scan (dual energy X-ray absorptiometry) should be obtained annually on women using DMPA because of the effect on bone mineral density (BMD).
D) Adolescent girls using DMPA should be advised that they may experience a permanent decrease in bone mineral density (BMD) with use beyond 2 consecutive years.
E) DMPA should not be used for more than 2 consecutive years because of the effect on bone mineral density (BMD).
A) Depot medroxyprogesterone acetate (DMPA) is an injectable, progestin-only contraceptive that provides long-acting and reversible contraception. DMPA may be a particularly good choice for women who have contraindications to estrogen-containing contraception, those taking hepatic enzyme-inducing anticonvulsant drugs, women with sickle cell anemia, and women who smoke. The injection is given every 3 months, which makes it a good option for women who struggle to remember daily dosing of contraceptive pills.
In 2004, the U.S. Food and Drug Administration added a black box warning to the labeling of DMPA, recommending that alternate contraceptive options be considered in women who have used the product for 2 years because of studies suggesting a decline in bone mineral density (BMD). DMPA suppresses ovulation and also reduces ovarian estradiol production. This leads to an approximately 1%-2% annual decline in BMD at the hip and spine of current users. However, multiple medical societies, including the American College of Obstetrics and Gynecology, the Society for Adolescent Health and medicine, the World Health Organization, and the Society for Obstetricians and Gynaecologists of Canada advise that the advantages of DMPA use as a contraceptive outweigh theoretical concerns about BMD loss. After DMPA is discontinued, BMD recovers, and no studies have linked its use to the occurrence of osteoporosis or fractures.
References:
Kaunitz AM. “Depot medroxyprogesterone acetate for contraception.”UpToDate. (Accessed September 21, 2017)
Zieman M. Overview of contraception. In: Basow DS, ed. UpToDate. Accessed September 12, 2012.
Depot medroxyprogesterone acetate and bone density. In: American College of Obstetricians and Gynecologists. PROLOG: Patient Management in the Office. 5th ed, 2007:17.
A 17-year-old male with chronic persistent asthma presents for evaluation. History reveals that he is compliant with his medications and has experienced reduced episodes of wheezing. He does note that when he exerts himself or becomes upset, wheezing occurs. In order to reduce the effect of sympathetic tone, to which of the following anatomic structures should osteopathic manipulative treatment be performed?
A. C1-C3
B. T1-T6
C. T8-T12
D. costal nerves
E. phrenic nerve
ANSWER: B
Sympathetic innervation for the lungs derives from T2-T7 according to most references. Some would also describe it as T1-T6. Since this is a sympathetic disorder, and the derivations of the sympathetic nervous system (thoracic spine) should be looked at, C1-C3 would be incorrect. The costal and phrenic nerves are not sympathetic innervation and would also be incorrect. T8-T12 does not include the sympathetic innervation sites that should be activated in the treatment of asthma.
Reference: 5-Minute Osteopathic Manipulative Medicine Consult, 1st ed., 2009; pg. 12-13
What is the most likely etiology for cyclical pelvic pain that coincides with menstrual blood flow in a 24 year old female?
a) Adenomyosis
b)Pelvic inflammatory disease
c) Ruptured ectopic pregnancy
d) Endometriosis
e) A relatively common cause of chronic pelvic pain is endometriosis whose hallmark is a cyclical relationship. Symptoms can mimic other types of pelvic pathology. Diagnosis is made by laparoscopy.
Reference:
Hart D. Lipsky A. Acute Pelvic Pain in Women (Chapter 33) in Marx: Rosen's Emergency Medicine, 8th ed.: 2014.
A 72-year-old African American woman has longstanding chronic kidney disease (CKD) due to hypertension. She has recently started dialysis. Her hemoglobin level is 11 g/dL. She has hypertension treated with amlodipine, clonidine, and metoprolol.
For patients with CKD treated with dialysis, which one of the following statements is correct about erythropoiesis-stimulating agents (ESAs) as treatment for their anemia?
a) In patients on dialysis, ESAs have been shown to reduce cardiovascular risk.
b) ESAs should be used in patients on dialysis to reach a target hemoglobin level = 12 g/dL.
c) In patients on dialysis, ESAs should be initiated for hemoglobin levels < 10 g/dL and stopped or reduced once the hemoglobin level > 11 g/dL.
d) ESAs should be initiated at the time that hemodialysis is started.
c) Appropriately prescribe erythropoietin-stimulating agents to patients with chronic kidney disease receiving dialysis.
Key Point:
In patients on dialysis, ESAs should be initiated for a hemoglobin level < 10 g/dL and stopped or reduced once the hemoglobin level > 11 g/dL.
Explanation:
In 2011, the US Food and Drug Administration advised health care professionals to be more conservative in their use of ESAs in patients with CKD. The recommendations are based on the increased cardiovascular risks associated with these drugs. For patients with CKD requiring dialysis, ESAs are only recommended if the hemoglobin level is below 10 g/dL, and the drugs should be stopped or reduced in dose once the hemoglobin level approaches or exceeds 11 g/dL.
References:
Badve SV, Beller EM, Cass A, et al. Interventions for erythropoietin-resistant anaemia in dialysis patients. Cochrane Database Syst Rev. 2013;(8):CD006861
Bennett CL, Spiegel DM, Macdougall IC, et al. A review of safety, efficacy, and utilization of erythropoietin, darbepoetin, and peginesatide for patients with cancer or chronic kidney disease: a report from the Southern Network on Adverse Reactions (SONAR). Semin Thromb Hemost. 2012;38:783-796.
Schneider A, Gutjahr-Lengsfeld L, Ritz E, et al. Longitudinal assessments of erythropoietin-stimulating agent responsiveness and the association with specific clinical outcomes in dialysis patients. Nephron Clin Pract. 2014;128:147-52.
An 82-year-old man with type 2 diabetes mellitus, hypertension, dyslipidemia, congestive heart failure, and coronary artery disease presents to you. Over the past week, he reports worsening shortness of breath at rest and persistent bilateral lower extremity edema.
Echocardiography obtained last year demonstrated an ejection fraction of 35% to 40%. His vitals are: heart rate 78 beats/minute, respiratory rate 18 breaths/minute, blood pressure 160/90 mm Hg, and temperature 97.8 °F. His most recent glycated hemoglobin level was 6.7%.
On physical examination, there is grade 2+ bilateral pitting edema of his feet. Crackles are heard at both lung bases.
Which antidiabetic medication should be avoided in this patient?
a) glimepiride
b) sitagliptin
c) acarbose
d) metformin
e) pioglitazone
e) Thiazolidinediones act by activating peroxisome, proliferator-activated receptors (gamma) in the cell nuclei, leading to a complex transcriptional activation that then leads to decreased insulin resistance. These drugs have been shown to cause several side effects that often outweigh the benefits in glycemic control. Pioglitazone is contraindicated in patients with New York Heart Association classification III/IV heart failure, because it increases fluid retention and worsens the heart failure.
Metformin, glimerpiride, acarbose, and sitagliptin are not contraindicated in patients with New York Heart Association classification III/IV heart failure.
References:
Crandall J, Shamoon H. Diabetes mellitus. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016: 1527-1548.
Wright J, Tylee T. Pharmacologic therapy of type 2 diabetes. Med Clin North Am. 2016;100(4): 647-663.
A 42-year-old woman with 3 children wants to discuss her contraceptive options. Her body mass index is 29 kg/m2, blood pressure is 139/86 mm Hg, and she is a nonsmoker. Her mother died of ovarian cancer and her sister developed deep venous thrombosis (DVT) during pregnancy that was treated with anticoagulation therapy. Her past medical history includes migraine with aura, which she experiences 1-2 times a year, seasonal allergies, depression, and bothersome varicose veins. Her medications include diphenhydramine, fluoxetine, and ibuprofen. Which of the following components of her history is a contraindication to the use of combination oral contraceptives for pregnancy prevention?
a)Varicose veins
b) Family history of DVT
c) Blood pressure
d) Age
e) Migraine with aura
e) According to the U.S. Medical Eligibility Criteria for Contraceptive Use 2016 guidance, level 4 represents a condition that is associated with an unacceptable health risk if the combination (estrogen- and progesterone-containing) oral contraceptive pills are used for contraception and hence this is an absolute contraindication for use. In this patient, migraine with aura is the absolute contraindication to use of the combined oral contraceptive.
Age ≥35 years is a contraindication only in women who smoke ≥15 cigarettes a day. In addition, age should be taken into account when considering risk factors for cardiovascular disease. Multiple cardiovascular risk factors represents an absolute contraindication and older age is considered in this category. Age alone, however, is not an absolute contraindication to use of the combined oral contraceptive. Age ≥40 is a category 2 condition, meaning the advantages of using the method generally outweigh the theoretical or proven risks. A family history of DVT in a first-degree relative is also a category 2 condition, while an acute DVT/pulmonary embolism (PE) represents a category 4 condition. A personal history of DVT/PE not on anticoagulant therapy may be a category 4 condition when there is a high risk of repeat thrombosis. Patients considered high risk include those with DVT/PE secondary to contraceptive use, DVT/PE in pregnancy, idiopathic DVT/PE, known thrombophilia, or an active cancer. A history of DVT/PE without risk factors for recurrence is considered category 3, so the theoretical or proven risks usually outweigh the advantages of using the method.
Varicose veins are a category 1 condition and do not affect the prescribing decision in this case.
Blood pressure should certainly be considered alone and as part of cardiovascular risk. Elevated blood pressure is only considered a category 4 condition when the systolic is ≥160 mmHg or the diastolic is ≥100 mmHg.
Other conditions which are listed as category 4 conditions are:
In the medical history and examination findings described, migraine with aura precludes the use of combination oral contraceptive pills, the birth control patch, or a vaginal contraceptive ring in this patient. This patient would be a candidate for progesterone-only contraception, a copper intrauterine device, barrier methods, or permanent sterilization.
References:
Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016;65(3):1-103.
Centers for Disease Control and Prevention. United States medical eligibility criteria (USMEC) for contraceptive use. Accessed September 12, 2012.
Examination of a 1-week-old neonate reveals cranial dysfunction. Dysfunctional rotation of the occiput on the atlas (C1) has been shown to be clinically associated with
A. asymmetric head shape
B. fetal alcohol syndrome
C. low birth weight
D. mouth breathing
E. sudden infant death syndrome
ANSWER: A
Abnormal head shape, or, plagiocephaly, is a common occurrence, which has been exacerbated and has become more prevalent since the back-to-sleep campaign. It is characterized by asymmetric head shapes, most often conforming to a parallelogram shape. OA dysfunction can lead to suckling difficulty and cause decreases in weight after birth. If unaddressed, failure to thrive is a possible result of OA dysfunction. However, sudden infant death syndrome is not observed in increasing frequency in infants with OA dysfunction. Suckling difficulty is a far more common complication of this. If an infant has such profound suckling difficulties that they cannot nurse effectively, they are often supplemented with formula far before failure to thrive becomes a concern. There has been no established correlation between fetal alcohol syndrome and structural dysfunctions at the OA. Birth weight is unaffected by cranial dysfunctions since the fetus derives all of its nutrition via the umbilical cord. Infants are obligate nasal breathers; cervical and cranial dysfunctions have not been demonstrated to impact mouth breathing.
Reference: Somatic Dysfunction in Osteopathic Family Medicine, 2nd ed., 2015; Chapter 8, pg. 92
A 56-year-old woman presents to you with questions about preserving her cognitive function. Her mother was recently diagnosed with dementia, and she would like to avoid the same fate. She wonders if estrogen supplementation might help her retain her cognitive abilities. Which of the following statements is true regarding hormone therapy (HT) and dementia?
a) Randomized controlled trials have consistently found estrogen to have a positive effect on cognitive functioning.
b) The timing of when HT is initiated in relation to menopause has been shown to have no bearing on cognitive function.
c) Estrogen receptors in the brain are found in the amygdala and hippocampus.
d) Dementia onset is typically earlier in men than in women.
e) Observational studies have not shown any potential benefit of HT on cognitive functioning.
c) Women typically have an earlier onset of dementia than men. Thirty-three percent of women as opposed to 20% of men will develop dementia after the age of 65 years. This suggests a possible role for estrogen and progesterone in the development of dementia. Estrogen receptors have been found in the brain, especially in the hippocampus and amygdala. Observational studies have suggested that HT may have a beneficial effect on the development of dementia. Data from these studies also suggest that this benefit is most pronounced when HT is initiated at the time of menopause. Randomized controlled trials have not been able to demonstrate a protective effect of HT on the development of dementia.
References:
Brinton RD, Tran J, Proffit P, Montoya M. 17B-estradiol enhances the outgrowth and survival of neocortical neurons in culture. Neurochem Res. 1997;11:1339-1351.
Espeland MA, Shumaker SA, Leng I, et al; WHIMSY study group. Long-term effects on cognitive function of postmenopausal hormone therapy prescribed to women aged 50 to 55 years. JAMA Intern Med. 2013;173:1429-1436.
Henderson VW, Benke KS, Green RC, et al. Postmenopausal hormone therapy and Alzheimer’s disease risk: interaction with age. J Neurol Neurosurg Psychiatry. 2005;76:103-105.
Hogervorst E, Williams J, Budge M, Riedel W, Jolles J. The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: a meta-analysis. Neuroscience. 2000;101:485-512.
Kawas C, Resnick S, Morrison A, et al. A prospective study of estrogen replacement therapy and the risk of developing Alzheimer's disease: the Baltimore Longitudinal Study of Aging. Neurology. 1997;48:1517-1521.
Le Blanc ES, Janowsky J, Chan BKS, Nelson HD. Hormone replacement therapy and cognition: Systematic review and meta-analysis. JAMA. 2001;285:489-499.
Maki PM, Gast MJ, Vieweg AJ, et al. Hormone therapy in menopausal women with cognitive complaints: a randomized, double-blind trial. Neurology. 2007;69:1322-1330.
McEwen BS. Clinical review 108: the molecular and neuroanatomical basis for estrogen effects in the central nervous system. J Clin Enocrinol Metab. 1999;84:1790-1797.
Ott A, Breteler MM, van Harskamp F, Stijnen T, Hofman A. Incidence and risk of dementia: the Rotterdam study. Am J Epidemiol. 1998;147:574-580.
Resnick SM, Coker LH, Maki PM, et al; Women's Health Initiative Study of Cognitive Aging (WHISCA). A randomized clinical trial of the effects of hormone therapy on age-associated cognitive decline. Clin Trials. 2004;1:440-450.
Resnick SM, Espeland MA, An Y, Maki PM, et al; Women's Health Initiative Study of Cognitive Aging Investigators. Effects of conjugated equine estrogens on cognition and affect in postmenopausal women with prior hysterectomy. J Clin Endocrinol Metab. 2009;94:4152-4161.
Resnick SM, Maki PM, Rapp SR, et al; Women's Health Initiative Study of Cognitive Aging Investigators. Effects of combination estrogen plus progestin hormone treatment on cognition and affect. J Clin Endocrinol Metab. 2006;91:1802-1810.
Tang MX, Jacobs D, Stern Y, et al. Effect of oestrogen during menopause on risk and age at onset of Alzheimer's disease. Lancet. 1996;348:429-432.
Whitmer RA, Quesenberry CP, Zhou J, et al. Timing of hormone therapy and dementia: the critical window theory revisited. Ann Neurol. 2011;69:163-169.
Yaffe K. Hormone therapy and the brain. Dj vu all over again? JAMA. 2003;289:2717-2719.
A 63-year-old patient with long-standing, well-controlled type 2 diabetes mellitus, well-controlled hypertension with an angiotensin-converting enzyme inhibitor and calcium channel blocker, and hyperlipidemia presents to you with a creatinine level of 2.9 mg/dL. His hemoglobin level is 11 g/dL, which is down from 12 g/dL 1 year ago.
You previously ruled out occult blood loss as the cause of the anemia and you are monitoring his kidney function closely. At what hemoglobin level should you consider the use of an erythropoiesis-stimulating agent (ESA)?
a) hemoglobin level of 8 g/dL
b) hemoglobin level of 10 g/dL
c) hemoglobin level of 11 g/dL
d) patient is not a candidate for ESA treatment
b) Utilize the appropriate hemoglobin threshold for use of erythropoietin-stimulating agents.
Key Point:
In patients with chronic renal failure who are not on dialysis, a threshold hemoglobin level ≤ 10 g/dL is recommended for ESA use.
Explanation:
In 2011, the US Food and Drug Administration advised healthcare professionals to be more conservative in their use of ESAs in patients with chronic kidney disease. The recommendations are based on the increased cardiovascular risks associated with these drugs. For patients with chronic kidney failure not on dialysis, ESAs are only recommended if the hemoglobin level is below 10 g/dL and there is a predicted further decline in hemoglobin.
The target values of hemoglobin in patients treated with ESA is between 10 and 11.5 g/dL.
References:
Kliger AS, Foley RN, Goldfarb DS, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guidelines for anemia in CKD. Am J Kidney Dis. 2013;62:849-859.
Moist LM, Troyanov S, White CT, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for anemia in CKD. Am J Kidney Dis. 2013;62:860-873.
Vinhas J, Barreto J, Asuncao J, et al. Treatment of anemia with erythropoiesis-stimulating agents in chronic kidney disease does not lower mortality and can increase cardiovascular risk: a meta-analysis. Nephron Clin Pract. 2012;121:c95-c101.
A 15-year-old girl was recently diagnosed with type 1 diabetes mellitus. She has been treated for mild diabetic ketoacidosis, and now she is ready to eat and to be transitioned to subcutaneous insulin. Her current weight is 110 pounds.
What is the best way to start an insulin regimen in this patient?
a) sliding-scale insulin
b) 12.5 units insulin glargine every night at bedtime and 12.5 units of insulin lispro administered in 3 divided doses daily (4 units prior to breakfast and lunch, 4.5 units prior to dinner)
c) 10 units insulin glargine every night at bedtime and 10 units of insulin lispro administered in 3 divided doses daily (3 units prior to breakfast and lunch, 4 units prior to dinner)
d) 12.5 units of insulin lispro administered in 3 divided doses daily (4 units prior to breakfast and lunch, 4.5 units prior to dinner)
e) 25 units of insulin lispro administered in 3 divided doses daily (7.5 units prior to breakfast and lunch, 10 units prior to dinn
c)
A regimen of multiple daily insulin injections that include basal, premeal, and correction doses is preferred for optimal insulin control. A conservative total dose of 0.4 units/kg/day is given initially to a newly diagnosed patient. The dose is then adjusted using self-monitoring of blood glucose. A reasonable starting dose of basal insulin is 0.2 units/kg/day given once daily in case of insulin glargine and detemir. It should be adjusted until fasting plasma glucose is consistently below 130 mg/dL. The remainder of insulin requirements should be covered with premeal insulin, where rapid-acting insulins are preferred. The dose can be larger before the largest meal of the day--usually dinner.
References:
American Diabetes Association. Standards of medical care in diabetes – 2016 abridged for primary care providers. Diabetes Care. 2016;39(suppl):S3-S21.
Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:E26.
A 21-year-old woman is seeking contraception. She has been researching various methods and was confused when she came upon effectiveness rates for oral contraception. One resource stated oral contraception was 99.7% effective, but another reported an effectiveness rate of 92%. Which of the following best explains the differences?
a) The less-effective rate (92%) accounts for missed doses (1 per month), while the higher effectiveness rate (99.7%) assumes no missed doses.
b) The less-effective rate (92%) only takes oral contraceptive efficacy into account, while the higher effectiveness rate (99.7%) also includes patient use.
c) The less-effective rate (92%) refers to typical use of oral contraception, while the higher effectiveness rate (99.7%) refers to perfect use.
d) The less-effective rate (92%) refers to perfect use of oral contraception, while the higher effectiveness rate (99.7%) refers to typical use.
c)
Package inserts for oral contraceptives include an efficacy table listing statistics for both typical and perfect use of various contraceptive methods. Typical use shows the efficacy during actual use (including inconsistent or incorrect use), while perfect use shows the efficacy when directions are followed every time that method is used. Therefore, typical use efficacy rates (92%) are lower than perfect use efficacy rates (99.7%).
Missed doses are not the reason for the differences between the effectiveness rates (although they could be included in the reasons for typical use efficacy rates).
The lower efficacy rate takes into account patient use, not the higher efficacy rate.
Reference:
Trussell J. The essentials of contraception: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Stewart F, Nelson Al, Cates W, Guest F, Kowal D, editors. Contraceptive Technology. 18th ed. New York, Ardent Media, Inc; 2004. p. 225-7.
A healthy 28-year-old male presents to the office after falling backwards against a chair and injuring his back. He reports that he has pain between his shoulder blades at the level of the inferior angle of the scapula. Which of the following sets of symptoms would be most consistent with a sympathetic viscerosomatic response to this patient's injury?
A. belching and dyspepsia
B. difficulty defecating with straining and tenesmus
C. difficulty urinating and pain with intercourse
D. nasal drainage and sneezing
E. pain radiating down the back of the right leg to the back of the knee
ANSWER: A
Pain between the patient’s scapulae at the level of his inferior angle correlates with the thoracic level T7.
This thoracic level innervates the stomach and liver, so the correct answer is belching and dyspepsia.
Difficulty defecating would be T12-L2. Difficulty with urinating and pain with intercourse would be T12-
L2. Nasal drainage is T1-T4. Pain radiating down the back of the leg would be L3-S1.