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  1. AAFP

  2. Which of the following is an appropriate initial empirical regimen for H. pylori? A.Triple therapy with a PPI, clarithromycin, and amoxicillin B.Concomitant therapy with a PPI, clarithromycin, amoxicillin, and metronidazole C.Quadruple therapy with a PPI, bismuth, metronidazole, and tetracycline D.Either B or C

  3. Answer • D.Either B or C

  4.  The clarithromycin and tetracycline shortages will bring up more questions aboutappropriate drug regimens for H. pylori. Triple therapy with a PPI, clarithromycin, and amoxicillin or metronidazole is often used first-line...but usually should NOT be. Efficacy rates are falling due to increasing clarithromycin resistance.    Start with quadruple or concomitant therapy instead. Quadruple therapy with bismuth, metronidazole, and tetracycline (Helidac,Pylera) plus a PPI is making a comeback due to better efficacy.    Many pharmacies can't get tetracycline right now due to manufacturing shortages. If you get a call asking for a switch, DON'T automatically go to doxycycline. Some experts are trying doxy 100 mg BID, but there's no evidence that it works as well. Try other alternatives.    For patients willing to pay for the combo packs, use Helidac or Pylera. These are still available and contain tetracycline.    If you use Helidac, give extra metronidazole to overcome resistance. Give 250 mg TID...with the three mealtime doses of Helidac. Concomitant therapy means triple therapy with a PPI, clarithromycin, and amoxicillin...PLUS metronidazole to help boost efficacy.    This concomitant therapy CAN be used instead of quadruple therapy. It's given BID instead of QID. And it doesn't contain bismuth...so it avoids the black stools or tongue, constipation, etc.    If your pharmacy can't get plain clarithromycin, prescribe Prevpac(lansoprazole/amoxicillin/clarithromycin) PLUS metronidazole 500 mg BID.    Don't use another macrolide instead of clarithromycin...the others don't work forH. pylori. Extended-release clarithromycin (Biaxin XL) will probably work...but this isn't proven.    If necessary, consider whether antibiotics can be delayed until optimal ones are available. Start the PPI right away to heal the ulcer...and add the antibiotics later to help prevent recurrence.

  5. Which of the following is TRUE about using chlorthalidone instead of hydrochlorothiazide for hypertension? A.Chlorthalidone is longer-acting than hydrochlorothiazide. B.Chlorthalidone works better to lower blood pressure. C.Chlorthalidone has more evidence that it improves cardiovascular outcomes. D.All of the above

  6. Answer • D.All of the above

  7. CARDIOLOGY • The new Edarbyclor (eh-DAR-bih-clor) means you'll see more interest in usingchlorthalidone instead of hydrochlorothiazide for hypertension. Edarbyclor combines the ARB azilsartan (Edarbi) plus CHLORTHALIDONE...instead of hydrochlorothiazide like most BP combos.    It's the first new chlorthalidone combo in 20 years. The only others are with atenolol (Tenoretic, etc) or clonidine (Clorpres).    So why is hydrochlorothiazide used much more? It got a head start years ago due to concerns about more hypokalemia with chlorthalidone...especially with the high doses that were initially used with thiazides.    But hypokalemia is much less of a problem with today's lower doses...or when chlorthalidone is combined with an ACEI or ARB.    Chlorthalidone also has some significant advantages. It's longer-acting...works better to lower BP...and has more evidence that it improves cardiovascular outcomes and survival.    Consider using chlorthalidone instead of hydrochlorothiazide...especially for patients with hard-to-treat BP. When switching, use 12.5 mg of chlorthalidone for 25 mg of hydrochlorothiazide.    Recommend a pill cutter when prescribing chlorthalidone 12.5 mg...the 25 mg tabs AREN'T scored and it doesn't come in a 12.5 mg strength.    Don't feel compelled to switch patients with good BP control on hydrochlorothiazide...it may be more trouble than it's worth. SaveEdarbyclor for patients who need an ARB/chlorthalidone combo tablet. It'll cost about $100/month...compared to less than $20 for chlorthalidone and a generic ACEI.    Watch for a plethora of ARBs to go generic later this year...Atacand(candesartan), Avapro (irbesartan), and Diovan (valsartan). 

  8. CARDIOLOGY •    You'll hear debate about when it's okay to combine renin-angiotensin system blockers...ACEIs, ARBs, or aliskiren (Tekturna, etc).    Some experts hoped that combining these would improve outcomes.    But there's growing evidence that these combos usually DON'T provide any additional benefit...and are sometimes harmful. Aliskiren plus an ACEI or ARB increases the risk of stroke, renal complications, hyperkalemia, and hypotension in some diabetes patients.    Don't use this combo...especially in diabetes patients. ACEI plus ARB combos DON'T improve outcomes for uncomplicated hypertension, vascular disease, diabetes, or after a heart attack.    An ACEI plus ARB or aldosterone antagonist (spironolactone, etc) can improve systolic heart failure...and possibly kidney disease with proteinuria. But the combo can also cause more serious side effects.    Use an ACEI first in most cases...these have the most evidence for improving outcomes. Use an ARB if an ACEI isn't tolerated.    Save aliskiren for patients who can't use other first-line BP meds. There's no proof that aliskiren improves outcomes

  9. Which of the following is TRUE about new recommendations for hepatitis B and human papillomavirus (HPV) vaccines? A.HPV should be given to boys at age 11 or 12 to reduce the risk of genital warts and some precancerous lesions. B.Hepatitis B vaccine should be given to all adults with diabetes under age 60. C.Hepatitis B vaccine can be given to adults with diabetes over age 60 if they are at increased risk for hepatitis B. D.All of the above

  10. Answer • D.All of the above

  11. VACCINES • More people will get hepatitis B (Engerix-B, Recombivax HB) or HPV (Gardasil) vaccines.    CDC now recommends hepatitis B vaccine for adults with diabetes...and the HPV (human papillomavirus) vaccine for boys. Hepatitis B vaccine for diabetes. Recommend hepatitis B immunization for adults with diabetes under age 60.    Adults with diabetes are more prone to liver disease...have twice the risk of contracting hepatitis B...and seem more likely to develop a chronic infection than people without diabetes.    Patients are also at risk for hepatitis B if they're in a group setting that improperly shares blood glucose monitoring equipment.    Explain that one case of hepatitis B can be prevented for every 124 adults with diabetes under age 60 who are vaccinated.    Consider hep B vaccination for diabetes patients age 60 and up if they are at increased risk for hepatitis B. But keep in mind that the vaccine is less effective in these older patients. HPV vaccine for boys. Recommend routine HPV vaccination for boys aged 11 to 12...and for those up to 21 who haven't gotten it yet.    Explain that vaccination reduces the risk of genital warts and some precancerous lesions in males...and will likely reduce HPV transmission to their partner.    Use Gardasil for boys. Cervarix doesn't protect against the appropriate HPV types and it's not approved for males.

  12. OPIOIDS •    People are often surprised to hear that chronic opioids can lead to low testosterone and estrogen.    It's more common than you'd think...especially in men.    Opioids can decrease the release of testosterone and estrogen.    Hormone levels drop in up to 86% of chronic opioid users...leading to low libido, impotence, or irregular menses.    Check hormone levels if patients have symptoms. If levels are low, consider non-opioid options for pain.    If this isn't possible, consider hormone therapy...but weigh the risks and benefits carefully.   Combined estrogen and progestin therapy may increase the risk of cardiovascular disease and breast cancer in postmenopausal women...andtestosterone might cause edema and worsen BPH in older men.    Prostate cancer due to testosterone replacement is controversial...and any risk is likely small. But monitor men on testosterone for prostate cancer or worsening BPH.

  13. PEDIATRICS •    You'll hear questions about using ciclesonide (Omnaris) or other corticosteroid nasal sprays instead of antibiotics for ear infections.    Put this in perspective.    This is preliminary...and it's not for ACUTE ear infections.    Nasal steroids are being tried for otitis media WITH EFFUSION...fluid that persists in the middle ear without signs of an acute infection. This occurs mostly in kids under age 3.    It usually resolves on its own...but for persistent cases, kids often get ventilating tubes to drain the fluid and prevent hearing loss.    Drugs are sometimes used to address underlying causes...antibiotics for an infection or a steroid for inflammation. But drug treatment is falling out of favor because there's not much benefit.    Don't use nasal steroids for otitis media with effusion. There's not enough evidence that they're effective.

  14. PEDIATRICS •   New guidelines will help management of constipation in kids.    These are aimed at kids with "functional" constipation...usually due to a child withholding bowel movements to avoid pain.    If disimpaction is needed, use oral PEG (Miralax, etc) instead of enemas or digital disimpaction. Oral PEG works as well as enemas and is better tolerated.    Give 1 to 1.5 g/kg/day of PEG for 3 days.    For maintenance, recommend behavioral modification...dietary changes...and daily meds to soften stools (PEG, milk of magnesia, etc).    Use PEG first for maintenance. It works better than lactulose in kids...and as well as milk of magnesia with fewer side effects.    Start with PEG 0.4 to 1 g/kg/day and titrate as needed. Aim for one or two soft stools a day.    If needed, go to milk of magnesia or lactulose next. Avoid docusate...there's no proof that it works for constipation in kids.    Continue meds for at least 6 months to break the cycle of holding stools out of fear of pain.   Explain that carbohydrates in prune, pear, and apple juices also have a laxative effect

  15. STATINS • Do statins benefit very elderly patients?    Providers often wonder if there's an age at which statin benefits are outweighed by risks, such as myopathy or drug interactions.    But cholesterol is still an important modifiable risk factor...even in patients over 80. Each 40 mg/dL drop in LDL lowers CV risk by about 20% over one year...REGARDLESS of age.    Continue to use statins in the elderly if indicated...unless the patient is not likely to live a year or more. Keep in mind that a patient who survives to 80 will live another 8 years on average.    Watch for drug interactions and side effects. Keep in mind that using a statin to prevent cardiovascular events may not be worth causing muscle pain or weakness that leads to a fall and fracture.    Start with a low statin dose and slowly titrate to the patient's LDL goal to minimize side effects.    Try reducing the dose if patients complain of muscle pain.    Or consider switching to pravastatin or rosuvastatin (Crestor)...they have fewer drug interactions and might cause less myopathy.    Also check vitamin D status...not enough can also cause muscle pain. Most adults need 800 to 2000 IU/day to maintain adequate levels.    Many patients and prescribers swear by CoQ10 for myopathy. If you're an evidence-based type, tell them the evidence is sketchy. If you're comfortable trying this relatively safe approach, suggest 100 mg once or twice daily

  16. SUPPLEMENTS •   FDA will take some OTC HCG weight loss products off the market.    They're going after homeopathic products promoted for weight loss. Human chorionic gonadotropin (HCG) isn't an approved homeopathic.    Some weight loss clinics are giving Rx HCG injections...along with a 500 calorie/day diet.    They claim that HCG helps burn fat and maintain muscle...but there's NO scientific evidence to support this. In fact, FDA requires Rx HCG labeling to say that it DOESN'T work for weight loss.    Using HCG for weight loss is also linked to serious problems...clots, depression, heart attacks, and even death.    Explain that any weight loss is likely due to the very low-calorie diet. And point out that losing weight too rapidly can cause gallstones, electrolyte imbalances, and arrhythmias.    Keep in mind not all "HCG" supplements will disappear. Some contain amino acids that are supposed to stimulate HCG production. But these haven't been shown to help people lose weight either.    Steer patients away from HCG for weight loss. Encourage focusing on abalanced diet, exercise, and setting realistic goals.

  17. Which of the following is TRUE about treating latent tuberculosis (TB)? A.Giving isoniazid (INH) daily for 9 months is no longer recommended. B.A new alternative is INH plus rifapentine once a week for 12 weeks. C.The weekly regimen should be given as directly observed therapy to ensure adherence. D.Both B and C

  18. Answer • D.Both B and C

  19. INFECTIOUS DISEASES •   You'll hear about a new WEEKLY regimen for latent tuberculosis.    Patients with a recent positive TB test usually get isoniazid (INH) DAILY for 9 months to prevent an active infection.    A new alternative is INH plus rifapentine (Priftin) once a WEEK for only 12 weeks. This works as well as daily INH and causes less hepatoxicity...BUT stopping drugs early can lead to resistant TB.    That's why CDC wants a health professional to actually watch each dose get swallowed...called "directly observed therapy."    This new regimen costs $250 for the drugs plus extra for directly observed therapy...compared to $20 for 9 months of INH.    Continue to use daily INH for most patients. Add pyridoxine (vitamin B6) to prevent B6 deficiency and neuropathy.    Go to INH plus rifapentine if there's concern about adherence to INH for 9 months AND if directly observed therapy is feasible.    Currently there's a shortage of rifapentine. Ask the pharmacy to make sure the patient can get it for 12 weeks before starting.    Watch for interactions between rifapentine and hormonal contraceptives, warfarin, phenytoin, antiretrovirals, and others. Rifapentine is an enzyme inducer like rifampin.    See our PL Detail-Document for the regimens recommended for treating latent tuberculosis.

  20. WOMEN'S HEALTH • Women often ask what they can use for pain during pregnancy and breastfeeding. Acetaminophen is usually a good place to start for mild to    moderate pain. Tell women that it's not linked to birth defects...and isn't a problem for breastfed infants. NSAIDs (ibuprofen, etc) should usually be avoided during pregnancy.    Explain that they're linked to miscarriage and certain rare birth defects in the first trimester...and premature closure of the ductus arteriosus in the third trimester.    On the other hand, feel comfortable suggesting ibuprofen during breastfeeding...very little ends up in breast milk. Tramadol should be avoided in the first trimester...and used only with caution in the third. It can cause fetal toxicity in animals...and breathing problems and withdrawal symptoms in newborns.    Tell women that tramadol is usually okay to use during lactation...only small amounts pass into breast milk. Opioids (codeine, etc) are associated with an increase in heart defects and spina bifida when used during the first trimester. But if there's a risk, it's likely very small.    Keep this in perspective. Use an opioid if pain during pregnancy can't be managed with other options.    Be careful about using codeine, hydrocodone, or oxycodone during breastfeeding. These opioids are converted to active metabolites by CYP2D6 enzymes. Babies can get an opioid overdose if their mother is an ultrarapid 2D6 metabolizer.    Ultrarapid 2D6 metabolism occurs in up to 10% of Caucasians...3% of African Americans...and 1% of Chinese and Hispanics.    If an opioid is necessary during lactation, use a low-dose, short-acting agent...and recommend taking it AFTER feedings.    Also try to switch to acetaminophen or an NSAID within 4 days after delivery...before infants begin drinking a lot of milk.    Explain the importance of closely watching the infant for CNS depression or oversedation.

  21. Which of the following is TRUE about treating ADHD in ADULTS? A.Most kids with ADHD outgrow it by the time they are adults. B.Stimulants can be used in patients with hypertension if their BP is controlled and monitored. C.Stimulants are proven to increase the risk of substance abuse. D.Adderall XR is likely to have a longer duration than Vyvanse.

  22. Answer • B.Stimulants can be used in patients with hypertension if their BP is controlled and monitored.

  23. ADHD •   You'll hear new controversy about whether ADHD stimulants increase cardiovascular risk or substance abuse in ADULTS.    About 60% of kids with ADHD will have symptoms as adults. Cardiovascular risk concerns led to updated labeling in 2006.    Now new evidence suggests that ADHD stimulants or Strattera (atomoxetine) DON'T cause serious CV events in most kids OR adults.    These meds DO increase BP and heart rate...so it's easy to understand why experts worry about CV risk. But it IS okay to use them in hypertensive patients if BP is controlled...and monitored.    Avoid these meds in patients with serious arrhythmias, symptomatic heart disease, or a recent cardiovascular event. Substance abuse is about 6 times higher in patients with ADHD.    But explain that most evidence suggests that stimulants DON'T increase substance abuse...and might even DECREASE it.    Watch for signs of diversion...requests for higher doses, refills too soon, lost Rxs, etc.    If necessary, try an extended-release stimulant (Vyvanse, etc)...these are less likely to be abused than immediate-release products.    Or switch to Strattera or bupropion. These are rarely abused...but are less effective for ADHD.    Keep in mind some extended-release stimulants work longer than others. Expect about 8 hours with Ritalin LA... 10 hrs with Adderall XR or Focalin XR...and 12 hrs with Concerta, Daytrana, or Vyvanse. 

  24. PERIOPERATIVE CARDIAC RISK REDUCTIONWhich one of the following is classified as high-risk surgery?  (check one) A. Prostate surgery.  B. Breast surgery.  C. Aortic surgery.  D. Orthopedic procedures.

  25. Answer • C. Aortic surgery. 

  26. PERIOPERATIVE CARDIAC RISK REDUCTIONWhich of the following statements about drug therapy to reduce perioperative risk are correct?  (check all that apply) A. Perioperativestatin therapy reduces cardiovascular risk in patients undergoing vascular surgery.  B. For most patients, aspirin therapy should be discontinued before surgery.  C. Patients who are not already taking a beta blocker should begin therapy immediately before surgery.  D. Beta blockers should be initiated several weeks before surgery. 

  27. Answer • A. Perioperative statin therapy reduces cardiovascular risk in patients undergoing vascular surgery.  D. Beta blockers should be initiated several weeks before surgery. 

  28. Perioperative Cardiac Risk Reduction • Cardiovascular complications are the most common cause of perioperative morbidity and mortality. • Noninvasive stress testing is rarely helpful in assessing risk, and for most patients there is no evidence that coronary revascularization provides more protection against perioperative cardiovascular events than optimal medical management. • Patients likely to benefit from perioperative beta blockade include those with stable coronary artery disease and multiple cardiac risk factors. • Perioperative beta blockers should be initiated weeks before surgery and titrated to heart rate and blood pressure targets. • The balance of benefits and harms of perioperative beta-blocker therapy is much less favorable in patients with limited cardiac risk factors and when initiated in the acute preoperative period. • Perioperative statin therapy is recommended for all patients undergoing vascular surgery. • When prescribed for the secondary prevention of cardiovascular disease, aspirin should be continued in the perioperative period.

  29. Clinical recommendation • Initiation of fixed-dose beta blockers immediately before surgery may be harmful and is not advised. • B • Evidence-based guidelines and a randomized clinical trial • If the decision is made to initiate preoperative beta-blocker therapy, it should begin several weeks before surgery, allowing time for dose titration and monitoring of adverse events. • B • Evidence-based guidelines • Beta blockers and statins should be continued perioperatively in patients who are already taking these medications. • A • Evidence-based guidelines • Perioperative statin therapy is recommended for patients undergoing vascular surgery, regardless of the presence of cardiac risk factors. • A • Evidence-based guidelines and randomized clinical trials • Aspirin therapy for secondary prevention of cardiovascular disease should be continued perioperatively unless the risk of surgical bleeding is prohibitive. • B • Evidence-based guidelines and meta-analyses

  30. Surgical Risk Categories • Risk groupCardiac risk* (%)Examples • High • > 5 • Aortic or other major vascular surgery • Peripheral vascular surgery • Intermediate • 1 to 5 • Carotid endarterectomy • Head and neck surgery • Intraperitoneal or intrathoracic surgery • Orthopedic surgery • Prostate surgery • Low • < 1 • Superficial procedures • Breast surgery • Cataract surgery • Endoscopic procedures • Most ambulatory surgeries

  31. The most challenging patients to evaluate preoperatively are those with at least one cardiac risk factor and poor or uncertain functional capacity who are undergoing intermediate- or high-risk surgery. • Evidence from a randomized trial suggests that preoperative stress testing is of no value in patients with only one or two cardiac risk factors.8 • The positive predictive value of stress testing in this population is about 20 to 40 percent, meaning that most patients with positive test results will not have an adverse perioperative cardiac event.9 •  This is consistent with the finding that with optimal medical therapy, patients with minimal areas of reversible left ventricular myocardial ischemia on stress imaging have no greater incidence of perioperative cardiac events than those with no evidence of ischemia. •  Therefore, noninvasive stress testing is best reserved for patients with three or more cardiac risk factors in whom preoperative coronary revascularization is logistically feasible and would have been considered regardless of the surgical context.

  32. Interventional Myocardial Protection • PREOPERATIVE CORONARY REVASCULARIZATION • The Coronary Artery Revascularization Prophylaxis (CARP) trial was the first large (n = 5,859) randomized study designed to determine whether prophylactic coronary revascularization before major vascular surgery reduced perioperative cardiac events more than optimal pharmacologic management. • No difference in all-cause mortality was observed at a median follow-up of 2.7 years, and no difference was found in the incidence of postoperative myocardial infarction (MI). • One criticism of the CARP trial is that the selection criteria excluded too many high-risk patients. • To address this issue, the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-V) trial included patients undergoing vascular surgery who had significant cardiac risk factors and evidence of extensive ischemia.14 • Based on the composite end point of all-cause mortality and nonfatal MI, preoperative revascularization conferred no benefit (Table 4).13–15 •  These results are consistent with a study that showed no incremental benefit from prophylactic percutaneous coronary intervention (PCI) when added to rigorous medical therapy in nonsurgical patients with stable angina.16

  33. Pharmacologic Intervention • BETA BLOCKERS • The use of perioperative beta blockers is one of the most controversial topics in perioperative medicine. • Most evidence suggests that perioperative beta blockade reduces the risk of MI and cardiac death. • However, enthusiasm for perioperative beta blockade was significantly tempered in 2008 after results of the Perioperative Ischemic Evaluation (POISE) trial were published.34 • This trial randomized more than 8,000 patients to treatment with fixed-dose extended-release metoprolol (Toprol XL) or placebo initiated immediately before surgery. • Although beta-blocker therapy reduced the risk of nonfatal MI and cardiac death, overall mortality and stroke risk increased, possibly because of drug-induced hypotension. •  These findings caused the ACC and AHA to publish a focused update in which the only class I recommendation for perioperative beta blockade was that it be continued in patients who were already receiving chronic beta-blocker therapy. • Although perioperative beta blockade could still be considered in patients with inducible ischemia, coronary artery disease, or multiple cardiac risk factors, the ACC/ AHA update emphasized the mixed evidence and potential hazards of rigorous treatment. • New research is beginning to define the safest and most effective use of perioperative beta blockade. A recent cohort study found that acute preoperative beta blockade in a beta-blocker–naive population resulted in worse cardiac outcomes compared with a matched cohort receiving chronic beta-blocker therapy. • This effect was not related to an increased stroke risk, but to an increased occurrence of MI and cardiac death. It has been suggested that in addition to reducing myocardial oxygen demand, beta blockers have anti-inflammatory properties that contribute to plaque stabilization. • The onset of these effects is delayed, which may be why studies in which beta blockers have been initiated immediately before surgery have not shown the therapeutic benefit observed when they are started at least two weeks before surgery. • Early preoperative initiation of beta blockers also allows time for gradual dose adjustments and identification and management of adverse effects. • A study using a large administrative database found that the effect of perioperative beta blockers differed depending on the patient's underlying clinical risk profile. • In patients with a Revised Cardiac Risk Index score of at least 3, administration of beta blockers reduced the odds of in-hospital mortality. • However, in lower-risk patients, administration of beta blockers had no effect or increased the risk of in-hospital death.

  34. STATINS • In addition to their lipid-lowering ability, statins reduce vascular inflammation, improve endothelial function, and stabilize atherosclerotic plaques—so-called pleotropic effects. • The results of several clinical trials and a meta-analysis provide strong evidence that perioperativestatin therapy reduces cardiovascular risk in patients undergoing vascular surgery. • In the DECREASE-III trial, administration of fluvastatin (Lescol) reduced the incidence of perioperative MI, in addition to 30-day nonfatal MI and cardiac death.43 • The number needed to treat was 13 to prevent one occurrence of myocardial ischemia, 36 to prevent one nonfatal MI, and 42 to prevent one cardiac death. There is no evidence that perioperativestatin use is associated with an increase in adverse events, including rhabdomyolysis or liver dysfunction.43,45 • There is a rebound effect with abrupt cessation of statin therapy, during which the risk of cardiovascular events sharply increases.46,47 • For this reason, the perioperative use of an extended-release formulation is advisable because no intravenous statin is available. • Extended-release versions of lovastatin (Altoprev) and fluvastatin are available. • Ideally, statins should be initiated several weeks before surgery for maximal anti-inflammatory and plaque-stabilizing benefits.29,30 • However, benefits have been observed from statin initiation in the immediate preprocedural period.48

  35. ASPIRIN • Aspirin causes irreversible inactivation of cyclooxygenase 1 and 2, which reduces prostaglandin and thromboxane production and results in antiplatelet and anti-inflammatory effects. • Unstable coronary plaques are associated with inflammatory mediators and platelet accumulation, hence the benefit of aspirin in the treatment of acute coronary syndrome and secondary prevention of coronary artery disease. • In a meta-analysis of patients receiving aspirin as secondary prevention, discontinuation resulted in a threefold increase in the risk of adverse cardiac events.49 • Among patients with coronary stents, cessation of aspirin therapy resulted in a 90-fold increase in complications.49 • Aspirin withdrawal has been implicated as a causal factor in up to 10 percent of adverse perioperative cardiovascular events occurring an average of 10 days after aspirin cessation.50,51 • Aspirin increases surgical bleeding by approximately 20 percent.33 However, concern over hemorrhagic complications is not supported by evidence from clinical trials. • A meta-analysis of studies comparing surgical bleeding in patients taking low-dose aspirin with that of patients who were not taking aspirin found no difference in severity of bleeding events (with the exception of intracranial surgery and possibly transurethral prostatectomy) or mortality.50 • Therefore, in most cases, aspirin therapy should be continued in the perioperative period. • Communication between the primary care physician and surgeon is essential in weighing the cardiovascular risks of aspirin cessation against the bleeding risks of aspirin continuation.

  36. EVALUATING ACUTELY INJURED PATIENTS FOR INTERNAL DERANGEMENT OF THE KNEEWhich one of the following is the most accurate diagnostic test for meniscal injury?  (check one) A. Evaluation for joint line tenderness.  B. McMurray test.  C. Anterior drawer test.  D. Thessaly test. 

  37. Answer •  D. Thessaly test. 

  38. EVALUATING ACUTELY INJURED PATIENTS FOR INTERNAL DERANGEMENT OF THE KNEEWhich one of the following historical and physical examination findings would require radiography in a patient with acute knee pain?  (check one) A. Inability to flex knee to 90 degrees.  B. Age between 12 and 50 years.  C. Ability to bear weight for at least four steps immediately after injury or in the emergency setting.  D. Joint effusion 48 hours after a fall. 

  39. Answer •  A. Inability to flex knee to 90 degrees. 

  40. Evaluating Acutely Injured Patients for Internal Derangement of the Knee • Although historical findings have some value in diagnosing internal derangement of the knee, a thorough physical examination can often rule out fracture and ligamentous and meniscal injuries. • The Ottawa Knee Rule can help physicians determine which patients require radiography. • Positive physical examination tests and findings of acute effusion suggest internal derangement. • An abnormal McMurray or Thessaly test strongly suggests meniscal injury, whereas a normal Thessaly test may rule out meniscal injury. • Absence of evidence of joint effusion significantly decreases the probability of internal derangement. • Magnetic resonance imaging should be reserved for ruling out internal derangement in patients with suggestive historical and physical examination findings.

  41. Nearly one-half of adults will experience knee pain at some point in their lives.1 • Primary care physicians in the United States evaluate knee pain during approximately 4 million office visits each year, and knee symptoms are the 10th most common reason for outpatient visits.2 • Although most episodes of knee pain in primary care patients are caused by osteoarthritis, many patients have acute injuries. • Approximately 9 to 10 percent of patients with acute knee pain who are treated by family physicians have meniscal tears, 7 percent have collateral ligament injury, and about 4 percent have a cruciate ligament injury

  42. Clinical recommendation • The Ottawa Knee Rule should be used to determine which patients with acute knee injury require radiography. • A • Further testing is not immediately needed in patients with knee injury who have negative physical examination findings, although close clinical follow-up is required. • C • In patients with suspected meniscal injury, the Thessaly test is preferred over the McMurray test and evaluation for joint line tenderness. • C • Internal derangement should be suspected in patients with knee trauma and effusion. • C

  43. Indications for Radiography in Patients with Acute Knee • InjuryIndicationAmerican College of Radiology criteria5Ottawa Knee Rule6Pittsburgh Knee Rule7 • Age < 12 years or > 50 years • X P • Age ≥ 55 years • X O • Altered mental status • X • Fall or blunt trauma • X P • Inability to bear weight for four steps (unable to transfer weight twice) immediately after injury or in the emergency setting • X O P • X • X • Inability to flex knee to 90 degrees • X O • X • Joint effusion within 24 hours of a direct blow or fall • X • Tenderness over head of fibula or isolated to patella without other bony tenderness • X O • X • Information from references 5 through 7.

  44. The American College of Radiology has published recommendations for use of knee radiography in patients who have acute knee trauma.5 • Although the recommendations have not been prospectively validated, they are similar to the Ottawa Knee Rule criteria. • They recommend against radiography in patients (excluding infants) who can walk without a limp or who have a twisting injury and no effusion. • The Pittsburgh Knee Rule criteria include blunt trauma or fall as the mechanism of injury, age younger than 12 years or older than 50 years, and inability to walk as independent predictors of fracture.7 • A prospective validation trial comparing the Ottawa and Pittsburgh criteria showed that each rule is sensitive (97 to 100 percent of fractures found), but that the Pittsburgh rule is more specific (60 versus 27 percent for the Ottawa rule).12

  45. Anterior cruciate ligament tear • Anterior drawer test3 • With the patient supine on the examining table, flex the hip to 45 degrees and the knee to 90 degrees. Sit on the dorsum of the foot, wrap hands around the hamstrings (ensuring that these muscles are relaxed), then pull and push the proximal part of the leg, testing the movement of the tibia on the femur. Do these maneuvers in three positions of tibial rotation: neutral, 30 degrees externally rotated, and 30 degrees internally rotated. A normal test result is no more than 6 to 8 mm of laxity.

  46. Lachman test3 • With the patient supine on the examining table and the leg at the examiner's side, slightly externally rotated and flexed (20 to 30 degrees), stabilize the femur with one hand and apply pressure to the back of the knee with the other hand, with the thumb on the joint line. A positive test result is movement of the knee with a soft or mushy end point.

  47. Pivot shift test3 • Fully extend the knee and rotate the foot internally. Apply a valgus (abduction) force while progressively flexing the knee, watching and feeling for translation of the tibia on the femur.

  48. Meniscal tear • Joint line tenderness3 • Palpate medially or laterally along the knee to the joint line between the femur and tibial condyles. Pain on palpation is a positive finding.