BCPS 2013: Infectious Diseases

/

My infectious disease review.  I've already talked about pneumonia and may be revising these to go from the direction of the bugs and then the drugs again.  One thing I will say:  Invanz is not active against MRSA, ampicillin-resistant enterococci, Pseudomonas aeruginosa or Acinetobacter species.  Hear me?  :)

BCPS ID Review

Pneumonia

CAP

HAP
Organisms M. pneumonia, S. pneumonia, H.flu, C. pneumonia, Legionella, Viruses S. aureus, Pseudomonas, Enterobacter, Klebsiella pneumo, Candida, Acinetobacter, Serratia, E.coli, S.pneumonia
Treatment Healthy no Abx in previous 3 months

Macrolide (clarith or azith) OR doxycycline

Cormorbidity or Abx in previous 3 months

FQ (moxi, gemi, levo 750mg)

Macrolide (or doxy) + [High-dose amox 1g

tid OR amox/clav 2g bid OR ceph ]

(ceftriaxone, cefuroxime, cefpodoxime)

 Early onset (< 5 days)

3rd ceph (ceftriaxone, cefotaxime)

FQ (levo, moxi, cipro)

Amp/sulbactam

Ertapenem

Late onset (> 5 days or RF for MDR)

   Ceftazidime OR cefepime + AG or FQ (cipro, levo)

Imi, mero, or dori + AG or FQ (cipro, levo)

Pip/taz + AG or FQ (cipro, levo)

   + Vanco/linezolid only if MRSA risk factors
Duration At least 5 days 7 days (14 days for Pseudomonas)

 

Influenza: Type A (Annual, H1N1, H1N2), Type B

Prophylaxis:  if outbreak and cannot receive vaccine

1. Amantadine, Rimantadine 5-7 weeks

2. Neuraminidase inhibitors: Oseltamivir 75-150mg daily x6wks; 75mg daily x7days within 2 days of contact

Zanamivir 10mg daily through inhalation x4wks

Treatment: only if severe symptoms or at risk for complications

1. Amantadine, Rimantadine- only against Type A, decreases symptoms 1 day  *do NOT use for at risk for complications

Dosing: 100mg bid x3-7 days [Elderly 100 daily]; ADJUST FOR RENAL DISEASE (amantadine> rimantadine)

AE: CNS, GI, peripheral edema, orthostatic hypotension

2. Oseltamivir- decreases symptoms 1-1.5 days

Dosing: 75mg bid x5days [CrCl <30 75mg daily]

AE: GI

3. Zanamivir- decreases symptoms 1-1.5 days

Dosing: 2 inhalations (5mg/inhalation) bid x5days

AE: bronchospasm, cough

 

UTIs Treatment Other Comment
Uncomplicated cystitis Nitrofurantoin 100mg bid

     X 5 days

TMP/SMX DS bid x 3 days

Or Fosfomycin 3 gm once

Duration: 3 days vs 5

 Alternatives:

Amox-clavulanate, cefdinir, cefaclor, or cefpodoxime x 3-7d or FQ x 3 d

  
Pregnancy Amoxicillin

Nitrofurantoin

Cephalexin

TMP/SMZ

Duration: 7 days

 AVOID:

FQ

Tetracyclines

AG

TMP/SMZ (esp 3rd trimester

 Pregnant women should be screened for UTI even if asymptomatic
Recurrent cystitis Relapse: treat 2-6 weeks Reinfection

<2/yr: pt initiated x3days

3+/yr: post-intercourse

TMP/SMZ SS, cephalexin 250mg, nitro 50-100mg

3+/yr: daily or 3x/wk

 3+/yr other can also use TMP 100mg, or Norfloxacin 200mg
Uncomplicated Pyelonephritis Not requiring hospital:

Cipro 500mg BID x 7d

Cipro ER 1000mg daily x 7d

OR Levo 750 mg daily x 5d

OR TMP-SMX DS bid x 14d

 

Hospitalized:

IV FQ

Aminoglycoside with or w/o ampicillin

OR extended-spectrum cephalosporin or an extended-spectrum pcn with or without an aminoglycoside or carbapenem

 

 Not requiring hospital:

Or Oral beta-lactam (less effective) plus initial IV ceftriaxone 1gm OR IV 24-hour dose of aminoglycoside

 

 For pts without N/V and not immunocompromised
Complicated UTIs FQ levo x 5 days

AG x 5-14 days

 Extended spectrum Beta lactam  
Catheter-related UTIs Symptomatic pts x 7-10 days and cath removal Assymptomatic pts should NOT be treated E.coli, Candida, Enterococcus, Pseudo, Kleb pneumo, Enterobacter
Prostatitis Acute: Duration 4 weeks TMP/SMZ

Cephalosporins

FQ

 Chronic: 1-4 months

TMP/SMZ

FQ

  
Epididymitis >35 yr: TMP/SMZ, FQ

x 10 days- 4 weeks

 < 35 yr: Ceftriaxone 250mg IM AND doxycycline 100mg bid

x 10 days

  

Skin and Soft Tissue Infections

Cellulitis Nafcillin, Oxacillin, Dicloxacillin x5-10 days Alternatives: Clinda, BL combos, 1st ceph Vanco/Linezolid for MRSA

PCN G if streptococcal
Erysipelas Penicillin G, Clindamycin

x 7-10 days

    
Necrotizing Fasciitis B lactam combo + clinda  + cipro

Carbapenems

Cefotaxime + clinda OR metron

 Streptococcal: High dose IV PCN + clindamycin ABX not curative, surgical debridement necessary!
DM Foot Infection Deep:  1-2 weeks

Amp/sulbac, Ticar/clav, Pip/taz

Ertapenem

FQ + [clindamycin OR metron]

Cefoxitin

3rd ceph + [clinda OR metron]

 Shallow: treat like cellulitis

PCN, 1st ceph, etc.

 Topical: Becaplermin 0.01%

Human platelet derived growth factor, improves healing from 35-50%

 

Surgery also important

 

Osteomyelitis: treat for 4-6 weeks (chronic IV 6-8 weeks + 3-12 months PO)

1. Neonates: Nafcillin + [cefotaxime OR AQ]

2. Infants: Cefuroxime OR ceftriaxone OR [Nafcillin + cefotaxime]

3. Peds (>3yr): Nafcillin OR Cefazolin OR Clindamycin

4. Adults: Nafcillin OR Cefazolin OR Vancomycin

5. Pts with Sickle Cell Anemia: Nafcillin + Ampicillin

6. Prosthetic Joint Infections: Vancomycin + rifampin OR Nafcillin + rifampin

 

CNS Infections: Meningitis

Empiric: 7-14 days

1. Neonates: Ampicillin + AQ OR + cefotaxime

2. 1 month- 50 yrs: 3rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3rd ceph +Vanco + ampicillin

4. penetrating head trauma: Vanco + cefepime, ceftazidime, meropenem

Pathogen Known: MOSTLY PCN G 4mill units IV q4h OR Ampicillin 2g q4h, alt: 3rd ceph, vanco, mero, FQ

Corticosteriods: Dexamethasone 0.15 mg.kg q6h x2-4 days; give 10-20 mins before (or at time of ) Abx

Benefit in: Peds with H.flu and Adults with S. pneumo

Brain Abscess: Treat based on source: mostly metron + 3rd Ceph                               Unknown source: Vanco + Metron+ 3rd ceph

 

Endocarditis: Strep, Staph, Entero, HACEK    Duration: 4-6 weeks (8+ weeks with VRE)

Strep: PCN G ± gent, Ceftriaxone ± gent, Vanco

Staph: Oxa/nafcillin ± gent (+ rifampin if prosthetic valve), Cefazolin ± gent (+ rifampin if prosthetic)

MRSA: Vanco (+ rifampin if prosthetic); may also use Vanco in severe PCN allergy

Entero: [PCN G or ampicillin or vanco]  + [gent or streptomycin]                 VRE: linezolid, Quin/Dalf

HACEK: ceftriaxone, Amp/sulbactam, FQ

PPx: dental and resp tract procedures: Amoxicillin 2g PO 1 hr prior                          PCN Allergy: Clinda, azith/clarith

Perotonitis/ Intra-Abdominal Infections

Mild-Mod: cefoxitin, Ticar/clav, ertapenem, moxifloxain,tigecycline;  [cipro/levo +metronidazole],

[cefazolin/ cefuroxime/ceftriaxone/cefotaxime + metronidazole]

Severe, healthcare acquired, High-risk: Pip/Taz, [ceftazidime/cefepime +metronidazole], imi/cil, mero, dori, [cipo/levo +

metronidazole (not for healthcare acquired)]

Duration: 4-7 days, [injuries repaired in 12hr can be treated for only 24 hr]

 

C. difficile: diagnose by presence of endotoxins

Initial Therapy:  Mild to moderate initial episode:  Metronidazole 500mg PO/IV tid x 10-14days OR Vanco 125mg PO QID x 10-14days

Severe initial episode:  Vancomycin 125 mg PO QID for 10-14 days

Severe complicated CDI: Vancomycin 500mg PO plus Metronidazole IV 500mg Q8H

Recurrences:  First recurrence:  Same as for initial episode

Second recurrence: Vancomycin tapered/pulsed

 

Medical/Surgical PPX

Procedure Treatment Comment
Gastric/duodenal Cefazolin 1-2g Indicated: morbid obesity, esophe obstruction, decreased gastric pH or motility
Biliary Cefazolin 1-2g Indicated with (without?): acute cholecystitis, obstr. jaundice, common duct stones, >70yr
Appendectomy Cefoxitin 1-2g

Cefazolin 1-2g  + metronidazole

OR amp/sulbactam

 If perforated treat x 3-7 days
Colorectal Cefoxitin 1-2g

Cefazolin + metronidazole OR amp/sulbacam

Gent/tobra 1.5mg/kg + clinda 600mg/metron 0.5-1g

± neomycin +erythromycin/

metronidazole

 PO/IV may be better bc PO only may cause Cdiff

Mechanical bowel prep is not recommended
Obstetrics/GYN Hysterectomy: Cefazolin/cefoxitin 1-2g

Caesarian: cefazolin 1-2g

  

Caesarian: administer AFTER cord clamped
Cardiothoracic Cardiac surg/Pulm resection:

cefazolin/cefur oxime 1-2g

Vascular surg: cefazolin 1g q8h x3doses

 For all: Use Vanco if MRSA risk

 
Orthopedic Cefazolin 1-2g (or cefur or vanco) Indicated: surgery involves prosthetics
Head/Neck Cefazolin 1-2g

Amp/sul 1.5-3g

Gent 1.5mg/kg + clinda 600-900mg

 Indicated: major surgery when incision through oral or pharyngeal mucosa
Urologic NOT recommended If (+) urine culture, treat then operate

Pseudomonas Putida BacteriaAnd because pseudomonas is always mentioned:

Pseudomonas aeruginosa
Drugs of Choice:  Piperacillin-tazobactam, Imipenem, Meropenem, Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin, Ciprofloxacin
Alternatives:  Timentin, Aztreonam, Levofloxacin
Third-Line agents: 
Comments:  (Gram-negative bacilli).   Consider using two agents from two different classes as empiric treatment in critically ill patients if P. aeruginosa is suspected. Once susceptibilities known, narrow to one drug according to susceptibility report. 

 

BCPS 2013: Cardiology II

/

More of what I was studying last week: Acute Coronary Syndromes

UA NSTEMI STEMI
CP +

CE –

ECG +

 CP +

CE +

ECG + (ST depress, T wave ∆s)

 CP +

CE +/– (90 min door to balloon, may not have dmg)

ECG + (ST elevation > 1 mm)
Risk factors → cath

Stress test

 Cath 12-24 hrs Cath 90 min

Chest pain → atypical, typical (exertional, relief from SL nitro, shorter (min-hr), substernal, radiating left)

Cardiac enzymes → troponin, CK-MB

ECG changes → ST or T wave ∆s

Therapeutic goals

UA/NSTEMI: prevent total occlusion, control chest pain and other symptoms

STEMI: restore patency of infacted artery, prevent complications (e.g. arrhythmias), control CP and Sx

  UA NSTEMI STEMI
Morphine 1-5 mg IV

Oxygen (if O2 sat < 90%)

Nitroglycerin

Aspirin (chew 162-325 mg)

 x x x
Beta blocker     x
Anticoagulation x x x
Antiplatelet x x x
IIb/IIIa If PCI If PCI If PCI
Fibrinolysis     If no PCI

 

UA/NSTEMI

  Early invasive (PCI < 12 hr) Delayed PCI (> 12 hrs) Early conservative (no PCI)
Anticoagulant UFH, enox, bival,

fonda (+ UFH w/ PCI)

 UFH, enox, bival,

fonda (+ UFH w/ PCI)

 Enox, fonda
Antiplatelet Clopidogrel or prasugrel

Abciximab or eptifib w/ PCI

 Clopidogrel or prasugrel

Eptifib or tirofib w/ PCI if high or moderate risk

 Clopidogrel

Abcix or eptifib w/ PCI if +stress test

 

STEMI PCI (w/in 90 min) Fibrinolysis (w/in 30 min, up to 12 hrs)
Anticoagulation UFH w/ abciximab (or eptifib or tirofib)

Bivalirudin alone

 UFH 48 hrs or

Enoxaparin 8 days or

Fondaparinux 8 days
Antiplatelet Clopidogrel or prasugrel Clopidogrel

 

Dosing and duration of antiplatelet

  ASA Clopidogrel/Prasugrel
Initial 162-325 mg chewed CLO 300-600 mg LD (300 mg if w/ fibrinolytics)
Pre-PCI 75-325 mg CLO 300-600 mg LD or PRA 60 mg LD
No stent 75-162 mg/day indefinitely CLO 75 mg for 14 d to 1 yr

BMS

DES

 

 162-325 mg 1 month

3 mo (siro), 6 mo (paclitaxel)

Then 75-162 mg/day infef.

 CLO 75 mg/day or PRA 10 mg/day (5 mg if < 60 kg)

for 12-15 mo

 

See Table 8, 9, 10 for IIb/IIIa, anticoagulants, thrombolytics. See Table 11 for contraindications to thrombolytics.

Post ACS:

1. Beta blockers,

2. ACEi or ARB,

3. ASA + CLO or warfarin,

4. Statin (LDL < 70-100 mg/dL)

 

Peripheral Artery Disease: vascular insufficiencies in noncoronary arteries 2/2 atherosclerotic occlusions

  1. Functional – due to spasms of vessels
  2. Organic – structural changes e.g. fatty buildup

Age > 50                 HTN

Smoking                 # homocysteine

Diabetes                                High sensitivity-CRP

HL                            Male

Family Hx

Symptoms: leg or hip pain, cold legs and feet, changes in skin color, pain reduced w/ resting, numbness or tingling

Ankle brachial index = ankle SBP ÷ arm SBP                  PAD risk factors

1-1.29 Normal
0.91-0.99 Borderline
0.41-0.9 Mild to moderate
0-0.4 Severe

 

Treatment: reduce risk factors

Diet, exercise, smoking cessation, HL drugs (goal LDL < 70), antihypertensives (goal BP < 140/90 or 130/80 if diabetic), diabetes control ( A1C < 7%), homocysteine, folic acid and B12, antiplatelet (ASA 75-325 or CLO 75)

Treatment of claudication: cilostazol 1st line, pentoxifylline 2nd line, IR for angioplasty or stents

Dyslipidemia

Fasting lipid panel (9-12 hrs)

LDL < 100

100-129

130-159

160-189

> 190

 Optimal

Above optimal

Borderline high

High

Very high
HDL < 40

> 60

 Low

High
TC < 200

200-239

> 240

 Desirable

Borderline high

High
TG < 150

150-199

200-499

> 500

 Normal

Borderline high

High

Very high

 

LDL goal

CHD risk equivalents: CHD (MI, CABG, PCI, ACS), atherosclerotic dx (PAD, AAA, carotid), DM, > 20% Framingham

Positive risk factors: smoking, HTN, low HDL, family Hx premature CHD (55m, 65w), Age (45m, 55w)

Negative risk factors: high HDL

 

Risk category LDL goal LDL to start Rx
CHD risk equiv, Fram > 20% < 100 (optional < 70) > 130, opt > 100 or < 100?
2+ risk factors, Fram 10-20% < 130 (optional < 100) > 130, opt > 100
2+ risk factors, Fram < 10% < 130 > 160
0-1 risk factor < 160 > 190, opt > 160

Non HDL goal = 30 + LDL goal

Lifestyle changes: weight loss, exercise, diet (plant sterols, soluble fiber, low cholestrol)

Low HDL: TG < 200, niacin safer combo w/ statins than fibrates, smoking cessation, exercise

TG 200-499 target non-HDL, TG > 500 target TG

High TG > 500: goal prevent pancreatitis

Low fat diet, fibrates or niacin, reduce TG before LDL

Pharmacotherapy

Statins (HMG-CoA reductase inhibitors)

$ LDL 24-60%, $ TG 7-40%, # HDL 5-15%. Reduce coronary events, CHD mortality, stroke, total mortality

AE: myopathy, elevated LFTs (check baseline, 3 month, yearly)

DI: SAL (simvastastin, atorvastatin, lovastatin) are CYP3A4. Fluva 2C9, Rosu 2C19, Pita 2C9. Avoid with inhibitors.

Myopathy risk higher with gemfibrozil than fenofibrate. Niacin lower risk than fibrates (careful if > 1g/day).

Efficacy

  5 mg 10 mg 20 mg 40 mg 80 mg
Fluvastatin     24 30 36
Pravastatin   24 30 36 40
Lovastatin   24 30 36 40
Simvastatin 24 30 36 42 48
Atorvastatin   36 42 48 54
Rosuvastatin 42 48 54 60  

Pitavastatin (1 mg = 30%, 2 mg = 36%, 4 mg = 42%). About 6% with each dose doubling and rank.

Bile acid sequestrants – inhibits bile acid recirculation. Liver converts cholesterol to bile acid

$ LDL 15-26%, # HDL 3-6%, reduce coronary events and CHD mortality.

Names: cholestyramine, cholestipol, colesevelam

AE: GI distress, constipation, may increase TG.

DI: decreased absorption of drugs (e.g. warfarin, BB, thiazides)

Niacin – inhibits mobilization of FFA from perif adipose tissue, reduces VLDL synthesis

$ LDL 15-26%, $ TG 20-50%, # HDL 15-26%, reduces coronary events, possibly reduces mortality

Formulations: IR Niacin, ER Niaspan, SR Slo-Niacin

AE: flushing, hyperglycemia, hyperuricemia, GI distress, hepatotoxicity (check LFTs base, q6-12wks, yearly)

Sustained release more hepatotoxic, less flushing (can give ASA 30 min prior to reduce flushing)

Fibrates – reduce lipogenesis in liver

$ LDL 5-20% (normal TG, may # TG up to 45% w/ high TG), $ TG 30-55%, # HDL 18-22%, reduce coronary events and progression of coronary lesions

Names: gemfibrozil, fenofibrate

AE: dyspepsia, gallstones, myopathy, # LFTs (check q3mo for 1st year, then yearly)

Ezetimibe – inhibits cholesterol absorption. Adjunct with statins.

$ LDL 18-20%, $ TG 7-17%, may # HDL 1-5%

AE: HA, rash

Omega-3 (Lovasa) – unknown mechanism

(may # LDL up to 45% w/ high TG), $ TG 26-45%, may # HDL 11-14%

AE: GI (burping, dyspepsia), inhibit plt aggregation, bleeding

Purple heart in the hands

 

BCPS 2013: Cardiology I

/

A little in the past on my study schedule, but what I'm studying this past week. Acute Decompensated Heart Failure

Parameter Normal ADHF  
MAP 80-100 60-80  
HR 60-80 70-90  
CO/CI 4-7 / 2.8-3.6 2-4 / 1.3-2 Low cardiac output
PCWP 8-12 18-30 Congestion
SVR 800-1200 1500-3000  
CVP 2-6 6-15 Fluid up

*want PCWP 15-18 for optimal filling pressure

Signs and symptoms

Congestion (PCWP) Hypoperfusion (CO)
Dyspnea Fatigue
Peripheral edema Cold extremities
Rales Narrow pulse pressure
Ascites Hypotension
Jugular venous distention Worsening renal function
Hepatomegaly, splenomegaly Hyponatremia

 

Subsets and Therapy

  Warm (CI > 2.2) Cold (CI < 2.2)
Wet (PCWP > 18) Congestion

IV diuretics + IV vasodiliators (venous)

 Congestion and Hypoperfusion
MAP < 50 Dopamine
MAP > 50 Inotrope* or vasodilator (V or A)
Dry (PCWP < 18) Normal

Optimize oral meds

 Hypoperfusion
PCWP < 15 IV fluids
PCWP > 15, MAP < 50 Dopamine
PCWP > 15, Map > 50 Inotrope* or vasodilator (arterial)

*SBP < 90, hypotension, worsening renal function

Home HF meds in ADHF

  • ACEi – caution with uptitration during diuresis and if Scr # more than 0.5 mg/dL above baseline
  • BBlockers – Do not discontinue if stable prior to admission, do not start until euvolemic, hold if hemodynamically unstable
  • Digoxin – goal conc 0.5-0.8 ng/mL, avoid discontinuation, caution if renal function worsens

Drugs for ADHF

Diuretics – congestion

Loop Furosemide 40 PO = Furosemide 20 IV = Bumetanide 1 mg = Torsemide 10 mg
Thiazide Not effective if CrCl < 30, used as adjunct

HCTZ 12.5-25 mg PO, metolazone 2.5-5 mg PO

Chlorothiazide 250-500 mg IV if GI edema (expensive)
Resistance to diuretics Fluid and sodium restriction

Increase dose, frequency, cont infusion

Add thiazide

 

Inotropes – hypoperfusion

Dobutamine

B1 agonist: inotropic, lusitropic, chronotropic

 Dose: 2.5-20 mcg/kg/min

AE: tachycardia, arrhythmia, myocardial ischemia

Consider if hypotension
Milrinone

PDE inhibitor: inotropic, lusitropic

 

 AE: arrhythmia, hypotension

Dose: 0.1-0.75 mcg/kg/min

Consider if on B-blocker

 

Vasodilators – congestion, (Venous $ PCWP for dyspnea), (Arterial  $ SVR for $ CO)

Nitroprusside

Arterial = venous

 Doses: 0.3-3 mcg/kg/min

AE: hypotension, cyanide/thiocyanate toxicity
Nesiritide

# Na excretion, UOP, CI

$ PCWP, SVR, NE, aldosterone

 Doses: 0.01 mcg/kg/min

AE: hypotension, some tachycardia
Nitroglycerine

Venous > arterial (art w/ high doses)

 Doses: 5-200 mcg/min

AE: hypotension, reflex tachycardia, HA

 

Arrhythmias

Drug therapy overview

  • Check thyroid function, K 4-5 mmol/L, Mg > 2 mg/dL, QTc < 500 ms
  • Potential drug causes: QTc prolongation, bradycardia, AV block

 

See figures on last page.

See Table 9.

Treatment of arrhythmias

Pulseless VT/VF Epinephrine, Vasopressin, Amiodarone, Lidocaine, eval reversible causes
PEA Epinephrine, Vasopressin, eval reversible causes
Sx Bradyarrhythmia If unstable: atropine 0.5-1.0 mg IV, repeat up to 3.0 mg
Sx Tachycardia If unstable: cardioversion

If stable: narrow/regular (SVT) – Vagal maneuvers, adenosine, β blockers, CCB, ablation

Note: avoid CCB and digoxin if WPW, adenosine 6/12 mg (caution in severe CAD)
Afib (narrow/irregular)
  1. Control ventricular rate (β blockers, CCB (diltiazem, verapamil), digoxin)
  2. Rate (leave in AF) OR rhythm control (restore sinus rhythm)
  • Rate control with drugs listed above
  • Rhythm control with electric cardioversion or antiarrhythmic drugs

IA (quinidine, procainamide), IC (flecainide, propofenone), III (amiodarone, sotalol, ibutalide, dofetilide)

  1. Anticoagulation
  • Rate control: chronic anticoagulation ASA or warfarin (INR goal 2-3) (CHADS2 score)
  • Rhythm depends on timing
    • < 48 hrs AF, no anticoagulation needed  prior to cardioversion
    • > 48 hrs AF, anticoagulation for 3 wks prior and 4 wks after CV
  1. Consider long term antiarrhythmics if pt still symptomatic despite rate control
Vtach, Vfib Cardiovert (shock) patients, give Epi or vasopressin as needed

Consider amiodarone or lidocaine during CV and after for prophy

Patients with LVEF < 30 to 40% should have implantable cardioverter defibrillator (ICD)
Torsades Mg
Special populations HF – amiodarone and dofetilide (LV dysfxn post MI) neutral effect on mortality

Post MI – ecainide, flecainide, moricizine, 1A meds # mortality

Dofetilide neutral mortality LV dysfxn post MI

 

Pulmonary Arterial Hypertension

Signs and symptoms

Dyspnea w/ exertion, fatigue, chest pain, syncope, weakness, orthopnea, peripheral edema (fluid backs up), liver congestion, ascites, hemodynamics (mPAP > 25, PCWP < 15, PVR > 3), RV hypertrophy

Treatment

Goal: relieve acute dyspnea, improve exercise capacity and QOL

Vasodilator response testing: epoprostenol, inhaled nitric oxide, IV adenosine

Initial treatment algorithm

Supportive care
Oxygen
Anticoagulation: warfarin goal INR 1.5-2.5 to prevent catheter thrombosis, VTE
Immunizations
Birth control
Oral CCB
If no sustained response to CCB:
Low risk High risk
1st line: ERA or PDEIs (oral)

Alt: epoprostenol, treprostinil (IV)

iloprost (inhaled), treprostinil (SC)

 1st line: epoprostenol, treprostinil (IV)

Alt: ERA or PDEIs (oral)

iloprost (inhaled), treprostinil (SC)

ERA: endothelin receptor antagonist (e.g. sentans)                      PDEIs (e.g. sildenafil)

Prostacyclin analogs (e.g. epoprostenol)

See Table 16.

Hypertensive Crises (Urgency and Emergency)

HTN urgency: acute elevation in BP > 180/120 without organ damage

HTN emergency: HTN with organ damage (encephalopathy, intracranial hemorrhage, angina or MI, pulm edema, aortic dissection, retinopathy, $ UOP or AKI, eclampsia)

Treatment

Urgency: goal to $ BP within 24 hrs

Agents (Table 18): captopril, clonidine, minoxidil, nifedipine, labetalol

 

Emergency: goal to $ MAP 25% or diastolic BP to 100-110 mmHg within 30-60 min

Agents (Table 17): sodium nitroprusside, esmolol, labetalol, nicardipine, nitroglycerin, hydralazine, enalaprilat, fenoldopam, clevidipine

Preferred agents for crises based on comorbidities

Acute aortic dissection Esmolol alone or w/ nicardipine or nitroprusside

(BB first!)
Acute HF Nitroprusside, nitroglycerin, nesiritide, ACEi with diuretics if pulm edema (no BBs)
Stroke (ischemic, hemorrhagic) Labetalol, nicardipine
Acute MI BB with nitro, if HR < 70 nicardipine, clevidipine
Acute pulm edema Nesiritide, nitroglycerin, nitroprusside
AKI Fenoldopam, nicardipine, clevidipine
Eclampsia Hydralazine, labetalol, nicardipine
HTN encephalopathy Nitroprusside, labetalol, fenoldopam, nicardipine
Perioperative HTN Clevidipine, esmolo, nicardipine, nitro
Sympathetic crisis Nicardipine and such (avoid unopposed BB)

 

 

Cardiac Muscle

cardiology

BCPS 2013: Statistics

/

statsThis is a collection of reviews that I have found across the web to help you on your journey of obtaining the BCPS certification (along with me, of course).  I don't know about you but statistics as a class was not my favorite.  In fact, I believe that I am not cut out for the left-brained thinking that statistics require.  HOWEVER, I feel that I had a MAJOR grasp on the statistics portion of the test in 2012 and yes...  statistics is on there in a big way.  (Don't let anyone kid you though, don't forget regulations and pharmacoeconomics like I did). This is a slide handout from Tony Gerlach, PharmD, BCPS

Dr. Ted Williams has a study guide here.

So first, you want to know the type of data you are dealing with.  How much (quantitative) vs. what type (categorical) data?

Quantitative variables can be continuous or discrete. Continuous variables, such as weight, can in theory take any value within a given range. Examples of discrete variables are: number of kids in a family, number of attacks of COPD per year.

Categorical variables are either nominal (unordered) or ordinal (ordered). Examples of nominal variables are male/female, alive/dead, blood type O, A, B, etc.

The key for nominal variables with more than two categories is that the order does not matter. For example, one cannot say that people in blood type A lie between those in A and O. Sometimes, however, people can provide ordered responses, such as grade of colon cancer.  In this case the order does matter and it is usually important to account for it.

stats-square-1-table-11

You could turn blood pressure measurements into nominal data by listing hypotension, normotensive, or hypertensive.  Height (continuous) could be changed by short, average, or tall.  Get it?

By this point you should understand what MEDIAN, MEAN, and MODE.

Mean is the average of all.

Median is the middle point in relation to mean points.

Mode is the most common data point.

Let's go deeper.

The mean is what we all know.  The average.  It is affected by changing data points.  A major disadvantage of the mean is that it is sensitive to outlying points.

The median is known as a measure of location; it tells us where the data are.   The value of the median isn't changed by making the smallest data point smaller and largest point larger.  It is LESS efficient in that it does not include all the information of the data.  JUST the middle point.

The range is an important measurement because it tells you the top and bottom of the data points.  However, they do not give much indication of the spread of observations about the mean. This is where the standard deviation (SD) comes in.

More later...

Have some better info?  Have some better links on learning stats?  Comment here!

 

 

More Medical Biostatistics: Who Doesn't Love It?

/

A coworker called me a numbers person yesterday.  This was shocking because I am not (I don't think)...  but, if you are going to take on the BCPS certification, statistics will be about 25% of the test (or so they say).  Guess what?  After studying and learning stats as it pertains to my field (medical studies and pharmacy) I can say that I may be a lover of stats now.  This statement would not have been uttered much less thought in April 2012 when I started this journey.

Background and the Endpoint:

  • We can’t study every single person.  We draw conclusions or make inferences to the data so that we can determine if we are going to accept or reject the null hypothesis.  There is no difference between the two groups (null hypothesis).

Mean:

  1. Known as the arithmetic mean - parametric, continuous data
  2. Caution with outliers; may need to present data as median

Median:

  1. Middle most value (or) 50th percentile value
  2. Usually used with ordinal data or continuous data not normally distributed (outliers that skewed the data)

Mode:

  1. Most frequently occurring number

Graphically:

Mean = Median = Mode (roughly equal)

Range = Interval between the lowest and highest value

Interquartile Range = 25th - 75th percentiles and related to the median

Standard Deviation (+/- SD):

  • SD = square root of variance
  • Estimates degree of scatter of sample data points about hte sample mean; only applicable to parametric data

Standard Error of the Mean (SEM):

  • SEM = SD/square root of n (sample size)
  • Average variability within a sampling distribution (if study repeated?)
  • Caution in its use and interpretation; smaller than SD

Confidence Interval:  95% confident that the data falls in this area (want tighter) -- make this tighter by increasing the sample size.

Types of Data Scales:

  1. Continuous - (Parametric) - follow assumption that the median = mode = mean (follow normal distribution (Common statistical tests: T-test, ANOVA)
  2. Nonparametric - Nominal data, Ordinal data, continuous data (not meeting certain assumptions) (Common stat tests:  Mann-Whitney U, Wilcoxan Rank Sum, Sign Test)

Positively Skewed Data - Skewed to Right (refers to most data points to the left and the tail to the right)  (Mean > Median > Mode)

Negatively Skewed Data - Skewed to the Left (refers to most data points to the right and the tail to the left)  (Mean < Median < Mode)

Nominal Data:

  • Categorial variables that have no sense of “ranking”
  • Only get a mode and frequency
  • No measure of variability to describe this type of data (i.e., standard error of the mean, SEM; or standard, SD)
  • Numbers are arbitrarily assigned to characteristics for data collection
  • Examples:  Gender (yes or no), Mortality (yes or no), Continuous data can also presented as a nominal endpoint so be careful how it is asked.  “How many people achieved SBP of < 140” -- trick question of using a continuous data type as NOMINAL by the way the question was asked (meeting a SBP goal or cut-off).

Ordinal Data:

  • Can generate a mode, median, and frequency
  • Still cannot use SEM and SD
  • Measure of variability:  Range, interquartile range
  • Numbers used to indicate rank-order, but do not have the same magnitude of difference between them
  • Examples:  NYHA FC for heart failure, Pain scale, Glasgow Coma Scale
  • Examples of trickery:  Blood pressures into groups - 100-120, 120-150, 150-190 treating the continuous points as ordinal data

Continuous Data:

  • Can get a mode, median and mean
  • Measure of variability - standard deviation and range, interquartile range
  • Interval Data - Units of equal magnitude, rank order but is without an absolute zero (temperature)
  • Ratio Data - Same as interval, but there is absolute zero (e.g., pulse or blood pressure)

Independent Groups:

  • Not the same pts in each group (i.e., they are different people, though they may be matched based on certain characteristics)

Dependent Groups:

  • Groups being studied are not different
  • Examples: patient in a cross-over study, identical twins, right eye vs left in the same pt

Fisher’s Exact is used in SMALL sample sizes (<30-40) over Chi-square (Nominal, two independent sample tests)

Mann Whitney U for continuous when the continuous data doesn’t meet the assumptions of being parametric or follow normal distribution.  (i.e., outlier)

Hypothesis Testing - Power Analysis

  • Power = 1 - Beta
    • Indicates the probability that a statistical test can detect a significant difference when it in fact it truly exists
    • Since Beta indicates the probability of making a type II error, the power calculation tells you the probability that you will NOT make a type II error.
    • If you reject the null hypothesis, low power not enough patients?

alpha = 0.5 - 5% chance that the results that you find are not right.  The smaller your alpha the least likely to make a Type I Error.

Power Analysis - Accept or Reject Null Hypothesis Decision -- Reality Null False or True

Factors that determine or impact the Power of a study:

  • Alpha value (alpha)    
  • Sample size (n)
  • Types of groups evaluated in the study
  • Type of alternative hypothesis selected
  • Choice of statistical test used

Components needed for power calculation:

  • Sample size (n)
  • Standard deviation
  • Practical significance (Delta)
  • Z alpha (1-sided is 1.65 and 2-sided is 1.96)
  • Z beta (based on level of power chosen)

Alpha (alpha) Value

  • Should be determined a-priori (prior to test)
  • Defined as the max acceptable probability of making a type I error
  • Most will not select alpha > 0.05 or 5% or < +/- 2 SD from the mean
  • The alpha and sample size have greatest impact on the power of a study

P-Values

  • WILL NOT tell you the degree of clinical significance
  • It helps to determine the likelihood that a difference seen is due to chance or random error
  • A p<0.0001 is NOT more “clinically significant” than a p<0.001
  • P=0.01 means that there is a 1% chance that the results you found in your statistical analysis are either due to chance or random error.
    • The smaller the p-value the more likely the results you found are real; that is why a researcher wants small p-values!!!

95% Confidence Interval

  • What does it really tell you?
  • This depends on the SEM and the degree of confidence we choose (95% vs. 99% CI)
    • 2 +/- SD is 95% of data; 3 +/- D is 99%
    • To calculate a CI you need the: mean, SD, sample size (n) and Z-score (which is 1.96 for 95% CI and 2.58 for 99% CI)
  • The closer a point lies to the middle of the 95% CI the more likely it will reperesent the true population
  • The CI can be made to be more narrow or precise with an increase in sample size (n)
  • Interpreting the significance in a given CI
    • 95% CI be rejected for Odds Ratio or Relative RIsk if it contains “1.0”

We are trying to avoid making a:

Type I Error (the results say there is a difference but in reality there is no difference)

Type II Error (the results say there is no difference but in reality there is a difference)

Relative and Absolute Risk and Odds Assessment

Relative Risk (RR):  the risk of the event after the experimental treatment as a percentage of the original risk

RR = incidence rate in exposed patients / incidence rate in non-exposed patients

RR = 1 (incidence is the same for both groups)

RR = >1 (incidence in exposed group is higher)

RR = <1 (incidence in exposed group is less)

RR = 0.33/0.24

     = 1.375

Nominal data - Chi Square

ERR = 37.5% excess risk in causing edema

RR > 1 excess risk of something to the exposed group - in this case the CCB causes edema

“37.5% excess risk in causing edema”

RRR - Relative Risk Reduction when the RR is < 1

RR=0.0126/0.0217

    =0.581

RRR = 1-0.581 = 0.419 = 41% of risk for an MI was decreased from use of ASA

Nominal data - Chi square

Absolute Risk Reduction

ARR = RR control - RR treatment

=(248/3,293) - (147/3,275)

=0.0226 or 2.26

NNT = 1/ARR

=1/0.0226 = 44 pts

So I would have to treat 44 pts for 4.9 years to prevent 1 MI or death from CHD

Sample RR Interpretation:

The effect of ASA on vascular death relative to no aspirin was a RR of 0.8 and the RRR was 20%.  How should we interpret that?

The risk of vascular death in the aspirin group at 5 weeks is 80% of the risk in the control group, therefore ASA reduced the risk of vascular death by 20%

Odds Ratio

Estimates the RR in retrospective studies, since the # of pts at risk is not known, preventing the calculation of incidence.

Use of OR in prospective study will overestimate the risk!

When incidence of isease is

OR = (AD)/(BC)

OR = 8.88 means that 8 times more likely to have an MI with cocaine use!

Correlation Coefficient (r)

  • r = -1 to +1
  • The strength of the “relationship” between 2 variables whereas regression analysis provides the “predictability” of one variable on another variable.
  • Correlation does NOT imply causation
  • The closer the absolute value is to +1, the stronger the “correlation” or “relationship” between the 2 variables.
  • The closer to -1 = no relationship

How to interpret an “r” value:

  • Though a “strong association (i.e., r= close to +1) may exist between 2 variables, it does not “imply” that one event or variable “caused” another.
  • The “r” value does not have the ability to determine which came first
  • Another variable may also be influencing the relationship
  • Most complex relationships can rarely be explained by only 2 variables
  • Thus, Spearman and Pearsons Correlations are only descriptors of the “strength” and “direction” of the relationship

Coefficient of variation (r-squared)

  • How much one variable can be explained or related to another
  • also called coefficient of determination
  • Example related to number of calories and weight gain:  If r=0.84, then r squared = 0.70; therefore 70% of the variation of Y is due to X
  • This implies that 70% of the variability in wt gain or loss is attributed to the variability in the amount of cals consumed (or) it can also be said that the amount of calories consumed provides us with 70% of the information needed to predict weight gain or loss.

Regression Analysis

  • Mathematical description or equation that provides the “predicctability” of one variable on another variable
  • Provides “statistical control” of confounders
  • Linear Regression - Relationship between 2 variables (1 independent and 1 dependent variable) - Uses line of best fit (y = mx + b)
  • Multilinear Regression - Relationship between > 1 independent variable and 1 dependent variable
  • Logistic Regression Analysis - which variables are important in predicting the outcome
    • A variable may not always be a significant influence on the outcome:
      • Main reason is no reln exists between the ind and dep variable
      • One variable is highly correlated with another variable already included in the regression and does not provide additional protective information
      • Lack of statistical power to detect a difference (usually from insufficient sample size).

BCPS 2013: Statistics (Introduction)

/

Statistics are heavily covered on the exam. One of the things I did upon starting the test was to copy this graph on the front cover of my  test book and used it throughout.  Yes, it would be easier if there were sections:  statistics, cardiology, etc... but what you'll find are questions that jump from topic to topic.   I will do this again!  Memorize:

 photo

BCPS Changes: HUGE!

/
m-logo.jpg

 

m-logo

BPS Announces Changes to the 2013 Examination

BPS is pleased to announce the following changes for the 2013 Pharmacy Specialty examinations:

Computer-Based Examination Administration BPS examinations will move from paper and pencil format to computer-based administration. Please note the content outlines for the BPS specialty examinations remain the same. Content outlines are available for review under the "Specialties" tab on this page. For 2013, there will still be 200 questions on each BPS specialty certification examination and 100 questions on the recertification examinations. The multiple-choice format remains. Four possible answers are provided for each question, with only ONE designated as the correct or best choice. For initial certification candidates the schedule remains unchanged from previous years and is as follows:

Examination Part 1 (100 multiple-choice items): 2.5 hour testing period in the morning Optional break Examination Part 2 (100 multiple-choice items): 2.5 hour testing period in the afternoonCandidates will have the ability to go back to review or change answers while they are seated in the specific 100 question portion of the examination.

Awesome!  Can I tell you how I was having major flashbacks to the 1980s doing the old scantron?  So does this mean we will all be sitting in a computer lab?  No wonder they had to have expanded test dates.  This is good though.  Rather than ruining my whole entire weekend, I can take off during the week, hole up somewhere (hopefully Nashville) and then return to party with my kids on the weekend.  Because, I will be partying this time! 

Expanded Test Dates Rather than test on a single day, candidates can choose their own testing day within the test administration window beginning on Thursday, September 19, 2013 through Saturday, October 5, 2013. Please note that most testing centers are not open on Sundays.

Expanded Test Locations BPS has expanded from 80 test sites in 2012 to more than 450 domestic (U.S. and Canada) test centers as well as more than 200 international testing centers. This dramatic expansion is possible because of a new testing services agreement with Castle Worldwide, Inc. Founded in 1987 in North Carolina, Castle is one of the nation's leading certification testing companies. For a list of testing centers visit: https://www.castleworldwide.com/castleweb/clients/testing-services/ibt-testing-sites.aspx

2013 BPS Examination Registration Registration for the 2013 BPS examinations is scheduled to open during the first week in April, 2013. Candidates whose completed examination applications are approved first will receive scheduling priority. BPS examination registration will close on August 1, 2013.

For More Information The 2013 BPS Candidate's Guide will contain more information on the examination process and will be posted to the BPS website in March, 2013. Please continue to check the BPS website for updates and additional details.

SO what does this mean for waiting on the test results?  Anyone have any ideas?  Quicker, I hope.

High Yield Med Reviews: My Thoughts for the BCPS

/

High Yield Med ReviewsHigh Yield Med Reviews is a site for high quality, yet affordable medical review courses and practice test banks for preparing for advancement of clinical competency (and board licensures) among healthcare professionals. I personally subscribed to their service last year months after spending money on the ACCP material to help prepare me for the BCPS Pharmacotherapy Exam 2012. Last year, this service only had Q-Bank and not the course Lectures that are added this year. This is a much more valuable addition for the price and solidifies my decision that this service is an equal if not superior contender to the ACCP materials generally bought.

The great thing about the High Yield Med Reviews service it is that the material covers the same topics and MORE for a lower cost. To say that $800+ for just the .pdf files of the ACCP is expensive is an understatement. The BCPS Online Review Course is only $299. It includes 1,700 practice questions and flashcards including biostatistics, access to the BCPS Online Lecture Center, and spiral bound notebook with all the lectures.

The Online Lecture Center shows something called Access to Lecture and shows how many times you can watch. You receive 2 redemptions per lecture. It is recommended to use one when studying the first time or when ready to tackle that particular topic and then the other closer to the time of the test. You have 24 hours per redemption which is like a DVD rental. This is nice in that it puts time constraints on the lectures. It is not nice in that it puts time constraints on the lectures. Limits make it hard but also force you to use them in the best possible conditions. Basically though, two should be enough if you plan to use them appropriately. Luckily you can watch on your iPad or iPhone.

The Q-Bank Questions is the section I used last year. It contains both the test and tutorial mode which is nice to help study and then quiz yourself on the material. Had I known about this service earlier (the added course lectures this year), I would have used it alone and not paid for the ACCP material (Therapeutics update) because it is more in-depth. The questions are of a more complex nature in wording, but cover the same concepts more in-depth than the actual test questions. In other words, I believe if you start now on studying the High Yield Med Reviews materials, there should be NO reason for you not to pass. You have to put in the time to get through the massive amount of material. See FAQ for more in-depth questions/answers of what this product will do.

No matter what, the amount of material on this test is very significant. If you have been out of school for just a short period of time, the material will be fresher in your mind. If you finished a residency, you are much more prepared. If you are like me and decided to do this as a personal goal (I graduated with a PharmD in 1999) you need to start studying MUCH earlier. The biggest challenge is finding ALL of the material you need. Guess what? There were actually topics ON the test itself that were not in the study materials I had or if were in the study materials not covered in enough detail to be able to answer the question correctly.

High Yield Med Reviews has material that encompasses all that you will need to pass. The material is a bit more in-depth than the ACCP material while being A LOT cheaper. For me, those two things make this a better buy.

If you have any questions, please feel free to leave a comment! And please follow along studying with us on the calendar!

 

 

 

BCPS Study Schedule 2013: Who is With Me?

/

The Study Schedule is posted in the menu above for those interested!  Basically I'm following a similar format as listed on Dr. Ted Williams BCPS Study Group.  

Basically this is it.  I have already started studying prior to today of course, but since it would do me good to have a written plan, I went ahead and added this.  I always worry that the BCPS studygroup website will go down.  Just in case:  (hope you don't mind Ted ;))

Ted's BCPS Study Tips (after passing in 2010)

Study Schedule

Things to know

  • Know the basic statistics cold.  (I agree 100% with this!!!)
    • You can't fake these and there are a lot of questions
    • Knowing wont guarantee passing, but not knowing will guarantee failing
  • Know treatment algorithms - know guidelines -- FIRST, SECOND, and some THIRD LINE THERAPY
  • Know indications for therapy
  • Know contraindications to therapy
  • Know therapeutic window for drugs with narrow/targeted window (e.g. Lithium)
  • Know ADRs of significance
    • And if that ADR arises, how to change therapy (e.g. cough from lisnopril, switch to ARB)
  • Know basic kinetics (e.g. volume of distribution, half life, dose adjustments based on plasma concentration, etc)
  • Know major CYP interactions
    • know the drugs that strongly induce or inhibit
    • Know drugs which are major substrates, especially when inducers and inhibitors are likely to be co-administered (e.g. Seizures)
    • Know which way the plasma concentrations will go

Things not to worry about

  • Exact doses for complex regimens (e.g. ICU insulin drip rate protocols)
  • Complex statistical calculations
  • Complex Kinetics (e.g. Vancomycin initial dose)
  • Minutia of side effects (ie if you wouldn't change therapy, it's not a big deal)
  • Obscure treatments for very obscure disorders

Final thoughts

  • Just like NAPLEX, you can miss a bunch of questions and still pass (2010 passing was 67%) - 2011 was a 111/200 and last year 2012 was higher 123/200 I think?
  • Test is designed to test practical application, not minute details, so focus on patient treatment
  • The BCPS study group schedule will definitely prepare you.
    • I only did the first two cycles through and I was fine
    • Even if you get off schedule, if you go through the material twice, you'll definitely have a fighting chance
    • Spending 1 hour a night on the schedule will get you ready, don't stress
    • The Sample questions in the PSAPs,on the BPS website, and most in the study guide are NOT helpful
      • Not structured like the questions on the exam
      • Content is not validated
      • If you haven't taken an exam for a while, they might be helpful to get you back in the groove. But if you are taking the exam immediately after a residency and pharmacy school, don't worry about them. They will stress you out.

BCPS Topic Areas 2010

Key Statistical Tests to Memorize

Statistics

Clinical Trials

Included from Clinical Trials

Bone Joint Rheumatology

Pediatrics

Geriatrics

Kinetics?

Describe Kinetics? here.

Neurology

BCPS Psychiatry

Affective Disorders

Psychoses

Miscellaneous

Fluid and Electrolytes & Nutrition?

Acute Cardiac Care

Critical Care

Endocrine

Infectious Disease

BCPS HIV

Gender Health Issues

Ambulatory Cardiology

Ambulatory Care

Gastrointestinal Disorders

Nephrology

Oncology Support

Hematology

Oncology

Dermatologic Disorders

Eyes Ears Nose Throat

Immunologic

Pulmonary Disorders