Internal Medicine Questions 2

Colorectal Cancer: Trends in Screening Prevalence, Incidence, and Mortality• Screening continues to rise while new CRC cases and deaths continue to fall.• The latest data on colorectal cancer (CRC) screening prevalence, incidence, and mortality in the U.S.

population are now available. To evaluate trends over time, researchers compiled data from the Behavioral Risk Factor Surveillance System (BRFSS; a telephone-based health survey in the U.S.) and state-specific incidence and mortality data.

• BRFSS survey data were utilized to estimate the prevalence of CRC screening. In 2010, 236,186 individuals aged 50 to 75 responded to the BRFSS survey. Every 2 years since 2002, respondents aged 50 have been asked whether they have ever used a fecal occult blood test (FOBT) kit or have ever received a screening endoscopy, and, if so, how long ago. Self-reported use of FOBT within 1 year or endoscopy within 10 years was considered current receipt of CRC screening. Incidence and mortality data in the U.S. were respectively obtained from cancer registries and death certificates.

• The prevalence of CRC screening overall increased from 52.3% in 2002 to 65.4% in 2010, and FOBT use declined from 21.1% to 11.8%. From 2003 to 2007, CRC incidence and mortality declined by 13% and 12%, respectively — representing 66,000 fewer new CRC cases and 32,000 fewer CRC deaths than expected during that period compared with 2002. CRC incidence decreased in 35 states, and mortality decreased in 49 states and the District of Columbia. The biggest reductions in incidence and mortality typically occurred in states with the highest screening rates.

• Comment: These findings add to recent encouraging evidence regarding colorectal cancer incidence (JW Gastroenterol Jan 15 2010). The authors recommend development of individual state-based programs to enhance screening service delivery systems and further increase adherence.

PPIs Are the Most Effective Drugs to Reduce Risk for Upper GI Bleeding

• Proton-pump inhibitors bested histamine-2–receptor antagonists and nitrates in patients taking gastrotoxic drugs and in the general population.

• Multiple studies have demonstrated the ability of proton-pump inhibitors (PPIs) to reduce the risk for upper gastrointestinal bleeding (UGIB) in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or clopidogrel. To determine if this effect is also seen in general practice, investigators conducted a nested, case-control study involving 2049 patients with UGIB and 20,000 age- and sex-matched controls who were identified in The Health Improvement Network UK primary care database between 2000 and 2007. Records were reviewed to determine the use of drugs that increase the risk for UGIB as well as the use of acid-reduction therapy with PPIs, histamine-2–receptor antagonists (H2RAs), or nitrates.

• Current PPI use for >1 month versus nonuse was associated with a reduction in UGIB in the general population (relative risk, 0.80; 95% confidence interval, 0.68–0.94) and in patients taking low-dose aspirin, clopidogrel, both aspirin and clopidogrel, warfarin, and NSAIDs (RR, 0.58; 95% CI, 0.42–0.79). No significant effect was seen in patients taking cyclooxygenase-2 inhibitors or steroids. The impact of H2RAs on the incidence of UGIB was smaller than that of PPIs and was significant only for patients taking NSAIDs. Nitrate use had no effect on the risk for UGIB in the general population or in gastrotoxic drug users.

• Comment: This study adds 2 years of follow-up to a prior report that used the same database. The effectiveness of PPI therapy to reduce risk for UGIB in patients taking gastrotoxic drugs confirms results from prior randomized trials. That PPI use reduces the risk for UGIB in the general population suggests that some confounding risk factors for bleeding that are affected by PPI therapy remain unidentified in the current analysis. One of these might be Helicobacter pylori infection, which was not consistently reported. The relatively limited reduction in UGIB with H2RA use is also consistent with other randomized trials, showing that these drugs are not as effective in preventing UGIB. The broad confidence intervals seen in the study suggest that it might have been underpowered to identify a small, but significant effect of H2RAs on bleeding risk. Nonetheless, PPIs seem to be the most effective drugs to prevent UGIB in patients at risk.

Helicobacter pylori Therapy in Latin America: Triple-Drug Regimen Still Best

• Standard 14-day triple-drug therapy — despite its suboptimal eradication rate — was more effective than shorter-duration concomitant or sequential four-drug regimens.

• Helicobacter pylori eradication rates with standard triple therapy are decreasing in Europe and Asia because of antibiotic resistance. Little research has been done to determine the optimal therapeutic regimen in Latin America, where  H. pyloriinfection is endemic and antibiotic resistance patterns might be different. Now, investigators have conducted an open trial at seven sites in Latin America to compare the effectiveness of three treatments.

• Potentially eligible adults were recruited from the general population; H. pylori infection was confirmed using a urea breath test. A total of 1463 participants were randomized to receive one of three therapy regimens using generic drugs:

• Standard (14 days of triple therapy with lansoprazole, amoxicillin, and clarithromycin)

• Concomitant (5 days of lansoprazole, amoxicillin, clarithromycin, and metronidazole)

• Sequential (5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and metronidazole)

• Assessment with a second urea breath test 6 to 8 weeks after randomization showed that the standard-therapy group had the highest eradication rate (82.2%), followed by the sequential- and concomitant-therapy groups (76.5% and 73.6%, respectively). These results did not vary significantly by study site, sex, age, or presence of chronic dyspeptic symptoms. The authors concluded that standard 14-day triple therapy is currently the preferred empirical treatment for H. pylori infection in Latin America.

• Comment: This study was undertaken with the aim of possible population-based H. pylori eradication to decrease the incidence of gastric cancer in the region. The authors hypothesized that concomitant or sequential therapy would be at least as effective as standard therapy and would provide a less -expensive alternative. However, the alternative approaches proved inferior to standard therapy, perhaps because antibiotic exposure and resistance are less common in Latin America than in previous study sites. It is important to note that even the standard therapy had a poor eradication rate (82.2%). Further study is needed to evaluate the feasibility and advisability of empirical population-based H. pylori eradication efforts. The study does not assess the frequency of recrudescence and reinfection. Authors and an editorialist note the lack of definitive evidence that mass treatment would reduce incidence of gastric cancer. The editorialist also cautions about potential consequences of population-wide treatment, including adverse drug reactions and antibiotic resistance of H. pylori and other bacteria.

Sunscreen Is Expensive• Sun-protective clothing and bulk buying can help reduce the cost.• Skin cancer incidence is rising in the Western world. Ultraviolet (UV) radiation is a known carcinogen and sun-protection

strategies, including sunscreen use, have long been advocated. However, many individuals fail to use sunscreen adequately. Sunscreen cost may contribute to poor compliance.

• Investigators performed a cost analysis study of sunscreen needs in two scenarios: a family of four on a 1-week beach vacation (4 hours/day in the sun, females in bikinis, males in swim trunks, reapplying sunscreen twice for adults and 3 times for children, no other sun-protective measures taken), and a transplant patient using sunscreen year round.

• The researchers evaluated costs of 607 sunscreens from 17 Internet drugstores in seven countries (Europe and North America). Median sunscreen price was US$1.70 per 10 g. Assuming that standard sunscreen application recommendations (2 mg/cm2) were followed, the median cost to the family varied from $178.20 per week (if children were 2-year-olds) to $238.40 per week (if children were 10-year-olds). The cost decreased by 33% if the family wore UV-protective T-shirts and by 41% if large-volume bottles were used (price per gram was less for larger bottles) — both strategies combined produced a 58% decrease in cost. The median cost to the transplant patient varied from $245.30 to $292.30 per year.

• The authors conclude that the cost of sunscreen for a weeklong vacation seems acceptable if sun-protective clothing is worn and larger-bottle sunscreens are purchased. Conversely, for sun-sensitive individuals requiring year-round protection, the annual cost is relatively high, and patients may require financial assistance to be compliant.

• Comment: Sun-protection behaviors are complex, but there is no doubt — sunscreen is expensive. Buying in bulk and wearing sun-protective clothing greatly decreases sunscreen cost. A sun-protective shirt also offers better protection than sunscreen alone during water sports — very few individuals will interrupt their activity every 1 to 2 hours to reapply sunscreen. In addition, sun-protective shirts and hats can last more than one summer, making them money savers in the long run.

Cranberries vs. TMP-SMX to Prevent Urinary Tract Infections

• Trimethoprim-sulfamethoxazole was better, at the expense of greater antibiotic resistance.

• Premenopausal women who experience recurrent urinary tract infections (UTIs) are sometimes prescribed low-dose antibiotic prophylaxis. Growing concern about antibiotic resistance, coupled with many patients' desire for nonpharmacologic remedies, has led to renewed interest in cranberry consumption for UTI prophylaxis. The presumed mechanism is prevention of bacterial adhesion to uroepithelial cells by proanthocyanidins, a constituent of cranberries.

• In a double-blind study, Dutch investigators randomized 221 women (median age, 35) who reported having a median of 6 to 7 UTIs in the previous year to receive either cranberry extract (500 mg twice daily) or trimethoprim-sulfamethoxazole (TMP-SMX; 480 mg nightly). During 12 months of treatment, cranberry-extract recipients had a mean of 4 symptomatic UTIs compared with a mean of 1.8 in the TMP-SMX group — a significant difference; the median time to first recurrence was 4 months in the cranberry group and 8 months in the antibiotic group. Adverse events did not differ between groups, but the dropout rate was about 50% in both.

• Comment: Whereas cranberry extract recipients had fewer UTIs than they did in the preceding year, TMP-SMX was more effective. However, antibiotic resistance to TMP-SMX developed in >85% ofEscherichia coli strains in women taking the antibiotic, compared with <30% in those taking cranberry extract. Unfortunately, cranberry juice was no better than placebo for preventing UTIs in a recent study (JW Gen Med Jan 20 2011); whether cranberry or one of its constituents ultimately will prove to be clinically useful remains unclear.

Regular Updates of Family History Can Change Cancer Screening Recommendations

• Updates are recommended every 5 to 10 years.• Family history of cancer can influence screening recommendations, particularly for colorectal,

breast, and prostate cancers. Little is known about the value of regular updates of family history. Researchers used a U.S. population-based registry of people with personal or family histories of cancer to assess changes in family cancer history retroactively (from birth to study enrollment in about 12,000 people) and prospectively (from enrollment for a median of 8 years in a subset of about 2000 people).

• Clinically relevant family history that would influence screening recommendations increased with age for all three evaluated cancers. For example, as patients aged from 30 to 50, 5% had clinically significant changes in family histories of colorectal cancer, and 4% had changes for breast cancer. Roughly 2 to 4 per 100 women would have clinically significant changes in family histories in each age decade (20–29, 30–39, and 40–49), based on both retrospective and prospective assessments.

• Comment: The full study provides additional helpful information, but the main point is that clinically significant changes in a patient's family history of cancer occur with sufficient frequency that clinicians should update family history on a regular basis — the authors recommend every 5 to 10 years — particularly between the ages of 30 and 50. Once elevated risk has been identified, the challenge then is to overcome the many barriers to appropriate screening.

Physical Activity and Cognitive Health, Revisited

• Rx: 30 minutes of brisk walking daily to maintain cognition despite vascular risk factors• Cerebrovascular disease risk factors are known to be associated with cognitive decline. Recent epidemiologic, cohort,

and clinical-trial data support a role for physical activity in maintaining cognitive health. To assess the effect of physical activity on cognition in the setting of cerebrovascular disease, researchers conducted a retrospective subgroup analysis of more than 2800 female health professionals (age 65) with at least three vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. The cognitive evaluation was conducted via telephone; 81% of the respondents completed at least three assessments at 2-year intervals. All instruments were previously validated.

• Women in the two highest quintiles of physical activity level — equivalent to brisk walking 30 minutes daily — had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the two highest quintiles of physical activity were cognitively 5 to 7 years "younger" than those in the lowest quintile. A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit.

• Comment: This analysis adds to a growing body of literature emphasizing the role of physical exercise throughout the life span as an important modifiable risk factor in maintaining cognitive health, even in the context of cerebrovascular risk factors. Although the self-report of physical activity is a potential confounder in this study, another study published in the same journal issue used an objective measure of energy expenditure and showed similar results in a mixed-sex cohort (Arch Intern Med 2011; 171:1251). On the basis of the accumulating evidence correlating physical exercise with cognitive health, a prescription for a daily walk should quite literally be "just what the doctor ordered."

ABCD2 Score Might Be Poor Predictor of Stroke Risk

• Sensitivity of the score was poor in a cohort of emergency department TIA patients with a 1.8% incidence of stroke at 7 days.

• The ABCD2 score (Age, Blood pressure [BP], Clinical features,Duration of symptoms, and Diabetes) was developed to predict which patients with transient ischemic attack (TIA) might be at high risk for stroke, but it has not been prospectively validated in a large study. In this prospective, multicenter Canadian study, researchers assessed the accuracy of the ABCD2 score in 2056 patients (mean age, 68) with emergency department diagnoses of TIA or minor stroke.

• Physicians completed ABCD2 data forms and calculated the score for each patient. (The score assigns 1 point each for age 60, BP 140/90 mm Hg, impaired speech without weakness, duration of symptoms 10–59 minutes, and diabetes and assigns 2 points each for unilateral weakness and duration of symptoms 60 minutes.)

• The overall incidence of stroke at 7 days was 1.8%. An ABCD2 score >5 had a sensitivity of 32% and a specificity of 87% for predicting stroke at 7 days. At the American Heart Association recommended score cutoff of >2, sensitivity increased to 95% but specificity dropped to 13%.

• Comment: In this study, no ABCD2 score cutoff reliably predicted TIA patients at risk for stroke. A cutoff of >5 missed too many at-risk patients. Use of a lower cutoff improved sensitivity, but the reduced specificity would lead to testing many patients who are not at risk. In this population with a 1.8% overall incidence of stroke at 7 days, the ABCD2 score was not an accurate screening tool.

When LP Is Not Necessary to Detect Subarachnoid Bleed

• CT performed within 6 hours of symptom onset in neurologically intact patients had 100% negative predictive value in this prospective multicenter study.

• Standard teaching is that lumbar puncture (LP) is essential in patients with suspected subarachnoid hemorrhage (SAH) despite normal head computed tomography (CT) scans. Researchers prospectively enrolled 3132 consecutive neurologically intact patients older than 15 who underwent head CT with third-generation multislice scanners to evaluate nontraumatic acute headache or headache with syncope at 11 tertiary emergency departments in Canada from 2000 to 2009. LP was performed at the discretion of the treating physician. Experienced radiologists who were blinded to the study interpreted all CT scans. SAH was defined by subarachnoid blood on CT, aneurysm on cerebral angiography, or xanthochromia in cerebrospinal fluid.

• Mean headache peak pain severity was 8.7 on a 0–10 scale. LP was performed in 49% of patients after negative CT scans. Overall, 240 patients (7.7%) were diagnosed with SAH. The sensitivity of head CT for SAH was 92.9%, and the negative predictive value (NPV) was 99.4%. Emergency physicians identified all but three cases of SAH; all three patients were scanned >6 hours after headache onset. Among 953 patients who were scanned within 6 hours of symptom onset, head CT had 100% sensitivity and 100% NPV. Follow-up at 1 and 6 months did not identify any cases of missed SAH.

• Comment: Because subarachnoid blood diffuses and hemolyzes within hours, CT might not be able to distinguish cerebrospinal fluid from blood as time passes. Patients with histories that raise concern for SAH should be prioritized to undergo CT within 6 hours of symptom onset. If CT is performed with a modern scanner and is interpreted as negative for SAH by an experienced radiologist, LP is unnecessary, unless it is being performed to detect other causes of headache.

Safety of Attention-Deficit/Hyperactivity Disorder Medications in Children and Adolescents

• The absolute risk for cardiovascular events in stimulant users was low and did not differ significantly from risk in nonusers.

• The American Heart Association recommendation to obtain electrocardiograms in children and adolescents taking stimulants for attention-deficit/hyperactivity disorder (ADHD) raised concerns about the safety of these drugs (JW Pediatr Adolesc Med Apr 30 2008). In an industry-supported study, investigators analyzed data from two U.S. administrative databases (1999–2006) to compare rates of severe cardiovascular events (sudden death or ventricular arrhythmia, stroke, or myocardial infarction) among 241,417 children aged 3 to 17 years who received a first prescription for amphetamine, atomoxetine, or methylphenidate and 945,668 nonusers (matched for data source, sex, state, and age). Median follow-up was 135 days of active use for users and 609 days for nonusers.

• Rates of validated sudden death or ventricular arrhythmia and of all-cause mortality did not differ significantly between users and nonusers of stimulants (hazard ratios, 1.60 [95% confidence interval, 0.19–13.60] and 0.76 [95% CI, 0.52–1.12], respectively). In both users and nonusers, review and validation of cardiovascular events from medical records was possible for only half the children (155 records).

• Comment: These data suggest that ADHD medications do not confer increased risk for severe cardiovascular events. Although review and validation of medical records was possible for only half the children with cardiovascular events, the medical record retrieval rate was similar in users and nonusers.

Stable Patients with Pulmonary Embolism Can Be Treated as Outpatients

• In a randomized trial of outpatient versus inpatient care, outcomes did not differ between groups.• Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers performed an

open-label, randomized, noninferiority study to compare outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4% (based on the PE Severity Index; see table). Patients were excluded if they had oxygen saturation <90% on room air, systolic blood pressure <100 mm Hg, chest pain requiring opioids, active bleeding, or were at high risk for hemorrhage (recent stroke or gastrointestinal bleeding or platelet count >75,000/mm3). All patients initially received subcutaneous enoxaparin (1 mg/kg twice daily) followed by anticoagulation with vitamin K antagonists for at least 90 days.

• Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient in each group died, neither from PE. Recurrent venous thromboembolism occurred in only one patient (outpatient group). Major bleeding occurred within 90 days in three outpatients (intramuscular hematoma on day 3 and day 13 and menometrorrhagia on day 50) and no inpatients. At 14 days, more than 90% of patients in both groups were satisfied or very satisfied with treatment.

• Comment: These data suggest that stable low-risk patients with PE can be safely and effectively treated as outpatients with low-molecular-weight heparin. The results might not be applicable to older patients than those in this study or to patients with cancer.

Guidelines for Delirium Prevention in At-Risk Adults

• U.K. national guidelines provide 13 specific recommendations for a multidisciplinary intervention.

• Delirium, a common and costly problem among hospitalized elders, has been associated with longer hospital stays, greater relative likelihood of being discharged to a nursing home, and risk for subsequent dementia and death. Now, the U.K.'s National Institute for Health and Clinical Excellence (NICE) has published guidelines on the prevention of delirium in both surgically and medically managed hospitalized adults; members of the guideline development group provided a summary report.

• The guidelines are based on a systematic review that ultimately identified eight studies of multicomponent interventions to prevent delirium, although only two studies were of moderate or high quality. The guidelines contain 13 recommendations for interventions that could be tailored to individual patients at high risk for delirium, defined as those older than 65 and those with cognitive impairment, severe illness, or hip fracture.

• The recommendations emphasize a multidisciplinary, team–oriented approach that addresses cognitive impairment, dehydration, hypoxia, infection, immobility, pain, poor nutrition, medication overuse, vision and hearing impairment, and sleep deprivation. The authors conclude that this approach could reduce delirium incidence by one third. Results of a cost-effectiveness analysis suggest that the approach would save £8180 per surgically treated patient and £2200 per medically treated patient.

• Comment: The NICE clinical guidelines highlight relatively simple, holistic, patient-centered interventions that have been shown to prevent delirium in at-risk hospitalized adults, albeit only in two relatively small, single-center studies of moderate to high quality. At the same time, the guidelines highlight the paucity of data on delirium prevention, despite the prevalence, adverse medical consequences, and economic impact of the condition. A large, multicenter clinical trial is clearly needed to confirm the effectiveness of the recommended interventions; however, because they pose little risk for harm and are likely to be cost-effective, it makes sense for hospitals to explore how to implement them. The NICE guidelines potentially set the standard of care for delirium prevention; at the least, they represent a roadmap for future multicenter studies. Regardless, they are a major step forward.

Triglycerides and Cardiovascular Disease: The Experts Speak• Experts redefine an optimal triglyceride level and stress that lifestyle changes are required to reach it.• While debate continues about whether hypertriglyceridemia independently predicts coronary artery disease, mean triglyceride levels in the U.S.

are rising, along with rates of obesity and diabetes. In a new scientific statement, the American Heart Association (AHA) outlines the scope of the problem and offers treatment recommendations. Triglyceride levels directly influence high- and low-density lipoprotein metabolism, and hypertriglyceridemia can be mediated genetically or acquired (e.g., in patients with hypothyroidism, diabetes, or renal disease).

• The authors propose a "practical algorithm" for initial screening with nonfasting triglyceride measurement. If levels are <200 mg/dL (corresponding to <150 mg/dL on a fasting sample), they suggest that patients continue with healthy diet and activity levels. At levels 200 mg/dL, fasting lipoprotein measurement is advised, and suggested targets are provided for weight loss and intake of dietary carbohydrates, sugars, and fats. Increased physical activity and intake of -3 fatty acids also are advocated for their profound effects on elevated triglyceride levels. At the highest triglyceride levels or in symptomatic patients, pharmacologic therapy can be useful (e.g., to lower risk for pancreatitis in patients with triglycerides >500 mg/dL). At all triglyceride levels, the AHA recommends avoiding consumption of trans fats, which raise triglyceride levels and atherogenic lipid particles. Finally, the guidelines set <100 mg/dL as an optimal triglyceride level.

• This statement summarizes what we know about triglycerides and their relation to disease and provides a framework for treating the many patients with suboptimal triglyceride levels (see JW Cardiol Jul 13 2011 for additional commentary from Harlan Krumholz). Patients should be advised that lifestyle changes in diet, weight loss, and exercise are basic to treating most cases of hypertriglyceridemia, although tightening the definition of an optimal triglyceride level could inadvertently invite additional prescribing.

• — Kirsten E. Fleischmann, MD, MPH• AN ADDITIONAL PERSPECTIVE FROM the Journal Watch general medicine EDITOR-in-chief:• In this AHA-sponsored statement, the authors acknowledge that the evidence for triglycerides as an independent predictor of cardiovascular events

(i.e., after adjustment for other lipid fractions) remains controversial. They also acknowledge the lack of convincing clinical-trial evidence to support triglyceride-lowering drug therapies, independent of LDL-cholesterol–lowering or statin therapy; indeed, no benefit was seen in the recent AIM-HIGH study. Hence, this statement is somewhat self-contradictory: If drugs are not indicated (except to lower risk for pancreatitis when triglycerides are extremely elevated), and if lifestyle modifications that happen to lower triglycerides are worthwhile regardless of triglyceride levels, why should we closely monitor triglyceride levels? I am unaware of evidence that patients who track their triglyceride levels are more motivated to exercise, lose weight, and eat a heart-healthy diet than are patients who receive similar counseling without following triglycerides. A move to more-intense focus on triglyceride levels, and to a more stringent definition of "optimal" triglycerides, thus seems unnecessary and misguided.

All the following are examples of normal cognitive changes that

occur with aging, except: A) Delayed recall B) Disorientation

 C) Difficulty finding words or names

 D) Slowed information processing

Answer

• B) Disorientation

Which of the following is the most likely diagnosis in a patient with mild cognitive impairment

affecting memory only? A) Depression

 B) Vascular dementia C) Frontal temporal dementia

 D) Lewy body dementia

Answer

•  A) Depression

Unsafe driving increases when personality is characterized as:

 A) Forgetful B) Introverted C) Aggressive

 D) Anxious

Answer

•  C) Aggressive

Which of the following is(are) associated with increased risk for

unsafe driving? A) Clinical rating score ≥0.5

 B) Marginal or unsafe driving rating given by caregiver

 C) History of serious traffic issues

 D) All the above

Answer

• D) All the above

Falls occurring in women are less likely to cause _______ and

twice as likely to cause _______ as those in men.

 A) Death; fractures B) Fractures; death

Answer

• A) Death; fractures

Which of the following statements about risk of developing breast cancer is incorrect? A) Breast cancer represents 26% of all

cancers (excluding skin cancer) in women B) 40% of woman with breast cancer have a

family history of the disease C) Breast-feeding for >1 yr is recommended

for risk reduction D) Early child-bearing is associated with

reduced risk

Answer

•  B) 40% of woman with breast cancer have a family history of the disease

Studies on the effects of vitamin E supplementation showed an

increase in which of the following conditions?

 A) Uterine and breast cancers B) Colon and breast cancers

 C) Breast cancer and macular degeneration

 D) Coronary artery disease and congestive heart failure

Answer

•  D) Coronary artery disease and congestive heart failure

Aspirin has been shown to be highly effective for preventing

myocardial infarction in women. A) True B) False

Answer

•  B) False

Bilateral oophorectomy before menopause increases the rate of

all the following, except: A) Osteoporosis

 B) Parkinson disease C) Lung cancer D) Breast cancer

Answer

•  D) Breast cancer

Which of the following has not been shown to be a benefit of drinking one to two glasses of alcoholic

beverage each day? A) Reduced risk for cardiovascular

disease B) Reduced all-cause mortality

 C) Reduced risk for breast cancer D) Increased insulin sensitivity

Answer

• C) Reduced risk for breast cancer

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

Which one of the following includes all 3 facial abnormalities associated with fetal alcohol

syndrome?  (check one)

 A. Low-set ears, large eye openings, large forehead.  B. Small palpebral fissures, smooth philtrum, thin

vermilion border.  C. Large palpebral fissures, smooth philtrum, thin

vermilion border.  D. Large forehead, flattened cheeks, small eyes. 

 E. Thin vermilion border, distinct upper lip, esotropia. 

Answer

•  B. Small palpebral fissures, smooth philtrum, thin vermilion border. 

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

Which one of the following secondary disabilities is experienced by individuals with fetal alcohol

syndrome?  (check one)

 A. Increased incidence of depression.  B. Decreased IQ. 

 C. Inability to live independently.  D. Increased likelihood to experience trouble with

the law.  E. All of the above. 

Answer

•  E. All of the above. 

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

Which one of the following provides a clue to fetal alcohol effects?  (check one)

 A. Microcephaly.  B. Growth delays.  C. Cardiac defects.  D. Clinodactyly. 

 E. All of the above. 

Answer

•  E. All of the above. 

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

Which one of the following groups is at high risk of fetal alcohol syndrome?   (check one)

 A. Individuals who flush when they ingest alcohol. 

 B. Individuals with low socioeconomic status. 

 C. Individuals with poor nutrition.  D. All of the above. 

 E. None of the above. 

Answer

•  D. All of the above. 

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

Which one of the following statements regarding fetal alcohol syndrome (FAS) is true?  (check one)

 A. The US Preventive Services Task Force recommends screening and behavioral interventions

to reduce alcohol misuse by adults, including pregnant women, in primary care settings. 

 B. Alcohol use during the second trimester is associated with spontaneous abortion. 

 C. FAS is associated with radioulnar synostosis.  D. All of the above. 

 E. None of the above. 

Answer

•  D. All of the above. 

CLINICAL TOPIC: FETAL ALCOHOL SYNDROME

There is a standard amount and type of alcohol that is safe for

pregnant women to consume.  (check one)

 A. True  B. False 

Answer

•  B. False 

HYPERTENSION MANAGEMENT IN OLDER PATIENTS

Hypertension is a major risk factor for which one of the following conditions?  (check one)

 A. Myocardial infarction.  B. Stroke. 

 C. Congestive heart failure.  D. Atrial fibrillation.  E. All of the above. 

Answer

•  E. All of the above.  Book said C online E is correct and I agree. JD

 HYPERTENSION MANAGEMENT IN OLDER PATIENTS

Which one of the following statements most accurately describes stovepipe

syndrome?  (check one)

 A. Reduction in renal function.  B. Rapid blood pressure elevation.  C. Rigidity of the blood vessels. 

 D. All of the above.  E. None of the above.

Answer

•  C. Rigidity of the blood vessels. 

HYPERTENSION MANAGEMENT IN OLDER PATIENTS

The HYpertension in the Very Elderly Trial (HYVET) study showed that management of

hypertension in elderly patients leads to which one of the following outcomes?  (check one)

 A. Increases the relative risk of stroke.  B. Decreases cardiovascular-related

mortality.  C. Increases all-cause mortality. 

 D. All of the above.  E. None of the above. 

Answer

• B. Decreases cardiovascular-related mortality. 

HYPERTENSION MANAGEMENT IN OLDER PATIENTS

Which one of the following drugs is associated with an elevated blood

pressure?  (check one)

 A. Nonsteroidal anti-inflammatory drugs.  B. Corticosteroids.  C. Bromocriptine. 

 D. Pseudoephedrine.  E. All of the above. 

Answer

• E. All of the above.

HYPERTENSION MANAGEMENT IN OLDER

PATIENTSIndividuals 65 years and older

have a 90% probability of developing hypertension.  (check

one)

 A. True  B. False 

Answer

•  A. True 

HYPERTENSION MANAGEMENT IN OLDER

PATIENTSSerum creatinine measurement is

a sensitive marker of reduced renal function in older patients.    (check one)

 A. True  B. False 

Answer

•  B. False 

HYPERTENSION MANAGEMENT IN OLDER

PATIENTSPet ownership is associated with reduced blood pressure in elderly

patients.   (check one)

 A. True  B. False 

Answer

•  A. True 

HYPERTENSION MANAGEMENT IN OLDER PATIENTS

Increasing the dosage of hydrochlorothiazide to 50 mg 2 times/day correlates with

improved blood pressure control in older patients with stovepipe syndrome.    (check

one)

 A. True  B. False 

Answer

• B. False 

COLON CANCER SCREENINGWhich one of the following is true for colon

cancer?  (check one)

 A. Capsule endoscopy detects 95% of colon cancers detected by optical colonoscopy. 

 B. Family physicians who obtain colonoscopy detect colon cancer at lower rates than

gastroenterology subspecialists.  C. The best predictor of being up-to-date for colon

cancer screening is having a personal healthcare professional. 

 D. Crohn disease does not increase the risk of colon cancer. 

Answer

•  C. The best predictor of being up-to-date for colon cancer screening is having a personal healthcare professional. 

 COLON CANCER SCREENING

Patients with familial adenomatous polyposis typically develop colon cancer by age 40

years.   (check one)

 A. True  B. False 

Answer

• A. True 

COLD AND COUGH MEDICATIONS; VITAMIN E

The voluntary withdrawal of cough and cold medications for children younger than 2 years has been associated with a

decrease in the number of adverse effect–related emergency department

visits.   (check one)

 A. True  B. False 

Answer

•  A. True 

COLD AND COUGH MEDICATIONS; VITAMIN E

Vitamin E supplement use is associated with a statistically significant decrease in stroke

compared with placebo.   (check one)

 A. True  B. False 

Answer

• B. False 

During the past decade, the rate of obesity in the United States

has _______.A) IncreasedB) DecreasedC) Stabilized

D) Demonstrated no discernible trend

Answer

• C) Stabilized

Normal exercise has been proven to be an excellent short-term

weight-loss strategy.A) TrueB) False

Answer

• B) False

Which of the following diets has been shown to produce weight

loss and health benefits superior to those associated with the other

options?A) High-protein

B) High-carbohydrateC) Balanced macronutrient

D) None of the above

Answer

• D) None of the above

Which of the following is not associated with successful long-

term maintenance of weight loss?A) One-half hour of moderate

exercise 3 days/wkB) Regular self-monitoring of

weightC) Consistent daily protocol

D) Grazing (ie, frequent small meals)

Answer

• A) One-half hour of moderate exercise 3 days/wk

Medications for weight loss generally produce a reduction in

weight of _______ of initial body weight.A) ≈2%B) ≈5%

C) ≈10%D) ≈15%

Answer

• B) ≈5%

During pregnancy, obese women have an increased risk for:

A) DiabetesB) Stillbirth

C) Wound complicationsD) All the above

Answer

• D) All the above

At baseline, obese women have an increased risk for unplanned

pregnancy, compared to nonobese women.

A) TrueB) False

Answer

• B) False

Which of the following contraceptive methods is

contraindicated in obese women?A) IUDs

B) Oral contraceptivesC) Hormone patch

D) None of the above

Answer

• D) None of the above

All the following are limitations of current data on the efficacy of

contraception in obese women, except:A) Obese women are often excluded

B) Most studies are observationalC) Most studies focus on barrier methods

of contraceptionD) There is little pharmacokinetic data

Answer

• C) Most studies focus on barrier methods of contraception

Of the following contraception methods, which has been

associated with a 5-lb weight gain during the first year of use?A) Intrauterine devices (IUDs)

B) Etonogestrel implant (Implanon)

C) Depot medroxyprogesterone acetate (Depo-Provera)

D) Hormone patch

Answer

• C) Depot medroxyprogesterone acetate (Depo-Provera)

A 46-year-old man has a 1-year history of almost daily nonseasonal nasal congestion associated with a clear nasal

discharge but without sneezing or itchy eyes. Symptoms are worse on humid days or days when the air quality is poor. There is no relationship to spicy foods. The patient has not

had headache, facial pain or pressure, fatigue, malaise, fever, sore throat, cough, or change in sense of smell. Oral

antihistamines do not relieve his symptoms, and he has not used any nasal sprays. Medical history is significant for

hypertension managed with hydrochlorothiazide. There is no family history of asthma or hay fever.

Vital signs, including temperature, are normal. Examination of the nose shows only a clear mucoid discharge. The sclerae

are not erythematous. The lungs are clear to auscultation. Which of the following is the most likely diagnosis?

AAllergic rhinitisBChronic sinusitis

CChronic vasomotor rhinitisDRhinitis medicamentosa

Chronic vasomotor rhinitis• This patient has chronic vasomotor (nonallergic) rhinitis, which is caused by increased sensitivity to irritants in

the air. The pathophysiology of vasomotor rhinitis is less clear than that of allergic rhinitis, but the chemical mediators causing symptoms are similar in both conditions. Symptoms of vasomotor rhinitis include nasal congestion and rhinorrhea and may develop after exposure to odors, humidity, temperature change, and alcohol. Sneezing and itching occur less often than in allergic rhinitis. Some experts consider the diagnosis one of exclusion. Results of skin tests and radioallergosorbent tests are normal in patients with vasomotor rhinitis and can be used to differentiate this condition from allergic rhinitis. Some patients have both allergic and nonallergic rhinitis. Chronic nonallergic rhinitis is less responsive to therapy than is allergic rhinitis. Topical intranasal corticosteroids, topical intranasal antihistamine, and topical ipratropium are the most consistently effective treatments.

• Allergic rhinitis is unlikely in this patient because his symptoms are increased by humidity and pollutants, and there is no seasonal variation in symptoms, no family history of allergies, and no constitutional symptoms associated with allergic rhinitis. In addition, most patients develop allergic rhinitis before 20 years of age.

• Chronic sinusitis is unlikely in this patient because of the absence of mucopurulent nasal drainage, facial pain or pressure, or decreased sense of smell.

• Rhinitis medicamentosa refers to the syndrome of rebound nasal congestion after discontinuing topical α-adrenergic decongestant sprays. Symptoms may occur after using these sprays for 5 or more days and resolve with prolonged discontinuation of these agents. However, this patient has not used nasal sprays. Rhinitis may be induced by other drugs, as well. Medications generally associated with drug-induced rhinitis include aspirin, NSAIDs, oral contraceptive agents, angiotensin-converting enzyme inhibitors, prazosin, methyldopa, β-blockers, and chlorpromazine.

A 78-year-old man comes for a routine annual physical examination. The patient feels well. He is accompanied by his

wife, who is concerned about his hearing. The review of systems is normal, and the patient states that he does not have

any difficulty hearing. Which of the following is the best way to screen this patient

for hearing impairment?AAdminister the Screening Hearing Handicap Inventory

BPerform the Weber and Rinne testsCPerform the whispered-voice test

DRefer for audiometric testingENo further evaluation is needed

C Perform the whispered-voice test• Screening for hearing loss is important in elderly persons because hearing impairment is

prevalent but frequently underdiagnosed in this population. In addition, significant hearing loss is still possible despite a patient’s denial of having trouble hearing. A recent systematic review evaluated the accuracy and precision of office clinical maneuvers for diagnosing hearing impairment. The whispered-voice test is a quick and easy assessment tool that has the best test characteristics among the office maneuvers. This test assesses the ability to hear a whispered voice with the examiner standing behind the patient 2 feet from the patient’s ear while occluding and simultaneously rubbing the opposite external auditory canal and whispering three numbers or letters. Using a battery-powered handheld audioscope is an acceptable alternative screening modality.

• The systematic review also found that the Screening Hearing Handicap Inventory and the Weber and Rinne tests did not perform as well as the whispered-voice test in detecting hearing impairment.

• Referring patients for formal audiometry, although the gold standard for evaluating hearing loss, is expensive and time consuming. It is also unnecessary to do routinely, since a normal result on the whispered-voice test effectively rules out significant hearing loss.

A 36-year-old man is evaluated for follow-up after a recently obtained fasting lipid profile that revealed a low HDL cholesterol level. He denies chest pain. He currently smokes, and has a 10 pack-year smoking history.

He is overweight and does not exercise regularly. There is no family history of coronary artery disease.

On physical examination, blood pressure is 133/82 mm/Hg and BMI is 29. Heart examination reveals regular rhythm without murmur or gallop.

Fasting lipid levels are as follows: total cholesterol, 198 mg/dL (5.13 mmol/L); HDL cholesterol, 33 mg/dL (0.85 mmol/L); LDL cholesterol,

129 mg/dL (3.34 mmol/L); and triglycerides, 183 mg/dL (2.07 mmol/L). Which of the following is the most appropriate management option for

this patient?AExercise stress test

BGemfibrozilCNicotinic acid

DPravastatinETherapeutic lifestyle modification

The most appropriate management option for this patient is therapeutic lifestyle modification. This patient’s HDL cholesterol is low, total cholesterol is below 200 mg/dL (5.18 mmol/L), and triglyceride level is borderline high. HDL cholesterol levels are inversely related to risk for the development of coronary artery disease (CAD). Patients such as this one, who have low HDL cholesterol as the primary lipid abnormality and who have no CAD, are managed with therapeutic lifestyle modification. Because exercise, weight loss, and tobacco cessation raise HDL cholesterol, physicians should counsel patients about these lifestyle changes.

Although this patient’s risk for the development of CAD is increased because of his low HDL cholesterol level, his weight, his sedentary lifestyle, and his smoking status, a cardiac stress test is not indicated because he has no complaints of chest

pain or CAD equivalents. Medications such as gemfibrozil or nicotinic acid to treat isolated low HDL cholesterol are only indicated in the setting of CAD. Although in practice,

nicotinic acid is often used for patients such as this one, therapeutic lifestyle changes should be attempted first.

LDL cholesterol goal is based on the presence or absence of five cardiovascular risk factors: smoking, hypertension (≥140/90 mm Hg or taking antihypertensive medication), older age (men ≥45 years, women ≥55 years), low HDL cholesterol (<40 mg/dL [1.04 mmol/L]), and family history of premature CAD (male first-degree relative <55 years or female first-degree relative <65 years). This patient

has two major risk factors: cigarette smoking and low HDL cholesterol; therefore, his LDL cholesterol goal is 130 mg/dL (3.37 mmol/L). A statin is not indicated

because his LDL cholesterol level is already below this goal.

A 21-year-old man is evaluated in the emergency department 1 hour after twisting his ankle while playing basketball. The pain was immediate and has hurt constantly since. His coach

immediately wrapped his ankle in ice. On physical examination, there is swelling in the ankle and significant lateral bruising. It is tender on palpation, but not on the medial or lateral malleolus. When the foot is inverted

by the examiner, there is no laxity of the calcaneofibular ligament. The patient is able to ambulate 10 steps with pain.

Which of the following is the next most appropriate management option?

AAnkle joint corticosteroid injectionBAnkle radiograph

CAnkle splintDMRI of ankle

C Ankle splint• This patient’s ability to bear weight and the absence of instability on examination are consistent with a

grade I or II ankle sprain. Most patients with grade I sprains, which involve stretching of a ligament with mild pain and swelling but no joint instability or difficulty ambulating, do not seek medical care. Grade II sprains involve partial tears and are accompanied by moderate pain and disability and some difficulty bearing weight. Grade III sprains involve complete rupture of ligaments with significant swelling, tenderness, and an inability to bear weight. Fifteen percent of patients with sprains have complications involving fractures of the ankle or midfoot; however, decisions about routine radiography should be guided by the Ottawa ankle rules. These rules do not recommend a radiograph for an ankle injury unless there is bone tenderness at the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or an inability to bear weight. A systematic review has determined this instrument to be nearly 100% sensitive and able to reduce the number of unnecessary radiographs by 30% to 40%. Because this patient is able to bear weight and does not have tenderness on the medial or lateral malleolus, neither plain film radiographs nor an MRI of the ankle would be appropriate.

• The initial management of a sprained ankle is to Protect, Rest, Ice, Compress, and Elevate the injured ankle (PRICE treatment). The patient should have the PRICE treatment for 3 days, and then the injury should be reassessed. If the patient does not improve with conservative therapy, plain radiography may then be employed to look for fractures that were not apparent on the initial examination.

• While an ankle joint corticosteroid injection might be appropriate for certain inflammatory arthropathies, it is not appropriate in an ankle sprain.

A 65-year-old man with a 2-year history of severe osteoarthritis of the right knee is evaluated before undergoing total knee replacement surgery. Until 1 month ago, the patient was able to walk four or more blocks and four flights of stairs but now can only walk one block because of severe knee pain. He has a 3-year history of occasional chest pain that occurs less than once each month and develops only

after walking too quickly. There has been no change in the severity or frequency of the chest pain and no dyspnea. Medical history is significant for a myocardial

infarction 4 years ago, type 2 diabetes mellitus, and hypertension. Current medications are metoprolol, fosinopril, atorvastatin, insulin glargine, metformin,

and aspirin. Blood pressure is 140/80 mm Hg, pulse rate is 60/min. BMI is 30. There is no

jugular venous distention. The lungs are clear. There are no murmurs or gallops. Serum creatinine is 1.5 mg/dL (132.6 µmol/L). An electrocardiogram shows

normal sinus rhythm with Q waves in leads II, III, and aVF; nonspecific ST-T wave changes; and left ventricular hypertrophy. A chest radiograph is normal. Which of the following is the most appropriate preoperative cardiac testing?

ACoronary angiographyBDobutamine stress echocardiographyCExercise (treadmill) thallium imaging

DResting two-dimensional echocardiographyENo additional testing is indicated

E No additional testing is indicated• According to the American College of Cardiology/American Heart Association guidelines, no further

preoperative cardiac testing is indicated in a patient without “active cardiac conditions” (unstable coronary syndrome, decompensated heart failure, significant arrhythmia, or severe valvular heart disease) who has adequate exercise capacity. This patient was able to walk four or more blocks until 1 month ago, when his arthritis symptoms worsened, but he is still considered to have adequate exercise capacity. Despite multiple cardiac risk factors, he has stable cardiac symptoms and is on optimal medical therapy with good control of heart rate. A study of intermediate-cardiac-risk patients randomized to testing or no testing found no benefit to noninvasive cardiac testing if the heart rate was adequately controlled with β-blockers.

• Coronary angiography is only indicated for patients with severe or unstable coronary artery disease or significant ischemia detected by noninvasive testing.

• The goal of noninvasive testing is to identify a high-risk subgroup of patients who may benefit from coronary artery revascularization (patients with three or more cardiac risk factors and five or more abnormal segments on dobutamine stress echocardiography). Because this patient has adequate exercise capacity and only two clinical cardiac risk factors (history of ischemic heart disease, diabetes mellitus), noninvasive testing with dobutamine stress echocardiography would probably not alter management.

• Even if the patient described here required cardiac testing, an exercise test (without a pharmacologic stressor) with nuclear imaging would be inadequate in someone who can only walk one block because he will not achieve 85% of his maximum heart rate. A resting echo-cardiogram has not been found to predict ischemic complications, but may be helpful in a patient with suspected valvular disease or heart failure, which this patient does not have.

A 45-year-old woman is evaluated because of the gradual onset of right-sided hearing loss and a 3-year history of tinnitus. She does not have ear pain or drainage, dizziness, or headache. There is no history of trauma to

the ear or excessive exposure to loud noises. On examination, the patient is unable to hear numbers whispered 2 feet

from the right ear with the left auditory canal blocked. Examination of the external auditory canals and tympanic membranes is normal. Neurologic

examination is normal. When a tuning fork is placed on the top of her head, she reports that the sound is heard toward the left ear (Weber test).

Results of audiometry show normal hearing on the left and 45-decibel high-frequency hearing loss on the right.

Which of the following is the most likely diagnosis?AAcoustic neuroma

BCholesteatomaCMeniere disease

DOtosclerosisEPresbycusis

A Acoustic neuroma• This patient most likely has an acoustic neuroma, which is an important cause of asymmetric sensorineural

hearing loss that usually originates from the vestibular portion of the acoustic nerve. The two major symptoms are hearing loss and tinnitus. Unilateral hearing loss occurs in approximately 90% of patients with this disorder, but many patients may be unaware of the deficit. Two thirds of patients have tinnitus. Both hearing loss and tinnitus are present, on average, slightly more than 3 years prior to diagnosis, although acoustic neuroma can cause sudden acute hearing loss. Other symptoms include dizziness and headaches. MRI is the imaging modality of choice because it is more sensitive than CT for detecting small tumors.

• Cholesteatoma is a growth of desquamated, stratified, squamous epithelium within the middle ear. Patients may present with otorrhea, pain, hearing loss, or neurologic symptoms. Otosclerosis is a bony overgrowth that involves the footplate of the stapes, eventually resulting in total fixation and inability to transmit vibration from the tympanic membrane along the ossicular chain. Cholesteatomas and otosclerosis cause a conductive hearing loss rather than a sensorineural loss.

• Although Meniere disease also causes unilateral sensorineural hearing loss, this is most often a low-frequency loss. Patients with Meniere disease usually have episodic vertigo that lasts for several hours and is associated with tinnitus and a sensation of aural fullness. Occasionally, patients experience episodic low-frequency hearing loss that develops on a daily, weekly, or monthly basis and remits within 12 to 24 hours.

• Presbycusis is the term used to describe sensorineural hearing loss associated with aging. It is typically symmetric, starts in the high-frequency range, becomes more noticeable in the sixth decade, and steadily progresses. Patients experience problems understanding speech in a crowded or noisy environment and often have tinnitus. Unilateral or asymmetric hearing loss is not typical for presbycusis and requires further evaluation when present.

B “Get up and go” test• Risk factors for falling include lower extremity weakness, gait deficit, arthritis, impaired

activities of daily living, female sex, and age over 80 years. Other risk factors for falls include balance deficits, impaired vision, depression, cognitive impairment, psychotropic drug use, and use of an assistive device. Because falls often have multiple causes and more than one predisposing risk factor, there is no standard diagnostic evaluation for patients who fall or are at risk for falling. However, evaluations should begin with balance and gait screening, such as the “get up and go” test. The “get up and go” test is appropriate for screening because it is a quantitative evaluation of general functional mobility. A strong association exists between performance on this test and a person’s functional independence in activities of daily living. Persons are timed in their ability to rise from a chair, walk 10 feet, turn, and then return to the chair. Most adults can complete this task in 10 seconds, and most frail elderly persons, in 11 to 20 seconds. Those requiring more than 20 seconds should undergo a fall evaluation. Typically, this consists of a focused history and physical examination, much of which has already been performed in this patient. Further evaluation, including measurement of 25-hydroxyvitamin D levels, should be directed according to findings of the evaluation. Interventions to prevent falls should be tailored to the patient’s needs.

• A CT scan of the head, 24-hour electrocardiographic monitoring, and echocardiography are not routine studies for fall evaluation and should not be done before balance and gait screening.

A 58-year-old man is evaluated as a new patient. He reports that he is healthy, he drinks one martini

before dinner, and has wine with dinner. There is no family history of alcohol problems. He has recently

retired. Which of the following is the best choice to screen

this patient for alcohol problems?AAlanine and aspartate aminotransferase

concentrationsBCAGE questionnaire

CComplete blood count and mean corpuscular volume

DEthanol level

B CAGE questionnaire• Alcohol abuse may be difficult to diagnose. Patients often present with complaints that may be attributable to other medical conditions but actually are caused by alcohol consumption. These problems might include depression, insomnia, injuries, gastroesophageal reflux disease, uncontrolled hypertension, and important social problems. Other potential clues to alcohol misuse are recurrent legal or marital problems, absenteeism or loss of employment, and committing or being the victim of violence. The U.S. Preventive Services Task Force (USPSTF) recommends routine screening of adults with either directed questioning or use of a standardized tool to identify persons whose alcohol use puts them at risk. More likely to be at risk are those with prior alcohol problems, young adults, and smokers. The USPSTF found good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer.

• Although the optimal interval for screening is not known, screening at the time of an initial visit is clearly important. There are multiple screening instruments; the CAGE questionnaire is one of the most widely used. Two positive responses indicate that further assessment for alcohol misuse is warranted.

• C Have you ever felt you should cut down on your drinking?

• A Have people annoyed you by criticizing your drinking?

• G Have you ever felt bad or guilty about your drinking?

• E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

• The CAGE questionnaire has a reported sensitivity ranging from 43% to 94% and specificity ranging from 70% to 97%.

• Laboratory tests such as an elevated mean corpuscular volume (sensitivity 63%; specificity 48%) and an elevated aspartate aminotransferase/alanine aminotransferase ratio (sensitivity 12%; specificity 91%) can be suggestive but are not diagnostic of alcohol abuse and dependence. Their relatively low sensitivities make them unsuited for screening.

• Because of the short half-life of ethanol, a random ethanol level should not be used to screen for alcoholism.

A 75-year-old man treated with a fentanyl patch for chronic pain due to spinal stenosis seeks advice regarding the use of alternative therapies to help with pain relief. He does not want surgery but does not feel he has been getting sufficient pain relief with the fentanyl, and did not like the sedation that was associated with oral narcotics in the past. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia,

and type 2 diabetes mellitus. Current medications are warfarin, hydrochlorothiazide, and metformin. He denies anhedonia or feeling down, depressed, or hopeless. On examination, there is no tenderness

over the spine or paraspinous muscles, and no tightness or spasm of the paraspinous muscles is detected.

Which of the following is the best management option for this patient?AGinkgo

BGraduated exercise programCLocal application of ice

DSt. John’s wort (Hypericum)ETraction

B Graduated exercise program• A systematic review jointly conducted by the American Pain Society and the American

College of Physicians found that exercise is slightly to moderately superior to no treatment for chronic low back pain for pain relief at earliest follow-up. Several other reviews drew similar conclusions, and one review identified reduced sick leave in the first year, as well as a higher percentage of patients returning to work at 1 year. Other nonpharmacologic methods with some evidence to support them include cognitive-behavioral therapy, spinal manipulation, and interdisciplinary rehabilitation.

• Ginkgo should be discouraged for this patient. While there are some studies of debatable quality suggesting potential benefits with ginkgo in depression, anxiety, and memory difficulties, there is very little evidence of efficacy in chronic pain. More concerning for this particular patient is that ginkgo can increase bleeding time or cause spontaneous hemorrhage.

• There is some evidence of modest benefit with the local application of heat for chronic low back pain, but none for ice. Although St. John’s wort is unlikely to be harmful, it is also unlikely to be of significant benefit, as the only condition for which it has some evidence of efficacy is mild to moderate depression. The Cochrane review of therapies for low back pain found that traction was no better than placebo, sham, or no treatment for any reported outcome.

A 57-year-old woman is seen following a stenting procedure of the left main coronary artery. The patient has type 2

diabetes mellitus. Her father had a myocardial infarction at age 62 years. Current medications are rosuvastatin, 40 mg/d;

aspirin, 81 mg/d; and glipizide, 10 mg/d. On physical examination, blood pressure is 152/92 mm Hg. Lungs are clear. Cardiac examination reveals no murmurs, and the point of maximal impulse is not displaced. Fasting

lipid levels are as follows: total cholesterol, 200 mg/dL (5.18 mmol/L); HDL cholesterol, 42 mg/dL (1.09 mmol/L); LDL cholesterol, 121 mg/dL (3.13 mmol/L); triglycerides, 183

mg/dL (2.07 mmol/L). Hemoglobin A1c is 6.9%. Which of the following is the most appropriate treatment for

this patient?AAdd a second lipid-lowering drugBIncrease the dose of rosuvastatin

CSubstitute fenofibrate for rosuvastatinDSubstitute metformin for glipizide

A Add a second lipid-lowering drug• LDL cholesterol should be less than 100 mg/dL (2.59 mmol/L) in patients with coronary artery disease (CAD) or

CAD-equivalent disease. In patients at very high risk, decreasing LDL cholesterol to less than 70 mg/dL (1.81 mmol/L) is considered a therapeutic option. This patient is at very high risk of future major cardiac events because she has diabetes mellitus and CAD. Most authorities would recommend using more aggressive drug therapy by adding a second lipid-lowering drug to further lower LDL cholesterol in patients such as this one.

• Although increasing the statin dose for patients still above their LDL goal is a therapeutic option often employed in practice, the incremental reduction in LDL cholesterol by increasing the dose of a statin that is already near the maximal recommended dose is less than that which could be achieved by using combination therapy. In this patient, rosuvastatin is already at the maximum recommended dose. Adding a resin, nicotinic acid, or ezetimibe are reasonable options. Although the ENHANCE trial did not show a benefit of adding ezetimibe to simvastatin when carotid intimal thickness was used as the outcome, the American College of Cardiology Statement on the ENHANCE trial (www.acc.org/enhance.htm ) concluded that major decisions could not be made on the basis of that trial and that ezetimibe remains a reasonable option for patients who cannot tolerate statins or do not reach goal with statins alone. Adding gemfibrozil in this patient would require lowering the dose of rosuvastatin to reduce the risk of myopathy. Because fenofibrate does not interfere with statin catabolism, there is less risk of myopathy if this is the fibrate chosen.

• Substituting fenofibrate for rosuvastatin would further lower the triglyceride level, but, despite the fact that this patient’s non-HDL cholesterol (158 mg/dL [4.09 mmol/L]) is above her goal of 130 mg/dL (3.37 mmol/L), LDL cholesterol lowering is the higher priority in this very-high-risk patient.

• Substituting metformin for glipizide may have a beneficial effect on this patient’s diabetes control, but her hemoglobin A1c is already less than 7%, and LDL cholesterol lowering is the higher priority.