In the News
for the Week of 3-1-11
- IDSA updates guidelines for uncomplicated urinary tract infections
- Screening mammography may be less accurate in women with previous breast cancer
- MKSAP Quiz: office evaluation of progressive chronic kidney disease
- Long-term bisphosphonate treatment may increase risk of some fractures in older women
- Aspirin without PPI cost-effective despite small bleeding risk
- Induction of oral steroids before topical steroids may help chronic rhinosinusitis with nasal polyps
- HRSA needs grant reviewers
From ACP Internist
- The next issue is online and coming to your mailbox
From the College
- ACP appoints new senior vice president for medical education
- Saudi Arabia chapter of ACP established
- ACP's John Tooker, MACP, blogs at KevinMD
Cartoon caption contest
- And the winner is …
Physician editor: Darren Taichman, FACP
IDSA updates guidelines for uncomplicated urinary tract infections
The Infectious Diseases Society of America updated its clinical practice guidelines for treating women with acute uncomplicated cystitis and pyelonephritis.
IDSA published its previous guidelines in 1999. Since then, antimicrobial resistance, collateral damage (defined as selection of drug-resistant organisms associated with broad-spectrum cephalosporins), newer agents and different durations of therapy have been studied. Drug-resistant courses have been included in some studies, allowing for estimations of expected response rates in real-life clinical settings.
Recommendations for acute uncomplicated cystitis are as follows:
- Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) has minimal resistance and collateral damage, with efficacy comparable to 3 days of trimethoprim-sulfamethoxazole (good evidence from one or more randomized, controlled trials).
- Trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice daily for 3 days) is appropriate if local resistance rates do not exceed 20%, or if the infecting strain is susceptible (good evidence from one or more randomized, controlled trials).
- Fosfomycin trometamol (3 g in a single dose) has minimal resistance and propensity for collateral damage, but it appears to have inferior efficacy compared with standard short-course regimens (good evidence from one or more randomized, controlled trials).
- Ofloxacin, ciprofloxacin and levofloxacin are highly efficacious in 3-day regimens but have a propensity for collateral damage and should be reserved for important uses other than acute cystitis (good evidence from one or more randomized, controlled trials).
- β-Lactam agents in 3- to 7-day regimens are appropriate when other recommended agents cannot be used (moderate evidence from one or more randomized, controlled trials). Other β-lactams, such as cephalexin, are less well studied but may also be appropriate in certain settings (moderate evidence from expert consensus). β-lactams generally have inferior efficacy and more adverse effects compared with other urinary tract infection antimicrobials (moderate evidence from one or more randomized, controlled trials). For these reasons, β-lactams other than pivmecillinam should be used with caution for uncomplicated cystitis.
- Amoxicillin or ampicillin should not be used because of poor efficacy and very high antimicrobial resistance (good evidence from one or more randomized, controlled trials).
Recommendations for acute pyelonephritis are as follows:
- A urine culture and susceptibility test should always be performed, and initial empirical therapy should be tailored to the infecting uropathogen (good evidence from one or more randomized, controlled trials).
- Oral ciprofloxacin (500 mg twice daily) for 7 days, with or without an initial 400-mg dose of intravenous ciprofloxacin, is appropriate in patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones does not exceed 10% (good evidence from one or more randomized, controlled trials). If resistance exceeds 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (moderate evidence from expert consensus) or a consolidated 24-hour dose of an aminoglycoside (moderate evidence from expert consensus), is recommended.
- A once-daily oral fluoroquinolone, including ciprofloxacin (1,000 mg extended release for 7 days) or levofloxacin (750 mg for 5 days), is an appropriate choice for therapy in patients not requiring hospitalization where the prevalence of resistance of community uropathogens does not exceed 10% (moderate evidence from one or more nonrandomized, case-controlled trials). If fluoroquinolone resistance exceeds 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (moderate evidence from expert consensus) or a consolidated 24-hour dose of an aminoglycoside, is recommended (moderate evidence from expert consensus).
- Oral trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 14 days) is appropriate if the uropathogen is known to be susceptible (good evidence from one or more randomized, controlled trials). If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (moderate evidence from one or more nonrandomized, case-controlled trials) or a consolidated 24-hour dose of an aminoglycoside (moderate evidence from expert consensus), is recommended.
- Oral β-lactam agents are less effective than other agents (moderate evidence from expert consensus). If an oral β-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (moderate evidence from one or more nonrandomized, case-controlled trials) or a consolidated 24-h dose of an aminoglycoside (moderate evidence from expert consensus), is recommended.
- Cases requiring hospitalization should be initially treated with an intravenous antimicrobial regimen, such as a fluoroquinolone; an aminoglycoside with or without ampicillin; an extended-spectrum cephalosporin or extended-spectrum penicillin with or without an aminoglycoside; or a carbapenem. The choice among these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results (moderate evidence from expert consensus).
Uncomplicated cystitis or pyelonephritis due to methicillin-resistant Staphylococcus aureus (MRSA) is uncommon, and no data support using MRSA-active agents for uncomplicated cases. Ampicillin resistance among gram-negative organisms is rising, so ampicillin accompanied by an aminoglycoside should be limited to patients in whom Enterococcus infection is suspected. Broad-spectrum antimicrobial coverage should be tailored on the basis of urine culture and susceptibility results, the guidelines said..
Screening mammography may be less accurate in women with previous breast cancer
Screening mammography may be less accurate in women who have had breast cancer than in those who have not, according to a new study.
Researchers matched a cohort of women who had had early-stage breast cancer with women who had not. All had undergone screening mammography between 1996 and 2007 at Breast Cancer Surveillance Consortium-affiliated facilities. Women were matched by age, breast density, year of mammography and Breast Cancer Surveillance Consortium registry. Early-stage breast cancer was defined as in situ or stage I-II invasive disease. The study's primary outcomes were accuracy of mammography according to final assessment, cancer detection and interval cancer rates, and cancer stage at diagnosis. The study results appear in the Feb. 23 Journal of the American Medical Association.
Overall, 58,870 screening mammograms were performed in 19,078 women with a history of early breast cancer versus 58,870 screening mammograms in 53,315 women without. Within a year after screening, 655 cases of cancer were found in women with a personal history, 499 of which were invasive and 156 of which were in situ. Among women with no personal history, 342 cases of cancer, 285 invasive and 57 in situ, were found. Women with a history of breast cancer had cancer rates of 10.5 per 1,000 screens (95% CI, 9.7 to 11.3) versus 5.8 per 1,000 screens (95% CI, 5.2 to 6.4), a cancer detection rate of 6.8 per 1,000 screens (95% CI, 6.2 to 7.5) versus 4.4 per 1,000 screens (95% CI, 3.9 to 5.0), and an interval cancer rate of 3.6 per 1,000 screens (95% CI, 3.2 to 4.1) versus 1.4 per 1,000 screens (95% CI, 1.1 to 1.7) compared with those who had no history. Mammogram sensitivity was 65.4% (95% CI, 61.5% to 69.0%) versus 76.5% (95% CI, 71.7% to 80.7%), respectively, and specificity was 98.3% (95% CI, 98.2% to 98.4%) versus 99.0% (95% CI, 98.9% to 99.1%). Overall, 2.3% (95% CI, 2.2% to 2.5%) of mammogram results were abnormal in those with a family history versus 1.4% (95% CI, 1.3% to 1.5%) in those without. The P value for all comparisons was less than 0.001.
In women with a personal history of breast cancer, mammography screening was more sensitive for in situ disease (78.7%; 95% CI, 71.4% to 84.5%) than for invasive disease (61.1%; 95% CI, 56.6% to 65.4%) (P<0.001). Mammography was less sensitive in the first five years after a woman's first cancer than after five years had passed (60.2%; 95% CI, 54.7% to 65.5% vs. 70.8%; 95% CI, 65.4% to 75.6%) (P=0.006); sensitivity was similar for ipsilateral cancer (66.3%; 95% CI, 60.3% to 71.8%) and contralateral cancer (66.1%; 95% CI, 60.9% to 70.9%) (P=0.96). Most interval cancers and cancers detected by screening were early stage in all women regardless of personal breast cancer history.
The authors concluded that screening mammography helps detect second cases of breast cancer at an early stage in women with a personal history of early-stage disease. However, its sensitivity is lower and there is a higher rate of interval cancer than in women who have not had breast cancer. The authors noted that the higher interval cancer rates in this group may in part reflect a higher awareness and willingness to seek prompt treatment, a higher rate of adjunct screening between scheduled screening mammography exams, or a predisposition to cancers that aren't as likely to be detected with mammography. Their findings, they wrote, indicate that women with a personal history of breast cancer have "heterogeneous risk for developing another breast cancer; thus, consideration of a more tailored screening approach might be warranted" in some patients in this group.
MKSAP Quiz: office evaluation of progressive chronic kidney disease
A 28-year-old female graduate student with progressive chronic kidney disease due to IgA nephropathy and hypertension is evaluated in the office.
She has fistulous Crohn disease for which she has undergone multiple abdominal surgeries, including distal ileum and proximal colon resection as well as a temporary ileostomy and subsequent ileocolic anastomosis. She has been referred to a nephrologist, nutritionist, and social worker and has discussed various methods of kidney replacement therapy, including the risks and benefits. She would prefer kidney transplantation. Medications are lisinopril, calcium acetate, and epoetin alfa. There is no family history of kidney disease. She has type O blood, and her mother and father have blood types B and A, respectively. She has no siblings.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 130/78 mm Hg, pulse rate is 62/min, and respiration rate is 14/min. BMI is 24. Cardiopulmonary examination is normal.
Estimated glomerular filtration rate is 23 mL/min/1.73 m2.
Which of the following is the most appropriate next step in this patient’s management?
A) Begin training for peritoneal dialysis
B) Evaluate her father as a potential kidney donor
C) Evaluate her mother as a potential kidney donor
D) Plan placement of an arteriovenous fistula
Click here to see the answer and critique for this question.
Long-term bisphosphonate treatment may increase risk of some fractures in older women
Older women who took bisphosphonates for more than five years had a higher risk of subtrochanteric and femoral shaft fractures than those who didn't, but the absolute risk was low, a new study reports.
Researchers performed a population-based, nested case-control study to determine the relationship between bisphosphonate use and fractures in a Canadian cohort. The study included women 68 years of age and older who had begun taking oral bisphosphonates between April 1, 2002 and March 31, 2008. Case-patients hospitalized with subtrochanteric or femoral shaft fractures were matched with five or fewer controls who had taken bisphosphonates but did not have fractures. The median age of both case-patients and controls was 83 years. The study's main outcome measure was the association between hospitalization for subtrochanteric or femoral shaft fracture and time taking bisphosphonates. To test specificity, the authors also examined the association between bisphosphonate exposure and femoral neck or intertrochanteric fractures. The study results appear in the Feb. 23 Journal of the American Medical Association.
Participants were followed until first subtrochanteric or femoral shaft fracture, death, or the end of the study (March 31, 2009). A total of 719 women had subtrochanteric or femoral shaft fractures after starting bisphosphonate therapy. In addition, 9,723 had intertrochanteric or femoral neck fractures, which are commonly associated with osteoporosis. Women who had taken bisphosphonates for five years or more had a higher risk of subtrochanteric or femoral shaft fracture (adjusted odds ratio, 2.74, 95% CI, 1.25 to 6.02) than women who had taken them transiently, or for less than 100 days. However, among 52,595 women who had taken bisphosphonates for at least five years, only 71 (0.13%) had a subtrochanteric or femoral shaft fracture within the next year and just 117 (0.22%) had one within the next two years. Long-term use of bisphosphonates was associated with lower risk of usual osteoporotic fractures (adjusted odds ratio, 0.76, 95% CI, 0.63 to 0.93) than transient use.
The authors noted that their results could have been affected by potential residual confounding and misclassification of bisphosphonate exposure, among other limitations. They concluded that at least five years of bisphosphonate therapy was associated with a higher risk for subtrochanteric or femoral shaft fractures in older women but also noted that the absolute risk for such fractures appeared low. They wrote that based on their findings, individual fracture risk should be assessed before long-term bisphosphonate therapy is initiated and that the therapy may not be warranted in patients whose risk is relatively low. "It may be appropriate to consider a drug holiday for selected patients, particularly as the cumulative duration of bisphosphonate therapy surpasses 5 years," they said.
Aspirin without PPI cost-effective despite small bleeding risk
Despite the risk of gastrointestinal bleeding, low-dose aspirin is cost-effective for primary prevention of coronary heart disease in many middle-aged men, and the addition of a proton-pump inhibitor (PPI) does not add significant benefit, a new study found.
Researchers used a Markov model to compare costs and outcomes associated with low-dose aspirin alone, aspirin with a PPI (omeprazole, 20 mg/d), or no medication for coronary heart disease (CHD) prevention in men over 45 years old. Overall, in the studied population, aspirin reduced nonfatal myocardial infarctions by 30%, increased stroke by 6% and doubled the risk of gastrointestinal (GI) bleeding. The results were published in the Feb. 14 Archives of Internal Medicine.
According to the model, a 45-year-old man with a 10-year CHD risk of 10% and 0.8 per 1,000 annual GI bleeding risk would have lower medical costs and more quality-adjusted life-years (QALYs) if he took aspirin alone instead of no treatment ($17,571 and 18.67 QALYs vs. $18,483 and 18.44 QALYs). However, adding a PPI (which researchers assumed to cost $200 per year) significantly increased the cost per QALY—to $21,037 and 18.68, an incremental cost per QALY of $447,077. Models of risk for 55-year-old and 65-year-old men found similar results.
Preventive use of PPIs would be cost-effective in men who have a higher than average risk of bleeding, the modeling study found. If a 45-year-old man had a GI bleeding risk of 5 per 1,000 (about four times the typical risk), adding a PPI to aspirin for $200 per year would have a favorable cost-effectiveness ratio of $22,000 per QALY gained. However, if the PPI cost is that of a branded drug ($1,951 per year), the bleeding risk would have to 6.7 per 1,000 to make the drug cost-effective.
Based on these findings, the researchers concluded that aspirin is cost-effective as primary prevention in middle-aged men with a range of CHD and GI bleeding risks, and its benefits are only outweighed by the risks of GI bleeding in men with high existing risk, such as those who have had previous bleeds. The addition of PPI therapy to an aspirin regimen is not cost-effective for patients at low or medium bleeding risk, but may be valuable for men who have a risk of more than 4 per 1,000 per year, the study found. Clinicians should assess patients' risk of GI bleeding by considering age, GI bleeding history, and use of other medications that increase bleeding risk, the study authors recommended.
Induction of oral steroids before topical steroids may help chronic rhinosinusitis with nasal polyps
In patients with chronic rhinosinusitis and at least moderate nasal polyposis, an initial course of oral steroids before topical steroid therapy was more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction.
Researchers conducted a parallel, blinded, randomized trial of 60 nonsmoking adults with or without asthma with chronic rhinosinusitis and moderate-sized or larger nasal polyps who were referred by their primary physicians to a specialty rhinology clinic in Tayside, Scotland. (More than 50% of the cohort had concomitant asthma treated with inhaled corticosteroids.) The study results appear in the March 1 Annals of Internal Medicine.
Patients were randomly assigned in a 1:1 ratio to receive oral prednisolone, 25 mg/d, or placebo for 2 weeks, followed in both groups by fluticasone propionate nasal drops, 400 µg twice daily, for 8 weeks and then fluticasone propionate nasal spray, 200 µg twice daily, for 18 weeks.
The mean decrease in polyp grade from baseline to 2 weeks was 2.1 units (SD, 1.1) in the prednisolone group and 0.1 unit (SD, 1.0) in the placebo group (mean difference between groups, −1.8 units [95% CI, −2.4 to −1.2 units]; P<0.001). The difference between groups was −1.08 units (95% CI, −1.74 to −0.42 unit; P=0.001) at 10 weeks and −0.8 unit (CI, −1.8 to 0.2 unit; P=0.11) at 28 weeks.
The mean decrease in hyposmia score from baseline to 2 weeks was 31.12 mm (SD, 30.1) in the prednisolone group and 1.41 mm (SD, 30.6) in the placebo group (mean difference between groups, −28.33 mm [95% CI, −42.71 to −13.96 mm]; P=0.002). The difference between groups was −16.06 mm (95% CI, −30.99 to −1.13 mm; P=0.03) at 10 weeks and −12.13 mm (95% CI, −30.55 to 6.29 mm; P=0.19) at 28 weeks.
Twenty-five participants (83%) in the prednisolone group improved by more than the minimal important difference in either polyp grade or hyposmia visual analogue scale at the end of 28 weeks, compared with 17 participants (57%) in the placebo group. Oral prednisolone therapy did not change levels of Staphylococcus aureus enterotoxin-specific IgE (P>0.05). No adverse events attributable to oral steroids were reported.
The applicability of these findings to patients seen only in primary care is unclear, the study authors concluded, writing "Future studies should consider whether an induction and maintenance approach should be considered at the point of first diagnosis of [chronic rhinosinusitis] with nasal polyposis (for example, in primary care) and whether it is beneficial in milder disease, in which ostiomeatal complex obstruction is less severe."
ACP Internist recently published an article on managing chronic sinusitis.
Jantoven and other meds recalled
A number of medications manufactured by Upsher-Smith Laboratories are being recalled after a bottle labeled as Jantoven warfarin sodium 3-mg tablets was found by a pharmacy to contain 10-mg tablets.
The recall includes batches of amantadine, amlodipine, Androxy, baclofen, bethanechol, Jantoven and oxybutynin. The recalled drugs were packaged on the same packaging line as the mislabeled bottle between May 17, 2010 and Nov. 17, 2010, and were distributed to wholesalers, retail chains and independent pharmacies throughout the United States. A list of the specific batches of medication affected by the recall is online.
Any adverse reactions related to the recall may be reported to the FDA’s MedWatch Adverse Event Reporting program..
New home health rules to be enforced starting April 1
A new rule from CMS now requires that the initial certification for home health services must include a face-to-face encounter with the patient.
While the rule has technically been in effect since Jan. 1, CMS announced earlier this year that they would not start enforcement of the requirement until April 1. The requirement can be satisfied by a non-physician practitioner, as long as the practitioner is working with the physician and not for a home health agency. It can also be satisfied by an encounter with a hospitalist.
As part of the encounter, physicians must provide documentation of who saw the patient, the date of the visit, and a description of how the clinical findings of the visit support the need for home health services. Further details will be included in the April issue of ACP Internist. In the meantime, information can be found on the CMS website.
HRSA needs grant reviewers
The Health Resources and Services Administration is soliciting reviewers for the Primary Care Training and Enhancement (Title VII) grant program.
Grant reviewers are responsible for objectively evaluating and scoring applicants against published evaluation criteria. Reviewer selection for specific grant programs is based on knowledge, education and experience. Potential reviewers are needed in the areas of academic administrative units, predoctoral training, residency training, physician faculty development and physician assistant training.
If you would like to be considered as a reviewer, please register in HRSA’s reviewer database, the Electronic Handbook (EHB). Please visit the Grant Reviewer Portal and begin the registration process. Under Apply Now, click on “Registering.” Complete the registration and application processes as instructed.
Registration with the HRSA Grant Reviewer Portal is needed only once. If you have completed the registration and application process in the past, please click on the "Login" link on the left hand side of the page and make sure your information is current. If you do not remember your password, use the "Forgot Password" link to have a new password e-mailed to you.
For online assistance, contact the HRSA Call Center at 877-464-4772 or 301-998-7373 or by e-mail or use the questions/comments link on each page. HRSA Call Center hours are from 9:00 a.m. to 5:30 p.m. ET, Monday through Friday. If you have any questions about the HRSA review process, please e-mail CDR Donna Rusch, HRSA, Division of Independent Review (DIR) at firstname.lastname@example.org.
From ACP Internist.
The next issue is online and coming to your mailbox
The next issue of ACP Internist is online, featuring the following stories.
Learning to parry patient requests. Negotiating the doctor-patient relationship requires understanding what a patient expects from treatment, instead of outright saying “no.” There are easier ways to sort out what a request really means, and how to quickly address the real underlying issue.
Treat metabolic syndrome’s many causes. Metabolic syndrome’s prevalence has rapidly advanced in just the past decade. But medical societies don’t recommend treating it as a distinct entity. They’d rather that physicians address the individual components of the illness, and encourage lifestyle modifications as the primary way to achieve such a goal.
Simple tools, teamwork manage depression in primary care. Embedding mental health professionals directly into a primary care setting threatens to add complexity to primary care’s already hefty "to do” list. Clinics that have accomplished that task explain how it was not only easier than expected, but added tremendous benefits to the practice.
From the College.
ACP appoints new senior vice president for medical education
ACP has appointed Patrick C. Alguire, FACP, to the position of senior vice president for medical education.
As senior vice president for medical education, Dr. Alguire is responsible for the development and publication of ACP’s medical knowledge products and services, advancement of career and faculty development in internal medicine, and the development of ACP’s clinical practice guidelines and resources for certification and maintenance of certification. More information about Dr. Alguire's appointment is available online..
Saudi Arabia chapter of ACP established
ACP is pleased to announce the establishment of a new ACP Saudi Arabia chapter with the support of the Saudi Commission for Health Specialties (SCHS).
The Saudi Society of Internal Medicine, the King Fahad Medical City, in conjunction with an ACP steering committee led by former College Regent Faroque Khan, MACP, provided support in establishing the new chapter. Khalid Qushmaq, FACP, chairman of medicine at the King Fahad Medical City, is serving as interim governor until a new governor is elected.
Members of the Saudi Arabia Chapter will have the opportunity to network with other Saudi internists as well as participate fully in College-sponsored activities. The official ceremony marking the establishment of the new chapter took place on Feb. 20, 2011..
ACP's John Tooker, MACP, blogs at KevinMD
John Tooker, MACP, ACP's associate executive vice president, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's column looks at ACP's High-Value, Cost-Conscious Care Initiative.
Cartoon caption contest.
And the winner is …
ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
"Congratulations! You're my first mouse call."
This issue's winning cartoon caption was submitted by Kenneth G. Combs, FACP, from Evansville, Ind. Readers cast 114 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 42.1% of the votes.
The runners-up were:
"You've got a virus. Let me write you a script for Norton."
"That wasn't a seizure. That was a power surge.".
MKSAP answer and critique
The correct answer is D) Plan placement of an arteriovenous fistula. This item is available to MKSAP 15 subscribers as item 46 in the Nephrology section.
This patient has stage 4 chronic kidney disease due to IgA nephropathy and will need kidney replacement therapy. She prefers kidney transplantation but may need to undergo dialysis before an appropriate donor kidney is available. Although she can be referred to a transplant center, she cannot accumulate time on the deceased donor transplant waiting list until her glomerular filtration rate is 20 mL/min/1.73 m2 or less. The most appropriate next step in management is therefore placement of an arteriovenous fistula and training for home hemodialysis.
Compared with peritoneal dialysis, daily home hemodialysis is associated with better control of hyperphosphatemia, blood pressure, and volume overload in patients with chronic kidney disease. Furthermore, peritoneal dialysis requires an intact peritoneum and is unlikely to succeed in a patient with a history of fistulous Crohn disease and multiple abdominal surgeries whose peritoneum is unlikely to be intact.
Evaluation of this patient’s parents as potential kidney donors would not be appropriate. This patient and her parents are not ABO compatible, and kidney transplantation would most likely cause an early and immediate allograft rejection. Furthermore, most transplant programs do not perform ABO-incompatible transplants. Preemptive kidney transplantation is associated with better patient and allograft survival but often is not possible in the absence of a suitable living donor because of the long wait for a deceased donor kidney transplant.
- Compared with peritoneal dialysis, daily home hemodialysis is associated with better control of hyperphosphatemia, blood pressure, and volume overload in patients with chronic kidney disease.
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Copyright 2011 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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