American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP InternistWeekly



In the News for the Week of June 4, 2013




Highlights

Anticoagulation likely OK for stroke patients undergoing dental procedures

Stroke patients on blood thinners who undergo dental procedures can routinely continue aspirin or warfarin, according to level A recommendations issued by the American Academy of Neurology. More...

Daily sunscreen appears better than beta-carotene for preventing skin aging

Daily sunscreen use prevents skin aging better than discretionary use or beta-carotene supplementation, according to a new study. More...


Test yourself

MKSAP Quiz: fatigue and fever of 3 days' duration

A 52-year-old man is admitted to the hospital with fatigue and fever of 3 days' duration. He is a health care worker and has a bicuspid aortic valve. He takes no medications. In the hospital, his blood cultures become positive for gram-positive cocci and grow methicillin-resistant Staphylococcus aureus. What is the most appropriate management? More...


COPD

Long-acting beta-agonists and anticholinergics pose similar cardiovascular risks

Patients with chronic obstructive pulmonary disease (COPD) faced increased risk of a cardiovascular event after starting treatment with a long-acting bronchodilator, whether it was a beta-agonist or an anticholinergic, a new study found. More...


Venous thromboembolism

Aspirin may be noninferior to dalteparin for VTE prophylaxis following hip replacements

Aspirin therapy for 28 days may be a reasonable alternative to low-molecular-weight heparin for extended venous thromboembolism (VTE) prophylaxis among hip replacement patients who have already received low-molecular-weight heparin for 10 days, a study found. More...


Stroke

Cognitive impairment better predictor of first stroke in the oldest old

Cognitive impairment appears to predict risk for first stroke in very elderly patients better than the Framingham stroke risk score, according to a recent study. More...


From ACP Internist

The next issue of ACP Internist is online

The next issue of ACP Internist is online and coming to your mailbox. June's issue wraps up coverage of Internal Medicine 2013. More...


Health information technology

Using personal health records for chronic care coordination

The American Medical Informatics Association (AMIA) is working on a project for the Office of the National Coordinator for Health Information Technology about personal health records (PHRs), rural health and care coordination. More...


Glycemic control

ACP issues high-value care recommendations for inpatient glucose management

Intensive insulin therapy (IIT) for inpatient glycemic control can result in more harm than benefit, ACP's Clinical Guidelines Committee recently reminded clinicians in a best practice advice paper. More...


Smoking cessation

ACP supports CDC's smoking cessation initiative, "Talk With Your Doctor"

The American College of Physicians and four other medical associations representing a total of more than 600,000 physicians are supporting the Centers for Disease Control and Prevention's (CDC) initiative "Talk with Your Doctor," a smoking cessation program that is part of the CDC's national tobacco education campaign, "Tips from Former Smokers." More...


From the College

Who in your office speaks Templatish, Beancounterese, Complyian, or Rushian?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com about how and why English has become the second language of medical documentation. More...

Governance Committee seeks Regent candidates for 2014

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2014. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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Anticoagulation likely OK for stroke patients undergoing dental procedures

Stroke patients on blood thinners who undergo dental procedures can routinely continue aspirin or warfarin, according to level A recommendations issued by the American Academy of Neurology.

In patients being treated with antithrombotic therapy for ischemic cerebrovascular disease, individual decisions regarding periprocedural management of these medications need to weigh bleeding risks from drug continuation against thromboembolic risk from discontinuation. The American Academy of Neurology has issued a new evidence-based clinical practice guideline to provide assistance to clinicians in managing antithrombotic therapy in this group of patients undergoing procedures.

The available evidence on when to stop blood thinners or resort to bridging medications varies from medication to medication and procedure to procedure, the Academy noted in its recommendations. For certain minor procedures, particularly dental ones, the evidence shows that antithrombotics should not be stopped in most stroke patients.

Recommendations appeared in the May 28 Neurology.

Specifically, the Academy's statement states that patients taking aspirin or warfarin should be counseled that they are highly unlikely to increase clinically important bleeding complications with dental procedures (Level A) and it is reasonable to routinely continue the drugs in stroke patients undergoing dental procedures (Level A).

In addition, doctors can tell patients that aspirin probably does not increase clinically important bleeding complications with invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures and carpal tunnel surgery (Level B), the recommendations stated. It is reasonable that stroke patients undergoing these procedures can continue aspirin (Level B). Patients taking aspirin should be counseled that it probably increases bleeding risks during orthopedic hip procedures (Level B, not supportive).

Aspirin might not increase clinically important bleeding in vitreoretinal surgery, electromyography (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy with biopsy, sphincterotomy and abdominal ultrasound-guided biopsies, the statement continued. Because of the weaker data, the recommendations stated that it is reasonable that some stroke patients undergoing these procedures should possibly continue aspirin (Level C). Studies of transurethral resection of the prostate could not exclude clinically important bleeding risks with aspirin (Level U).

Physicians can counsel patients that continuing warfarin is probably associated with a 1.2% increased risk for bleeding during dermatologic procedures, based on a meta-analysis of heterogeneous and conflicting studies (Level B), so patients undergoing dermatologic procedures should probably continue it (Level B).

Warfarin might be associated with no increase in clinically important bleeding with EMG, prostate procedures, inguinal herniorrhaphy and endothermal ablation of the great saphenous vein. Patients undergoing these procedures should possibly continue warfarin (Level C). Patients should be counseled that continuing it might increase bleeding with colonoscopic polypectomy (Level C, not supportive) so they should possibly temporarily stop it (Level C).

Although warfarin is probably not associated with an increased risk of clinically important bleeding with ocular anesthesia (Level B), anticoagulant practices during ophthalmologic procedures may be driven by the postanesthesia procedure, so there was insufficient evidence to make practice recommendations about stopping it (Level U).


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Daily sunscreen appears better than beta-carotene for preventing skin aging

Daily sunscreen use prevents skin aging better than discretionary use or beta-carotene supplementation, according to a new study.

annals.jpg

Researchers in Australia performed a randomized, controlled, community-based trial to determine whether regular sunscreen use compared with discretionary use or beta-carotene supplements compared with placebo helped slow skin aging. Patients were randomly assigned to use broad-spectrum sunscreen and take 30 mg of beta-carotene daily, use sunscreen and take placebo, use discretionary sunscreen and take 30 mg of beta-carotene, or use discretionary sunscreen and take placebo. The main outcome measure was change in microtopography between 1992 and 1996 in the sunscreen and beta-carotene groups compared with controls. Skin surface replicas from the back of the left hand were taken by using silicone-based impression materials and graded replicas by using the Beagley and Gibson scale. Grades increase from 1 (undamaged skin with fine lines evenly spaced in a two-directional network) to 6 (increasing severity of changes characterized by surface flattening, deepening of horizontal lines and loss of vertical lines).

Results appear in the June 4 Annals of Internal Medicine.

The study included 903 adults younger than 55 years of age who were randomly chosen from a community register. Patients randomly assigned to daily sunscreen use were directed to apply it to their heads, necks, arms and hands every morning and to reapply after heavily sweating, bathing or spending extended time outdoors. After four and a half years, patients who used sunscreen daily had no detectable increase in skin aging. From baseline to the end of the trial, those who used sunscreen daily exhibited 24% less skin aging than those who used it on a discretionary basis (relative odds, 0.76; 95% CI, 0.59 to 0.98). Beta-carotene supplementation appeared to have no overall effect on skin aging.

The authors acknowledged that the study was missing some outcomes data and that it had only modest power to detect moderate treatment effects, among other limitations. However, they concluded that regular sunscreen use appears to slow skin aging in healthy, middle-aged men and women. Although beta-carotene did not have a measurable effect on skin aging, the authors noted that further study is needed to completely exclude the potential for benefit or harm.



Test yourself


.
MKSAP Quiz: fatigue and fever of 3 days' duration

A 52-year-old man is admitted to the hospital with fatigue and fever of 3 days' duration. He is a health care worker and has a bicuspid aortic valve. He takes no medications.

mksap.gif

Blood cultures are obtained at the time of admission, and he is started on empiric vancomycin for possible endocarditis.

On hospital day 2, his initial blood cultures become positive for gram-positive cocci in clusters, and on hospital day 3, his blood cultures grow methicillin-resistant Staphylococcus aureus. Susceptibility to vancomycin is intermediate (MIC = 4 µg/mL).

On hospital day 4, the patient continues to appear ill. Temperature is 38.6 °C (101.5 °F), blood pressure is 105/65 mm Hg, and pulse rate is 110/min. On cardiopulmonary examination, the lungs are clear, and a grade 2/6 systolic ejection murmur is heard at the right upper sternal border, but there is no evidence of heart failure or septic emboli.

Which of the following is the most appropriate management?

A: Discontinue vancomycin and begin daptomycin
B: Discontinue vancomycin and begin linezolid
C: Discontinue vancomycin and begin trimethoprim-sulfamethoxazole
D: Increase vancomycin dose

Click here or scroll to the bottom of the page for the answer and critique.


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COPD


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Long-acting beta-agonists and anticholinergics pose similar cardiovascular risks

Patients with chronic obstructive pulmonary disease (COPD) faced increased risk of a cardiovascular event after starting treatment with a long-acting bronchodilator, whether it was a beta-agonist or an anticholinergic, a new study found.

Researchers conducted a nested case-control analysis of a retrospective cohort study, using a database of adults 66 years or older in Ontario, Canada, treated for COPD between September 2003 and March 2009. They compared the rate of emergency department (ED) visits and hospitalizations for cardiovascular events among patients newly prescribed a drug in either class and those not taking either type of drug.

Results were published by JAMA Internal Medicine on May 20.

Of the almost 200,000 patients, 28% had a hospitalization or ED visit for a cardiovascular event. Patients in the newly prescribed group were significantly more likely to have an event than non-users (adjusted odds ratio, 1.31 for beta-agonists vs. non-use [95% confidence interval [CI], 1.12 to 1.52; P<0.001) and 1.14 for anticholinergics vs. non-use (95% CI, 1.01 to 1.28; P=0.03]). Between the two medications, there was no significant difference in events.

The results confirm previous observational studies finding cardiovascular risks of these drugs, although they contradict some data from randomized controlled trials, perhaps due to differences between patient populations in controlled trials and the real world, the study authors speculated. As with any observational study, there is a risk of confounding, but it appears that new users of these drug classes have similarly increased risk of cardiovascular events.

"These results support the need for close monitoring of all patients with COPD who require long-acting bronchodilators regardless of drug class," the authors concluded.

The findings are helpful, but still leave a lot of unanswered questions, including what kind of monitoring is appropriate for these patients, wrote the author of an accompanying commentary. Physicians are also still uncertain, and await future research findings, on the relative safety of different delivery methods of anticholinergics and the use of a beta-agonist alone or with an inhaled corticosteroid, the commentary noted.



Venous thromboembolism


.
Aspirin may be noninferior to dalteparin for VTE prophylaxis following hip replacements

Aspirin therapy for 28 days may be a reasonable alternative to low-molecular-weight heparin for extended venous thromboembolism (VTE) prophylaxis among hip replacement patients who have already received low-molecular-weight heparin for 10 days, a study found.

annals.jpg

Researchers conducted a multicenter, randomized, controlled trial, the EPCAT (Extended Prophylaxis Comparing Low Molecular Weight Heparin to Aspirin in Total Hip Arthroplasty) study, among 778 patients who had elective, unilateral total hip arthroplasty from 2007 to 2010 at 12 tertiary care orthopedic referral centers in Canada.

After an initial 10 days of dalteparin prophylaxis, patients were randomly assigned to 28 days of dalteparin (n=400) or aspirin (n=386). Researchers noted symptomatic VTE confirmed by objective testing (primary efficacy outcome) and bleeding.

Results appeared in the June 4 Annals of Internal Medicine.

The study was halted prematurely because of decreasing enrollment after a major shift in the use of anticoagulant prophylaxis in Canada following the approval of rivaroxaban. This prompted an unplanned interim analysis by the data safety monitoring board, which found that the primary objective of noninferiority of aspirin had been reached.

Of the enrolled patients, five of 398 (1.3%) randomly assigned to dalteparin and one of 380 (0.3%) randomly assigned to aspirin had VTE (absolute difference, 1.0 percentage point; 95% confidence interval [CI], −0.5 to 2.5 percentage points). Aspirin was noninferior (P<0.001) but not superior (P=0.22) to dalteparin. Clinically significant bleeding occurred in five patients (1.3%) receiving dalteparin and two (0.5%) receiving aspirin. The absolute between-group difference in a composite of all VTE and clinically significant bleeding events was 1.7 percentage points (95% CI, −0.3 to 3.8 percentage points; P=0.091) in favor of aspirin.

The researchers noted that given its low cost and greater convenience, aspirin may be considered a reasonable alternative for extended thromboprophylaxis after total hip arthroplasty.

They wrote, "We believe our findings are valid and generalizable, given that the demographic and surgical characteristics were similar between the groups and the study was performed in several centers involving many orthopedic surgeons. The study design reflected clinical practice in that no screening tests for VTE were performed and the primary events were symptomatic ones that caused patients to seek medical attention."



Stroke


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Cognitive impairment better predictor of first stroke in the oldest old

Cognitive impairment appears to predict risk for first stroke in very elderly patients better than the Framingham stroke risk score, according to a recent study.

Researchers examined 480 patients from the Leiden 85-plus Study, an observational, prospective, population-based cohort study of elderly people in the Netherlands. Framingham stroke risk score and Mini-Mental State Examination (MMSE) score were obtained at baseline, and risk of first stroke was calculated in tertiles of each of these variables. Results were published online May 16 by Stroke.

All patients were 85 years of age at the start of the study. Fifty-six had a stroke during five years of follow-up, for an incidence rate of 30.3 per 1,000 person-years. Patients with high Framingham scores did not have a higher risk for stroke than those with low Framingham scores (hazard ratio, 0.77; 95% confidence interval [CI], 0.39 to 1.54), but those with high cognitive impairment did have higher risk than those with low cognitive impairment (hazard ratio, 2.85; 95% CI, 1.48 to 5.51). MMSE score had discriminative power for stroke prediction when compared with the Framingham risk score (area under the receiver-operating characteristic curve, 0.65; 95% CI, 0.57 to 0.72), and the two prediction tools differed significantly in area under the receiver-operating characteristic curves, with the MMSE curve being higher (P=0.006).

The authors pointed out that some of the study participants may have had silent strokes that went undetected and that MMSE was the only measure used to assess cognitive impairment. However, they concluded that cognitive impairment appears to be a better tool to determine risk for first stroke in very elderly patients than the Framingham stroke risk score. "Assessment of cognitive function can be considered as an easily accessible tool to identify very old subjects at risk for stroke," they wrote. They noted that their results need to be validated in other elderly cohorts.



From ACP Internist


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The next issue of ACP Internist is online

The next issue of ACP Internist is online and coming to your mailbox. June's issue wraps up coverage of Internal Medicine 2013, and includes stories on the following:

acpi-20130604-internist.jpg

How to start and stop bisphosphonates. A new online tool and a few simple rules can inform internists how to start bisphosphonates and when to consider a drug holiday at the request of another physician, a dentist or even the patient.

Don't be anxious about psychiatric diagnoses. Tips can help physicians with the screening and treatment of mental disorders seen in primary care, including somatoform, bipolar and anxiety disorders.

'Party drugs' require hard work to spot and treat. Taking a history is important for identifying abuse of some drugs that aren't caught by screening tests but may still have serious consequences for users.

More stories, the MKSAP Quiz, and our newest acrostic puzzle, Crossed Words, are now online.



Health information technology


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Using personal health records for chronic care coordination

The American Medical Informatics Association (AMIA) is working on a project for the Office of the National Coordinator for Health Information Technology about personal health records (PHRs), rural health and care coordination.

As part of the project, AMIA will be convening stakeholders to discuss their use of PHRs. AMIA seeks to identify practitioners who are using PHRs, practice in rural communities and/or are helping patients with cancer care coordination. Part of the project is to identify potential best practices and lessons learned regarding the ability of patients and their providers to use PHRs to improve care coordination (especially for rural health and cancer care).

If you are interested in possibly participating in the stakeholder discussions and/or for more information, please contact Meryl Bloomrosen, AMIA's Vice President for Public Policy and Government Relations at Meryl@amia.org or 301-657-5917. A brief description of the overall program can be found online.



Glycemic control


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ACP issues high-value care recommendations for inpatient glucose management

Intensive insulin therapy (IIT) for inpatient glycemic control can result in more harm than benefit, ACP's Clinical Guidelines Committee recently reminded clinicians in a best practice advice paper.

ACP recommends that clinicians should target a blood glucose level of 140 to 200 mg/dL if IIT is used in surgical or medical intensive care unit patients, and clinicians should avoid targets less than 140 mg/dL because harms are likely to increase with lower blood glucose targets, noted the paper, published in the American Journal of Medical Quality on May 23.

In a review of the evidence, ACP's Clinical Guidelines Committee found that IIT with a goal of achieving normal or near-normal blood glucose in patients with or without diabetes does not provide substantial benefits and may lead to harm. IIT costs include implementation in a hospital and downstream expenses incurred to manage the consequent harms. No recent cost-effectiveness studies have incorporated results from recent trials to evaluate the impact of IIT.

"Even in light of the new evidence, many systems continue to recommend moderate blood glucose control because of the association of high blood glucose with infection, poor wound healing, dehydration, and other complications. Clinicians caring for these patients must keep the harms of hypoglycemia in mind when managing hyperglycemia and should avoid aggressive glucose management," the ACP experts wrote.



Smoking cessation


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ACP supports CDC's smoking cessation initiative, "Talk With Your Doctor"

The American College of Physicians and four other medical associations representing a total of more than 600,000 physicians are supporting the Centers for Disease Control and Prevention's (CDC) initiative "Talk with Your Doctor," a smoking cessation program that is part of the CDC's national tobacco education campaign, "Tips from Former Smokers."

The goal of "Talk with Your Doctor" is to motivate smokers to work with their physicians to develop a plan for quitting, and to encourage doctors to use the CDC's tips to start a dialogue with patients who use tobacco. The "Tips from Former Smokers" campaign features compelling stories of real people who are living with serious diseases, such as chronic obstructive pulmonary disease, cancer, heart disease, asthma, and diabetes, that were caused by smoking or secondhand smoke exposure.

From May 27 through June 2, select "Tips from Former Smokers" television ads, as well as digital and online ads, will feature "You Can Quit. Talk With Your Doctor for Help."



From the College


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Who in your office speaks Templatish, Beancounterese, Complyian, or Rushian?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com.

In his latest post, Dr. Ejnes looks at how and why English has become the second language of medical documentation.


.
Governance Committee seeks Regent candidates for 2014

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2014.

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2014.

The Governance Committee will strive to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

All candidates for Regent must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by Aug. 1, 2013.

Letters of nomination should include the following sections:

  • brief description of the nominee's current activities,
  • special attributes the candidate would bring to the BOR in terms of the desired characteristics outlined above,
  • previous and current service in College-related activities,
  • service in organizations other than the College (medical and nonmedical) and
  • identification of two individuals who will write letters of support for the candidate.

Letters of support do not need to have specific content or format but will be most useful if they focus on the candidate's qualifications and how he or she would contribute to the BOR and the College.

Please send your confidential nominations, no later than Aug. 1, 2013, to:

Governance Committee

ATTN: Mrs. Florence Moore

American College of Physicians

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Fax: 215-351-2829

e-mail: fmoore@acponline.org

Only candidates who submit a letter of nomination and two letters of support by Aug. 1, 2013, will be advanced to the Governance Committee for review.



Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20130604-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is A: Discontinue vancomycin and begin daptomycin. This item is available to MKSAP 16 subscribers as item 10 in the Infectious Disease section. More information is available online.

In this patient, vancomycin should be discontinued and daptomycin should be initiated. The causative pathogen is a vancomycin-intermediate Staphylococcus aureus (VISA), which has a minimal inhibitory concentration (MIC) of 4 micrograms/mL to vancomycin. Although vancomycin is a reasonable initial choice for empiric therapy for treating a possible methicillin-resistant S. aureus (MRSA) bloodstream infection, daptomycin is recommended as an alternative to vancomycin for treatment of bloodstream infection caused by vancomycin-intermediate S. aureus, particularly in patients treated with vancomycin who do not appear to be responding to treatment. Daptomycin is a bactericidal agent, which has been studied extensively for treatment of bloodstream infections due to S. aureus, including MRSA. Daptomycin retains activity against many strains of S. aureus with elevated MICs to vancomycin (≥2 micrograms/mL).

Linezolid has activity against S. aureus but is not indicated for the treatment of bloodstream infection.

Recently, trimethoprim-sulfamethoxazole has been used more frequently for treatment of MRSA skin infection, but it is not recommended as a primary agent for the treatment of bloodstream infection.

Because of the intermediate sensitivity of the identified organism to vancomycin, optimal pharmacodynamic targets may not be possible by increasing the vancomycin dose. To avoid treatment-related toxicity, the use of an alternative agent is preferred versus increasing the vancomycin dose.

Key Point

  • Daptomycin is recommended for treatment of bloodstream infections caused by methicillin-resistant Staphylococcus aureus when the minimal inhibitory concentration to vancomycin is more than 2 micrograms/mL.

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Test yourself

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

Find the answer

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