1. Update in General Internal Medicine 2006 Laura Zakowski MD No financial disclosures

2. Learning objectives  Recognize that famciclovir can be used to treat herpes labialis  Recall that all patients with inguinal hernias do not need referral for repair  Understand a rationale for use of rapid strep culture for pharyngitis  Recognize α-Lipoic Acid as a treatment for diabetic neuropathy  Identify a risk factor for abnormal Pap smears in postmenopausal women

3. Famciclovir for herpes labialis Spruance et al. J Am Acad Derm 2006;55:47-53  Rationale: For the many patients experience “fever blisters” is there an effective treatment?  Industry-sponsored  N = 701 outpatients in US, Canada and Australia  Included: patients with 3 or more outbreaks over a year, prodromal sxs,

4. Study design  Randomized to three groups:  1500 mg once  750 BID for one day  Placebo  Began treated within one hour of symptoms  Returned to clinic and recorded sxs with lesion

5. Results  Time to healing better in both treatment groups  Similar adverse effects in all groups  Headache  Nausea DAYSDAYS

6. Bottom line  Single daily dose of 1500 mg famciclovir  Reduces time to healing by two days  Comparable to other treatments Valacyclovir 2000 mg BID: 1 day faster Penciclovir cream: q2 hr x4 days: 0.7 day faster Acyclovir 400 mg 5x/day x5 days: 1 day faster  No study compares treatments directly

7. Repair of inguinal hernia Fitzgibbons et al. JAMA. 2006;295:285-292  Should we send all patients with inguinal hernias to the surgeons?  Referred by PCC, surgeons, self  N = 720 men of a potential 3074  Asymptomatic or minimally symptomatic  18 years of age or older, mean age 57  Excluded:  Pain, discomfort, undetectable hernias

8. Study design  Randomized and watched for 2-4.5 years  Examined regularly  Primary outcome: pain and discomfort interfering with normal activities

9. Results at 2 years  Intention to treat:  Pain interfering with activities: 2-5%  Both groups had less pain after two years  More pain reduction in surgical group  Complications:  Medical: 1.8/1000 patient-years (n=2)  Surgical: 25%  Cross-over  To surgery: 23%  To watchful waiting: 17%

10. Copyright restrictions may apply. Fitzgibbons, R. J. et al. JAMA 2006;295:285-292. Probability of Crossover From Watchful Waiting to Surgery

11. Bottom line  Waiting for hernia repair is reasonable  Pain does improve after hernia repair

12. Management of Acute Pharyngitis in Adults Humair J-P, et al. Arch Intern Med 2006;166:640-644  What should we use: Centor criteria, Rapid Strep or culture?  Swiss university-based primary care clinic  N = 372 patients  Pharyngitis  Between 2 and 4 clinical symptoms:  Fever  Tonsillar exudate  Tender cervical adenopathy  Absence of cough

13. Study Design  Determined Centor criteria  Obtained rapid strep and culture  Assumed certain costs:  $25 for PCN  $5 for rapid strep  $18 for throat culture  Analyzed different strategies

14. Results  Symptoms:  Temperature: 60%  Tonsillar exudate: 70%  Painful lymph nodes: 74%  No cough: 75%  Centor criteria:  2: 40%  3: 42%  4: 18%

15. Results Rapid Strep 3 or 4 Centor Culture % PCN 376038 % overuse 3320 % underuse 390 % Appropriate 9459100 Cost$15$25$32

16. Bottom line  Use of rapid strep test can limit over and underuse of antibiotics  This approach is also cost-effective

17. α-Lipoic Acid for Diabetic Neuropathy Ziegler, et al. Diabetes Care 2006;29:2365-2370  Does this supplement improve diabetic neuropathy?  Nutritional supplement  Liver and renal excretion  Initial worsening of neuropathy symptoms  In combination with any diabetic medication: increased risk of hypoglycemia

18. Study Design  N = 181  Industry sponsored  Conducted in Israel and Russia  Ages 18-74  type 1 or type 2  Other causes of neuropathy ruled out  Excluded:  Hepatic or renal disease  PVD  Measured TSS: Pain, paresthesia, numbness

19. Results at 5 weeks 50% reduction in TSS NNT = 3 (CI 2,6)

20. Adverse effects  No hypoglycemic events reported (%)Placebo 600 mg 1200 mg 1800 mg Nausea0132148 Vomiting02426 Vertigo04411 Overall21274354

21. Bottom Line  α-Lipoic Acid improved symptoms of diabetic neuropathy  A dose of 600 mg is best  An uncontrolled supplement  Cost is about $5 per month  No comparison to other effective treatments

22. Cervical cytological abnormalities with aging Yasmeen, et al. Obstet Gynecol 2006;108:410-9  USPTF recommends against screening after 65. Is this appropriate?  N = 16,608 in WHI study  Ages 50-79 with normal Pap or LSIL  Excluded: cancers including cervical

23. Study Design  Follow-up cytology at years 3 and 6  Collected information on potential cervical cancer risk factors  Age, ethnicity, history of smoking  Married  Not married, not sexually active  Not married, sexually active  Recorded incidence of Pap abnormalities  Results for 13,546 at year 3 and 3,398 at year 6

24. Results Any abnormality HSIL Cervical cancer E+P179*236 Placebo130*314 Reported in person-years

25. Results: HSIL or cancer Hazard Ratio P value Married or living as married 1.0 Not married, no sexual activity 2.3.02 Not married, sexual activity 3.5.005 Placebo1.0 Estrogen and Progestin.9.75

26. Bottom Line  Living as not married with ongoing sexual activity a risk factor for abnormal Pap smears  Estrogen with progestin:  did not affect incidence of HSIL or cervical cancer  Did cause more cytologic abnormalities