NYACP Board Review Question of the Week

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Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam.  Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.


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March 12, 2024

MKSAP 18 Booster Pack C General Internal Medicine Question 12

Stem:

A 38-year-old woman is evaluated during a routine examination. She has recently divorced and is interested in some form of hormonal contraception, as her ex-husband had a vasectomy after their last child, and she does not want to use condoms. She has no history of deep venous thrombosis, hypertension, or heart disease. She drinks one glass of wine four or five nights per week and smokes a pack of cigarettes daily. Family history is significant for stroke in her mother at age 72 years. All previous cervical cancer screenings have been negative, the last 1 year ago.

Physical examination, including pelvic examination, is normal.

Which of the following is the most appropriate hormonal contraceptive option for this patient?

Responses Received from Members (746 Responses):

The Correct Answer is:   C. Progesterone contraceptive

Educational Objective

Recommend contraception options for a woman who smokes.

Critique

The best hormonal contraception option for this 38-year-old woman who smokes is a progesterone-only preparation. Women older than 35 years who smoke more than 15 cigarettes daily should not be prescribed estrogen-containing preparations because of the increased risk of thromboembolic disease. A family history of stroke itself is not a contraindication to the use of estrogen-containing preparations, although a personal history of stroke or thromboembolic disease is; progesterone-only contraceptives are considered safe in these women. Progesterone-only options for women with contraindications to estrogen include the “mini-pill,” long- acting progesterone compounds (such as depot medroxyprogesterone acetate), subcutaneous progesterone implants, and progesterone-containing intrauterine devices.

Estrogen-only patches are never appropriate for contraception; they may be used as hormone replacement therapy in postmenopausal women without an intact uterus.

Combined estrogen-progesterone preparations are available in the form of patches and vaginal rings, which avoid first-pass hepatic metabolism and may limit estrogen's effects on the liver and on lipids. These products do not negate the thrombogenic effects of estrogen, however, and so they are still contraindicated in women who smoke.

Key Points

Estrogen-containing contraceptives are contraindicated in women older than 35 years who smoke more than 15 cigarettes daily because of the increased risk of thromboembolic disease.

Copyright 2018, American College of Physicians.

February 27, 2024

MKSAP 18 Hematology & Oncology Question 11

Stem:

A 55-year-old man is evaluated in the emergency department for abrupt loss of consciousness after a fall. Medical history is notable for atrial fibrillation. He has otherwise been well without additional medical problems. Medications are warfarin and metoprolol.

On physical examination, temperature is 37 °C (98.6 °F), blood pressure is 135/85 mm Hg, pulse rate is 83/min and irregular, and respiration rate is 16/min. The patient is obtunded without localizing neurologic findings.

Cardiac examination reveals an irregularly irregular rhythm. The remainder of the examination is unremarkable.

Head CT scan shows a large subdural hematoma.

Laboratory studies show a hemoglobin level of 13 g/dL (130 g/L), platelet count of 183,000/µL (183 × 109/L), and INR of 3.0.

Intravenous vitamin K is administered, and plans are made for emergent neurosurgery.

Which of the following is the most appropriate treatment?

Responses Received from Members (1,005 Responses):

February 27 answer distribution graph

The Correct Answer is:   B. Four-factor prothrombin complex concentrate

Educational Objective

Reverse warfarin anticoagulation with four-factor prothrombin complex concentrate.

Critique

This patient should be given four-factor prothrombin complex concentrate (4f-PCC). Patients who receive anticoagulation with a vitamin K antagonist have an increased risk for major gastrointestinal and central nervous system bleeding and an increased risk for periprocedural bleeding. Although vitamin K alone can be effective in reversing the effect of warfarin, its hemostatic effect can take several hours, and, in urgent situations, simultaneous replacement of the vitamin K–dependent coagulation factors is necessary. 4f-PCC contains factors II, VII, IX, and X as a lyophilized powder and can be administered quickly in a small reconstituted volume. It provides effective hemostasis 90% of the time and is the preferred option for most patients who require urgent warfarin reversal. Thromboembolism is a potential adverse effect. 4f-PCC should be avoided in patients with a history of heparin-induced thrombocytopenia because it contains residual heparin.

Cryoprecipitate would be indicated to treat severe hypofibrinogenemia, usually arising as a consequence of disseminated intravascular coagulation (DIC) or severe liver disease. There is no reason to anticipate DIC in this patient, and he has no history of liver disease.

Plasma transfusion is more time consuming (preparation and administration) and is associated with a much higher risk of fluid overload from the volume needed to replace the coagulation factors. It is no longer the best option to reverse warfarin with the availability of 4f-PCC.

Idarucizumab is a monoclonal antibody that binds the non–vitamin K antagonist oral anticoagulant dabigatran and causes a rapid reduction in available dabigatran in the body for up to 24 hours. Idarucizumab will not reverse warfarin anticoagulation.

Key Points

Four-factor prothrombin complex concentrate should be used to reverse the effects of warfarin anticoagulation in patients experiencing severe bleeding and those requiring urgent surgery.

Bibliography

Goldstein JN, Refaai MA, Milling TJ Jr, Lewis B, Goldberg-Alberts R, Hug BA, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet. 2015;385:2077-
87. PMID: 25728933 doi:10.1016/S0140-6736(14)61685-8

Copyright 2018, American College of Physicians.


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Last Updated:  2.29.24

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