Is there benefit to adding ezetimibe to a statin for the secondary prevention of CVD?

YES. In patients with known cardiovascular disease (CVD), ezetimibe with a statin decreases major adverse cardiovascular events (MACE) but has no effect on all-cause and cardiovascular mortality, compared to a statin alone (strength of recommendation [SOR], A; meta-analysis of randomized controlled trials [RCTs] including 1 large RCT). In adults with atherosclerotic CVD (ASCVD), the combination of ezetimibe and a moderate-intensity statin (rosuvastatin 10 mg) was noninferior at decreasing cardiovascular death, major cardiovascular events, and nonfatal stroke, but was more tolerable, compared to a high-intensity statin (rosuvastatin 20 mg) alone (SOR, B; 1 RCT).

Tips and tools to help refine your approach to chest pain.

Which history and exam findings have high predictive value for different causes of chest pain? Which decision tool can best assess for CAD in your practice setting?

Is an underlying cardiac condition causing your patient's palpitations?

This review lists the questions to ask to obtain important diagnostic clues and provides an algorithm for evaluating palpitations when the initial Dx is not evident on EKG.

CSF studies which ultimately led to the possible diagnosis of anti-NMDAR encephalitis.

A 17-year-old man with no significant medical history presented with new-onset seizure activity and altered mental status manifesting as bizarre behaviour, which included rapid pressured and tangential speech, psychomotor agitation, insomnia and delusions. He also had autonomic dysregulation, manifested in labile blood pressures. He had been recently discharged from his first psychiatric hospitalisation. Many studies were performed, including electroencephalogram (EEG), head CT, laboratory work, urine drug screen and lumbar puncture with cerebral spinal fluid studies, which ultimately led to the diagnosis of anti-N-methyl-D-aspartate receptor (NMDAR) autoimmune encephalitis. He was treated with five rounds of plasmapheresis with complete resolution of his altered mental status. This case highlights the importance of being familiar with the presentation of anti-NMDAR autoimmune encephalitis, especially in cases of new-onset mental status changes with psychotic like symptoms, seizure-like activity and autonomic dysregulation as early detection and treatment improves chances of good prognosis with return to baseline cognitive function.

Clostridioides difficile Infection: Update on Management.

Guidelines for the diagnosis and treatment of Clostridioides difficile infection have recently been updated. Risk factors include recent exposure to health care facilities or antibiotics, especially clindamycin. C. difficile infection is characterized by a wide range of symptoms, from mild or moderate diarrhea to severe disease with pseudomembranous colitis, colonic ileus, toxic megacolon, sepsis, or death. C. difficile infection should be considered in patients who are not taking laxatives and have three or more episodes of unexplained, unformed stools in 24 hours. Testing in these patients should start with enzyme immunoassays for glutamate dehydrogenase and toxins A and B or nucleic acid amplification testing. In children older than 12 months, testing is recommended only for those with prolonged diarrhea and risk factors. Treatment depends on whether the episode is an initial vs. recurrent infection and on the severity of the infection based on white blood cell count, serum creatinine level, and other clinical signs and symptoms. For an initial episode of nonsevere C. difficile infection, oral vancomycin or oral fidaxomicin is recommended. Metronidazole is no longer recommended as first-line therapy for adults. Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes. Good antibiotic stewardship is a key strategy to decrease rates of C. difficile infection. In routine or endemic settings, hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior. The Infectious Diseases Society of America does not recommend the use of probiotics for prevention of C. difficile infection.

Functional Dyspepsia: Evaluation and Management.

Functional dyspepsia is defined as at least one month of epigastric discomfort without evidence of organic disease found during an upper endoscopy, and it accounts for 70% of dyspepsia. Symptoms of functional dyspepsia include postprandial fullness, early satiety, and epigastric pain or burning. Functional dyspepsia is a diagnosis of exclusion; therefore, evaluation for a more serious disease such as an upper gastrointestinal malignancy is warranted. Individual alarm symptoms do not correlate with malignancy for patients younger than 60 years, and endoscopy is not necessarily warranted but should be considered for patients with severe or multiple alarm symptoms. For patients younger than 60 years, a test and treat strategy for Helicobacter pylori is recommended before acid suppression therapy. For patients 60 years or older, upper endoscopy should be performed. All patients should be advised to limit foods associated with increased symptoms of dyspepsia; a diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) is suggested. Eight weeks of acid suppression therapy is recommended for patients who test negative for H. pylori, or who continue to have symptoms after H. pylori eradication. If acid suppression does not alleviate symptoms, patients should be treated with tricyclic antidepressants followed by prokinetics and psychological therapy. The routine use of complementary and alternative medicine therapies has not shown evidence of effectiveness and is not recommended.

PURL: Best timing for measuring orthostatic vital signs?

We typically take a blood pressure within 3 minutes of a patient rising from a supine to a standing position. But is that too long?

Head & neck cancers: What you'll see, how to proceed.

What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here's what you need to know.