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UCSD eConsult Newsletter
Vol. 3 No. 4
Feb/Mar 2017













































 























































































 









 




































 
At long last: ID eConsults!
After a groundswell of requests, the option of eConsults to the Division of Infectious Disease is (finally!) here. Thanks to our intrepid Epic Build Team, the following templates are now available:
  • Latent TB
  • Lyme Disease
  • M Chimaera
  • Recurrent C Diff
  • Recurrent furunculosis
  • Recurrent UTI
  • Zika

Faculty from the ID Division look forward to fielding low-complexity questions on these topics.

And, as always, enjoy this month's Exemplary eConsults.

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Exemplary eConsult:
Sleep Medicine


PCP 'My Clinical Question': 
I am requesting an eConsult from Sleep Medicine for my 65yo female patient with Restless Leg Syndrome.

The patient has a complex medical hx (h/o breast ca, Q Fever requiring long-term IV abx, chronic pain, and depression) who developed restless leg symptoms six months ago.

She was titrated up to 3 mg of Ropinirole qhs with no relief, then switched to gabapentin (now up to 300mg/600 mg) with minimal relief but now able to sleep. She was started on tramadol + lorazepam in the ED four months ago, and states this is only medication combination that relieves her symptoms during the day. Of note, her ferritin has repeatedly been normal

 At this point, how do we best proceed?  I am reluctant to continue her on the tramadol + lorazepam (especially since we are trying to wean her off Fentanyl patches), but she is adamant that this is the only thing that works for her.

Thanks in advance!

____________________

eConsultant
Atul Malhotra, MD
Division Chief
Pulmonary, Critical Care & Sleep Medicine



Thanks for sending this question.

The treatment of refractory RLS can be tough. After reviewing the records, i have a few thoughts:

1) it is hard to tell from the chart whether this could be RLS or a mimic; e.g., sometimes akathisias or peripheral neuropathy can mimic RLS.

2) there are newer drugs like Horizant (gabapentin extended release) and Neupro (transdermal rotigotine). While they do have some efficacy, they are often not covered by insurance.

3) I have had some luck with Lyrica, but going up on the gabapentin first might be helpful.

4) even in patients with normal ferritin, there are some who respond to intravenous iron. 
There is a ongoing randomized trial. I have tried this in rare cases with some success.

5) i have used chronic narcotics in these patients. There is obviously a stigma these days with chronic opioid use but there are some data showing stable dosing in RLS for up to 20 years.

I am not averse to tramadol and lorazepam for the same reason, as long as there is no dose escalation etc.

Bottom line, these cases are tough. I would probably try increasing the gabapentin first. If this doesn't work, try switching to Lyrica if insurance will cover. If not, continue tramadol and lorazepam.

Thank you for the eConsult.

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eConsult or standard consult?

There are two goals of the eConsult Project: provide an efficient response to a low complexity clinical question AND improve specialty clinic access.

Please do not order an eConsult AND a standard consult simultaneously. If the answer can be provided electronically, the patient does not need a standard consult. This saves a specialty cliic slot and lessens the wait time for a higher-complexity patient who truly needs an in-person standard consultation.
 
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Exemplary eConsult:
HIV Medicine


PCP 'My Clinical Question': 
I am requesting an eConsult from HIV Medicine for my 61yo male patient with a urinary tract infection

The patient is a 61 y/o HIV+ who presented with symptoms of dysuria and urinary frequency. Urine culture is positive for >100K E. coli (ESBL). Sensitivities demonstrate that the E coli is resistant to all oral medications other than nitrofurantoin.  Is it reasonable to treat this patient with niotrofurantoin, given that it is only bacteriostatic?

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eConsultant
Ankita Kadakia, MD
Associate Professor of Medicine
HIV Medicine



Chart and labs reviewed.  Yes, you can treat ESBL E.coli with nitrofurantoin; however, there is a higher failure and relapse rate. Treatment of ESBL E.coli UTI is usually for 14 days. You should extend the patient's nitrofurantoin prescription from 7 days to 14 days at 100mg twice daily. If the follow up urine culture grows ESBL E.coli again, please ask the Micro Lab to add sensitivities for fosfomycin. This is an oral antibiotic which is better at treating ESBL E.coli. The dosage is 3 grams orally every 3 days X 3 doses. 

Thank you for the eConsult.

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Apologies!
Our web page is currently under repair

Check back to find prior newsletters,
the monthly eConsultant schedule, and more.

Would you like to contribute a notable eConsult
to the monthly newsletter? Contact Us!
eConsults@ucsd.edu
Available eConsults:
Allergy, Cardiology, Dermatology, Endocrinology, Gastroenterology,
Hematology, Hepatology, HIV Medicine, Infectious Disease, Neurology,
Orthopedics, Otolaryngology, Pain Medicine, Psychiatry, Pulmonary, Renal,
Rheumatology, Sleep Medicine, Urology
In the works: Reproductive Medicine






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