1. Class I ICD indications:
- EF < 35, s/p at least 3 months of optimal medical management in NIDCM and 9 months in Ischemic DCM.
- Sustained v-tach + structural heart disease
- Syncopal episode of unknown origin + inducible v-tach or v-fib on EP testing
2. CI to spironolactone
- Cr < 2.5 in men, <2 in women
- K > 5
3. Osteoporosis:
- Defined as either fragility fracture (fracture with low impact, like falling from standing) or T-score <2.5 on bone mineral density. Osteopenia is T-score <1-2.5.
- Start bisphosphonae. Aledronate is poorly absorbed orally so it has to be taken on an empty stomach.
- Zaledronate is a long-acting injectable (can be given once a year as IV infusion)
- CI to aledronate: achalasia/stricture/dysphagia, can't remove upright for 30-60 minutes after taking, malabsorption (bad celiac's or IBD)
- Ca + vitamin D supplementation: 50,000 IU vitamin D every day for 1 week (loading), followed by 2,000 IU daily maintenance.
- Screen women at age 65, and at 60 if they are higher risk (weight < 70 kg/154lbs)
- Calcitonin is second line- effects on bone mass are modest and doesn't impact fracture rates
- Raloxifen is also second line- increases bone mass, prevents vertebral fractures but no data showing that it prevents hip fractures. Also carries the estrogen-agonist effects (DVTs, cardiovascular effects, etc)
- Teriparatide is an anabolic agent that stimulates osteoblasts and builds up bone mass and prevents vertebral and non-vertebral fractures. Limit use to 2 years in the most at risk people (T-score <3.0-2.5 with fragility fracture who can't take bisphosphonates). Daily subQ injections. Can increase risk of osteosarcoma so don't use in people with Paget's, history of bone cancer, history of radiation to bone.
4. Psoriatic arthritis: manage with NSAIDs, anti-TNF, methotrexate. Don't use systemic steroids.
5. Hypercalcemia of malignancy
- usually caused by PTHrP secretion, either systemically or locally (ie blood levels normal); PTH binds osteoblasts and increase expression of RANKL which activates RANK on osteoclasts and promotes growth/activity
- Tumors that can secret PTHrP (squamous cell cancer in general, h&n, breast, lung, renal + bladder, esophagus, ovarian and endometrial
- Some tumors also can secrete local cytokines that directly promote bone resorption by osteoclasts: multiple myeloma, lymphoma, breast, leukemia
6. Aortic dissection
- Manage with beta-blockers rather than vasodilators (ca-channel blockers, hydralazine), which can cause reflex tachycardia and worsen the shear forces on the aorta. Only use vasodilators if beta blockade is inadequate to lower BP
- Goal vitals: HR <60, BP <120 systolic {source:study in circulation showing tighter HR control lead to better outcomes}
7. Correcting hypernatremia:
- Euvolemic or Hypervolemic hypernatremia: D5W. Giving straight water may be an osmolar shock and cause red cell lysis-- hence the D5
- Hypovolemic hypernatremia: depending on how bad the hypernatremia is, either 0.9 NS or D5 half-normal.
8. Analgesic nephropathy: 
- Most common cause of drug-induced chronic renal failure.
- 3-5% of ESRD
- Usually females (peak 50-55) who use combined analgesics - aspirin and Naproxen for example.
- Typically occurs after cumulative ingestion of 2-3 kg of index drugs
- Papillary necrosis, tubulointerstitial nephritis
- Polyuria, sterile pyuria (WBC casts) seen early, with hematuria if papillary necrosis happens
- HTN, proteinuria, impaired ability to concentrate urine as disease progresses. May even seen nephrotic range proteinuria in advanced disease.
9. Other complications of chronic analgesia abuse: 
- Atherosclerotic disease
- Premature aging
- Urinary tract cancer
10. Cutoff BMI between anorexia and bullemia - 18.5