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March 19, 2013 Issue

Clinical Practice Points

Access to Subspecialty Care for Patients With Mobility Impairment. A Survey

This survey of over 250 practices found more than half reported being unable to accommodate a fictional obese, hemiparetic patient who used a wheelchair and could not self-transfer to an examination table.

Use this study to:

  • Discuss what these findings suggest about access to care for patients with impaired mobility.
  • Discuss whether your residents are comfortable providing care to outpatients with impaired mobility or other disabilities. Do they feel prepared? Do they “cut corners” when seeing patients who require extra time or assistance to be examined?
  • What could be done to make things better for these patients?

Chlorthalidone Versus Hydrochlorothiazide for the Treatment of Hypertension in Older Adults. A Population-Based Cohort Study

This study found little difference between chlorthalidone and hydrochlorothiazide in a composite outcome of death and hospitalization with heart failure, stroke, or myocardial infarction. Patients treated with hydrochlorothiazide, however, had fewer hospitalizations for hypokalemia or hyponatremia than did those treated with chlorthalidone.

Use this study to:

  • Start a teaching session with a multiple choice question. We’ve provided one below.
  • Discuss where diuretics fit in the treatment of hypertension. Which drugs do your residents use as first line agents in newly diagnosed hypertension?
  • When your residents use diuretics as antihypertensive agents, which ones do they use? Do they prescribe hydrochlorothiazide? Chlorthalidone?
  • Discuss the limitations of a cohort study. In what ways did the groups of patients in this study treated with chlorthalidone and hydrochlorothiazide differ, and why might that matter?

Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement

This guideline recommends screening women of childbearing age for intimate partner violence and to provide and refer those women who screen positive to intervention services.

Use this guideline to:

  • Ask who is at risk for intimate partner violence. Is it just women? Residents can review the guideline as well as the information at PIER.
  • Discuss how to screen. The guideline concludes that a number of screening tools work well.
  • Ask residents if they know what to do if they discover a patient is being abused.

Ideas & Opinions

The Road to Health Reform: What Can Physicians Expect Over the Next 4 Years?

This short commentary discusses the political and practical obstacles over the next 4 years on the “road to health care reform,” and describes how US physicians can chart a path to a better health care system.

Use this article to:

  • Discuss how the Affordable Care Act plans to provide coverage for more people using expansion of Medicaid and health insurance plans offered through exchanges.
  • Ask what will happen in States that choose not to accept federal funding to expand Medicaid. What are the plans in your State?
  • Discuss whether your residents think federal health care spending can be reduced and how.
  • Ask if your residents feel they should be involved in these discussions? What would they say if they were asked what should happen?

Humanism and Professionalism

On Being a Doctor: Moving Pieces and On Being a Doctor: It’s Not Just the Patient

Take time to discuss the “art” of practicing medicine, and how sometimes just being there or listening is more important than prescriptions. Play the audio recordings of this issue’s two On Being A Doctor essays by following their 'Audio/Video' tabs. One of our colleagues discovers the value of playing backgammon with her bored and frustrated hospitalized patient, while another finds his caring makes a difference to his patient’s mother (even as her son leaves the emergency room against advice).

Use these essays to:

  • Share your own discoveries about your patients. How did they happen? Why don’t they happen more often?
  • Discuss why we don’t make the time for these interactions more often, even though whenever they occur we seem to find the time was worth it, and nothing else could have mattered more.

Other Teaching Resources from ACP

Document Your Residents’ Learning

Looking for a way to monitor and document your residents’ fund of knowledge? Consider the assignment of specific MKSAP 16 Digital questions. Residents can use the program’s Document Your Learning feature, which lets them email you a PDF report on their incorrectly and correctly answered questions and related learning objectives.


mksap16

A 57-year-old man is evaluated for a 20-year history of hypertension. He reports a 4.5-kg (10-lb) weight gain during the past 6 months. The patient is black. He does not smoke cigarettes. His only medication is low-dose chlorthalidone.

On physical examination, seated blood pressure is 146 to 150/88 mm Hg, and pulse rate is 78/min. BMI is 29. The remainder of the examination is unremarkable.

Laboratory studies reveal a serum creatinine level of 1.7 mg/dL (150 µmol/L), an estimated glomerular filtration rate of 51 mL/min/1.73 m2, and a urine protein–creatinine ratio of 0.45 mg/mg.

Which of the following is the most appropriate next step in managing this patient's hypertension?

A. Add amlodipine
B. Add metoprolol
C. Add ramipril
D. Increase the chlorthalidone dose

Answer: C. Add ramipril

Key Point: In black patients with hypertensive kidney disease and proteinuria, treatment with the ACE inhibitor ramipril is appropriate for blood pressure control and to decrease kidney disease progression

Educational Objective: Manage hypertension in a black patient with chronic kidney disease.

The addition of the ACE inhibitor ramipril is indicated for this black patient with hypertension, stage 3 chronic kidney disease (CKD), and proteinuria. Black patients tend to experience enhanced target organ damage at any level of blood pressure compared with most other groups, particularly white patients. Cardiovascular complications are also more frequent in black patients, and black patients are approximately fourfold more likely to experience end-stage kidney disease compared with white patients. These findings emphasize the need for aggressive blood pressure control in black patients, although the optimal level of control relative to other patient groups is unclear. Recommendations for high blood pressure management in black patients were released in the International Society on Hypertension in Blacks (ISHIB) consensus statement. ISHIB defines treatment goals in black patients based on either the absence of target organ damage (primary prevention), in which the blood pressure goal is less than 135/85 mm Hg, or the presence of target organ damage (secondary prevention), in which the blood pressure goal is less than 130/80 mm Hg. In hypertensive patients with proteinuria, treatment with a renin-angiotensin system inhibitor (an ACE inhibitor or angiotensin receptor blocker) has been shown to decrease proteinuria and slow the progression of kidney disease. Despite the finding that black patients do not respond well to an ACE inhibitor as monotherapy for hypertension without proteinuria, the African American Study of Kidney Disease and Hypertension (AASK), performed in patients with long-standing hypertension and mild proteinuria, demonstrated that the ACE inhibitor ramipril slowed kidney disease progression in black patients with impaired kidney function caused by hypertension and is therefore an appropriate addition to this patient's treatment regimen.

In this same study, both metoprolol and amlodipine were inferior to ramipril for progression of kidney disease and are therefore not preferable agents to add to this patient's regimen.

The benefit of an ACE inhibitor in mitigating progression of kidney disease is due to hemodynamic changes within the glomerulus and other effects due to renin-angiotensin system blockade, in addition to treating systemic hypertension. While increasing this patient's dose of diuretic might successfully lower his blood pressure, he would not benefit from the treatment of his proteinuria associated with ramipril.

Bibliography,
Flack JM, Sica DA, Bakris G, et al; International Society on Hypertension in Blacks. Management of high blood pressure in blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56(5):780-800. PMID: 20921433

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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