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May 20, 2014 Issue


Clinical Practice Points


Medical Knowledge
Patient Care
Practice Based Learning and Improvement

Low-Dose Aspirin for Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force

This systematic review analyzed studies of aspirin to reduce adverse outcomes for preeclampsia. A significant reduction in adverse outcomes was noted, with no additional harms seen, but the authors suggest the benefit may be overestimated due to small study sizes.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the presentation, diagnosis, and treatment of preeclampsia with your learners. You can also use the ACP Smart Medicine – Preeclampsia for tables of differential diagnosis, laboratory findings, and more to help prepare for this discussion.
  • After reviewing this article, ask your learners whether they would recommend aspirin to their patient at high risk for preeclampsia. What about for those at average risk? Discuss the limitations of this and other systematic reviews. The authors address several in the paper’s discussion.
  • Answer the brief quiz that accompanies this article to claim CME for yourself!


Medical Knowledge
Systems-based Practice
High Value Care

Routine Echocardiography Screening for Asymptomatic Left Ventricular Dysfunction in Childhood Cancer Survivors: A Model-Based Estimation of the Clinical and Economic Effect.

Cost-Effectiveness of the Children’s Oncology Group Long-Term Follow-Up Screening Guidelines for Childhood Cancer Survivors at Risk for Treatment-Related Heart Failure

Cardiac assessment every 1 to 5 years for childhood cancer survivors is recommended to detect asymptomatic left ventricular dysfunction. These 2 studies estimated the clinical benefit and cost-effectiveness of different intervals for screening echocardiography on survivors of childhood cancer. An accompanying editorial reviews some basic concepts important in cost-effectiveness analysis, and points out how these 2 studies help clinicians and patients consider which variables might be most important in deciding how often to screen for left ventricular dysfunction.

Use these studies to:

  • Review the cardiac side effects of chemotherapy and radiation therapies.
  • Ask your learners how much they think a quality-adjusted life-year (QALY) is worth in dollars?
  • Discuss why the "perspective" used in cost-effectiveness studies is important to understanding how the results relate to individual patients. The accompanying editorial helps to explain this.
  • Use a recent concise review of key concepts for clinicians related to cost-effectiveness and evaluating value to help you prepare a teaching session.


Medical Knowledge
Interpersonal and Communication Skills

Health and Economic Benefits of Early Vaccination and Nonpharmaceutical Interventions for a Human Influenza A Pandemic. A Modeling Study

Large-scale vaccination did not occur until 9 months into the 2009 influenza A (H1N1) pandemic. This study estimated the effects of a more rapid vaccination schedule and more aggressive nonpharmaceutical strategies and found that more rapid vaccination would yield reductions in infections, deaths, and health care costs. Nonpharmaceutical interventions showed similar reductions.

Use this study to:

  • Review influenza vaccine indications and contraindications. Use In The Clinic: Influenza to review key clinical questions and for key tables on indications, treatments, and their side effects.
  • Discuss strategies to improve patient adherence to recommended vaccination administration.
  • Review the recommended 2014 immunization schedule for adults.


Medical Knowledge
Practice Based Learning and Improvement
High Value Care

Update in Hematology and Oncology

This update summarizes 12 key articles in hematology and oncology with an emphasis on providing value-based care.

Use these summaries to:

  • Organize a "mini–journal club." Have learners identify which articles have the greatest potential impact on the care they deliver to their patients and pull the full article to read.
  • As the author of this synopsis of key articles points out, many of the studies identify where certain common practices are not of value. While perhaps not as "exciting" as news of newly identified effective therapy, such studies have the potential to improve care. Encourage learners to explore the Choosing Wisely campaign to improve the value of care delivered.

Humanism and Professionalism


Systems-based Practice
Professionalism

On Being a Doctor: What’s in a Name?

In this essay, Dr. Rangaswami describes the social stigma and challenges of an uninsured patient with a serious medical condition.

Use this essay to:

  • Play an audio recording of the essay to your team, read by Michael LaCombe, MD, the editor of On Being a Doctor.
  • Discuss whether your learners think health care is a right?
  • Ask what resources are available to uninsured patients in your area?
  • Ask who pays for a hospitalization for an uninsured patient? How does this make you feel?
  • Ask whether the Affordable Care Act will impact these issues.

Video Learning

Consult Guys logo

The Consult Guys - Surgery With a Prosthetic Valve: What About the Warfarin?

Play this month’s episode of the consultative medicine talk show. The Guys (Howard and Geno) talk about anticoagulation and prosthetic valves. After watching (and chuckling) with your team, quiz yourselves by with the multiple-choice questions. You can enter your answers as well online to claim CME credit.


mksap16

A 30-year-old woman is evaluated during a prenatal visit. She is 18 weeks pregnant, and this is her first pregnancy. She has a history of borderline hypertension, and her blood pressure measurements since conception have been in the range of 120 to 130/80 to 90 mm Hg without antihypertensive therapy. She adheres to a low sodium diet; a dietary assessment shows adequate amounts of dietary calcium. Family history is notable for her mother who had preeclampsia at 37 weeks' gestation. She takes prenatal vitamins.

Urinalysis is negative for protein.

Which of the following interventions may reduce this patient's risk of preeclampsia?

A. Low-dose aspirin
B. Methyldopa
C. Oral calcium supplement
D. Oral magnesium supplement
E. Reduce blood pressure to less than 120/80 mm Hg

Correct Answer
A. Low-dose aspirin

Key Point
Low-dose aspirin (75 to 150 mg/d) is associated with a 10% to 15% relative risk reduction in preventing preeclampsia and reducing adverse maternal and fetal outcomes.

Educational Objective
Prevent preeclampsia.

Low-dose aspirin (75 to 150 mg/d) is associated with a 10% to 15% relative risk reduction in preventing preeclampsia and reducing adverse maternal and fetal outcomes. Preeclampsia is defined as a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg and a 24-hour urine protein excretion greater than 300 mg/24 h after the 20th week of gestation in a woman who did not have hypertension or proteinuria earlier in pregnancy. Clinical manifestations of preeclampsia may include headache, visual disturbances, liver dysfunction, and fetal growth restriction. The HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a variant of preeclampsia. Several factors are associated with an increased risk of preeclampsia, including a personal history of preeclampsia, chronic hypertension, chronic kidney disease, and a family history of preeclampsia. This patient is at risk for preeclampsia because of her family history of preeclampsia, the fact that she is primiparous, and her personal history of borderline hypertension. Currently, only low-dose aspirin has been shown to modestly decrease the risk of preeclampsia, and most experts recommend this agent to women at risk.

Methyldopa is a first-line agent in the treatment of hypertension in the setting of pregnancy but has not been shown to decrease the risk of preeclampsia from chronic hypertension.

Calcium supplements reduce hypertension and preeclampsia modestly only in women consuming a baseline low-calcium diet.

Intravenous magnesium sulfate is used as an anticonvulsant to prevent eclampsia, but oral formulations of magnesium have not been shown to prevent either preeclampsia or eclampsia.

Reducing blood pressure to less than 120/80 mm Hg has not been shown to decrease the risk of preeclampsia. Instead, blood pressure goals are less stringent than those used for nonpregnant persons and are aimed primarily at limiting maternal end-organ damage during this finite period. Specific targets vary somewhat by professional society but generally aim for less than 150/100 mm Hg.

Bibliography
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 125: chronic hypertension in pregnancy. Obstet Gynecol. 2012;119(2 Pt 1):396-407. PMID: 22270315

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


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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