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August 19, 2014 Issue


Clinical Practice Points


Medical Knowledge
Patient Care
Systems-based Practice

Longevity of Patients With Cystic Fibrosis in 2000 to 2010 and Beyond: Survival Analysis of the Cystic Fibrosis Foundation Patient Registry

This study found that survival of patients with cystic fibrosis (CF) has continued to improve, and that infants born and diagnosed in 2010 can expect to live into their 30s if survival remains steady or their 50s if improvements in survival continue at the same rate.

Use this study to:

  • Ask a colleague in pulmonary medicine if she or he has diagnosed CF in an adult. If so, present this patient as a “new encounter” and ask your learners to generate a differential diagnosis. What tests would be appropriate? Review the radiographs and pulmonary function test results.
  • If you cannot identify a “case,” start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners to list causes of obstructive lung disease as well as causes of bronchiectasis in adults. What are the distinguishing features in each?
  • Review with your readers the pulmonary and extra-pulmonary complications of cystic fibrosis. Use ACP Smart Medicine – Cystic Fibrosis to help prepare.
  • Read the accompanying editorial and ask your learners what role internists should play in the care of adults with CF. Can appropriate care be provided outside the current CF care center model? If not, how can such care be paid for?


Medical Knowledge
Practice Based Learning and Improvement

Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Other Adverse Outcomes in Older Adults: A Population-based Cohort Study

This retrospective cohort study found an increased risk for hospitalization with acute kidney injury (AKI) as well as hypotension, acute urinary retention, or death in older adults who had been prescribed an atypical antipsychotic drug within the previous 90 days.

Use this article to:

  • Review indications for use of atypical antipsychotic medication, and their known complications. Use the information in the Bipolar Disorder and Schizophrenia modules of ACP Smart Medicine.
  • Focus a teaching session on study design, here a retrospective cohort study. Ask your learners how the authors identified those with the exposure of interest (drug) and the outcome (AKI). Would this approach capture all patients exposed, and all those with AKI? How might failure to identify exposures or outcomes have influenced the results? What might be sources of residual confounding? The authors discuss these on the last page. Why is it important to control for site-level effects (i.e., whether patients at certain locations were exposed or identified with AKI differently)?


Medical Knowledge
Patient Care
High Value Care

Screening for Hepatocellular Carcinoma in Chronic Liver Disease: A Systematic Review

Some professional societies recommend routine screening for hepatocellular carcinoma (HCC) in individuals at high risk. This review of available evidence concluded that it is unclear whether screening in patients with chronic liver disease leads to a survival advantage.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provide one below.
  • Review the pathophysiology, epidemiology, diagnosis, and treatment of HCC.
  • Discuss with your learners how they will apply this article to their practice. Will they change their screening approach in patients with chronic liver disease? Use the accompanying editorial to help frame your discussion.

Clinical Guideline


Medical Knowledge
High Value Care

Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement

The Task Force recommends 1-time screening with ultrasonography in men aged 65 to 75 years who have ever smoked, selectively offering screening in men aged 65 to 75 years who have never smoked, and no routine screening in women who have never smoked. There is insufficient evidence regarding whether to screen women aged 65 to 75 who ever smoked.

Use this guideline to:

  • Review the epidemiology and risk of rupture of an AAA at various aortic diameters.
  • Ask your learners what the differential diagnosis is of each a pulsatile abdominal mass and a ruptured aortic aneurysm. Use the table (and other information) in ACP Smart Medicine – AAA.
  • Use the multiple-choice questions provided for teaching, and sign on to submit your answers to earn CME for yourself!

The Business of Medicine


Systems-based Practice
Professionalism

Medicare and Physician Payment Data: Is This Transparency?

The Medicare Data Release Conundrum

These papers discuss the recently released Medicare payment data, which showed individual physician’s payments from Medicare.

Use these papers to:

  • Ask if your learners know how Medicare is designed. What do the different parts (A–D) pay for? Use www.cms.gov as a resource about Medicare.
  • Ask your learners to interpret the report on a specific physician. What information can be drawn from this publicly available payment data?
  • Is the release of information like this useful? To whom? Will it enhance patient care? Save money?
  • Ask what the limitations are to these data released by Medicare. How might these limitations lead to erroneous conclusions about a physician's practice or behavior?

Video Learning


Medical Knowledge

Consult Guys logo

Consult Guys: Is That Hemoglobin High Enough?

Watch the medical consult talk show. In this episode, the Consult Sages discuss “thresholds” for blood transfusion.

Use this video to:

  • Ask your learners at what hemoglobin level they begin to consider transfusion even in the absence of a concern for active bleeding.
  • What are the benefits of transfusion?
  • What are the risks and harms?
  • Answer the multiple-choice questions together at the end. Sign on and enter your answers for more CME credit.

Humanism and Professionalism


Professionalism
Systems-based Practice

On Being a Doctor: Inside Special Care

In his essay, Dr. Benson describes working in a Special Care unit of an emergency department where intoxicated patients are evaluated. He recalls an encounter with a particular patient and wrestles with the challenges of treating homeless patients with chronic alcoholism.

Use this paper to:

  • Play an audio recording of the essay, read by Annals editor for On Being a Doctor pieces, Dr. Michael LaCombe.
  • Discuss your learners’ experiences with patients who are homeless. What resources are available? Are you ethically or legally required to try to arrange treatment for this patient’s alcoholism? What if it had been a cold night and he did not have a place to go? What can or should you do?
  • Invite a social worker to discuss what options are available. Invite an expert in alcoholism to discuss what the best options are for treatment of such patients.

mksap16

Question 1

A 19-year-old man is evaluated during a routine examination. He has a history of episodes of bronchitis since early childhood; symptoms include productive cough, wheezing, and shortness of breath. He is being treated for asthma, but his symptoms have not been well controlled. His current medications are a medium-dose inhaled corticosteroid and a long-acting β2-agonist, with documented satisfactory inhaler technique.

On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 110/65 mm Hg, pulse rate is 82/min, and respiration rate is 18/min; BMI is 20. Small nasal polyps are noted. Pulmonary examination reveals diffuse rhonchi and scattered wheezing. The neck veins are flat. Cardiac examination reveals a normal S1 and S2 with a soft grade 1/6 systolic murmur. Clubbing is noted. There is no pedal edema, and pulses are intact and symmetric. Oxygen saturation breathing ambient air is 93%.

Laboratory studies reveal a hemoglobin level of 11 g/dL (110 g/L) and a leukocyte count of 9800/μL (9.8 × 109/L). Chest radiograph shows increased bronchial markings consistent with bronchiectasis in the upper lung zones.

Which of the following is the most appropriate next step in management?

A. Measure sweat chloride
B. Perform bronchoscopy
C. Perform echocardiography
D. Record symptoms and medication use over 2 weeks

Correct Answer
A. Measure sweat chloride

Key Point
Delayed diagnosis can occur in patients with a mild form of cystic fibrosis; these patients are often misdiagnosed as having asthma when symptoms are limited to the respiratory tract.

Educational Objective
Evaluate for cystic fibrosis in a patient whose disease mimics asthma.

The most appropriate management is measurement of sweat chloride. This young man has been diagnosed with asthma, but he is more likely to have cystic fibrosis based on his symptoms and the presence of clubbing and upper-lobe bronchiectasis. The diagnosis should be confirmed with measurement of sweat chloride, which is elevated (greater than 60 meq/L [60 mmol/L]) in patients with cystic fibrosis. Genetic testing for cystic fibrosis is recommended for patients who have positive sweat chloride tests and helps support the diagnosis. Most cases of cystic fibrosis are diagnosed during childhood; however, delayed diagnosis can occur in patients with a mild form of cystic fibrosis, who are often misdiagnosed as having asthma when the symptoms are limited to the respiratory tract.

Diagnostic bronchoscopy can be helpful in patients with regional bronchiectasis to exclude proximal airway obstruction. However, in this patient bronchoscopy is unlikely to lead to additional information, and it is a more invasive test than the measurement of sweat chloride.

Echocardiography is helpful in evaluating patients with clubbing suspected of having congenital heart disease; however, this patient has no other stigmata to suggest congenital heart disease, such as a loud pathologic murmur, asymmetric pulses, evidence of heart failure, or cyanosis.

Keeping a home diary of asthma symptoms and/or peak expiratory flow rate can be helpful to assess asthma control; however, in this patient with good inhaler technique, the persistence of symptoms is not likely to be related to asthma. In addition, uncontrolled asthma cannot explain the presence of bronchiectasis and clubbing in this patient.

Bibliography
National Asthma Education and Prevention Program. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. Accessed July 27, 2012.


Question 2

A 55-year-old man is evaluated during a routine follow-up visit for compensated cirrhosis. He is currently asymptomatic. His medical history is significant for chronic hepatitis B infection and esophageal varices. He currently takes nadolol.

On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 120/70 mm Hg, pulse rate is 68/min, and respiration rate is 16/min. BMI is 31. Spider angiomata are noted on the neck and upper chest. The spleen tip is palpable.

Screening abdominal ultrasound discloses a nodular-appearing liver, splenomegaly, and intra-abdominal venous collaterals consistent with portal hypertension. A 1.6-cm lesion is noted in the right hepatic lobe; the lesion was not present in an ultrasound done 6 months ago.

Which of the following is the most appropriate diagnostic test to perform next?

A. Contrast-enhanced CT
B. Liver biopsy
C. Repeat ultrasound in 6 months
D. Serum carcinoembryonic antigen level

Correct Answer
A. Contrast-enhanced CT

Key Point
In patients with chronic hepatitis B infection or cirrhosis and a positive screening abdominal ultrasound for hepatocellular carcinoma, triple-phase CT or gadolinium MRI is the most appropriate next diagnostic test.

Educational Objective
Diagnose hepatocellular carcinoma.

The most appropriate next diagnostic test is a contrast-enhanced abdominal CT. Hepatocellular carcinoma (HCC) usually develops in patients with advanced chronic liver disease; however, patients with hepatitis B may develop HCC in the absence of advanced liver disease. HCCs derive their blood supply through neovascularization, whereby the cancer develops a new blood supply fed through small branches of the hepatic artery. It is this characteristic vascular supply that helps identify potential cancers on contrast-enhanced imaging, such as triple-phase CT and gadolinium MRI. Although these modalities tend to be better at identifying HCC than ultrasonography, the current screening guidelines for HCC recommend ultrasonography every 6 to 12 months.

The diagnosis of HCC can be made using noninvasive radiologic criteria in patients with cirrhosis. Multiple studies have documented the high sensitivity and specificity of CT and MRI for HCC in patients with cirrhosis with lesions 2 cm or larger in diameter. If CT and MRI radiologic criteria are typical of HCC, a biopsy is not necessary and the lesion should be treated as HCC.

Repeat ultrasound at 6 months is within the recommended surveillance interval of 6 to 12 months for patients with no liver masses on a previous ultrasound; it is not the correct diagnostic test in a patient with a liver lesion that is between 1 and 2 cm.

Serum carcinoembryonic antigen (CEA) levels are not clinically useful in the diagnosis of HCC.

Bibliography
Forner A, Vilana R, Ayuso C, et al. Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma [erratum in Hepatology. 2008;47(2):769.]. Hepatology. 2008;47(1):97-104. PMID: 18069697

These questions were 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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