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December 2, 2014 Issue


Clinical Practice Points

Medical Knowledge

Diabetes in Midlife and Cognitive Change Over 20 Years. A Cohort Study

Type 2 diabetes is associated with dementia risk, but whether diabetes and prediabetes are associated with cognitive decline is unclear. This prospective cohort study found that prediabetes, diabetes, and poor diabetic control in midlife were each associated with increased cognitive decline over 20 years.

Use this study to:

  • Ask your learners who is at risk for dementia? How is dementia differentiated from mild cognitive impairment? Use the information in a recent In the Clinic: Dementia to find the answers.
  • Ask if dementia can be prevented by addressing modifiable risk factors, such as physical inactivity, smoking, and obesity.
  • Invite a member of the team at your center that evaluates neurocognitive disorders to demonstrate some of the cognitive tests used in this study (e.g., the delayed word-recall test, the Wechsler Adult Intelligence Scale, and the Word Fluency Test). What is executive function? How is “normal” defined? Have your learners take these tests. What do they tell you? What are their limitations?
  • What advantages does a cohort study have over a cross-sectional evaluation? How do you interpret the results of this study in light of a shorter-duration randomized trial that found no effect of tighter glucose control on cognitive decline? The authors address this issue in their discussion.


Medical Knowledge
Patient Care

Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S. Preventive Services Task Force Recommendation Statement

This updated U.S. Preventive Services Task Force recommendation on aspirin prophylaxis in pregnancy applies to asymptomatic pregnant women who are at increased risk for preeclampsia and have no prior adverse effects with or contraindications to low-dose aspirin. The Task Force recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask how preeclampsia is defined. What is eclampsia? How is preeclampsia diagnosed? Use the information in ACP Smart Medicine: Preeclampsia to help prepare a teaching session.
  • What is the differential diagnosis of hypertension in a pregnant woman?
  • How is preeclampsia treated? What are the potential complications?
  • Review this guideline from the USPSTF. The Task Force recommends the use of aspirin to prevent preeclampsia only in women at high risk. Who is at increased risk? This is reviewed in Table 1 of the guideline. Why not use aspirin in all pregnant women?


Medical Knowledge
Systems-based Practice
In the Clinic:

Hypertension

This concise review covers screening, evaluation, and treatment for hypertension.

Use it to:

  • Review the essential elements of the physical examination in a patient with hypertension. Table 2 provides a guide.
  • When should secondary causes of hypertension be considered, and how should they be evaluated? See Table 3 and accompanying text.
  • How do blood pressure goals differ among patients? Use the Figure to help answer and teach.
  • Break up a teaching session by interspersing the multiple-choice questions provided at the end. After, log on and enter your answers to claim CME credit for yourself.
  • Use the already prepared teaching slides to help prepare your session.

Medicine and Society


Practice Based Learning and Improvement
Systems-based Practice
Patient Care

Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization. A Retrospective Cohort Study

Effect of Clinical and Social Risk Factors on Hospital Profiling for Stroke Readmission. A Cohort Study

Many hospital readmissions are believed to be preventable, and hospitals face penalties if readmission rates are higher than expected. Whether hospitals’ readmission rates should be adjusted according to the socioeconomic factors of the populations they serve is controversial. The first of these studies concluded that living in a disadvantaged neighborhood is a predictor of rehospitalization and that measures of neighborhood disadvantage could be used to inform policy and care after discharge. The second study of patients discharged from VA medical centers after stroke found that adding measures of social risk to a CMS model to assess readmissions did not affect the comparison of the hospitals’ readmission rates.

Use this series of papers to:

  • Ask your learners how patients’ socioeconomic circumstances affect how well they do following an admission to the hospital. Can hospitals adjust their processes and plans for care following discharge to accommodate for these factors? How do your learners consider such issues as they make discharge plans for a patient?
  • The editorialists outline why they believe that quality assessment should reflect how well hospitals care for their patients regardless of financial circumstances. Other authors have recently argued that failing to adjust readmission rates for socioeconomic factors will punish the hospitals who serve disadvantages populations, where resources are already scarce.
  • Do your learners believe that the readmission rates for which a hospital might be penalized should be adjusted according to these factors?

Humanism and Professionalism


Professionalism

On Being a Doctor: This Little Girl Dies Today, in Front of the Americans

Dr. Riggs describes the terrifying experience of encountering a 12-year-old girl with a problem that would be routine in the United States, but deadly where no organized medical care was in reach.

Use this essay to:

  • Listen to a reading by Dr. Michael LaCombe.
  • Ask your learners how they would have reacted to the response to his first request for a medical evacuation.
  • Although it made no difference to the 12-year-old girl (she received the care she needed), does it matter to us the reason why care was provided in response to the second, and not the first, request?
  • This essay powerfully portrays how regions of the world lack care we might take for granted. Do your learners think that patients in the United States face similar situations as this girl in Honduras?

Other resources from the American College of Physicians


HVC

Teach Like a Champion at the Bedside

Chief Residents and Program Directors: mark your calendar and register now for a FREE ACP webinar based on the highly acclaimed workshop at the AAIM meeting – Teach Like a Champion at the Bedside. This 1-hour webinar combines videos of actual patients, learners, and faculty with practical techniques to improve your bedside teaching skills. Join the program on Tuesday, December 9, at 2:00 p.m. ET.


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

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 is 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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