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November 3, 2015 Issue


Clinical Practice Points

Medical Knowledge
Patient Care

Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain. A Randomized Trial

Patients with chronic neck pain often use complementary health care strategies, such as acupuncture or the Alexander Technique, for treatment of their symptoms. In this randomized, controlled trial, the long-term clinical effectiveness of acupuncture or the Alexander Technique was compared with usual care for patients with chronic neck pain.

Use this study to:

  • Ask your learners what history and physical examination are appropriate when a patient complains of neck pain.
  • What is the differential diagnosis of chronic neck pain? When is testing appropriate, and what kind?
  • Ask your learners if they recommend “alternative” therapies (e.g., acupuncture, chiropractic manipulation) for their patients with musculoskeletal complaints. Why or why not? How do they know what does or does not work? Are there potential harms?
  • Review the description of the Alexander Technique and the intervention used in this trial presented in the article's Appendix. Ask your learners what the challenges are in interpreting the results from educational and behavioral interventions. What might affect the generalizability of the results?


Medical Knowledge

Effects on Clinical Outcomes of Adding Dipeptidyl Peptidase-4 Inhibitors Versus Sulfonylureas to Metformin Therapy in Patients With Type 2 Diabetes Mellitus

In this study of add-on treatments to metformin, the addition of dipeptidyl peptidase-4 (DPP-4) inhibitors was associated with a lower risk for all-cause mortality, stroke, and hypoglycemia compared with use of sulfonylureas. In contrast to prior studies, there was no increased risk for myocardial infarction or hospitalization for heart failure with DPP-4 inhibitor use.

Use this study to:

  • Review the classes of drugs used for the treatment of type 2 diabetes mellitus. How does each work? Use the information and tables in In the Clinic: Type 2 Diabetes.
  • Ask your learners if they have prescribed DPP-4 inhibitors. What are the benefits and potential harms? Are they reassured by this study regarding cardiovascular risks?
  • Read the accompanying editorial, pointing out that with 6 drug classes to treat diabetes, there are 30 possible 2-agent combinations and 120 possible 3-agent combinations. In the absence of evidence for each, how do we choose among these combinations when more than one drug is needed? What variables do your learners consider when individualizing care?
  • Ask why the lack of information regarding the patients' hemoglobin A1c levels is important. The editorialist discusses this issue.
  • This study used a propensity score to “adjust” for differences between the patients included in the study. Invite an expert in epidemiology and/or biostatistics to review what such an approach can and cannot do. Use a short essay that discusses the potential utility and pitfalls of propensity score adjustments to help frame your discussion. Consider combining this with the study below assessing outcomes with emergency medical transport to create a teaching session about the importance of potential confounders.


Clinical Guideline

Medical Knowledge
Interpersonal / Communication Skills
Professionalism

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

Testing patients with suspected acute pulmonary embolism has risen drastically. However, overuse of some tests may not improve care and may lead to patient harm and unnecessary expense. This Best Practice Advice report from the American College of Physicians presents an evidence-based and high-value diagnostic strategy for the diagnosis of pulmonary embolism.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below!
  • Ask your learners why they think diagnostic tests are overused in the evaluation of patients with possible venous thromboembolism.
  • Ask why assessing a clinical suspicion (“pretest probability”) matters. How does it help in choosing, and interpreting, diagnostic tests?
  • Present the history and examination of a few patients seen recently in the emergency department in whom the possibility of pulmonary embolism was raised. Have your learners discuss their pretest clinical suspicion for pulmonary embolism in each. Use clinical decision tools (e.g., Wells, PERC) to ensure your learners know how. Discuss whether each patient requires testing, and if so, which would be best.
  • Ask in whom a D-dimer is a valuable test? In whom is it a waste?


In the Clinic

Medical Knowledge

Restless Leg Syndrome

This eminently practical review discusses the evaluation, diagnosis, and treatment of restless leg syndrome, which is estimated to affect between 2% to 4% of adults in the general population.

Use this review to:

  • Use the multiple-choice questions provided to start a teaching session and to introduce topics along the way.
  • Download the already-prepared teaching slides to assist in preparing and running a teaching session.
  • Ask if your learners inquire about symptoms suggestive of restless leg syndrome when patients report insomnia. Review what the history should include.
  • Review the diagnostic criteria presented in the box. Ask what evaluation should be performed.
  • Ask what treatments are available and how to choose among them. How should patients be monitored?
  • Be sure to log on and enter your answers to the multiple-choice questions to earn CME for yourself!


Methods in Health Care Research

Systems-based Practice
Medical Knowledge

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies

Although advanced life support (ALS) is used preferentially for emergency medical transportation, whether outcomes are better than with basic life support (BLS) is not known. To compare short- and long-term survival rates and neurologic functioning, the authors assessed outcomes among patients transported emergently for any of several common diagnoses by ALS and BLS ambulances.

Use this study to:

  • Ask your learners if they know the differences between the services provided by BLS and ALS responders.
  • Look at Table 1, and compare the characteristics of the patients to whom BLS and ALS emergency services were sent for each condition (e.g., number of comorbidities, race). Before looking at the study results, ask your learners which group they predict would have worse outcomes. Do the results indicating better outcomes with BLS surprise your learners?
  • Ask your learners to define a confounder. What potential confounders would they consider when comparing the outcomes of patients receiving BLS or ALS? What are the potential patient-level confounders? Are there potential societal/health system confounders? The authors and editorialists discuss these and their importance. Invite an expert in epidemiology and/or biostatistics to discuss these and the 2 approaches the authors of this study took to address them.
  • Discuss what a propensity score does (consider using also the diabetes study above), and what an instrumental variable analysis does. In this study, which analysis aims to control for patient-level factors and which for “system-level” factors?
  • Do your learners think this study should alter how our society delivers emergency medical transport services? The editorialists offer their opinions.


Humanism and Professionalism

Patient Care
Interpersonal / Communication Skills
Professionalism

Annals Graphic Medicine: The Daily Grind: A Day in the Life of Someone Living With Diabetes

Annals Graphic Medicine

This Annals Graphic Medicine video illustrates the challenges, failures, and successes of a patient trying to manage his diabetes.

Use this Annals Graphic Medicine to:

  • Watch the video with your learners.
  • Ask if they got bored or impatient. Why? Might the authors have intended that to happen?
  • Ask your learners if they grow impatient with patients who are not compliant with your recommendations for management of their diabetes. Does watching this video alter their thinking?


Professionalism

On Being a Patient: Through My Eyes

Hannah Breit tells us about how, as a medical student, her mirrored reflection changed upon hearing she had cancer, and how it has since returned.

Use this essay to:

  • Listen to an audio recording of this powerful essay, read by Dr. Michael LaCombe.
  • Ask your learners what they think their response would have been to such news.
  • What was their reaction to hearing about the wait to see a surgeon? Shocked? Appalled? Was it surprising?
  • Have your learners ever considered how the well-intentioned outreach by others to patients with an illness might be a source of well-appreciated support, but also a burden?
  • How can such an essay make us better doctors? Better people?


mksap16

A 56-year-old woman is evaluated in the emergency department for a 4-hour history of nonproductive cough and shortness of breath. She does not have chest pain, hemoptysis, or other localizing signs. She underwent laparoscopic cholecystectomy under general anesthesia 6 weeks ago. Her medical history is notable for a childhood history of asthma, but she has not had asthma symptoms as an adult. Her sister and daughter both have asthma. She currently takes no medications.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 140/86 mm Hg in both arms, pulse rate is 72/min and regular, and respiration rate is 18/min; BMI is 33. Mild injection of the pharynx is noted. Cardiac examination is normal. Pulmonary examination reveals rare scattered wheezes bilaterally over the chest with no tenderness to palpation. Surgical incisions are healing well. The abdomen is minimally tender, and bowel sounds are normal. There is no swelling or tenderness of the legs.

Laboratory studies reveal a D-dimer level of less than 0.5 µg/mL (0.5 mg/L) and a leukocyte count of 4,900/µL (4.9 × 109/L). Pulse oximetry is 93% breathing ambient air. Electrocardiogram and chest radiograph are normal.

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

A. Abdominal CT
B. CT angiography
C. Duplex ultrasonography of the legs
D. Peak flow measurement

Correct Answer
D. Peak flow measurement

Key Point
In clinically stable patients with a low pretest probability of pulmonary embolism using the Wells or Revised Geneva scores, a normal D-dimer assay effectively excludes an acute thrombotic process and eliminates the need for further testing.

Educational Objective
Exclude pulmonary embolism with a D-dimer test in a low-risk patient.

The most appropriate next step in management is measurement of peak flow. This patient has a strong family history of asthma and a remote personal history of asthma. She has wheezing and pharyngeal injection on examination, which could reflect a viral respiratory infection or reflux triggering bronchospasm as the cause of her dyspnea. Thus, assessment for airflow obstruction is appropriate. Despite a history of recent surgery and symptoms of acute onset of dyspnea, this patient's pulmonary embolism (PE) risk score determined by either the Wells or Revised Geneva scoring systems suggests a low probability of PE. Immunologic D-dimer assays are particularly sensitive for detecting the presence of intravascular thrombosis. In this patient with a low PE risk score, the normal D-dimer level effectively excludes PE; therefore, further testing for PE, either by CT angiography or by duplex ultrasound of the legs (to identify deep venous thrombosis as a source for PE), is not indicated.

Although abdominal surgery (particularly an open procedure) is associated with an increased risk for perioperative pulmonary complications, there is no suggestion by history or physical examination of an ongoing abdominal process as a cause of this patient's respiratory symptoms that would indicate the need for abdominal imaging.

Bibliography
Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest. 2011;140(2):509-518. PMID: 21813530

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, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University.

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