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September 15, 2015 Issue


Clinical Practice Points

Medical Knowledge
Practice-based Learning / Improvement

Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality. A Population-Based Study

Ankylosing spondylitis (AS) is associated with an increased risk for cardiovascular disease, but few studies have examined its relationship with mortality from cardiovascular or cerebrovascular disease. This study analyzes administrative health data to examine the risk for vascular death among patients with AS compared with patients without the disease.

Use this study to:

  • Start a teaching session with a multiple choice question. We've provided one below!
  • Ask your learners to describe the “typical” presentation of a patient with AS. What are the diagnostic criteria? What testing is required? What other conditions should be considered? Use the information in DynaMedPlus: Ankylosing Spondylitis (log in using your ACP membership).
  • Ask your learners what complications need to be considering in patients with AS (e.g., osteoporosis, neurologic conditions, pulmonary fibrosis).
  • Discuss the design of this retrospective, matched cohort study. What are its limitations? How does the use of an administrative database limit the clinical information available, and why might this matter? How was AS defined in this study, and how might differences in the definition affect the results?
  • How will this study influence your learners' approach to the care of patients with AS?


Patient Care
Systems-based Practice
Interpersonal / Communication Skills
High Value Care

Cost-Effectiveness of Adding Cardiac Resynchronization Therapy to an Implantable Cardioverter-Defibrillator Among Patients With Mild Heart Failure

In this analysis, cardiac resynchronization therapy in addition to an implantable cardioverter-defibrillator (ICD) is found to be cost-effective in patients with mild heart failure.

Use this study to:

  • Start a teaching session with a multiple choice question. We've provided one below.
  • Ask your learners what the indications for an ICD and cardiac resynchronization therapy are. Ask how resynchronization is thought to be helpful.
  • Discuss with your learners the difference between cost and cost-effectiveness. Review how costs, benefits, and harms of an intervention must be assessed to determine value. Must an intervention have a low monetary cost to be cost-effective? Are interventions with low monetary cost necessarily cost-effective? Ask what the incremental cost-effectiveness ratio is. Use a succinct primer to brush up on these concepts.
  • What are the implications of this study for national health care planning? What are the implications for an individual patient?
  • Ask what a quality-adjusted life-year is—and compare the quality-adjusted life-year estimates here with those in the paper discussed below assessing the cost-effectiveness of diabetes prevention strategies.
  • Invite a palliative care physician and an electrophysiologist to discuss the end-of-life considerations for patients with ICDs. Role-play a discussion with a patient considering turning his or her ICD off. How would your learners approach these conversations?


Clinical Guideline: Prevention of Diabetes

Patient Care
Medical Knowledge
Systems-based Practice
High Value Care

Combined Diet and Physical Activity Promotion Programs for Prevention of Diabetes: Community Preventive Services Task Force Recommendation Statement

Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force

Economic Evaluation of Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force

This guideline, the supporting systematic reviews, and cost-effectiveness analysis address combined diet and physical activity promotion programs for adolescents and adults at increased risk for type 2 diabetes. They find that these programs are cost-effective and recommend that health care systems and communities implement them.

Use this study to:

  • Review diet and activity recommendations for adults with risk factors for diabetes. Discuss the challenges that patients face when trying to implement them.
  • Compare the cost per intervention and the savings per quality-adjusted life-year here with those in the ICD article above. How do such studies help policymakers decide how to allocate limited health care resources? How does one get the “biggest bang for the buck” to help patients?
  • Does your institution have any of the recommended promotion components described in the clinical guideline? Review with your learners how they may enroll patients in those services if available.


Patient Care
Practice-based Learning / Improvement
High Value Care

Clinical Guideline: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

This guideline provides recommendations for the appropriateness of placing and continuing intravenous catheters.

Use this guideline to:

  • Review the differences between peripherally inserted central catheters (PICCs), midline catheters, tunneled and nontunneled central catheters, and implanted ports.
  • Ask your learners which of their patients have central catheters of any type. Ask why for each. How long has it been present? Review a recent study that assessed how often clinicians were or were not aware of the presence of such catheters in their patients.
  • Review the recommendations for appropriate and inappropriate use of PICC lines. Are these followed at your institution? Discuss your local practices and how these guidelines should inform them.


Humanism and Professionalism

Professionalism
Patient Care

On Being a Doctor: On Losing Your Humanity

Dr. Stepanyan discusses the need to preserve humanism in the practice of medicine, but explores the idea that humanism manifests itself in many different ways.

Use this essay to:

  • Listen to an audio recording of the essay, read by Michael LaCombe, MD, Associate Editor for On Being a Doctor.
  • Explore what your learners consider “humanistic care” of patients. What challenges are there to preserving it?
  • Dr. Stepanyan fears learning “…how to not care or not feel sad when someone died.” Do your learners share this fear?
  • Ask your learners to each learn something about patients on their service not related to their medical condition. What do they look forward to the most? What's on their “bucket lists”? Do they have partners? How did they meet? How did they end up practicing whatever profession they do? Share these stories on your team's next rounds. Why do they matter?


Video Learning

Medical Knowledge
Consult Guys logo

The Consult Guys: Proceed to Surgery? Are You Kidding Me?

Watch and enjoy this short episode of the consultative medicine talk show, as Howard and Geno (The Consult Guys) ask commonly encountered questions: Should an upper respiratory infection halt a surgery? A urinary tract infection? Use of fish oil? Use the short CME questions provided as a way to quiz your team before watching the video. Log on and enter your answers to claim CME for yourself!



Teaching Tools

Annals Teaching Tools

Did you know that you can search the Annals for Educators Alerts archive for teaching tips? Have a topic you want to cover, and looking for a relevant recent paper and ideas of how to cover it? Go to Annals Teaching Tools collection and use the custom search tool just below the Annals for Educators icon!



mksap17

Question 1

A 30-year-old man is evaluated for a 1-year history of low back pain. The pain frequently spreads to the buttocks but does not radiate to the legs. The pain is worse in the morning and is associated with stiffness but improves 2 hours later after he starts working. Symptoms are worse at the end of the day and during the night. He takes ibuprofen with good relief of the pain. He is otherwise healthy and reports no other joint pain, rash, diarrhea, or dysuria.

On physical examination, vital signs are normal. Eye examination is normal. There is mild pain with normal range of motion in all directions of the lumbar spine. Tenderness over the buttocks is noted. There is no joint swelling or tenderness in the upper or lower extremities. There is no rash or nail pitting.

Laboratory studies are significant for an erythrocyte sedimentation rate of 40 mm/h, and HLA-B27 testing is positive.

Plain radiographs of the lumbar spine and sacroiliac joints are normal.

Which of the following is the most likely diagnosis?

A. Ankylosing spondylitis
B. Lumbar degenerative disk disease
C. Psoriatic arthritis
D. Reactive arthritis

Correct Answer
A. Ankylosing spondylitis

Key Point
Ankylosing spondylitis is characterized by inflammatory back pain that manifests as pain and stiffness in the spine that is worse after immobility and better with use.

Educational Objective
Educational Objective: Diagnose ankylosing spondylitis.

The most likely diagnosis is ankylosing spondylitis, which is characterized by inflammatory back pain that manifests as pain and stiffness in the spine that is worse after immobility and better with use. Symptoms are prominent in the morning (>1 hour), and patients can be symptomatic during the night. Buttock pain is common and correlates with sacroiliitis, which is typically bilateral. This patient has symptoms/signs consistent with ankylosing spondylitis, including more than 3 months of inflammatory back pain of primarily axial involvement, age of onset younger than 45 years, a positive HLA-B27, and a good response to an NSAID. The lack of sacroiliitis or other inflammatory changes on his radiographs does not rule out this diagnosis; these changes may not be evident early in the disease course and may not be seen on plain radiographs if there are no bone erosions. He fulfills the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial spondyloarthritis because he has a positive HLA-B27 plus at least two other features of spondyloarthritis, including inflammatory back pain and a good response to NSAIDs. The ASAS classification criteria use a nomenclature that defines spondyloarthritis as axial or peripheral, and ankylosing spondylitis would be the prototype disease in the spectrum of axial spondyloarthritis. These criteria allow patients who have not yet developed radiographic sacroiliitis to be classified as having “non-radiographic” axial spondyloarthritis.

Distinguishing between inflammatory and noninflammatory joint pain is critical in evaluating patients with musculoskeletal conditions. Inflammation may be the only symptom that distinguishes ankylosing spondylitis from lumbar degenerative disk disease. Subjective manifestations of joint inflammation include morning stiffness for more than 1 hour. Lumbar degenerative disk disease is not likely in this patient because his radiographs are normal and he has inflammatory back pain.

Characteristic features of psoriatic arthritis include enthesitis, dactylitis, tenosynovitis, arthritis of the distal interphalangeal joints, asymmetric oligoarthritis, and spondylitis. The HLA-B27 antigen may be positive in patients with axial involvement. Psoriatic arthritis involving only the axial skeleton is possible in this patient but less likely because he has no evidence of psoriasis.

Reactive arthritis (formerly known as Reiter syndrome) is a postinfectious arthritis that occurs in both men and women. Infections may include urethritis or diarrhea, although patients may be asymptomatic. Arthritis, usually oligoarticular, develops several days to weeks after the infection. The HLA-B27 antigen may be positive in these patients. Reactive arthritis is also less likely as this patient has no history of a gastrointestinal or genitourinary infection preceding the onset of arthritis.

Bibliography
Rudwaleit M, van der Heijde D, Landewé R, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011 Jan;70(1):25-31. PMID: 21109520

This question was derived from MKSAP® 17, the latest edition of the Medical Knowledge Self-Assessment Program.



Question 2

A 55-year-old man with a 6-month history of heart failure is evaluated during a follow-up appointment. At diagnosis, his left ventricular ejection fraction was 15%, and he had moderate mitral and tricuspid regurgitation. Cardiac catheterization at that time revealed normal coronary arteries. He was started on the appropriate medications and is now back to working at a desk job. He has dyspnea walking up a flight of stairs. Medical history is also significant for hypertension. Medications are enalapril, carvedilol (25 mg twice daily), furosemide, and spironolactone.

On physical examination, blood pressure is 100/65 mm Hg, and pulse rate is 56/min. Weight is 72 kg (159 lb). On cardiovascular examination, there is a grade 3/6 holosystolic murmur at the apex radiating to axilla and no S3 gallop. The remainder of the examination is normal.

Serum electrolyte levels and kidney function tests are normal. Recent echocardiogram shows a left ventricular ejection fraction of 20% and moderate mitral regurgitation. Electrocardiogram demonstrates normal sinus rhythm with a QRS width of 100 ms.

Which of the following is the most appropriate management?

A. Add an angiotensin receptor blocker
B. Implantable cardioverter-defibrillator placement
C. Increase carvedilol to 37.5 mg twice daily
D. Mitral valve replacement

Correct Answer
B. Implantable cardioverter-defibrillator placement

Key Point
Implantable cardioverter-defibrillator placement is indicated for patients with heart failure and a left ventricular ejection fraction less than or equal to 35% and New York Heart Association functional class II or III heart failure while on optimal medical therapy.

Educational Objective
Educational Objective: Manage risk of sudden cardiac death in a patient with heart failure with placement of an implantable cardioverter-defibrillator.

This patient with heart failure and a low left ventricular ejection fraction should be referred for placement of an implantable cardioverter-defibrillator (ICD). For patients with an ejection fraction less than or equal to 35% and New York Heart Association (NYHA) functional class II or III heart failure on optimal medical therapy, placement of an ICD is a class I indication. Patients with new-onset heart failure should not undergo placement of an ICD because ventricular function often recovers to above 35%. This patient, however, is on appropriate medical therapy, has had heart failure for at least 6 months, and is still symptomatic. For patients with NYHA functional class IV heart failure symptoms, an ICD is not warranted unless the patient is a cardiac transplant candidate.

Cardiac resynchronization therapy (CRT) with a biventricular pacemaker to improve hemodynamic function of the heart may also be considered in patients with persistent heart failure but is reserved for patients with evidence of conduction system disease. The 2013 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS) guideline recommends CRT in patients with an ejection fraction of 35% or below, NYHA functional class III to IV symptoms on guideline-directed medical therapy, and left bundle branch block with QRS duration greater than or equal to 150 ms. With a QRS width of 100 ms, this patient is not a candidate for a biventricular pacemaker in addition to an ICD.

Adding an angiotensin receptor blocker to a heart failure regimen that already includes an ACE inhibitor would not be indicated in this patient as it would not provide additional benefit, and this medication combination has been shown to increase risk of hyperkalemia and kidney injury.

Because this patient's heart rate is 56/min, indicating adequate β-blockade, and his blood pressure is at a desired level, no benefit would be expected by increasing his dose of carvedilol.

Indications for mitral valve replacement, an invasive procedure that carries risks, include the presence of severe mitral regurgitation and NYHA class III or IV symptoms attributed to the valve disease. None of these are present in this patient. This patient's mitral regurgitation is “functional,” meaning it is more likely to be a result of his dilated cardiomyopathy and not the underlying cause.

Bibliography
Bardy GH, Lee KL, Mark DB, et al; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005 Jan 20;352(3):225-37. Erratum in: N Engl J Med. 2005 May 19;352(20):2146. PMID: 15659722

This question was derived from MKSAP® 17, the latest edition of 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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