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September 16, 2014 Issue


Clinical Practice Points


Practice Based Learning and Improvement
Medical Knowledge

Quality-of-Life Outcomes With Coronary Bypass Graft Surgery in Ischemic Left Ventricular Dysfunction. A Randomized Trial

This trial found that coronary artery bypass grafting (CABG) plus guideline-based medical therapy resulted in clinically important improvements in several health status domains compared with medical therapy alone. The trial evaluated patients with ischemic left ventricular dysfunction, a group not represented in earlier clinical trials.

Use this article to:

  • Review recommendations for the medical therapy of patients with CAD. Use a recent concise clinical review to structure your discussion. There are teaching slides to assist in preparing a session.
  • Ask your learners which patients need surgery or PCI in the setting of CAD. Use the figure in the review noted above to help answer this question. How should the results of this study alter thinking about interventions for their patients with CAD?
  • Ask how you define “health-related quality of life.” Look at the questions asked in a QOL tool (e.g, the SF-36). If the answer to each is “important,” how do researchers establish what is a “clinically important” change in a QOL tool? What is the difference between a statistically significant and a clinically significant change in a clinical trial? Why must we always note the difference when evaluating the results of a study?
  • Use the multiple-choice questions at the end of the review to help break up and structure a teaching session.


Patient Care
HVC

Comparative Effectiveness of Generic and Brand-Name Statins on Patient Outcomes.
A Cohort Study

Despite statins being the most frequently prescribed drugs in the United States, patients do not fully adhere to statin therapy. This study of Medicare beneficiaries suggests that initiation of a generic statin was associated with lower out-of-pocket costs, improved adherence to therapy, and improved clinical outcomes.

Use this study to:

  • Ask your learners whether there are differences between brand-name and generic drugs. Is there a difference in efficacy or manufacturing standards? Use information at the FDA Web site as a resource.
  • If we know that generic drugs work as well as brand-name drugs, cost less, and may improve adherence to therapy, why aren’t they used more often? What are the barriers to their use? Use the accompanying editorial to help frame your discussion.
  • Ask your learners if their patients have ever requested they write “brand-name necessary” on their prescriptions. What do they do? What should they do? How should they discuss this with a patient? Is there time for such discussions?


Medical Knowledge
Patient Care
Systems-based Practice

Treatment of Latent Tuberculosis Infection. A Network Meta-analysis.

This analysis of data from 53 trials addresses the benefits and harms of 15 regimens aimed at preventing active tuberculosis in patients with latent infection. Therapies containing rifamycin, given for 3 months or more, were reasonably well-tolerated and efficacious. Such regimens containing rifamycin may be effective alternatives to isoniazid monotherapy.

Use this study to:

  • Review treatment guidelines for diagnosis and treatment of latent TB.
  • What are the public health considerations for patients with suspected TB? What kind of isolation does a hospitalized patient require? Who helps track the contacts of known cases? When is a patient no longer considered infectious? Invite a local health department representative to join your discussion.
  • Use the accompanying editorial to guide a discussion of the tensions between efficacy and tolerability of treatment strategies, as well as adherence.

Clinical Guideline


Medical Knowledge
Patient Care

Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians

This guideline on the nonsurgical management of urinary incontinence (UI) recommends pelvic floor muscle training in women with stress UI, bladder training in women with urgency UI, and both in women with mixed UI. It also recommends against systemic pharmacologic therapy for stress UI but recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful.

Use this guideline to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners what are the different types of urinary incontinence. Use ACP Smart Medicine – Urinary Incontinence in Women to review how each presents and how they are diagnosed.
  • Discuss the pharmacologic treatment of incontinence. Ask what pelvic floor muscle training involves. Invite a gynecologist or urologist to participate in the session: How do you teach these exercises to patients? What benefits may be expected?
  • Ask if patients should be screened for urinary incontinence?

Video Learning


Medical Knowledge

Consult Guys logo

The Consult Guys: Clean Coronaries—But a Broken Heart

They’re back! Geno and Howard, the Consult Sages, solve another clinical stumper. Can your team get the correct answer before Howard does?

Use this video to:

  • Take a break from a more “typical” learning session, and start by watching this fun video.
  • Pause the video after Geno describes the case and Howard reviews the electrocardiogram and the angiographic images. Can your team get the right answer before Howard explains it?
  • Log on and answer the quick multiple-choice questions to get CME for yourself!



Humanism and Professionalism


Professionalism
Patient Care
Interpersonal and Communication Skills

On Being a Doctor: The Other Side

Dr. Genao describes the jarring experience of finding herself on the “other” side of care, as she anxiously awaits answers from the physicians caring for her hospitalized mother.

Use this essay to:

  • Play an audio recording of this essay, read by Annals Associate Editor for the On Being a Doctor series, Dr. Michael LaCombe.
  • Ask your learners if they have ever been “on the other side” of health care. What did they experience? Were they bothered by anything that they realize they do themselves? Did they find themselves noting whether each person entering the room cleansed his or her hands? Did they pay newly focused attention to a clinician’s bedside manner?
  • How can Dr. Genao’s comments help us to improve our care of patients?

Other Teaching Resources From ACP


Professionalism
Patient Care
HVC

Online High Value Care Cases

These free online teaching resources will assist you in preparing sessions covering core topics in internal medicine. The cases and questions emphasize essential issues in providing high-value care to our patients, including weighing the benefits, harms, and costs of tests and treatment options for common conditions.

Use these resources to teach your learners to:

  • Avoid unnecessary testing
  • Use emergency and hospital-level care judiciously
  • Improve outcomes with health promotion and disease prevention
  • Prescribe medications safely and cost-effectively
  • Overcome barriers to high-value care
  • Get free CME and ABIM MOC credit for yourself!

mksap16

A 69-year-old woman is evaluated for involuntary leakage of urine with coughing, sneezing, laughing, or when lifting heavy boxes at work. She has no dysuria, frequency, or urgency and she has no mobility problems. She is gravida 4, para 4, and underwent a total abdominal hysterectomy 20 years ago for uterine fibroids. She has type 2 diabetes mellitus. Medications are metformin and lisinopril. She has no known drug allergies.

On physical examination, vital signs are normal. BMI is 31. There is bulging of the anterior vaginal wall when the patient is asked to cough, accompanied by leakage of urine. Bimanual examination is unremarkable. The remainder of her examination is normal.

Laboratory studies show fasting plasma glucose level of 89 mg/dL (5.0 mmol/L) with hemoglobin A1c of 6.5%. Urinalysis is normal.

Which of the following is the most appropriate treatment?

A. Pelvic floor muscle training
B. Prompted voiding
C. Pubovaginal sling
D. Tolterodine

Correct Answer
A. Pelvic floor muscle training

Key Point
Pelvic floor muscle training is first-line treatment for stress urinary incontinence.

Educational Objective
Treat stress urinary incontinence.

This patient has stress urinary incontinence and should receive pelvic floor muscle training (PFMT). Stress urinary incontinence, defined as loss of urine with physical activity, cough, or sneeze, is caused by sphincter incompetence. Findings on physical examination include weakened anterior or posterior vaginal wall support (cystocele or rectocele, respectively). PFMT is considered first-line therapy for urinary stress incontinence. In PFMT, women learn repetitive exercises (Kegel exercises) to strengthen the voluntary urethral sphincter and levator ani muscles. For PFMT to be effective, it is important that the patient learn to correctly contract her muscles without straining, which increases abdominal pressure. Each contraction is held for approximately 10 seconds, followed by an equal relaxation period. The number of repetitions should be increased weekly until the patient is performing 8 to 12 repetitions three times daily, every day or at least 3 to 4 days per week. In a systematic review of nonsurgical therapy, PFMT improved stress urinary incontinence episodes. Outcomes were even better when PFMT was combined with biofeedback and when skilled therapists directed the treatment.

Prompted voiding is indicated in and is effective in patients with significant mobility or cognitive impairments that may hinder the patient's ability to reach the toilet in time, neither of which this patient has.

Sling procedures are effective for moderate to severe stress incontinence, but surgery is usually reserved for patients who do not benefit from more conservative approaches, including behavioral or appropriate pharmacologic therapy.

Tolterodine, a selective antimuscarinic anticholinergic medication, is most effective for patients with urge, rather than stress, incontinence. This patient does not experience the classic sense of urinary urgency with her incontinence episodes, and, therefore, tolterodine would not be an appropriate first choice.

Bibliography
Shamliyna TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459-473. PMID: 18268288

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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