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Annals for Educators - 15 March 2016Annals for Educators - 15 March 2016 FREE

Darren B. Taichman, MD, PhD
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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.


Ann Intern Med. 2016;164(6):ED6. doi:10.7326/AFED201603150
© 2016 American College of Physicians
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Female sex is predictive of adverse prognosis among patients having surgical aortic valve replacement, but whether it is associated with a similarly increased risk among patients having transcatheter aortic valve replacement (TAVR) is uncertain. This analysis of a randomized trial compared postprocedural complications and 1-year all-cause mortality among women and men who had TAVR.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below.

  • Teach at the bedside! Examine a patient with aortic stenosis with your team. What is the quality and timing of the murmur? Do you hear an S4? If so, what does it represent? What is meant by, “pulsus parvus and tardus?” To help prepare for teaching, use the information at DynaMed Plus: Aortic Stenosis (a benefit of your ACP membership).

  • Ask your learners what the clinical manifestations are of aortic stenosis. What is the cause of angina? What does syncope signify?

  • How is the severity of aortic stenosis evaluated, and how should mild disease be followed? What are the indications for intervention? How would your learners choose between surgical aortic valve replacement and TAVR for a patient?

  • In this study, outcomes after TAVR differed between women and men. What are some potential reasons for these differences? Use the editorial to help frame your discussion.

Although financial incentives are common in workplace wellness programs aimed at increasing physical activity, the optimal design of such incentives is not known. This trial evaluated whether providing rewards when step goals were met, as opposed to allocating them up front and then taking them away when goals were not met, resulted in greater activity.

Use this study to:

  • Before reviewing the results of this study with your learners, ask which of the incentive approaches they think would be most effective.

  • Ask if they feel it is ethically appropriate for employers to offer incentives to their employees regarding health-related actions. Is it okay to offer and then take away incentives as was done here?

  • Can your learners think of other ways in which they might use “incentives” to help improve their patients' health-related actions in other areas?

  • Ask you learners to use the step-counter app on their smartphones (or other devices) to record their own activity. Do they achieve the goals set in this study? How often do we encourage our patients to do things we don't do ourselves? Do we adhere to the dietary and exercise guidelines we recommend to our patients? Is it okay to ask patients to do things we don't do ourselves?

The first of this pair of reviews assesses the comparative effectiveness of N-acetylcysteine, sodium bicarbonate, statins, and ascorbic acid to reduce contrast-induced nephropathy in adults. The second analyzes the results from 29 randomized trials that compared the effects of different low-osmolar and iso-osmolar contrast media on the incidence of contrast-induced nephropathy.

Use these reviews to:

  • Ask your learners who is at risk for contrast-induced nephropathy.

  • What is currently done at your institution to reduce the risk of contrast-induced nephropathy? How strong is the evidence in support of your approach? Should you consider alternative means of prevention? If so, which?

  • Given the low strength of available evidence identified in these reviews, how will your learners decide what to do, if anything?

  • Ask your learners if there are clinical circumstances where studies using intravenous contrast are commonly ordered, but might be readily avoided?

Antibiotics are often inappropriately prescribed for patients with acute respiratory tract infection. In this article, the American College of Physicians and the Centers for Disease Control and Prevention present best practice advice for antibiotic use in healthy adults presenting with ARTI.

Use this report to:

  • What are the circumstances in which antibiotics should be considered for the treatment of an acute respiratory tract infection? Review with your learners the 4 high-value care advice statements and the information in Table 1. What are the benefits of antibiotic use for acute bronchitis, pharyngitis, acute rhinosinusitis, and the common cold? What are the harms?

  • When is testing for group A streptococcus appropriate for a patient with acute pharyngitis? What circumstances should prompt consideration of a more severe infection (e.g., an abscess, epiglottitis, or Lemeirre syndrome)?

  • We have all heard many times that antibiotics are inappropriate for most patients with acute respiratory tract infections. Ask your learners why antibiotics continue to be prescribed inappropriately so often.

  • Have your learners role-play the evaluation of patients with acute respiratory tract infections whose history and risk factors indicate that antibiotics are not indicated. How do your learners respond when the patient requests an antibiotic (“But a Z-pack always makes me feel better” or “If I don't get an antibiotic, this always goes down to my chest”)?

The long-term effects of the patient-centered medical home (PCMH) are uncertain. This longitudinal study compared performance on quality-of-care measures and health care utilization for practices using paper records, those using electronic health records (EHRs), and PCMH practices during a 5-year period.

Use this paper to:

  • Ask your learners what a PCMH is. Is your center or practice designated as a PCMH? If so, invite a director to explain to your group how you achieved this status and what it means for the clinicians and patients involved.

  • Check out what the National Committee of Quality Assurance says about PCMH. Do you or your learners feel the definitions are clear? Why do the definitions matter? Read the accompanying editorial to help frame a discussion.

  • What do this paper's results regarding the differences between paper and EHRs indicate? Are your learners surprised by the lack of differences in outcomes between practices using paper and EHRs? What would our learners expect to be different? In the absence of clearly identified changes in patient outcomes, what do your learners think is the motivation for so many institutions to adopt EHRs at high cost? In what way(s) might EHRs have a negative impact on patient care or outcomes?

This story of Stella's surprisingly pleasant first encounter with a new doctor has an unexpected twist.

Use this essay to:

  • Listen to an audio recording read by Dr. Michael LaCombe.

  • Ask your learners whether a new patient might reasonably expect a similar experience at your practice? If not, why not?

  • Can your learners think of ways to make the experience of their patients more like Stella's?

A 68-year-old man is evaluated for a newly diagnosed cardiac murmur. He is active and swims and jogs regularly. Medical history is otherwise unremarkable, and he takes no medications.

On physical examination, he is afebrile, blood pressure is 140/70 mm Hg, pulse rate is 82/min, and respiration rate is 16/min. Cardiac examination reveals a late-peaking systolic murmur located at the right upper sternal border with an audible S2.

Transthoracic echocardiogram shows normal left ventricular systolic function. Aortic valve area is 0.8 cm2. The mean gradient is 44 mm Hg, with a peak gradient of 53 mm Hg.

Which of the following is the most appropriate management?

A. Balloon aortic valvuloplasty

B. Follow-up echocardiography in 6 to 12 months

C. Surgical aortic valve replacement

D. Transcatheter aortic valve replacement

Correct Answer

B. Follow-up echocardiography in 6 to 12 months

Educational Objective

Educational Objective: Manage asymptomatic severe aortic stenosis.

Critique

Although this patient has severe aortic stenosis based on quantitative echocardiographic findings, he is asymptomatic with normal left ventricular (LV) systolic function; therefore, follow-up echocardiography in 6 to 12 months is the most appropriate management. Appropriate follow-up in patients with asymptomatic severe aortic stenosis includes a clinical evaluation and echocardiography every 6 to 12 months. Patients should also be educated to identify and report possible aortic stenosis–related symptoms, such as dyspnea, reduced exercise tolerance, exertional chest pain, lightheadedness, and syncope, before scheduled follow-up.

Balloon valvuloplasty, although important in the treatment of the pediatric patient with severe aortic stenosis, has a more limited role in adults owing primarily to its limited efficacy and the high rate of complications associated with the procedure. Additionally, this patient is asymptomatic, so there is no indication for intervention at present.

Surgical aortic valve replacement is indicated for symptomatic patients with severe aortic stenosis, asymptomatic patients with severe aortic stenosis and LV systolic dysfunction (LV ejection fraction <50%), and patients with severe aortic stenosis who are undergoing coronary artery bypass graft or surgery on the aorta or other heart valves. This patient is asymptomatic with normal LV systolic function, and he does not have any other cardiac procedures planned.

Transcatheter aortic valve replacement (TAVR) is indicated for patients with symptomatic severe aortic stenosis who are considered unsuitable for conventional surgery because of severe comorbidities. Currently, TAVR should not be performed in patients with intermediate or low surgical risk, and no therapeutic intervention is currently indicated in this asymptomatic patient.

Key Point

In patients with asymptomatic severe aortic stenosis, close clinical follow-up with echocardiography every 6 to 12 months is appropriate.

Bibliography

Manning WJ. Asymptomatic aortic stenosis in the elderly: a clinical review. JAMA. 2013 Oct 9;310(14):1490-7.

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Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

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