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April 21, 2015 Issue

Clinical Practice Points

Patient Care

Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United States

More than 40% of adults aged 75 years or older use statins, but there is little evidence to guide their use for primary prevention in this population. This study found that the use of statins in adults aged 75 years or older was cost-effective for primary prevention but that even a small increase in geriatric-specific adverse effects could offset the cardiovascular benefit.

Use this study to:

  • Review current guidelines addressing stable ischemic heart disease and cholesterol treatment for the use of statins in prevention of coronary heart disease.
  • Discuss with your learners how to interpret a recommendation against a therapy due to lack of evidence. Would they discontinue statins in 75- to 94-year-olds based on those recommendations?
  • Ask how the balance of potential benefits and harms are weighed in an assessment of cost-effectiveness. The authors examine this balance in the figure, and discuss it on the paper’s last page.

Patient Care
Medical Knowledge

Metformin Prescription for Insured Adults With Prediabetes From 2010 to 2012: A Retrospective Cohort Study

Lifestyle changes or metformin can delay the progression of prediabetes to overt diabetes. This study of a large sample of insured adults with prediabetes found that only 3.7% were prescribed metformin over 3 years. It suggests infrequent prescription for diabetes prevention.

Use this study to:

  • Review with your learners how to diagnose prediabetes. Ask who is at risk? Is there a role for screening? Use the information and teaching slides in a recent In the Clinic: Type 2 Diabetes to help prepare a teaching session.
  • Discuss the use of metformin. How do you choose a dose? What are the potential side effects and adverse events? Must metformin by held when a patient needs a study involving the use of contrast dye?
  • Ask your learners what interventions prevent progression to overt diabetes. How can they apply these findings to their patients? What benefits of treating prediabetes can their patients expect?

Patient Care
Medical Knowledge

Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Pregnancy: A Systematic Review for the U.S. Preventive Services Task Force

This study found no relevant trials of screening for iron deficiency anemia in asymptomatic, nonanemic pregnant women living in developed countries. Trials and observational studies did show that iron supplementation improved some maternal hematologic indices, but these studies provided inconclusive evidence that routine prenatal supplementation improved maternal or infant clinical outcomes.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review with your learners the hematologic problems frequently encountered in the care of pregnant women.
  • Review how to evaluate anemia. How is the diagnosis of iron deficiency anemia made? What underlying causes need to be considered? How is it treated?

Beyond the Guidelines

Screening for Lung Cancer With Low-Dose Computed Tomography: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center

In April 7’s Annals for Educators Alert, we told you about Ms. D, a 60-year-old former smoker who has “issues” that make deciding whether to screen for lung cancer with low-dose CT uncertain. Now, seasoned clinicians engage in a lively debate regarding the potential value and pitfalls to screening patients who might not “fit the guideline.”

Use the Beyond the Guidelines resources to:

  • Watch the brief video interview of Ms. D. Ask your learners if they would order a CT scan for Ms. D to screen for lung cancer.
  • Watch the video of the moderated discussion at Grand Rounds. Read the accompanying paper. Now ask your learners what they would do?
  • Earn MOC and CME for yourself by logging on and completing the brief quiz!

Video Learning

Medical Knowledge
Consult Guys logo

The Consult Guys - The Asymptomatic Carotid Bruit: Not Such a Pain in the Neck After All?

Enjoy watching this short episode of the consultative medicine talk show. Geno and Howard take on the carotid bruit.

Use this video to:

  • Ask your learners whether they “screen” for a carotid bruit by listening for it in a patient without neurologic symptoms. Should they? What will they do with the results?
  • What is the recommended management of an asymptomatic carotid bruit?
  • Log on and answer the brief multiple-choice questions to earn CME for yourself!

Humanism and Professionalism

Systems-based Practice

On Being a Doctor: World Changing

Dr. Plumb tells of the pain that resulted from being named in a medical malpractice lawsuit during her residency, and how she continues to struggle navigating the emotional sequelae while simultaneously striving to be a physician who will “change the world.”

Use this essay to:

  • Listen to an audio recording read by Annals’ editor for On Being a Doctor, Dr. Michael LaCombe.
  • Explore your learners’ feelings around bad patient outcomes (e.g., guilt, anxiety, anger, frustration, fear) and how they may cope with them.
  • Ask your learners if they fear being sued? How is that different from the fear of one’s medical decisions turning out not to be the best for a patient? Do these fears prompt us to be better or worse physicians?
  • Invite a physician who has been sued for malpractice to discuss his or her experience. How has it affected him or her going forward?
  • Invite your risk management team to discuss what your learners may do to decrease the risk of a lawsuit. Discuss the “lifecycle” of a lawsuit and the possible outcomes.


A 22-year-old woman is evaluated for a 6-month history of decreased exercise tolerance, a lack of a sense of well-being, and headaches. She is otherwise healthy and eats a normal diet. Medical history is unremarkable, and she takes no medications.

On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 110/72 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. BMI is 22. The patient has pale conjunctivae. Her lungs are clear, her heart is without murmurs, and the neurologic examination is normal. There is no splenomegaly.

Laboratory studies:

Hemoglobin 7.9 g/dL (79 g/L)
Leukocyte count 5600/ μ L (5.6 × 109/L)
Mean corpuscular volume 62 fL
Platelet count 625,000/ μ L (625 × 109/L)
Red blood cell distribution width 22% (Normal range: 14.6-16.5%)

A peripheral blood smear is shown.


Which of the following is the most effective treatment?

A. Intramuscular iron dextran
B. Intravenous iron sucrose
C. Oral ferrous sulfate
D. Erythrocyte transfusion

Correct Answer
C. Oral ferrous sulfate

Key Point
For patients with simple iron deficiency, oral ferrous sulfate is the least expensive and simplest treatment option.

Educational Objective
Treat iron deficiency in a menstruating woman.

The most appropriate treatment is oral ferrous sulfate. Iron deficiency can result from blood loss or malabsorption in addition to increased iron use. Women of reproductive age may lose enough iron through normal menstrual blood loss to become iron deficient in the absence of uterine or gastrointestinal disease. Patients with mild iron deficiency may note fatigue, lack of sense of well-being, irritability, decreased exercise tolerance, and headaches before symptoms of overt anemia occur. This patient has signs and symptoms of iron deficiency, likely secondary to menstrual blood loss. The peripheral blood smear in patients with iron deficiency is remarkable for microcytic, hypochromic erythrocytes, with marked anisopoikilocytosis (that is, abnormalities in erythrocyte size and shape). The variation in the size of erythrocytes is quantified in the red blood cell distribution width (RDW) measurement. An increased RDW is most often associated with a nutrient deficiency such as iron, folate, or vitamin B12. Patients with iron deficiency anemia caused by blood loss can have a mild thrombocytosis, which resolves with treatment of iron deficiency and does not require the use of cytoreductive agents such as hydroxyurea. For simple iron deficiency, oral ferrous sulfate is the least expensive and simplest treatment option, and, therefore, the most appropriate.

Parenteral iron is reserved for patients receiving dialysis or for patients who cannot absorb or tolerate oral iron replacement.

Erythrocyte transfusion would be reserved for patients with severe symptomatic anemia in whom rapid correction is necessary to prevent cardiovascular complications, including heart failure and infarction.

Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am Fam Physician. 2007;75(5):671-678. PMID: 17375513

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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