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December 17, 2013 Issue

Clinical Practice Points

Medical Knowledge
Patient Care

Oral High-Dose Multivitamins and Minerals After Myocardial Infarction. A Randomized, Controlled Trial

This randomized trial did not find high-dose multivitamins and minerals to be beneficial for the secondary prevention of cardiovascular events and death after myocardial infarction.

Use this study to:

  • Discuss proven therapies for the primary and secondary prevention of cardiovascular disease. Use ACP Smart Medicine Acute Coronary Syndromes and Coronary Heart Disease to prepare your teaching.
  • Discuss potential complications of high doses of vitamins (e.g., vitamin A and vitamin C).
  • Discuss dietary modifications to manage the risk factors for coronary disease. Discuss indications for niacin as a lipid-lowering therapy.
  • Read the accompanying editorial. Ask your learners what they plan to recommend to their patients. Why do they think supplements are so popular despite a lack of evidence?

Medical Knowledge
Patient Care

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

This review found insufficient evidence of benefit from nutritional vitamin and mineral supplementation to prevent cardiovascular disease and cancer. It found evidence supporting no benefit with vitamin E and confirmation that β-carotene increases the risk for lung cancer in smokers.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review U.S. Department of Agriculture recommendations on daily nutritional intake of key vitamins and minerals. Which populations are at risk for nutritional deficiencies of specific nutrients (e.g., vegans, alcoholics, and persons who had gastric bypass surgery or have celiac disease and pernicious anemia)? How do those deficiencies present? Use the information, including tables, in ACP Smart Medicine Nutritional Syndromes.
  • Ask who should receive vitamin D supplementation.
  • Discuss specific nutritional deficiencies (e.g., rickets, scurvy, kwashiorkor, Wernicke’s encephalopathy, beriberi, and pellagra).
  • Answer the CME questions that accompany the review to get credit for yourself!

Clinical Guideline

Practice Based Learning and Improvement
High Value Care

Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the Clinical Guidelines Committee of the American College of Physicians

Recommendations in this guideline include not screening for chronic kidney disease (CKD) in asymptomatic adults without risk factors, using angiotensin-converting enzyme inhibitors or angiotensin II–receptor inhibitors for the treatment of hypertension in patients with stage 1 to 3 CKD and others.

Use this guideline to:

  • Review the definitions of the CKD stages (you can find them in Table 1).
  • Review the recommendations.
  • Ask what the sensitivity and specificity requirements are for a good screening test. Use the teaching materials of the High Value Care Curriculum, Utilizing Biostatistics in Diagnosis, Screening and Prevention.
  • Teach at the bedside: During your next teaching encounter with a patient at risk for CKD (e.g., with hypertension, cardiovascular disease, or diabetes), use this article to determine whether to screen for CKD and how to do so and to determine therapy and monitoring. Discuss the lipid and hypertension goals for a patient with CKD.
  • Answer the CME questions that accompany the guideline to get credit for yourself!

Humanism and Professionalism

Interpersonal and Communication Skills

On Being a Doctor: Miracle on 39th Street

In this narrative, Dr. Broxterman wrestles with an unexpectedly good outcome of a patient thought to be terminally ill.

Use this essay to:

  • Play an audio recording of the essay to your group.
  • Discuss techniques for delivering bad news. One example is the SPIKES protocol involving Setting the discussion, obtaining the patient’s Perspective and Invitation to provide Knowledge, addressing Emotions, and formulating a Strategy and Summary.
  • Have learners discuss their experiences with terminally ill patients and times when patient or families expected “miracles.” How do you emotionally support such patients and families without giving false hope? Is this harder with a long-term patient or a new patient?

Video Learning

The Consult Guys: Hyperglycemia — Am I A Control Freak?

Watch this month’s episode of the Consult Guys, the medical consultation talk show starring seasoned clinicians and comedians, Howard Weitz, MD, and Geno Merli, MD. This week, they resolve the battle between colleagues whose thoughts differ on appropriate glycemic control.

Use this video to:

  • Ask what are thought to be the benefits of tight glucose control.
  • What might be the harms?
  • Review any protocols your hospital might have for glycemic control.
  • Answer the questions that accompany the Consult Guys with your learners. Then, sign on and get CME credit for yourself—you’ve already done the work.


A 34-year-old man is evaluated in the emergency department for confusion. Three weeks ago he underwent a Roux-en-Y gastric bypass for morbid obesity. He has had poor oral intake since the surgery because of nausea. Vitamin B12 injections were prescribed, but he has not started them yet. He recently took hydrocodone for pain, but he has not needed it for several days. His only current medication is a multivitamin with iron.

On physical examination, he is afebrile. Blood pressure is 115/80 mm Hg (no orthostatic changes), and pulse rate is 85/min. The mucous membranes are moist, and there is no skin tenting. He has an ataxic gait, nystagmus, and a disconjugate gaze. The remainder of the neurologic examination is normal.

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

A. CT of the head
B. Glucose infusion
C. Intravenous naloxone
D. Intravenous thiamine
E. Subcutaneous vitamin B12

Correct Answer
D. Intravenous thiamine

Key Point
Patients who have recently undergone bariatric surgery may develop thiamine deficiency, which is characterized by confusion, ataxia, nystagmus, and ophthalmoplegia.

Educational Objective
Manage thiamine deficiency following bariatric surgery.

The most appropriate next step is to administer intravenous thiamine. This patient has clinical features of thiamine deficiency manifesting as Wernicke encephalopathy (nystagmus, ophthalmoplegia, ataxia, and confusion), and administration of intravenous thiamine should occur promptly. Thiamine deficiency has been reported in patients who have undergone bariatric surgery and is caused by poor postoperative oral intake. Body stores of thiamine deplete quickly. Early recognition of thiamine deficiency is crucial before the patient develops irreversible neurologic and cognitive changes.

This patient has new-onset ataxia and ocular findings on examination, but these findings can be explained by a thiamine-deficient state. Therefore, a CT of the head would be unnecessary and could delay the urgently needed administration of appropriate treatment.

Although hypoglycemia could present with neurologic features, this patient's plasma glucose level was normal on admission. Glucose administration in a patient who is thiamine deficient may worsen the clinical course because thiamine is required as a cofactor in glucose metabolism.

Although naloxone can be helpful for reversal of opiate activity, the patient has not received opioids for several days, and opioid ingestion or withdrawal would not account for his neurologic changes.

Vitamin B12 deficiency can cause neurologic manifestations, typically beginning with paresthesias and ataxia associated with loss of vibration and position sense; however, it often takes months to years after vitamin intake or absorption is impaired for a deficient state to develop. This patient will be at risk for vitamin B12 deficiency if he does not take supplemental vitamin B12, but deficiency would not have occurred within the 3 weeks since his surgery.

Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008;248(5):714-720. PMID: 18948797

This question was derived from MKSAP® 16, 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, Program Director in Internal Medicine, Thomas Jefferson University.


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