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November 18, 2014 Issue

Clinical Practice Points

Patient Care
Systems-based Practice

A Cascade of Care for Diabetes in the United States: Visualizing the Gaps

This study used data from the National Health and Nutrition Examination Surveys to apply the “cascade-of-care model”—a method of showing how many patients are lost to follow-up at each stage of diagnosis, referral, and treatment—to U.S. diabetes care to help visualize gaps in care.

Use this study to:

  • Ask your learners why so many patients with diabetes remain undiagnosed, and what the implications might be for their long-term outcomes. The authors discuss these issues at the beginning of the paper’s Discussion section.
  • Generate a list of the “tasks” that are recommended for the care of patients with diabetes (e.g., tests to be obtained and how often, ophthalmologic evaluation, meet with a dietitian).
  • Ask your learners to list each step that must be completed to accomplish a few of these “tasks” or goals of diabetic care (e.g., established primary care, consultations with podiatrists, ophthalmologists, or dietitians, pharmacy education, self-monitoring). Where do your learners see barriers that lead to lower-quality care or poor adherence? Use the diagram in Figure 2 to help map it out.

Patient Care
Medical Knowledge

Relation of Nonsteroidal Anti-inflammatory Drugs to Serious Bleeding and Thromboembolism Rates in Patients With Atrial Fibrillation

This study examined all citizens of Denmark who had a first-time diagnosis of AF during a hospitalization between 1997 and 2011. It found that NSAIDs increased the risk for bleeding and thromboembolism, even when they were used for short periods.

Use this study to:

  • Teach at the bedside! Review the CHA2DS2-VASc scoring system with your learners to determine a patient’s risk for embolic stroke from AF. Review HAS-BLED scoring for determining a patient’s risk for bleeding. Calculate these scores during rounds on each of your team’s patients with atrial fibrillation.
  • Ask your learners how NSAIDs may lead to an increased risk for bleeding and thromboembolism.
  • Discuss the difference between statistical significance and clinical significance with your learners. Are the differences in event rates associated with and without NSAID exposure clinically significant?
  • Ask your learners how they will approach the treatment of pain in their patients who require anticoagulants.

Medical Knowledge
Practice Based Learning and Improvement

Renin–Angiotensin System Blockade Therapy After Surgical Aortic Valve Replacement for Severe Aortic Stenosis

This cohort study evaluated renin–angiotensin system (RAS) blockade therapy, survival, and changes in echocardiographic findings in patients who underwent surgical aortic valve replacement for severe aortic stenosis. It found that RAS blockade was associated with improved survival rates.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review RAS, the actions of ACE inhibitors and angiotensin-receptor blockers, and their use in blood pressure management.
  • Review with your learners the presentation and evaluation of aortic stenosis. What are the indications for aortic valve replacement surgery? Use ACP Smart Medicine: Aortic Stenosis. where you’ll find information on treatment, tables for differential diagnosis and drug therapy, and images of stenotic valves and echo findings.
  • Discuss the cohort design of this study. Does such a cohort mimic a randomized trial? Why or why not? What conclusions may be drawn from this study regarding RAS blockade after valve surgery for aortic stenosis? Will you change your behavior based on these findings? Do your learners think a randomized trial should be performed?

Patient Care
Medical Knowledge

Comparative Effectiveness of Pharmacologic Treatments to Prevent Fractures

This comprehensive update found good-quality evidence that several medications, including bisphosphonates, denosumab, and teriparatide, reduce fracture risk. Side effect profiles and frequency varied among drugs, and atypical subtrochanteric fracture and osteonecrosis of the jaw were rare risks.

Use this study to:

  • Review bone metabolism and calcium homeostasis. Ask your learners if they know the mechanisms of action of bisphosphonates, denosumab, and teriparatide.
  • Ask your learners what nonpharmacologic interventions can prevent falls and fractures. What medical problems contribute to the risk for falls? Find the answers in In the Clinic: Osteoporosis and ACP Smart Medicine: Falls. Interject the multiple-choice questions at the end of In the Clinic at key points in your teaching session.

Fear and Practicing Medicine

Medical Knowledge
Systems-based Practice

Serotherapy for Ebola: Back to the Future

Ebola, Ethics, and Public Health: What’s Next?

Ebola Hemorrhagic Fever in 2014: The Tale of an Evolving Epidemic

Ebola Vaccination: If Not Now, When?

Ebola Fever: Reconciling Planning With Risk in U.S. Hospitals

Protecting Health Care Workers From Ebola: Personal Protective Equipment Is Critical but Is Not Enough

This series of essays, all released over the past few weeks, highlights the intense attention being paid to the Ebola epidemic in West Africa, and fears of its arrival in the U.S.

Consider using any of these essays to discuss:

  • What are the manifestations of Ebola infection, and how is a diagnosis made? What is the differential diagnosis? You may find this information at ACP Smart Medicine: Ebola and Marburg Viruses.
  • Ask your learners if they know what exactly to do if they encounter a patient in whom Ebola infection is a consideration. In what order should they do these things?
  • Do your learners believe they should be asked to care for such patients? What risks may a health care provider be asked to take by her or his medical center in order to care for patients? What risks do we all take on a regular basis in the care of our patients?
  • Is all this attention to Ebola appropriate? Does it help or hurt? Does it draw attention away from other public health issues about which we can do more?

Video Learning

Medical Knowledge
Consult Guys logo

The Consult Guys: Clearing the Air

It is 3 weeks before a scheduled noncardiac surgical procedure, and you’re asked whether a currently active smoker should stop before the surgery? Does smoking cessation this soon before surgery increase the risk for perioperative pulmonary complications? The Consult Guys take on this tough one and debunk old teaching.

Use this video to:

  • Watch with your learners.
  • Ask how they would use the upcoming surgery as an opportunity to help promote smoking cessation. How might they counsel or help the patient after surgery to prevent a return to smoking following discharge?
  • Log in, and answer the short questions to earn CME for yourself.

FYI: Internal Medicine Program Directors


Development of a High-Value Care Subscore on the Internal Medicine In-Training Examination

Although balancing benefits of tests or treatments against potential harms and costs has been a recently emphasized competency for internal medicine residents, few tools to assess knowledge in this domain are available. This study developed high-value care (HVC) subscore calculated from selected items on the Internal Medicine In-Training Examination (ITE) and then evaluated the relationship of program-level performance on this subscore to the Dartmouth Atlas hospital care intensity index.

Did you know that you may see your program’s HVC subcore on the final score report? Here you may compare how your program did relative to all others. You may also see which of the educational objectives on the ITE were high value care questions.


A 72-year-old woman is evaluated during a routine follow-up appointment for aortic stenosis. She does not have any symptoms, including chest pain or dyspnea. She feels that she is in good health “for her age.”

On physical examination, vital signs are normal. Estimated central venous pressure is normal. Carotid upstrokes are diminished and delayed. The apical impulse is sustained but not displaced. S1 is normal, but S2 is decreased in intensity. There is a grade 3/6 late-peaking, systolic, crescendo-decrescendo murmur at the right upper sternal border which radiates to the right carotid. Lungs are clear to auscultation.

Transthoracic echocardiogram shows normal left ventricular ejection fraction (62%) with moderate concentric hypertrophy (septal and posterior wall thickness 1.4 cm). The aortic valve leaflets are calcified with poor mobility. There is severe aortic stenosis with a peak aortic valve gradient of 65 mm Hg, mean gradient of 42 mm Hg, and calculated aortic valve area of 0.8 cm2.

Which of the following is the most appropriate management of this patient?

A. Aortic valve replacement surgery
B. Balloon aortic valvuloplasty
C. Dobutamine stress echocardiography
D. Repeat echocardiography in 12 months

Correct Answer
D. Repeat echocardiography in 12 months

Key Point
In patients with severe aortic stenosis without symptoms, aortic valve replacement is indicated if left ventricular ejection fraction is below 50%, exercise results in hypotension or symptoms, or rapid progression of stenosis or very severe stenosis (mean gradient >60 mm Hg) has occurred.

Educational Objective
Evaluate need for aortic valve replacement.

This patient should undergo repeat echocardiography in 12 months. She has severe aortic stenosis; however, she is active and has not experienced any symptoms related to aortic stenosis, such as dyspnea, chest discomfort, or syncope. In asymptomatic patients with severe aortic stenosis, current guidelines recommend an interval examination in 6 months and an interval echocardiogram in 12 months, or sooner if symptoms develop.

In patients with severe aortic stenosis without symptoms, aortic valve replacement is indicated if left ventricular ejection fraction is abnormal (<50%), response to exercise is abnormal (hypotensive or development of symptoms), rapid progression of stenosis or very severe stenosis (mean gradient >60 mm Hg) has occurred, or if other cardiac surgery is indicated and planned. This patient does not have indications for aortic valve replacement.

Balloon aortic valvuloplasty is indicated for calcific aortic stenosis in patients with hemodynamic instability or decompensation, as a bridge to eventual aortic valve replacement. However, the degree of improvement in aortic valve area from this procedure is modest, and many patients have residual severe aortic stenosis immediately after valvuloplasty. Furthermore, balloon aortic valvuloplasty is associated with procedural risks, including stroke, myocardial infarction, vascular complications, and death, and is not indicated in this asymptomatic patient.

Dobutamine stress echocardiography may be utilized in determining the severity of aortic stenosis in the presence of severe left ventricular systolic dysfunction and a moderate aortic valve gradient (low-flow, low-gradient aortic stenosis). The assessment of the aortic valve gradient and area during higher flow rate is useful to differentiate a severe, fixed degree of stenosis from less severe stenosis. Dobutamine stress echocardiography may also be used to evaluate for possible ischemic response to suggest underlying coronary artery disease. However, this patient has no symptoms of coronary artery disease. In addition, dobutamine may result in hypotension and arrhythmias, which may have adverse consequences in a patient with severe aortic stenosis.

Iung B. Management of asymptomatic aortic stenosis. Heart. 2011;97(3):253-259. PMID: 21189311

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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