Clinical Practice Points
The long-term benefits and risks of moderate alcohol intake among patients with type
2 diabetes mellitus (T2DM) are unclear. This trial found that moderate alcohol intake,
particularly red wine, among patients with T2DM was associated with improved plasma
lipid levels and no significant adverse events. It also found that genetic typing
for alcohol dehydrogenase may identify patients who may experience improved glycemic
control from moderate alcohol consumption.
Use this study to:
- Moderate alcohol intake has been studied for its potential beneficial cardiovascular
effects. Ask your learners to define “moderate” and “heavy” alcohol intake. How do your learners ask patients about the amount of alcohol they
- On the basis of this study, will your learners recommend moderate alcohol intake to
their patients with well-controlled T2DM? If so, how will they describe “moderate” alcohol intake, and how will they follow to be sure their patients are not “heavy” drinkers?
- Ask your learners to list cardiometabolic risk factors (e.g., blood pressure, plasma
lipids). How do they differ from cardiovascular disease? How does one define a surrogate
end point? What is the advantage to using risk factors, such as the ones assessed
in this study, when conducting a clinical trial? What are the disadvantages?
Tobacco use is the leading preventable cause of disease, disability, and death in
the United States. This review and clinical guideline address important behavioral
and pharmacologic interventions to help patients stop smoking.
Use these papers to:
- Start a teaching session with a multiple-choice question. We've provided one below!
- The guideline notes the 5 A's framework as a useful strategy to engage patients in discussions about smoking cessation.
Review what the 5 A's are with your learners.
- Teach at the bedside! Talk about smoking cessation with patients on your team who
smoke. Be sure to ask what barriers your patients anticipate to quitting. Do your
learners have ideas that might help?
- Do your learners know how to refer a patient for behavioral therapy for smoking cessation?
- Review the pharmacologic interventions available for smoking cessation, including
nicotine replacement, bupropion, and varenicline. How do your learners choose which
- Ask your learners what the potential effects of maternal smoking are on infants (e.g.,
preterm birth, fetal growth retardation, placental abruption, miscarriage, and others).
Why does the guideline not recommend the use of pharmacotherapy for smoking cessation
in pregnant women?
- Ask if your learners' patients use electronic nicotine delivery devices (“vape”). What do they know about their benefits and harms? Use a recent pair of “In the Balance” essays to review what is known, and not known, about electronic cigarettes: Electronic Cigarettes: Aggregate Harm and Electronic Cigarettes: Perhaps the Devil Unknown Is Better Than the Devil Known.
Contamination of high-touch surfaces plays an important role in the transmission of
pathogens in the hospital. This report reviews what is known, and not known, about
the effectiveness and comparative effectiveness of surface cleaning practices.
Use this study to:
- Review with your learners the epidemiology of nosocomial infections. What pathogens
are most common, and how are they spread?
- Ask your learners what broad approaches are required to eliminate nosocomial infections
(e.g., hand hygiene, antimicrobial stewardship, and environmental cleaning and disinfection).
Invite a member of your institution's infection control or hospital epidemiology team
to lead the discussion.
- Ask what roles your learners need to play in this effort. Do they cleanse their hands
each time they enter and leave a patient's room? Review the contact precaution policies
in your hospital. How compliant are your learners with these? Ask a member of your
infection control team to share monitoring data evaluating how good (or not) physicians
are at your institution.
- How would your learners improve the efforts at your institution? What studies might
help plan improvements at your hospital and others? Use the accompanying editorial to help frame your discussion.
A 46-year-old woman is evaluated during a routine examination. Her 72-year-old mother
was just diagnosed with lung cancer, so the patient asks you for help with quitting
smoking. She has a 27-pack-year smoking history. She made one previous quit attempt
several years ago using over-the-counter nicotine gum, but she was unable to quit
for more than a few days. Medical history is significant for seizure disorder. Review
of systems discloses mild shortness of breath with exertion and occasional wheezing.
Medications are a multivitamin and phenytoin.
On physical examination, vital signs are normal. Lung examination reveals occasional
wheezing and a prolonged expiratory phase. The rest of the examination is normal.
In addition to counseling regarding tobacco use, which of the following is an appropriate
adjunct to increase her likelihood of successful smoking cessation?
C. Electronic smokeless cigarette use
D. Nicotine replacement therapy
D. Nicotine replacement therapy
Smoking cessation is achieved more effectively with a combination of counseling and
anti-smoking medication use than with either intervention alone.
Counsel a patient regarding methods for smoking cessation.
Although both counseling and pharmacotherapy are effective strategies for smoking
cessation, the combination of counseling with medication use is more effective than
either intervention alone. Nicotine replacement is effective for smoking cessation;
its availability in multiple formulations (gum, lozenge, patch, aerosol) allows for
alternative options in patients who have not benefited from one type of therapy, as
in this patient. Although centrally acting agents (bupropion, varenicline) are also
effective treatment options, bupropion would be contraindicated in this patient with
an underlying seizure disorder. The choice of cessation method is less important than
that an effective method is used correctly by the patient; the array of treatment
options allows for individualization based on patient preference, previous experience,
cost, and potential side effects. Counseling may be brief or intensive; the two most
effective counseling components include practical problem-solving skills and social
Many smokers indicate that stress reduction is a primary reason for their tobacco
use. Although selected individuals with true anxiety disorders may benefit from anxiolytic
therapy, the use of benzodiazepines as a smoking cessation medication has not been
Electronic smokeless cigarettes deliver a warmed aerosol through a cigarette-like
device that bears the appearance, physical sensation, and possibly the taste of tobacco
smoke, with the intention of helping smokers maintain the activities associated with
smoking but without the harmful effects. However, their use in smoking cessation has
not been established.
2008 PHS Guideline Update Panel, Liasons, and Staff. Treating tobacco use and dependence:
2008 update U.S. Public Health Service Clinical Practice Guideline executive summary.
Respir Care. 2008;53(9):1217-1222. PMID: 18807274
This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.