Annals for Educators - 21 March 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives21 March 2017Annals for Educators - 21 March 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201703210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAnnals for Hospitalists Inpatient Notes - What Do French Wine and Hospital Infections Have in Common?Major advances in the reduction of nosocomial infections and resultant patient mortality have historically been met by initial skepticism in the medical community. The authors of this short essay ask what might be done to improve adherence to appropriate hand hygiene practices.Use this essay to:Assign each of your team members to quietly observe the activities of staff going in and out of patients' rooms for 10 minutes. Did everyone cleanse going in and out of the room?Invite a member of your hospital's infection control team to discuss how they monitor hand hygiene practices and what they do to try to improve them.What are the reasons health care professionals continually fail to cleanse 100% of the time? Why is the excuse, “I did not touch anything in the room” not acceptable? Even if true, might it not help to promote thinking that it is acceptable to enter or leave a patient's room without cleansing? How would someone else, particularly someone who looks up to you, know you “did not touch anything”?The authors suggest practicing “mindfulness” as a team and engaging patients in hand hygiene as a means to improve practices. Try it with your team.Should we be punished—substantially—if we are caught failing to cleanse our hands? If not, why not? Can we reasonably argue that we didn't know it was hazardous to our patients? Would we permit the routine insertion of central lines without appropriate attention to cleanliness, such as gowning?Ask each member of your team to think about a patient he or she has cared for who has contracted a nosocomial infection. Might he or she individually be responsible for the harm caused to this patient?The Relationship of Obesity to Hospice Use and Expenditures. A Cohort StudyObesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use (a cornerstone of end-of-life care) and Medicare expenditures is unknown. In this retrospective cohort study of deceased Medicare fee-for-service beneficiaries in the Health and Retirement Study, the authors studied the associations between body mass index and hospice use and Medicare expenditures in the last 6 months of life.Use this study to:Ask your learners what challenges are encountered in the care of patients with obesity specifically. Encourage your learners to think beyond direct health risks, such as diabetes and hypertension. What about challenges in providing care?Do we use obesity as an “excuse” (even subconsciously) not to thoroughly examine some patients? Is it possible that at times we treat patients with obesity with less concern or less compassion?What do your learners think might be the potential explanations for the relative underuse of hospice services among patients with obesity? The authors provide a few potential explanations in the paper's discussion. They note that “there is an established record of negative provider attitudes and implicit bias against obese persons, and these attitudes may continue to influence care for obese persons at the end of life.” Do your learners agree?What do your learners suggest be done about the problem identified in this study? How can they act in their own practices?Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family PhysiciansThis jointly developed guideline from the American College of Physicians and the American Academy of Family Physicians provides recommendations about the benefits and harms of higher versus lower blood pressure targets for the treatment of hypertension in adults aged 60 years or older.Use this guideline to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they think they do a good job screening for and managing hypertension in their outpatients. How do they know? Is there a system in place within your practice to alert clinicians of the need to evaluate blood pressure? Does it work? Do your learners pay attention to it?What are your learners' targets for blood pressure? Do they vary according to patient variables? Which ones?How do your learners choose pharmacologic therapy for their patients with hypertension? Use the table in In the Clinic: Hypertension to help review.Do your learners base their diagnoses and monitoring of hypertension management on measures made in the office? Should they pursue ambulatory monitoring? How would they do so?Humanism and ProfessionalismOn Being a Doctor: The Incredible Heart of Mr. BJulia Schoen describes how her first patient, on her first clinical rotation, helped her to learn how to be a great doctor in ways she had not expected.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners if they recall patients who enjoyed being their “guinea pigs” so they could learn to be doctors. Did your learners ever thank their patients for this gift?Do your learners think serving as “guinea pigs” and assisting medical students and residents to learn helps the patient in some way as well? How?MKSAP 17 QuestionA 54-year-old man is evaluated for elevated blood pressure noted recently at a local health fair. He has no other medical history and takes no medications.On this visit and on two subsequent nurse visits, the patient's blood pressure measurements are less than 140/90 mm Hg. BMI is 34. Cardiac examination reveals an S4 gallop. The remainder of the examination is normal.Laboratory studies show a normal chemistry panel, and a urine dipstick demonstrates no blood or protein.Electrocardiogram demonstrates evidence of left ventricular hypertrophy.Which of the following is the most appropriate next step in management?A. Ambulatory blood pressure monitoringB. LisinoprilC. Plasma aldosterone-plasma renin ratioD. Repeat blood pressure measurement in 6 monthsCorrect AnswerA. Ambulatory blood pressure monitoringEducational ObjectiveDiagnose masked hypertension using ambulatory blood pressure monitoring.CritiqueAmbulatory blood pressure monitoring (ABPM) is appropriate for this patient who likely has masked hypertension. He has evidence of end-organ manifestations (left ventricular hypertrophy) that is potentially related to hypertension, yet has not presented with blood pressure measurements consistent with hypertension (≥140/90 mm Hg). This raises the possibility of masked hypertension, which is defined as normal office blood pressure measurements but elevated blood pressure (>135/85 mm Hg) in the ambulatory setting. Prior to initiating medical therapy, a more detailed assessment of this patient's blood pressure should be pursued, with ABPM as an appropriate next step. Although ABPM does not carry a formal indication for the diagnosis of masked hypertension, it may be useful in establishing this blood pressure pattern. ABPM-ascertained hypertension is associated with a higher risk of cardiovascular death compared with office or home blood pressure–determined hypertension.The left ventricular hypertrophy identified by electrocardiogram in this case may be secondary to hypertension but also may be due to other (such as genetic) causes and requires formal echocardiography to further evaluate and guide therapy. Initiating a blood pressure–lowering agent is not appropriate until both blood pressure and the electrocardiogram findings are clarified further with ABPM and echocardiography.A plasma renin-plasma aldosterone ratio is used to evaluate for hyperaldosteronism as a secondary cause of hypertension and is typically indicated in patients with difficult-to-treat blood pressure elevations and hypokalemia. This patient has not been diagnosed with hypertension and has no electrolyte abnormalities.Because this patient has evidence of end-organ damage possibly due to hypertension, follow-up assessment of his blood pressures in 6 months might further delay diagnosis and is not appropriate.Key PointAmbulatory blood pressure monitoring may be helpful in diagnosing masked hypertension in patients with end-organ manifestations but normal office blood pressure measurements.BibliographyPierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens. 2011 Jan;24(1):52-8.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: 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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 21 March 2017Volume 166, Issue 6Page: ED6KeywordsBlood pressureElectrocardiographyHygieneHypertensionLeft ventricular hypertrophyMedicareObesityOverweightSecondary hypertensionTouch ePublished: 21 March 2017 Issue Published: 21 March 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...