Annals for Educators - 21 May 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives21 May 2019Annals for Educators - 21 May 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201905210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCases in Precision Medicine: Genetic Assessment After a Sudden Cardiac Death in the FamilyAssessing the cause of a sudden death may help determine risk for family members. In cases of arrhythmia, standard autopsy will not reveal the cause of death. Evaluation of the circumstances, the medical history of the deceased, and results of genetic testing may reveal a diagnosis. This article discusses the current clinical utility of genetic testing in the context of advising patients with a family member who has died suddenly.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to list conditions that may cause sudden cardiac death. Which conditions have a known genetic cause? Use Table 2.What is a “genetic autopsy,” and when should it be considered?What is long QT syndrome? When should it be considered?What behavioral modifications should be discussed with a patient with long QT syndrome? What pharmacologic interventions are indicated?Maternal Glycemic Control in Type 1 Diabetes and the Risk for Preterm Birth. A Population-Based Cohort StudyWhether currently recommended glycemic targets in pregnant women with type 1 diabetes reduce risk for adverse neonatal outcomes is unknown. This study of a nationwide Swedish registry examined the relationships between maternal periconceptional glycemic control and preterm birth and other adverse neonatal outcomes.Use this study to:Ask your learners what adverse maternal and neonatal outcomes are associated with maternal diabetes.How is diabetes managed during pregnancy? What drugs may and may not be used?What medical issues require collaboration between the obstetrician and the internist? Who should oversee diabetes management during pregnancy?Do glycemic goals change during pregnancy? What do the results of this study suggest?Scam Awareness Related to Incident Alzheimer Dementia and Mild Cognitive Impairment. A Prospective Cohort StudyThis study of 935 older persons who were free of dementia at baseline evaluated whether scam awareness was associated with risk for Alzheimer dementia and mild cognitive impairment. In 264 persons who died, the association between scam awareness and Alzheimer disease pathology in the brain at the time of death was also examined.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Have your learners' patients or their loved ones expressed concern about a patient's declining cognitive function? Are such concerns often related to social functioning? How do your learners respond?What is meant by “social cognition”? Use the accompanying editorial to help frame your discussion. Ask your learners whether and when they assess cognitive function in their patients. How do they do so?What are the potential implications of the results of cognitive assessments? How might discussions about future cognitive abilities be beneficial for patients and their families? How might they cause harm?What do we know about what can and cannot be done to prevent the development of dementia? Use recent reviews of pharmacologic and exercise interventions. Humanism and ProfessionalismOn Being a Doctor: LunchDr. Todd recalls her feelings as an intern on the oncology service, noting, “When Dr. Z turned his face, lit with incandescent self-righteous rage, toward us interns, I felt I was getting what I deserved.”Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Ask your learners if they have worked with people who behave like Dr. Z.When faced with abusive behavior from others, how have your learners reacted? Did they quietly accept the abuse? Did they fight back in any way? Were their reactions different when the abuser was someone with authority?How should we react to such abusive behavior from professional colleagues? To whom should your learners turn for help in such situations?MKSAP 18 Question 1A 51-year-old woman is evaluated in the ICU after being admitted 2 days ago for severe community-acquired pneumonia. A chest radiograph demonstrated right lower lobe consolidation, and she was started on moxifloxacin. Today, she developed an arrhythmia that terminated after 20 seconds. An electrocardiogram (ECG) obtained at the time of admission was normal. Medical history is significant for hypertension, hyperlipidemia, and depression. Other medications are venlafaxine, carvedilol, and simvastatin.On physical examination, temperature is 38.4 °C (101.1 °F), blood pressure is 140/90 mm Hg, pulse rate is 61/min, and respiration rate is 18/min. Diminished breath sounds are located in the right lower posterior thorax. The remainder of the examination is unremarkable.An ECG at the time of the arrhythmic event is shown. An ECG after the episode reveals a corrected QT interval of 550 ms.Which of the following medications should be discontinued on the basis of this patient's ECG findings?A. CarvedilolB. MoxifloxacinC. SimvastatinD. VenlafaxineCorrect AnswerB. MoxifloxacinEducational ObjectiveManage acquired QT-interval prolongation.CritiqueMoxifloxacin should be discontinued in this patient who had an episode of nonsustained polymorphic ventricular tachycardia (VT). VT is subdivided into sustained VT and nonsustained VT. VT is sustained when it persists for longer than 30 seconds or requires termination because of hemodynamic collapse. Nonsustained VT has three or more beats but lasts for less than 30 seconds. VT is also categorized by the morphology of the QRS complexes. VT is monomorphic if QRS complexes in the same leads do not vary in contour or polymorphic if the QRS complexes in the same leads vary in contour. In this patient, the electrocardiogram obtained after the episode of VT also demonstrates QT-interval prolongation, which is consistent with the diagnosis of torsades de pointes. Torsades de pointes is a special subset of polymorphic VT; the ventricular rate ranges from 200/min to 300/min and is associated with long QT syndrome, which may be congenital or acquired. The patient's electrocardiogram was normal upon admission, and her corrected QT interval is greater than 550 ms following the arrhythmic event, suggesting an acquired long QT interval. Causes of acquired QT-interval prolongation include medications such as antiarrhythmic agents, antibiotics (macrolides and fluoroquinolones), antipsychotic drugs, and antidepressants; structural heart disease; and electrolyte abnormalities.Although carvedilol slows the heart rate and can increase the risk for bradycardia-dependent arrhythmias in patients with acquired QT-interval prolongation, discontinuing the offending QT-prolonging agents is the most important intervention in this patient.Simvastatin is a statin used in the treatment of dyslipidemia. It has no effect on the QT interval and does not need to be discontinued.Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is used to treat depression and anxiety disorders. There is a possible risk for QT-interval prolongation with venlafaxine, but there is no evidence that this occurs when the medication is taken as recommended. Therefore, discontinuation of venlafaxine is unnecessary.Key PointQT-interval prolongation has many causes, including medications such as antiarrhythmic agents, antibiotics (macrolides and fluoroquinolones), antipsychotic drugs, and antidepressants; structural heart disease; and electrolyte abnormalities.BibliographyIsbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment of the QT interval in clinical practice. Br J Clin Pharmacol. 2013;76:48-57. doi:10.1111/bcp.12040MKSAP 18 Question 2A 79-year-old woman is accompanied to the office by her son for an evaluation of her memory. The patient forgot to attend her last two scheduled appointments. The patient lives alone; her son visits her daily and sets up a weekly pillbox with her medications. The son reports that on several occasions lately, pills that his mother should have taken have been left in the compartments. The patient admits that she sometimes gets confused as to which section of the pillbox is the correct one for that day. Medical history is significant for hypothyroidism, hypertension, gastroesophageal reflux disease, and osteoarthritis. Medications are levothyroxine, amlodipine, omeprazole, vitamin D, and acetaminophen.On physical examination, vital signs are normal. The patient is pleasant and interactive. The physical examination is normal, including neurologic and gait assessment. Depression screening with PHQ-2 is negative.Which of the following is the most appropriate test to perform next?A. Apolipoprotein E (APOE-ε4) genotypingB. Fluorodeoxyglucose-PET brain imagingC. Formal neurocognitive testingD. Mini-Cog testingCorrect AnswerD. Mini-Cog testingEducational ObjectiveTest for cognitive impairment in a symptomatic older woman.CritiqueThis patient would most benefit from evaluation with the Mini-Cog test or another validated screening test for cognitive function. Cognitive impairment is a progressive decline that impairs function in at least two areas: attention, executive function, language, memory, or visual-spatial function. Patients with signs and symptoms of cognitive impairment, such as this patient who reports difficulty with both memory and executive function, should undergo evaluation. A variety of validated tools are available to assess cognitive function. Among the free tools, the Montreal Cognitive Assessment and Mini-Cog test have been validated in primary care populations; these instruments screen for impairments in executive function. Self-administered instruments, such as the Self-Administered Gerocognitive Examination and Test Your Memory examination, have been validated in memory clinic populations to detect mild cognitive impairment and early dementia. Although the Mini–Mental State Examination has been the most extensively studied screening instrument, it is now proprietary, with a cost per use.Although numerous factors have been studied, and some have been associated with a higher risk for progression to dementia (such as baseline functional impairment, abnormal results of fluorodeoxyglucose-PET brain imaging, and the apolipoprotein E [APOE-ε4] genotype), no reliable clinical markers can predict the clinical likelihood that an individual patient with mild cognitive impairment will develop dementia. More importantly, these tests do not establish the diagnosis of cognitive impairment.In clinical practice, a careful history and results of a standard mental examination are often sufficient to diagnose cognitive impairment, and extensive formal cognitive testing is not routinely required. Occasionally, a formal battery of neuropsychologic testing beyond the standard mental examination is needed to distinguish particularly mild cases of cognitive impairment from normal aging.Key PointCognitive impairment is a progressive decline that impairs function in at least two areas, including attention, executive function, language, memory, and visual-spatial function; it is best measured with assessment examinations, such as the Mini-Cog and the Mini–Mental State Examination, rather than laboratory testing or imaging.BibliographyLin JS, O’Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;159:601-12.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 May 2019Volume 170, Issue 10Page: ED10KeywordsArrhythmiaCognitionCognitive impairmentDementiaElectrocardiographyMemoryMild cognitive impairmentPregnancyThoraxVentricular tachycardia ePublished: 21 May 2019 Issue Published: 21 May 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...