Annals for Educators - 7 November 2017,Annals of Internal Medicine

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Annals for Educators - 7 November 2017
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2017-11-07 , DOI: 10.7326/afed201711070
Darren B. Taichman

Clinical Practice Points

Discontinuing Inappropriate Medication Use in Nursing Home Residents. A Cluster Randomized Controlled Trial

Inappropriate prescribing of medications is a common problem associated with increased risk for adverse outcomes in older adults. This randomized controlled trial examined the effect of a multidisciplinary medication review performed by physicians and pharmacists on the discontinuation of inappropriate medication use and clinical outcomes among nursing home residents.

Use this paper to:

Start a teaching session with a multiple-choice question. We've provided one below!
Teach at the bedside! Review with your team the admitting medication list of several nursing home residents on your service. Are the lists long? Are all of the drugs necessary? Do any present potential problems?
Ask your learners how they would define polypharmacy. In what ways might it lead to adverse events? The authors address these issues in the introduction to their study. Need the list be long for it to include inappropriate drugs?
Review the intervention used in this cluster randomized controlled trial (Table 1). Who was involved? How were medications assessed?
How well do your learners think they can assess the appropriateness of each medication for all of their patients? Ask them to do so for each of the patients on their service (or each of the outpatients they see) before your next meeting. Did they identify any potentially inappropriate drugs?
Ask whether your learners ever leave patients on drugs they do not think or are not sure are needed. Are they hesitant to discontinue drugs they did not prescribe? How should they approach this issue? To whom should they talk?
Who reviews a patient's discharge medication list at your hospital? Look at the Annals Graphic Medicine piece described below. How do patients end up using long lists of medicines they no longer need?
Ask what a cluster randomized trial is. How does it differ from more traditional clinical trials? What is the unit of randomization in each? How does this difference influence what may be learned?
This study did not find a difference in the secondary outcomes that were assessed. The authors note that the trial was not powered to assess them. What does it mean if a study is “underpowered”? Look at the 95% confidence intervals around the point estimates for the secondary outcomes (Table 4). How should they be interpreted?
Why might the study have found only modest effects? Use the accompanying editorial to help frame your discussion.

The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension. A Cohort Study

Primary aldosteronism is the most common and modifiable form of secondary hypertension and is usually considered when the classic phenotype of severe hypertension or hypokalemia is encountered. This study assessed whether a spectrum of subclinical primary aldosteronism that increases risk for hypertension exists among normotensive persons.

Use this study to:

Ask your learners which patients require an evaluation for secondary causes of hypertension. What should the evaluation include? Use In the Clinic: Hypertension to quickly find answers.
What are the presenting signs and symptoms of primary aldosteronism? How is it currently diagnosed? Use the information in DynaMed Plus: Primary Aldosteronism (a benefit of your ACP membership).
Review with your learners the regulation of renin and aldosterone. How is urinary sodium affected by renin and aldosterone concentrations? Invite a nephrologist to join your discussion.
Review the key results of this study. The authors suggest that a state of clinically relevant renin-independent aldosteronism might be common and could affect the risk for subsequent cardiovascular disease. Do your learners think that we should test normotensive patients for this? What additional studies would they want before adopting such a practice? Use the accompanying editorial to help inform your discussion.

Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus

This synopsis summarizes key features of the 2017 joint clinical practice guideline from the U.S. Department of Veterans Affairs and the U.S. Department of Defense for the management of type 2 diabetes mellitus.

Use this guideline synopsis to:

Go down the list of recommendations in Table 1 with your team. Check off items your learners believe they should address with each of their diabetic patients. How would they assess whether they are doing these things? Can your EHR help? Should they review the charts of several of their own patients?
Does your practice have a telehealth system available to improve the care of patients with diabetes? What members of the health care team are available to assist in providing diabetes care?
The authors discuss the importance of individualizing glycemic goals according to patients' risks, life expectancy, personal goals, and other variables. How should each of these be considered when determining glycemic goals? Do your learners know how to discuss them with patients when choosing a goal, and what questions to ask?
The authors discuss how their guideline differs from others. Why do glycemic targets differ in this manner? Use the accompanying editorial to help frame your discussion.
Does your institution have protocols for inpatient glycemic control among diabetic patients? What do the authors recommend? Why don't they recommend as tight control for patients outside the ICU compared with those in the ICU? The authors recommend a “basal–bolus-plus-correction” approach to care outside the ICU but note that many inpatients are managed only with “correction” doses of insulin on a sliding-scale basis. What is the difference? What is done at your center, and why?

In the Clinic

In the Clinic: Acute Kidney Injury

Acute kidney injury (AKI) occurs in approximately 20% of hospitalized patients, with major complications that include volume overload, electrolyte disorders, uremic complications, and drug toxicity. Are your learners prepared to prevent and manage AKI?

Use this feature to:

Ask your learners to list risk factors for AKI. Compare their list with the one provided in the Box.
What measures are effective at preventing AKI, and in which patients should they be used?
What are the major causes of AKI? Review Figure 2 with your learners. What features help distinguish between decreased kidney perfusion and acute tubular necrosis? List drugs that may cause AKI, and how. Use the information in the boxes for quick lists to help teach.
Teach at the bedside (or microscope)! How do urinary tract findings help differentiate among the potential causes? Do your learners know how to assess urinary sediment? Take fresh samples of urine from patients on your service with AKI to the laboratory and review the sediment. Invite a nephrologist to help.
Use the multiple-choice questions to introduce new topics for discussion in a teaching session. Download the teaching slides. Log in to answer the multiple-choice questions and claim CME/MOC credit for yourself!

Comics and Medicine

Annals Graphic Medicine - The “Problem” List

Laugh (or cry?) as what starts as a simple issue evolves into a complex medical problem list.

Use this feature to:

Show the cartoon to your learners. Do they think there is truth to what the author depicts?
What drives our medical system's desire to label everything? What practices can help to prevent needless labeling and inappropriate treatment of patients?
How might this cartoon relate to the use of inappropriate medications addressed in the first study noted above?

Humanism and Professionalism

On Being a Patient: The Worst of Days

Dr. Grinberg's horrible loss brings back the memories of a patient who was labeled as “crazy.”

Use this essay to:

Listen to an audio recording, read by Dr. Virginia Hood.
Accept that sometimes discussion is not needed. Just listening together might be best.
Consider asking if your learners worry that we sometimes brush aside a patient's suffering as mere “hysteria.” Do we sometimes worry about looking foolish for caring too much?

MKSAP 17 Question

A 90-year-old woman is brought to the emergency department by her son for a 1-week history of worsening cognition, weakness, dizziness, and anorexia. She lives in an assisted-care facility and is generally alert. She is ambulatory when using a cane. Medical history includes hypertension, chronic heart failure, chronic kidney disease, osteoarthritis, allergic rhinitis, hyperlipidemia, and urinary stress incontinence. Current medications are lisinopril, bisoprolol, oxybutynin, loratadine, acetaminophen, pravastatin, and omeprazole.

On physical examination, she appears frail but is in no acute distress. Temperature is normal, blood pressure is 100/60 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. BMI is 20. Oxygen saturation is 97% with the patient breathing ambient air. There is no orthostasis. Cardiac examination discloses an irregularly irregular rate. Pulmonary examination reveals slightly diminished breath sounds bilaterally but no crackles. The abdomen is mildly distended but nontender. Rectal examination reveals hard stool that is negative for occult blood. There is no edema. Neurologic examination is nonfocal, and the patient scores 24/30 on the Mini–Mental State Examination.

Laboratory studies:

Hematocrit	34%
Leukocyte count	7100/µl (7.1 × 10⁹/L); normal differential
Creatinine	1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L])
Electrolytes	Normal
Glucose	78 mg/dL (4.3 mmol/L)
Urinalysis	Trace protein, trace ketones, no cells

Chest radiograph shows no evidence of heart failure or pulmonary infiltrates.

Which of the following is the most likely cause of this patient's recent symptoms?

A. Acute kidney injury

B. Adverse medication effects

C. Occult pneumonia

D. Urinary tract infection

Correct Answer

B. Adverse medication effects

Educational Objective

Manage polypharmacy in an older patient.

Critique

This older patient's clinical findings are most likely the result of adverse medication effects related to polypharmacy, and her drug regimen requires adjustment. She has significant medical comorbidities and is taking numerous drugs. Administration of multiple medications increases the risk for inappropriate use, drug-drug interactions, adverse reactions, poor adherence, and medication errors. This patient is taking two anticholinergic agents (oxybutynin for urinary incontinence and the over-the-counter antihistamine loratadine). The American Geriatrics Society Beers Criteria recommend against the use of anticholinergic agents in older patients because they can cause confusion, urinary retention, constipation, and dry mouth. She is also on the proton pump inhibitor omeprazole without an apparent indication for treatment. In addition, the risk-to-benefit ratio of using a lipid-lowering agent to confer long-term benefits must be reassessed in very elderly adults. Prescriptions for statins are frequently carried over from previous years, but statin use results in additional cost, extra pills, and increased risk for drug-drug interactions. Lastly, parameters for blood pressure control are less stringent in older adults, and, in this patient, antihypertensive agents should be reassessed, as her hypertension is overtreated. Ongoing review of the indications, risks, benefits, and dosing of all drugs in older patients is recommended.

This patient has a history of mild chronic kidney disease; however, with normal volume status, normal electrolytes, and a minimal change in her serum creatinine level, she does not have evidence of significant worsening of her kidney function. This would make acute kidney injury an unlikely cause of her current clinical findings.

Infections are a frequent cause of systemic symptoms, including weakness, dizziness, anorexia, and altered mental status in older patients, with pneumonia and urinary tract infection being the most common types. However, this patient has no clinical findings consistent with pneumonia given her normal oxygenation, leukocyte count, and chest radiograph, or suggestion of urinary tract infection with a normal urinalysis. Therefore, the absence of evidence of infection makes this an unlikely cause of her current clinical findings.

Key Point

Administration of multiple medications, especially in older patients, increases the risk for inappropriate use, drug-drug interactions, adverse reactions, and medication errors.

Bibliography

Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.

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中文翻译：

教育家年鉴-2017年11月7日

临床实践要点

停止在疗养院居民中使用不当的药物。聚类随机对照试验

药物处方不当是与老年人不良结局风险增加相关的常见问题。这项随机对照试验研究了医师和药剂师进行的多学科药物审查对疗养院居民中不适当药物使用的中断和临床结局的影响。

使用本文可以：

从选择题开始教学。我们在下面提供了一个！
在床边教书！与您的团队一起审查您服务中几位疗养院居民的允许用药清单。名单长吗？所有药物都是必需的吗？现在有潜在的问题吗？
询问您的学习者他们如何定义多元药房。它可能以什么方式导致不良事件？作者在研究导言中解决了这些问题。该清单是否需要较长的时间以包含不适当的药物？
回顾本整群随机对照试验中使用的干预措施（表1）。谁参与其中？如何评估药物？
您的学习者认为他们可以评估每种药物对所有患者的适当性如何？在下一次会议之前，请他们为服务中的每个患者（或他们看到的每个门诊患者）这样做。他们是否发现了任何潜在的不适当药物？
询问您的学习者是否曾经让患者服用他们认为不需要或不确定是否需要的药物。他们是否犹豫要停止未开处方的药物？他们应该如何处理这个问题？他们应该和谁说话？
谁在您的医院查看患者的出院药物清单？请看下面描述的Annals Graphic Medicine文章。患者如何最终使用不再需要的一长串药物？
询问什么是整群随机试验。它与更传统的临床试验有何不同？每种随机数的单位是什么？这种差异如何影响可能学到的东西？
这项研究在评估的次要结局中未发现差异。作者指出，该试验无权评估它们。如果一项研究“动力不足”是什么意思？查看次要结果的点估计值周围的95％置信区间（表4）。应该如何解释它们？
为什么研究可能只发现适度的影响？使用随附的社论来帮助您进行讨论。

亚临床原发性醛固酮增多症和突发性高血压的频谱。队列研究

原发性醛固酮增多症是继发性高血压的最常见和可改变的形式，通常在遇到严重高血压或低钾血症的典型表型时被考虑。这项研究评估了在正常血压人群中是否存在会增加高血压风险的亚临床原发性醛固酮增多症。

使用此研究可以：

询问您的学习者哪些患者需要评估高血压的继发原因。评估应包括哪些内容？使用在诊所：高血压快速找到答案。
原发性醛固酮增多症的表现体征和症状是什么？目前如何诊断？使用《DynaMed Plus：原发性醛固酮增多症》（ACP会员的好处）中的信息。
与您的学习者一起检查肾素和醛固酮的调节。尿钠如何受到肾素和醛固酮浓度的影响？邀请肾科医生参加您的讨论。
回顾这项研究的主要结果。作者认为，临床上与肾素无关的醛固酮增多症可能很常见，并可能影响随后发生心血管疾病的风险。您的学习者是否认为我们应该为此测试血压正常的患者？在采用这种做法之前，他们还希望进行哪些其他研究？使用随附的社论来帮助您进行讨论。

2017年美国退伍军人事务部/美国国防部临床实践指南摘要：2型糖尿病的管理

本摘要概述了美国退伍军人事务部和美国国防部针对2型糖尿病管理的2017年联合临床实践指南的关键特征。

使用此指南摘要可以：

与您的团队一起了解表1中的建议列表。核对您的学习者认为应该与他们的每位糖尿病患者联系的项目。他们将如何评估自己是否在做这些事情？您的EHR可以提供帮助吗？他们应该复习几位患者的病历吗？
您的诊所是否有可用于改善糖尿病患者护理的远程医疗系统？卫生保健团队的哪些成员可以协助提供糖尿病护理？
作者讨论了根据患者的风险，预期寿命，个人目标和其他变量来个性化血糖目标的重要性。确定血糖目标时应如何考虑这些因素？您的学习者是否知道选择目标时如何与患者讨论，以及要问什么问题？
作者讨论了他们的指南与其他指南有何不同。为什么血糖目标以这种方式不同？使用随附的社论来帮助您进行讨论。
贵机构是否有糖尿病患者住院血糖控制方案？作者有什么建议？他们为什么不建议对ICU以外的患者进行严格控制而不是ICU中的患者？作者建议在ICU以外进行“基础-推注+矫正”方法的护理，但请注意，许多住院患者仅采用“矫正”剂量的胰岛素进行滑移治疗。有什么区别？在您的中心做什么，为什么呢？

在诊所

在诊所：急性肾损伤

大约20％的住院患者发生急性肾损伤（AKI），主要并发症包括容量超负荷，电解质紊乱，尿毒症并发症和药物毒性。您的学习者是否准备好预防和管理AKI？

使用此功能可以：

要求您的学习者列出AKI的危险因素。将其列表与包装盒中提供的列表进行比较。
哪些措施可有效预防AKI，应在哪些患者中使用它们？
AKI的主要原因是什么？与您的学习者一起回顾图2。什么特征有助于区分肾脏灌注减少和急性肾小管坏死？列出可能导致AKI的药物，以及操作方法。使用框中的信息获取快速列表以帮助教学。
在床边教书（或显微镜）！尿路发现如何帮助区分潜在原因？您的学习者知道如何评估尿沉渣吗？在使用AKI服务时，将患者的新鲜尿液样本带到实验室，并检查沉积物。邀请肾脏科医生提供帮助。
使用多项选择题来介绍新主题，以便在教学中进行讨论。下载教学幻灯片。登录以回答多项选择题，并为自己申请CME / MOC积分！

漫画与医学

年鉴图形医学-“问题”列表

笑（或哭泣？）从一个简单的问题开始发展成为一个复杂的医疗问题列表。

使用此功能可以：

向学生展示动画片。他们认为作者所描绘的内容是真的吗？
是什么驱使我们的医疗系统标记所有内容？哪些做法可以帮助防止不必要的标签和不适当地的患者治疗？
该动画片与上述第一个研究中涉及的不适当药物的使用有何关系？

人文主义和专业精神

关于当病人：最坏的日子

格林伯格博士的惨败让他回想起被贴为“疯子”的病人的回忆。

通过这篇文章可以：

收听录音，由弗吉尼亚·胡德博士（Virginia Hood）朗读。
接受有时不需要讨论。最好只是一起听。
考虑询问您的学习者是否担心我们有时会把患者的痛苦抛在一边，这仅仅是“歇斯底里”。我们有时会担心因照顾过多而显得愚蠢吗？

MKSAP 17问题

一名90岁的妇女被她的儿子带到急诊室，经历了1周的认知，无力，头晕和食欲减退的病史。她住在辅助护理机构中，通常处于戒备状态。她在使用拐杖时正在走动。病史包括高血压，慢性心力衰竭，慢性肾脏疾病，骨关节炎，过敏性鼻炎，高脂血症和尿失禁。当前的药物是赖诺普利，比索洛尔，奥昔布宁，氯雷他定，对乙酰氨基酚，普伐他汀和奥美拉唑。

经身体检查，她看上去很虚弱，但没有严重的不适。温度正常，血压为100/60 mm Hg，脉搏速率为88 / min，呼吸速率为14 / min。BMI为20。患者呼吸环境空气时，氧饱和度为97％。没有矫正。心脏检查发现心律不规则。肺部检查发现双侧呼吸音略有减弱，但无crack声。腹部轻度扩张，但不嫩。直肠检查发现粪便坚硬，对潜血不利。没有水肿。神经系统检查是非重点检查，患者在迷你精神状态检查中得分为24/30。

实验室研究：

分血器	34％
白细胞计数	7100 /微升（7.1×10 ⁹ /升）; 正态微分
肌酐	1.6 mg / dL（141 µmol / L）（2个月前：1.3 mg / dL [114 µmol / L]）
电解质	普通的
葡萄糖	78 mg / dL（4.3 mmol / L）
尿液分析	痕量蛋白质，痕量酮，无细胞

胸部X光片未显示心力衰竭或肺部浸润的迹象。

以下哪项是该患者最近出现症状的最可能原因？

A.急性肾损伤

B.药物不良反应

C.隐匿性肺炎

D.尿路感染

正确答案

B.药物不良反应

教育目标

在年长的患者中管理多药房。

批判

该老年患者的临床发现很可能是与多药房相关的药物不良反应的结果，她的药物治疗方案需要调整。她患有严重的合并症，正在服用多种药物。多种药物的管理增加了使用不当，药物与药物相互作用，不良反应，依从性差和药物错误的风险。该患者正在服用两种抗胆碱能药（用于尿失禁的奥昔布宁和非处方抗组胺药氯雷他定）。美国老年医学会啤酒标准建议不要在老年患者中使用抗胆碱能药物，因为它们会引起混乱，尿retention留，便秘和口干。她还服用了质子泵抑制剂奥美拉唑，没有明显的治疗指征。此外，必须重新评估使用降脂剂带来长期利益的风险收益比。他汀类药物的处方经常从前几年延续下来，但是他汀类药物的使用会导致额外的费用，更多的药丸以及增加药物与药物相互作用的风险。最后，老年人的血压控制参数不太严格，由于过度治疗高血压，应重新评估该患者的降压药。建议对老年患者中所有药物的适应症，风险，益处和剂量进行持续审查。以及增加药物与药物相互作用的风险。最后，老年人的血压控制参数不太严格，由于高血压的治疗过度，应重新评估该患者的降压药。建议对老年患者中所有药物的适应症，风险，益处和剂量进行持续审查。以及增加药物与药物相互作用的风险。最后，老年人的血压控制参数不太严格，由于过度治疗高血压，应重新评估该患者的降压药。建议对老年患者中所有药物的适应症，风险，益处和剂量进行持续审查。

该患者有轻度慢性肾脏病病史。然而，在正常的体液状态，正常的电解质和血清肌酐水平的最小变化下，她没有肾脏功能明显恶化的证据。这将使急性肾损伤不可能成为她目前临床发现的原因。

感染是全身症状的常见原因，包括老年患者的虚弱，头晕，厌食和精神状态改变，其中以肺炎和尿路感染为最常见的类型。但是，由于该患者的正常氧合作用，白细胞计数和胸部X光片检查正常，或提示尿路感染伴有正常的尿液分析，因此没有与肺炎相符的临床发现。因此，缺乏感染的证据使得这不可能是她目前临床发现的原因。

重点

服用多种药物，尤其是在老年患者中，会增加使用不当，药物与药物相互作用，不良反应和药物错误的风险。

参考书目

Maher RL，Hanlon J，Hajjar ER。老年人使用多药房的临床后果。专家观点药物安全组织。2014; 13（1）：57-65。

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更新日期：2017-11-07

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