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Clinical Practice Points
Video Learning – Annals Consult Guys - Nausea and Vomiting After Surgery
Geno and Howard, the Consult Gurus, take on how to approach the problem of nausea and emesis in patients after surgery.
Use this feature to:
Ask your learners what variables increase the risk for postoperative nausea and vomiting. How do your learners manage it? Do they consider prophylactic treatment?
Now, watch the short video with your learners.
Ask your learners whether they inquire about previous postoperative nausea and vomiting when evaluating a patient for planned surgery. Should they? Will it alter their management?
What drugs are useful for the prevention of postoperative nausea and vomiting? What receptors do they target?
Which patients should receive prophylaxis? How would your learners choose an agent to use?
Log on and answer the multiple-choice question to earn CME/MOC credit!
Altered Risk for Cardiovascular Events With Changes in the Metabolic Syndrome Status. A Nationwide Population-Based Study of Approximately 10 Million Persons
Metabolic syndrome has become a growing public health problem worldwide. Much effort has been devoted to the prevention and treatment of this syndrome because affected persons have increased risk for cardiovascular disease. The objective of this population-based retrospective cohort study was to evaluate the risk for major adverse cardiovascular events among persons who develop or recover from metabolic syndrome.
Use this study to:
Ask your learners how metabolic syndrome is defined.
Discuss why metabolic syndrome is important.
Ask your learners whether they discuss the importance of metabolic syndrome with their patients. How do they explain the risks? What are their goals in such discussions? To motivate the patient? To scare the patient?
Look at Figure 2 with your learners. How might these results be helpful in discussions with patients to motivate change?
Suicide Case-Fatality Rates in the United States, 2007 to 2014. A Nationwide Population-Based Study
The suicide case-fatality rate (CFR)—the proportion of suicidal acts that are fatal—depends on the distribution of methods used in the act and the probability of death given a particular method. In this cross-sectional study, the authors use data from 3 large databases from 2007 to 2014 to evaluate rates of suicide deaths and nonfatal suicide attempts, overall and method-specific CFRs, and distributions of methods used among persons aged 5 years or older.
Use this study to:
Ask your learners whether and when they ask patients about suicidal thoughts.
What do they ask?
Is the rate of suicidal acts higher for men or women? Are suicidal acts more commonly fatal in men or women? Why?
Do your learners discuss the presence of firearms in their patients' homes? Should they? How should they do so? What should be discussed? Use the recent In the Clinic: Preventing Firearm-Related Death and Injury.
Cases in Precision Medicine: The Role of Tumor and Germline Genetic Testing in Breast Cancer Management
Genetic testing has improved the care of women with breast cancer, informing therapeutic and preventive management decisions. As a result of increasing availability and use of genetic testing, physicians frequently need to address patients' questions and concerns about the meaning of test results. The authors explain the importance of somatic and germline mutation analyses and their implications for patients and their families.
Use this feature to:
Start a teaching session with a multiple-choice question. We've provided one below!
Read the presentation of the 47-year-old woman in the first paragraph to your learners.
Then, ask your learners whether genetic testing would influence the care of this patient.
Ask what the difference is between germline genetic testing and somatic testing of a tumor. How is each used?
What counseling should occur before germline testing is performed? Invite a genetic counselor to join your discussion.
MKSAP 18 Question
A 26-year-old woman is interested in genetic testing for BRCA1 and BRCA2 gene mutations based on her family history. Her mother was diagnosed with triple-negative breast cancer at age 53 years and died at age 55 years. Her maternal aunt was diagnosed with ovarian cancer at age 48 years and is still alive but is not interested in genetic testing. Her maternal and paternal relatives are of Ashkenazi Jewish descent. The patient is premenopausal and takes no medications.
On physical examination, vital signs are normal. Breast and gynecologic examination findings are normal.
Which of the following is the most appropriate management?
A. Recommend a direct-to-consumer genetic test
B. Recommend against genetic testing
C. Recommend genetic testing for the three BRCA1 and BRCA2 mutations most common in patients of Ashkenazi Jewish ethnicity
D. Refer to a genetic counselor
Correct Answer
D. Refer to a genetic counselor
Educational Objective
Recommend genetic counseling to an asymptomatic patient with a family history of BRCA-related cancers.
Critique
The most appropriate management for this patient is referral to a genetic counselor. This patient has a family history suggestive of an inherited breast and ovarian cancer susceptibility gene and is interested in genetic testing. Both her mother and maternal aunt had cancers suggestive of a BRCA1 or BRCA2 mutation. Women with triple-negative breast cancers diagnosed before age 60 years are recommended to have BRCA1 and BRCA2 genetic testing, as are women with ovarian cancer diagnosed at any age. Referral to a genetic counselor or other suitably trained health care provider is the best option for genetic risk assessment. The U.S. Preventive Services Task Force has published guidelines for risk assessment and recommends referral to a genetic counselor for asymptomatic women who have not been diagnosed with a BRCA-related cancer but have a family history of BRCA-related cancers. These guidelines include screening tools designed to identify a family history that may be associated with an increased risk for BRCA1 or BRCA2 mutations. Family history factors suggesting an increased likelihood of BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in one or more male family members, multiple cases of breast cancer in the family, one or more family member with two primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity. Genetic counseling should always occur before any genetic test is performed. The essential components of counseling include informing the patient of the test purpose, implications of diagnosis, alternative testing options (including foregoing testing), and any possible risks and benefits. The National Society of Genetic Counselors Web site can be used to locate a genetic counselor.
Direct-to-consumer tests may not include the appropriate type of genetic testing. In addition, genetic testing should be done after pretest genetic counseling, which is not always available in patients being tested by direct-to-consumer commercial genetic tests.
Although BRCA1 and BRCA2 testing for the three mutations most common in the Ashkenazi Jewish population (called multisite testing) is recommended for Ashkenazi Jewish women with breast cancer diagnosed at any age, comprehensive BRCA1 and BRCA2 testing is recommended if additional criteria for BRCA1/2 testing are met.
Key Point
Asymptomatic patients with a family history of BRCA-related cancers should receive genetic counseling for genetic risk assessment.
Bibliography
Moyer VA; U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:271-81.
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