The Journal of Family Practice

Resources

Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67:1-44.

Centers for Disease Control and Prevention. Pertussis (whooping cough). Available at: https://www.cdc.gov/pertussis/index.html. Accessed July 6, 2018.

Resources

Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67:1-44.

Centers for Disease Control and Prevention. Pertussis (whooping cough). Available at: https://www.cdc.gov/pertussis/index.html. Accessed July 6, 2018.

Resources

Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67:1-44.

Centers for Disease Control and Prevention. Pertussis (whooping cough). Available at: https://www.cdc.gov/pertussis/index.html. Accessed July 6, 2018.

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

EVIDENCE SUMMARY

A meta-analysis of RCTs evaluating levofloxacin-based triple therapy as a secondary treatment regimen for patients with H pylori infection who had failed initial clarithromycin-based triple therapy found cure rates averaging 76% (TABLE).¹ Most of the regimens comprised levofloxacin (500 mg), amoxicillin (1 g), and a PPI (40 mg), all twice daily for 7 to 10 days. Ten-day regimens produced better cure rates than 7-day regimens (84% vs 69%; comparison statistic not supplied).

The meta-analysis also included RCTs evaluating bismuth-based quadruple therapy as secondary treatment, which found cure rates averaging 78%.¹ The regimens varied, comprising bismuth salts (120-600 mg, 2-4 times daily), metronidazole (250-500 mg, 2-4 times daily), tetracycline (250-500 mg, 2-4 times daily), and a PPI (40 mg twice daily). Longer duration of therapy produced higher cure rates (7 days=76%; 95% confidence interval [CI], 0.72-0.80 in 29 RCTs with 2097 patients; 10 days=77%; 95% CI, 0.60-0.93 in 2 RCTs with 142 patients; 14 days=82%; 95% CI, 0.76-0.88 in 12 RCTs with 831 patients).

Repeating the original clarithromycin-based triple therapy (8 RCTs, 265 patients) produced low cure rates (46%).¹

Metronidazole-based therapy has high cure rate in a homogeneous population

A meta-analysis of 24 RCTs (1611 patients) that evaluated metronidazole-based triple therapy (mostly composed of amoxicillin 750 mg, metronidazole 250 mg, and any of a number of PPIs, all dosed at 40 mg) twice daily for 7 days found cure rates averaging 87% in an exclusively Japanese study population.¹

Comparable cure rates for levofloxacin- and bismuth-based therapy

Six RCTs with a total of 1057 patients compared cure rates for levofloxacin-based triple therapy with bismuth-based quadruple therapy and found no difference.¹

Two earlier meta-analyses not included in the previously described study, comprising 8 RCTs with a total of 613 patients, produced conflicting results. The larger study (15 RCTs, 1462 patients) found no difference in cure rates.² The smaller study (7 RCTs, 787 patients) favored quadruple therapy.³

Continue to: Two secondary antibiotic regimens show similar cure rates

 

 

Two secondary antibiotic regimens show similar cure rates

A meta-analysis of 4 RCTs (total 460 patients) that compared susceptibility-guided antibiotic secondary treatment (SGT) with empiric antibiotic secondary treatment found no difference in cure rates, although the largest single RCT (172 patients) favored SGT.⁴

RECOMMENDATIONS

The Maastricht IV/Florence Consensus Report (a periodically updated European study group evaluating Helicobacter management) includes expert opinion-based guidelines for H pylori treatment that recommend using antibiotic susceptibility to select treatment regimens in the event of 2 treatment failures.⁵ The report also notes that bismuth-based quadruple therapy may not be available in all countries and has a more complex dosing regimen, and that local resistance to levofloxacin must be taken into account when prescribing levofloxacin-based triple therapy.

EVIDENCE SUMMARY

A meta-analysis of RCTs evaluating levofloxacin-based triple therapy as a secondary treatment regimen for patients with H pylori infection who had failed initial clarithromycin-based triple therapy found cure rates averaging 76% (TABLE).¹ Most of the regimens comprised levofloxacin (500 mg), amoxicillin (1 g), and a PPI (40 mg), all twice daily for 7 to 10 days. Ten-day regimens produced better cure rates than 7-day regimens (84% vs 69%; comparison statistic not supplied).

The meta-analysis also included RCTs evaluating bismuth-based quadruple therapy as secondary treatment, which found cure rates averaging 78%.¹ The regimens varied, comprising bismuth salts (120-600 mg, 2-4 times daily), metronidazole (250-500 mg, 2-4 times daily), tetracycline (250-500 mg, 2-4 times daily), and a PPI (40 mg twice daily). Longer duration of therapy produced higher cure rates (7 days=76%; 95% confidence interval [CI], 0.72-0.80 in 29 RCTs with 2097 patients; 10 days=77%; 95% CI, 0.60-0.93 in 2 RCTs with 142 patients; 14 days=82%; 95% CI, 0.76-0.88 in 12 RCTs with 831 patients).

Repeating the original clarithromycin-based triple therapy (8 RCTs, 265 patients) produced low cure rates (46%).¹

Metronidazole-based therapy has high cure rate in a homogeneous population

A meta-analysis of 24 RCTs (1611 patients) that evaluated metronidazole-based triple therapy (mostly composed of amoxicillin 750 mg, metronidazole 250 mg, and any of a number of PPIs, all dosed at 40 mg) twice daily for 7 days found cure rates averaging 87% in an exclusively Japanese study population.¹

Comparable cure rates for levofloxacin- and bismuth-based therapy

Six RCTs with a total of 1057 patients compared cure rates for levofloxacin-based triple therapy with bismuth-based quadruple therapy and found no difference.¹

Two earlier meta-analyses not included in the previously described study, comprising 8 RCTs with a total of 613 patients, produced conflicting results. The larger study (15 RCTs, 1462 patients) found no difference in cure rates.² The smaller study (7 RCTs, 787 patients) favored quadruple therapy.³

Continue to: Two secondary antibiotic regimens show similar cure rates

 

 

Two secondary antibiotic regimens show similar cure rates

A meta-analysis of 4 RCTs (total 460 patients) that compared susceptibility-guided antibiotic secondary treatment (SGT) with empiric antibiotic secondary treatment found no difference in cure rates, although the largest single RCT (172 patients) favored SGT.⁴

RECOMMENDATIONS

The Maastricht IV/Florence Consensus Report (a periodically updated European study group evaluating Helicobacter management) includes expert opinion-based guidelines for H pylori treatment that recommend using antibiotic susceptibility to select treatment regimens in the event of 2 treatment failures.⁵ The report also notes that bismuth-based quadruple therapy may not be available in all countries and has a more complex dosing regimen, and that local resistance to levofloxacin must be taken into account when prescribing levofloxacin-based triple therapy.

EVIDENCE SUMMARY

A meta-analysis of RCTs evaluating levofloxacin-based triple therapy as a secondary treatment regimen for patients with H pylori infection who had failed initial clarithromycin-based triple therapy found cure rates averaging 76% (TABLE).¹ Most of the regimens comprised levofloxacin (500 mg), amoxicillin (1 g), and a PPI (40 mg), all twice daily for 7 to 10 days. Ten-day regimens produced better cure rates than 7-day regimens (84% vs 69%; comparison statistic not supplied).

The meta-analysis also included RCTs evaluating bismuth-based quadruple therapy as secondary treatment, which found cure rates averaging 78%.¹ The regimens varied, comprising bismuth salts (120-600 mg, 2-4 times daily), metronidazole (250-500 mg, 2-4 times daily), tetracycline (250-500 mg, 2-4 times daily), and a PPI (40 mg twice daily). Longer duration of therapy produced higher cure rates (7 days=76%; 95% confidence interval [CI], 0.72-0.80 in 29 RCTs with 2097 patients; 10 days=77%; 95% CI, 0.60-0.93 in 2 RCTs with 142 patients; 14 days=82%; 95% CI, 0.76-0.88 in 12 RCTs with 831 patients).

Repeating the original clarithromycin-based triple therapy (8 RCTs, 265 patients) produced low cure rates (46%).¹

Metronidazole-based therapy has high cure rate in a homogeneous population

A meta-analysis of 24 RCTs (1611 patients) that evaluated metronidazole-based triple therapy (mostly composed of amoxicillin 750 mg, metronidazole 250 mg, and any of a number of PPIs, all dosed at 40 mg) twice daily for 7 days found cure rates averaging 87% in an exclusively Japanese study population.¹

Comparable cure rates for levofloxacin- and bismuth-based therapy

Six RCTs with a total of 1057 patients compared cure rates for levofloxacin-based triple therapy with bismuth-based quadruple therapy and found no difference.¹

Two earlier meta-analyses not included in the previously described study, comprising 8 RCTs with a total of 613 patients, produced conflicting results. The larger study (15 RCTs, 1462 patients) found no difference in cure rates.² The smaller study (7 RCTs, 787 patients) favored quadruple therapy.³

Continue to: Two secondary antibiotic regimens show similar cure rates

 

 

Two secondary antibiotic regimens show similar cure rates

A meta-analysis of 4 RCTs (total 460 patients) that compared susceptibility-guided antibiotic secondary treatment (SGT) with empiric antibiotic secondary treatment found no difference in cure rates, although the largest single RCT (172 patients) favored SGT.⁴

RECOMMENDATIONS

The Maastricht IV/Florence Consensus Report (a periodically updated European study group evaluating Helicobacter management) includes expert opinion-based guidelines for H pylori treatment that recommend using antibiotic susceptibility to select treatment regimens in the event of 2 treatment failures.⁵ The report also notes that bismuth-based quadruple therapy may not be available in all countries and has a more complex dosing regimen, and that local resistance to levofloxacin must be taken into account when prescribing levofloxacin-based triple therapy.

THE CASE

A 29-year-old G1P0 woman at 13 weeks’ gestation came in for a routine prenatal visit complaining of sudden-onset heart palpitations that were occurring about once a week. Each episode lasted between 15 and 60 minutes and was accompanied by chest tightness, with no identifiable cause. The patient could inconsistently terminate the episodes with Valsalva maneuvers. She reported having had 2 similar incidents of palpitations within the past year. Her family history was significant for sudden cardiac death of her father and paternal grandfather in their fifth decades of life.

A cardiovascular exam was normal; heart auscultation revealed a regular rate and rhythm without murmurs, rubs, or gallops, and the peripheral pulses were normal. A thyroid-stimulating hormone (TSH) level, basic metabolic panel (BMP), and complete blood count (CBC) were within normal limits. A transthoracic echocardiogram was negative for structural heart disease.

THE DIAGNOSIS

An initial Holter monitor study failed to capture an episode of her palpitations. The frequency of her palpitations increased as her pregnancy progressed, occurring almost daily by the second half of the third trimester, and a repeat Holter monitor study in the third trimester was significant for a 3-minute episode of supraventricular tachycardia (SVT) that correlated with patient-recorded symptoms (FIGURE).

Based on these results, we diagnosed the patient with an atrioventricular nodal reentry tachycardia (AVNRT). Although atrioventricular reciprocating tachycardia (AVRT) remained a remote possibility, it is far less common, and a 12-lead electrocardiogram (EKG) showed no evidence of pre-excitation.

DISCUSSION

AVNRT is the most common form of paroxysmal supraventricular tachycardia (PSVT). It occurs more frequently in women and typically manifests in the second to fourth decades of life.¹ AVNRT is a narrow complex tachycardia characterized by a heart rate of 120 to >200 beats/min.

Hemodynamic changes in pregnancy can trigger arrhythmias

During pregnancy, hemodynamic changes (including increased blood volume and cardiac output) are thought to stimulate stretch-activated ion channels within the walls of the heart.^2-4 Such changes may exacerbate previously existing cardiac arrhythmias or (less commonly) cause new-onset arrhythmias.^3,4 A family history positive for arrhythmias or sudden cardiac death increases the likelihood of developing tachyarrhythmia during pregnancy.³ Women with a known history of PSVT might experience symptom exacerbation despite being on prophylactic therapy.⁴

Detection and diagnosis

While AVNRT is relatively benign in pregnancy, other cardiac arrhythmias (eg, atrial fibrillation/flutter, ventricular tachycardia) carry a greater risk for fetal and maternal complications, underscoring the need to correctly identify the type of arrhythmia.^2,3

Continue to: Physical exam findings

Physical exam findings are often unremarkable unless the patient is actively experiencing SVT in the office, in which case prominent jugular pulsations may be seen due to simultaneous contraction of the atria and ventricles.

The initial evaluation of a pregnant patient presenting with tachycardia should include a BMP, TSH, 12-lead EKG, and transthoracic echocardiography.^3,5 In most patients with AVNRT, the results of these tests will be normal. A Holter monitor can be used to document an arrhythmia if the episodes are relatively frequent or an event monitor can be used if the episodes are infrequent.⁵

EKG findings. When patients are actively experiencing SVT, EKG findings include a P wave obscured by the QRS complex, sometimes manifesting as a pseudo-R wave in the V1 lead and a pseudo-S wave in leads II, III, and AVF. The QRS complex is narrow and the R-R interval is regular.⁶

Types of treatment

Valsalva maneuvers. Treatment of AVNRT in pregnancy should first involve addressing any precipitating causes, including metabolic and endocrine abnormalities.³ As virtually all antiarrhythmic drugs cross the placenta and are traceable in breast milk,^2,3 patients should be counseled to try to stop episodes using Valsalva maneuvers before moving to pharmacologic treatment.

Antiarrhythmics. First-line pharmacologic treatment for the prevention of AVNRT in pregnancy is metoprolol or verapamil.^2,5 Neither drug has been associated with adverse outcomes in infants, although there is a large body of evidence suggesting that low levels of metoprolol are present in breast milk.⁷

Continue to: Acute episodes of SVT that are refractory to...

Acute episodes of SVT that are refractory to vagal maneuvers or occur despite medical management can be treated acutely in pregnancy with adenosine, which effectively stops episodes about 90% of the time.² (See the TABLE^8,9 for a list of antiarrhythmics that may be used to treat AVNRT.)

Catheter ablation is first-line treatment for AVNRT in nonpregnant patients.^1,5 The risks of undergoing ablation during pregnancy include fetal exposure to radiation and anesthetic drugs.^2,3 Therefore, this treatment should be used only when pharmacologic treatment is unsuccessful and risks to the mother and fetus due to the arrhythmia outweigh the risks of the procedure. Ablation can be offered postpartum as more definitive therapy.

Our patient was started on metoprolol tartrate 12.5 mg bid at 35 weeks’ gestation due to increasingly common and persistent palpitations. This helped control the episodes for 2 weeks, at which point they increased again in frequency. These were terminated using Valsalva maneuvers; increasing the metoprolol dosage was prohibitive due to patient intolerance.

Tachyarrhythmias such as atrioventricular nodal reentry tachycardia may worsen or manifest with physiologic changes that occur during pregnancy.

Following an uncomplicated delivery, and discontinuation of metoprolol, the patient reported a decrease in both the number of episodes and the duration of SVT. Ultimately, she opted for a catheter ablation to prevent SVT exacerbation during subsequent pregnancies.

THE TAKEAWAY

AVNRT (and other tachyarrhythmias) may worsen or manifest with physiologic changes that occur during pregnancy. After establishing the diagnosis, effort should be made to manage the condition conservatively with Valsalva maneuvers and medication. Catheter ablation should be offered postpartum as a more definitive treatment option.

CORRESPONDENCE
Joseph Lane Wilson, MD, ECU Brody School of Medicine, Department of Family Medicine Medical Director, 101 Heart Drive, Greenville, NC 27834; [email protected].

THE CASE

A 29-year-old G1P0 woman at 13 weeks’ gestation came in for a routine prenatal visit complaining of sudden-onset heart palpitations that were occurring about once a week. Each episode lasted between 15 and 60 minutes and was accompanied by chest tightness, with no identifiable cause. The patient could inconsistently terminate the episodes with Valsalva maneuvers. She reported having had 2 similar incidents of palpitations within the past year. Her family history was significant for sudden cardiac death of her father and paternal grandfather in their fifth decades of life.

A cardiovascular exam was normal; heart auscultation revealed a regular rate and rhythm without murmurs, rubs, or gallops, and the peripheral pulses were normal. A thyroid-stimulating hormone (TSH) level, basic metabolic panel (BMP), and complete blood count (CBC) were within normal limits. A transthoracic echocardiogram was negative for structural heart disease.

THE DIAGNOSIS

An initial Holter monitor study failed to capture an episode of her palpitations. The frequency of her palpitations increased as her pregnancy progressed, occurring almost daily by the second half of the third trimester, and a repeat Holter monitor study in the third trimester was significant for a 3-minute episode of supraventricular tachycardia (SVT) that correlated with patient-recorded symptoms (FIGURE).

Based on these results, we diagnosed the patient with an atrioventricular nodal reentry tachycardia (AVNRT). Although atrioventricular reciprocating tachycardia (AVRT) remained a remote possibility, it is far less common, and a 12-lead electrocardiogram (EKG) showed no evidence of pre-excitation.

DISCUSSION

AVNRT is the most common form of paroxysmal supraventricular tachycardia (PSVT). It occurs more frequently in women and typically manifests in the second to fourth decades of life.¹ AVNRT is a narrow complex tachycardia characterized by a heart rate of 120 to >200 beats/min.

Hemodynamic changes in pregnancy can trigger arrhythmias

During pregnancy, hemodynamic changes (including increased blood volume and cardiac output) are thought to stimulate stretch-activated ion channels within the walls of the heart.^2-4 Such changes may exacerbate previously existing cardiac arrhythmias or (less commonly) cause new-onset arrhythmias.^3,4 A family history positive for arrhythmias or sudden cardiac death increases the likelihood of developing tachyarrhythmia during pregnancy.³ Women with a known history of PSVT might experience symptom exacerbation despite being on prophylactic therapy.⁴

Detection and diagnosis

While AVNRT is relatively benign in pregnancy, other cardiac arrhythmias (eg, atrial fibrillation/flutter, ventricular tachycardia) carry a greater risk for fetal and maternal complications, underscoring the need to correctly identify the type of arrhythmia.^2,3

Continue to: Physical exam findings

Physical exam findings are often unremarkable unless the patient is actively experiencing SVT in the office, in which case prominent jugular pulsations may be seen due to simultaneous contraction of the atria and ventricles.

The initial evaluation of a pregnant patient presenting with tachycardia should include a BMP, TSH, 12-lead EKG, and transthoracic echocardiography.^3,5 In most patients with AVNRT, the results of these tests will be normal. A Holter monitor can be used to document an arrhythmia if the episodes are relatively frequent or an event monitor can be used if the episodes are infrequent.⁵

EKG findings. When patients are actively experiencing SVT, EKG findings include a P wave obscured by the QRS complex, sometimes manifesting as a pseudo-R wave in the V1 lead and a pseudo-S wave in leads II, III, and AVF. The QRS complex is narrow and the R-R interval is regular.⁶

Types of treatment

Valsalva maneuvers. Treatment of AVNRT in pregnancy should first involve addressing any precipitating causes, including metabolic and endocrine abnormalities.³ As virtually all antiarrhythmic drugs cross the placenta and are traceable in breast milk,^2,3 patients should be counseled to try to stop episodes using Valsalva maneuvers before moving to pharmacologic treatment.

Antiarrhythmics. First-line pharmacologic treatment for the prevention of AVNRT in pregnancy is metoprolol or verapamil.^2,5 Neither drug has been associated with adverse outcomes in infants, although there is a large body of evidence suggesting that low levels of metoprolol are present in breast milk.⁷

Continue to: Acute episodes of SVT that are refractory to...

Acute episodes of SVT that are refractory to vagal maneuvers or occur despite medical management can be treated acutely in pregnancy with adenosine, which effectively stops episodes about 90% of the time.² (See the TABLE^8,9 for a list of antiarrhythmics that may be used to treat AVNRT.)

Catheter ablation is first-line treatment for AVNRT in nonpregnant patients.^1,5 The risks of undergoing ablation during pregnancy include fetal exposure to radiation and anesthetic drugs.^2,3 Therefore, this treatment should be used only when pharmacologic treatment is unsuccessful and risks to the mother and fetus due to the arrhythmia outweigh the risks of the procedure. Ablation can be offered postpartum as more definitive therapy.

Our patient was started on metoprolol tartrate 12.5 mg bid at 35 weeks’ gestation due to increasingly common and persistent palpitations. This helped control the episodes for 2 weeks, at which point they increased again in frequency. These were terminated using Valsalva maneuvers; increasing the metoprolol dosage was prohibitive due to patient intolerance.

Tachyarrhythmias such as atrioventricular nodal reentry tachycardia may worsen or manifest with physiologic changes that occur during pregnancy.

Following an uncomplicated delivery, and discontinuation of metoprolol, the patient reported a decrease in both the number of episodes and the duration of SVT. Ultimately, she opted for a catheter ablation to prevent SVT exacerbation during subsequent pregnancies.

THE TAKEAWAY

AVNRT (and other tachyarrhythmias) may worsen or manifest with physiologic changes that occur during pregnancy. After establishing the diagnosis, effort should be made to manage the condition conservatively with Valsalva maneuvers and medication. Catheter ablation should be offered postpartum as a more definitive treatment option.

CORRESPONDENCE
Joseph Lane Wilson, MD, ECU Brody School of Medicine, Department of Family Medicine Medical Director, 101 Heart Drive, Greenville, NC 27834; [email protected].

THE CASE

A 29-year-old G1P0 woman at 13 weeks’ gestation came in for a routine prenatal visit complaining of sudden-onset heart palpitations that were occurring about once a week. Each episode lasted between 15 and 60 minutes and was accompanied by chest tightness, with no identifiable cause. The patient could inconsistently terminate the episodes with Valsalva maneuvers. She reported having had 2 similar incidents of palpitations within the past year. Her family history was significant for sudden cardiac death of her father and paternal grandfather in their fifth decades of life.

A cardiovascular exam was normal; heart auscultation revealed a regular rate and rhythm without murmurs, rubs, or gallops, and the peripheral pulses were normal. A thyroid-stimulating hormone (TSH) level, basic metabolic panel (BMP), and complete blood count (CBC) were within normal limits. A transthoracic echocardiogram was negative for structural heart disease.

THE DIAGNOSIS

An initial Holter monitor study failed to capture an episode of her palpitations. The frequency of her palpitations increased as her pregnancy progressed, occurring almost daily by the second half of the third trimester, and a repeat Holter monitor study in the third trimester was significant for a 3-minute episode of supraventricular tachycardia (SVT) that correlated with patient-recorded symptoms (FIGURE).

Based on these results, we diagnosed the patient with an atrioventricular nodal reentry tachycardia (AVNRT). Although atrioventricular reciprocating tachycardia (AVRT) remained a remote possibility, it is far less common, and a 12-lead electrocardiogram (EKG) showed no evidence of pre-excitation.

DISCUSSION

AVNRT is the most common form of paroxysmal supraventricular tachycardia (PSVT). It occurs more frequently in women and typically manifests in the second to fourth decades of life.¹ AVNRT is a narrow complex tachycardia characterized by a heart rate of 120 to >200 beats/min.

Hemodynamic changes in pregnancy can trigger arrhythmias

During pregnancy, hemodynamic changes (including increased blood volume and cardiac output) are thought to stimulate stretch-activated ion channels within the walls of the heart.^2-4 Such changes may exacerbate previously existing cardiac arrhythmias or (less commonly) cause new-onset arrhythmias.^3,4 A family history positive for arrhythmias or sudden cardiac death increases the likelihood of developing tachyarrhythmia during pregnancy.³ Women with a known history of PSVT might experience symptom exacerbation despite being on prophylactic therapy.⁴

Detection and diagnosis

While AVNRT is relatively benign in pregnancy, other cardiac arrhythmias (eg, atrial fibrillation/flutter, ventricular tachycardia) carry a greater risk for fetal and maternal complications, underscoring the need to correctly identify the type of arrhythmia.^2,3

Continue to: Physical exam findings

Physical exam findings are often unremarkable unless the patient is actively experiencing SVT in the office, in which case prominent jugular pulsations may be seen due to simultaneous contraction of the atria and ventricles.

The initial evaluation of a pregnant patient presenting with tachycardia should include a BMP, TSH, 12-lead EKG, and transthoracic echocardiography.^3,5 In most patients with AVNRT, the results of these tests will be normal. A Holter monitor can be used to document an arrhythmia if the episodes are relatively frequent or an event monitor can be used if the episodes are infrequent.⁵

EKG findings. When patients are actively experiencing SVT, EKG findings include a P wave obscured by the QRS complex, sometimes manifesting as a pseudo-R wave in the V1 lead and a pseudo-S wave in leads II, III, and AVF. The QRS complex is narrow and the R-R interval is regular.⁶

Types of treatment

Valsalva maneuvers. Treatment of AVNRT in pregnancy should first involve addressing any precipitating causes, including metabolic and endocrine abnormalities.³ As virtually all antiarrhythmic drugs cross the placenta and are traceable in breast milk,^2,3 patients should be counseled to try to stop episodes using Valsalva maneuvers before moving to pharmacologic treatment.

Antiarrhythmics. First-line pharmacologic treatment for the prevention of AVNRT in pregnancy is metoprolol or verapamil.^2,5 Neither drug has been associated with adverse outcomes in infants, although there is a large body of evidence suggesting that low levels of metoprolol are present in breast milk.⁷

Continue to: Acute episodes of SVT that are refractory to...

Acute episodes of SVT that are refractory to vagal maneuvers or occur despite medical management can be treated acutely in pregnancy with adenosine, which effectively stops episodes about 90% of the time.² (See the TABLE^8,9 for a list of antiarrhythmics that may be used to treat AVNRT.)

Catheter ablation is first-line treatment for AVNRT in nonpregnant patients.^1,5 The risks of undergoing ablation during pregnancy include fetal exposure to radiation and anesthetic drugs.^2,3 Therefore, this treatment should be used only when pharmacologic treatment is unsuccessful and risks to the mother and fetus due to the arrhythmia outweigh the risks of the procedure. Ablation can be offered postpartum as more definitive therapy.

Our patient was started on metoprolol tartrate 12.5 mg bid at 35 weeks’ gestation due to increasingly common and persistent palpitations. This helped control the episodes for 2 weeks, at which point they increased again in frequency. These were terminated using Valsalva maneuvers; increasing the metoprolol dosage was prohibitive due to patient intolerance.

Tachyarrhythmias such as atrioventricular nodal reentry tachycardia may worsen or manifest with physiologic changes that occur during pregnancy.

Following an uncomplicated delivery, and discontinuation of metoprolol, the patient reported a decrease in both the number of episodes and the duration of SVT. Ultimately, she opted for a catheter ablation to prevent SVT exacerbation during subsequent pregnancies.

THE TAKEAWAY

AVNRT (and other tachyarrhythmias) may worsen or manifest with physiologic changes that occur during pregnancy. After establishing the diagnosis, effort should be made to manage the condition conservatively with Valsalva maneuvers and medication. Catheter ablation should be offered postpartum as a more definitive treatment option.

CORRESPONDENCE
Joseph Lane Wilson, MD, ECU Brody School of Medicine, Department of Family Medicine Medical Director, 101 Heart Drive, Greenville, NC 27834; [email protected].

A 52-year-old woman presented to the emergency department (ED) with a 4-month history of recurrent painful blisters on her fingertips and the tips of her toes (FIGURE 1), arthralgias, painful discoloration of her distal toes and fingers when exposed to cold, and painful nodules on her forearms. She was started on prednisone and was sent to our clinic for follow-up.

At her initial visit to our office, she was continued on prednisone and referred to Rheumatology and Interventional Cardiology, where a work-up for rheumatoid arthritis, systemic lupus erythematosus, and other vasculitides was negative. The patient had normal arterial pressures and a normal echocardiogram. An angiogram revealed segmental occlusions of the distal vessels in her arms and legs. The patient denied chest pain, syncope, dyspnea on exertion, or fever. She reported a >30 pack-year history of cigarette smoking.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Thromboangiitis obliterans

Thromboangiitis obliterans (TAO), or Buerger’s disease, is a rare nonatherosclerotic disease that affects the medium and small arteries. The disease has a male predominance, primarily occurs in those younger than 45 years of age, and is most common in people from the Middle and Far East.¹ Its distinctive features include ulcerations of the distal extremities and symptoms of claudication and pain at rest. More than 40% of affected patients develop Raynaud’s phenomenon.¹ Superficial thrombophlebitis in the form of painful nodules has also been described.²

The etiology of TAO is likely due to disordered inflammation of endothelial cells, which has a strong association with smoking.³ The exact pathogenesis is unknown, but genetics and autoimmunity are suspected contributing factors.

The diagnosis is based on exclusion of other causes

The differential diagnosis includes diabetic angiopathy, embolic disease, atherosclerosis, hypercoagulability/thrombophilia, vasculitis or connective tissue diseases, and drug-associated (eg, cocaine) vasculitis.⁴

The diagnosis of TAO is based on the exclusion of other causes, although several diagnostic criteria have been proposed, including:

• age <45 years
• current or recent history of tobacco use
• distal extremity involvement (ulcers, claudication, or pain at rest)
• exclusion of diabetes, peripheral artery disease, thrombophilia, or embolic disease
• typical arteriographic findings on imaging, including distal small to medium vessel involvement, segmental occlusions, and “corkscrew-shaped” collaterals.^1,2,5,6

Continue to: Lab tests

Lab tests. There are no specific laboratory markers for TAO. The initial evaluation should include an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete metabolic panel (CMP), and urinalysis (UA). Tests to exclude other autoimmune diseases include rheumatoid factor, antinuclear antibody, anticentromere antibody and Scl-70 to exclude CREST syndrome and scleroderma, antiphospholipid antibodies to exclude disorders of hypercoagulability, and drug testing and history-taking to evaluate for drug-related (eg, cocaine) etiologies. Further studies should be performed based on clinical suspicion.

Imaging. Patients with suspected TAO should undergo an arteriogram of the affected extremities and large arteries. Other imaging modalities include computed tomographic angiography and magnetic resonance angiography. Biopsy is rarely indicated, unless there are atypical findings, such as large artery involvement or arterial nodules. Interestingly, a positive Allen test in a young smoker can be highly suggestive of TAO.¹ (For a demonstration of the Allen test, see https://www.youtube.com/watch?v=D1tJO0RW9UM.)

Our patient tested negative for rheumatoid arthritis, CREST, and scleroderma and had a normal UA and CMP. She did have a slightly elevated anticardiolipin antibody test, but a negative lupus anticoagulant test, the significance of which is uncertain. Her CRP and ESR were elevated.

Complete smoking cessation is essential for treatment

Several treatments have been proposed, including prostanoids and surgery (surgical revascularization or endovascular therapy).^1,4 In severe cases, amputation may be required to remove the affected extremity. However, the most important and most effective treatment for TAO is smoking cessation.¹ Of note, several case reports have found that replacing smoking with other nicotine-containing products (eg, chewing tobacco) may not prevent limb loss.^7-9

Our patient was tapered off prednisone and was continued on amlodipine 5 mg/d for vasospasm. She was started on varenicline 0.5 mg/d, which was increased to twice daily by Day 4 to aid with smoking cessation. Two months later, the patient’s pain and ulcerations had almost completely resolved (FIGURE 2). She experienced occasional relapses with smoking, during which her ulcerations and Raynaud’s would return. This case reinforces the age-old aphorism of “no tobacco, no Buerger’s disease.”⁴

CORRESPONDENCE
Seth Mathern, MD, 14300 Orchard Parkway, Westminster, CO 80023; [email protected].

A 52-year-old woman presented to the emergency department (ED) with a 4-month history of recurrent painful blisters on her fingertips and the tips of her toes (FIGURE 1), arthralgias, painful discoloration of her distal toes and fingers when exposed to cold, and painful nodules on her forearms. She was started on prednisone and was sent to our clinic for follow-up.

At her initial visit to our office, she was continued on prednisone and referred to Rheumatology and Interventional Cardiology, where a work-up for rheumatoid arthritis, systemic lupus erythematosus, and other vasculitides was negative. The patient had normal arterial pressures and a normal echocardiogram. An angiogram revealed segmental occlusions of the distal vessels in her arms and legs. The patient denied chest pain, syncope, dyspnea on exertion, or fever. She reported a >30 pack-year history of cigarette smoking.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Thromboangiitis obliterans

Thromboangiitis obliterans (TAO), or Buerger’s disease, is a rare nonatherosclerotic disease that affects the medium and small arteries. The disease has a male predominance, primarily occurs in those younger than 45 years of age, and is most common in people from the Middle and Far East.¹ Its distinctive features include ulcerations of the distal extremities and symptoms of claudication and pain at rest. More than 40% of affected patients develop Raynaud’s phenomenon.¹ Superficial thrombophlebitis in the form of painful nodules has also been described.²

The etiology of TAO is likely due to disordered inflammation of endothelial cells, which has a strong association with smoking.³ The exact pathogenesis is unknown, but genetics and autoimmunity are suspected contributing factors.

The diagnosis is based on exclusion of other causes

The differential diagnosis includes diabetic angiopathy, embolic disease, atherosclerosis, hypercoagulability/thrombophilia, vasculitis or connective tissue diseases, and drug-associated (eg, cocaine) vasculitis.⁴

The diagnosis of TAO is based on the exclusion of other causes, although several diagnostic criteria have been proposed, including:

• age <45 years
• current or recent history of tobacco use
• distal extremity involvement (ulcers, claudication, or pain at rest)
• exclusion of diabetes, peripheral artery disease, thrombophilia, or embolic disease
• typical arteriographic findings on imaging, including distal small to medium vessel involvement, segmental occlusions, and “corkscrew-shaped” collaterals.^1,2,5,6

Continue to: Lab tests

Lab tests. There are no specific laboratory markers for TAO. The initial evaluation should include an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete metabolic panel (CMP), and urinalysis (UA). Tests to exclude other autoimmune diseases include rheumatoid factor, antinuclear antibody, anticentromere antibody and Scl-70 to exclude CREST syndrome and scleroderma, antiphospholipid antibodies to exclude disorders of hypercoagulability, and drug testing and history-taking to evaluate for drug-related (eg, cocaine) etiologies. Further studies should be performed based on clinical suspicion.

Imaging. Patients with suspected TAO should undergo an arteriogram of the affected extremities and large arteries. Other imaging modalities include computed tomographic angiography and magnetic resonance angiography. Biopsy is rarely indicated, unless there are atypical findings, such as large artery involvement or arterial nodules. Interestingly, a positive Allen test in a young smoker can be highly suggestive of TAO.¹ (For a demonstration of the Allen test, see https://www.youtube.com/watch?v=D1tJO0RW9UM.)

Our patient tested negative for rheumatoid arthritis, CREST, and scleroderma and had a normal UA and CMP. She did have a slightly elevated anticardiolipin antibody test, but a negative lupus anticoagulant test, the significance of which is uncertain. Her CRP and ESR were elevated.

Complete smoking cessation is essential for treatment

Several treatments have been proposed, including prostanoids and surgery (surgical revascularization or endovascular therapy).^1,4 In severe cases, amputation may be required to remove the affected extremity. However, the most important and most effective treatment for TAO is smoking cessation.¹ Of note, several case reports have found that replacing smoking with other nicotine-containing products (eg, chewing tobacco) may not prevent limb loss.^7-9

Our patient was tapered off prednisone and was continued on amlodipine 5 mg/d for vasospasm. She was started on varenicline 0.5 mg/d, which was increased to twice daily by Day 4 to aid with smoking cessation. Two months later, the patient’s pain and ulcerations had almost completely resolved (FIGURE 2). She experienced occasional relapses with smoking, during which her ulcerations and Raynaud’s would return. This case reinforces the age-old aphorism of “no tobacco, no Buerger’s disease.”⁴

CORRESPONDENCE
Seth Mathern, MD, 14300 Orchard Parkway, Westminster, CO 80023; [email protected].

A 52-year-old woman presented to the emergency department (ED) with a 4-month history of recurrent painful blisters on her fingertips and the tips of her toes (FIGURE 1), arthralgias, painful discoloration of her distal toes and fingers when exposed to cold, and painful nodules on her forearms. She was started on prednisone and was sent to our clinic for follow-up.

At her initial visit to our office, she was continued on prednisone and referred to Rheumatology and Interventional Cardiology, where a work-up for rheumatoid arthritis, systemic lupus erythematosus, and other vasculitides was negative. The patient had normal arterial pressures and a normal echocardiogram. An angiogram revealed segmental occlusions of the distal vessels in her arms and legs. The patient denied chest pain, syncope, dyspnea on exertion, or fever. She reported a >30 pack-year history of cigarette smoking.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Thromboangiitis obliterans

Thromboangiitis obliterans (TAO), or Buerger’s disease, is a rare nonatherosclerotic disease that affects the medium and small arteries. The disease has a male predominance, primarily occurs in those younger than 45 years of age, and is most common in people from the Middle and Far East.¹ Its distinctive features include ulcerations of the distal extremities and symptoms of claudication and pain at rest. More than 40% of affected patients develop Raynaud’s phenomenon.¹ Superficial thrombophlebitis in the form of painful nodules has also been described.²

The etiology of TAO is likely due to disordered inflammation of endothelial cells, which has a strong association with smoking.³ The exact pathogenesis is unknown, but genetics and autoimmunity are suspected contributing factors.

The diagnosis is based on exclusion of other causes

The differential diagnosis includes diabetic angiopathy, embolic disease, atherosclerosis, hypercoagulability/thrombophilia, vasculitis or connective tissue diseases, and drug-associated (eg, cocaine) vasculitis.⁴

The diagnosis of TAO is based on the exclusion of other causes, although several diagnostic criteria have been proposed, including:

• age <45 years
• current or recent history of tobacco use
• distal extremity involvement (ulcers, claudication, or pain at rest)
• exclusion of diabetes, peripheral artery disease, thrombophilia, or embolic disease
• typical arteriographic findings on imaging, including distal small to medium vessel involvement, segmental occlusions, and “corkscrew-shaped” collaterals.^1,2,5,6

Continue to: Lab tests

Lab tests. There are no specific laboratory markers for TAO. The initial evaluation should include an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete metabolic panel (CMP), and urinalysis (UA). Tests to exclude other autoimmune diseases include rheumatoid factor, antinuclear antibody, anticentromere antibody and Scl-70 to exclude CREST syndrome and scleroderma, antiphospholipid antibodies to exclude disorders of hypercoagulability, and drug testing and history-taking to evaluate for drug-related (eg, cocaine) etiologies. Further studies should be performed based on clinical suspicion.

Imaging. Patients with suspected TAO should undergo an arteriogram of the affected extremities and large arteries. Other imaging modalities include computed tomographic angiography and magnetic resonance angiography. Biopsy is rarely indicated, unless there are atypical findings, such as large artery involvement or arterial nodules. Interestingly, a positive Allen test in a young smoker can be highly suggestive of TAO.¹ (For a demonstration of the Allen test, see https://www.youtube.com/watch?v=D1tJO0RW9UM.)

Our patient tested negative for rheumatoid arthritis, CREST, and scleroderma and had a normal UA and CMP. She did have a slightly elevated anticardiolipin antibody test, but a negative lupus anticoagulant test, the significance of which is uncertain. Her CRP and ESR were elevated.

Complete smoking cessation is essential for treatment

Several treatments have been proposed, including prostanoids and surgery (surgical revascularization or endovascular therapy).^1,4 In severe cases, amputation may be required to remove the affected extremity. However, the most important and most effective treatment for TAO is smoking cessation.¹ Of note, several case reports have found that replacing smoking with other nicotine-containing products (eg, chewing tobacco) may not prevent limb loss.^7-9

Our patient was tapered off prednisone and was continued on amlodipine 5 mg/d for vasospasm. She was started on varenicline 0.5 mg/d, which was increased to twice daily by Day 4 to aid with smoking cessation. Two months later, the patient’s pain and ulcerations had almost completely resolved (FIGURE 2). She experienced occasional relapses with smoking, during which her ulcerations and Raynaud’s would return. This case reinforces the age-old aphorism of “no tobacco, no Buerger’s disease.”⁴

CORRESPONDENCE
Seth Mathern, MD, 14300 Orchard Parkway, Westminster, CO 80023; [email protected].

ILLUSTRATIVE CASE

Your practice manager comes to you to discuss ways that you can reduce expenses. He asks whether the practice could reduce the amount of money spent on gloves for procedures. How do you reply?

A decision involving a small difference, spread over a larger number of events, can have a sizable effect. An example is whether to use sterile vs nonsterile gloves for minor procedures. The cost difference between a box of sterile gloves and a box of nonsterile gloves is relatively small, and certainly worth the difference if the more expensive sterile gloves reduce the number of surgical site infections (SSIs).

However, if there is no difference in the number of SSIs, there may be no value to the extra cost, which, given the number of such procedures, becomes a large unnecessary expense. The choice to use sterile gloves often stems from habit, product availability, or the perceived benefit of fewer SSIs.² While some evidence exists comparing glove choice, there is wide variability in physicians’ choice of gloves.^3-5 This large systematic review compared rates of SSIs using sterile vs nonsterile gloves.

STUDY SUMMARY

RCTs/observational studies find sterile no better than nonsterile gloves

This systematic review and meta-analysis of 13 randomized controlled trials (RCTs) and observational (prospective or retrospective) studies compared infection rates using sterile vs nonsterile gloves in 11,071 unique patients undergoing cutaneous surgery, including Mohs microsurgery or outpatient dental procedures. The methods used in the review followed the Cochrane collaboration guidelines.⁶ The inclusion criteria were that the studies had to be either RCTs or observational studies. Patients included in each study underwent outpatient cutaneous or mucosal surgical procedures, including laceration repair, standard excisions, Mohs micrographic surgery, or tooth extractions. In addition to glove type, documentation of postoperative SSI was necessary for inclusion.

Methodology. The authors of the analysis reviewed a total of 512 publications for inclusion; of these, 14 met the inclusion criteria. One study was later removed due to incomplete data, leaving a total of 13 trials for the analysis. Of the 11,071 patients included in the final analysis, 1360 patients were randomly assigned to treatment with sterile gloves, while 1381 patients were assigned to treatment with nonsterile gloves as the intervention in a clinical trial. The remaining patients participated in either prospective or retrospective observational trials; 4680 patients were treated with sterile gloves, and 3650 patients were treated with nonsterile gloves. Heterogeneity was low for the included studies. Of note, the researchers performed a subgroup analysis on 9 total studies (4 RCTs and 5 observational studies) involving cutaneous surgeries only. These represented procedures most likely performed in the primary care setting.

The primary outcome of this review was postoperative wound infection. The results did not show any difference in SSIs between sterile vs nonsterile gloves in all trials (2% vs 2.1%; relative risk [RR]=1.06; 95% confidence interval [CI], 0.81-1.39). There was also no difference in infection rates in the subgroup analysis of 9 trials limited to cutaneous surgery (2.2% vs 2.2%, respectively; RR=1.02; 95% CI, 0.78-1.34) or when the analysis was limited to only RCTs.

[polldaddy:10063798]

Continue to: WHAT'S NEW

WHAT’S NEW

Highest-quality evidence shows no difference in SSIs

This systematic review found no difference in SSI rates when using sterile vs nonsterile gloves. Given that the analysis represents the highest-quality level of evidence (a systematic review of RCTs) and that sterile gloves are several times more expensive per pair than nonsterile gloves, the findings should impact future practice.

CAVEATS

A risk of bias and limited applicability

Not every trial in this meta-analysis was an RCT, and the inclusion of observational studies increases the risk of bias. However, the results of the observational studies were similar to those of the RCTs, somewhat alleviating this potential threat to validity.

The results did not show any difference in surgical site infections between sterile and nonsterile gloves.

It is worth noting that more extensive surgeries and more complicated repairs were not included in the trials, meaning that the findings are limited to oral surgery, Mohs micrographic surgery, standard incisions, and laceration repairs.

CHALLENGES TO IMPLEMENTATION

Inertia, medicolegal concerns, and personal preference

Clinical inertia may lead to slow adoption of these recommendations. Physicians may worry about potential medicolegal ramifications from this change.¹ Lastly, some physicians may prefer the fit and feel of sterile gloves for their procedures.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

Your practice manager comes to you to discuss ways that you can reduce expenses. He asks whether the practice could reduce the amount of money spent on gloves for procedures. How do you reply?

A decision involving a small difference, spread over a larger number of events, can have a sizable effect. An example is whether to use sterile vs nonsterile gloves for minor procedures. The cost difference between a box of sterile gloves and a box of nonsterile gloves is relatively small, and certainly worth the difference if the more expensive sterile gloves reduce the number of surgical site infections (SSIs).

However, if there is no difference in the number of SSIs, there may be no value to the extra cost, which, given the number of such procedures, becomes a large unnecessary expense. The choice to use sterile gloves often stems from habit, product availability, or the perceived benefit of fewer SSIs.² While some evidence exists comparing glove choice, there is wide variability in physicians’ choice of gloves.^3-5 This large systematic review compared rates of SSIs using sterile vs nonsterile gloves.

STUDY SUMMARY

RCTs/observational studies find sterile no better than nonsterile gloves

This systematic review and meta-analysis of 13 randomized controlled trials (RCTs) and observational (prospective or retrospective) studies compared infection rates using sterile vs nonsterile gloves in 11,071 unique patients undergoing cutaneous surgery, including Mohs microsurgery or outpatient dental procedures. The methods used in the review followed the Cochrane collaboration guidelines.⁶ The inclusion criteria were that the studies had to be either RCTs or observational studies. Patients included in each study underwent outpatient cutaneous or mucosal surgical procedures, including laceration repair, standard excisions, Mohs micrographic surgery, or tooth extractions. In addition to glove type, documentation of postoperative SSI was necessary for inclusion.

Methodology. The authors of the analysis reviewed a total of 512 publications for inclusion; of these, 14 met the inclusion criteria. One study was later removed due to incomplete data, leaving a total of 13 trials for the analysis. Of the 11,071 patients included in the final analysis, 1360 patients were randomly assigned to treatment with sterile gloves, while 1381 patients were assigned to treatment with nonsterile gloves as the intervention in a clinical trial. The remaining patients participated in either prospective or retrospective observational trials; 4680 patients were treated with sterile gloves, and 3650 patients were treated with nonsterile gloves. Heterogeneity was low for the included studies. Of note, the researchers performed a subgroup analysis on 9 total studies (4 RCTs and 5 observational studies) involving cutaneous surgeries only. These represented procedures most likely performed in the primary care setting.

The primary outcome of this review was postoperative wound infection. The results did not show any difference in SSIs between sterile vs nonsterile gloves in all trials (2% vs 2.1%; relative risk [RR]=1.06; 95% confidence interval [CI], 0.81-1.39). There was also no difference in infection rates in the subgroup analysis of 9 trials limited to cutaneous surgery (2.2% vs 2.2%, respectively; RR=1.02; 95% CI, 0.78-1.34) or when the analysis was limited to only RCTs.

[polldaddy:10063798]

Continue to: WHAT'S NEW

WHAT’S NEW

Highest-quality evidence shows no difference in SSIs

This systematic review found no difference in SSI rates when using sterile vs nonsterile gloves. Given that the analysis represents the highest-quality level of evidence (a systematic review of RCTs) and that sterile gloves are several times more expensive per pair than nonsterile gloves, the findings should impact future practice.

CAVEATS

A risk of bias and limited applicability

Not every trial in this meta-analysis was an RCT, and the inclusion of observational studies increases the risk of bias. However, the results of the observational studies were similar to those of the RCTs, somewhat alleviating this potential threat to validity.

The results did not show any difference in surgical site infections between sterile and nonsterile gloves.

It is worth noting that more extensive surgeries and more complicated repairs were not included in the trials, meaning that the findings are limited to oral surgery, Mohs micrographic surgery, standard incisions, and laceration repairs.

CHALLENGES TO IMPLEMENTATION

Inertia, medicolegal concerns, and personal preference

Clinical inertia may lead to slow adoption of these recommendations. Physicians may worry about potential medicolegal ramifications from this change.¹ Lastly, some physicians may prefer the fit and feel of sterile gloves for their procedures.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

Your practice manager comes to you to discuss ways that you can reduce expenses. He asks whether the practice could reduce the amount of money spent on gloves for procedures. How do you reply?

A decision involving a small difference, spread over a larger number of events, can have a sizable effect. An example is whether to use sterile vs nonsterile gloves for minor procedures. The cost difference between a box of sterile gloves and a box of nonsterile gloves is relatively small, and certainly worth the difference if the more expensive sterile gloves reduce the number of surgical site infections (SSIs).

However, if there is no difference in the number of SSIs, there may be no value to the extra cost, which, given the number of such procedures, becomes a large unnecessary expense. The choice to use sterile gloves often stems from habit, product availability, or the perceived benefit of fewer SSIs.² While some evidence exists comparing glove choice, there is wide variability in physicians’ choice of gloves.^3-5 This large systematic review compared rates of SSIs using sterile vs nonsterile gloves.

STUDY SUMMARY

RCTs/observational studies find sterile no better than nonsterile gloves

This systematic review and meta-analysis of 13 randomized controlled trials (RCTs) and observational (prospective or retrospective) studies compared infection rates using sterile vs nonsterile gloves in 11,071 unique patients undergoing cutaneous surgery, including Mohs microsurgery or outpatient dental procedures. The methods used in the review followed the Cochrane collaboration guidelines.⁶ The inclusion criteria were that the studies had to be either RCTs or observational studies. Patients included in each study underwent outpatient cutaneous or mucosal surgical procedures, including laceration repair, standard excisions, Mohs micrographic surgery, or tooth extractions. In addition to glove type, documentation of postoperative SSI was necessary for inclusion.

Methodology. The authors of the analysis reviewed a total of 512 publications for inclusion; of these, 14 met the inclusion criteria. One study was later removed due to incomplete data, leaving a total of 13 trials for the analysis. Of the 11,071 patients included in the final analysis, 1360 patients were randomly assigned to treatment with sterile gloves, while 1381 patients were assigned to treatment with nonsterile gloves as the intervention in a clinical trial. The remaining patients participated in either prospective or retrospective observational trials; 4680 patients were treated with sterile gloves, and 3650 patients were treated with nonsterile gloves. Heterogeneity was low for the included studies. Of note, the researchers performed a subgroup analysis on 9 total studies (4 RCTs and 5 observational studies) involving cutaneous surgeries only. These represented procedures most likely performed in the primary care setting.

The primary outcome of this review was postoperative wound infection. The results did not show any difference in SSIs between sterile vs nonsterile gloves in all trials (2% vs 2.1%; relative risk [RR]=1.06; 95% confidence interval [CI], 0.81-1.39). There was also no difference in infection rates in the subgroup analysis of 9 trials limited to cutaneous surgery (2.2% vs 2.2%, respectively; RR=1.02; 95% CI, 0.78-1.34) or when the analysis was limited to only RCTs.

[polldaddy:10063798]

Continue to: WHAT'S NEW

WHAT’S NEW

Highest-quality evidence shows no difference in SSIs

This systematic review found no difference in SSI rates when using sterile vs nonsterile gloves. Given that the analysis represents the highest-quality level of evidence (a systematic review of RCTs) and that sterile gloves are several times more expensive per pair than nonsterile gloves, the findings should impact future practice.

CAVEATS

A risk of bias and limited applicability

Not every trial in this meta-analysis was an RCT, and the inclusion of observational studies increases the risk of bias. However, the results of the observational studies were similar to those of the RCTs, somewhat alleviating this potential threat to validity.

The results did not show any difference in surgical site infections between sterile and nonsterile gloves.

It is worth noting that more extensive surgeries and more complicated repairs were not included in the trials, meaning that the findings are limited to oral surgery, Mohs micrographic surgery, standard incisions, and laceration repairs.

CHALLENGES TO IMPLEMENTATION

Inertia, medicolegal concerns, and personal preference

Clinical inertia may lead to slow adoption of these recommendations. Physicians may worry about potential medicolegal ramifications from this change.¹ Lastly, some physicians may prefer the fit and feel of sterile gloves for their procedures.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

THE CASE

A 22-year-old man presented to our family medicine clinic with hip pain of 2 weeks’ duration. The patient played hockey around the time of onset, but denied any specific injury. The pain, which affected the anterolateral aspect of the patient’s right hip, first started when he stood up after eating a meal. He rated the pain as an 8/10 on average and said that it was worse with movement. The patient had not shown improvement with conservative therapy (rest, ice, and ibuprofen). His medical and surgical history were noted as noncontributory. He was not taking any medications other than over-the-counter pain medication, did not drink alcohol or use tobacco, and he exercised regularly. A review of systems was negative except for right hip pain.

The physical exam revealed pain on active flexion and abduction of the hip. Passive range of motion (ROM) was negative for pain. The right hip was grossly normal with no pain on palpation or crepitus. There was no associated muscle tenderness. The patient was advised to continue to rest and ice the hip, as well as to take ibuprofen for pain relief. He was referred to Physical Therapy.

He returned to our clinic 4 weeks later with no improvement in his symptoms despite several sessions of physical therapy. We ordered radiographic images and magnetic resonance imaging (MRI) of the right hip.

THE DIAGNOSIS

Plain films (FIGURE 1A) showed bilateral avascular necrosis (AVN) of the femoral heads, which was worse on the right side than the left. An MRI (FIGURE 1B) further supported this diagnosis, revealing changes in the femoral neck consistent with a stress reaction and no significant collapse of the femoral head.

DISCUSSION

AVN of the hip has an incidence ranging from 10,000 to 20,000 new cases annually.^1,2 It has many possible causes, including trauma, systemic lupus erythematosus, glucocorticoid use, and chronic excessive alcohol use. Although the underlying pathophysiology varies, experts hypothesize that most cases are caused by a disruption of the blood supply, which leads to hyperemia and cortical destruction and collapse.^1,2

Certain medications can cause AVN

A more thorough history-taking at this patient’s initial visit would have prompted imaging at that time and ensured that the standard of care was met. Upon further investigation at his follow-up appointment, it was discovered that he had been diagnosed with acute pre-B cell lymphoblastic leukemia (ALL) 2 years earlier and had undergone chemotherapy with cytarabine, vincristine, L-asparaginase, daunorubicin, methotrexate, and glucocorticoids. This discovery, along with the lack of symptom improvement, prompted the ordering of his imaging studies. Long-term glucocorticoid therapy is the second leading cause of AVN, following traumatic events.³ High daily dosages (>40 mg/d) and high cumulative dosages of glucocorticoids are associated with a significantly increased risk for AVN.^4,5

The other chemotherapy agents with which our patient had been treated (cytarabine, vincristine, L-asparaginase, daunorubicin, and methotrexate) have no reported links to AVN. When mentioned in the literature, however, they are usually coupled with the use of dexamethasone or prednisone.

Continue to: One case report described a patient with...

One case report described a patient with acute promyelocytic leukemia who was treated with all-transretinoic acid, daunomycin, cytarabine, and a short course of dexamethasone, and was diagnosed with AVN 2 years after the cessation of chemotherapy.⁶ This demonstrates that steroid use does not need to be recent to have a contributory effect.

Did leukemic burden play a role?

We also considered whether the patient’s leukemic burden contributed to his osteonecrosis. Leukemia and its therapy regimens have been reported to cause cerebrovascular complications,⁷ so it would be logical to postulate that they might also pose a risk to the vasculature of the femoral head. One case report describes hip pain and AVN as the initial manifestation of chronic myeloid leukemia (CML).⁸ But CML is more often associated with a severely increased white blood cell (WBC) count than is ALL, and our patient’s WBC count was in the expected range for a patient in the maintenance phase of chemotherapy, making leukemic burden a less likely culprit.

Know your patient’s history

Our patient had received an initial dose of approximately 120 mg/d prednisone alone during the first 28 days of his induction therapy for ALL. In addition, he received dexamethasone maintenance therapy, which can accumulate to >140 mg/m² over the course of therapy.⁹ This information was ultimately integral to his diagnosis and treatment.

Our patient was referred to Orthopedics. He underwent therapy with alendronate and did not require surgical intervention.

THE TAKEAWAY

This case illustrates the importance of obtaining a thorough medical history, including previous drug exposures, as a means to raise or lower one’s index of suspicion appropriately.

CORRESPONDENCE
Patrick Basile, 7124 Bristol Boulevard, Edina, MN 55435; [email protected].

THE CASE

A 22-year-old man presented to our family medicine clinic with hip pain of 2 weeks’ duration. The patient played hockey around the time of onset, but denied any specific injury. The pain, which affected the anterolateral aspect of the patient’s right hip, first started when he stood up after eating a meal. He rated the pain as an 8/10 on average and said that it was worse with movement. The patient had not shown improvement with conservative therapy (rest, ice, and ibuprofen). His medical and surgical history were noted as noncontributory. He was not taking any medications other than over-the-counter pain medication, did not drink alcohol or use tobacco, and he exercised regularly. A review of systems was negative except for right hip pain.

The physical exam revealed pain on active flexion and abduction of the hip. Passive range of motion (ROM) was negative for pain. The right hip was grossly normal with no pain on palpation or crepitus. There was no associated muscle tenderness. The patient was advised to continue to rest and ice the hip, as well as to take ibuprofen for pain relief. He was referred to Physical Therapy.

He returned to our clinic 4 weeks later with no improvement in his symptoms despite several sessions of physical therapy. We ordered radiographic images and magnetic resonance imaging (MRI) of the right hip.

THE DIAGNOSIS

Plain films (FIGURE 1A) showed bilateral avascular necrosis (AVN) of the femoral heads, which was worse on the right side than the left. An MRI (FIGURE 1B) further supported this diagnosis, revealing changes in the femoral neck consistent with a stress reaction and no significant collapse of the femoral head.

DISCUSSION

AVN of the hip has an incidence ranging from 10,000 to 20,000 new cases annually.^1,2 It has many possible causes, including trauma, systemic lupus erythematosus, glucocorticoid use, and chronic excessive alcohol use. Although the underlying pathophysiology varies, experts hypothesize that most cases are caused by a disruption of the blood supply, which leads to hyperemia and cortical destruction and collapse.^1,2

Certain medications can cause AVN

A more thorough history-taking at this patient’s initial visit would have prompted imaging at that time and ensured that the standard of care was met. Upon further investigation at his follow-up appointment, it was discovered that he had been diagnosed with acute pre-B cell lymphoblastic leukemia (ALL) 2 years earlier and had undergone chemotherapy with cytarabine, vincristine, L-asparaginase, daunorubicin, methotrexate, and glucocorticoids. This discovery, along with the lack of symptom improvement, prompted the ordering of his imaging studies. Long-term glucocorticoid therapy is the second leading cause of AVN, following traumatic events.³ High daily dosages (>40 mg/d) and high cumulative dosages of glucocorticoids are associated with a significantly increased risk for AVN.^4,5

The other chemotherapy agents with which our patient had been treated (cytarabine, vincristine, L-asparaginase, daunorubicin, and methotrexate) have no reported links to AVN. When mentioned in the literature, however, they are usually coupled with the use of dexamethasone or prednisone.

Continue to: One case report described a patient with...

One case report described a patient with acute promyelocytic leukemia who was treated with all-transretinoic acid, daunomycin, cytarabine, and a short course of dexamethasone, and was diagnosed with AVN 2 years after the cessation of chemotherapy.⁶ This demonstrates that steroid use does not need to be recent to have a contributory effect.

Did leukemic burden play a role?

We also considered whether the patient’s leukemic burden contributed to his osteonecrosis. Leukemia and its therapy regimens have been reported to cause cerebrovascular complications,⁷ so it would be logical to postulate that they might also pose a risk to the vasculature of the femoral head. One case report describes hip pain and AVN as the initial manifestation of chronic myeloid leukemia (CML).⁸ But CML is more often associated with a severely increased white blood cell (WBC) count than is ALL, and our patient’s WBC count was in the expected range for a patient in the maintenance phase of chemotherapy, making leukemic burden a less likely culprit.

Know your patient’s history

Our patient had received an initial dose of approximately 120 mg/d prednisone alone during the first 28 days of his induction therapy for ALL. In addition, he received dexamethasone maintenance therapy, which can accumulate to >140 mg/m² over the course of therapy.⁹ This information was ultimately integral to his diagnosis and treatment.

Our patient was referred to Orthopedics. He underwent therapy with alendronate and did not require surgical intervention.

THE TAKEAWAY

This case illustrates the importance of obtaining a thorough medical history, including previous drug exposures, as a means to raise or lower one’s index of suspicion appropriately.

CORRESPONDENCE
Patrick Basile, 7124 Bristol Boulevard, Edina, MN 55435; [email protected].

THE CASE

A 22-year-old man presented to our family medicine clinic with hip pain of 2 weeks’ duration. The patient played hockey around the time of onset, but denied any specific injury. The pain, which affected the anterolateral aspect of the patient’s right hip, first started when he stood up after eating a meal. He rated the pain as an 8/10 on average and said that it was worse with movement. The patient had not shown improvement with conservative therapy (rest, ice, and ibuprofen). His medical and surgical history were noted as noncontributory. He was not taking any medications other than over-the-counter pain medication, did not drink alcohol or use tobacco, and he exercised regularly. A review of systems was negative except for right hip pain.

The physical exam revealed pain on active flexion and abduction of the hip. Passive range of motion (ROM) was negative for pain. The right hip was grossly normal with no pain on palpation or crepitus. There was no associated muscle tenderness. The patient was advised to continue to rest and ice the hip, as well as to take ibuprofen for pain relief. He was referred to Physical Therapy.

He returned to our clinic 4 weeks later with no improvement in his symptoms despite several sessions of physical therapy. We ordered radiographic images and magnetic resonance imaging (MRI) of the right hip.

THE DIAGNOSIS

Plain films (FIGURE 1A) showed bilateral avascular necrosis (AVN) of the femoral heads, which was worse on the right side than the left. An MRI (FIGURE 1B) further supported this diagnosis, revealing changes in the femoral neck consistent with a stress reaction and no significant collapse of the femoral head.

DISCUSSION

AVN of the hip has an incidence ranging from 10,000 to 20,000 new cases annually.^1,2 It has many possible causes, including trauma, systemic lupus erythematosus, glucocorticoid use, and chronic excessive alcohol use. Although the underlying pathophysiology varies, experts hypothesize that most cases are caused by a disruption of the blood supply, which leads to hyperemia and cortical destruction and collapse.^1,2

Certain medications can cause AVN

A more thorough history-taking at this patient’s initial visit would have prompted imaging at that time and ensured that the standard of care was met. Upon further investigation at his follow-up appointment, it was discovered that he had been diagnosed with acute pre-B cell lymphoblastic leukemia (ALL) 2 years earlier and had undergone chemotherapy with cytarabine, vincristine, L-asparaginase, daunorubicin, methotrexate, and glucocorticoids. This discovery, along with the lack of symptom improvement, prompted the ordering of his imaging studies. Long-term glucocorticoid therapy is the second leading cause of AVN, following traumatic events.³ High daily dosages (>40 mg/d) and high cumulative dosages of glucocorticoids are associated with a significantly increased risk for AVN.^4,5

The other chemotherapy agents with which our patient had been treated (cytarabine, vincristine, L-asparaginase, daunorubicin, and methotrexate) have no reported links to AVN. When mentioned in the literature, however, they are usually coupled with the use of dexamethasone or prednisone.

Continue to: One case report described a patient with...

One case report described a patient with acute promyelocytic leukemia who was treated with all-transretinoic acid, daunomycin, cytarabine, and a short course of dexamethasone, and was diagnosed with AVN 2 years after the cessation of chemotherapy.⁶ This demonstrates that steroid use does not need to be recent to have a contributory effect.

Did leukemic burden play a role?

We also considered whether the patient’s leukemic burden contributed to his osteonecrosis. Leukemia and its therapy regimens have been reported to cause cerebrovascular complications,⁷ so it would be logical to postulate that they might also pose a risk to the vasculature of the femoral head. One case report describes hip pain and AVN as the initial manifestation of chronic myeloid leukemia (CML).⁸ But CML is more often associated with a severely increased white blood cell (WBC) count than is ALL, and our patient’s WBC count was in the expected range for a patient in the maintenance phase of chemotherapy, making leukemic burden a less likely culprit.

Know your patient’s history

Our patient had received an initial dose of approximately 120 mg/d prednisone alone during the first 28 days of his induction therapy for ALL. In addition, he received dexamethasone maintenance therapy, which can accumulate to >140 mg/m² over the course of therapy.⁹ This information was ultimately integral to his diagnosis and treatment.

Our patient was referred to Orthopedics. He underwent therapy with alendronate and did not require surgical intervention.

THE TAKEAWAY

This case illustrates the importance of obtaining a thorough medical history, including previous drug exposures, as a means to raise or lower one’s index of suspicion appropriately.

CORRESPONDENCE
Patrick Basile, 7124 Bristol Boulevard, Edina, MN 55435; [email protected].

THE CASE

A 35-year-old police officer visited his family physician (FP) with complaints of low energy, trouble sleeping, a lack of enjoyment in life, and feelings of hopelessness that have persisted for several months. He was worried about the impact they were having on his marriage and work. He had not experienced suicidal thoughts. His Patient Health Questionnaire (PHQ9) score was 18 (moderately severe depression). He had been seen intermittently for similar complaints and had tried several medications (fluoxetine, bupropion, and citalopram) without much effect. He was taking no medications now other than an over-the-counter multivitamin. He had one brother with anxiety and depression. He said his marriage counselor expressed concerns that he might have bipolar disorder or borderline personality disorder.

How would you proceed with this patient?

The prevalence of a spectrum of bipolarity in the community has been shown to be 6.4%.¹ Depressive episodes predominate in bipolar disorder (BPD),² with patients spending less time in manic or hypomanic states.³ Not surprisingly, then, depressive episodes are the most common presentation of BPD.

The depressive symptoms of BPD and unipolar depression, or major depressive disorder (MDD), are similar, making it difficult to distinguish between the disorders.³ As a result, BPD is often misdiagnosed as MDD.^4,5 Zimmerman et al point out that “bipolar disorder is prone to being overlooked because its diagnosis is more often based on retrospective report rather than presenting symptoms of mania or hypomania assessment.”⁶

Accurately recognizing BPD is essential in selecting effective treatment. It’s estimated that approximately one-third of patients given antidepressants for major depression show no treatment response,⁷ possibly due in part to undiagnosed BPD being more prevalent than previously thought.^4,8 Failure to distinguish between depressive episodes of BPD and MDD before prescribing medication introduces the risk of ineffective or suboptimal treatment. Inappropriate treatment can worsen or destabilize the course of bipolar illness by, for instance, inducing rapid cycling or, less commonly, manic symptoms.

Screen for BPD when depressive symptoms are present

Identifying BPD in a patient with current or past depressive symptoms requires screening for manic, hypomanic, and mixed episodes (TABLE 1⁹). Two brief, complementary screening tools — the Mood Disorder Questionnaire (MDQ) and the 9-item PHQ9—are helpful in this assessment. Both questionnaires (TABLE 2^8,10-14) can be conveniently completed by the patient in the waiting room or with staff assistance before the physician encounter.