Postpartum Depression
Which one of the following statements about screening for peripartum depression is correct?
a. Thyroid-stimulating hormone and prolactin should be measured in all peripartum patients with symptoms of depression.
b. Peripartum depression should be considered in all patients who are pregnant or postpartum who have symptoms for three to four days.
c. Patients who screen positive should be assessed for suicidal ideation and comorbid anxiety disorder.
d. Initial screening is recommended using the Patient Health Questionnaire-2 screening tool.
c
Peripartum depression must be differentiated from the baby blues. The baby blues typically occur within two to three days of delivery and recede by 10 days postpartum. Peripartum depression lasts for more than two weeks. Laboratory testing is not routinely recommended. When peripartum depression is identified, further evaluation should occur. The patient should be screened for suicidal ideation and considered for anxiety screening, given the high comorbidity rate between depression and anxiety. The most widely used tools are the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9. These tools are recommended by the U.S Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics for peripartum depression screening.
Which one of the following statements about primary aldosteronism is correct?
a. A normal potassium level excludes the diagnosis.
b. It can lead to hyperkalemia.
c. It is the cause of hypertension in more than 1 in 20 patients in primary care settings.
d. Well-controlled hypertension excludes the diagnosis.
c
Primary aldosteronism has been shown to be the underlying cause of hypertension in roughly 6% of patients in primary care settings. Primary aldosteronism should be considered in patients with resistant hypertension and in those with controlled hypertension and a first-degree relative with primary aldosteronism, hypokalemia, an adrenal nodule, atrial fibrillation, obstructive sleep apnea, or a family history of an early stroke (i.e., younger than 40 years). A normal potassium level does not exclude the diagnosis.
Which one of the following treatments is the most effective for the prevention of delirium in patients who are hospitalized?
a. Nonpharmacologic interventions.
b. Haloperidol, 1 mg intravenously.
c. Aripiprazole, 5 mg orally.
d. Olanzapine (Zyprexa), 10 mg orally.
a
A multidisciplinary approach that addresses sleep hygiene, cognitive impairment, immobility, visual and hearing impairment, and dehydration should be used to prevent delirium. Antipsychotics should not be used for the prevention of delirium in patients who are hospitalized.
Clinical Question
Is chlorthalidone or hydrochlorothiazide (HCTZ) associated with a difference in the rate of major adverse cardiovascular events when used to treat hypertension?
There is no difference in cardiovascular outcomes when HCTZ is compared with chlorthalidone. There is a slightly higher risk of hypokalemia with chlorthalidone. (Level of Evidence = 1b)
Your 52-year-old patient who has diverticulosis presents with left-sided cramping abdominal pain, diarrhea, and nausea. There is no evidence of sepsis, and radiography corroborates your suspicion that this is uncomplicated diverticulitis. Which one of the following statements about antibiotic therapy for uncomplicated diverticulitis is correct? (check one)
a. It decreases the risk of emergency surgery within 30 days.
b. It lowers the risk of surgery after 30 days.
c. It lowers the risk of all-cause mortality.
d. It does not lower the risk of emergency surgery or mortality.
a
A systematic review showed that antibiotics for uncomplicated diverticulitis do not decrease the risk of complications or the need for surgery. This conclusion is consistent with the American Gastroenterological Association guidance that suggests selectively using antibiotics in patients with acute uncomplicated diverticulitis who are immunocompromised, pregnant, or critically ill.
Which one of the following statements about peripartum depression and medications is correct?
a. Use of selective serotonin reuptake inhibitors has not been associated with poor pregnancy outcomes.
b. Breastfeeding is an absolute contraindication to pharmacotherapy.
c. Omega-3 fatty acids are recommended for prevention in patients in their second and third trimesters.
d. If the benefit outweighs the risk, sertraline, citalopram, and escitalopram may be considered for treatment during pregnancy.
d
There is low-quality evidence for supplements such as omega fatty acids, vitamin D, folate, and St. John’s wort, and more robust studies are needed. Sertraline, citalopram, and escitalopram have not been associated consistently with negative outcomes and may be considered if the risk of untreated or inadequately treated depression outweighs the risk of medication use during pregnancy. Paroxetine and fluoxetine have been associated with an increased risk of specific birth defects and should be avoided during pregnancy. Breastfeeding is not an absolute contraindication to pharmacotherapy, and the risks of medication use must be weighed against the risks of untreated or inadequately treated depression.
Your patient is hypertensive and has risk factors for primary aldosteronism. Which one of the following steps would be appropriate for initial case detection?
a. Measure aldosterone levels two hours after oral administration of an angiotensin-converting enzyme inhibitor.
b. Simultaneously measure plasma aldosterone concentration and plasma renin activity.
c. Measure 24-hour urine aldosterone level after three days of a high-salt diet.
d. Order computed tomography of the adrenal glands.
b
Initial case detection for primary aldosteronism is performed by simultaneously measuring plasma aldosterone concentration and plasma renin levels. Confirmatory testing may include the captopril challenge test, the oral salt loading test, or the fludrocortisone test. Computed tomography is used in subtyping primary aldosteronism.
Which one of the following strategies is a useful intervention to prevent delirium?
a. Sufficient hydration and nutrition.
b. Bed rest.
c. Opioids to eliminate pain.
d. Physical restraints.
a
Nonpharmacologic interventions are the foundation of delirium management and prevention. A meta-analysis of four randomized trials found a 44% decrease in delirium with conservative treatment only. Nonpharmacologic management includes sufficient hydration and nutrition, early mobilization, pain management, and infection prevention. The use of opioids may exacerbate delirium. Physical restraints have been correlated with worse outcomes.
Clinical Question
Is a strategy of treat-to-target statin dosing noninferior to high-intensity dosing for adults with coronary artery disease (CAD)?
Bottom Line
The study found that statin dosing based on a treat-to-target low-density lipoprotein (LDL) level of 50 to 70 mg per dL (1.29 to 1.81 mmol per L) is noninferior to a high-intensity strategy to reduce adverse events in adults with established CAD. Although the authors see this as an advantage that allows a tailored approach for individual dosing variability, it also serves as some of the best evidence yet that CAD can be managed with a high-intensity strategy and patients can avoid the costs and burdens of repeated LDL testing. (Level of Evidence = 1b)
Which one of the following statements about the Ask Suicide-Screening Questions tool is correct?
a. It has not been validated for use in the primary care setting.
b. It has not been validated for use in the emergency department.
c. It takes 20 minutes to administer.
d. The negative predictive value was 99.5% to 100% in the study populations.
d
The Ask Suicide-Screening Questions tool has been validated in emergency department, primary care, and hospital settings. The tool consists of four questions that can be completed in minutes. The test was found to be highly sensitive for suicidal ideation, with a negative predictive value of 99.5% to 100% across settings.
Name 5 risk factors of peripartum depression
Adolescent pregnancy
breastfeeding issues
comorbid anxiety
hx of depression
hx of physicaal / sexual abuse
Lack of financial support
Lack of social support
Low SES
Ongoing stressful event
Pre-existing DM or gestational DM
Unplanned pregnancy
1. What are the clinical criteria for patients who require case detection testing for primary aldosteronism?
controlled HTN
- adrenal nodule
- atrial fibrillation
- family hx of early stroke
- first degree relative with primary aldosteronism
- hypokalemia
- OSA
Resistant HTN
- all patients
Clinical Question
In patients with pain and function loss due to knee osteoarthritis, does high-dose medical exercise therapy improve pain and function scores more than low-dose exercise?
Bottom Line
Tailored exercise therapy, at least 20 to 30 minutes three times per week, improves pain and function scores in approximately one-half of patients with painful knee osteoarthritis. For patients interested in sports and recreation, high-dose, longer exercise (70 to 90 minutes) produces better results. (Level of Evidence = 1b−)
Clinical Question
What is the best pharmacologic approach in adults 60 years and older with treatment-resistant depression?
Bottom Line
There are several takeaways from the trial. Aripiprazole and bupropion augmentation produce similar modest improvements, and both are a reasonable option. Although injurious falls appear to be more common with bupropion, the authors did not report weight gain and hyperglycemia, which are both known adverse effects of aripiprazole. In the second comparison, a switch to nortriptyline seems preferable to lithium augmentation based on the simplicity of dosing and a lower risk of injurious falls. (Level of Evidence = 1b−)
A 53-year-old patient without diabetes mellitus is admitted to the hospital for a skin and soft tissue infection after outpatient antibiotic therapy has failed. On day 2, point-of-care testing shows a glucose level of 220 mg per dL (12.21 mmol per L). According to the Endocrine Society, which one of the following treatments would be most appropriate for this patient? (check one)
a. Start basal-bolus treatment with basal, mealtime, and corrective insulin.
b. Corrective insulin dosing for elevated glucose.
c. Daily dipeptidyl-peptidase-4 inhibitors.
d. Insulin pump therapy.
b
Corrective insulin dosing, also called sliding scale insulin, results in only slight increases in average glucose levels compared with basal-bolus regimens and appears to decrease the risk of hypoglycemia. For patients without diabetes, and patients with diabetes not treated by insulin, corrective insulin dosing (sliding scale insulin) alone is recommended. Although some evidence suggests that dipeptidyl-peptidase-4 inhibitors offer glycemic control equivalent to that of insulin for patients with diabetes, they have not been studied in patients without diabetes. Insulin pump therapy is recommended only for patients who use an insulin pump as an outpatient.
1. What is first line medication for patients at risk for peripartum depression?
2. What is first line medication for patients with peripartum depression?
The U.S. Preventive Services Task Force recommends referral for cognitive behavior therapy (i.e., talk therapy that focuses on one's negative thinking and explores ways to change it) and interpersonal psychotherapy (i.e., talk therapy that focuses on interpersonal functioning) for all pregnant people at increased risk of perinatal depression.
Psychotherapy is the most widely studied intervention, with a reduction of up to 39% in the risk of development of peripartum depression.
2. Although psychotherapy is the mainstay of treatment, selective serotonin reuptake inhibitors (SSRIs) may be considered in those with moderate to severe peripartum depression.32 Risks of medication use during pregnancy and breastfeeding must be weighed against the risks of untreated or inadequately treated depression
When do you perform confirmatory testing?
Name and explain 2 confirmatory tests for primary aldosteronism
- if aldosterone-renin ratio > 30 and if plasma renin activity 0.6-1 ng/ml/hr OR plasma aldo 11-19 ng/dl or plasma aldo 20-29 with (K>3.5 or K<3.5)
CAPTOPRIL CHALLENGE TEST
In the captopril challenge test, aldosterone levels are measured at baseline and then two hours after oral administration of 25 to 50 mg of the angiotensin-converting enzyme inhibitor captopril. In patients without primary aldosteronism, interruption of the RAAS by an angiotensin-converting enzyme inhibitor will cause a significant decrease in plasma aldosterone levels. A decrease of less than 30% is consistent with autonomous aldosterone secretion (i.e., primary aldosteronism).
ORAL SALT LOADING TEST
For the oral salt loading test, a high-salt diet supplemented with sodium chloride tablets is consumed for three days with a goal sodium intake of 6 g per day. High salt intake should cause physiologic suppression of the RAAS and a marked decrease in aldosterone levels. A 24-hour urine collection is performed on the third day. Persistently elevated 24-hour urine aldosterone levels (more than 12 mcg in 24 hours) are consistent with nonphysiologic production of aldosterone and confirm the diagnosis of primary aldosteronism. The saline infusion test can also confirm pathologic aldosterone production if plasma aldosterone concentration is greater than 10 ng per dL after an infusion of 2 L of normal saline.
FLUDROCORTISONE TEST
The fludrocortisone test involves administration of the synthetic mineralocorticoid fludrocortisone at a dosage of 0.1 mg every six hours for four days. Exogenous mineralocorticoid administration should suppress serum aldosterone levels. A plasma aldosterone concentration of greater than 6 ng per dL on day 4 confirms the diagnosis of primary aldosteronism.
1. what is confusion assessment method?
2. what the criteria
Initially developed in the late 1980s, the Confusion Assessment Method was created to increase recognition of delirium. This tool provides a standardized method enabling nonpsychiatric-trained clinicians to identify delirium quickly and accurately in clinical settings. A positive screen for delirium requires an abnormal rating for criteria 1 and 2 and either 3 or 4
- acute onset and fluctuating course
- Inattention
- disorganized thinking
- altered level of consciousness
Clinical Question
What is the best pharmacologic approach in adults 60 years and older with treatment-resistant depression?
Bottom Line
There are several takeaways from the trial. Aripiprazole and bupropion augmentation produce similar modest improvements, and both are a reasonable option. Although injurious falls appear to be more common with bupropion, the authors did not report weight gain and hyperglycemia, which are both known adverse effects of aripiprazole. In the second comparison, a switch to nortriptyline seems preferable to lithium augmentation based on the simplicity of dosing and a lower risk of injurious falls. (Level of Evidence = 1b−)
A 55-year-old man presents after being admitted for heart failure exacerbation. During the admission, an echocardiogram shows a left ventricular ejection fraction of 38%. He is currently taking lisinopril, atorvastatin, carvedilol (Coreg), and spironolactone. According to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, which one of the following medications should also be offered? (check one)
a. Empagliflozin (Jardiance), a sodium-glucose cotransporter-2 (SGLT-2) inhibitor.
b. Hydralazine, a vasodilator.
c. Isosorbide dinitrate, a nitrate.
d. Verapamil, a nondihydropyridine calcium channel blocker.
a
The ACC, AHA, and Heart Failure Society of America recommend guideline-directed medical therapy for symptomatic heart failure with reduced ejection fraction, including a renin-angiotensin system inhibitor, one of three beta blockers proven effective in heart failure, a mineralocorticoid receptor antagonist, and a SGLT-2 inhibitor. In this case, only a SGLT-2 inhibitor is missing from the patient’s medication, and the recommendation is independent of the presence of diabetes mellitus. There is some evidence of a benefit from hydralazine and isosorbide dinitrate in patients who self-identify as African American, but this is controversial because the main evidence is from a single study that was stopped early, it has minimal testing in patients who do not identify as African American, and the regimen is poorly tolerated in practice. Calcium channel blockers should be avoided in heart failure, especially nondihydropyridine calcium channel blockers such as verapamil.
What SSRIs need to be avoided in pregnancy?
Although most SSRIs have not been linked to birth defects, paroxetine and fluoxetine have been associated with an increased risk and should be avoided during pregnancy and lactation
1. what is the treatment for UNILATERAL ALDOSTERONE PRODUCTION?
2. What is the treatment for bilateral aldosterone production?
1. Adrenalectomy
Compared with medical management, adrenalectomy reduces the rate of composite adverse cardiovascular outcomes by one-half 31 and is associated with superior quality of life.
2. Medical therapy is essential - Mineralocorticoid receptor antagonists are the cornerstone of therapy for patients with primary aldosteronism. They are often used concurrently with other antihypertensives. Dietary sodium restriction of less than 1,500 mg per day is recommended. Spironolactone is a nonselective mineralocorticoid receptor antagonist and is the initial medication of choice.
Typical starting dosages are 12.5 to 25 mg per day and are increased, as needed, to a maximum dosage of 400 mg per day
What are the criteria for formal diagnosis of delirium per the Diagnostic and Statistical Manual of Mental Disorders, 5th ed.,?
The DSM-5 classification of delirium includes (1) a disturbance in attention, (2) an acute change from baseline, (3) a disturbance in cognition, (4) that the first two criteria are not better explained by another preexisting neurocognitive diagnosis, and (5) that the disturbance is not a direct consequence of another medical condition
What is the recommendation for Folic Acid Supplementation for the Prevention of Neural Tube Defects per USPSTF
What is the timeframe for this
The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid.
For all persons planning to or could be pregnant, atleast one month prior to pregnancy and through 2-3 months into pregnancy.
This does not apply to persons who have had previous pregnancy affected by neural tube defecrs or at very high risk from family hx of folic acid blocking receptors etc
D.H., a 24-year-old patient with opioid use disorder, presents to my clinic for care following minor injuries sustained during an altercation with the police. D.H. spent the weekend in a detention center before being able to post bail. During initial screening for mental health and substance use, D.H. reports symptoms of hypervigilance and increased opioid cravings. What specific clinical or medicolegal issues should I, as the treating family physician, consider or be aware of to optimize the quality of care provided to this patient?
In the case presented here, the family physician should clearly and concisely inquire about D.H.'s justice system involvement, including their police encounter and detention. The physician should assess the patient's injuries and provide follow-up care as needed. If possible, D.H. should begin taking buprenorphine and be prescribed naloxone, given their high risk of overdose.
The physician should address their fiduciary role and legal and ethical responsibilities to act in the patient's interest.
The physician should strongly encourage and facilitate follow-up with counseling, case management and/or social work support and care for SUD, and primary care.
If equipped to address, the physician should use validated social screening tools and referrals to assist the patient's life needs and other social drivers of health