<i>Annals</i> for Educators - 16 August 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives16 August 2016Annals for Educators - 16 August 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201608160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThe Prevalence of Resident-to-Resident Elder Mistreatment in Nursing HomesMistreatment of nursing home residents by staff is a well-known phenomenon, and policies and initiatives have been developed to detect, prevent, and prosecute such abuse. In an observational study, mistreatment committed by other residents, including threats and physical, verbal, and sexual actions, was determined and compared with that committed by staff.Use this study to:Ask your learners to list the ways in which elderly patients might be abused. What forms of abuse need to be considered, beyond physical and psychological? Use the accompanying editorial to help frame the discussion.When should we consider the possibility that our patients have been victims of elder abuse?Road trip! Have your learners ever visited a nursing home? Do they think visiting one (or more) might help them to better understand their patients' worlds and factors that might be important to consider when providing care and/or planning ongoing care? Can you plan a visit to one of the nursing homes where patients on your service reside?In what ways might patients be financially abused? By whom?During team rounds, ask each of the patients on your service about his or her living arrangement. Do they like them? Do they feel safe? What would they change given their medical needs? To whom can they turn for help when they have problems?Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for PainUnintentional overdose involving opioid analgesics is a leading cause of death in the United States. This study evaluates the feasibility and impact of prescribing naloxone prescription to patients receiving opioids for chronic pain in 6 safety net primary care clinics in San Francisco.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners to describe the physical examination findings of opioid overdose. What findings may be seen at the skin? The eyes? What are the cardiovascular complications? What are the arterial blood gas findings? Use the information in DynaMed Plus: Opioid Overdose (a benefit of your ACP membership) to help prepare a teaching session.How should an opioid overdose be managed? What are the immediate concerns? Who requires intubation and mechanical ventilation?Review the results of this study. Ask your learners if they have prescribed naloxone to their patients who use opioids for treatment of chronic pain. Should they? What might be the benefits or concerns? What does the Centers for Disease Control and Prevention recommend? Use the accompanying editorial to help frame your discussion.How is naloxone prescribed? How are patients and their families taught to use it? See the patient educational material included as an appendix to this research paper. Could these materials be helpful in your learners' practice?Is naloxone being coprescribed with long-term opioids to outpatients in your health system? Could your learners design a study using your electronic health record to find out? Are any approvals needed for such a study? How could they use the results to help educate clinicians? How would your learners propose to measure the effect of such an intervention?Video LearningThe Consult Guys - Fact or Fiction: O2 for Myocardial Infarction?In this episode of the consultative medicine talk show, Howard and Geno (The Consult Guys) challenge us to consider what we know about the common practice of routinely providing supplemental oxygen to patients with myocardial infarction.Use this feature to:Take a brief break with your team to watch the video.Ask your team what the theoretical rational for supplemental oxygen use is in acute coronary syndromes. Are there mechanisms by which it might be harmful?How do practices become “entrenched” in medical practice if they have not been proven to be effective?What do your learners plan to do in the future? Will they use supplemental oxygen in all their patients with myocardial infarction?Enter your answers to the brief multiple-choice questions online to earn CME for yourself!Understanding Clinical Research—Terms for the FutureGenomic Alteration–Driven Clinical Trial Designs in OncologyNew designs for precision medicine in oncology clinical trials are being developed to utilize our greater understanding of the molecular heterogeneity of human cancer types. The author describes some of the newer trial designs, cites examples of such trials, and presents detailed schematics to highlight their important features.Use this paper to:Ask what the goal of randomization is in a clinical trial. What are the benefits and shortcomings of population heterogeneity in a clinical trial?Review phase 1, 2, and 3 trials and their goals. The author provides a concise summary.Ask why “conventional” trials that enroll and randomize patients on the basis of the primary tumor site and stage might be less than optimal in oncology. How does current understanding of tumor biology and progression, together with the emergence of drugs targeting the effects of specific gene mutations, suggest the potential benefit of a “basket” trial?Invite an oncologist and/or someone expert in oncology clinical trials to discuss what the terms “basket,” “enrichment,” and “umbrella” designs mean. Use the article's figures to help illustrate.Annals for HospitalistsAnnals for Hospitalists - 16 August 2016Annals for Hospitalists Inpatient Notes - Sepsis-3 for Hospitalists—Sepsis Without SIRSThis new monthly Annals feature is designed especially for busy hospitalists. And, because many hospitalists are central to their institutions' teaching programs, its content frequently compliments Annals for Educators. In addition to highlighting content most relevant to the practice of hospital medicine in Annals and ACP Journal Club, the feature includes a monthly commentary, “Inpatient Notes,” that provides unique perspectives on contemporary topics in hospital medicine. This month's commentary explains the evolution of and recent changes in the approach taken to identify patients at risk for sepsis.Use the commentary to:Ask your learners to define sepsis.Ask why early identification of patients with sepsis can be important.Apply the quick Sequential Organ Failure Assessment (qSOFA) to each of your team's patients on morning rounds. What does this tell you about a patient's risk for sepsis? Does your team find this useful? What do the authors suggest the value is (see the end of this short piece)?MKSAP 17 QuestionA 76-year-old woman is evaluated in the emergency department for altered sensorium. Medical records indicate a history of osteoarthritis. Listed medications are acetaminophen, naproxen, aspirin, and tramadol.On physical examination, the patient is not communicative. Temperature is 36.5 °C (97.7 °F), blood pressure is 108/62 mm Hg, pulse rate is 104/min, and respiration rate is 12/min. BMI is 24. Lung examination reveals no crackles or wheezing. Neurologic examination is remarkable for somnolence but with appropriate responsiveness to noxious stimuli.Laboratory studies:Creatinine1.2 mg/dL (106.1 µmol/L)Electrolytes: Sodium139 mEq/L (139 mmol/L) Potassium3.9 mEq/L (3.9 mmol/L) Chloride102 mEq/L (102 (mmol/L) Bicarbonate26 mEq/L (26 mmol/L)Arterial blood gas studies: pH7.30 PCO255 mm Hg (7.3 kPa) PO265 mm Hg (8.6 kPa)Overdose of which of the following is the most likely cause of this patient's findings?A. AcetaminophenB. AspirinC. NaproxenD. TramadolCorrect AnswerD. TramadolEducational ObjectiveIdentify tramadol overdose as a cause of respiratory acidosis.CritiqueTramadol, a weak opioid agonist, is the most likely cause of this patient's respiratory findings. She has primary respiratory acidosis characterized by an elevation in PCO2, a decrease in pH, and a slight increase in bicarbonate. This patient has laboratory findings that suggest an acute onset. For each 10 mm Hg (1.3 kPa) increase in PCO2, serum bicarbonate increases acutely by 1.0 to 2.0 mEq/L (1.0-2.0 mmol/L) due to the extracellular-to-intracellular shift of hydrogen ions as an immediate compensatory mechanism. Later, renal compensation leads to increased bicarbonate generation, and, after 24 to 48 hours, leads to an increase in serum bicarbonate of 3.0 to 4.0 mEq/L (3.0-4.0 mmol/L) for every 10 mm Hg (1.3 kPa) increase in PCO2. Primary respiratory acidosis is due to decreased effective ventilation, often noted with opioid overdose, leading to hypercapnia and retention of hydrogen ions. Respiratory acidosis can also result from intrinsic lung pathology or from processes that impede ventilation.The early phase of acetaminophen overdose is often not associated with any acid-base abnormality. After 72 to 96 hours, patients will often develop an increased anion gap metabolic acidosis related to lactic acidosis. This patient's anion gap is only 11 with no evidence of a metabolic acidosis, making acetaminophen overdose an unlikely cause of her acid-base disorder.Although decreased respiratory drive can occur in the setting of salicylate intoxication in the later stages, it is more commonly associated with a mixed acid-base abnormality, including an increased anion gap acidosis and respiratory alkalosis, making this an unlikely diagnosis for this patient.NSAID overdose typically presents with azotemia and hyperkalemia in addition to an increased anion gap metabolic acidosis (primarily a lactic acidosis), making this diagnosis unlikely in this patient.Key PointPrimary respiratory acidosis is due to decreased effective ventilation, often noted with opioid overdose, leading to hypercapnia and retention of hydrogen ions.BibliographyAdrogué HJ, Madias NE. Secondary responses to altered acid-base status: the rules of engagement. J Am Soc Nephrol. 2010;21:920-3.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 16 August 2016Volume 165, Issue 4Page: ED4KeywordsAcidosisAnionsBicarbonatesClinical trialsNursing homesOpioidsOxygenPartial pressure of carbon dioxideResearch laboratoriesSepsis ePublished: 16 August 2016 Issue Published: 16 August 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...