Annals for Educators - 1 November 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives1 November 2016Annals for Educators - 1 November 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201611010 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsEffect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection. A Randomized TrialDespite increasing use, evidence for the efficacy and safety of fecal microbiota transplantation (FMT) in recurrent Clostridium difficile infection (CDI) is limited and is based largely on observational or inadequately controlled studies. In this double-blind, randomized trial conducted at 2 academic medical centers, the authors evaluated the efficacy and safety of colonoscopic FMT among patients who had 3 or more recurrences of CDI and received a full course of vancomycin for their most recent acute episode.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how they diagnose and treat an initial episode of CDI. How about recurrent CDI? Use Dynamed Plus: Clostridium difficile infection to help you prepare to teach (a benefit of your ACP membership).Review the overall difference in cure rates between the intervention and control groups in this trial with your learners. Then, note the differences observed between the 2 trial sites. Ask your learners to discuss why these differences might have occurred. The authors present ideas in the discussion.Ask your learners to list the symptoms of postinfectious irritable bowel syndrome. What else is on the differential diagnosis of recurrent CDI?What shortcomings of observational and open-label controlled trials do the findings of this double-blind, randomized trial point out? What more do we need to know regarding the diagnosis of recurrent CDI and who might benefit from FMT?How might patients' and clinicians fears of persistent or recurrent CDI drive overzealous management? Use the accompanying editorial to help frame your discussion.Is polymerase chain reaction testing for C difficile useful in the diagnosis of CDI? The authors and the editorialist provide insight regarding why not.Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. An Updated Systematic ReviewThis systematic review of 83 studies compares benefits and harms of percutaneous transluminal renal angioplasty with stent placement (PTRAS) versus medical therapy alone in adults with atherosclerotic renal artery stenosis (ARAS).Use this study to:Ask your learners when to consider the presence of renal artery stenosis (RAS)? How is it managed? Are all cases of RAS due to atherosclerosis?What are the options for the treatment of ARAS? How would one judge their success? Ask an interventionalist to show your team radiographic images of ARAS before and after PTRAS. Do your readers believe PTRAS is appropriate for most patients as compared with medical management alone?The authors concluded that the strength of evidence regarding the relative benefits and harms of PTRAS versus medical therapy alone for patients with ARAS is low. Ask your learners what variables are used to assess the strength of a body of evidence. In the discussion, the authors summarize why the strength of evidence is low for randomized and observational studies.Look at Table 3. How are directness, consistency, and precision defined? How is the risk of bias assessed? Invite an expert in systematic reviews to help your learners understand these important ideas. Why do we need systematic reviews? Did your learners think that randomized trials were the “last word” on a therapy?Log on and answer the multiple-choice questions to claim CME credit for yourself!Giant Cell ArteritisGiant cell arteritis (GCA) is the most common form of vasculitis in older adults. Are your learners prepared to identify its possible presence and respond appropriately? This eminently practical review is organized by asking—and answering—key questions that all internal medicine trainees need to know.Use this review to:Download the prepared slides to help prepare a teaching session.Ask your learners to list risk factors for GCA. What are the possible localized and systemic presentations? Use Table 1.Why is the name “giant cell arteritis” preferred over either “temporal arteritis” or “cranial arteritis?”Why might GCA and polymyalgia rheumatic represent a spectrum of one rather than distinct diseases? This is addressed in the paper's discussion of important physical examination findings. What are the differential diagnoses of each? Use Tables 2 and 3.When should a temporal artery biopsy be obtained, and how do you arrange for it promptly at your institution? How does one approach a “negative biopsy”? What is the role of imaging or other testing? Do all patients need to be seen by a rheumatologist?How should therapy be initiated and managed over the initial months of treatment? What is the rationale for also using aspirin as part of management? Should a nonsteroidal immunosuppressant be considered?How should patients be monitored on therapy, and what is their prognosis?Download the multiple-choice questions in the CME section, and use them to introduce sequential teaching points for discussion. Be sure to log on and enter your answers to claim CME credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Slaves“I knew where this was going. It was not the first time a patient had asked me about my training. Some patients are just curious. Others are trying to get at something deeper, more insidious.” Dr. Gupta shares her jarring encounter with prejudice and her feeling of isolation.Use this essay to:Listen to an audio recording of the essay read by On Being a Doctor editor, Dr. Michael LaCombe.Ask your learners for their reactions to what happened to Dr. Gupta. How do they think they would have responded?Have you or any of your learners ever experienced or witnessed something similar?Are we “obligated” to put up with such comments from patients? Are there right and wrong ways to respond? How does the responsibility to ensure the best care for the patient influence what is appropriate? Are we obligated to accommodate prejudicial requests? What if a patient's antagonism makes productive interactions for the provision of appropriate care impossible?What resources are available to help physicians navigate such situations?MKSAP 17 QuestionA 77-year-old woman is evaluated for a 5-day history of diarrhea. She has been diagnosed with Clostridium difficile colitis twice in the last 3 months and both times was successfully treated with metronidazole. This is her third episode. She has four to six liquid bowel movements per day. She reports no fevers, abdominal pain, nausea, or vomiting.On physical examination, the patient is afebrile, blood pressure is 150/82 mm Hg, pulse rate is 106/min, and respiration rate is 18/min. The patient's abdomen is soft and nontender with positive bowel sounds.Laboratory studies reveal a leukocyte count of 8800/µL (8.8 × 109/L) and serum creatinine of 0.8 mg/dL (70.7 µmol/L). Stool polymerase chain reaction assay is positive for C. difficile toxin.Which of the following is the most appropriate oral treatment?A. Metronidazole for 14 daysB. Metronidazole for 6 weeksC. Rifaximin for 14 daysD. Vancomycin for 14 daysE. Vancomycin for 6 weeksCorrect AnswerE. Vancomycin for 6 weeksEducational ObjectiveTreat a patient with a second recurrence of Clostridium difficile infection.CritiqueThis patient with a second recurrence of mild to moderate Clostridium difficile infection (CDI) should be treated with oral vancomycin for 6 weeks. Approximately 20% of patients with CDI will experience a relapse. In 2010, an expert panel outlined evidence-based recommendations for treatment of CDI. A recent study found that adherence to these guidelines resulted in significantly improved outcomes and fewer recurrences of CDI.The initial treatment regimen is based on the severity of illness, with a 10- to 14-day course of oral metronidazole recommended for mild to moderate illness and a 10- to 14-day course of oral vancomycin for severe illness. For the first recurrence, guidelines specify that treatment decisions should be based on the severity of illness, similar to the determination of appropriate treatment with the initial presentation. However, for subsequent relapses, the probability of sustained response is significantly decreased, and it is therefore recommend that all patients receive a prolonged course of vancomycin, typically given at tapered doses over 6 to 8 weeks.Metronidazole is not recommended for use in multiple recurrences of CDI because prolonged administration is associated with a risk for neurotoxicity, and luminal concentrations of the antibiotic decrease to subtherapeutic levels after resolution of colitis.Small studies have suggested that rifaximin may be useful in multiple recurrences of CDI when given at the end of the vancomycin taper, but this agent is not recommended as a stand-alone therapy.Key PointPatients who have more than one recurrence of Clostridium difficile infection should be treated with oral vancomycin given at tapered doses over 6 to 8 weeks.BibliographyLeffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med. 2015;372:1539-48. doi:10.1056/NEJMra1403772Do 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. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited bySocial Protection in an Aspiring 'Developmental State': The Political Drivers of Ethiopia's PSNP 1 November 2016Volume 165, Issue 9Page: ED9KeywordsClostridium infectionsFecal microbiota transplantPolymerase chain reactionRandomized trialsRenal arteriesSafetyStenosisSystematic reviewsTreatment guidelinesVancomycin ePublished: 1 November 2016 Issue Published: 1 November 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...