Annals for Educators - 1 May 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives1 May 2018Annals for Educators - 1 May 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201805010 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAssociation of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization. A Prospective StudyAlthough many smokers report using e-cigarettes to help them quit smoking, whether e-cigarettes aid cessation efforts is uncertain. This study examines whether e-cigarette use after hospital discharge by smokers who plan to quit and are advised to use evidence-based treatment is associated with subsequent tobacco abstinence.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they discuss smoking cessation with their hospitalized patients. Does hospitalization represent a “teachable moment”? How do they discuss smoking cessation during a hospitalization?Teach at the bedside! Ask patients on your service who smoke whether it has been difficult for them to abstain while in the hospital. Ask whether they can use the opportunity to remain abstinent going forward. How can you help?Do your learners recommend e-cigarettes to patients who wish to stop smoking? Are they safer than combustible cigarettes? What are the potential harms of e-cigarettes? Use the accompanying opinion piece to help frame your discussion. What do the results of this study tell us about e-cigarettes as aids to smoking cessation? How might your learners interpret the finding of a negative association between e-cigarette use and tobacco abstinence? The authors offer potential explanations in the paper's discussion.Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018This synopsis of the 2018 American Diabetes Association Standards of Medical Care focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.Use this guideline to:Ask your learners what they do in their practice to address the increased risk for cardiovascular events among their patients with diabetes.What blood pressure goals do your learners aim to achieve in these patients? Do they instruct their patients to monitor blood pressure at home? If so, how do they tell patients to do so?Ask which classes of antihypertensives have been shown to reduce cardiovascular events in patients with diabetes. (Hint: the answer is in the “Pharmacologic Intervention Recommendations” section.)Should your learners screen for coronary artery disease in diabetic patients without symptoms?What do these guidelines say about aspirin and statin use? Who should receive them?What lifestyle changes are recommended? How do your learners counsel patients on each? Do they have the time and knowledge to do a good job? Who else is available to help with such counseling?In the Clinic: Acute Colonic DiverticulitisAcute colonic diverticulitis is frequently encountered by primary care practitioners, hospitalists, surgeons, and gastroenterologists. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.Use this feature to:Ask your learners who is at increased risk for acute colonic diverticulitis.Ask how acute colonic diverticulitis might present. What might be seen on physical examination?What is the differential diagnosis? Use Table 1 to help answer this.When is imaging needed, and which tests should be done?Are antibiotics required for management of acute colonic diverticulitis? If so, which ones should be used?What are the potential complications of diverticulitis? When is consultation with a gastroenterologist and/or surgery needed?Can recurrence be prevented?Download the prepared teaching slides to help prepare for a learning session. Use the multiple-choice questions to help introduce topics, and be sure to log on and enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismEthical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position PaperShort-term experiences in global health (STEGHs) may help improve the health and well-being of the individuals and communities where they occur and may also benefit participating physicians. This position paper from the American College of Physicians addresses the obligations of physicians planning to participate in STEGHs and the ethical challenges associated with them.Use this position paper to:Ask your learners whether they have participated in a global health experience. Do any of them have plans to do so?Ask what the potential benefits are to participation in such a program. What are the potential harms? Did any of your learners mention potential harms to the people in the communities where these programs occur, or did they only mention potential harms to the participating physicians?How would your learners react to practicing in a setting where standards of care differ according to social factors (for example, gender or ethnic disparities)?How might such an experience make us better physicians? Is that an appropriate goal for such programs?How should we evaluate the organizations that offer such experiences? Use the accompanying editorial to help frame your discussion. Invite someone from your center who regularly participates in or organizes such activities to join your discussion.On Being a Doctor: A Physician's Place in the #MeToo MovementDr. Peters recalls feeling unable to speak up and defend herself in response to sexual harassment, and how that changed.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether your institution has informed them of policies and programs related to harassment.In what situations might a house officer be harassed at work? Are there sufficient safeguards in place to provide help and prevent this from happening?How can your learners support each other?Do your learners know where to turn for help if they have been harassed? What should they do?MKSAP 17 QuestionA 45-year-old man is evaluated during a routine examination. He is interested in quitting smoking. He has a history of seizures but has not had a seizure in 15 years and discontinued his seizure medication 4 years ago. He also has hypertension. His only medication is amlodipine.Physical examination is unremarkable.Which of the following will most likely give this patient the greatest chance of success in quitting smoking?A. BupropionB. Electronic cigarettesC. Nicotine replacement patchesD. VareniclineCorrect AnswerD. VareniclineEducational ObjectiveRecommend appropriate pharmacologic treatment for smoking cessation.CritiqueVarenicline will most likely give this patient the greatest chance of success in quitting smoking. A recent Cochrane meta-analysis showed that varenicline increased the odds of quitting smoking compared with placebo (OR, 2.88; 95% CI, 2.40-3.47). Although concerns have been raised regarding varenicline use and an increase in cardiovascular events, the FDA noted that the benefits outweigh potential risks in terms of cardiovascular risk.Varenicline is more effective than bupropion (OR, 1.59; 95% CI, 1.29-1.96). Additionally, there is also concern that bupropion can lower seizure threshold and thus would not be the best option for this patient who has a history of seizures. Both varenicline and bupropion also have FDA warnings highlighting the risk of serious neuropsychiatric symptoms in patients using these medications.Electronic cigarettes (E-cigarettes) may not be effective in reducing smoking cessation rates. In a recent randomized controlled superiority trial, adult smokers were randomly assigned to nicotine E-cigarettes, nicotine patches, or placebo E-cigarettes (no nicotine), with low-intensity behavioral support. At 6 months, the risk difference for nicotine E-cigarettes versus nicotine patches was 1.51 (95% CI, 2.49-5.51); for nicotine E-cigarettes versus placebo E-cigarettes, 3.16 (95% CI, -2.29-8.61). There was insufficient statistical power to conclude superiority of nicotine E-cigarettes to patches or to placebo E-cigarettes. Currently, the role of E-cigarettes in smoking cessation is uncertain.Varenicline was also found to be more effective than the nicotine patch (OR, 1.51; 95% CI, 1.22-1.87) and nicotine gum (OR, 1.72; 95% CI, 1.38-2.13), and the nicotine inhaler, spray, tablets, or lozenges (OR, 1.42; 95% CI, 1.12-1.79) all used as single agents. Varenicline was not more effective than combination nicotine replacement therapy (OR, 1.06; 95% CI, 0.75-1.48) such as the combination of a rapid-onset nicotine replacement product (for example, nicotine spray or inhaler) with a long-duration nicotine replacement product (for example, a nicotine patch).Key PointVarenicline is more effective in achieving smoking cessation than bupropion or single-agent nicotine replacement therapy but not more effective than combination nicotine replacement therapy.BibliographyCahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013 May 31;5:CD009329.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 1 May 2018Volume 168, Issue 9Page: ED9KeywordsDiverticulitisEpileptic seizuresGastroenterology and hepatologyGlobal healthGraduate medical educationHospitalizationsHypertensionNicotineNicotine replacement therapySmoking cessation ePublished: 1 May 2018 Issue Published: 1 May 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...