Annals for Educators - 6 February 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives6 February 2018Annals for Educators - 6 February 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201802060 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsImproving Decisions About Transport to the Emergency Department for Assisted Living Residents Who FallFalling is a frequent problem for residents of assisted living facilities. The problem is aggravated when institutional policy requires transport to an emergency department after every fall, even when there is little or no injury. The paramedics who provide emergency medical services and some of the primary care physicians who provide care in 1 geographic area worked together to address this problem. The result was a remarkable improvement.Use this study to:Ask your learners what questions they ask when contacted about patients who have fallen. What do they look for on physical examination?On what basis do your learners decide whether further evaluation is necessary (e.g., transport to the hospital or further assessments for patients who are already hospitalized)? Review the algorithm used for this study (presented in Figure 1 in the paper's Supplement). Do your learners like this approach to triage?Review the results of this study. Do your learners think the approach is sound? Why or why not? What are the benefits of such an approach? What are the risks?How big of a problem are falls among residents of assisted living facilities? Are the results of this study generalizable? Use the accompanying editorial to help frame your discussion. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018The Advisory Committee on Immunization Practices (ACIP) presents the recommended immunization schedule for adults aged 19 years or older for 2018. This schedule has been approved by the ACIP, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.Use this guideline to:Start a teaching session with a multiple-choice question. We've provided one below!Review the recommended immunization schedule with your learners. What's new this year? What changed in the recommendations regarding MMR immunization? How about zoster vaccination?Ask your learners whether they think they do a good job of reviewing their patients' immunization status. What systems are in place in your practice to facilitate keeping patients up to date with immunizations? Are they effective? How do you know for sure?Invite someone from your organization's quality improvement group to review what is known about how well your practice performs in adult immunization. Ask your learners where the problems lie, and ask them to design interventions to address each problem. How would they assess whether each intervention works? Will your institution try them?Beyond the GuidelinesShould This Patient Receive Hormone Therapy for Her Menopausal Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterUse of hormone therapy (HT) for the vasomotor symptoms of menopause has been controversial since publication of the Women's Health Initiative trial in the early 2000s. However, the 2017 guideline from the North American Menopause Society recommends HT for these symptoms. Here, 2 experts discuss the guideline and whether to prescribe HT to Ms. R, a 52-year-old woman with severe hot flashes, sleep disturbance, and irritability.Use this feature to:Ask your learners what symptoms may be due to perimenopause and menopause. How are they diagnosed? Is testing required? Use the recent In the Clinic: Perimenopause to find answers quickly. Watch an interview of Ms. R with your learners.Ask your learners what treatment options are available for Ms. R's symptoms. If treatment is started, how long should it be continued?Watch or have your learners read the presentations by 2 expert clinicians whose answers to these questions differ. Now what would your learners do?Download the prepared slides to help prepare for teaching. Use the multiple-choice questions to help reinforce learning points, and log on to enter your answers and earn CME/MOC credit for yourself!In the Clinic: Cellulitis and Soft Tissue InfectionsBacterial skin and soft tissue infections are a diverse group of diseases ranging from uncomplicated cellulitis, which can be treated in the outpatient setting with oral antibiotics, to necrotizing fasciitis, a life-threatening condition that requires emergent surgical debridement. Are your learners prepared to appropriately evaluate and manage these problems?Use this review to:Ask who is at increased risk for cellulitis and soft tissue infections. What preventive measures should be taken? Is antibiotic prophylaxis ever indicated?What is the differential diagnosis of cellulitis and soft tissue infections? When are laboratory tests indicated, and which ones?When are topical, oral, or intravenous antibiotics indicated? When should surgical intervention be considered? How is necrotizing fasciitis diagnosed?Download the teaching slides to help with a teaching session, and break it up with the multiple-choice questions to help introduce new topics. Be sure to log on and enter the answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Long Coat Doctor“The letter was on my desk when I returned from lunch. Though its plain envelope was unremarkable, the name on the return address caught my attention and unlocked a distant memory.”—Dr. Bertram recalls his role in turning around a struggling medical student.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe.Ask your learners to think about the teachers and mentors who made a difference in their lives. What qualities made them so influential?Do your learners consider themselves teachers? Of whom?Have they had opportunities to help students in need of extra attention? Did they find the time to help? How did it affect their students? How has it rewarded them as teachers?Have they missed such opportunities? Why?Does teaching come more naturally to some of us? How can thinking about our own experiences as students help us be better teachers? What motivates us to teach?MKSAP 17 QuestionA 17-year-old girl is evaluated during a routine preventive examination. She is a college student. Medical history is unremarkable, and she is not and has never been pregnant. A review of the patient's immunization records reveals that she received a complete human papillomavirus vaccine series, and she is up to date on tetanus, diphtheria, and acellular pertussis immunization. She received the quadrivalent meningococcal conjugate vaccine at age 12 years, with a booster vaccine at age 16 years. She takes no medications.Findings on physical examination are unremarkable.According to recommendations of the Advisory Committee on Immunization Practices, which of the following is the most appropriate management to offer this patient?A. Herpes zoster vaccineB. Meningococcal serogroup B vaccineC. 13-Valent pneumococcal conjugate vaccineD. No vaccination at this timeCorrect AnswerB. Meningococcal serogroup B vaccineEducational ObjectiveOffer vaccination against serogroup B meningococcal disease to an adolescent patient.CritiqueThe most appropriate management is to offer this patient the meningococcal serogroup B (MenB) vaccine. Meningococcal disease is rare (estimated incidence of 0.18 per 100,000 among persons of all ages), but each case is rapidly life threatening. The Advisory Committee on Immunization Practices (ACIP) recommends that all individuals be vaccinated by age 18 years against serogroups A, C, Y, and W135 with the quadrivalent meningococcal conjugate vaccine; however, the quadrivalent vaccine does not offer protection against serogroup B. In October 2015, the ACIP recommended that adolescents and young adults aged 16 to 23 years may be vaccinated with the MenB vaccine, with a preference to vaccinate between ages 16 and 18 years. This ACIP recommendation is classified as category B (recommended for individual clinical decision making).Two MenB vaccines were recently licensed by the FDA: MenB-FHbp and MenB-4C. Both were licensed under an accelerated approval pathway, and thus confirmatory studies in the postmarketing period will be conducted. Because the prevalence of disease is low, and postmarketing data are not yet available regarding safety and efficacy, the ACIP determined that there was insufficient evidence to make a routine recommendation that all adolescents be vaccinated with a MenB vaccine. In patients who choose to be vaccinated, the MenB vaccine can be administered concomitantly with other vaccines. Pregnant and lactating women should not be vaccinated unless they are at high risk. High-risk conditions include persistent complement deficiencies, treatment with the terminal complement inhibitor eculizumab, and anatomic or functional asplenia including sickle cell disease. Healthy persons may also be identified as having increased risk due to a serogroup B meningococcal outbreak.In healthy adults such as this one, the 13-valent pneumococcal conjugate vaccine (PCV13) is recommended at age 65 years.Although varicella vaccines are given in childhood, with catch-up series provided for individuals who have not had primary chicken pox or the vaccination series, the ACIP recommends the herpes zoster vaccine for shingles prevention at age 60 years in otherwise healthy adults.Key PointThe Advisory Committee on Immunization Practices recommends that adolescents and young adults aged 16 to 23 years may be vaccinated with serogroup B meningococcal (MenB) vaccine.BibliographyMacNeil JR, Rubin L, Folaranmi T, Ortega-Sanchez IR, Patel M, Martin SW. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep. 2015 Oct 23;64(41):1171-6.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 6 February 2018Volume 168, Issue 3Page: ED3KeywordsAdolescentsCellulitisConjugate vaccinesHormonal therapyMenopausePerimenopausePregnancySoft tissue infectionsVaccinesYoung adults ePublished: 6 February 2018 Issue Published: 6 February 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...