Annals for Educators - 7 February 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives7 February 2017Annals for Educators - 7 February 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201702070 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsBrain-Type Natriuretic Peptide and Amino-Terminal Pro–Brain-Type Natriuretic Peptide Discharge Thresholds or Acute Decompensated Heart Failure. A Systematic ReviewThis meta-analysis of trials and observational studies addresses the clinical implications of achieving predischarge natriuretic peptide thresholds in patients hospitalized for acute decompensated heart failure.Use this study to:Ask your learners what natriuretic peptides (NPs) are. What is the difference between BNP and NT-BNP?How do your learners use measurement of these in their practices? To assess treatment response in patients hospitalized for acute heart failure?Ask your learners to read this study's abstract. Then, ask whether they should measure NPs to guide discharge decisions in acute heart failure. Pay attention to whether your learners focus only on the changes in outcomes reported (e.g., “achievement of absolute BNP thresholds reduced postdischarge all-cause mortality”) or also on the quality and strengths of the available evidence (e.g., “high risk of bias” and “low-strength evidence”).How was the “risk of bias” assessed for each of the studies included in this systematic review? The authors explain on page 181 and in the Appendix. Why does it matter? Ask your learners how, for example, a failure to adjust for LVEF or NYHA functional class when comparing the outcomes of patients who did or did not achieve a target NP might bias the results of a study.Use this review to emphasize to your learners why they need to pay attention to the details and methods of a study, and not only the ‘”one-liner” conclusion. Indeed, one of the most important things a good systematic review does is to tell us the quality of available evidence. Use the accompany editorial to help frame your discussion of this important point.Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2017The Advisory Committee on Immunization Practices (ACIP) presents the Recommended Adult Immunization Schedule for Adults Aged 19 Years or Older for 2017. This schedule has been approved by the ACIP, American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Review with your learners the changes to this year's recommended immunization schedule (e.g., chronic liver disease conditions for which hepatitis B vaccination is recommended). These are detailed in the paper's introduction.Do your learners know when and how to report a vaccine-reportable disease? Why is this important? What about clinically significant postvaccination reactions? The guideline provides a link in the table.How is a patient's immunization record accessed in your learners' outpatient practice? Are your learners prompted in some manner to review their patients' immunization status? Or, is there a system that informs them that a patient is due for a vaccination? Is there a system in place to promote influenza vaccination each year?Ask your learners to design a practical way to study whether their practice does a good job assessing their patients' vaccination status. How would they define “good”? What information will be needed to assess ways to improve (e.g., who asks about immunizations and how, where it is recorded)? Might thinking about this ahead of time allow for collection of useful information to identify where change might be helpful?Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease. A Systematic ReviewThis systematic review of 17 observational studies addresses clinical outcomes of metformin use in persons with type 2 diabetes and moderate to severe chronic kidney disease, congestive heart failure, or chronic liver disease with hepatic impairment. These major findings, which support recent labeling changes by the U.S. Food and Drug Administration, have important clinical implications.Use this study to:Ask your learners when they use metformin.What are the potential benefits of metformin? What are the potential adverse events?The FDA recently altered its recommendations and contraindications for the use of metformin. Do your learners know whether it remains contraindicated in patients with heart failure? With kidney or liver disease?Although warnings have been relaxed, what else might your learners want to know about the potential benefits or harms of metformin? What do (or don't) we know about its benefits in patients for whom the drug was previously not recommended? Use the accompanying editorial to help frame your discussion.How will your learners use metformin in patients with heart failure, liver disease, or kidney disease in the future?Beyond the GuidelinesShould We Prescribe Antibiotics to This Patient With Persistent Upper Respiratory Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThis Grand Rounds summarizes a discussion between 2 expert clinicians about the benefits and harms of prescribing antibiotics to a patient with recurrent sinusitis presenting with persistent upper respiratory symptoms.Use this feature to:Watch an interview with the patient, a 62-year-old man with a history of recurrent sinusitis who has previously been prescribed antibiotics for episodes of sinusitis.Ask your learners how they would manage this patient. Would they prescribe antibiotics? What are the potential benefits and harms? What does the ACP and CDC recommend?Watch the discussion by 2 experienced clinicians who differ in whether they would recommend antibiotics. Has the discussion altered your learners' opinions?Log on and answer the multiple-choice questions provided to earn CME/MOC credit for yourself!In the Clinic: TuberculosisAlthough tuberculosis (TB) rates remain low in the United States, 10.4 million people were diagnosed and 1.4 million died of the disease in 2015 worldwide. Despite advanced in its prevention, diagnosis, and treatment, TB surpassed HIV/AIDS as the deadliest infection worldwide in 2014, and it continues to be a leading cause of death among patients with HIV. This concise review is structured around answering key questions regarding TB prevention, screening, diagnosis, and treatment.Use this review to:Ask your learners who should be screened for TB. How should it be done?What advice do your learners give to patients with TB to reduce the likelihood that they will infect others?How should latent TB be managed?How do your learners approach the diagnosis of TB? Which tests do they order? Do your learners know what the physicians' public health responsibilities are after diagnosing active TB?Which patients with TB should be referred to a specialist? What is the best way to monitor therapy? What is followed?What are the extra-pulmonary manifestations of TB?Download the available teaching slides to help conduct a learning session.Use the CME/MOC questions provided to break up a teaching session, and to introduce new topics for discussion. Be sure to log on and enter your answers to earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: GuidingIn his essay, Dr. Hund sees analogies between his experiences as a mountaineering guide and as a physician.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners if they draw on any of their nonmedical life experiences to help them to be better physicians.Can your learners imagine a campfire at the end of their patient's bed as they sit and listen?Dr. Hund notes that, “The price of experience is sometimes regret.” How have your learners learned from tragedies?Do your learners see themselves as “guides” for their patients?Education for EducatorsHow to Incorporate High Value Quality Improvement into Your Training ProgramsThis precourse is designed for internal medicine educators at all levels and combines high-value care and quality improvement educational goals through experiential curricula. Key foundational knowledge is combined with specific clinical examples and tools to help participants implement these activities at their own institutions.Course directors: Jessica Dine, MD, and Jennifer S. Myers, MD, Raymond and Ruth Perelman School of Medicine at the University of PennsylvaniaAcademic Internal Medicine Week 2017Sunday, March 19, 2017, 8:00 a.m.–4:15 p.m.Baltimore Convention Center Click here for more information.MKSAP 17 QuestionA 30-year-old woman is evaluated in follow-up after being recently diagnosed with HIV infection. She is asymptomatic. Medical history is unremarkable, and she takes no medications; she has not yet started antiretroviral therapy. She received all scheduled childhood immunizations.On physical examination, vital signs are normal. She has shotty cervical lymphadenopathy, but the examination is otherwise unremarkable.Laboratory studies:Absolute CD4 cell count461/µLHIV viral load44,874 copies/mLHepatitis A IgG antibodyNegativeHepatitis B surface antibodyPositiveHepatitis B surface antigenNegativeHepatitis C antibodyNegativeWhich of the following immunizations should this patient receive today?A. Hepatitis A vaccineB. Hepatitis B vaccineC. Human papillomavirus vaccineD. Pneumococcal conjugate vaccineE. Pneumococcal polysaccharide vaccineCorrect AnswerD. Pneumococcal conjugate vaccineEducational ObjectiveManage immunizations in a patient with HIV infection.CritiqueThis patient should receive the 13-valent pneumococcal conjugate vaccine (PCV13) now. Vaccination against Streptococcus pneumoniae is indicated in all persons with HIV infection because of the increased risk of invasive pneumococcal disease. Immunocompromised persons, including those with HIV, should receive PCV13 first, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later, in a “prime-boost” strategy that is used to improve the antibody response to immunization. This recommendation applies regardless of the patient's CD4 cell count.HIV infection alone is not an indication to receive hepatitis A vaccination. Hepatitis A vaccination would be indicated if the patient had another risk factor, such as men who have sex with men or other liver disease, including chronic hepatitis B or C virus infection. She does not have hepatitis B or C virus infection, as shown by negative results on laboratory testing, so hepatitis A vaccination is unnecessary at this time.All patients with HIV should be vaccinated for hepatitis B if not already immune or infected. However, this patient has positivity for hepatitis B surface antibody, demonstrating existing immunity. Therefore, she does not require hepatitis B immunization.This patient is beyond the recommended age (approximately 11-26 years) for females in the general population to receive human papillomavirus vaccination. This recommendation does not change for patients with HIV infection.This patient should receive PPSV23, but not until at least 8 weeks after PCV13, so giving it now would be inappropriate. Patients with HIV infection who have received PPSV23 in the past should receive PCV13 followed by another PPSV23 dose at least 8 weeks later.Key PointImmunocompromised persons, including those with HIV, should receive the 13-valent pneumococcal conjugate vaccine first, followed 8 weeks later by the 23-valent pneumococcal polysaccharide vaccine.BibliographyBridges CB, Coyne-Beasley T, Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for adults aged 19 years or older: United States, 2014. Ann Intern Med. 2014;160:190.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 7 February 2017Volume 166, Issue 3Page: ED3KeywordsAntibioticsConjugate vaccinesHIV infectionsHeart failureHepatitis AHepatitis BLiver diseasesPolysaccharidesSystematic reviewsVaccines ePublished: 7 February 2017 Issue Published: 7 February 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...