Annals for Educators - 15 January 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives15 January 2019Annals for Educators - 15 January 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201901150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLong-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia. A Retrospective Cohort StudyRandomized clinical trials have shown similar outcomes with less frequent transfusions in hospitalized patients with moderate anemia. Longer-term clinical outcomes associated with a restrictive approach to transfusion have not been well described. This analysis describes the prevalence of moderate anemia among patients discharged from the hospital as well as 6-month outcomes in these patients.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to explain the mechanism by which anemia is potentially deleterious. What harms may occur, and are the risks different among hospitalized patients?What is the rationale for red blood cell transfusions in patients with anemia?What are the potential complications of blood transfusion?Do your learners have “threshold” hemoglobin values below and above which transfusion will or will not be considered, respectively? Does the clinical context alter the threshold?What does this study contribute to the conversation regarding the safety of “tolerating” anemia?Why do the editorialists emphasize that transfusion is a short-term treatment method? What is the best longer-term management for anemia? Identify the last several blood transfusions performed on your team's service. Review the circumstances with your team. Was it clear that transfusion was needed? Would your learners have considered not performing transfusion in these patients? Do the results of this study alter their thinking?Effectiveness and Safety of Reference Infliximab and Biosimilar in Crohn Disease: A French Equivalence StudyCT-P13 is a biosimilar of the reference product infliximab and is an approved treatment for ankylosing spondylitis and rheumatoid arthritis. Regulatory agencies extended the approval of CT-P13 to other inflammatory conditions, including Crohn disease. This analysis of French nationwide health administrative data compares outcomes among patients with Crohn disease treated with CT-P13 or infliximab.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what therapies are available for Crohn disease. In which patients is infliximab a consideration?How does infliximab work? What are the potential benefits and harms? How expensive is it?Ask your learners to define a biosimilar and generic drug. The FDA's definition is noted in the first paragraph of the article. Why is establishing equivalence potentially more challenging for a biosimilar than a generic drug? Use the accompanying editorial to help frame your discussion. What end points were used in this cohort study? Why were they chosen for a bioequivalence study?What are the limitations to what may be concluded about efficacy and safety? What more needs to be done? (The editorialists provide an answer at the end of the editorial.)Video LearningAnnals Consult Guys – Low Risk for Postoperative Myocardial Infarction: What Do We Really Know?Howard and Geno (the Consult Guys) challenge what we know and don't know about evaluating the risk for perioperative myocardial infarction.Use this feature to:Take a short break to watch this episode of the consultative medicine talk show with your learners. Before doing so, challenge your learners with the 2 multiple-choice questions provided to help focus their viewing and learning.Ask your learners what their goals are when they evaluate a patient before surgery.What key information are anesthesiologists and surgeons looking for from us?How do your learners assess a patient's risk for perioperative myocardial infarction?Humanism and ProfessionalismAmerican College of Physicians Ethics Manual. Seventh EditionThis updated edition of the ACP Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still pertinent. It reflects on many of the ethical tensions in medicine and the principles to be applied to emerging concerns.Use this paper to:Ask your learners whether they agree that medicine is “a profession to be entered, rather than a trade to be learned.” What is the difference?What is beneficence, and how do we define what is in a patient's “interest” or “best interest”? Use the accompanying editorial to help frame your discussion. Under what circumstances may a physician elect to discontinue the relationship with a patient? How should this be done, if at all?Does telemedicine raise new ethical issues?Are physicians obligated to provide care to patients if doing so places the physician at risk for harm (e.g., from infection)?Is it appropriate to accept a gift from a patient?Review the ethics manual for other topics to discuss with your learners.On Being a Doctor: Physician, Heal ThyselfDr. Thomas describes how a sudden change in his health status altered his routine, and his perspective.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether medical school and training have interfered with their ability to lead healthy lifestyles. If so, in what ways?Do we exercise enough? Do we sleep enough?Do we eat a healthy diet? What about at the hospital? Is the food available to us (or provided for free) healthy? If not, why not? What might be done about that?Are there ways your learners can together find ways to encourage and help each other to lead healthier lifestyles? Could the leadership of the training program help?MKSAP 17 QuestionA 73-year-old man develops acute respiratory distress near the completion of a transfusion of 1 unit of erythrocytes following a total hip arthroplasty. Medical history is significant for hypertension, type 2 diabetes mellitus complicated by nephropathy, and hyperlipidemia. Medications are amlodipine, insulin, atorvastatin, and subcutaneous unfractionated heparin.On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 184/72 mm Hg, pulse rate is 114/min, and respiration rate is 24/min. Oxygen saturation is 86% breathing ambient air. Jugular venous pressure measured above the sternal notch with the patient positioned 45 degrees from horizontal is 8 cm H2O. Crackles are heard halfway up both lung fields. Cardiac examination reveals tachycardia but no murmurs. Trace bilateral pedal edema is noted.Laboratory studies:Hemoglobin7.7 g/dL (77 g/L) (6.8 g/dL [68 g/L] before transfusion)Bilirubin, total1.2 mg/dL (20.5 µmol/L)Creatinine2.8 mg/dL (248 µmol/L) (2.7 mg/dL [239 µmol/L] before transfusion)Lactate dehydrogenase90 U/LUrinalysisNegative for protein or bloodElectrocardiography demonstrates sinus tachycardia but shows no evidence of ST-segment or T-wave abnormalities. A chest radiograph reveals bibasilar airspace opacities.Which of the following is the most likely diagnosis?A. Acute hemolytic transfusion reactionB. Transfusion-associated circulatory overloadC. Transfusion-related acute lung injuryD. Transfusion-transmitted sepsisCorrect AnswerB. Transfusion-associated circulatory overloadEducational ObjectiveDiagnose transfusion-associated circulatory overload.CritiqueThe most likely diagnosis is transfusion-associated circulatory overload (TACO). TACO is an underdiagnosed condition that occurs in 0.3% to 8% of patients undergoing transfusion in the hospital and is associated with increased inpatient mortality and a longer length of hospital stay. TACO is defined as the new onset or exacerbation of at least three of the following findings within 6 hours of completing a transfusion: acute respiratory distress, elevated B-type natriuretic peptide (BNP) level, elevated central venous pressure (CVP), evidence of left heart failure, evidence of positive fluid balance, and radiographic evidence of pulmonary edema. Risk factors include age older than 60 years, chronic kidney disease, chronic heart failure, number of blood products transfused, and the volume transfused per hour. Preventive measures include a slower rate of infusion for those at risk (1 mL/kg/hour) and diuretic therapy to maintain euvolemia.An acute hemolytic transfusion reaction (AHTR) is unlikely. The patient's hemoglobin level increased appropriately after the transfusion (1 g/dL/U [10 g/L/U]), and the lactate dehydrogenase and total bilirubin levels are not elevated. No protein was seen on urinalysis, kidney function is unchanged, and the patient is not hypotensive. Additionally, pulmonary opacities as seen on the radiograph would not be expected with AHTR.Distinguishing TACO from transfusion-related acute lung injury (TRALI) can be challenging. Fever and hypotension occur in only one third of patients with TRALI. However, TRALI is not associated with signs of volume overload (increased jugular venous pressure, lower extremity edema, elevated CVP). BNP and N-terminal proBNP levels have not been studied in TRALI but are elevated with TACO.Transfusion-associated sepsis is highly unlikely in the absence of fever and hypotension.This content was last updated in March 2016.Key PointPatients experiencing acute respiratory distress, elevated B-type natriuretic peptide level, elevated central venous pressure, evidence of left heart failure, evidence of positive fluid balance, or radiographic evidence of pulmonary edema within 6 hours of transfusion should be diagnosed with transfusion-associated circulatory overload.BibliographyMurphy EL, Kwaan N, Looney MR, et al; TRALI Study Group. Risk factors and outcomes in transfusion-associated circulatory overload. Am J Med. 2013 Apr;126(4):357, e29-38.MKSAP 18 QuestionA 26-year-old woman with Crohn disease is evaluated for a 2-week history of worsening abdominal pain in the right lower quadrant. She reports passage of one to two formed and nonbloody stools per day with no changes in bowel habits. The patient has required three courses of prednisone for disease flares over the past year. Her only medication is azathioprine.On physical examination, temperature is 37.7 °C (99.9 °F) and pulse rate is 115/min; other vital signs are normal. Abdominal examination shows fullness and tenderness in the right lower quadrant with no distinct mass. The remainder of the examination is unremarkable.Laboratory studies show a hemoglobin level of 10.5 g/dL (105 g/L) and a C-reactive protein level of 32 mg/dL (320 mg/L). Leukocyte count and liver chemistry tests are normal.CT enterography shows asymmetric mural thickening and mucosal inflammation of a long segment of distal ileum without luminal narrowing.Which of the following is the most appropriate treatment?A. BudesonideB. InfliximabC. MesalamineD. PrednisoneCorrect AnswerB. InfliximabEducational ObjectiveTreat ileal Crohn disease.CritiqueInfliximab is the most appropriate treatment for this patient. This patient has moderate to severe ileal Crohn disease that has required multiple courses of tapering prednisone for flares of disease over the last year, despite treatment with the immunomodulator azathioprine. Infliximab is an anti–tumor necrosis factor (TNF)-α antagonist effective in inducing and maintaining remission in moderate to severe Crohn disease. Other FDA-approved anti-TNF agents include adalimumab and certolizumab pegol. Evidence indicates that efficacy is better when an anti-TNF agent is used together with an immunomodulator. In addition, the risk for developing antibodies against the anti-TNF agent is lower with combination therapy. Patients whose disease does not respond to one anti-TNF agent are often switched to a second or third anti-TNF agent. Fibrostenosing Crohn disease in the absence of ongoing mucosal inflammation is unlikely to respond to any anti-TNF agent. Patients with no response to or intolerance of anti-TNF agents should be treated with either surgery or a leukocyte trafficking blocker (natalizumab or vedolizumab).Budesonide is a potent glucocorticoid with high first-pass metabolism in the liver, which limits systemic side effects related to conventional glucocorticoids. Budesonide can be an effective therapy for treating mild flares of ileal Crohn disease, but it is unlikely to induce remission in more severe Crohn disease and cannot be used to maintain remission.Mesalamine agents are mainly used to treat ulcerative colitis of mild to moderate severity. Mesalamine may have efficacy in treating mild to moderate Crohn colitis, but it is not efficacious in treating small-bowel Crohn disease.Reinitiating prednisone may induce remission of the patient's current disease flare, but it would not be helpful for maintenance of remission. Because this patient has required three separate tapering doses of glucocorticoids over the last year, she requires a medication such as infliximab that can both induce remission and maintain Crohn disease in remission.This content was last updated in August 2018.Key PointAnti–tumor necrosis factor agents such as infliximab are effective in inducing and maintaining remission in moderate to severe Crohn disease.BibliographyLichtenstein GR, Hanauer SB, Sandborn WJ; Practice Parameters Committee of American College of Gastroenterology. Management of Crohn's disease in adults. Am J Gastroenterol. 2009;104:465-83; quiz 464, 484.doi:10.1038/ajg.2008.168Do 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 15 January 2019Volume 170, Issue 2Page: ED2KeywordsAnemiaCrohn's diseaseEdemaHeart failureHemoglobinLungsSurgeryTachycardiaTemperatureVentilators ePublished: 15 January 2019 Issue Published: 15 January 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...