Annals for Educators - 7 January 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives7 January 2020Annals for Educators - 7 January 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202001070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCompassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes ProjectThe 3 Wishes Project was pioneered in an academic medical center's intensive care unit (ICU) to promote compassionate end-of-life care by eliciting and fulfilling the wishes of dying patients or their families. This study evaluates the implementation and value of this project in various ICUs and medical centers.Use this study to:Ask your learners whether they ask dying patients or their families about their wishes and hopes. What sort of answers have they heard?Describe what the 3 Wishes Project entailed. Look at Table 1 to provide examples of the wishes involved in this study. Use the visual abstract to help explain the study to your learners. Watch the 7-minute author insight video with your team. Do your learners think an initiative to elicit and fulfill wishes like this one could be implemented at your center? Would they like to try? Does it have to be in the ICU only?Ask them how they could start. Is an organized project required, or could your learners try this one patient at a time?With whom could your learners speak to discuss implementing 3 Wishes at your center? What other team members should be involved in planning? Ask your learners to read the paper to be sure they know how much (or how little) was required in terms of commitment and investment by the centers involved in this study.An Emerging Crisis: Vaping-Associated Pulmonary InjuryIn the context of the emergence of vaping-associated pulmonary injury (VAPI), this commentary discusses what we know about the health effects of vaping and, more important, what we need to learn. Research on the respiratory toxicity of vaporized e-cigarette compounds and cannabis extracts, population studies on consumption patterns, and increased physician attention are urgently needed to mitigate the effects of VAPI.Use this paper to:Ask your learners if they know how VAPI is currently defined.In what settings should they consider VAPI in the differential diagnosis?What other causes of respiratory failure need to be considered? How should they be evaluated?Why would establishing a diagnosis of VAPI be useful if “supportive care” is all we currently have to offer?Do your learners talk to their patients about vaping? Should they? What should they discuss?Effectiveness and Cost-Effectiveness of Human Papillomavirus Vaccination Through Age 45 Years in the United StatesIn the United States, the vaccine against human papillomavirus (HPV) is usually administered to girls and boys beginning just before the start of adolescence. Studies have shown that the vaccine prevents cancer and saves money when it is given this way. The U.S. Food and Drug Administration recently approved the vaccine for use in women and men up to age 45 years, and this article estimates the cost-effectiveness of the vaccine in these adults.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!For which patients is the HPV vaccine recommended? Look at the most recent recommendations from the Advisory Committee on Immunization Practices. Ask how cost-effectiveness analyses can be useful. How is “cost-effective” defined? What is the meaning of an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years gained? What ICER is often used as a benchmark for making health policy decisions? Invite an expert in cost-effectiveness studies or health policy to join your discussion.In the Clinic: Celiac DiseaseGluten-related disorders, including celiac disease, wheat allergy, and nonceliac gluten sensitivity, are increasingly reported worldwide. Celiac disease is a multisystem disorder affecting approximately 0.7% of Americans and 1% of non-Hispanic white persons, many of whom have not been diagnosed. Unrecognized or untreated disease is associated with increased mortality and risk for intestinal lymphoma. Are your learners prepared?Use this feature to:Ask your learners what symptoms or signs should prompt consideration of celiac disease. See the boxes on pages 4 and 5. What are the potential gastrointestinal and extraintestinal manifestations? What autoimmune disorders are associated with celiac disease?What is dermatitis herpetiformis? Use Figure 1 to show your learners. Why might this physical finding be helpful?When should serum IgA and tissue transglutaminase testing be considered?What is the role of intestinal biopsy?What do your learners know about a gluten-free diet? How difficult is it to follow? Invite a nutritionist to join your discussion.Can a patient with celiac disease safely reintroduce gluten into his or her diet after initial control of their symptoms? Why or why not?Use the provided multiple-choice questions to help introduce topics in a teaching session. And, log on to enter your answers and earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: Rise UpDr. Collins implores us, “We must do better. These men deserve better.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners what the common causes of death from AIDS were in the 1990s. Invite a physician who cared for patients during that time to join your discussion. How commonly were patients with “end-stage” HIV infection admitted? What has changed? Why?What prevents some patients from receiving care for HIV infection? Does the social stigma of HIV infection continue to present a barrier to care? What can we as health care professionals do to combat it?MKSAP 18 QuestionA 22-year-old man returns for follow-up evaluation; he was recently diagnosed with HIV infection, and he began antiretroviral therapy 2 weeks ago. He also received influenza vaccination and the 13-valent pneumococcal conjugate vaccine at that time. He reports that he has sex with men. Medical history is notable for previous chlamydia infection and genital warts. Medications are tenofovir, emtricitabine, and dolutegravir.On physical examination, vital signs are normal. A few small lesions consistent with warts are noted on the penis. The examination is otherwise unremarkable.Laboratory studies:CD4 cell count527/µLHepatitis A IgGPositiveHepatitis A IgMNegativeHepatitis B surface antibodyNegativeHepatitis B surface antigenPositiveWhich of the following is the most appropriate immunization to be given today?A. 23-Valent pneumococcal polysaccharide vaccineB. Hepatitis A vaccineC. Hepatitis B vaccineD. Human papillomavirus vaccineCorrect AnswerD. Human papillomavirus vaccineEducational ObjectiveProvide appropriate immunizations for a patient with HIV infection.CritiqueHuman papillomavirus (HPV) is the most appropriate immunization for this patient at this time. He was recently diagnosed with HIV infection and has begun antiretroviral therapy. At baseline, his CD4 cell count is normal. He is in an age group for which HPV immunization is recommended, and that recommendation is the same regardless of HIV status. The presence of genital warts does not change the indication for HPV vaccination. He should begin the HPV vaccine series with the first injection today. Indications for influenza, tetanus-diphtheria-pertussis, and hepatitis A virus (HAV) vaccines are also the same for patients with HIV infection as for the general population.Pneumococcal vaccination is important for all persons with HIV infection, regardless of CD4 cell count. As with other immunocompromised persons, patients with HIV should receive the 13-valent conjugate and 23-valent polysaccharide vaccines, in that order. This patient has already received the pneumococcal conjugate vaccine and needs the polysaccharide vaccine, but at least 8 weeks must elapse between these two vaccines to allow for better immune response in this prime-boost strategy. Therefore, giving him the pneumococcal polysaccharide vaccine at this visit would be premature.Serum IgM antibodies to HAV are detectable at the time of symptom onset and remain detectable for approximately 3 to 6 months. Serum IgG antibodies appear in convalescence and remain detectable for decades. The presence of anti-HAV IgG in the absence of anti-HAV IgM indicates past infection or vaccination. This patient does not need vaccination against HAV.Hepatitis B virus (HBV) surface antibody testing is negative, indicating a lack of immunity to HBV; he also has risk factors for HBV that would warrant HBV vaccination. However, the patient tested positive for hepatitis B surface antigen, indicating he already has HBV infection and would not benefit from immunization with the HBV vaccine.Key PointIndications for influenza, tetanus-diphtheria-pertussis, hepatitis A virus, and human papillomavirus vaccines are the same for patients with HIV infection as for the general population.BibliographyPanel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed April 12, 2018. 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 Cited byCentral venous catheter–related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)Self-reported sleep and wake disorders in patients with ostheoarthrosis and end-stage renal diseaseHypercoagulopathy and Adipose Tissue Exacerbated Inflammation May Explain Higher Mortality in COVID-19 Patients With Obesity 7 January 2020Volume 172, Issue 1Page: ED1KeywordsAdolescentsAntibodiesCeliac diseaseHIV infectionsHuman papillomavirusIntensive care unitsOpportunistic infectionsPolysaccharidesVaccinesWarts ePublished: 7 January 2020 Issue Published: 7 January 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...