Annals for Educators - 1 January 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives1 January 2019Annals for Educators - 1 January 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201901010 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsTrends in Drug Use–Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017. A Study of Statewide Discharge DataThe opioid epidemic has led to an increase in hospital admissions for drug use–associated infective endocarditis (DUA-IE). The authors used a statewide database to examine 10-year trends in the characteristics and outcomes of patients hospitalized with DUA-IE, including the proportion having valve surgery.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how IE presents. How should patients with possible IE be evaluated? When should treatment be initiated? What antibiotic coverage should be started? Use the information at DynaMed Plus: Infective Endocarditis, a benefit of your ACP membership. What bacteria are most commonly involved? Which valves? Do the answers differ with DUA-IE?What are the indications for valve surgery in patients with IE? Why has surgery for DUA-IE been controversial? What are the concerns and possible ethical considerations? Invite a cardiac surgeon to join your discussion. Would she or he perform valve surgery in a patient who has recently used intravenous drugs?Do your learners understand how to address a patient's substance use and its importance in the care of patients with DUA-IE?Ask your learners why they think hospitalizations are longer among patients with DUA-IE than among those without it. The authors address this in the paper's discussion.What duration of antibiotic therapy is required for IE? Is parenteral therapy required?Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure. A Meta-analysis of Randomized Controlled TrialsWhat are the benefits and harms of catheter ablation versus drug therapy alone for patients with atrial fibrillation (AF) and heart failure (HF)? This meta-analysis of 6 trials provides the answers.Use this study to:Ask your learners why the prevalence of AF is higher among patients with HF. How might structural and electrical changes associated with AF and HF perpetuate a vicious cycle?What are the medical options for treating AF?When should catheter ablation be considered for treatment of AF? How is it performed? Are there contraindications? Ask an interventional cardiologist to join your discussion and show your learners the catheterization films of a procedure to help understand what is done.What are the possible complications of catheter ablation for AF?In the Clinic: Rheumatoid ArthritisRheumatoid arthritis (RA) is a chronic, systemic inflammatory disease that affects 0.5% to 1% of U.S. adults—an estimated 1.5 million people. In addition to articular involvement, patients with RA may present with or later develop disease manifestations in other organs, pericarditis, pleural effusion, or interstitial lung disease. Are your learners prepared?Use this review to:Ask who is at increased risk for RA.What are the possible presentations of RA? Describe the “classic” articular findings.Teach at the bedside! Identify patients on your service with articular findings that are typical of RA. Ask them whether they would allow you to demonstrate these findings to your learners. Ask the patient to tell your learners how RA affects his or her daily life.How is RA diagnosed? What is the role of laboratory testing?Are radiographs required to establish a diagnosis? Should “baseline” films be obtained?How should treatment be approached? Why is methotrexate considered the “backbone” of treatment? When should biologic disease-modifying antirheumatic drugs be considered?What are the goals of treatment, and how is it monitored?When should a patient be referred to a rheumatologist?Use the provided multiple-choice questions to help introduce topics for discussion, and log on to enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: The ApocalypseDr. Fitzgerald recalls her patient imploring, “You must not tell them or anyone until I am dead what I will tell you now. Promise?”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners if they have asked patients whether they fear death. If so, what have they said they fear?In addition to controlling physical suffering, how can we assist patients in addressing emotional suffering as they face death?Do we as physicians frequently feel we must have an answer for any concern a patient has?Annals Graphic MedicineAnnals Graphic Medicine - Caring for Dying Patients: Visual Narratives From the Intensive Care UnitIn this powerful series of drawings, Dr. Bao looks at and into her patients in the intensive care unit as she reflects on how daily medical interventions affect a patient's experience.Use this feature to:Ask your learners to look quietly at each of the 6 drawings without reading the artist's comments.Have your learners share their thoughts on each drawing, and then read the artist's comments. Did people see different things?In the first drawing, Dr. Bao asks, “At what point are we treating ‘numbers' instead of treating the patient?” Have your learners ever asked that same question? Is this question asked enough?Do any of the drawings change how your learners will think about patients in similar situations? How?MKSAP 18 QuestionA 33-year-old woman was hospitalized 8 days ago for fever and severe dyspnea. Her current symptoms began 1 month ago with chills, malaise, and low-grade fever. She was diagnosed 5 years ago with a bicuspid aortic valve with regurgitation but had been healthy otherwise. On admission, an echocardiogram demonstrated a 12-mm vegetation involving the aortic valve with severe regurgitation and preserved left ventricular function. Blood cultures grew Staphylococcus aureus that was sensitive to oxacillin. After 8 days of intravenous antimicrobial therapy, she has continued to be febrile, and her dyspnea has progressed such that she has symptoms at rest.On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 110/60 mm Hg, pulse rate is 96/min, and respiration rate is 23/min. Lung examination demonstrates bilateral crackles. The estimated central venous pressure is 10 cm H2O. There is a grade 3/6 diastolic decrescendo murmur along the left sternal border. An S3 is present.Repeat blood cultures performed yesterday continue to grow S. aureus sensitive to oxacillin. An echocardiogram obtained today shows findings similar to those on the initial study done at admission. A transesophageal echocardiogram confirms the valve findings without evidence of additional complications.Which of the following is the most appropriate next step in management?A. Cardiac catheterizationB. Cardiac valve surgeryC. Intra-aortic balloon pump placementD. Switch oxacillin to vancomycinCorrect AnswerB. Cardiac valve surgeryEducational ObjectiveTreat a patient with infective endocarditis and refractory bacteremia with cardiac valve surgery.CritiqueThe most appropriate next step in management is cardiac valve surgery. This patient has infective endocarditis with refractory bacteremia. For patients such as this one, cardiac surgery is the most appropriate next step when there is evidence of persistent infection lasting longer than 5 to 7 days while the patient is receiving appropriate antimicrobial therapy. Cardiac surgery also is recommended for patients with infective endocarditis who have the following: symptomatic heart failure; left-sided involvement with Staphylococcus aureus, fungal infections, or highly resistant organisms; associated complications, such as heart block, annular or aortic abscess, or destructive penetrating lesions; or prosthetic valve infective endocarditis and relapsing infection.Cardiac catheterization is not indicated in this patient and may increase the risk for embolization of vegetation or worsen hemodynamic status. Cardiac catheterization before planned cardiac surgery is indicated in patients with risk factors for coronary artery disease, which are not present in this patient.The most common indications for intervention with an intra-aortic balloon pump are cardiogenic shock unresponsive to other interventions and acute mitral regurgitation. This patient does not have any indication for an intra-aortic balloon pump. Additionally, an intra-aortic balloon pump is contraindicated in the presence of significant aortic regurgitation, as seen in this patient, because it will increase the volume of regurgitant blood flow.Surgical intervention should not be delayed for observation of the patient's response to another antibiotic once surgical indications have been met. In this patient, switching to another antibiotic without immediate surgical intervention may result in further decompensation of the patient's clinical status and an increased operative risk for intervention at a later time.This content was last updated in August 2018.Key PointFor patients with infective endocarditis, cardiac surgery is indicated for persistent infection lasting longer than 5 to 7 days while on appropriate antimicrobial therapy; symptomatic heart failure; left-sided involvement with Staphylococcus aureus, fungal infections, or highly resistant organisms; complications such as heart block, annular or aortic abscess, or destructive penetrating lesions; and prosthetic valve infective endocarditis and relapsing infection.BibliographyBaddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435-86. doi:10.1161/CIR.0000000000000296Do 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 January 2019Volume 170, Issue 1Page: ED1KeywordsAntibioticsAntimicrobialsCardiac surgeryCatheterizationEndocarditisHeart failureProsthetic device infectionsStaphylococcal infectionSurgeryThoracic surgery ePublished: 1 January 2019 Issue Published: 1 January 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...