Annals for Educators - 16 April 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives16 April 2019Annals for Educators - 16 April 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201904160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMeasles, Mumps, Rubella Vaccination and Autism. A Nationwide Cohort StudyThe hypothesized link between the measles, mumps, rubella (MMR) vaccine and autism continues to cause concern and challenge vaccine uptake. This study found no association between the MMR vaccine and autism in a large cohort, even among children with other risk factors for autism.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!What are the signs and symptoms of measles? What are the potential complications? Use the information at DynaMed Plus: Measles, a benefit of your ACP membership. Ask your learners what they know about claims that vaccines cause autism. Have they heard this opinion expressed by patients or others? How have they responded?Why do you think these concerns persist despite numerous studies refuting such a link and the retraction of the fraudulent “scientific” paper that claimed this association?How might such misconceptions cause harm?Do your learners believe that medical professionals have a responsibility to speak up when they hear such concerns expressed? What knowledge do we need to be effective?Ask your learners to practice explaining, in lay language, why the MMR vaccine is recommended and the reasons why the concerns about its causing autism are unfounded. They can use the patient summary to help consider what they might say. What else should be communicated? What do your learners know about the current outbreaks of measles in the United States and immunization rates among the affected communities?Acute Illness Associated With Cannabis Use, by Route of Exposure. An Observational StudyLittle is known about acute illness due to use of cannabis products. This study compares symptoms, diagnoses, and outcomes in adults who had emergency department visits related to edible or inhaled cannabis exposure.Use this study to:Ask your learners whether they are aware of acute harms from cannabis use. Do the potential harms differ according to whether the cannabis is inhalable or edible?What cannabis-attributable conditions were identified in the emergency department visits evaluated in this study?Why might the adverse effects of inhalable and edible cannabis differ? This is discussed in the accompanying editorial. How should hyperemesis syndrome be managed?What acute psychiatric symptoms were reported? How would your learners manage these patients?When might patients with cannabis-related adverse effects require hospitalization?Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of PhysiciansThis guidance statement from the American College of Physicians, based on review of existing guidelines and evidence underpinning those guidelines, provides advice to clinicians on breast cancer screening in average-risk women.Use this paper to:Ask whether your learners order mammograms for their patients. Which patients? How often? Why?Ask your learners what potential harms may result from breast cancer screening.What is overdiagnosis?Do your learners perform clinical breast examinations? What does this guidance statement recommend?This guidance statement is intended for women at average risk for breast cancer. How is that defined? How do your learners determine whether a patient is at average risk? Use the accompanying editorial to help frame your discussion. How would your learners counsel a 45-year-old woman at average risk for breast cancer who is unsure about whether to undergo screening?Annals Graphic MedicineAnnals Graphic Medicine – Progress Notes: House of CardsDr. Natter's comics, created while he progresses through his internal medicine residency, consider the ups, downs, tragedies, and triumphs of becoming a doctor.Use this comic to:Ask your learners whether they feel confident in their clinical skills.Does it differ from day to day? From hour to hour?Are they ever overconfident?What shakes their confidence? Are they too hard on themselves?Is there a proper balance? Is sharing their experiences helpful?Humanism and ProfessionalismOn Being a Patient: The Specter and the GoldfishDr. Pyzer recalls, “The lure of my own comfortable bed fought against the pandemonium of the emergency room. I acquiesced when I realized I could not swallow my own saliva, the physician in me finally, briefly, surfacing.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether any specific experience Dr. Pyzer describes hit them particularly hard. If necessary, prompt your learners by telling what was most powerful to you (for example, the taste of acid in one's throat with hypercarbia or the experience of being “bagged”).How does hearing about these experiences help us to be better physicians? What commonly observed patient experience do your learners fear most?Teach at the bedside! Ask patients who have experienced one of these things to discuss their memories.On Being a Doctor: Seven Easy StepsDr. Coulehan wished that everyone in the room was aware that he's a doctor, and therefore special.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have an urge to make others aware that they are physicians when they find themselves on the “other side” of patient care.What might motivate us to do this?Should we do this? Do we really want to be treated differently than nonphysician patients? Are there dangers to that? Are there benefits?Is being aware of these concerns and desires useful when we serve as physicians to other physicians? How should we behave?MKSAP 18 QuestionA 22-year-old man is evaluated during a pre-employment examination. The patient is starting a new job as a registered nurse. He is asymptomatic. He received the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 7 years ago and the influenza vaccine during the last influenza season. Approximately 6 months ago, he received one dose of the measles, mumps, and rubella (MMR) vaccine because of lack of documented immunity on serologic testing. Medical history is negative for chronic medical conditions. He is a nonsmoker, and he does not plan to travel outside of the United States in the near future. He takes no medications.Physical examination is normal.Laboratory studies are significant for a positive result on a hepatitis B surface antibody test. Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis A IgG antibody levels are undetectable.Which of the following is the most appropriate vaccination strategy for this health care worker?A. Administer a second dose of MMR vaccineB. Administer the hepatitis A vaccineC. Administer the hepatitis B vaccineD. Administer the 23-valent pneumococcal polysaccharide vaccineE. No vaccination at this timeCorrect AnswerA. Administer a second dose of MMR vaccineEducational ObjectiveManage vaccination of a health care worker.CritiqueThis patient should receive a second dose of the measles, mumps, and rubella (MMR) vaccine. In all immunocompetent adults who lack documented immunity against measles, mumps, and rubella, at least one dose of the MMR vaccine should be administered. Health care workers are at increased risk for acquiring and transmitting measles, mumps, and rubella and should receive a second dose of the MMR vaccine at least 28 days after the first dose. A second dose should also be administered to postsecondary students and international travelers. For persons who have been previously vaccinated with two doses of a mumps virus–containing vaccine but are at increased risk because of an outbreak, the Advisory Committee on Immunization Practices recommends administering a third dose of mumps virus–containing vaccine to improve protection.This patient's status as a health care worker does not necessitate administration of the hepatitis A vaccine, despite serologic tests indicating that he lacks immunity. The hepatitis A vaccine should be administered to patients who are at increased risk for infection or complications of infection, such as those who work or travel to endemic areas, men who have sex with men, individuals with chronic liver disease, illicit drug users, persons with clotting disorders, persons who conduct hepatitis A–related research, and household or close contacts of adopted children from endemic areas. Hepatitis A vaccination is also indicated in persons who desire vaccination and could be administered to this patient if he wishes.Hepatitis B vaccination is indicated in all health care workers who lack immunity. This patient has a positive hepatitis B surface antibody test result, whereas his surface antigen and core antibody levels are undetectable. This pattern is consistent with prior vaccination with an appropriate immune response. As such, hepatitis B vaccination is unnecessary in this patient.Pneumococcal vaccination is recommended in all adults aged 65 years and older and adults aged 19 to 64 years with certain high-risk conditions. This patient does not have any chronic medical conditions and is also a nonsmoker; therefore, vaccination with the 23-valent pneumococcal polysaccharide vaccine is not indicated.This content was last updated in August 2018.Key PointHealth care workers are at increased risk for acquiring and transmitting measles, mumps, and rubella and should receive a second dose of the MMR (measles, mumps, and rubella) vaccine.BibliographyKim DK, Riley LE, Hunter P; Advisory Committee on Immunization Practices. Recommended immunization schedule for adults aged 19 years or older, United States, 2018. Ann Intern Med. 2018;168:210-220.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 16 April 2019Volume 170, Issue 8Page: ED8KeywordsAutismHealth care providersHepatitis AHepatitis BImmunityMMR vaccineMeaslesMumpsRubellaVaccines ePublished: 16 April 2019 Issue Published: 16 April 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...