Annals for Educators - 6 August 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives6 August 2019Annals for Educators - 6 August 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201908060 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsExcess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia. A Multihospital Cohort StudyRandomized trials have demonstrated the safety of shorter courses of antibiotic treatment for pneumonia, but how often excess treatment durations are prescribed is not known. This large multicenter cohort study assessed how often patients hospitalized with pneumonia received excess durations of antibiotic treatment and whether this was associated with harm.Use this study to:Ask your learners how they choose the duration of antibiotic therapy for pneumonia.What is recommended? How often do they think antibiotics are used for longer than necessary? What are the potential harms of excessive use? Are there harms to a duration that is too short?What did this study find?Why do your learners think that most of the excess antibiotic days occurred during outpatient care?What is the practice at your institution regarding the duration of antibiotic therapy prescribed at the time of hospital discharge? Can your team identify patients discharged after treatment for pneumonia from your service (perhaps with a clinical inquiry application in your EHR)? What was prescribed at discharge?How might the total duration of antibiotic therapy be optimized?Benefits and Harms of Oral Anticoagulant Therapy in Chronic Kidney Disease. A Systematic Review and Meta-analysisThis meta-analysis of 45 trials compared the benefits and harms of vitamin K antagonists and non– vitamin K oral anticoagulants in patients with chronic kidney disease stages 3 to 5.Use this study to:Ask your learners why patients with chronic kidney disease are at increased risk for thrombotic complications. Which ones?Why are they at increased risk for bleeding complications with anticoagulation?What do we know about the benefits and safety of non–vitamin K oral anticoagulants in patients with chronic kidney disease? Why have these patients so frequently been excluded from clinical trials of these agents?What did this systematic review find?What do your learners think is best when considering anticoagulation in patients with chronic kidney disease and which drugs to use? What more do we need to know?Beyond the GuidelinesHow Would You Manage This Patient With Nonalcoholic Fatty Liver Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterNonalcoholic fatty liver disease (NAFLD) is increasing in prevalence in the United States. However, identifying which patients with NAFLD will develop cirrhosis remains challenging, and management is controversial. In this feature, 2 gastroenterologists discuss updated practice guidelines regarding NAFLD screening; the use of noninvasive studies and liver biopsy for diagnosis; and approaches to clinical management, including weight loss, reduced alcohol consumption, and pharmacologic therapies.Use this feature to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how NAFLD is defined. How is it usually identified?Do your learners think we should screen for NAFLD? If so, in which patients? How would screening be performed?How should patients with NAFLD be monitored? Should they undergo liver biopsy?What interventions should be recommended?How is liver stiffness assessed? Ask an expert to demonstrate performance of the test and interpretation of the results for your team.Watch the video interview of Mr. L, a 59-year-old man with NAFLD. And, watch the video of the grand rounds presentation or consider asking members of your team to summarize the points made by the 2 experts.Have your learners' thoughts about screening, monitoring, or management changed?In the Clinic: Stable Ischemic Heart DiseaseStable ischemic heart disease (SIHD) is a leading cause of death in the United States and many other countries. The defining pathobiology is an imbalance between the metabolic demands of the myocardium and its oxygen supply, which most often results from coronary artery atherosclerosis. The classic presenting symptom of SIHD is angina, but clinical presentation varies greatly among patients. Do your learners know what to do to reduce ischemic complications, such as myocardial infarction and congestive heart failure?Use this review to:Ask your learners how SIHD is differentiated from unstable angina. What is the differential diagnosis of SIHD? (See the Box: Alternative Diagnoses to Angina for Patients With Chest Pain.)What testing should be considered, and how does it differ according to the risk assessment for coronary artery disease? Review the algorithm provided.Which patients should have stress testing, and how should the appropriate test be chosen?What are essential elements of patient education regarding SIHD? Who should provide this education?Which medical therapies can prevent myocardial infarction or death in SIHD?Which patients should be referred to a cardiologist?In which patients should revascularization be considered? What are the advantages and disadvantages of coronary artery bypass grafting and percutaneous coronary intervention?How might the answers to these questions differ in older patients? What about those with chronic kidney disease?Use the provided multiple-choice questions to introduce topics in a teaching session. And, be sure to log on to enter your answers to earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Patient: The Promise“‘Make sure you take care of Robbie,’ was the last thing that she said. Sometimes she acted like she'd only had one child.”Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners whether they ask patients about their fears and concerns if they are unable to return home.Do the authors' descriptions alter your learners' views of common occurrences that we as physicians might see as “routine”? How are such views helpful to us?MKSAP 18 QuestionA 48-year-old woman is evaluated at a follow-up appointment for elevated liver chemistry tests over the preceding 6 months. She reports no symptoms. She has type 2 diabetes mellitus and hypertension. Her family history is unremarkable. She drinks two glasses of wine one or two times per month. Her medications are metformin and lisinopril.On physical examination, vital signs are normal; BMI is 31. No spider angiomata, palmar erythema, splenomegaly, abdominal distention, or lower-extremity edema is noted.Laboratory studies:Alkaline phosphatase96 U/LAlanine aminotransferase85 U/LAspartate aminotransferase74 U/LAnti–smooth muscle antibodyPositive (1:20 titer)Results of other studies, including hepatitis C antibody, hepatitis B surface antigen, iron saturation, α1-antitrypsin phenotype, tissue transglutaminase IgA antibody, antimitochondrial antibody, and IgG, are within normal limits.On ultrasonography, the liver is hyperechoic and enlarged.Which of the following is the most likely diagnosis?A. Antimitochondrial antibody–negative primary biliary cholangitisB. Autoimmune hepatitisC. Nonalcoholic fatty liver diseaseD. Primary sclerosing cholangitisCorrect AnswerC. Nonalcoholic fatty liver diseaseEducational ObjectiveDiagnose nonalcoholic fatty liver disease.CritiqueThe most likely diagnosis is nonalcoholic fatty liver disease (NAFLD). Up to 108 million Americans have NAFLD, which far exceeds the prevalence of any other form of chronic liver disease. Risk factors include obesity, diabetes mellitus, insulin resistance, hypertension, and hyperlipidemia. This patient has three risk factors for NAFLD, as well as an enlarged liver on physical examination. Her elevated alanine aminotransferase and aspartate aminotransferase levels are within the typical range for patients with NAFLD. Alkaline phosphatase (ALP) levels may be slightly elevated as well, typically less than 2 to 2.5 times the upper limit of normal. The finding of a hyperechoic liver on ultrasonography is also consistent with NAFLD. Because other liver diseases may also result in hepatic steatosis, patients with elevated liver chemistries and suspected nonalcoholic steatohepatitis should be evaluated to exclude other causes of chronic liver disease.The diagnosis of primary biliary cholangitis (PBC) is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive antimitochondrial antibody test. The predominant liver enzyme abnormality is an increase in serum ALP levels, but a mild to moderate increase in aminotransferase levels is also seen. Antimitochondrial antibody–negative PBC accounts for about 10% of cases of PBC, but in suspected antimitochondrial antibody–negative PBC, other PBC-specific autoantibodies (sp100 or gp210) can establish the diagnosis in a patient with a compatible cholestatic liver enzyme profile. This patient's liver chemistry profile is hepatocellular (elevations primarily of aminotransaminase levels), not cholestatic, making PBC unlikely.Although this patient has a positive anti–smooth muscle antibody test, the low titer alone is not diagnostic of autoimmune hepatitis. Autoimmune hepatitis is typically accompanied by higher autoantibody titers and elevated γ-globulin levels. It requires a liver biopsy to establish the diagnosis. Between 20% and 30% of patients with NAFLD exhibit low-titer autoantibodies.This patient has a minimally elevated ALP level, which helps to exclude primary sclerosing cholangitis (PSC) or PBC. In addition, the patient's risk factors and ultrasound findings make these diagnoses unlikely. MR cholangiopancreatography is required to diagnose PSC.This content was last updated in May 2019.The American Association for the Study of Liver Diseases issued practice guidance on primary biliary cholangitis. The guidance offers updated recommendations about when liver biopsy is necessary for diagnosis, as well as health care considerations for primary care providers managing patients with PBC. (Updated May 2019)Key PointNonalcoholic fatty liver disease is the most common cause of abnormal liver test results in the United States.BibliographyChalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55:2005-23. doi:10.1002/hep.25762Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology. 2019;69:394-419. doi:10.1002/hep.30145Do 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 6 August 2019Volume 171, Issue 3Page: ED3KeywordsAntibioticsBiopsyChronic kidney diseaseGastroenterology and hepatologyLiverLiver diseasesMedical risk factorsNon-alcoholic fatty liver diseasePneumoniaUltrasound imaging ePublished: 6 August 2019 Issue Published: 6 August 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...