Annals for Educators - 18 August 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives18 August 2020Annals for Educators - 18 August 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202008180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRisk for Subdeltoid Bursitis After Influenza Vaccination. A Population-Based Cohort StudyShoulder bursitis has been reported as an adverse event after intramuscular vasculitis. This study estimated the risk for subdeltoid bursitis after influenza vaccination using data from the Vaccine Safety Datalink, which contains encounter information from 10.2 million members seen in 7 U.S. health care organizations.Use this study to:Ask your learners what bursitis is. What are the potential causes?Teach at the bedside! Do your learners know how to examine the shoulder to assess potential causes of pain? Practice on each other, or demonstrate the examination with a patient who has agreed to do so on rounds.Do your learners know how to give an intramuscular injection?The authors of this study discuss that the technique used when administering injections may affect the occurrence of bursitis. Read the accompanying editorial and review the accompanying figure for a discussion and illustration of how to administer an injection. Can you arrange for your learners to administer intramuscular injections (e.g., this year's influenza vaccine)? Who should teach them how to do it properly?Should the small risk for bursitis dissuade us from recommending influenza vaccination? See what the editorialists and the study authors note at the end of their papers. Comparative Effectiveness of Glucose-Lowering Drugs for Type 2 Diabetes. A Systematic Review and Network Meta-analysisThe selection of pharmacologic therapy for type 2 diabetes has become increasingly complex as clinicians aim to match patients' individual risks and preferences to a growing number of available drug classes. Head-to-head comparisons are not available to inform the choice between all pairs of available drugs. This systematic review and network meta-analysis evaluated available evidence from randomized trials to help fill these evidence gaps.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what outcomes and patient-specific variables they consider when choosing pharmacologic therapy for their patients with type 2 diabetes.Are the choices different for therapy for treatment-naive patients versus add-on therapy?What did this study find regarding the choice of initial therapy for treatment-naive patients?How would your learners choose among the available drug classes for subsequent therapy? What might sway them toward the use of one class versus another? Does it vary according to patients' risks for adverse diabetic outcomes, such as cardiovascular disease?Use the editorial to help frame your discussion. Medical ScienceBiomedical Research in Times of Emergency: Lessons From HistoryCOVID-19 has disrupted the lives of billions of people worldwide. Emergencies can stimulate substantial investment of resources that catalyze impressive scientific accomplishments but can also lead to false promises and ethical breaches. The authors discuss how history shows the importance of treating early results with caution, given that we are only beginning to understand SARS-CoV-2.Use this essay to:Ask your learners what aspects of medical research needed to be altered to address the current coronavirus pandemic.What are the potential benefits and risks to changes in how we prioritize, organize, and conduct research during such an emergency?The authors of this essay point to tragic lessons from prior public health emergencies (e.g., the transmission of infectious disease, unethical research practices). Do your learners think we have learned from these mistakes? Are there safeguards to protect against them normally, and are those safeguards threatened in times of emergency?Humanism and ProfessionalismAnnals Graphic Medicine - The Palliative PathThis graphic (yup, a cartoon!) depicts 2 paths by which a patient might arrive at the same outcome.Use this feature to:Ask your learners to look at the short cartoon for a minute.What do they think the story is? What is the significance of the initial and final panels on each side being the same?Does palliative care alter the outcome, the path a patient experiences along the way, or possibly both? At your center, do all patients receive attention to their “path,” or only those enrolled in a palliative care program?Why does this matter? When should a palliative care consultation be considered? Do our responsibilities for palliation of a patient's symptoms differ according to our specialties? Invite an expert in palliative care to join your discussion.On Being a Doctor: Seven O’ClockTo Dr. Sindhu, as New Yorkers hunker down in their apartments to slow the spread of the virus, the nightly 7:00 cheer has become a cherished tradition.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have received words or other gestures of gratitude for the work they have done to care for patients with COVID-19.Do we need such boosts to get through these challenging times? Do we give them to others as often as we should?How do your learners think these public demonstrations of gratitude help those who are doing the cheering and clapping?MKSAP 18 QuestionA 45-year-old woman is evaluated for management of type 2 diabetes mellitus diagnosed 3 months ago. She was asymptomatic at diagnosis with an initial hemoglobin A1c value of 9.7%. Her initial interventions included lifestyle modifications with weight loss and metformin. She is motivated to continue to lose weight. Medical history is significant for hypertension, hyperlipidemia, and frequent vulvovaginal candidiasis. She has no family history of thyroid or pancreatic malignancy. Medications are metformin, lisinopril, and atorvastatin.On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is unremarkable.Results of laboratory studies show a hemoglobin A1c level of 9.1%. Chemistry panel and creatinine levels are normal.Which of the following is the most appropriate management for this patient's diabetes?A. Initiate empagliflozinB. Initiate glipizideC. Initiate insulin glargineD. Initiate liraglutideCorrect AnswerD. Initiate liraglutideEducational ObjectiveTreat type 2 diabetes mellitus in a patient with obesity.CritiqueAccording to the American Diabetes Association (ADA), this patient's goal hemoglobin A1c level is less than 7% given that she is healthy and early in the disease course. The American College of Physicians (ACP) recommends a target hemoglobin A1c level between 7% and 8% for most patients with type 2 diabetes. The ACP notes that more stringent targets may be appropriate for patients who have a long life expectancy (>15 years) and are interested in more intensive glycemic control despite the risk for harms, including but not limited to hypoglycemia, patient burden, and pharmacologic costs. Her hemoglobin A1c level remains above goal despite 3 months of lifestyle modifications and metformin. The ADA recommends advancing to dual-therapy if the hemoglobin A1c remains at 9% or above after 3 months of metformin therapy. Sequential therapeutic agents added to metformin should be selected based on the degree of hyperglycemia, comorbidities, weight, side effect profiles, cost, and patient preferences. Liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, is an appropriate adjunctive agent with metformin in this patient as it will improve glycemic control and contribute to desired weight loss. There are potential concerns for development of pancreatitis and medullary thyroid carcinoma with GLP-1 receptor agonists. The patient does not have a personal or family history of these abnormalities to preclude use of liraglutide.Empagliflozin, a sodium-glucose transporter-2 (SGLT2) inhibitor, may be added to metformin when the hemoglobin A1c remains above goal. SGLT2 inhibitor use improves glycemic control and induces weight loss, but it also increases the risk of genital mycotic infections. Empagliflozin should not be used in this patient because it may exacerbate her frequent vulvovaginal candidiasis infections.Glipizide, a sulfonylurea, may also be added to metformin when the hemoglobin A1c remains above goal. Glipizide will improve glycemic control, but it is associated with weight gain that is not in concordance with the patient's desire for continued weight loss.Basal insulin coverage can be provided with one to two daily injections of insulin detemir, glargine, or neutral protamine Hagedorn (NPH) insulin. Basal insulin may be added to metformin when the hemoglobin A1c level remains above goal. Basal insulin will improve glycemic control, but it is associated with weight gain that is not in concordance with the patient's desire for continued weight loss.Key PointLiraglutide is an add-on therapy to metformin to achieve improvement in hemoglobin A1c level and weight loss.BibliographyAmerican Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S73-S85. doi:10.2337/dc18-S008Do 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 18 August 2020Volume 173, Issue 4Page: ED4KeywordsCOVID-19Drug therapyHemoglobinInsulinPalliative carePatientsType 2 diabetesVaccinesWeight gainWeight loss ePublished: 18 August 2020 Issue Published: 18 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...