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

Web Exclusives7 April 2020Annals for Educators - 7 April 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202004070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Coronavirus Resources: Selections From the Annals Collection of Recent PublicationsUse of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic: What Every Clinician Should KnowA Rush to Judgment? Rapid Reporting and Dissemination of Results and Its Consequences Regarding the Use of Hydroxychloroquine for COVID-19These concise papers summarize what we know and do not know about using hydroxychloroquine for the treatment of COVID-19, and the consequences of acting on preliminary data.Use these papers to:Ask your learners if they think it is appropriate to consider the use of hydroxychloroquine for the treatment of COVID-19.What are the limitations of the available data? What adverse events may occur with hydroxychloroquine?What are the potential consequences of widespread use or stockpiling of the drug? What do your learners propose is the appropriate response? Should they offer it if a patient or family requests it? How would they explain their answer?Annals On Call - Protecting Health Care Workers From COVID-19Listen to this concise and informative discussion about personal protection for health care professionals.Additional articles related to coronavirus are freely available here.Clinical Practice PointsDual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention. A Systematic Review and Meta-analysisThis meta-analysis of 4 large trials examines the potential benefits and harms of dual versus triple antithrombotic therapy for patients with atrial fibrillation (AF) who have had percutaneous coronary intervention (PCI) to treat acute coronary syndrome.Use this study to:Ask your learners what the rationale is for using triple therapy in patients with AF following PCI.What agents are used at your institution? Do the cardiologists have a preference? Ask them why.Do your learners think that triple therapy reduces the risk for stent thrombosis, myocardial infarction, and/or stroke compared with dual therapy? Does it increase the risk for bleeding?What did this review find? How should we interpret the confidence intervals regarding the risk for major adverse cardiovascular events?What do your learners plan to do in the future? Invite a cardiologist to join your discussion.Beyond the GuidelinesShould You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterMedical inpatients are at high risk for venous thromboembolism (VTE) because of immobility and comorbid conditions. The American Society of Hematology has suggested chemoprophylaxis against VTE for non–critically ill medical inpatients, leaving much to the discretion of the treating physician. A hematologist and a hospitalist discuss the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.Use this feature to:Start a teaching session with a multiple-choice question. We've provided one below.Present the history of Ms. X, a 40-year-old woman with risk factors for VTE who was admitted to the hospital. Consider watching the video of her interview with your learners. Would your learners have ordered VTE prophylaxis for Ms. X? Why or why not?Assign members of your team to summarize the arguments in favor of prophylaxis made by the hematologist and against it by the hospitalist.Ask what the limitations of current guidelines are. Do we have sufficiently reliable ways to identify patients at high risk for VTE? Are the outcomes used in randomized trials sufficiently informative?What do your learners plan to do in the future?In the Clinic: HyperthyroidismThe prevalence of thyrotoxicosis in the United States is estimated at 1.2%, with approximately 40% of cases being overt and 60% being subclinical. Are your learners prepared to diagnosis, evaluate, and treat it?Use this review to:Ask your learners who is at risk for thyrotoxicosis.What symptoms should prompt an evaluation for possible hyperthyroidism? What tests should be ordered, and how are they interpreted?What is the differential diagnosis?How is thyrotoxicosis treated? What adverse events may occur with treatment? How are patients to be monitored?Use the multiple-choice questions to introduce topics in a teaching session. Log on to enter your answers to earn CME/MOC credit for yourself.Understanding Clinical ResearchStudies Using Randomized Trial Data to Compare Nonrandomized ExposuresPost hoc analyses of randomized trial data can help answer important questions by making use of valuable data collected in controlled settings. Using trial data to compare nonrandomized exposures requires care because the comparisons are not protected by randomization. This article helps readers understand the potential biases that need to be considered when evaluating such studies.Use this paper to:Ask your learners what the purpose of randomization is in a clinical trial.What do the authors mean when they note that some analyses not intended in the original trial may lose the protection of randomization?What does a propensity score aim to accomplish?Taking Care of Our Learners and OurselvesOn Being a Doctor: On Leaving Clinical MedicineOn Being a Doctor: Laura and the Terrible, Horrible, No Good, Very Bad DayIn the first piece, Dr. Lynch recalls his immersion into residency training: “As soon as I dissolved, I began to react—or perhaps I should say ‘combust.’” In the second piece, Dr. Rock describes her terrible, horrible, no good, very bad birthday.Use these essays to:Listen to audio recordings ( here and here), read by Drs. Hood and LaCombe. Ask your learners whether they feel like “impostors.” Do they think others feel the same way, or do your learners feel alone?Do they feel inadequate and incompetent as physicians? Do they blame themselves for their patients' poor outcomes?Do they know to whom they can turn for support?Does your training program have well-established avenues for communication and help for individuals in need?What does Dr. Rock mean when she wonders how people whose jobs don't provide distraction from their own problems manage?MKSAP 18 QuestionA 30-year-old man is evaluated after being hospitalized for an acute flare of extensive ulcerative colitis. He reports six to eight bloody bowel movements daily with prominent urgency and lower abdominal cramping for the past 2 weeks. He has been taking prednisone daily for 1 week. His only other medication is mesalamine.On physical examination, vital signs are normal. Abdominal examination reveals lower abdominal tenderness. The abdomen is not distended and bowel sounds are normal. Blood is seen on digital rectal examination.Hemoglobin level is 10 g/dL (100 g/L). He remains hemodynamically stable.Which of the following is the most appropriate venous thromboembolism prophylaxis for this patient?A. AspirinB. Graduated compression stockingsC. HeparinD. Intermittent pneumatic compressionE. Low-dose warfarinCorrect AnswerC. HeparinEducational ObjectivePrevent venous thromboembolism in a hospitalized patient with inflammatory bowel disease.CritiqueSubcutaneous heparin is the most appropriate venous thromboembolism (VTE) prophylaxis for this patient. VTE is a common clinical problem and is associated with substantial morbidity and mortality among hospitalized patients. Most medical patients have one or more risk factors for VTE. More than a quarter of patients with undiagnosed and untreated pulmonary embolism (PE) will have a subsequent fatal PE, and between 5% and 10% of all in-hospital deaths are a direct result of PE. VTE is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD); patients with IBD have a three-fold risk for VTE compared to patients without IBD. VTE represents a significant cause of morbidity and mortality in patients with IBD, and risk for VTE is highest at the time of disease flare. Although the incidence of VTE increases with age, the highest relative risk for VTE in IBD is observed in patients younger than 40 years old. Patients with IBD who develop VTE have an increased mortality rate, and the most important risk factor for development of VTE is active IBD. For these reasons, prevention of VTE in patients with IBD is essential. All hospitalized patients with IBD should be given pharmacologic VTE prophylaxis with subcutaneous heparin. Systematic reviews of trials comparing prophylactic low-molecular-weight heparin with unfractionated heparin have not shown a statistically significant difference for mortality or major bleeding events, although there was a nonsignificant trend favoring low-molecular-weight heparin in the prevention of PE.Mechanical VTE prophylaxis with graduated compression stockings or intermittent pneumatic compression devices is not recommended either with or in place of pharmacologic prophylaxis, although intermittent pneumatic compression has shown some efficacy in surgical patients and may be an option for nonsurgical patients with a contraindication to pharmacologic therapy, such as severe gastrointestinal bleeding. Compression stocking are no more effective than placebo in preventing VTE and are associated with harm in the form of increased incidence of skin breakdown.Aspirin and low-dose warfarin have no role in VTE prophylaxis for hospitalized medical patients or patients with IBD.Key PointAll hospitalized patients with inflammatory bowel disease should be given pharmacologic venous thromboembolism prophylaxis with subcutaneous heparin.BibliographySeah D, De Cruz P. Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther. 2016;43:482-513. doi:10.1111/apt.13491Do 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 7 April 2020Volume 172, Issue 7Page: ED7KeywordsHematology and oncologyHemorrhageHeparinHydroxychloroquineInflammatory bowel diseaseMedical risk factorsMortalityPercutaneous coronary interventionProphylaxisVenous thromboembolism ePublished: 7 April 2020 Issue Published: 7 April 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...