Annals for Educators - 4 August 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives4 August 2020Annals for Educators - 4 August 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202008040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLong-Term Rituximab Use to Maintain Remission of Antineutrophil Cytoplasmic Antibody–Associated Vasculitis. A Randomized TrialBiannual infusions with rituximab for 18 months have become the standard of care for maintaining remission in patients with antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis. This randomized controlled trial examined the efficacy of biannual rituximab infusions for an additional 18 months in patients with ANCA-associated vasculitis who completed a previous regimen of rituximab maintenance therapy and were in complete remission.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how granulomatosis with polyangiitis might present. How about microscopic polyangiitis? What organs are most often affected? How do these diseases differ? How is each diagnosed?What are ANCAs, and how are they used? Which diseases are more often associated with antibodies to myeloperoxidase and to proteinase-3?Why has the demonstration of rituximab's efficacy in ANCA-associated vasculitis been so important? What was standard therapy previously, and what were the problems?How long should patients be treated with rituximab? What are the potential benefits and harms? Use the accompanying editorial to frame your discussion. Invite a rheumatologist to join your discussion.The primary end point in this study was disease relapse, evaluated using the Birmingham Vasculitis Activity Score, which assesses patients' symptoms. What are the advantages and disadvantages of using patients' symptoms as an end point? Is it “patient centered”?Health System Costs of Treating Latent Tuberculosis Infection With Four Months of Rifampin Versus Nine Months of Isoniazid in Different SettingsAlthough a 4-month rifampin regimen for latent tuberculosis infection (LTBI) is safer, has superior treatment completion rates, and is as effective as a 9-month isoniazid regimen, it is associated with higher daily medication costs. In this study, the authors use data from 2 randomized clinical trials to compare health care use and associated costs of these regimens in high-, middle-, and low-income countries.Use this study to:Ask your learners who should be evaluated for possible LTBI. Why is it important to find LTBI?What testing should be performed? Should skin testing or interferon-gamma release assays be used? Do all patients need a chest x-ray? Use the information in DynaMed: Latent Tuberculosis Infection, a benefit of your ACP membership. How should LTBI be treated? What regimens are available?What are the relative advantages and disadvantages of isoniazid and rifamycin-containing regimens for treatment?What did this study find?Why are studies like this helpful if the clinical benefits of one regimen over another have already been established?Annals Clinical Decision Making: Incorporating Perspective Into Clinical DecisionsIncreasingly, physicians are required to consider the implications of clinical decisions beyond those for the patient. This article in the Annals Clinical Decision Making series provides guidance on how to navigate perspective that may push in multiple directions.Use this paper to:Present the first case to your learners. What would influence their decision about whether to admit the patient? Are the patient-specific variables the only considerations?Is it appropriate to consider issues beyond the patient's needs alone? How can we do so without compromising care?Present the second case. What non–patient-specific perspectives should be considered? Is it appropriate to consider cost when making recommendations and decisions with patients?Beyond the GuidelinesManagement Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia. Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe Kidney Disease Outcomes Quality Initiative recommends that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both renal replacement therapy, including dialysis or transplantation, and conservative management. Here, 2 experts—a nephrologist and a general internist–palliative care physician—reflect on the care of a patient with advanced chronic kidney disease (CKD) and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among them.Use this feature to:Watch the interview of the patient's daughter.Ask your learners what the options are for management of the patient's kidney disease.What are the relative pros and cons of dialysis and conservative management? What does each involve?What symptoms are more likely to be alleviated with dialysis than conservative management? At what potential price?How would your learners engage in shared decision making with the patient and his family? What is the “worst case/best case” approach to such a discussion?Watch the video of the Grand Rounds discussion. What would your learners recommend to this patient and his family?In the Clinic: Chronic Obstructive Pulmonary DiseaseChronic obstructive pulmonary disease (COPD) affects close to 400 million people and is already the third leading cause of death worldwide, which the World Health Organization had not predicted to occur until 2030. In the United States, the number of deaths from COPD in women has surpassed that in men since 2000. Are your learners prepared to diagnose and manage COPD?Use this review to:Ask your learners whether they should screen for COPD. Why or why not? What must be known about screening for it to be recommended? What is the difference between screening and case finding?How is the diagnosis of COPD made? In whom should an α1-antitrypsin level be measured? Why is it important to identify α1-antitrypsin deficiency?How should symptom burden and risk for exacerbations be evaluated? How are these evaluations used to guide the choice of therapy?Teach at the bedside! Ask a patient to demonstrate her or his use of a short-acting bronchodilator. Be sure you know how to teach the appropriate technique. Invite an expert to join and show your team. Why is it important to assess a patient's technique?Who should be referred for pulmonary rehabilitation? Why?Which patients should be seen by a pulmonologist?When should lung volume reduction or lung transplant be considered?Use the provided multiple-choice questions to introduce topics for discussion. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!MKSAP 18 QuestionA 55-year-old man is hospitalized for acute respiratory failure requiring intubation and mechanical ventilation. He also has increasing leg swelling with nonhealing skin ulcers on the legs for the past 4 weeks, and pain with swelling of the bilateral wrists and finger joints for the past 6 weeks. He quit smoking 15 years ago. History is otherwise unremarkable. Prior to hospitalization he was taking no medications.On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 150/95 mm Hg, pulse rate is 110/min, respiration rate is 20/min (ventilator set rate, 14/min), and oxygen saturation is 92% on FIO2 of 40%. There is blood in the endotracheal tube. Lung crackles are heard bilaterally. Swelling of the wrists, metacarpophalangeal joints, and proximal interphalangeal joints is noted. Two necrotic ulcers on the left leg and one necrotic ulcer on the right leg are present. There is 2+ pitting edema of the legs.Laboratory studies show normal C3, C4, and rheumatoid factor; negative antinuclear antibodies; positive ANCA with a perinuclear pattern; and 3+ protein on urinalysis. Blood and sputum cultures are negative.Chest radiograph shows diffuse bilateral infiltrates. Biopsy of a skin ulcer shows nongranulomatous, necrotizing small-vessel vasculitis with immunofluorescence negative for immune complexes.Which of the following is the most likely diagnosis?A. Granulomatosis with polyangiitisB. IgA vasculitisC. Microscopic polyangiitisD. Rheumatoid vasculitisE. Thromboangiitis obliteransCorrect AnswerC. Microscopic polyangiitisEducational ObjectiveDiagnose microscopic polyangiitis.CritiqueThe most likely diagnosis is microscopic polyangiitis (MPA), which characteristically affects the lungs and kidneys, along with other organ systems. Diagnosis is suspected based upon typical clinical findings and positive ANCA. The diagnostic gold standard is a biopsy demonstrating nongranulomatous necrotizing pauci-immune vasculitis of small vessels or pauci-immune necrotizing crescentic glomerulonephritis in the kidney. This patient has pulmonary hemorrhage, pauci-immune small-vessel necrotizing vasculitis of the skin, proteinuria, inflammatory arthritis, and a positive p-ANCA (directed against myeloperoxidase)—all consistent with the diagnosis of MPA.Granulomatosis with polyangiitis (GPA) can cause the same lung, skin, joint, and kidney findings but is usually associated with a positive c-ANCA (directed against proteinase-3). Furthermore, GPA causes granulomatous inflammation; absence of granulomas distinguishes MPA from GPA.IgA vasculitis (Henoch-Schönlein purpura) can affect lungs, skin, joints, and kidneys but it is an immune complex–mediated vasculitis with deposition of IgA containing immune complexes identified on biopsy, which is not present in this patient.Rheumatoid vasculitis usually occurs in long-standing disease with positive rheumatoid factor and is immune complex mediated, none of which is present in this patient.Thromboangiitis obliterans is a smoking-related vasculopathy affecting small to medium vessels with inflammation and thrombosis of vessels in upper and lower limbs, leading to reduced pulses and gangrenous ulcers. This diagnosis is unlikely because this patient no longer smokes, and has involvement of internal organs in addition to the legs.Key PointThe diagnostic gold standard of microscopic polyangiitis is a biopsy demonstrating nongranulomatous necrotizing pauci-immune vasculitis of small vessels or pauci-immune necrotizing crescentic glomerulonephritis in the kidney.BibliographyKallenberg CG. The diagnosis and classification of microscopic polyangiitis. J Autoimmun. 2014;48-49:90-3. doi:10.1016/j.jaut.2014.01.023Do 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 4 August 2020Volume 173, Issue 3Page: ED3KeywordsBiopsyDecision makingImmune complexInflammationKidneysLungsProteinsTuberculosisUlcersVasculitis ePublished: 4 August 2020 Issue Published: 4 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...