Annals for Educators - 1 October 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives1 October 2019Annals for Educators - 1 October 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201910010 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAntipsychotics for Preventing Delirium in Hospitalized Adults. A Systematic ReviewAntipsychotics for Treating Delirium in Hospitalized Adults. A Systematic ReviewOld Habits Die Hard: Antipsychotics for Treatment of DeliriumThese systematic reviews of randomized trials and observational studies examine benefits and harms of antipsychotics for prevention and treatment of delirium in adults. The editorial discusses the findings and why we need to abandon old habits of using antipsychotics to treat delirium.Use these reviews to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to define delirium. Why is a precise definition important? Is a patient with dementia necessarily delirious? What is the difference? Why does it matter?What do your learners do when informed that a hospitalized patient is delirious? What evaluation should they perform? What are the potential causes?Teach at the bedside! Are your learners familiar with diagnostic tools such as the Cognitive Assessment Method (CAM) for delirium? Demonstrate the use of CAM or another validated approach to evaluate potential delirium.Are all patients with delirium agitated? What is “calm delirium”?In what ways is delirium dangerous?What do these systematic reviews tell us about the use of antipsychotics for prevention or treatment of delirium? What can we do when a patient is delirious? What behavioral interventions can be helpful? What causes are reversible?Will your learners be tempted to “just order a drug” the next time they are called about an agitated patient who is delirious? Will they feel pressured to do so? How should they respond?How would your learners evaluate the effect of an intervention to treat delirium? What “end points” would they use to assess success? The editorial discusses these challenges.Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C Virus Infection in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2018 Clinical Practice GuidelineThis synopsis of a clinical practice guideline provides key recommendations pertinent to prevention, diagnosis, treatment, and management of hepatitis C virus (HCV) infection in adults with chronic kidney disease (CKD).Use this guideline to:Ask your learners whether screening for HCV infection is recommended for patients with CKD. If so, why? Use this opportunity to discuss the criteria for an effective screening test.What therapy should be used for the treatment of HCV infection in a patient with CKD? Review the algorithm in Figure 1.What kidney diseases are related to HCV infection itself? How is each managed?Vibrio vulnificus Infections From a Previously Nonendemic AreaThis brief report provides concise descriptions of patients with necrotizing soft tissue infections caused by Vibrio vulnificus after water or shellfish exposures in the Delaware Bay, an area not commonly associated with such exposure.Use this paper to:Ask your learners what organisms should be considered when patients present with cellulitis. What signs and symptoms should raise concern about fasciitis and the need for surgical debridement?Have your learners heard of Vibrio vulnificus? Where are infections with this organism most commonly reported?What changes appear to have led to an increase in Vibrio infections outside its more commonly reported geographic distribution?How might climate change alter how we approach the differential diagnosis of infectious diseases?Beyond the GuidelinesTo What Target Hemoglobin A1c Level Would You Treat This Patient With Type 2 Diabetes? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterControversy surrounds the optimal glycemic target for treatment of patients with type 2 diabetes (T2D). In this multimedia feature, a general internist and a diabetologist debate how to apply recent divergent professional guideline recommendations to the care of Ms. K, a 60-year-old woman who fears the need for insulin therapy and wonders whether she would gain any benefits from tighter glycemic control.Use this feature to:Watch the video of Ms. K's interview.Ask your learners what the risks and benefits are of aiming for tight glucose control in patients with T2D. What target hemoglobin A1c level should be used? When should one consider deintensifying hemoglobin A1c goals?Watch the video of the Grand Rounds presentations, or assign members of your team to summarize the arguments made by each of the 2 discussants.What questions would your learners ask Ms. K? How might her answers influence what your learners recommend? How would they explain the risks and benefits of tighter or less intense glycemic control to Ms. K?Teach at the bedside! Ask a patient with T2D who uses insulin how she or he felt about starting it. What challenges has it posed? Watch a short cartoon depicting patient worries about “going on the needle.” Log on to enter answers to the multiple-choice questions to earn CME/MOC credit for yourself!In the Clinic: AsthmaAsthma affects more than 300 million people globally, including 26 million in the United States. It causes substantial health and economic burdens, with more than 11 million office visits and 10.0 deaths per 1 million persons in the United States each year. Are your learners prepared to diagnose, treat, and prevent the complications of asthma?Use this review to:Ask your learners when they should suspect a patient has asthma. How is the diagnosis established?Do normal spirometric values rule out the diagnosis?What alternative diagnoses should be considered?What advice should your learners provide to patients about environmental exposures in the management of asthma?Review the “step therapy” algorithm provided in the Figure.How do your learners explain “maintenance” and “rescue” therapy to patients? What language do they use?Teach at the bedside! Ask a patient to demonstrate the use of his or her inhaler. Do your learners know how inhalers should be used? Is it easy? Why does such an evaluation matter? Invite an expert in asthma education to demonstrate how they teach appropriate use.When should a patient be referred to a specialist?What are the potential complications of asthma?Use the provided self-assessment questions to help introduce teaching topics. And, log on to enter your answers to earn CME/MOC credit for yourself!On Being a DoctorMy Grandmother, the DoctorDr. Morris notes that when his grandmother went to medical school, supervisors taunted, “Women go to medical school, get married, and have babies. It's a waste of a physician.”Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Ask your learners whether the challenges faced by the author's grandmother persist today.Are the contributions of women in medicine valued less than those of men today?Are the expectations of women and men in medicine the same?Do women in medicine receive the same compensation and support as men?Why do inequalities persist? What should be done to address them?EndorseDr. Shabot realizes he has moved on to be that senior—or just plain old—physician.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners whether they enjoy hearing from older physicians about how things used to be.Ask whether the “old days” were the “days of the giants.”Do your learners believe it is a problem if they don't have the same acumen in physical diagnosis as physicians who trained decades ago?Might some of the more senior faculty members at your institution and your trainees enjoy talking about such issues? What can they learn from each other?MKSAP 18 QuestionA 56-year-old man hospitalized for respiratory failure is evaluated for new-onset confusion. He has acute respiratory distress syndrome secondary to community-acquired pneumonia. He has been in the critical care unit for 3 days. He is orally intubated and placed on mechanical ventilation. Current medications are ceftriaxone, azithromycin, and propofol for light sedation according to protocol.On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 100/45 mm Hg, pulse rate is 112/min, and respiration rate is 24/min. He cannot focus his attention, does not follow simple commands, and has demonstrated fluctuating mental status during the past 8 hours. The neurological examination is otherwise normal. He appears to be comfortable and shows no signs of pain.Arterial blood gas studies show a pH of 7.41, a PCO2 of 38 mm Hg (5.1 kPa), and a PO2 of 62 mm Hg (8.2 kPa). Serum sodium, serum creatinine, and blood urea nitrogen are normal.Chest radiograph shows multifocal opacities consistent with pneumonia and acute respiratory distress syndrome.In addition to orientation strategies and promoting a normal sleep-wake cycle, which of the following is the most appropriate management?A. Add haloperidolB. Add lorazepamC. Early mobilizationD. Increase propofolCorrect AnswerC. Early mobilizationEducational ObjectiveTreat a patient on mechanical ventilation for delirium using nonpharmacologic interventions.CritiqueEarly mobilization with physical and occupational therapy and interruption of sedation should be used to decrease the duration of delirium. This patient has acute onset of cognitive dysfunction, impairment of attention, and fluctuating mental status, which are features of delirium. Increased or decreased psychomotor activity, disorganized thinking, disorientation, and perceptual disturbances are other supportive features. The use of a screening instrument (such as the Confusion Assessment Method) allows for improved recognition and diagnosis of delirium. Delirium contributes to length of ICU stay, morbidity, mortality, and post-intensive care cognitive impairment. A study of critically ill patients on mechanical ventilation demonstrated that an early physical and occupational therapy program reduced delirium by 2 days compared to controls.Haloperidol is used to decrease hyperactive features of delirium. Currently, there is no strong evidence in favor of its use for treating delirium in critically ill patients.Current guidelines for sedation in the ICU favor strategies that control pain, target lighter sedation, avoid benzodiazepines, and favor early mobility. The use of benzodiazepines is associated with an increased incidence of delirium, and would not be appropriate for this patient showing signs of delirium when compared with nonbenzodiazepine sedation strategies.The practice of having all critically ill patients on mechanical ventilation receive continuous deep sedation is no longer followed, thus increasing the propofol dosage would not be appropriate. A practice-changing trial demonstrated that daily interruption of sedation decreased length of mechanical ventilation and stay in the ICU. Recent trials demonstrated that the use of a light sedation protocol had similar patient outcomes to daily interruption of sedation. Light levels of sedation using a protocol are associated with shorter length of mechanical ventilation and ICU stay.Key PointEarly mobilization with physical and occupational therapy and interruption of sedation should be used to prevent and treat delirium in critically ill patients.BibliographySchweickert WD, Pohlman MC, Pohlman AS, et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:1874– 1882Do 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 1 October 2019Volume 171, Issue 7Page: ED7KeywordsAntipsychoticsAsthmaDeliriumInfectious diseasesIntensive care unitsPneumoniaSedationSystematic reviewsVentilatorsVibrio ePublished: 1 October 2019 Issue Published: 1 October 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...