Annals for Educators - 3 September 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives3 September 2019Annals for Educators - 3 September 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201909030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsSevere Malaria Treatment in the United States at the PrecipiceIn November 2017, manufacture of quinidine gluconate, the only medication approved by the U.S. Food and Drug Administration to treat severe malaria, was discontinued. The authors discuss actions that clinicians, hospitals, federal agencies, and professional societies can take to ensure effective treatment and prevent a catastrophe.Use this short perspectives piece to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what symptoms and signs should prompt consideration of malaria.What tests should be sent when there is concern about malaria? Ask a hematologist or infectious disease specialist to review the thick smear findings of malaria with your team.What interventions should be started, and when? Does your health system have plans in place to obtain therapy for an acutely ill patient with severe malaria? If not, what should be done, and can your learners play a role in ensuring it is done?Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice GuidelinesTreatments for the Prevention and Management of Suicide. A Systematic ReviewThis systematic review and synopsis of 2019 clinical practice guidelines from the U.S. Department of Veterans Affairs and the U.S. Department of Defense address the assessment and management of patients at risk for suicide.Use these papers to:Ask your learners to name risk factors for suicide. What do your learners do when they see patients with these risk factors?Do your learners know how to ask a patient about suicidal ideation? Do they worry they might introduce the idea? Why is that incorrect? Invite a mental health expert to join your discussion and provide advice.What should your learners do if they are concerned about a patient's risk for suicide? Review the algorithms presented in the figures in the guideline synopsis.What questions should your learners ask? Should they inquire about firearms? What should they do if firearms are available? What about other lethal means?Do your learners know how to arrange for the care of a patient at risk for suicide? To whom should they turn for assistance, and how? How should they manage the patient until this assistance is available?In assessing the available literature on the prevention and management of suicide, the editorialist comments that “one is challenged by the use of ‘evidence’ as a definitive term.” What does this mean? Institutional Variation in Quality of Cardiovascular Implantable Electronic Device Implantation. A Cohort StudyCardiovascular implantable electronic devices (CIEDs) are among the most common devices implanted in hospitalized patients. Placement of CIEDs is associated with several potential procedure-related complications. In this study, the authors examined institutional variation in the risk-standardized rates of complications related to CIED implantation across hospitals in Australia and New Zealand.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what the indications are for the placement of a permanent pacemaker. What about for an implantable cardioverter-defibrillator?What are the potential complications associated with each of these CIEDs?What patient-specific variables should be considered when assessing who will benefit and who might be harmed by placement of a CIED?Invite an interventional cardiologist to join your discussion. Ask how your institution monitors its rates of complications. Are rates above or below the average reported for institutions included in this study? What are potential explanations for the differences?How would your learners propose to evaluate the rate of certain complications of CIEDs at your institution? How would they develop and implement potential solutions for improvement and to monitor their effects?In the Clinic: DementiaAn estimated 5.5 million adults aged 65 years or older are living with Alzheimer disease (AD) in the United States. As AD and other dementia syndromes become more common, primary care physicians need knowledge about approaches to prevention of cognitive decline, dementia screening, diagnosis, and treatment. Are your learners prepared?Use this review to:Ask what is known about the effectiveness of interventions to prevent the onset or progression of cognitive decline. What do your learners advise patients and their families?Should we screen for dementia? Why or why not?What studies should be considered when evaluating a patient with cognitive deficits?Should medications be used for AD? Should your learners discuss ineffective therapies with patients and families? Why?What should your learners ask about a patient's sleep, and why?When and how should your learners discuss end-of-life care with patients with dementia and their families?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!Humanism and ProfessionalismOn Being a Doctor: The N-WordDr. Youmans wondered, “Had he really just said what I thought I heard?”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether they have experienced patients or others making racist or other inappropriate remarks in the health care setting. What was the reaction of others? How was the situation handled?How should we react if a patient is verbally abusive? To whom should your learners turn for help?How do we set boundaries regarding unacceptable behavior by patients while still providing appropriate care? What happens if the patient continues to cross the boundaries?On Being a Doctor: Not Taking New PatientsDr. Pierce reflected on that remarkable day, filled with emotions of guilt, anxiety, confusion, exhaustion, and finally comfort.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Is it appropriate to “close” one's practice to new patients? Why or why not? Is it OK for exceptions to be made? When they are made, are some patients being provided special treatment? Is this right?How do your learners manage the guilt that accompanies being late for outpatient appointments and making patients wait? What can they do to avoid this? What can they do when it happens despite their best efforts?Teaching Scholarship Opportunity for Chief ResidentsHerbert S. Waxman Chief Resident Teaching ScholarshipAll chief residents who are members of ACP are eligible to apply for a Herbert S. Waxman Chief Resident Teaching Scholarship. Waxman Scholars assist in teaching popular workshops under the guidance and mentorship of expert faculty in the Clinical Skills Center at ACP's Internal Medicine Meeting. The scholarship includes the cost of meeting registration, travel, and accommodations for the ACP Internal Medicine Meeting 2020, to be held April 23–25 in Los Angeles, California.This is an opportunity to build your CV and to gain valuable experience teaching a workshop.The submission deadline for applications is September 27, 2019. Don't miss it—click here to complete your application! MKSAP 18 Question 1A 27-year-old woman is hospitalized with a 5-day history of intermittent fever, headache, muscle pains, and abdominal cramps. She returned 8 days ago from a 1-week trip to Kenya and Tanzania. She spent time outdoors in the evening and went hiking in a wooded park. She is pregnant at 20 weeks' gestation. She declined pretravel immunizations as well as antimalarial chemoprophylaxis. Her only medication is a prenatal vitamin.On physical examination, temperature is 39.1 °C (102.3 °F), blood pressure is 98/64 mm Hg, pulse rate is 112/min, and respiration rate is 16/min. Her conjunctivae are icteric. Cardiopulmonary examination reveals regular tachycardia. The remainder of the examination is unremarkable.A peripheral blood smear is shown.Which of the following is the most likely causative agent?A. Plasmodium falciparumB. Plasmodium knowlesiC. Plasmodium malariaeD. Plasmodium ovaleE. Plasmodium vivaxCorrect AnswerA. Plasmodium falciparumEducational ObjectiveDiagnose Plasmodium falciparum malaria.CritiqueThis pregnant woman has contracted Plasmodium falciparum malaria after visiting a part of the world where malaria is endemic. Her clinical presentation and peripheral blood smear showing many parasitized erythrocytes demonstrating signet ring forms, together with the absence of trophozoites and schizonts, are typical for infection with P. falciparum. Of returning travelers with acute and potentially life-threatening febrile diseases, P. falciparum malaria accounts for most infections. Furthermore, pregnant women are at increased risk of severe disease and a heightened mortality rate, which is likely related to a reduced immune response. Additionally, effects on the microvasculature and sequestering of organisms in the placenta during pregnancy are known to significantly increase the risk of miscarriage, premature delivery, low-birth-weight neonates, congenital infection, and fetal demise.Accurate identification of P. falciparum and Plasmodium knowlesi is critical because of the risk for severe and potentially lethal infection. P. falciparum should be suspected if the patient traveled to Africa, symptoms begin soon after return from an endemic area, and the peripheral blood smear shows a high level of parasitemia. P. knowlesi is a more recently recognized human pathogen; infection may be severe because of high levels of parasitemia. Examination of the peripheral blood smear reveals all stages of the parasite. The epidemiologic history is helpful because P. knowlesi is not encountered in Africa but rather South and Southeast Asia.Plasmodium malariae, Plasmodium ovale, and Plasmodium vivax are all associated with a low or very low degree of parasitemia, typically less than 2%, and although the risk of recurrence is high, with the exception of P. vivax, the risk for severe disease is low.This content was last updated in August 2018.Key PointPlasmodium falciparum infection should be suspected if the patient traveled to Africa, symptoms begin soon after return from an endemic area, and the peripheral blood smear shows a high level of parasitemia.BibliographyHahn WO, Pottinger PS. Malaria in the traveler: how to manage before departure and evaluate upon return. Med Clin North Am. 2016;100:289-302. doi:10.1016/j.mcna.2015.09.008MKSAP 18 Question 2A 71-year-old man is evaluated for a 10-day history of malaise and fatigue. Two years ago, he underwent dual-chamber pacemaker implantation for third-degree atrioventricular block. He reports discomfort at the site of his pacemaker. He has had no fever, chills, or weight loss. Medical history is otherwise significant for well-controlled hypertension and hyperlipidemia treated with chlorthalidone and atorvastatin.On physical examination, vital signs are normal. The skin overlying the patient's pacemaker pocket is slightly erythematous and is warm and tender to palpation. The remainder of the physical examination is noncontributory.A complete blood count and erythrocyte sedimentation rate are ordered.Which of the following is the most appropriate management?A. Blood culturesB. Empiric therapy with cephalexinC. Pacemaker pocket aspirationD. PET/CT scanningCorrect AnswerA. Blood culturesEducational ObjectiveDiagnose infection of a cardiac implanted electronic device.CritiqueThe most appropriate management of this patient is to obtain a complete blood count, erythrocyte sedimentation rate, and two sets of blood cultures. Patients with a cardiac implanted electronic device can develop a localized tissue infection at the implant site (pocket infection) or a systemic infection with bacteremia (such as endocarditis). These infections can occur after initial implantation, late after implantation, or after a battery replacement or revision. The most common pathogens are skin colonizers, such as the coagulase-negative Staphylococcus spp. and S. aureus. Symptoms of cardiac device infection include fever, chills, malaise, lassitude, or failure to thrive, especially in the elderly. There may also be local findings suggestive of infection, such as redness or warmth at the pacemaker pocket. These patients should undergo laboratory evaluation for signs of infection. An elevated erythrocyte sedimentation rate, leukocytosis with a left shift, and anemia all suggest infection of a cardiac implanted electronic device. All patients suspected of having infection (with or without fever) should have a minimum of two blood cultures drawn from separate sites. Once there is suspicion for infection of a cardiac implanted electronic device, referral to an electrophysiologist or an infectious disease specialist is mandatory.Empiric antibiotic therapy without first identifying the presence and cause of the infection is not best medical practice. In addition, antibiotic therapy for a confirmed infection without removal of the device is not curative and is associated with a high fatality rate.Pacemaker pocket aspiration should never be performed because it can seed a sterile pocket and lead to infection, especially if there is superficial cellulitis without deeper tissue involvement.In patients with high suspicion of infection despite equivocal laboratory findings, PET/CT can help determine whether there is evidence of local tissue inflammation consistent with a device infection. However, the basic evaluation for infection should be completed and analyzed first.This content was last updated in August 2018.Key PointIn all patients suspected of having infection of a cardiac implanted electronic device, a minimum of two blood cultures should be drawn from separate sites.BibliographyHarrison JL, Prendergast BD, Sandoe JA. Guidelines for the diagnosis, management and prevention of implantable cardiac electronic device infection [Editorial]. Heart. 2015;101:250-2. doi:10.1136/heartjnl-2014-306873Do 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 3 September 2019Volume 171, Issue 5Page: ED5KeywordsBloodFeversInfectious diseasesMalariaPacemakersParasitemiaPlasmodiumPlasmodium falciparumPregnancySuicide ePublished: 3 September 2019 Issue Published: 3 September 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. 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