Annals for Educators - 19 November 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives19 November 2019Annals for Educators - 19 November 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201911190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome. A Randomized Noninferiority TrialLong-term anticoagulation with vitamin K antagonists (VKAs) is the standard of care for preventing thrombosis in patients with antiphospholipid antibody syndrome (APS), but VKAs require frequent monitoring and are associated with food and drug interactions. This 3-year randomized controlled trial compared the efficacy and safety of a newer oral anticoagulant versus dose-adjusted VKAs in patients with APS.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners when a diagnosis of APS should be considered. What are the possible clinical manifestations?How is APS treated? Use the information in DynaMed: Antiphospholipid Antibody Syndrome, a benefit of your ACP membership! Ask your learners what a noninferiority study is. What does the noninferiority margin mean? How are the results interpreted?The authors present the results of “intention-to-treat” and “per protocol” analyses. What is the difference? What are the potential biases introduced by a per protocol analysis? Why might a per protocol analysis be useful?Why might rivaroxaban not be noninferior to dose-adjusted VKAs in this study? The authors offer some possible explanations in the discussion.Invite an expert in study design to join your discussion.Incidence of Bloodstream Infections, Length of Hospital Stay, and Survival in Patients With Recurrent Clostridioides difficile Infection Treated With Fecal Microbiota Transplantation or Antibiotics. A Prospective Cohort StudyFecal microbiota transplantation (FMT) aims to restore the normal composition of gut microbiota and is recommended for treatment of recurrent Clostridioides difficile infection (CDI). Restoration of healthy microbiota through FMT might also prevent CDI-associated bloodstream infections. The objective of this prospective cohort study was to compare the incidence of bloodstream infections in patients with recurrent CDI treated with either FMT or antibiotics.Use this study to:Ask your learners why recurrent CDI might be a life-threatening condition. What are the potential complications?Why might patients with recurrent CDI be at increased risk for bloodstream infections? Which ones?How is recurrent CDI treated? Is FMT used at your center?What were the outcomes of this study?What are the limitations of an observational study (versus a randomized trial) to compare 2 approaches to therapy? What is the goal of propensity score matching? How well does this approach mimic a randomized trial? Invite an expert in biostatistics to join your discussion.Annals for Hospitalists Inpatient Notes - Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers—The Michigan Program on Value EnhancementThis short essay summarizes the steps used to assess a problem within a health system, devise a solution, plan how to study the effect of the solution, and assess its success.Use this paper to:Invite your learners to identify a problem with the system in which they practice every day. Can they identify the causes of the problem? What are potential ways to fix it?Invite an expert in quality improvement to join your discussion. Could your learners work to test a solution to the problem they identified?Video LearningAnnals Consult Guys - Procedures With DOACs: How Long to Wait?Howard and Geno tackle the challenge of managing direct oral anticoagulants (DOACs) when an invasive procedure is planned.Use this feature to:Ask your learners to list the available DOACs. What are their mechanisms of action?Can they be reversed in the event of bleeding?Watch the video. Then, ask how to calculate the time required after stopping the DOAC before an invasive procedure.Humanism and ProfessionalismOn Being a Doctor: A Portrait of the Physician as a Young ManDr. Ross describes how the tired physician recalls himself as a boy and wonders, “Who was that boy—that confident creator?”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners what professions they thought they would pursue when they were younger. What drew them to each?Are there aspects of medicine that encompass the talents involved in those other professions?MKSAP 18 QuestionA 32-year-old woman is evaluated for a recent episode of transient left monocular blindness. She noted dimness of vision in the left eye that came on suddenly and persisted for 15 minutes and then resolved completely. She had no accompanying headache or other symptoms. She has an 8-year history of systemic lupus erythematosus, which initially manifested as photosensitivity, discoid rash, and arthritis. She has responded well to treatment and has been doing well without active disease for the past year. History is significant for recurrent first trimester pregnancy loss attributed to positive antiphospholipid and anticardiolipin antibodies. Medications are hydroxychloroquine, prednisone, aspirin, and a daily multivitamin.On physical examination, vital signs are normal. Cardiac rhythm is normal. A 2/6 holosystolic murmur is heard at the apex with radiation toward the axilla. Temporal and carotid artery pulsations are normal; there is no scalp tenderness or vascular bruits. The remainder of the physical examination, including ophthalmologic examination, is normal.Which of the following is the most likely cause of her visual symptom?A. Bacterial endocarditisB. Carotid artery stenosisC. Giant cell arteritisD. Libman-Sacks endocarditisCorrect AnswerD. Libman-Sacks endocarditisEducational ObjectiveDiagnose Libman-Sacks endocarditis.CritiqueLibman-Sacks endocarditis (nonbacterial thrombotic endocarditis) is the most likely cause of this patient's transient monocular blindness. She has an 8-year history of systemic lupus erythematosus (SLE) and positive antiphospholipid antibodies (anticardiolipin antibodies plus lupus anticoagulant) with recurrent pregnancy loss. She meets the criteria for antiphospholipid syndrome. Patients who have SLE with positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, and in some cases manifesting as Libman-Sacks endocarditis. A recent study confirmed this significant association between valvular heart disease and antiphospholipid antibody positivity. It was also found that the highest risk was seen in double-positive antiphospholipid antibodies/lupus anticoagulant patients, as is the case in this patient. Libman-Sacks endocarditis may affect 11% or more of patients with SLE and has no relationship to disease activity. The condition is associated with large verrucous lesions near the edge of the valve, most often the mitral valve. Typical lesions consist of immune complexes, mononuclear cells, and fibrin and platelet thrombi. Libman-Sacks endocarditis is usually asymptomatic but can be responsible for numerous complications, including embolic stroke, or in this case a transient ischemic attack in the territory of the ophthalmic artery, peripheral emboli, and infective endocarditis.Bacterial endocarditis can be a source of cardiogenic emboli, but 90% of patients with infective endocarditis have fever, and often other constitutional symptoms, which are absent in this patient.Patients with SLE are prone to develop premature atherosclerosis (and can be a cause of stroke or transient ischemia attack), but this patient has no findings of atherosclerosis involving the carotid artery; furthermore, this diagnosis cannot account for the patient's heart murmur.Transient monocular blindness can be a manifestation of giant cell arteritis, but this diagnosis is extremely rare in individuals less than 40 years old.Key PointPatients with systemic lupus erythematosus and positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, in some cases manifesting as Libman-Sacks endocarditis.BibliographyVivero F, Gonzalez-Echavarri C, Ruiz-Estevez B, Maderuelo I, Ruiz-Irastorza G. Prevalence and predictors of valvular heart disease in patients with systemic lupus erythematosus. Autoimmun Rev. 2016;15:1134-1140. doi:10.1016/j.autrev.2016.09.007Do 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 19 November 2019Volume 171, Issue 10Page: ED10KeywordsAntibodiesAnticoagulantsAntiphospholipid syndromeBacteremiaBlindnessCarotid arteriesEndocarditisFecal microbiota transplantLupus erythematosusRandomized trials ePublished: 19 November 2019 Issue Published: 19 November 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...