Annals for Educators - 3 March 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives3 March 2020Annals for Educators - 3 March 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202003030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPoxvirus Vectored Cytomegalovirus Vaccine to Prevent Cytomegalovirus Viremia in Transplant Recipients. A Phase 2, Randomized Clinical TrialReactivation of latent cytomegalovirus (CMV) in CMV-seropositive recipients of allogeneic hematopoietic stem cell transplant (HCT) is associated with increased morbidity and mortality. This multicenter, double-blind, randomized, placebo-controlled, phase 2 trial evaluated the safety and efficacy of a vaccine to prevent CMV viremia in HCT recipients.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what the donor and recipient risk factors for CMV infection after solid organ transplant are. Use the information in DynaMed: CMV Infection in Solid-organ Transplant Recipients, a benefit of your ACP membership. What symptoms and signs should raise concerns about CMV disease?How is a diagnosis established? How is the disease treated?Can CMV infection be prevented?What are the potential long-term complications of CMV infection among transplant recipients?Sitters as a Patient Safety Strategy to Reduce Hospital Falls. A Systematic ReviewThis systematic review examines 20 studies that evaluated whether adding sitters to usual care or using alternatives to sitters (such as video monitors or close observation units) reduced falls in adult patients on general wards of acute care hospitals.Use this study to:Ask your learners how big a problem falls are among inpatients at your hospital.How common are falls among hospitalized patients nationally? What are the personal and health system costs? What are the implications for your hospital of the Centers for Medicare & Medicaid Services deeming a fall a “never event”? Use the editorial to help frame your discussion. What strategies are used at your hospital to identify patients at risk for falling? Who is responsible for identifying patients at risk?What strategies are used to prevent falls? Are they effective? How do you know? What did this study find?Do you use “sitters” at your institution? How about restraints? What are the potential benefits and complications with each approach? Invite a leader from your hospital's nursing department to join your discussion.What is the value of a systematic review that finds that the evidence base for a commonly used intervention is not great? In what ways might that be helpful?Recommended Adult Immunization Schedule, United States, 2020This article provides immunization recommendations from the Advisory Committee on Immunization Practices for adults aged 19 years or older.Use this paper to:Review the immunization recommendations with your learners.Is there a system in place to ensure identification of patients in need of immunizations in your practice? For which immunizations? What is the approach to others?Ask your learners what has changed since last year's recommendations.What is different in the recommendations for pneumococcal vaccination? Are PCV13 and PPSV23 both routinely recommended? Why the change? How would your learners discuss whether to use PCV13 with their patients?The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice GuidelinesThis synopsis of a 2019 clinical practice guideline addresses management of chronic insomnia disorder and obstructive sleep apnea.Use this synopsis to:Ask your learners whether they ask patients about insomnia. Should they?What questions do your learners ask when a patient reports problems sleeping? What evaluation should be performed?What should be the approach to management of insomnia? Is cognitive behavioral therapy useful? How do you arrange for it? When is pharmacologic therapy appropriate? Which drugs should be considered, and what are the benefits and risks?Do all patients with possible sleep apnea require an in-laboratory polysomnogram?In the Clinic: FibromyalgiaFibromyalgia is estimated to affect 2% to 4% of the general population, and the prevalence exceeds 15% in selected clinical groups. It is underdiagnosed. Are your learners prepared to recognize, evaluate, and treat it?Use this feature to:Ask your learners what they consider when patients complain of chronic, widespread pain.Should “screening” rheumatologic blood markers be tested?How is a diagnosis of fibromyalgia made?What is the role of cognitive behavioral therapy? What about sleep hygiene?Is referral to a specialist required for diagnosis or management?What is the prognosis?Use the provided multiple-choice questions to help introduce topics for discussion. And, sign on to enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Meaning at the FingertipsDr. Quagliarello recalls feeling pride and guilt when his patient remarked, “You're the only one who touches me.”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they believe too much emphasis is put on the importance of physical examination.Is there value to examining a patient even when it does not lead to a diagnosis or altered management?How might physical examination be harmful? Can it be “therapeutic”?Teaching Opportunity/CV BuilderClinical Skills Proposals Wanted for Internal Medicine Meeting 2022Interested in teaching procedural, physical examination, or communication skills?The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2022, which will be held in Chicago, Illinois, April 28-30, 2022. To submit a proposal, please complete the Clinical Skills Proposal. The deadline to submit proposals is April 24, 2020. MKSAP 18 QuestionA 45-year-old man is hospitalized with a 5-day history of fever, bloody diarrhea, and abdominal pain. Medical history is significant for end-stage kidney disease, for which he underwent kidney transplantation 1 year ago. Medications are prednisone, mycophenolate, and tacrolimus.On physical examination, vital signs are normal. Conjunctival pallor is present. Abdominal palpation elicits diffuse abdominal pain. The remainder of the examination is unremarkable.Laboratory studies:Hemoglobin9.5 mg/dL (95 g/L)Leukocyte count3400/µL (3.4 × 109/L)Platelet count98,000/µL (98 × 109/L)Alanine aminotransferase99 U/LAspartate aminotransferase88 U/LCreatinine1.5 mg/dL (133 µmol/L)Which of the following is the most likely diagnosis?A. Cytomegalovirus infectionB. Entamoeba histolytica infectionC. Salmonella enteritidis infectionD. Strongyloides stercoralis infectionCorrect AnswerA. Cytomegalovirus infectionEducational ObjectiveDiagnose cytomegalovirus infection in a solid organ transplant recipient with colitis.CritiqueThe most likely diagnosis in this patient is cytomegalovirus infection. Approximately 60% to 90% of adults have latent cytomegalovirus infection, with reactivation of disease common in persons who are immunosuppressed (patients with AIDS, transplant recipients, patients taking glucocorticoids). Cytomegalovirus is an important pathogen in kidney transplant recipients, and the risk of cytomegalovirus infection depends on the serologic status of the kidney donor and recipient at the time of transplantation. The highest risk occurs when a seronegative recipient (one who has never had a cytomegalovirus infection) receives a kidney from a seropositive donor. Cytomegalovirus can cause retinitis (especially in persons with AIDS), pneumonitis, hepatitis, bone marrow suppression, colitis with bloody diarrhea, esophagitis, and adrenalitis. This patient recently received a kidney transplant; he has bone marrow suppression (leukopenia and thrombocytopenia), hepatitis (elevated aminotransferase levels), and bloody diarrhea consistent with cytomegalovirus reactivation. Diagnosis relies on isolation of the virus from bodily fluids, such as urine; detection of cytomegalovirus pp65 antigen in leukocytes; cytopathic demonstration of “owl's eye” intracellular inclusions from tissue biopsy (colon in this case) (shown); polymerase chain reaction; and serologic assays. Antiviral treatment is typically indicated in cases of disease reactivation in immunocompromised patients and occasionally in immunocompetent hosts with severe disease. Valganciclovir is the first-line agent and is also used as prophylaxis or pre-emptive therapy in certain transplant patients.Entamoeba histolytica and Salmonella enteritidis can cause bloody diarrhea, but neither presents with pancytopenia. Therefore, they are unlikely possibilities in a solid organ transplant recipient. Furthermore, E. histolytica would not cause elevated aminotransferase levels in the absence of a liver abscess.Strongyloides stercoralis is the only parasite that has an autoinfection route (ability to complete its life cycle entirely within the human host) resulting in an increasing burden of parasites that can survive for decades in patients. Disseminated strongyloidiasis after solid organ transplantation can present with abdominal pain and diarrhea, but it is usually nonbloody. Furthermore, disseminated Strongyloides infection may present with sepsis with colonic bacteria, serpiginous rash, meningitis, or eosinophilic pneumonia. All patients scheduled for solid organ transplantation are now screened with a Strongyloides antibody and treated with ivermectin to decrease the incidence of this infection.Key PointLatent cytomegalovirus infection is present in 60% to 90% of adults, and patients who are immunosuppressed may experience disease reactivation with retinitis, pneumonitis, hepatitis, bone marrow suppression, colitis with bloody diarrhea, esophagitis, or adrenalitis.BibliographyAngarone M, Ison MG. Diarrhea in solid organ transplant recipients. Curr Opin Infect Dis. 2015;28:308-16. doi:10.1097/QCO.0000000000000172Do 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 March 2020Volume 172, Issue 5Page: ED5KeywordsAbdominal painBone marrowColitisCytomegalovirus infectionDiarrheaFallsInsomniaRenal transplantationSolid organ transplantationSystematic reviews ePublished: 3 March 2020 Issue Published: 3 March 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...