Annals for Educators - September 2021
Authors: Christine Laine
Journal: Annals of Internal Medicine (2021)

Web ExclusivesSeptember 2021Annals for Educators - September 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202109210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMortality Among Persons Entering HIV Care Compared With the General U.S. Population. An Observational StudyHIV: Closing the Mortality GapTo understand differences in mortality between persons entering HIV care and the general population, this study estimated cumulative risk for all-cause mortality over 5 years among a cohort of persons entering HIV care in the United States between 1999 and 2017. The editorialists highlight actions that could further decrease the mortality gap between persons with HIV infection and the general population.Use this article and the editorial to:Start the session with a multiple-choice question. We provide one below.Ask your learners if they have cared for patients with HIV infection who died while under their care. What were the causes of death?How do the causes of death in persons with HIV infection that your learners have observed compare with the causes observed in the study reported in the article?Invite physicians who trained in internal medicine in the 1980s to the mid-1990s to share their experiences in caring for persons with HIV infection during their training. Invite your learners to discuss the differences and the factors that have contributed to them.What interventions do your learners see as likely to be most effective in further reducing the mortality gap between persons with HIV infection and the general population?Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department. A Multicenter Prospective Cohort StudyOne Small Step for Sickle Cell Disease: Many More to GoThis study assessed whether care in an infusion center versus an emergency department leads to improved outcomes in uncomplicated vaso-occlusive crises by following adults with sickle cell disease at 4 U.S. sites and evaluating pain outcomes and whether patients were discharged home or hospitalized. The editorialist discusses the findings and the need to improve care of these patients.Use this article and the editorial to:Review the signs and symptoms of sickle cell vaso-occlusive crises. This In the Clinic review may be helpful. Invite a hematologist or refer to this In the Clinic review to discuss the recommendations for care of patients with uncomplicated sickle cell vaso-occlusive crises. Ask your learners to share their observations about barriers to providing recommended care to patients with vaso-occlusive crises at your institution. What changes could improve care?What factors limit drawing definitive conclusions from the study? Ask your learners to describe what a stronger study might look like.Prevalence of Symptoms More Than Seven Months After Diagnosis of Symptomatic COVID-19 in an Outpatient SettingThis article systematically characterized the prevalence and longitudinal evolution of COVID-19 symptoms more than 7 months after diagnosis among 410 relatively healthy, nonhospitalized patients.Use this article to:Ask your learners whether they are observing patients who have recovered from acute SARS-CoV-2 infection with symptoms similar to those observed in this study.Ask your learners what criteria they would use to identify a patient whose persistent symptoms could be related to a prior SARS-CoV-2 infection. This article may be helpful. If your institution has a specific “post-COVID clinic,” ask a physician who practices in that setting to describe the evaluation and care provided in that clinic. Which patients should your learners consider referring to specialized settings for post-COVID care?Watch this episode of Annals Consult Guys with your learners. Could some symptoms described in the study be due to postural orthostatic tachycardia syndrome? Clinical GuidelinesManagement of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice GuidelineTargeting the Standardized Blood Pressure: New Guidelines for Blood Pressure Management in Chronic Kidney DiseaseThis synopsis of the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on blood pressure management in patients with chronic kidney disease (CKD) not receiving dialysis summarizes key recommendations to support shared decision making by health care professionals and patients with CKD. The editorialists discuss why broad implementation of the 2021 KDIGO recommendations has the potential to improve outcomes for a very-high-risk population.Use this article and the editorial to:Review the 2021 KDIGO recommendations for the care of patients with hypertension and CKD.Ask your learners to compare these recommendations to those for patients with hypertension and no kidney disease.Demonstrate the correct way to measure blood pressure, and have your learners practice by measuring each other's blood pressure. Note ways they can improve their blood pressure measurement skills.Bring several commonly used home blood pressure measuring devices to the session and demonstrate how they work. Have your learners role-play how they would explain the method for using the home monitor to a patient.Care of the Patient With Abnormal Liver Test ResultsLiver tests are commonly performed in primary care and may signal the presence of acute or chronic liver disease. Abnormal results are defined by standardized rather than individual laboratory thresholds and must be interpreted in the context of a patient's history and examination. The pattern and severity of liver injury may provide clues about disease etiology and should guide diagnostic evaluation with serologic testing and liver imaging. A systematic, stepwise approach to the evaluation and management of abnormal liver test results is recommended to optimize high-value care.Use this article to:Discuss the differential diagnosis of liver injury.Ask your learners to describe history and physical examination findings that are helpful in determining the cause of abnormal liver test results.Ask your learners when they would order imaging studies in a patient with abnormal liver test results.Invite a hepatologist to join the teaching session to review indications for subspecialty referral and liver biopsy for a patient with abnormal liver test results.Quality of CareAssociation Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020When COVID-19 Strikes Your HospitalThe effect of surges in COVID-19 caseload on COVID-19 survival rates is unclear, especially independent of temporal changes in survival. This retrospective cohort study used data from a large U.S. hospital database to study the association between caseload surges and risk-adjusted mortality in patients with COVID-19. The editorialist outlines strategies that could help to mitigate the deleterious effects of future COVID-19 surges on patients and hospital staff.Use this article and the editorial to:Ask your learners whether they find the results of this study to be surprising or what they would have expected.Ask willing learners to share their experiences in providing care to patients hospitalized with COVID-19 during a peak in caseload at your institution.What differences in the care of patients hospitalized with COVID-19 have they observed during surges in COVID-19 caseload versus times when the caseload was lower?Of the improvement strategies the editorialist recommends, which do your learners think are likely to have the greatest benefit?Effect of Bedside Compared With Outside the Room Patient Case Presentation on Patients' Knowledge About Their Medical Care. A Randomized, Controlled, Multicenter TrialBringing Teaching Back to the BedsideMedical educators have debated whether teaching rounds on hospitalized patients should be done primarily at the bedside or outside the patient's room. This trial compared how these approaches affect patients' understanding of their condition and treatment. The editorialist discusses why he believes these findings suggest that bedside teaching is efficient and why it should be used more often.Use this article and the editorial to:Poll your learners: Do they prefer conducting rounds on hospitalized patients at the bedside or away from the patient? Why?Next time you conduct teaching rounds, alternate being at the bedside and in the hallway and then have your learners reflect on the pros and cons of each.Brainstorm ways to reduce the patient confusion that was observed in the study and reported in the article.The Case for Mandating COVID-19 Vaccines for Health Care WorkersMandating COVID-19 Vaccination for Health Care WorkersHealth care workers who have not yet been vaccinated against COVID-19 might change their minds if the argument for vaccination were sufficiently clear. The first article attempts to provide that clarity. The related commentary presents arguments for why health care employers should mandate COVID-19 vaccination for their employees. A joint statement signed by dozens of health care professional societies and organizations endorses this requirement.Use these articles to:Ask an infection control colleague to join your session and review the vaccination policy for staff at your institution.Poll your learners: Do they think COVID-19 vaccination should be mandated for health care workers?After reading the articles, listen to the Annals On Call podcast interview with Dr. Klompas with your learners. Discuss the situations that would warrant waiving the vaccine requirement for a particular staff member.MKSAP 18 QuestionA 27-year-old man is evaluated during a routine health maintenance visit with his internist. He asks about reducing his risk for HIV infection because he has sex with men, has multiple partners, and reports using condoms “sometimes.” Medical history is unremarkable, and he takes no medications.The physical examination is normal.Laboratory studies show a normal serum creatinine level. A serum rapid plasma reagin test is negative. Nucleic acid amplification testing for gonorrhea and chlamydia from urine, pharynx, and rectum are all negative. An HIV test is negative.Which of the following is the most appropriate preventive measure?A. Reinforce consistent condom use and avoid antiretroviral therapyB. Tenofovir and emtricitabine single dose before each sexual encounterC. Tenofovir and emtricitabine single dose after each sexual encounterD. Tenofovir disoproxil fumarate and emtricitabine dailyCorrect AnswerD. Tenofovir disoproxil fumarate and emtricitabine dailyCritiqueThe most appropriate preventive measure for this patient is daily tenofovir disoproxil fumarate and emtricitabine (TDF-FTC). He has multiple risk factors for acquiring HIV infection, including having sex with multiple partners without consistent condom use. Data support the use of pre-exposure prophylaxis (PrEP) in specific populations with ongoing high risk for infection, such as sexual partners of infected persons, men who have sex with men, and injection drug users. PrEP is recommended for persons in such groups who can adhere to the daily regimen. Efficacy has varied depending on adherence to the regimen; rates of reduction in new infections ranged from 42% to 75% and up to 92% in patients whose adherence was documented by monitoring drug blood levels. This patient is in a group shown in clinical trials to benefit from PrEP for HIV. Daily combination tenofovir alafenamide and emtricitabine is approved for PrEP as well, except in women engaging in receptive vaginal intercourse. Risk of kidney dysfunction from TDF is low, but kidney function should be checked every 6 months during PrEP. Patients taking PrEP should be counseled to continue using barrier precautions and should undergo testing for HIV, other sexually transmitted infections (STIs), and pregnancy in women, every 3 months.TDF-FTC given as a single dose before or after each sexual exposure has not been proven effective, and because of concerns for lower effectiveness and possible selection for resistance, these methods should not be used for prevention.Patients should be counseled regarding the need for continued barrier precautions during sex because the effectiveness of PrEP is less than 100% and to reduce transmission of other STIs. However, counseling the patient about consistent condom use without PrEP places the patient at unnecessary risk for HIV infection. PrEP and barrier protection is now the standard of prevention for men who have sex with men at risk for HIV infection.BibliographyUS Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, et al. Preexposure Prophylaxis for the Prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA. 2019 Jun 11;321(22):2203-2213. doi: 10.1001/jama.2019.6390Teaching Scholarship OpportunityHerbert 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 2022, to be held April 28–30 in Chicago, Illinois.This is an opportunity to build your CV and to gain valuable experience teaching a workshop.The submission deadline for applications is September 27, 2021. Don't miss it—click here to complete your application! Do 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 September 2021Volume 174, Issue 9Page: ED9 ePublished: 21 September 2021 Issue Published: September 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...