Annals for Educators - 17 November 2020
Authors: Christine Laine
Journal: Annals of Internal Medicine (2020)

Web Exclusives17 November 2020Annals for Educators - 17 November 2020FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202011170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsObesity and Mortality Among Patients Diagnosed With COVID-19: Results From an Integrated Health Care OrganizationBody Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection. A Retrospective Cohort StudyThe first study examined the association between obesity and death 21 days after diagnosis of COVID-19 among patients in an integrated health care system, accounting for obesity-related comorbidities and sociodemographic factors. The second study evaluated whether obesity is associated with intubation or death—as well as biomarkers of inflammation, cardiac injury, or fibrinolysis—in the context of COVID-19 independent of obesity-related comorbidities.Use these studies to:Review the definitions of overweight, obesity, and morbid obesity with your learners.Ask your learners to identify comorbidities that often coexist with obesity and how they might affect outcomes of SARS-CoV-2 infection.Read the editorial and discuss the mechanisms that may account for poor outcomes in patients with obesity. National Trends in Drug Payments for HIV Preexposure Prophylaxis in the United States, 2014 to 2018. A Retrospective Cohort StudyImproving uptake of preexposure prophylaxis (PrEP) for people at risk for HIV is a priority of the National HIV/AIDS Federal Action Plan. This analysis estimated the distribution of PrEP costs in the United States between 2014 and 2018.Use this study to:Ask your learners if they have ever prescribed PrEP for a patient at risk for HIV infection.Discuss the patients for whom PrEP is likely to be beneficial.Invite a pharmacist to your teaching session to discuss the drugs used in PrEP regimens and their costs.Discuss resources that your learners might access if their patients are interested in PrEP but would have difficulty paying for it.Read the editorial and discuss strategies to increase use of PrEP to prevent HIV infection. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. A Systematic Review for the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Management of DyslipidemiaManagement of Dyslipidemia for Cardiovascular Disease Risk Reduction: Synopsis of the 2020 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice GuidelineThe systematic review provides evidence underpinning the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense (VA/DoD) guidelines for management of dyslipidemia, with a focus on interventions to improve statin tolerance and adherence. The guideline includes recommendations for managing dyslipidemia in adults; topics include targeting of statin dosage, tests for risk prediction, primary and secondary prevention, laboratory testing, physical activity, and nutrition.Use the evidence review and clinical guideline to:Start a teaching session with a multiple-choice question. We provide one below!Ask your learners what the indications are for prescribing statins to reduce risk for cardiovascular disease events.Read the editorial and discuss how the VA/DoD guideline differs from those of other organizations. Ask your learners which statins they typically prescribe, and at what doses, for patients at elevated risk for cardiovascular disease events.Role-play a discussion with a patient who admits to taking statins only occasionally rather than as prescribed.Humanism and ProfessionalismConnecting With Older Adults via TelemedicineUse of telemedicine is increasing rapidly, but some older patients are having difficulty with the transition. This article describes how they and their clinicians can have better experiences.Use this article to:Ask your learners about their experiences with telemedicine visits. What do they like and dislike about telemedicine?Discuss the challenges they have experienced when conducting telemedicine visits with older patients.Review the telemedicine communication checklist in the Table. Discuss the feasibility of these suggestions in the settings where your learners practice.Role-play the start of a telemedicine visit with an 87-year-old patient.Bereavement Care in the Wake of COVID-19: Offering Condolences and ReferralsThe COVID-19 pandemic is causing deaths with forced separations that deny final goodbyes and traditional mourning rituals. This article describes resources for clinicians to use when circumstances make providing ideal bereavement care difficult.Use this article to:Ask your learners if they have had a patient who died of COVID-19.Provide an opportunity for your learners to share stories about these experiences with each other.Review the framework provided in the Table and role-play conversations in which your learners need to tell a family member about their loved one's death over the telephone.MKSAP 18 QuestionA 59-year-old man is evaluated during a routine examination. He feels well and has no symptoms. Medical history is significant for hypertension. He does not smoke, and he does not have diabetes mellitus. He is active, performing aerobic exercise for 20 to 30 minutes four times per week. Medications are lisinopril and chlorthalidone.On physical examination, the patient is afebrile, blood pressure is 122/74 mm Hg, and pulse rate is 76/min. Cardiac examination is unremarkable.Laboratory studies:Total cholesterol169 mg/dL (4.38 mmol/L)HDL cholesterol36 mg/dL (0.93 mmol/L)LDL cholesterol106 mg/dL (2.75 mmol/L)Triglycerides135 mg/dL (1.53 mmol/L)Which of the following is the most appropriate next step in management?A. Begin low-intensity statin therapyB. Begin moderate-intensity statin therapyC. Begin high-intensity statin therapyD. Calculate the 10-year atherosclerotic cardiovascular disease riskE. Repeat lipid level measurement in 5 yearsCorrect AnswerD. Calculate the 10-year atherosclerotic cardiovascular disease riskCritiqueThe most appropriate next management step is to calculate this patient's 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Results of lipid measurements and patient-specific data (age, race, blood pressure, hypertension treatment, diabetes mellitus, and smoking) allow for the calculation of 10-year ASCVD risk using the Pooled Cohort Equations. In adults aged 40 to 75 years who have at least one ASCVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year ASCVD risk of 10% or greater, the U.S. Preventive Services Task Force (USPSTF) recommends statin therapy for the primary prevention of ASCVD. The USPSTF also recommends that clinicians selectively prescribe statins to adults aged 40 to 75 years without a history of ASCVD who have one or more ASCVD risk factors and a calculated 10-year ASCVD event risk of 7.5% to 10% (grade C recommendation). Because this patient has one ASCVD risk factor (hypertension), it is appropriate that his risk be assessed, and through use of the Pooled Cohort Equations, his 10-year risk for ASCVD is 9.3%. According to the USPSTF recommendation, he should be considered as a potential candidate for statin therapy. The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends that patients without ASCVD or diabetes who have a 10-year ASCVD risk of 7.5% to less than 20% should be engaged in a discussion regarding cardiovascular risk reduction and offered moderate-intensity statin therapy if risk-enhancing factors are also present.The initiation of statin therapy might be reasonable for this patient but not until his 10-year ASCVD risk is calculated. Such information can be used to determine the need for and intensity of stain therapy.The optimal interval for assessment of ASCVD risk is undetermined; however, it is reasonable to measure lipid levels every 5 years in adults aged 40 to 75 years. This patient should not wait 5 years to have his ASCVD risk assessed and delay potentially beneficial therapy.BibliographyBibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, García FA, et al; US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:1997-2007. doi:10.1001/jama.2016.15450Do 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: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 November 2020Volume 173, Issue 10Page: ED10KeywordsAtherosclerotic cardiovascular diseaseCOVID-19Cardiovascular diseasesCardiovascular therapyDyslipidemiaHypertensionObesityPreexposure prophylaxisStatinsTelemedicine ePublished: 17 November 2020 Issue Published: 17 November 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...