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

Web ExclusivesJune 2021Annals for Educators - June 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202106150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsComparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis. Two Nationwide Cohort StudiesThis retrospective cohort study compared the effectiveness and harms of 2 antibiotic regimens commonly used for outpatient diverticulitis: metronidazole with a fluoroquinolone, and amoxicillin–clavulanate. The findings could inform the choice of antibiotic regimen in this clinical setting.Use this article to:Start your session with a multiple-choice question. We provide one below.Present a case of diverticulitis seen in the setting where your learners provide outpatient care.Review the prevention, diagnosis, and management of uncomplicated diverticulitis. This In the Clinic article can help guide the discussion. Discuss whether there were opportunities to improve the care of the patient in the case that was presented.Ask your learners to propose an appropriate antibiotic regimen for a patient with diverticulitis who has a β-lactam allergy.Risk for Non–AIDS-Defining and AIDS-Defining Cancer of Early Versus Delayed Initiation of Antiretroviral Therapy. A Multinational Prospective Cohort StudyThis multinational prospective cohort study compared 10-year absolute risks for non–AIDS-defining and AIDS-defining cancer associated with immediate initiation of antiretroviral therapy (ART) versus deferral of ART until 2 thresholds of CD4 cell count were reached.Use this article to:Ask your learners to name cancers that are “AIDS defining.”Invite an infectious disease specialist to join your session to review appropriate initiation of ART in a patient with a new diagnosis of HIV infection.Discuss whether there have been any substantial changes in the management of newly diagnosed HIV infection compared with the recommendations in this 2011 In the Clinic article. Development of Severe COVID-19 Adaptive Risk Predictor (SCARP), a Calculator to Predict Severe Disease or Death in Hospitalized Patients With COVID-19Predicting the clinical trajectory of individual patients hospitalized with COVID-19 is necessary to inform clinical care. This article describes the development of an online tool to predict severe illness or death in patients hospitalized with COVID-19.Use this article to:Ask your learners about the factors they have observed that seem to be associated with poor outcomes for patients with COVID-19.Review any triage instruments or processes that your hospital uses to decide whether to hospitalize a patient with COVID-19 and/or admit them to the intensive care unit.Go to the link for the app provided in the article. Use the instrument to predict risk for severe disease or death using variables available on the day of hospital admission for several patients with COVID-19 hospitalized in your institution. How well did the instrument perform in predicting the clinical course of these patients?Racial Disparities in COVID-19 Testing and Outcomes. Retrospective Cohort Study in an Integrated Health SystemThis retrospective cohort study, based on data from a large integrated health system, assessed the contributions of age, sex, race/ethnicity, neighborhood of residence, comorbidities, and measures of acute physiology to rates of COVID-19 testing, infection, hospitalization, mortality, and other health outcomes.Use this article to:Ask your learners to describe disparities they have seen in the care of patients with SARS-CoV-2 infection.Discuss factors that could contribute to observed disparities in testing based on patients' race/ethnicity and place of residence. What interventions might reduce these disparities in testing?Discuss factors that could contribute to observed disparities in hospitalization and mortality rates based on patients' race/ethnicity and place of residence. What interventions might reduce these disparities in hospitalization and outcomes?Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of PhysiciansThis guideline describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with acute bronchitis with chronic obstructive pulmonary disease exacerbation, community-acquired pneumonia, urinary tract infection, and cellulitis.Use this article to:Present brief clinical scenarios of 4 patients who present to the outpatient practice with the following conditions: uncomplicated acute bronchitis with chronic obstructive pulmonary disease exacerbation, community-acquired pneumonia, urinary tract infection, and cellulitis.Ask your learners to discuss whether they would prescribe antibiotics. If so, which antibiotics, and for what duration?Review how the learners' responses correspond to the ACP recommendations.Beyond the GuidelinesHow Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterIn this article, 2 gastroenterologists debate approaches to blood transfusion and endoscopy timing in the hospital and the recommended duration of proton-pump inhibitor therapy after discharge in a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer.Use this article to:Watch the video of the patient providing her history.Poll your learners about how they would manage this patient.Watch the video of the Grand Rounds discussion that accompanies this article.Complete the quiz at the end of the article. How did the group do?Multiple SclerosisMany groundbreaking advances have occurred in the field of multiple sclerosis (MS). Since 2014, the FDA has approved 7 new medications for relapsing–remitting MS and also approved the first medication for primary progressive MS. Diagnostic criteria were updated in 2017, and there are now blood tests to help differentiate neuromyelitis optica spectrum disorder from MS. Also, new medications for symptomatic MS have been introduced. Primary care providers will be interested to navigate the myriad new diagnostic and treatment options for MS.Use this article to:Start the session by having your learners complete the CME quiz that accompanies this article. Review the correct answers—how did the group do?Ask your learners to describe the clinical presentations that should prompt consideration of a diagnosis of MS.Ask your learners which tests they would use to evaluate a patient with suspected MS.Invite a neurologist to join the teaching session to review indications for neurology consultation, tests that are helpful to complete before referral, and current treatment options.Ethics and ProfessionalismEthical and Professionalism Implications of Physician Employment and Health Care Business Practices: A Policy Paper From the American College of PhysiciansThis ACP policy paper highlights 6 contemporary issues surrounding business practices that are relevant to ethics and professionalism in medical practice and offers ethical guidance to enable physicians to advocate for arrangements that align with medicine's core values.Use this article to:Ask your learners if physicians who have a financial interest in the products they prescribe should disclose these interests to patients.Look at the faculty bios on your institution's website. Do the bios include industry relationships? Debate whether they should or should not.Debate the pros and cons of physicians serving as paid consultants to industry.Public HealthAnother Two Mass Shootings: Déjà Vu All Over AgainThe public health threat from firearm injury and death has continued its lethal course during the COVID-19 pandemic. This commentary discusses the important role that physicians can play in mitigating the threat to the U.S. public.Use this article to:Ask your learners if they agree with the author of this commentary that firearm injury is a public health threat in the United States. Why or why not?Ask your learners if they ask patients about the presence of guns in their homes. If so, which patients do they ask?Discuss ways to approach firearm injury prevention with patients. Use this In the Clinic article to guide your discussion. MKSAP 18 QuestionA 58-year-old woman is evaluated in the emergency department for sharp, nonradiating pain in the left lower quadrant that has persisted for 2 days. She reports no fever, diarrhea, or blood in stools and has not traveled recently. Her last colonoscopy, performed 1 year earlier, showed pandiverticulosis.On physical examination, her temperature is 37.2 °C (99.0 °F), blood pressure is 130/85 mm Hg, pulse rate is 88/min, and respiratory rate is 18/min; BMI is 26. Abdominal examination is positive for left-lower-quadrant tenderness on palpation with no rebound or guarding.Results of laboratory studies show an elevated leukocyte count; other findings are normal.Abdominal CT shows focal diverticulitis in the sigmoid colon, without abscess.Which of the following is the most appropriate next step in management?A. ColonoscopyB. Intravenous antibioticsC. Oral antibioticsD. SurgeryCorrect AnswerC. Oral antibioticsEducational ObjectiveTreat uncomplicated diverticulitis.CritiqueThe patient has uncomplicated diverticulitis that can be managed with oral antibiotics. Approximately 5% of patients with diverticula will experience an episode of diverticulitis. Symptoms include abdominal pain, fever, and altered bowel habits. Physical examination findings include fever, left-lower-quadrant tenderness, and/or a lower abdominal or rectal mass. If clinical features are highly suggestive of diverticulitis, imaging studies are unnecessary. If the diagnosis is not clear or if an abscess is suspected (severe pain, high fever, palpable mass), CT imaging is indicated. Although the use of a 7-day course of oral antibiotics does not shorten the clinical course of diverticulitis, it may prevent complications from diverticulitis, such as an abscess, and may help prevent a future episode of diverticulitis. The antimicrobial agents used should cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole). Treatment can be done on an outpatient basis with close monitoring, and the patient should adhere to a liquid diet for 2 to 3 days, then advance the diet as tolerated. The routine use of antibiotics in uncomplicated diverticulitis has been questioned because of overuse of antibiotics.Colonoscopy should not be done during acute diverticulitis due to the risk for perforation. In patients who have not undergone screening colonoscopy within the past 3 years, colonoscopy should be done 4 to 8 weeks after resolution of symptoms to exclude colon malignancy.Intravenous antibiotics are appropriate in patients who cannot take oral medications or who have complicated diverticulitis, such as abscess or fistula formation. Fistulas may form between the colon and other adjacent structures including the bladder, vagina, skin, or peritoneum. CT-guided percutaneous drainage of abscesses is preferred.Surgery is required for diverticulitis complicated by peritonitis and may be lifesaving. Patients with recurrent diverticulitis may also benefit from surgical resection of the affected area of the colon.Key PointPatients with uncomplicated diverticulitis should be treated conservatively with oral antibiotics.BibliographyStrate LL, Peery AF, Neumann I. American Gastroenterological Association Institute technical review on the management of acute diverticulitis. Gastroenterology. 2015;149:1950-1976.e12. doi:10.1053/j.gastro.2015.10.001Do 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 June 2021Volume 174, Issue 6Page: ED6KeywordsAbscessesAntibioticsAntiretroviral therapyCOVID-19Cohort studiesColonoscopyDiverticulitisFeversMultiple sclerosisOutpatients ePublished: 15 June 2021 Issue Published: June 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...