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

Web ExclusivesOctober 2021Annals for Educators - October 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202110190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical PracticeMidodrine for the Prevention of Vasovagal Syncope. A Randomized Clinical TrialEstablishing the Efficacy of Midodrine to Prevent Vasovagal SyncopeSome persons with vasovagal syncope have frequent fainting episodes, which increases their risk for injury when they fall, when they are driving, or in other potentially dangerous situations. This well-powered trial examined whether the oral drug midodrine might be useful for these patients. The accompanying editorial discusses the findings of the trial and predicts that the future of therapy will be personalized and mechanism-directed.Use this article and the editorial to:Start your session with a multiple-choice question. We provide one below.Review the clinical presentation of vasovagal syncope. What clinical factors should prompt concern that vasovagal syncope is not the cause of a patient's fainting episode?Review the mechanism of action, dosing, potential side effects, and potential drug–drug interactions of midodrine.Ask your learners to describe clinical scenarios in which prescription of midodrine would be reasonable based on the results of this clinical trial.Use of Hydroxychloroquine, Remdesivir, and Dexamethasone Among Adults Hospitalized With COVID-19 in the United States. A Retrospective Cohort StudySelecting Treatments During an Infectious Disease Pandemic: Chasing the EvidenceThis large multicenter cohort study of 137,870 persons hospitalized with confirmed or suspected COVID-19 assessed temporal and institutional variation in use of 3 of the most widely used drugs for treatment of COVID-19. The accompanying editorial discusses lessons learned that will improve how we assess and disseminate emerging data.Use this article and the editorial to:Invite colleagues from infectious diseases and pulmonary/critical care to review the current protocols for use of hydroxychloroquine, remdesivir, and dexamethasone in the treatment of patients hospitalized with COVID-19 at your institution.Compare the practices at your institution with the care recommended in guidelines on the use of these therapies from the NIH, the CDC, and the American College of Physicians.Ask your learners to reflect on how those protocols have evolved over time since the beginning of the pandemic.Discuss strategies for keeping up with rapidly emerging clinical evidence. What sources do your learners turn to? How do they determine whether a source is trustworthy? This article from the Guidelines International Network may help guide the discussion. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism. A Systematic Review and Meta-analysisThis review examined risk for major bleeding with extended anticoagulation for at least 6 months beyond the initial 3 to 6 months recommended by guidelines. This information can help inform decisions on the risks and benefits of extended anticoagulation for first-time, unprovoked venous thromboembolism.Use this article to:Ask your learners to name the conditions that categorize venous thromboembolism as provoked.Review the acute management of unprovoked venous thromboembolism. This In the Clinic review may help guide the discussion. Ask your learners what factors they consider when determining whether to prescribe anticoagulation for 3 months, 6 months, or longer.Based on the results of this systematic review, ask your learners to describe patients for whom they would and would not extend anticoagulation beyond 6 months.Beyond the GuidelinesWould You Recommend Aspirin to This Patient for Primary Prevention of Atherosclerotic Cardiovascular Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterBalancing the benefits and harms of aspirin for primary prevention of atherosclerotic vascular disease is challenging. Two expert clinicians discuss and debate current guidelines, the appropriate risk threshold for starting aspirin therapy, and the role of the coronary artery calcium score in decision making.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?ProfessionalismFinancial Profit in Medicine: A Position Paper From the American College of PhysiciansFinancial Profit: Not the Mission of MedicineIn this position paper, ACP considers the effect of nonprofit to for-profit conversions, nonprofit hospital requirements, private equity investment, and mergers and integration on patients, physicians, and the health care system. The position paper rejects the for-profit approach to the business of medicine and calls for limits on private equity investment. The authors of the accompanying editorial discuss the policy and possible improvements; overall, they believe that ACP provides an important critique of the profit motive in medicine.Use this article and the editorial to:Ask your learners whether your hospital or health care system is for-profit or not-for-profit. How about other institutions in your community?Discuss the potential pitfalls of private equity investment in health care institutions. This article about Hahnemann Hospital in Philadelphia may help frame the discussion. Review each of the ACP recommendations, and poll your learners about whether they agree with them. If they disagree, why?Disparate Impact: How Colorblind Policies Exacerbate Black–White Health InequitiesThis commentary uses illustrative examples in clinical practice, financing policies, and COVID-19 vaccination policies to show how policies designed to ensure that all persons are treated the same regardless of race may exacerbate inequities.Use this article to:Ask your learners to identify examples of colorblind policies that may exacerbate inequities.Discuss alternative policies and practices that could help to minimize inequities.Ask your learners to identify potential unintended adverse consequences of the alternative policies and practices they proposed.Eliminating the “Morbid” in Obesity: A Step Toward More Sensitive Documentation in the Era of Open NotesQuoting Patients in Clinical Notes: First, Do No HarmThe new federal rule that mandates sharing of medical notes with patients may help engage them in their care, but use of certain terms in medical documents can offend patients. In the first article, the authors advocate for a more sensitive and empathetic approach to patients with obesity. In the second article, the authors explore historical and current reasons for using quotation marks when documenting a clinical encounter and identify examples where quotation marks can be harmful or misinterpreted and may convey ridicule or doubt.Use these articles to:Discuss whether and how patients at your institution access their electronic health records.If a patient portal exists, ask someone from your institution's technical staff to demonstrate the portal and share data on patients' use of it.Ask your learners to draft sample progress notes on a patient who is substantially above her ideal body weight and has type 2 diabetes, hypertension, and knee osteoarthritis. Have them share the notes with the group for comment.Have your learners draft 2 sample progress notes: one that uses quotation marks in a potentially harmful manner, and one that uses them in a more acceptable manner.Chlamydia and GonorrheaGonorrhea and chlamydia rates have risen to record-high levels in the United States over the past decade. Because these infections are often asymptomatic, effective clinical management relies on screening asymptomatic patients, particularly women younger than 25 years and men who have sex with men. If undetected and untreated, gonorrhea and chlamydia can lead to infertility, ectopic pregnancy, and chronic pelvic pain and can facilitate HIV acquisition and transmission. Primary care providers need to be aware of recent changes in recommended treatments for both infections.Use this article to:Ask your learners to describe history and physical examination findings that are helpful in determining whether a patient with genitourinary symptoms has gonorrhea or chlamydia.Ask your learners to identify diagnostic tests indicated for gonorrhea and chlamydia.Discuss whether there are scenarios in which it is acceptable to treat for gonorrhea or chlamydia without performing diagnostic tests.Ask your learners to identify first-line treatment for gonorrhea and chlamydia. How would they treat patients who had a contraindication to first-line therapy?MKSAP 19 QuestionA 28-year-old woman is evaluated in the emergency department for an episode of syncope. Before the syncopal event, she was standing motionless in a warm environment for several minutes, and then she felt warm, dizzy, and nauseated. She lost consciousness for less than 30 seconds. She experienced no trauma during the event and had no confusion afterward. She has previously experienced presyncope at work while standing for long periods of time but had never lost consciousness. She has no medical problems and takes no medications.On physical examination, vital signs and the remainder of the examination are normal.An ECG is normal.Which of the following is the most appropriate treatment?A. Avoidance of triggersB. FludrocortisoneC. MidodrineD. PropranololCorrect AnswerA. Avoidance of triggersEducational ObjectiveTreat vasovagal syncope.CritiqueThe most appropriate treatment is education about avoidance of triggers (Option A). This patient probably has vasovagal syncope, which is provoked by noxious stimuli, fear, stress, or heat overexposure and is preceded by a prodrome of warmth, dizziness, and nausea. In cases of vasovagal (reflex) syncope, explaining the diagnosis to the patient is strongly recommended, along with targeted education about avoiding triggers (e.g., prolonged standing, warm environments) and how to cope with noxious events (e.g., blood draws). In addition, physical counterpressure measures, such as squatting and leg crossing, and increased fluid and salt intake can decrease the risk for recurrence of the syncopal event in selected patients.Fludrocortisone (Option B) has mineralocorticoid activity that increases blood volume through sodium and water retention. Hypertension and hypokalemia are expected adverse effects. Fludrocortisone might be considered for patients with vasovagal syncope not responding to avoidance of triggers and physical counterpressure measures. Studies show a 31% non–statistically significant reduction in recurrent syncope in patients with frequent vasovagal syncope after 2 weeks of therapy. Fludrocortisone is not indicated in this patient who has yet to try more effective means of syncope prevention that are associated with fewer side effects.Midodrine (Option C) is metabolized to a peripherally active α-agonist that may counter the reduction of sympathetic neural outflow and resultant venous pooling associated with vasovagal syncopal. A meta-analysis suggests that midodrine can reduce recurrent vasovagal syncopal episodes by 43%. However, this patient has yet to try less expensive, and presumably safer, nonpharmacologic options.Trials of β-blockers for the prevention of vasovagal syncope have, for the most part, been negative. However, some studies have documented benefit with β-blocker therapy in patients aged 42 years or older. It is unlikely that this young patient needs or will respond to β-blocker therapy, such as propranolol (Option D).Key PointVasovagal syncope is treated with targeted education about avoiding triggers, such as prolonged standing and warm environments. Physical counterpressure measures, such as squatting and leg crossing, as well as increased fluid and salt intake, can decrease the risk for recurrent vasovagal syncope.BibliographyShen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017;136:e25-59. doi:10.1161/CIR.0000000000000498Do 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 October 2021Volume 174, Issue 10Page: ED10 ePublished: 19 October 2021 Issue Published: October 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...