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

Web ExclusivesNovember 2021Annals for Educators - November 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202111160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants. A Nationwide Propensity Score–Weighted StudyThis study used a database with enhanced clinical information to estimate differences in gastrointestinal bleeding and to compare rates of upper versus lower gastrointestinal bleeding with the direct oral anticoagulants (DOACs) apixaban, dabigatran, and rivaroxaban.Use this article to:Ask your learners to describe factors that contribute to decision making regarding whether to prescribe warfarin or a DOAC for a patient who requires long-term anticoagulation.Review the available DOACs and their approved indications, dosing, and potential adverse effects.Present several clinical scenarios of patients who require anticoagulation but are not good candidates for warfarin, and discuss which DOAC, based on the findings of this study, would be appropriate to prescribe. What if the patient's insurance would not pay for your first choice of DOAC?Acute Consumption of Alcohol and Discrete Atrial Fibrillation EventsHoliday Heart Confirmed: Alcohol-Associated Atrial FibrillationAtrial fibrillation (AF) is the most common heart arrhythmia, and long-term alcohol use has been associated with it. This case-crossover study examined the relationship between acute ingestion of alcohol and AF among 100 patients who served as their own controls. The authors of the accompanying editorial believe the results suggest that patients with paroxysmal AF should be informed of the association between alcohol consumption and recurrent AF.Use this article and the editorial to:Start your session with a multiple-choice question. We provide one below.Review factors that are associated with AF.Ask your learners whether they routinely discuss alcohol use with patients with AF.Discuss whether, based on this study, clinicians should counsel patients with paroxysmal AF to abstain from alcohol use.Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care. A Cluster Randomized Controlled TrialPreparation Matters: What We Can Learn From an Olympic Swimmer About the Value of Advance Care Planning InterventionsAdvance care planning is important for persons and their loved ones in times of decision incapacity, but it is underutilized. This trial examined an intervention consisting of a brief assessment of readiness and individualized feedback to increase the completion of advance care planning activities. The accompanying editorial discusses the strengths and limitations of the trial's intervention.Use this article and the editorial to:Ask your learners whether they ever discuss advance care planning with their patients during outpatient encounters. If so, under what circumstances?Review the intervention used in this study. Would it be feasible to implement at your own institution?Draft a few patient scenarios, and ask your learners to role-play an advance care planning discussion with these hypothetical patients.Medical Knowledge and Systems-Based CareWhat Will It Take to End HIV in the United States? A Comprehensive, Local-Level Modeling StudyEnding HIV in the United States Will Require a Substantial Financial CommitmentThe Ending the HIV Epidemic initiative aims to reduce incident HIV infections by 90% over the next 10 years. This article describes an interactive model that was developed to assist policymakers in prioritizing interventions at the local level to achieve this goal. The accompanying editorial explains what is needed for the United States to meet its stated goals of ending the HIV epidemic.Use this article and the editorial to:Ask your learners to describe the frequency with which they encounter patients with newly diagnosed or known HIV infection.Ask your learners if they have ever prescribed preexposure prophylaxis (PrEP) to patients at high risk for HIV infection.Review for whom it is appropriate to consider PrEP and how to prescribe it.Review the model, and discuss how it might be useful in U.S. health policy discussions.Population Immunity Against COVID-19 in the United StatesMuch attention has been given to vaccination as a path to achieving herd immunity against COVID-19, but immunity is gained from both natural infection and vaccination. In this study, the authors used statistical and simulation modeling and data on reported deaths to estimate U.S. population immunity.Use this article to:Invite an infectious disease expert to your teaching session to discuss the concept of herd immunity and discuss why estimates of the population level of immunity that is needed to end the COVID-19 pandemic vary substantially.Ask your learners to name infectious diseases that have been eradicated because of adequate population levels of immunity.Review what is currently known about whether immunity via infection or vaccination offers greater reduction in risk for COVID-19.Review the current CDC recommendations for vaccination of persons with previous documented SARS-CoV-2 infection.U.S. Food and Drug Administration Reasoning in Approval Decisions When Efficacy Evidence Is Borderline, 2013–2018Moving the U.S. Food and Drug Administration ForwardThe FDA has substantial flexibility in its approval criteria. To understand the FDA's decisional processes and evidentiary standards, this study reviewed applications submitted between 2013 and 2018 that went through multiple review cycles after the strength of evidence for clinical efficacy was initially deemed insufficient. The editorial offers suggestions for how the FDA can regain and maintain community trust.Use this article and the editorial to:Review the FDA's process for drug approval. This site may help to guide the discussion. Ask your learners if they have had patients or patients' family members ask them to prescribe aducanumab. If so, what advice would they offer?Review the controversy surrounding the FDA approval of aducanumab for the treatment of patients with Alzheimer dementia. This commentary may help to frame the discussion. Poll your learners: Do they think it is appropriate for the FDA to approve a drug if data on clinical outcomes that are important to patients are not available?The Health Benefits of Urgent Upstream Action on Climate ChangeClimate change has immediate and long-term health implications, and vulnerable populations disproportionately bear the brunt of severe outcomes. This commentary discusses how climate change creates new health problems and inequities and exacerbates existing ones.Use this article to:Ask your learners to describe ways that climate change is currently affecting health.Review the ACP position paper on climate change and health. Debate with your learners whether they think climate change advocacy is an appropriate topic for medical professional organizations to engage in.InfluenzaSeasonal influenza epidemics of variable severity pose challenges to public health. Annual vaccination is the primary way to prevent influenza, and a wide range of vaccines are available, including inactivated or live attenuated standard-dose, recombinant vaccines, as well as adjuvanted or high-dose vaccines for persons aged 65 years or older. Persons who are at high risk for influenza complications include young children, those with underlying medical conditions, and older adults. Prompt diagnosis of influenza can facilitate early initiation of antiviral treatment. This article summarizes recommendations for providers on influenza vaccination, diagnostic testing, and antiviral treatment.Use this article to:Ask your learners to describe how they make the diagnosis of influenza.Discuss how the diagnostic process could differ in the setting of the ongoing COVID-19 pandemic.Review the types of influenza vaccines that are available and the indications for each.Ask your learners to name situations in which influenza vaccination is contraindicated.Review the use of antivirals in the treatment of patients with influenza.MKSAP 18 QuestionWhich of the following abnormalities is demonstrated on this electrocardiogram?A. Atrial fibrillationB. Atrial flutterC. Junctional tachycardiaD. Multifocal atrial tachycardiaCorrect AnswerA. Atrial fibrillationCritiqueThis electrocardiogram is characteristic of atrial fibrillation, with an irregularly irregular rhythm and no discernible P waves. Atrial fibrillation can present with a rapid ventricular response, with an average rate of more than 120/min; a controlled ventricular response, with an average rate between 70/min and 110/min; or a slow ventricular response, with an average rate of less than 60/min. The tracing shows an average rate of approximately 100/minDo 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 November 2021Volume 174, Issue 11Page: ED11 ePublished: 16 November 2021 Issue Published: November 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...