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

Web ExclusivesApril 2021Annals for Educators - April 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202104200 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsComparison of Knowledge and Information-Seeking Behavior After General COVID-19 Public Health Messages and Messages Tailored for Black and Latinx Communities. A Randomized Controlled TrialMessages to Increase COVID-19 Knowledge in Communities of Color: What Matters Most?This randomized trial examined whether physician-delivered prevention messages affect knowledge and information-seeking behavior among Black and Latinx persons and if this differs according to the race or ethnicity of the physician and the tailored content. The accompanying editorial discusses strategies to improve the effectiveness of public health messages.Use this article and the accompanying editorial to:Watch several of the videos used in the study and discuss which ones your learners find most compelling.Review the characteristics of effective public health messages.Ask your learners to reflect on whether they have observed differences in their interactions with patients who are demographically similar to versus demographically different from themselves.Discuss strategies that might be helpful in convincing patients who are reluctant about vaccines to receive the COVID-19 vaccine. This panel discussion and this article might be useful food for thought. The Effect of Flat Flexible Versus Stable Supportive Shoes on Knee Osteoarthritis Symptoms. A Randomized TrialExperts recommend stable supportive shoes for persons with knee osteoarthritis, but some evidence suggests that flat flexible shoes may reduce knee joint loading and symptoms. This randomized trial compared the effectiveness of flat flexible versus stable supportive shoes in improving symptoms of knee osteoarthritis.Use this article to:Start your session with a multiple-choice question. We provide one below.Ask your learners what pharmacologic interventions they typically consider for their patients with painful knee osteoarthritis.Ask your learners if they typically suggest nonpharmacologic interventions for their patients with painful knee osteoarthritis.End your session by listening to the discussion of this study on the Annals On Call podcast. Pulmonary HypertensionPulmonary hypertension is a term used to describe a group of disorders characterized by abnormally high pressures within the pulmonary arteries. Initial evaluation is focused on identifying the cause of pulmonary hypertension, which helps guide appropriate treatment. Pulmonary hypertension is often a consequence of common diseases, such as chronic obstructive pulmonary disease and left heart disease, and treatment is focused primarily on the underlying disease.Use this article to:Discuss the pathophysiology of pulmonary hypertension.Ask your learners to describe the typical physical examination findings in a patient with pulmonary hypertension.Ask your learners which test they would choose to evaluate a patient with suspected pulmonary hypertension if they could only order one test.Invite a cardiologist to join the teaching session to review echocardiograms from patients with pulmonary hypertension with your learners.Public HealthSpeed Versus Efficacy: Quantifying Potential Tradeoffs in COVID-19 Vaccine DeploymentAlternative Dose Allocation Strategies to Increase Benefits From Constrained COVID-19 Vaccine SupplyA Public Health COVID-19 Vaccination Strategy to Maximize the Health Gains for Every Single Vaccine DoseU.S. COVID-19 Vaccination Challenges Go Beyond SupplyThe availability of multiple vaccine options is a welcome development but one that has created policy dilemmas. How do we define the “best” vaccine, and which populations should receive it? Might a 75% effective, single-dose vaccine that takes 2 weeks to achieve protection better contain the pandemic than a 95% effective vaccine requiring 2 doses? Would vaccinating twice as many people with a single dose of a 2-dose vaccine control the pandemic more quickly than vaccinating half as many people with both doses? The above 3 articles and the accompanying editorial address these issues.Use these articles and the accompanying editorial to:Go to the CDC COVID Data Tracker and review the vaccination rates in the communities near your hospital. Ask your learners, “If you were a public health official, would you continue to view clinical trials or move to vaccinate more people with a single dose?”Ask your learners to list the pros and cons of altering the COVID-19 vaccine schedule.Health PolicyA Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care: A Policy Paper From the American College of PhysiciansRacial and ethnic minorities in the United States experience disparities in health and health care due to interacting factors, including racism and discrimination, social drivers of health, health care access and quality, individual behavior, and biology. This ACP policy paper proposes a framework to confront the elements of U.S. society that contribute to poorer health outcomes.Use this article to:Ask your learners to share examples of health care disparities they have witnessed while caring for patients during the COVID-19 pandemic.Review each of the policy recommendations and have your learners discuss whether the recommendation, if implemented, would likely be effective in reducing the health care disparities they witnessed.Discuss ways in which physicians can become active in advocacy efforts to reduce health care disparities in the United States.Go to ACP's Advocacy Toolkit to learn how to participate in ACP's advocacy efforts. HumanitiesThe Uncomfortable LookThe author of this On Being a Doctor essay writes, “As a Black man, being a physician doesn't make me immune from this.”Use this article to:Have one of your learners read the essay to the group.Ask your learners whether they have witnessed each of the following: 1) a patient making an inappropriate racist comment in reference to a Black physician or nurse; 2) a physician making an inappropriate racist comment in reference to a Black patient; 3) a physician making an inappropriate racist comment in reference to a Black health care professional.Have the group role-play potential responses in each of the above scenarios that would support the patient or colleague who was the target of the racist comment.MKSAP 18 QuestionAn 85-year-old woman is evaluated for left knee pain of moderate intensity that occurs with ambulation and at night. Acetaminophen provides no relief. History is significant for coronary artery disease, hypertension, and stage 3 chronic kidney disease. Medications are aspirin, lisinopril, metoprolol, and vitamin D.On physical examination, blood pressure is 152/88 mm Hg; other vital signs are normal. The left knee demonstrates crepitus and decreased passive range of motion; a small effusion is present, and there is no warmth or tenderness. Joint aspiration of the left knee shows a leukocyte count of 1100/µL (1.1 × 109/L).Which of the following is the most appropriate treatment for long-term symptom control?A. Intra-articular glucocorticoid injectionsB. Low-dose prednisoneC. NaproxenD. OxycodoneE. Topical diclofenacCorrect AnswerE. Topical diclofenacEducational ObjectiveTreat osteoarthritis in an elderly patient using a topical NSAID.CritiqueTopical diclofenac is the most appropriate treatment for long-term symptom control for this elderly patient with knee osteoarthritis (OA). Acetaminophen has not provided relief; furthermore, the efficacy of acetaminophen for OA is increasingly being questioned because recent controlled trials and meta-analyses demonstrated no benefit from the drug, even at high doses. NSAIDs are available in oral, topical, and intravenous forms. Due to efficacy and cost-effectiveness, oral preparations are usually first-line NSAID therapy in patients without contraindications to treatment. In OA, topical NSAIDs are considered to provide similar pain relief as oral medications with fewer gastrointestinal effects. Furthermore, the American College of Rheumatology currently recommends topical NSAIDs rather than oral NSAIDs for patients aged 75 years or older. However, they are associated with more skin reactions and are significantly more expensive than oral NSAIDs. This elderly woman with unilateral knee OA is an ideal candidate for topical NSAIDs—she has just one area of musculoskeletal pain and has several relative contraindications to oral NSAIDs (age, chronic kidney disease, coronary artery disease, and aspirin intake).When a single symptomatic joint is present, injection directly into the joint may deliver medication to the affected site while minimizing the potential for systemic effects. Intra-articular injections may be used along with or in place of oral or topical analgesics. Intra-articular glucocorticoids are associated with short-term benefit with few side effects. Glucocorticoid injection alone would not likely provide long-term benefit for this patient.Low-dose oral prednisone is associated with modest reductions in short-term knee pain and may increase a 6-minute walk distance in older patients with moderate-to-severe knee OA. However, long-term use is associated with significant complications, including an increased risk for diabetes mellitus, osteoporosis, osteonecrosis, weight gain, fluid retention, hypertension, cardiovascular disease, striae and bruising, and glaucoma and cataracts.Oral naproxen and other oral NSAIDs are relatively contraindicated given the patient's hypertension, chronic kidney disease, and coronary artery disease.Traditional opiates may rarely be warranted to control pain in patients with OA who have not responded to other agents or are poor candidates for other interventions to treat painful joints, such as surgery. Opioid analgesics are inappropriate for this patient because other treatment options are available. In addition, opioids have limited effectiveness for chronic joint pain and are associated with substantial side effects in the elderly, especially increased fall risk, cognitive changes, and constipation.Key PointTopical NSAIDs are beneficial for patients at high risk for toxicity from oral NSAIDs.BibliographyRannou F, Pelletier JP, Martel-Pelletier J. Efficacy and safety of topical NSAIDs in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Semin Arthritis Rheum. 2016;45:S18-21. doi:10.1016/j.semarthrit.2015.11.007Do 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 April 2021Volume 174, Issue 4Page: ED4KeywordsCOVID-19ElderlyHealth careHealth care policyKneesNSAIDsOsteoarthritisPrevention, policy, and public healthPulmonary hypertensionVaccines ePublished: 20 April 2021 Issue Published: April 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...