Annals for Educators - March 2022
Authors: Christine Laine
Journal: Annals of Internal Medicine (2022)

Web ExclusivesMarch 2022Annals for Educators - March 2022FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202203150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPrediction of End-Stage Kidney Disease Using Estimated Glomerular Filtration Rate With and Without Race. A Prospective Cohort StudyEliminating Racial Inequities in Kidney Health: Much More Than Revising Estimating EquationsEquations that estimate glomerular filtration rate have recently been modified to remove the adjustment for race. This study examined the predictive performance of estimated glomerular filtration rate equations with and without the variable for Black race. The accompanying editorial notes potential harms of removing race from the equations and contends that achieving racial equity in kidney health requires more than fine-tuning these equations.Use this article and the editorial to:Review the equations the clinical laboratory at your institution uses to estimate glomerular filtration rate.Based on the findings of the study reported in this article, initiate a discussion among your learners about which equation they think the laboratory should use.Discuss the potential advantages and disadvantages of removing race from equations used to estimate glomerular filtration rate.The editorialist believes that changing the equations will have a limited influence on reducing racial disparities in kidney disease outcomes. Ask your learners to identify other interventions that might be more effective at reducing disparities.Cardiometabolic Disease Burden and Steroid Excretion in Benign Adrenal Tumors. A Cross-Sectional Multicenter StudyCardiometabolic Morbidity of Mild Cortisol ExcessBenign adrenal tumors are commonly discovered on cross-sectional imaging that is done for other reasons. This study examined whether the mild autonomous cortisol secretion often found with these tumors carries risk for cardiometabolic conditions. The accompanying editorial discusses the results of the study, the clinical lessons it offers, and the issues that warrant further exploration.Use this article and the editorial to:Discuss the natural history of adrenal incidentalomas. This systematic review can help to guide the discussion. Review the recommendations for evaluation of patients with incidentally discovered adrenal tumors.Given the results of this study, what clinical actions might be reasonable to take in patients with benign adrenal tumors?Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous CongestionUse of point-of-care ultrasonography (POCUS) is growing rapidly in clinical medicine. In this prospective observational study of patients undergoing right heart catheterization for heart failure indications, the investigators examined the accuracy of POCUS in estimating jugular venous pressure and elevated central venous pressure.Use this article to:Invite a colleague with expertise in POCUS to join your session and demonstrate how to use bedside ultrasound to estimate jugular venous pressure and elevated central venous pressure.Review the availability of POCUS at your institution, and discuss clinical scenarios in which it would be appropriate and inappropriate to use it.Clinical GuidelinesRecommended Adult Immunization Schedule, United States, 2022This article provides immunization recommendations from the Advisory Committee on Immunization Practices (ACIP) for adults aged 19 years or older. The purpose of the immunization schedule is to consolidate and summarize updates to ACIP recommendations on vaccination of adults and to assist providers in implementing current ACIP recommendations.Use this article to:Start your session with the multiple-choice question provided below.Invite a colleague from nursing to your session to demonstrate the proper technique for administering an intramuscular vaccine.Review the changes in the ACIP vaccine recommendations between 2021 and 2022.Ask your learners to share strategies they find helpful in discussing vaccination with patients who are hesitant to receive it. This article may help to stimulate the discussion. Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis. A Systematic ReviewEvaluation and Management After Acute Left-Sided Colonic Diverticulitis. A Systematic ReviewDiagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of PhysiciansColonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of PhysiciansThe first systematic review was conducted to support the American College of Physicians' (ACP's) new clinical practice guidelines on diagnosis and management of acute left-sided colonic diverticulitis, which include specific recommendations on the role of computed tomographic imaging, outpatient versus inpatient management for acute uncomplicated diverticulitis, and antibiotic use for acute diverticulitis. The second systematic review was conducted to support ACP's new clinical practice guidelines on patient evaluation and management after an episode of acute left-sided colonic diverticulitis, which include specific recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer after acute left-sided colonic diverticulitis and the role of pharmacologic and elective surgical interventions to prevent recurrence after initial treatment.Use these articles to:Start your session by viewing a video summarizing key findings from one of the systematic reviews that provide the evidence base for the guideline recommendations. Review the factors that characterize trustworthy clinical guidelines. This article and this article can help guide the discussion. Review the factors that characterize complicated diverticulitis.What factors characterize patients with diverticulitis who can be managed as outpatients?Present several clinical scenarios of patients with possible diverticulitis, and ask your learners whether they would obtain imaging studies and/or prescribe antibiotics.Type 1 Diabetes MellitusType 1 diabetes mellitus is an endocrine disorder in which the beta cells of the pancreas no longer produce insulin, typically due to autoimmune destruction resulting in hyperglycemia and ketosis. Insulin replacement is vital to management. Type 1 diabetes can occur at any age. Symptoms include polyuria, polydipsia, and weight loss, and acute complications include diabetic ketoacidosis, which requires urgent management. Long-term complications include both microvascular and macrovascular disease. Patients with type 1 diabetes are at higher risk for other autoimmune diseases. The focus of management is on optimizing glucose control to reduce both acute and long-term complications.Use this article to:Review how to determine whether an adult who presents with new-onset diabetes has type 1 or type 2 diabetes.Invite an endocrinologist to join your session to review how to begin insulin therapy in a patient with newly diagnosed type 1 diabetes.Invite a diabetes nurse educator to join your session to review commonly used continuous glucose monitors and insulin pumps.Take the quiz associated with the article as a group, and review the answers.HumanitiesThe ShootingWe started to hear the rumors of an active shooter in the hospital, but no official announcement was made. We stood as a group.Use this article to:Review the procedures in place at your institution to manage an active shooter.Ask your learners to describe what they would do if they became aware that someone with a gun was threatening staff or patients on the premises of your health center.Ask your learners to share their perspectives on whether a physician should put his or her own life in danger to assist patients or colleagues in a situation such as the one described in this essay.MKSAP 19 QuestionA 26-year-old woman undergoes consultation to update her vaccinations. She is an elementary school teacher. Medical history is significant for well-controlled HIV diagnosed 6 years ago. Medications are tenofovir alafenamide, emtricitabine, and dolutegravir.The physical examination is normal.Her CD4 cell count is 520/µL and has been stable for several years. HIV viral load is undetectable.Which of the following vaccines is contraindicated in this patient?A. Human papillomavirusB. Inactivated influenzaC. Measles-mumps-rubellaD. VaricellaE. No contraindications existCorrect AnswerE. No contraindications existEducational ObjectiveIdentify appropriate vaccines for patients with HIV infection.CritiqueThis patient has no contraindications to routinely administered vaccines (Option E). Live vaccines, including varicella, varicella-zoster, measles-mumps-rubella, and influenza are not recommended for patients who are severely immunocompromised. Contraindications to live vaccines include persons with HIV with CD4 cell count ≤200/µL; pregnancy or probable pregnancy within 4 weeks; immunosuppressant therapy, including high-dose glucocorticoids; leukemia, lymphoma, or other bone marrow and lymphatic system malignancies; cellular immunodeficiency; solid organ transplant recipient; and recent hematopoietic stem cell transplantation.The live-attenuated influenza vaccine is contraindicated in patients with HIV infection regardless of CD4 cell count, but the inactivated vaccine can be given (Option B). Numerous other immunizations are recommended for all persons with HIV, including COVID-19, 13-valent pneumococcal conjugate, and 23-valent pneumococcal polysaccharide vaccines. Patients who are not already immune or infected with hepatitis B virus should receive the hepatitis B vaccine series. Tetanus-diphtheria-pertussis, hepatitis A, and human papillomavirus (HPV) vaccinations are indicated as for the general population (Option A). The Advisory Committee on Immunization Practices (ACIP) has expanded the age indications for HPV vaccination to 45 years, recommending that the decision to vaccinate between ages 26 and 45 years be determined through shared decision making with patients. The ACIP recommends that all persons with HIV infection be vaccinated for meningococcal disease with the quadrivalent meningococcal vaccine, including boosters every 5 years.For prevention of varicella-zoster, live-attenuated and recombinant vaccines are available; the inactivated recombinant vaccine is preferred and recommended for patients aged 50 years and older, even if the patient previously received the live varicella-zoster vaccine. For patients without immunity, selected live vaccines such as the measles-mumps-rubella and varicella vaccines can be given to patients with HIV infection as long as the CD4 cell count is greater than 200/µL (Option C, D).Key PointSelected live vaccines, including the varicella and measles-mumps-rubella vaccines, are safe to administer to nonimmune persons with HIV infection whose CD4 cell count has consistently been greater than 200/µL. The live influenza vaccine is contraindicated in immunocompromised patients and those with HIV regardless of CD4 cell count.BibliographyPanel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Updated 17 April 2020. Do 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 March 2022Volume 175, Issue 3Page: ED3 ePublished: 15 March 2022 Issue Published: March 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...