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

Web ExclusivesFebruary 2021Annals for Educators - February 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202102160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThe Effects of Four Doses of Vitamin D Supplements on Falls in Older Adults. A Response-Adaptive, Randomized Clinical TrialFalls: To D or Not to D—That Is Not the (Only) Question!Studies suggest that vitamin D supplements reduce fall risk in older adults, but evidence is inconsistent. In this trial, the investigators compared 4 doses of vitamin D3 to determine whether any of them reduced fall risk. The editorialist discusses how the findings reinforce some of what we know and underscore what we need to learn about preventing falls in elderly patients.Use this article and the accompanying editorial to:Ask your learners what clinical situations would lead them to consider prescribing vitamin D supplementation.Given the findings of the study reported here, ask your learners if they would prescribe vitamin D supplementation to prevent falls in a 77-year-old man with a history of a recent fall.Ask your learners what interventions should be considered to prevent falls in older patients.Invite a physical therapist or physiatrist to meet with your learners and discuss various types of canes and walkers that may help prevent falls in at-risk patients.Development and Validation of a Modified Full Age Spectrum Creatinine-Based Equation to Estimate Glomerular Filtration Rate. A Cross-sectional Analysis of Pooled DataImproving Glomerular Filtration Rate Estimation—Across the Age and Diversity SpectrumSeveral equations exist for estimating glomerular filtration rate (GFR) in children and adults, but they have well-known limitations. This article describes the development and validation of a modified full–age spectrum equation for estimating kidney function. The editorialists caution that such equations must be evaluated in a more racially and ethnically diverse population than the one contributing to the currently reported equation.Use this article and the accompanying editorial to:Start the session with a multiple-choice question. We provide one below.Discuss the method the laboratory at your institution uses to estimate GFR.Ask your learners about the arguments for and against continuing to use race-based estimates of GFR. These are summarized in this commentary. Beyond the GuidelinesShould You Recommend Cannabinoids for This Patient With Painful Neuropathy? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterIn this article, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature on cannabidiol to make recommendations for a patient with painful diabetic neuropathy, including counseling on potential benefits and harms.Use this article to:Ask your learners if they routinely ask patients about cannabis use.Ask your learners about the difference between tetrahydrocannabinol and cannabidiol.Discuss the legality of medical and recreational use of cannabis-related products in your state.After viewing the video of the patient interview and expert discussion, poll your learners about whether they would recommend cannabinoids for the patient described in the article.Research MethodsClinical Endpoints for Evaluating Efficacy in COVID-19 Vaccine TrialsSafe and effective vaccines are critical to controlling COVID-19. A group of industry, government, and academic researchers discuss pragmatic issues in the choice and interpretation of clinical endpoints for evaluating efficacy in COVID-19 vaccine trials.Use this article to:Review the primary endpoints being examined in the U.S.-based phase 3 clinical trials of COVID-19 vaccines.Ask your learners which clinical trial outcomes would need to be examined to determine whether a COVID-19 vaccine candidate prevents asymptomatic infection or transmission of infection.Discuss the methods that have been used to evaluate the safety of the mRNA-based COVID-19 vaccines that have gained emergency use authorization in the United States.Humanism and ProfessionalismCOVID-19 Vaccine: Promoting Vaccine AcceptanceThis article summarizes the ACP/Annals COVID-19 Vaccine Forum II, held on 16 December 2020.Use this article to:View the video of the forum with your learners.Ask your learners what strategies they use to encourage patients to receive influenza vaccinations.Have your learners role-play conversations with the following patients who are refusing COVID-19 vaccine: a medical assistant in a long-term care facility; an ICU nurse with a peanut allergy; and a 36-year-old Black woman with obesity, hypertension, and type 2 diabetes.Academic Health Centers' Antiracism Strategies Must Extend to Their Business PracticesAcademic medicine has made commitments that aim to reduce racism in medicine, such as developing antiracism curricula and increasing workforce diversity. This commentary proposes ways to confront institutional racism embedded in health care economics.Use this article to:Ask your learners to identify ways in which your academic health system may be contributing to racism in medicine.Ask your learners to identify strategies that an academic health system could implement to reduce institutional racism in medicine.Put Your Own Oxygen Mask On FirstHow could a doctor who meant so much to so many take his own life?Use this article to:Ask your learners what they would do if they had a colleague whose well-being they were concerned about.Discuss the policies and resources at your institution for clinicians who are burned out, depressed, or experiencing other mental health issues.Invite a psychiatrist to talk with your learners about how to identify if a colleague is at risk for self-harm.MKSAP 18 QuestionA 26-year-old man is evaluated during a follow-up visit after presenting to an urgent care clinic for back pain 1 week ago. Laboratory studies at that time were significant for a serum creatinine level of 1.4 mg/dL (123.8 µmol/L); other laboratory studies, including urinalysis, were normal. A urine albumin-creatinine ratio obtained in preparation for this visit is 10 mg/g. He is a personal trainer, and his daily exercise regimen includes weightlifting. He states that his back pain has resolved. He occasionally takes ibuprofen; the last use was 1 week ago. He takes no over-the-counter supplements.On physical examination today, vital signs are normal. BMI is 29. The patient is muscular, without signs of obesity. There is no muscle tenderness.Which of the following is the most appropriate management?A. Avoid all NSAID medicationsB. Measure the serum creatine kinase levelC. Measure the serum cystatin C levelD. Schedule a kidney biopsyCorrect AnswerC. Measure the serum cystatin C levelEducational ObjectiveIdentify increased muscle mass as a cause of an increase in serum creatinine.CritiqueMeasurement of the serum cystatin C level is appropriate for this patient. Cystatin C may be preferable to creatinine to assess kidney function in individuals with higher muscle mass. An increase in muscle mass would be expected to result in an increase in serum creatinine level in the absence of change in kidney function. This muscular man with a BMI of 29 has increase in muscle mass. Because serum creatinine is derived from the metabolism of creatinine produced by muscle, a significant increase in muscle mass would be expected to increase serum creatinine. An elevation in serum creatinine could also occur with creatine supplements, which he is not taking. This patient has a normal urinalysis and no proteinuria, all of which indicate no evidence of underlying kidney disease. Cystatin C, which is cleared by the kidney, is produced by all nucleated cells; therefore, levels are less dependent on muscle mass. Cystatin C can also be used for more accurate glomerular filtration rate estimation in these patients as a component of the Chronic Kidney Disease Epidemiology Collaboration equation.Although NSAIDs can cause acute kidney injury, the remote and infrequent use by this patient is unlikely to have any effect on serum creatinine. The hemodynamic effects of NSAIDs will disappear within 24 hours of stopping the medication, and interstitial nephritis from NSAIDs is unlikely to present with occasional dosing and is usually associated with proteinuria. The adverse effects of renal fibrosis associated with NSAIDs are only seen with extensive and long-term use.Creatine kinase levels can be measured to evaluate for the presence of rhabdomyolysis. Rhabdomyolysis significant enough to cause kidney injury would be expected to result in myoglobinuria reflected by heme-positive urine in the absence of red cells. No blood was seen on urinalysis.In the absence of other changes suggesting glomerular or interstitial disease, a kidney biopsy is not necessary.Key PointIncreased muscle mass can result in an increase in serum creatinine level in the absence of change in kidney function.BibliographyBaxmann AC, Ahmed MS, Marques NC, Menon VB, Pereira AB, Kirsztajn GM, et al. Influence of muscle mass and physical activity on serum and urinary creatinine and serum cystatin C. Clin J Am Soc Nephrol. 2008;3:348-54.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: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics February 2021Volume 174, Issue 2Page: ED2KeywordsCOVID-19Clinical trialsCreatinineFallsGlomerular filtration rateKidneysMusclesNSAIDsVaccinesVitamin D ePublished: 16 February 2021 Issue Published: February 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...