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

Web ExclusivesFebruary 2022Annals for Educators - February 2022FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202202150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCharacteristics and Outcomes of Hospitalized Pregnant Women With Influenza, 2010 to 2019. A Repeated Cross-Sectional StudyInfluenza-Related Morbidity in Pregnancy: A Call for Maternal ImmunizationPregnant women may be at increased risk for severe influenza-associated outcomes. This repeated cross-sectional analysis of data from the U.S. Influenza Hospitalization Surveillance Network sought to describe demographic and clinical characteristics, interventions, and maternal and fetal outcomes among pregnant women hospitalized with laboratory-confirmed influenza over 9 recent influenza seasons. The accompanying editorial discusses the findings and why they support the notion that pregnant women are a critical population to focus on for vaccine-preventable diseases like influenza and COVID-19.Use this article and the editorial to:Review the vaccines that should and should not be administered during pregnancy.Have your learners role-play a conversation between a physician and a pregnant patient who is hesitant to receive influenza vaccination.Have your learners role-play a conversation between a physician and a pregnant patient who is hesitant to receive COVID-19 vaccination.Associations of Serum Testosterone and Sex Hormone–Binding Globulin With Incident Cardiovascular Events in Middle-Aged to Older MenTestosterone and Cardiovascular Disease in MenStudies on the association between testosterone levels and risk for cardiovascular disease in men have reported conflicting results. Using data from the UK Biobank cohort, this study evaluated the association between serum testosterone levels and risk for myocardial infarction, stroke, heart failure, and major adverse cardiovascular events. The accompanying editorial argues that the findings imply that the decrease in serum testosterone levels in men is unlikely to be a major explanation for their age-related increase in cardiovascular disease.Use this article and the editorial to:Start your session with the multiple-choice question provided below.Review the American College of Physicians recommendations for testosterone replacement therapy. After reading the article and editorial, discuss whether your learners agree with the editorialists that a decrease in serum testosterone level is unlikely to be a major explanation for an age-related increase in cardiovascular disease.Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness. A Nationwide Retrospective Observational StudyThiamine deficiency can cause serious complications. Alcohol use disorder is the most common risk factor for thiamine deficiency, particularly during times of increased metabolic activity. This study described use of thiamine supplementation in patients with alcohol use disorder who were hospitalized with different critical illnesses.Use this article to:Review diagnostic criteria for alcohol use disorder.Review the clinical effects of thiamine deficiency in the setting of alcohol use disorder.Ask your learners to reflect on whether they think that thiamine supplementation is underutilized at your institution.Conduct a brainstorming session to generate potential strategies for ensuring the appropriate use of thiamine supplementation in patients with alcohol use disorder at your institution.Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups. A Systematic Review and Individual-Patient Data Meta-analysisHigher D-Dimer Thresholds for Excluding Pulmonary Embolism: No Free Lunch?How diagnostic strategies for pulmonary embolism perform across clinical patient characteristics is unclear. This meta-analysis pooled data from 20 533 patients across 16 studies to evaluate the potential utility of bedside decision rules coupled with D-dimer levels in the diagnosis of pulmonary embolism in patient subgroups. The accompanying editorial discusses the findings and why they offer reassurance that modifying D-dimer thresholds according to age or pretest probability is safe.Use this article and the editorial to:Ask your learners to describe the features that differentiate a systematic review from a narrative review and how the methods of an individual-patient data meta-analysis differ from the methods of study-level meta-analysis.Ask your learners to sketch out an algorithm for how they typically evaluate a patient with suspected pulmonary embolism.Review the Wells and Geneva scores.Invite a laboratory pathologist to your session to explain how the laboratory at your institution determines D-dimer thresholds.Rebooting Instrumental Activities of Daily Living for the 21st CenturyThis article describes how the evolution of technology since the development of instrumental activities of daily living (IADLs) in 1969 may interact with assessment and use of IADLs and pose challenges for the future.Use this article to:Review the traditional IADLs.Discuss ways in which the traditional IADLs may be biased by factors such as gender and socioeconomic status.Ask each of your learners to think of 2 to 3 activities involving technology that they would add to an assessment of a person's functional status in 2022. How does your learners' list compare with the list generated by the authors of this commentary?Beyond the GuidelinesWhen and How Would You Screen This Patient for Cervical Cancer? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe American Cancer Society and the U.S. Preventive Services Task Force have issued guidelines for cervical cancer screening that differ in their recommendations on the age at which to begin screening and which test to use. Two experts debate how these guidelines might be used in counseling a specific patient.Use this article to:Watch the patient video, and ask your learners when and how they would screen the patient for cervical cancer.Review the American Cancer Society and U.S. Preventive Services Task Force guidelines on cervical cancer screening.Read the article or watch the video of the grand rounds presentation, and then ask your learners again how and when they would screen this patient for cervical cancer. Ask those who changed their answer after hearing the experts' perspectives to share the rationale behind their change in thinking.Acute Gastrointestinal BleedingAcute gastrointestinal (GI) bleeding is a common clinical entity. Expert management of acute GI bleeding requires collaborative care between internists and other specialists. This In the Clinic article reviews the presentation, treatment, and prevention of acute GI bleeding using recommendations from recent guidelines and expert panel reviews. With this article, the authors acknowledge the pivotal role played by primary care providers in the inpatient and outpatient management of acute GI bleeding.Use this article to:Take the quiz associated with the article as a group. Where were the knowledge gaps?What clinical features are helpful in determining whether the source of GI bleeding is the upper or lower GI tract?Ask your learners how they would identify patients with GI bleeding who can be safely managed without hospitalization.What elements of the history, physical examination, and laboratory testing should a primary care or hospital medicine physician complete before consulting a gastroenterologist?Discuss interventions that can reduce risk for recurrent GI bleeding.Public HealthFirearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National Firearms SurveyThe surge in background checks in March 2020 suggested an acceleration in U.S. firearm purchases. This survey-based study estimated the number and describes characteristics of firearm purchasers over a period spanning time before and during the COVID-19 pandemic.Use this article to:Ask your learners if the observed trends in firearm purchases are what they would have expected.Discuss the implications of the findings for counseling patients about risk for firearm injury and strategies for reducing risk. Which patient groups might efforts focus on, considering the findings of this study?Review strategies for talking with patients about firearms and risk for firearm injury. This In the Clinic review can help guide the discussion. MKSAP 18 QuestionA 47-year-old man is evaluated during a follow-up visit to manage fatigue and decreased libido. Medical history is significant for hypertension and dyslipidemia. Medications are hydrochlorothiazide and atorvastatin.On physical examination, vital signs are normal. He has normal hair distribution, no gynecomastia, and normal testicular examination.Laboratory studies obtained at 3 PM revealed a total testosterone level of 275 ng/dL (9.5 nmol/L) and a luteinizing hormone level of 5 mU/mL (5 U/L).Which of the following is the most appropriate management?A. Initiate testosterone replacement therapyB. Measure serum iron and total iron binding capacityC. Measure testosterone at 8 AMD. Obtain pituitary MRICorrect AnswerC. Measure testosterone at 8 AMCritiqueThe most appropriate management is to repeat testosterone measurement at 8 AM. The clinical diagnosis of hypogonadism is made on the basis of signs and symptoms consistent with androgen deficiency with the finding of low morning testosterone concentrations on at least two occasions. Timing of initial laboratory assessment is important due to the diurnal variation of testosterone. Additionally, assessment of hypogonadism should not be undertaken during acute illness. The next step in management of this patient would be to obtain a morning testosterone concentration; if low, testing should be confirmed with a repeat morning measurement. After the initial diagnosis, determination of primary or secondary hypogonadism is established by measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. Elevated gonadotropin levels are seen in primary hypogonadism with LH and FSH levels low or inappropriately normal in secondary hypogonadism.Based on Endocrine Society guidelines, men with hypogonadism should be treated with exogenous testosterone when they have consistent signs and symptoms of hypogonadism and low serum testosterone levels. Patients requiring testosterone replacement therapy should have testosterone levels monitored at 3 and 6 months after initiation and annually thereafter; the goal total testosterone level should be in the mid-normal range. Monitoring of the prostate specific antigen and hematocrit level should follow Endocrine Society guidelines. Before initiating testosterone therapy in this patient, the diagnosis of hypogonadism needs to be confirmed with two appropriately timed testosterone measurements.The most sensitive and cost-effective initial diagnostic study in patients with suspected hemochromatosis is measurement of the fasting serum transferrin saturation (calculated as [serum iron/total iron binding capacity] ×100). Serum ferritin level measurement is indicated in patients with elevated transferrin saturation. Evaluation for hemochromatosis is only appropriate after the diagnosis of hypogonadism is established. The first diagnostic step for this patient is the collection of two properly collected serum testosterone levels to establish the diagnosis of hypogonadism.If subsequent evaluation of the patient confirms the presence of hypogonadotrophic hypogonadism (low testosterone and low LH and FSH levels), MRI of the pituitary to detect a pituitary adenoma or other mass would be appropriate. A pituitary MRI would be premature at this point.Key PointIn men with specific signs and symptoms of hypogonadism, measuring an 8 AM total testosterone level is indicated; if the testosterone level is low, a second 8 AM confirmatory testosterone level is measured.BibliographyBasaria S. Male hypogonadism. Lancet. 2014;383:1250-63. doi:10.1016/S0140-6736(13)61126-5Do 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 InformationAuthors: Christine Laine, MD, MPHFrom 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 February 2022Volume 175, Issue 2Page: ED2 ePublished: 15 February 2022 Issue Published: February 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...