Annals for Educators - 3 December 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives3 December 2019Annals for Educators - 3 December 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201912030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsManagement of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus GroupThis guideline updates the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB).Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!What are the immediate considerations for evaluation and management of patients with potential UGIB?Ask your learners what the risk factors are for UGIB.Do all patients with UGIB require hospitalization? How do your learners decide? Review the variables of the Glasgow Blatchford score. What score is recommended to identify a sufficiently low risk for rebleeding to consider outpatient management? Is this in line with practice at your hospital? Do your learners think it should be?Which patients require blood transfusion? Note the difference in thresholds for transfusion recommended in the multiple-choice question below and in the guideline. Why might recommendations differ? What do your learners plan to do?How should proton-pump inhibitors be administered, and for how long? How does a patient's need for anticoagulant or antiplatelet therapy influence the approach to proton-pump inhibitor therapy?Cases in Precision Medicine: A Personalized Approach to Stroke and Cardiovascular Risk Assessment in WomenCardiovascular disease is the leading cause of death among women in the United States, and stroke is third. This article discusses female-specific cardiovascular risk factors across the lifespan and describes a precision medicine–based approach to risk factor modification and primary prevention, including the current role of genetic testing in the assessment of risk for cardiovascular disease and stroke.Use this paper to:Read the presentation of a 46-year-old woman seeking advice about her risk for cardiovascular disease with your learners.Ask your learners how they would answer this patient's question regarding a “test” to assess whether “stroke is in her genes.”How would your learners assess this patient's risk?Is there a role for genetic testing?How does this patient's history of migraine influence your learners' assessment of her risk? What other variables influence her risk? Use the Figure.Beyond the GuidelinesShould This Patient Be Screened for Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterTwo cardiologists discuss the U.S. Preventive Services Task Force guidelines on atrial fibrillation and whether they would recommend anticoagulation for a specific patient with screen-detected atrial fibrillation.Use this feature to:Watch the video interview of Dr. V, a 69-year-old woman with an asymptomatic episode of tachycardia noted during ambulatory blood pressure monitoring.Ask your learners whether they would recommend screening patients for atrial fibrillation. Why or why not?What are the potential benefits and harms?Review the background material and the arguments made by the 2 discussants. Alternatively, watch the video of the grand rounds presentation.Have your learners changed their minds about screening?In the Clinic: Obstructive Sleep ApneaObstructive sleep apnea (OSA) is very common but is frequently undiagnosed. It occurs in 14% of men and 5% of women in the general adult population. Yet, only 1 in 50 patients with suggestive symptoms is evaluated and treated. Do your learners know when to consider OSA and how to evaluate for its possible presence?Use this review to:Ask your learners what conditions increase the risk for OSA. See the Box: Risk Factors for Obstructive Sleep Apnea.Should we screen for OSA? If so, in whom? How would your learners do so? Are they familiar with the STOP-BANG approach?What evaluation should occur if OSA is suspected?Are in-laboratory sleep studies required for diagnosis or treatment?How is treatment initiated? Is evaluation by a specialist always required?Use the provided multiple-choice questions to introduce topics during a teaching session. Be sure to log in and enter your answer to claim CME and MOC credit.Humanism and ProfessionalismA Veteran-Centric Model of Care: Crossing the Cultural DivideAlthough most U.S. physicians train at Veterans Health Administration hospitals, few have served in the military. The author, a veteran and physician, discusses how failure to appreciate the differences between the civilian and military cultures can result in misalignment of veterans' and physicians' perspectives during management of a veteran's health.Use this essay to:Ask your learners whether they have noted differences in their interactions with patients who are veterans compared with those who have not served in the military.Do your learners ask patients who are veterans about their service history? Should they? When? What questions should be asked? Use the Table. Why might these questions be helpful?Have your learners encountered the kinds of misunderstanding or miscommunication described by the author?On Being a Doctor: The Liver Transplant UnitThe reality that her partner's liver will fail plunges Dr. Adler into a different side of doctoring.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they are ever jarred by thoughts of a loved one when they see a patient with an illness.Is it different to face a loved one's illness as a physician? Do our knowledge of medicine and our experiences with advanced disease make things better or worse?MKSAP 18 QuestionA 55-year-old man is evaluated after being hospitalized for epigastric pain of 1 month's duration and melenic stools over the past 3 days associated with fatigue. He reports no hematochezia, hematemesis, chest pain, or shortness of breath. He has osteoarthritis treated with ibuprofen. He received an intravenous fluid bolus in the emergency department.On physical examination, blood pressure is 135/75 mm Hg and other vital signs are normal, with no orthostatic changes. Abdominal examination reveals epigastric tenderness but is otherwise unremarkable. No stigmata of chronic liver disease are seen.Laboratory studies show a hemoglobin level of 7.3 g/dL (73 g/L).Upper endoscopy shows a 1.5-cm duodenal bulb ulcer with a clean base.Which of the following is the most appropriate resuscitation measure?A. Transfuse red blood cells to a goal hemoglobin level of 8 g/dL (80 g/L)B. Transfuse red blood cells to a goal hemoglobin level of 9 g/dL (90 g/L)C. Transfuse red blood cells to a goal hemoglobin level of 10 g/dL (100 g/L)D. No transfusionCorrect AnswerD. No transfusionEducational ObjectiveTreat upper gastrointestinal bleeding.CritiqueThis patient does not require transfusion. For patients with upper gastrointestinal bleeding, initial resuscitation is the first priority and should include stabilization of blood pressure with infusion of sufficient volumes of crystalloid fluid and/or red blood cells. The decision to transfuse red blood cells is based mainly on the presenting hemoglobin level. In hemodynamically stable patients, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy (transfusion threshold of less than 9 g/dL [90 g/L] with a target hemoglobin level of 9-10 g/dL [90-100 g/L]). This patient is hemodynamically and physiologically stable with no evidence of ongoing overt gastrointestinal blood loss or symptoms of tissue ischemia; therefore, it is appropriate to continue maintenance intravenous fluids because he is at an appropriate target hemoglobin level of 7 to 9 g/dL (70-90 g/L).A modification of the restrictive transfusion threshold may be considered in specific subpopulations, such as patients with hypotension due to severe bleeding and patients with cardiovascular disease. It may be reasonable to give transfusions to patients who are hemodynamically unstable before a decline in hemoglobin level to less than 7 g/dL (70 g/L) to prevent complications of tissue underperfusion. There is uncertainty regarding the need for a higher transfusion threshold in patients with cardiovascular disease, but current guidelines recommend considering transfusion when hemoglobin levels decrease below 8 g/dL (80 g/L) or when cardiovascular symptoms develop (for example, chest pain, dyspnea) in patients who are otherwise hemodynamically stable.Key PointIn patients with upper gastrointestinal bleeding, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy.BibliographyFortinsky KJ, Bardou M, Barkun AN. Role of medical therapy for nonvariceal upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 2015;25:463-78. doi:10.1016/j.giec.2015.02.003Do 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 3 December 2019Volume 171, Issue 11Page: ED11KeywordsArmed forcesAtrial fibrillationBlood pressureCardiovascular diseasesHemoglobinHemorrhageIschemiaMedical risk factorsObstructive sleep apneaRed blood cells ePublished: 3 December 2019 Issue Published: 3 December 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. 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