<i>Annals</i> for Educators - 5 July 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives5 July 2016Annals for Educators - 5 July 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201607050 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLong-Term Risk for Device-Related Complications and Reoperations After Implantable Cardioverter-Defibrillator Implantation. An Observational Cohort StudyAlthough the short-term risks for complications after placement of implantable cardioverter-defibrillators (ICDs) are well-established, little is known about longer-term risks. This large national study evaluated long-term complications after ICD placement as well as the patient and device factors associated with them.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners to list the indications for ICD placement.What are the short-term complications? How should a patient be monitored immediately following placement?Ask your learners to list the potential long-term complications. Review this study's findings.Will the results of this study alter how your learners discuss the potential benefits and risks of ICD placement with their patients?Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United StatesThe total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear. This study found that PrEP, with frequent screening and prompt treatment for HIV, can reduce HIV burden among PWID and provide health benefits for the entire U.S. population. However, it remains an expensive intervention.Use this study to:Review with your learners the current CDC recommendations for the use of PrEP. In which at-risk patients should PrEP be considered? How effective is it? What are the potential concerns to using PrEP? Use the information in DynaMed Plus: Preexposure Prophylaxis for HIV (a benefit of your ACP membership) to help prepare a teaching session.How should PrEP be prescribed? How should it be monitored? What are the possible adverse effects of tenofovir and emtricitabine?Discuss the goals of a cost-effective analysis (CEA) with your learners. What variables need to be considered? How might different assumptions regarding each variable's cost, the prevalence of HIV infection among PWID, and the effectiveness of PrEP influence the conclusions of this CEA? Invite an expert in CEA to join your discussion.Use a concise primer that explains key terms important to understanding CEAs to help teach what comparative effectiveness, cost-effectiveness, and incremental cost-effectiveness ratios are. What does it mean when one intervention dominates another?Ask your learners how an analysis such as this one should influence planning for public health programs. Are the estimated costs of PrEP program for PWID worth it? Read the accompanying editorial to help frame your discussion.GoutAlthough the pathophysiology of gout is well-understood and effective therapies are available, it is frequently poorly managed. This concise review answers key clinical questions to assist your learners recognize, evaluate, treat, and monitor patients with gout.Use this review to:Ask your learners what the risk factors are for gout. How does diet affect risk? Does altering intake of certain foods reduce risk?How is a new diagnosis of gout made? Is joint aspiration always required? What is the differential diagnosis? How does one differentiate from septic arthritis?How is an acute flare managed? Which patients with gout flare require hospitalization?Which patients with gout require urate-lowering therapy? Which drugs should be used, when, and how are they monitored? When should allopurinol be used? Feboxostat? What are the potential adverse effects?Use the already prepared teaching slides.Use the already prepared multiple-choice questions to introduce various topics during a teaching session. Be sure to log on and answer the questions to earn CME for yourself.The Cost of CareAnnals Graphic Medicine - The Price of ProgressStemming the Escalating Cost of Prescription Drugs: A Position Paper From the American College of PhysiciansIn her graphic narrative (cartoon!), Dr. Farris describes how a “complication” of gout therapy was unexpectedly the “cause” of her patient's subdural hematoma. The ACP position paper discussed why the U.S. pays more for prescription drugs than other developed countries and makes recommendations to address their rising costs.Use these articles to:Read the comic with your learners.Teach at the bedside! Ask your team's patients on morning rounds how they pay for each of their medications. What is their copay? How much does their entire regimen cost each month? Ask each if they ever “cut corners” to try to save money? Is there variation in how much the similar (or same) drugs cost your patients? Were your learners surprised?Review key sections of the position paper's appendix to identify the variables that affect drug pricing in the U.S. Ask your learners to list them. Why are drug prices higher in the U.S. than elsewhere? Why do costs vary from one patient to another? Do your learners think the recommendations will be enacted? Would they work if they were enacted?Your Residents' CareersHow Employed Physicians' Contracts May Threaten Their Patients and ProfessionalismThis commentary discusses how clauses in the contracts that physicians sign with their employers or that their employers sign with third parties may be part of a growing class of subtle restrictions on employed physicians' professionalism and autonomy.Use this essay to:Organize a seminar for residents who are looking for jobs for after training.Invite physicians who have contracts with your health system for each inpatient and outpatient care to discuss what has surprised them in the “real world” regarding the “business” of being employed by others to provide care.Review the paper's table with your learners. Why do they think the clauses noted in the table are placed in contracts? Are their good reasons? What are the problems?On Being a PatientBrain Anatomy: Thoughts From the InsideDr. Pordy describes how the challenges posed by the poorly understood neurologic condition he has led to his novel theory on how we form words.Use this essay to:Listen to an audio recording of this essay, read by Dr. Michael LaCombe.Ask your learners how physicians may differ from other patients in their response to having an illness. In what ways can our medical knowledge be an advantage in facing disease? Can it be a burden?What are frontotemporal dementia and frontotemporal lobar degeneration? What language and behavioral disturbances may be seen? How well (or not) do the symptoms correlate with the anatomical sites of neurodegeneration?Have your learners ever considered how a lack of clear explanation for one's symptoms might affect a patient? How might it add an additional burden to dealing with illness? Do your learners think Dr. Pordy's intellectual curiosity and his medical training have helped him respond to this illness? How does it inspire them? Might his essay inspire and help some other patients?MKSAP 17 QuestionA 55-year-old man with a 6-month history of heart failure is evaluated during a follow-up appointment. At diagnosis, his left ventricular ejection fraction was 15%, and he had moderate mitral and tricuspid regurgitation. Cardiac catheterization at that time revealed normal coronary arteries. He was started on the appropriate medications and is now back to working at a desk job. He has dyspnea walking up a flight of stairs. Medical history is also significant for hypertension. Medications are enalapril, carvedilol (25 mg twice daily), furosemide, and spironolactone.On physical examination, blood pressure is 100/65 mm Hg, and pulse rate is 56/min. Weight is 72 kg (159 lb). On cardiovascular examination, there is a grade 3/6 holosystolic murmur at the apex radiating to axilla and no S3 gallop. The remainder of the examination is normal.Serum electrolyte levels and kidney function tests are normal. Recent echocardiogram shows a left ventricular ejection fraction of 20% and moderate mitral regurgitation. Electrocardiogram demonstrates normal sinus rhythm with a QRS width of 100 ms.Which of the following is the most appropriate management?A. Add an angiotensin receptor blockerB. Implantable cardioverter-defibrillator placementC. Increase carvedilol to 37.5 mg twice dailyD. Mitral valve replacementCorrect AnswerB. Implantable cardioverter-defibrillator placementEducational ObjectiveManage risk of sudden cardiac death in a patient with heart failure with placement of an implantable cardioverter-defibrillator.CritiqueThis patient with heart failure and a low left ventricular ejection fraction should be referred for placement of an implantable cardioverter-defibrillator (ICD). For patients with an ejection fraction less than or equal to 35% and New York Heart Association (NYHA) functional class II or III heart failure on optimal medical therapy, placement of an ICD is a class I indication. Patients with new-onset heart failure should not undergo placement of an ICD because ventricular function often recovers to above 35%. This patient, however, is on appropriate medical therapy, has had heart failure for at least 6 months, and is still symptomatic. For patients with NYHA functional class IV heart failure symptoms, an ICD is not warranted unless the patient is a cardiac transplant candidate.Cardiac resynchronization therapy (CRT) with a biventricular pacemaker to improve hemodynamic function of the heart may also be considered in patients with persistent heart failure but is reserved for patients with evidence of conduction system disease. The 2013 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS) guideline recommends CRT in patients with an ejection fraction of 35% or below, NYHA functional class III to IV symptoms on guideline-directed medical therapy, and left bundle branch block with QRS duration greater than or equal to 150 ms. With a QRS width of 100 ms, this patient is not a candidate for a biventricular pacemaker in addition to an ICD.Adding an angiotensin receptor blocker to a heart failure regimen that already includes an ACE inhibitor would not be indicated in this patient as it would not provide additional benefit, and this medication combination has been shown to increase risk of hyperkalemia and kidney injury.Because this patient's heart rate is 56/min, indicating adequate β-blockade, and his blood pressure is at a desired level, no benefit would be expected by increasing his dose of carvedilol.Indications for mitral valve replacement, an invasive procedure that carries risks, include the presence of severe mitral regurgitation and NYHA class III or IV symptoms attributed to the valve disease. None of these are present in this patient. This patient's mitral regurgitation is “functional,” meaning it is more likely to be a result of his dilated cardiomyopathy and not the underlying cause.Key PointImplantable cardioverter-defibrillator placement is indicated for patients with heart failure and a left ventricular ejection fraction less than or equal to 35% and New York Heart Association functional class II or III heart failure while on optimal medical therapy.BibliographyBardy GH, Lee KL, Mark DB, et al; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005 Jan 20;352(3):225-37. Erratum in: N Engl J Med. 2005 May 19;352(20):2146.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. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 5 July 2016Volume 165, Issue 1Page: ED1KeywordsCost effectiveness analysisDrugsGoutHIVHeart failureImplantable cardioverter defibrillatorsLeft ventricular ejection fractionMitral insufficiencyPreexposure prophylaxisSudden cardiac death ePublished: 5 July 2016 Issue Published: 5 July 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...