Annals for Educators - 19 September 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives19 September 2017Annals for Educators - 19 September 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201709190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsContinuous Glucose Monitoring Versus Usual Care in Patients With Type 2 Diabetes Receiving Multiple Daily Insulin Injections. A Randomized TrialContinuous glucose monitoring (CGM), which has been shown to be beneficial for adults with type 1 diabetes, has not been well-evaluated in those with type 2 diabetes receiving insulin. This randomized trial compares hemoglobin A1c reduction at 24 weeks using CGM versus usual care in adults with type 2 diabetes receiving multiple daily injections of insulin.Use this study to:Ask whether your learners have cared for patients who used CGM to manage their type 1 diabetes. What have been the challenges? Use the accompanying editorial to help frame your discussion. Invite a diabetes specialist to discuss the use of CGM with your team. In whom should it be considered? Are there contraindications?Is the difference between the changes in hemoglobin A1c values achieved in the trial's 2 groups clinically important? What is the difference between clinically important and statistically important? The authors discuss how many patients achieved a goal of a hemoglobin A1c level less than 7%. Why? What do your learners think is the best way to judge the performance of a diabetes intervention?Should CGM be considered for the management of patients with type 2 diabetes?Teach at the bedside! Is there an outpatient or inpatient who has used CGM with whom your team might discuss the experience? Did CGM improve the patient's glycemic control? At what cost (or benefit) to the patient's quality of life?Safety and Tolerability of Maraviroc-Containing Regimens to Prevent HIV Infection in Women. A Phase 2 Randomized TrialMaraviroc is a candidate drug for HIV preexposure prophylaxis (PrEP), and it has especially favorable properties in women. In this prospective, randomized, multicenter study, the authors compared the safety and tolerability of 4 antiretroviral regimens in U.S. women at risk for HIV infection.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they have discussed PrEP with their patients and whether they have prescribed it. For whom is PrEP recommended?What other practices should we discuss with our patients to prevent HIV infection?What are the goals of phase 1, 2, 3, and 4 clinical trials? Why is this study a phase 2 trial and not a phase 3 trial?What properties would your learners want to consider when choosing an agent for PrEP in women? See what the authors say in the paper's introduction.On the basis of this trial, what may we conclude about the safety and efficacy of maraviroc? What is needed before this approach to PrEP would be recommended? What end points would your learners suggest be evaluated in future studies?Some have expressed concern that the availability of PrEP might provide some patients with a false sense of security and thus encourage high-risk behaviors. How would your learners propose studying this concern? How would they counsel patients?Screening for Occult Cancer in Patients With Unprovoked Venous Thromboembolism. A Systematic Review and Meta-analysis of Individual Patient DataUsing data from 10 prospective studies, this meta-analysis of individual patient data examines the prevalence of occult cancer in patients with unprovoked venous thromboembolism (VTE) and whether prevalence differs in various subgroups.Use this study to:Ask your learners what “Trousseau syndrome” is.What is required to designate a VTE event as “unprovoked”? What needs to be excluded? How is this done?What is the risk for a subsequent cancer diagnosis among patients with unprovoked VTE? Is there a benefit to extensive testing for cancer? What did this systematic review find?Why do your learners think that despite the frequency of cancer among patients with unprovoked VTE, a clear benefit has been established only for age-appropriate screening tests? What is the difference between a screening test and one performed to evaluate a symptom?What should the approach to cancer screening be among patients with unprovoked VTE? Use the accompanying editorial to help frame your discussion. Video LearningAnnals Consult Guys - Abdominal Aortic Aneurysm: When to Screen? When to Follow?Howard and Geno (the Consult Guys) tackle the thorny issue of how to screen for an abdominal aortic aneurysm and how to follow it if it is present.Use this feature to:Take a break and watch the video.Use the provided multiple-choice questions before viewing the video to check your learners' knowledge or after viewing it to see whether they were paying attention. And, log on to enter your responses to earn CME and MOC credit for yourself!Our Health Care SystemThe Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?An Institute of Medicine (IOM) review in 2002 concluded that lack of insurance increases mortality, but several relevant studies have since appeared. This article summarizes current evidence concerning the relationship between insurance and mortality.Use this paper to:Ask your learners whether they have seen a lack of insurance affect a patient's outcome.Why do your learners think it is difficult to study the relationship between insurance status and mortality? Use Table 2, and see what the authors say in the paper's discussion.In what ways might insurance reduce mortality? Are there ways in which it might increase mortality? The authors provide 2 examples in the discussion.What other benefits to individuals and society might result from health insurance?Do your learners think physicians should be vocal in the national debate over health insurance?Humanism and ProfessionalismOn Being a Doctor: A Great GiftDr. Molitor describes how he saved a patient, and how she saved him.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners whether they have felt the way Dr. Molitor described feeling before he entered his patient's room. Have they ever doubted whether what they do matters?Ask your learners to list the things they do for their patients. If they need help or are too modest, read the list provided in the penultimate paragraph of a recent letter to new interns. Now how do they feel? Are there ways to remind ourselves of the ways in which we make a difference to help carry us through the tough times?MKSAP 17 QuestionA 39-year-old man undergoes consultation about HIV prevention. He has a male sex partner with HIV infection. He reports they use condoms “most of the time.” He asks about other options that can reduce his risk for acquiring HIV from his partner. He is asymptomatic. Medical history is noncontributory, although he has been vaccinated for hepatitis B. He takes no medications.On physical examination, vital signs are normal, as is the remainder of the examination.Results of testing for HIV are negative. Testing for hepatitis B surface antigen yields negative findings, and hepatitis B surface antibody results are positive.Which of the following is the most appropriate management?A. Counsel that consistent condom use provides adequate protectionB. Prescribe daily combination tenofovir-emtricitabineC. Prescribe daily combination tenofovir-emtricitabine and raltegravirD. Prescribe daily tenofovirCorrect AnswerB. Prescribe daily combination tenofovir-emtricitabineEducational ObjectiveProvide preexposure prophylaxis for HIV to a person at ongoing risk.CritiqueThis patient is at risk for HIV infection because of regular sexual activity with an infected person and should be considered for preexposure prophylaxis (PrEP). Daily combination tenofovir-emtricitabine therapy is FDA approved for prevention of HIV infection in persons considered at ongoing risk for infection. Studies have shown efficacy in men who have sex with men, heterosexual couples, and injection drug users. Rates of effectiveness in prevention depend on adherence to the medication, and prophylaxis should always be accompanied by safer-sex counseling. Testing for HIV and other sexually transmitted diseases, pregnancy, and kidney function should be performed before initiation of prophylaxis and every 2 to 3 months during preventive therapy.Reduction in viral load with antiretroviral therapy does reduce transmission of HIV, although transmission may still occur even with undetectable blood levels. Although consistent condom use can reduce the risk for HIV transmission, the addition of PrEP can further reduce rates of acquisition of HIV and should be considered in those at high risk. Such preventive therapy should be taken daily, however, and not episodically only with exposure.Studies on which FDA approval was based used a two-drug combination of tenofovir-emtricitabine alone without additional medication. Therefore, no clear indication exists for exposing the patient to the additional cost and risk of a third drug. The three-drug regimen of combination tenofovir-emtricitabine and raltegravir is the preferred regimen for postexposure prophylaxis. Whereas tenofovir alone has shown some benefit in reducing acquisition of HIV because of concerns about resistance, combination tenofovir-emtricitabine is preferred for PrEP.Key PointCombination tenofovir-emtricitabine should be considered as preexposure prophylaxis to prevent HIV infection in all persons considered at ongoing risk of infection.BibliographyCenters for Disease Control and Prevention (CDC). Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb Mortal Wkly Rep. 2011 Jan 28;60(3):65-8.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 19 September 2017Volume 167, Issue 6Page: ED6KeywordsHIVHIV infectionsHIV preventionHemoglobinMortalityPreexposure prophylaxisProspective studiesSafetyType 1 diabetesType 2 diabetes ePublished: 19 September 2017 Issue Published: 19 September 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...