Annals for Educators - 18 July 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives18 July 2017Annals for Educators - 18 July 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201707180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMissed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health ConsultationsMeasles outbreaks in the United States are mostly due to index infections occurring in returning U.S. travelers. In a study of travelers presenting to U.S. pretravel clinics, the authors assessed why those eligible for measles vaccination were not offered it or why they refused it.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!What questions do your learners ask when a patient reports upcoming travel? Do they discuss vaccinations? What else should be discussed?Ask your learners what the symptoms and signs of measles infection are. How is measles spread? How is it diagnosed?What are the potential complications of measles? How urgent do your learners feel it is to ensure vaccination against it? Have they ever seen a case of measles?The editorialists note that before vaccination was available in the United States, there were 500,000 cases of measles, 48,000 hospitalizations, 500 deaths, and 1000 cases of permanent brain damage due to encephalitis each year. Do your learners think that the success of vaccination in making the disease less commonly encountered by health care professionals has led to a lack of concern? Review the results of this study, which come from centers with dedicated travel clinics. How would your learners counsel a patient who says she does not want to be vaccinated? Which vaccines are stored and administered at your practice? How does one arrange for administration of other vaccines? Which ones will insurance pay for?Racial Differences in the Relationship of Glucose Concentrations and Hemoglobin A1c LevelsInterpreting observed differences between hemoglobin A1c (HbA1c) values in black and white patients may have implications for population health and the care of individual patients. This study used continuous glucose monitoring to assess whether higher HbA1c levels among black patients reflect worse glycemic control or biological differences in the glycation of hemoglobin.Use this study to:Ask your learners to explain what HbA1c values represent. What is known with regard to what HbA1c values tell us about the risk for complications of diabetes?Why have differences between black and white persons in the glycation of hemoglobin been postulated?What are potential explanations for higher mean HbA1c values in black populations than in white populations? Might socioeconomic factors play a role? Is that all? Use the editorial to help frame your discussion. Look at Figure 1 with your learners. How do they interpret the findings? Why are the findings on albumin and fructosamine (Figure 2) important?Why might these racial differences in hemoglobin glycation be important? Do the results suggest that we should not use HbA1c for either black or white patients? See what the editorialists say. Yoga, Physical Therapy, or Education for Chronic Low Back Pain. A Randomized Noninferiority TrialSeveral trials indicate that yoga is an effective treatment for chronic low back pain. This trial compared yoga with a standardized program of physical therapy and education in a group of low-income, racially diverse patients with chronic low back pain symptoms.Use this paper to:Ask your learners what they recommend for patients with chronic low back pain who do not require further evaluation. Do they recommend exercise? What type? Does it matter?What do the results of this study suggest?What is a “noninferiority” trial? How does it differ from a superiority trial? What are the noninferiority margins used in assessing whether one intervention is inferior to another?The authors concluded that yoga is noninferior to physical therapy. How does that differ from saying they are equal? Why might it matter? Invite an expert in clinical epidemiology and/or biostatistics to join your discussion.What will your learners recommend to their patients?23andMe Paves the Way for Direct-to-Consumer Genetic Health Risk Tests of Limited Clinical UtilityThis commentary discusses the limited clinical utility of 23andMe's direct-to-consumer (DTC) genetic test and raises concerns that its approval creates a pathway that could lead to expansive DTC genetic testing of similarly low clinical utility that the public will misunderstand and misuse.Use this essay to:Ask your learners if they are aware of what 23andMe's DTC genetic test provides.Review the limitations in the positive and negative predictive values and the other test performance variables noted by the authors. Do your learners think this testing should have been approved by the FDA? Why or why not? What are the potential benefits? What are the potential harms?How would your learners respond if their patients were to present the results of DTC genetic testing? Do they believe they are responsible for interpreting the results for their patients? What if a patient expects a change in her or his health care based on the results, but your learner sees no need for a change? Review a recent study of the perceptions of patients who presented DTC genetic test results to their physicians. Should all patients with DTC genetic test results be referred to a genetics expert for interpretation? If so, does the health system have the ability to provide such services?Video LearningAnnals Consult Guys - Let Me Out of Here! How Long to Remain Hospitalized After an MIIn this episode of Annals' consultative medicine talk show, the Consult Guys discuss the evolution in thinking about post–myocardial infarction (MI) hospitalization.Use this feature to:Take a break and watch this short, informative video with your learners.Ask your learners what the benefits of post-MI hospitalization are. What are the complications to watch for, when are they likely to occur, and how is being in the hospital beneficial?How is the readiness of a post-MI patient for discharge to home assessed at your center?Review the multiple-choice questions with your learners, and be sure to log on and enter your answers to earn CME and MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: Are There Weapons in the Home?Dr. Quinn tells how the answer to an inquiry about guns in a patient's home led to a disturbing answer and a change in her approach to the issue.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners whether they ask about the presence of firearms in their patients' homes. Should they? Use a recent article discussing why and how to approach this issue. After the encounter described in her essay, the author began asking patients more than whether there were guns at home. How might such an approach help to build rapport with a patient in addition to looking out for her or his safety?Do your learners know what to do if a patient reports concerns about harm at home?MKSAP 17 QuestionA 61-year-old woman is evaluated for immunization before traveling. She plans to travel to Cambodia in 2 weeks and will spend 4 weeks in rural areas. Medical history is significant for controlled rheumatoid arthritis. She has been provided all adult immunizations recommended by the Advisory Committee on Immunization Practices but has not previously received any hepatitis A immunization. Medications are infliximab and methotrexate.On physical examination, vital signs are normal. No active inflammatory joint disease is evident, and the remainder of the examination is unremarkable.Which of the following is the most appropriate hepatitis A prophylaxis regimen for this patient?A. Hepatitis A vaccine nowB. Hepatitis A vaccine and immune globulin nowC. Immune globulin nowD. Immune globulin now and hepatitis A vaccine upon returnCorrect AnswerB. Hepatitis A vaccine and immune globulin nowEducational ObjectivePrevent hepatitis A in a traveler to South Asia.CritiqueThis patient should receive hepatitis A virus (HAV) vaccine and a dose of intramuscular immune globulin now. Travel-related risk for acquiring HAV depends on the person's immune status to HAV and level of endemicity of this hepatotropic pathogen in the geographic area being visited. The adoption of routine childhood HAV vaccination programs in recent years has greatly decreased the incidence of infection. However, only approximately 40% of adults are immune to HAV and, therefore, are at risk for infection, particularly when traveling to developing parts of South Asia, Africa, and South and Central America. Transmission occurs by the fecal-oral route from close contact with an infected person or ingestion of contaminated water or food. Therefore, active immunization using either of the two available inactivated vaccines is effective for preventing infection and is strongly recommended when traveling to areas of high disease prevalence, such as Cambodia.One dose of vaccine administered any time before departure generally provides protection to most persons 40 years or younger, although a second dose given 6 to 12 months after the initial dose is required for long-term protection. However, persons older than 40 years, those with chronic medical conditions, immunocompromised persons, or those with chronic liver disease who plan to depart within 2 weeks to an endemic area should be treated with hepatitis A vaccination and intramuscular immune globulin given at a distant injection site to provide optimal protection. The use of immunosuppressive medications (as in this patient), including tumor necrosis factor α inhibitors, is not a contraindication to immunization with killed or inactivated vaccines.Hepatitis A vaccine is the primary method for triggering immunity to the virus, with immune globulin providing additional protection in patients at high risk. The use of immune globulin alone without hepatitis A vaccination is not indicated or recommended.Administering hepatitis A vaccine or immune globulin following exposure to hepatitis A in nonimmunized patients (postexposure prophylaxis) is effective in reducing attack rates of infection. However, preexposure prophylaxis is not contraindicated in this patient, and postexposure prophylaxis should not be necessary.Key PointHepatitis A virus vaccine, with a dose of intramuscular immune globulin to provide optimal protection to persons traveling within 2 weeks, should be given to any person planning travel to developing parts of South Asia, Africa, and South and Central America.BibliographyCenters for Disease Control and Prevention. Infectious Diseases Related to Travel, Hepatitis A. In: CDC Health Information for International Travel 2014. Updated July 10, 2015. Accessed July 20, 2015.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 18 July 2017Volume 167, Issue 2Page: ED2KeywordsGeneticsGlobulinsHbA1cHealth careHemoglobinHepatitis AHospitalizationsLower back painMeaslesVaccines ePublished: 18 July 2017 Issue Published: 18 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...