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February 4, 2014 Issue

Clinical Practice Points

High Value Care
Medical Knowledge

Repeated Upper Endoscopy in the Medicare Population. A Retrospective Analysis.

This study found that Medicare recipients frequently had repeated esophagogastroduodenoscopy (EGD) within 3 years of an initial examination. Approximately one half of the repeated EGDs seemed unjustified based on the diagnoses associated with the initial and follow-up examinations, suggesting overuse and the exposure of patients to unnecessary risk.

Use this study to:

  • Review the indications for EGD. Use a recent paper that reviewed when endoscopy is and is not beneficial.
  • Ask your learners when a repeat EGD is appropriate. Use a multiple-choice question to start the discussion. We’ve provided one below.
  • Ask what the limitations are to using administrative data in judging whether the EGDs these Medicare beneficiaries had were indicated. How did the authors deal with that limitation?
  • Ask why there might be overuse of EDG (and other procedures). Read the accompanying editorial to prompt discussion. What should be done about it? Ask your learners what their responsibility is if they think a patient is scheduled for an unnecessary procedure. How should they handle their concerns?
  • Use this topic to start a teaching series on High Value Care: A whole curriculum is freely available, including videos, slide sets, tutorials, and teaching cases.

Patient Care
Medical Knowledge

U.S. Physicians’ Perspective of Adult Vaccine Delivery

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2014

Adults are at risk for vaccine-preventable disease, but vaccination rates in adults remain low. This survey of U.S. general internists and family physicians assessed barriers to stocking and administering vaccines, as well as physicians’ practices in assessing patients’ vaccination status.

The Advisory Committee on Immunization Practices presents the recommended immunization schedule for adults aged 19 years or older for 2014.

Use this study and this report to:

  • Start a teaching session with multiple-choice questions. We’ve provided 2 related to vaccination below.
  • Ask your learners when and how they evaluate their patients’ vaccination status.
  • Review the current vaccination schedules. Download the teaching slides for Figures 1 and 2 to make reviewing as a group easier.
  • Pick a few random clinic charts and see which vaccines are recommended for each patient. Have they received those vaccinations?
  • Ask your learners to list the reasons patients refuse vaccination. Have them role-play to assess how they should respond and what they need to know to provide accurate information and advice to their patients.
  • What are the contraindications to certain vaccinations? The table reviews these.
  • Ask someone from your pharmacy staff how much it costs to maintain stocks of vaccines in your outpatient practices. Ask your learners if they ever considered how practices pay for vaccinations.

Medical Knowledge

In The Clinic: Concussion

This concise review is organized around answering key clinical questions occurring when evaluating and treating patients with possible concussion.

Use this review to:

  • Ask what acute symptoms after head injury should prompt consideration of concussion? What evaluation should be done, and do all patients need a head CT?
  • Discuss how concussion is managed. Who needs to have restrictions from work, school, or other activities?
  • Quiz your learners with the multiple-choice questions provided at the end (and get CME credit for yourself—just log on and enter your answers).

Humanism and Professionalism

Interpersonal and Communication Skills

The Seductress

Take time to discuss the "art" of practicing medicine. Play the audio recordings of this issue’s On Being a Doctor essay. One of our colleagues struggles to understand if he is being taken for a ride by a patient with drug addiction or if he is intervening in a meaningful way.

Use this essay to:

  • Ask whether your learners think they treat patients with drug addiction differently than those whose medical problems are in no way "self-imposed." Is it fair to say that a drug addiction is “self-imposed"? Do we lack compassion with such patients?
  • Ask when we are permitted (or obligated) to hold a patient against his or her wishes.

Other Teaching Resources From ACP

Patient Care
High Value Care

Online High Value Care Cases

Choose from a series of free online cases and questions addressing high-value care that are available to help clinicians weigh the benefits, harms, and costs of tests and treatment options for common conditions to improve health and eliminate waste.

Use these to teach your learners to:

  • Avoid unnecessary testing
  • Use emergency and hospital-level care judiciously
  • Improve outcomes with health promotion and disease prevention
  • Prescribe medications safely and cost-effectively
  • Overcome barriers to high-value care
  • Get free CME and ABIM MOC credit for yourself!


An 82-year-old man is evaluated for recurrent obscure gastrointestinal bleeding. He has experienced four episodes of melena in the past 6 months. Results of a colonoscopy and upper endoscopy 3 months ago were unremarkable. There is no family history of bleeding diathesis. His only medication is iron sulfate for anemia.

On physical examination, vital signs are normal. BMI is 32. There is no abdominal tenderness. Digital rectal examination is normal.

Laboratory studies reveal a hemoglobin level of 10.1 g/dL (101 g/L); platelet count, complete metabolic panel, and INR are normal.

Which of the following is the most appropriate diagnostic test to perform next?

A. Intraoperative endoscopy
B. Repeat upper endoscopy
C. Single-balloon enteroscopy
D. Wireless capsule endoscopy

Correct Answer
B. Repeat upper endoscopy

Key Point
Patients with suspected obscure gastrointestinal bleeding should undergo repeat colonoscopy and/or upper endoscopy (depending on the suspected site of bleeding), as approximately 30% to 50% of lesions can be detected using this approach.

Educational Objective
Evaluate obscure gastrointestinal bleeding.

The next diagnostic step is to repeat the upper endoscopy. The sources of gastrointestinal bleeding may not be readily identified at the time of the initial endoscopy for various reasons. Lesions may bleed intermittently. Volume contraction or a low hemoglobin concentration may alter the appearance of a bleeding source. In a patient with recurrent bleeding, endoscopy and/or colonoscopy should be repeated. Endoscopy also allows for treatment of the lesion if one is found. Approximately 30% to 50% of lesions can be detected on repeat endoscopy. If a repeat study is nondiagnostic, the next step depends upon the severity and suspected location of blood loss.

Wireless capsule endoscopy, single-balloon enteroscopy, and intraoperative endoscopy are reserved for patients in whom repeat endoscopy does not identify a diagnosis. Intraoperative endoscopy is not usually required for diagnosis because wireless capsule endoscopy and double-balloon enteroscopy have improved the ability to diagnose and treat small-bowel sources of bleeding. Nevertheless, intraoperative endoscopy may be required for ongoing life-threatening bleeding without an identified source. Push single-balloon enteroscopy consists of direct insertion of an endoscope longer than the standard upper endoscope. Push enteroscopy is most often performed for the evaluation of lesions detected on capsule endoscopy that are within the reach of the enteroscope. In wireless capsule endoscopy, a patient swallows a video capsule that passes through the stomach and into the small intestine. The video capsule transmits images to a recording device worn by the patient. The images are downloaded onto a computer where they can be reviewed. Capsule endoscopy has been shown to detect sources of bleeding in 50% to 75% of patients and is considered the test of choice to follow standard endoscopy in patients with obscure bleeding.

ASGE Standards of Practice Committee, Fisher L, Lee Krinsky M, Anderson MA, et al. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc. 2010;72(3):471-479. 5 PMID: 20801285

Question 2

A 48-year-old woman is evaluated in November before the initiation of rituximab for rheumatoid arthritis. Seven years ago, she was diagnosed with rheumatoid arthritis, which has been inadequately controlled with methotrexate and etanercept. She is also due to receive the influenza vaccination. She has no other personal pertinent medical history.

Physical examination findings are unremarkable, and vital signs are normal. Musculoskeletal examination reveals swelling in multiple joints.

Which of the following is the most appropriate next step in management?

A. Administer intramuscular influenza vaccine
B. Administer intranasal influenza vaccine
C. Begin zanamivir
D. Do not administer any influenza vaccine

Correct Answer
A. Administer intramuscular influenza vaccine

Key Point
Vaccination is best undertaken before initiation of treatment with rituximab or abatacept.

Educational Objective
Manage immunizations in a patient receiving biologic therapy.

Administration of intramuscular influenza vaccine before initiation of rituximab is indicated for this patient with rheumatoid arthritis. There are two influenza vaccine types, a trivalent inactivated virus appropriate for all age groups given intramuscularly, and an intranasal live attenuated influenza vaccine appropriate for persons aged 2 to 49 years. The live attenuated vaccine should be avoided in pregnant women as well as patients with chronic metabolic diseases, diabetes mellitus, kidney dysfunction, hemoglobinopathies, immunosuppression, and chronic diseases that can compromise respiratory function or the handling of respiratory secretions. There is no evidence that tumor necrosis factor α inhibitor therapy alters primary immune response to vaccination; however, treatment with rituximab or abatacept may attenuate primary immune responses due to associated blockade of T-cell costimulation by antigen-presenting dendritic cells (abatacept) or B cells (rituximab and abatacept). As such, whenever possible, updating of immunization schedules is best undertaken before initiation of treatment with rituximab or abatacept. Other than previous allergy to eggs or vaccine adjuvants, there is no contraindication to administering killed virus influenza vaccine to patients with rheumatoid arthritis or other autoimmune disorders.

Live attenuated virus vaccines as constituted in intranasal vaccine preparations are contraindicated in patients on immunosuppressive or biologic immunomodulating therapies because of the risk of disseminated viral infection.

Antiviral chemoprophylaxis with agents such as oseltamivir or zanamivir provides immediate protection and may be useful in persons who have not been vaccinated or who are not expected to respond to a vaccine or until vaccine-induced immunity becomes effective; however, antiviral chemoprophylaxis is expensive and can be associated with side effects. Persons who are candidates include residents in an assisted-living facility during an influenza outbreak, those who are at higher risk for influenza-related complications and have had recent household or other close contact with a person with influenza, and health care workers who have had recent close contact with a person with influenza. This patient meets none of these indications for antiviral prophylaxis.

van Assen S, Holvast A, Benne CA, et al. Humoral responses after influenza vaccination are severely reduced in patients with rheumatoid arthritis treated with rituximab. Arthritis Rheum. 2010;62(1):75-81. PMID: 20039396

Question 3

A 62-year-old man is evaluated during a routine examination in October. He was recently diagnosed with COPD. His COPD is controlled with tiotropium and albuterol as needed. He receives an influenza vaccination every year. He has never received the pneumococcal vaccination, but all other immunizations are up-to-date. On physical examination, vital signs are normal. The lungs are clear to auscultation.

Which of the following is the best influenza and pneumococcal immunization regimen for this patient?

A. Influenza vaccine now
B. Influenza and pneumococcal vaccines now
C. Influenza vaccine now and pneumococcal vaccine at the next routine visit
D. Influenza vaccine now and pneumococcal vaccine at age 65 years

Correct Answer
B. Influenza and pneumococcal vaccines now

Key Point
Influenza and pneumococcal vaccines are recommended for patients with COPD and can be administered at the same time but at different sites.

Educational Objective
Manage immunizations in a patient with COPD.

The most appropriate immunization regimen for this patient is influenza and pneumococcal vaccines now. Pneumococcal vaccine may be administered concurrently with other vaccines, such as the influenza vaccine, but at a separate site. Waiting for the next scheduled routine visit to administer the pneumococcal vaccine carries a risk of not administering the vaccine in a timely fashion and the possibility of failing to administer the vaccine at all. Influenza and pneumococcal vaccines are recommended for patients with COPD. Influenza vaccine is recommended annually for all adults. High-dose influenza vaccine is an option for patients 65 years and older. Pneumococcal vaccine is recommended for adults 65 years and older. Pneumococcal vaccine is recommended for all adults regardless of age if they have the following chronic conditions: chronic lung disease (including asthma), chronic liver disease, diabetes mellitus, cirrhosis, chronic alcoholism, functional or anatomic asplenia, immunocompromising conditions (including chronic kidney failure or the nephrotic syndrome), cochlear implants, or cerebrospinal fluid leaks. Other indications are smokers and residents of nursing homes or long-term care facilities. One-time revaccination is indicated after 5 years for persons aged 19 to 64 years with the nephrotic syndrome or chronic kidney failure, functional or anatomic asplenia, and immunocompromising conditions. One-time revaccination is recommended for patients who were vaccinated 5 or more years ago and were less than 65 years of age at the time of primary vaccination. The 7-valent pneumococcal polysaccharide vaccine seems to induce a superior immune response than the 23-valent-pneumococcal polysaccharide vaccine. Data suggest that influenza vaccination, but not pneumococcal vaccination, is associated with reduced all-cause mortality.

Centers for Disease Control and Prevention (CDC). Recommended adult immunization schedule—United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60(4):1-4. PMID: 21381442

These questions were derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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