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January 21, 2014 Issue

Clinical Practice Points


Medical Knowledge
Patient Care
Interpersonal and Communication Skills
Practice Based Learning and Improvement

Risk for Cardiovascular Disease Early and Late After a Diagnosis of Giant-Cell Arteritis. A Cohort Study

This observational cohort study found that myocardial infarctions, cerebrovascular accidents, and peripheral vascular disease occur more frequently following a diagnosis of giant-cell arteritis than in age- and sex-matched control patients.

Use this study to:

  • Start a teaching session with multiple-choice questions. We’ve provided a few below.
  • Review the clinical presentation, diagnosis, and management of giant-cell arteritis and polymyalgia rheumatica. Use ACP Smart Medicine’s review for teaching: differential diagnosis and treatment tables and figures with images of optic atrophy and a prominent, tender temporal artery.
  • Review strengths and weaknesses of observational cohort study design. How did the authors attempt to exclude preexisting cardiovascular disease? What are potential causes for the increase in cardiovascular events, particularly in the first few months after giant-cell arteritis diagnosis?
  • Ask what you will tell a patient with giant-cell arteritis about the risk of vascular events?


Patient Care
Medical Knowledge

Cost-Effectiveness of Canine Vaccination to Prevent Human Rabies in Rural Tanzania

Ninety-nine percent of human rabies cases are caused by domestic dog bites in Tanzania. Accordingly, this study found that vaccination of dogs was a cost-effective way to reduce the burden of disease from rabies.

Use this study to:

  • Review general management of animal bites and the microbiology associated with specific animals. The Centers for Disease Control and Prevention Web site provides a quick reference by disease.
  • Ask who should receive preexposure rabies vaccinations. Why should potential rabies exposure be treated as a medical emergency? What care do potentially exposed patients require?
  • Discuss prevention of infection in travelers, including insect-borne, water-borne, and other diseases. These are reviewed in a recent In The Clinic: Travel Medicine. Use the multiple-choice questions at the end as a fun way to review material—and to get CME credit for yourself.

The Health Care System and Public Health


High Value Care
Systems-based Practice
Professionalism

Insurance Status and the Transfer of Hospitalized Patients. An Observational Study

This study evaluated patients with 5 common diagnoses and assessed whether insurance status correlated with interhospital transfer. Patients without insurance were less likely to be transferred for most of the diagnoses.

Use this study to:

  • Ask whether your learners know what the Emergency Medical Treatment and Active Labor Act requires. What was the purpose for this law, and how might it be relevant for patients who were already admitted in addition to those in the emergency department? The introduction of this study reviews these.
  • Ask why patients might require transfer from 1 inpatient facility to another and how this is arranged. Ask your hospital’s admitting office whether a patient’s insurance status is checked before accepting or sending a patient for transfer. Why might patients without insurance be less likely to be transferred? Is it the insurance or other factors associated with a lack of insurance? Why might women have been transferred less frequently?
  • Discuss the ethical and financial implications of EMTALA. Have the group reflect on what potential biases physicians should be aware of in caring for uninsured patients. How can a physician resolve the conflict between wanting to provide standard of care for a patient and knowing that the patient may not be able to pay for it? Refer to the Charter on Medical Professionalism to help frame your discussion.


Patient Care
Systems-based Practice

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members. A Systematic Review and Meta-analysis

This review found that self-reported access to firearms was associated with risk for completed suicide and homicide victimization.

Use this study to:

  • Review ACP Smart Medicine Module on domestic violence with your learners.
  • Divide the group in half and stage a debate about whether firearms represent a public health risk that physicians should attempt to modify with their patients or whether screening for gun ownership violates the second amendment. Read a recent Ideas and Opinions piece that frames the discussion. Afterward, encourage your learners to become active participants in public discussions of medically related issues by submitting a comment with their reactions to this article.


Video Learning


Consult Guys Logo

Patient Care
Medical Knowledge

The Consult Guys: Atrial Fibrillation: How Controlled Is Well-Controlled?


What is the appropriate degree of heart rate control for a patient with atrial fibrillation? How long should a patient be kept in the hospital to achieve this goal? Enjoy this entertaining way to learn, watching the medical Consult Guys’ talk show. Use the downloadable slides and other resources and answer CME questions to get some credit for yourself.




mksap16

Question 1

A 67-year-old woman returns to the office 1 week following her initial visit for suspected giant cell arteritis. At that time, prednisone, 60 mg/d, was initiated and a left temporal artery biopsy was performed; the biopsy results were negative for arteritis. She also has hypertension, diabetes mellitus, and chronic kidney disease. Additional medications are atenolol, hydrochlorothiazide, and metformin.

On physical examination, temperature is 38.1 °C (100.5 °F), blood pressure is 130/90 mm Hg, pulse rate is 90/min, and respiration rate is 14/min. Pulses are present in both temporal arteries. Diffuse scalp tenderness is noted. There are no audible bruits over the carotid or subclavian vessels.

Laboratory studies:

Hematocrit 34%
Erythrocyte sedimentation rate 105 mm/h
Serum creatinine 2.1 mg/dL (185.6 μmol/L)
Estimated glomerular filtration rate 38 mL/min/1.73 m2
Urinalysis Normal

Which of the following is the most appropriate management?

A. CT angiography of the aortic arch, carotid, and subclavian vessels
B. Decrease prednisone to 10 mg/d
C. MR angiography of the aortic arch, carotid, and subclavian vessels
D. Ultrasound-guided biopsy of the right temporal artery

Correct Answer
D. Ultrasound-guided biopsy of the right temporal artery

Key Point
If temporal artery biopsy results are negative for giant cell arteritis (GCA) in a patient with cranial symptoms, a biopsy of the contralateral temporal artery is then indicated to diagnose GCA.

Educational Objective
Manage giant cell arteritis.

An ultrasound-guided biopsy of the contralateral temporal artery is indicated for this patient with suspected giant cell arteritis (GCA). Scalp tenderness and headache are common presenting features of GCA with cranial artery involvement. Treatment with corticosteroids is indicated immediately in patients clinically suspected of having GCA to avoid the development of visual loss and should not await temporal artery biopsy results. The initial temporal artery biopsy in this patient with cranial symptoms is negative for findings of GCA; therefore, a biopsy of the contralateral temporal artery is appropriate. Skip lesions are not uncommon in GCA, and ultrasound guidance to identify portions of the artery with transmural thickening and/or halo signal in the vessel has been shown to increase the diagnostic yield in patients with suspected GCA.

CT angiography can be used to identify GCA involvement of large branch vessels of the aorta; however, this test carries the risk of contrast-induced acute kidney injury in this patient with chronic kidney disease.

Until GCA has been thoroughly ruled out in this patient, it is not appropriate to decrease the dose of prednisone and risk visual loss.

MR angiography may be used to diagnose large-vessel vasculitis and can be helpful in cases of a negative temporal artery biopsy. However, patients with an estimated glomerular filtration rate of less than 40 mL/min/1.73 m2 are at great risk for developing nephrogenic systemic fibrosis (NSF) after administration of gadolinium, and use of this agent should be avoided in this population group. NSF manifests as a scleroderma-like disease associated with edema, plaque-like rash, and hardening of the skin.

Bibliography
Arida A, Kyprianou M, Kanakis M, Sfikakis PP. The diagnostic value of ultrasonography-derived edema of the temporal artery wall in giant cell arteritis: a second meta-analysis. BMC Musculoskelet Disord. 2010;11:44. PMID: 20210989


Question 2

A 58-year-old man is evaluated for a 6-week history of pain and stiffness of the shoulders and hips accompanied by persistent fever and a 2.2-kg (5-lb) weight loss. He reports no jaw claudication, headache, respiratory symptoms, abdominal pain, or swelling of the peripheral joints. The patient is otherwise healthy and takes no medications.

On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 140/70 mm Hg, pulse rate is 100/min and regular, and respiration rate is 16/min. Cardiopulmonary examination is normal. Cutaneous examination reveals no skin rash or temporal or scalp tenderness. There is no lymphadenopathy. Musculoskeletal examination reveals mild pain and limitation at the extremes of shoulder and hip rotation bilaterally. Neurologic examination is unremarkable.

Laboratory studies:

Hematocrit 32%
Leukocyte count 12,000/μL (12 × 109/L)
Platelet count 420,000/μL (420 × 109/L)
Erythrocyte sedimentation rate 103 mm/h
C-reactive protein 6.4 mg/dL (64 mg/L)
Serum creatinine Normal
Rheumatoid factor Negative
Antinuclear antibodies Negative
ANCA Negative
Urinalysis Normal

Peripheral blood smear and blood cultures are negative.

Chest radiograph and echocardiogram are normal. Results of bilateral temporal artery biopsies are negative.

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

A. Bone marrow biopsy
B. CT angiography of the neck and chest
C. Kidney and mesenteric angiography
D. MRI of the shoulder and hip joints

Correct Answer
B. CT angiography of the neck and chest

Key Point
CT angiography or MR angiography of the neck and chest is appropriate for patients with unexplained fever and polymyalgia rheumatica or for patients with suspected giant cell arteritis whose temporal artery biopsy results are negative.

Educational Objective
Diagnose giant cell arteritis.

CT angiography of the neck and chest is indicated for this patient with suspected giant cell arteritis (GCA). Patients with GCA typically have fever and fatigue; therefore, GCA should be considered in the differential diagnosis of fever of unknown origin in patients over the age of 50 years. Polymyalgia rheumatica symptoms such as hip and shoulder girdle stiffness and pain may be the predominant feature. Although many patients with GCA have symptoms referable to the cranial arteries, including temporal or scalp tenderness and jaw claudication, such symptoms may be absent in patients with arteritis confined to the great vessels. Imaging of the great vessels, including the aortic arch, common carotid, innominate, and subclavian arteries, is appropriate for patients with unexplained fever and polymyalgia rheumatica or for patients with suspected GCA whose temporal artery biopsy results are negative. MR angiography is also a suitable diagnostic test.

In the absence of leukopenia or thrombocytopenia and a normal peripheral blood smear, a bone marrow biopsy is not likely to be informative in revealing the cause of fever and joint symptoms in this patient.

Kidney and mesenteric angiography are useful in establishing a diagnosis of polyarteritis nodosa; however, this patient does not have findings associated with this disorder such as hypertension, abdominal pain, kidney dysfunction, or mononeuritis multiplex.

MRI of the shoulder and hip joints is unlikely to yield useful diagnostic information in a patient with limited findings on physical examination.

Bibliography
Marie I, Proux A, Duhaut P, et al. Long-term follow-up of aortic involvement in giant cell arteritis: a series of 48 patients. Medicine (Baltimore). 2009;88(3):182-192. PMID: 19440121

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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