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June 17, 2014 Issue

Clinical Practice Points


Interpersonal and Communication Skills
Systems-based Practice
Professionalism

What Are Cancer Centers Advertising to the Public? A Content Analysis

Direct-to-consumer advertising by cancer centers is common in popular magazines and on television. This study found that advertisements frequently used emotional appeals and testimonials but provided little data on treatment outcomes or risks of treatment.

Use this article to:

  • Discuss what outcomes data you would use to help a patient choose a provider of cancer care. Are these data available? Would a patient be able to find and understand them? Ask your learners if they think the information at government-hosted sites are helpful.
  • Ask your learners how direct-to-consumer ads affect what patients perceive and expect from health care. Are there benefits to such activities? What are the potential harms?
  • Take a look at your own center’s advertisements. Do your learners think they are fair?


Medical Knowledge
Patient Care

Prevention of Vertical Transmission of Hepatitis B: An Observational Study

The Centers for Disease Control and Prevention recommends prenatal screening for hepatitis B virus infection followed by postnatal prophylaxis. This study evaluated the effectiveness of prenatal screening followed by postnatal prophylaxis with hepatitis B immunoglobulin and the 3-step hepatitis B vaccine to reduce the transmission of hepatitis B to infants from their mothers. This practice was highly effective at preventing transmission and identified patients who were at extremely low risk for transmission.

Use this article to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review how to interpret hepatitis B serologies for the diagnosis of hepatitis B. Use the information provided in ACP Smart Medicine- Hepatitis B, including figures that illustrate differences between test results in acute and chronic infection.
  • Discuss the prevention of transmission of hepatitis B via other potential routes of exposure (e.g., needle-stick injuries in health care workers, sexual contact).
  • Discuss treatment options for hepatitis B, including considerations for the pregnant patient.


Medical Knowledge
Patient Care

Clinical Guideline: Stroke Prevention in Women: Synopsis of the 2014 American Heart Association/American Stroke Association Guideline

This synopsis summarizes recommendations for the prevention of stroke in women, including analysis of sex-specific risk factors and risk factors that are more prevalent in women.

Use this guideline to:

  • Review stroke risk factors and prevention in men and women. Use the concise material in ACP Smart Medicine- Stroke and Transient Ischemic Attack to help teach, including tables on risks, symptoms, indications for treatments, and more.
  • Review stroke treatment guidelines. Use a Clinical Guideline from the U.S. Preventive Services Task Force to discuss the use of aspirin for the prevention of stroke. Are they different from what the AHA is recommending?
  • Invite a neurologist and a neuroradiologist to join you for the teaching session. Ask that they bring CT and MRI images that may be used to correlate common stroke presentations (hemiparesis, aphasias, etc.) with important neuroanatomical findings.

Physicians and Public Policy


Professionalism
Patient Care
Interpersonal and Communication Skills

Internists’ Attitudes Toward Prevention of Firearm Injury

Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians

This survey of U.S. internists asked whether physicians believe firearm-related violence is a public health issue, whether doctors should have the right to discuss it with patients, and if they favor various public policies aimed at reducing it. A position paper from the ACP outlines its recommendations for reducing firearm-related injury and death in the U.S.

Use these papers to:

  • Have your learners complete the questionnaire that was used for the study (it is provided as a supplement to the paper, or you can use the questions listed in the tables and figures). Then show them the results of this national survey. Were they surprised by any of the results?
  • Do they think physicians have the right (or even responsibility) to use their professional standing to influence patients’ opinions or public policy on firearm-related violence?
  • Do they think the ACP is right to take a stand on this issue? Do they agree with it? Does it go too far, or not far enough?

Video Learning


Consult Guys logo
Medical Knowledge
Patient Care

The Consult Guys - A Trip to the Hardware Store: Is an MRI safe?

Enjoy this short video with your learners as senior physicians (and funny guys) Geno Merli and Howard Weitz discuss whether an MRI may be obtained in patients with specific types of medical devices. Answer the multiple-choice questions, and earn CME points for yourself!


Updates in Internal Medicine


Practice Based Learning and Improvement
Medical Knowledge
High Value Care

Updates in Geriatrics and Cardiology: Evidence Published in 2013

These updates summarize important recent articles and offer a convenient way to review clinical pearls and plan for activities, such as journal clubs. Assign each article to a learner to read and analyze for your group. Have them present for only 5 minutes, giving the context of the intervention studied and how the article should or shouldn’t change their practice of internal medicine.

Use these updates to:

  • Discuss findings that emphasize cost- effective care of an aging population in the clinics and hospital. Should you screen for dementia? Should you recommend a multivitamin?
  • Review the new hypertension guidelines. Discuss the implications and cautions outlined in the summary. Ask how you should manage a patient already stabilized under the old guidelines, using the new guidelines?
  • Review the new cholesterol guidelines. Discuss the implications and cautions outlined here. How should you manage a patient stabilized under the old guidelines, using the new guidelines?

mksap16

A 26-year-old woman is evaluated after recently undergoing community screening for viral hepatitis. She is currently asymptomatic. She is of Laotian descent, and she has two older siblings with hepatitis B virus (HBV) infection. There is no family history of malignancies. She takes no medications.

On physical examination, vital signs are normal. BMI is 22.

Laboratory studies

INR 0.9 (normal range, 0.8-1.2)
Alkaline phosphatase 90 units/L
Alanine aminotransferase 18 units/L
Aspartate aminotransferase 14 units/L
Albumin 4.2 g/dL (42 g/L)
Total bilirubin 2.2 mg/dL (37.6 μmol/L)
Direct bilirubin 0.2 mg/dL (3.4 μmol/L)

HBV serology

Hepatitis B surface antigen Positive
Antibody to hepatitis B surface antigen Negative
Hepatitis B core antibody Positive
Hepatitis B e antigen Positive
Antibody to hepatitis B e antigen Negative
HBV DNA >200,000 units/mL

Which of the following is the most appropriate next step in management?
A. Immunization against hepatitis B virus
B. Liver biopsy
C. Serial monitoring of aminotransferases
D. Tenofovir

Correct Answer
C. Serial monitoring of aminotransferases

Key Point
Monitoring of hepatic aminotransferases every 3 to 6 months is warranted in patients with immune-tolerant hepatitis B virus infection.

Educational Objective
Manage hepatitis B virus infection in a patient in the immune-tolerant state.

The most appropriate management for this patient is observation with serial monitoring of aminotransferases every 3 to 6 months. Various subgroups of patients with hepatitis B virus (HBV) infection reflect the natural history of infection; these subgroups include the immune-tolerant patient, the patient in a phase of immune clearance, and the inactive carrier. This patient has chronic HBV infection in the immune-tolerant state, as identified by a high circulating viral level in the absence of markers of liver inflammation (normal hepatic aminotransferase levels). This is typically seen in patients born in a hepatitis B–endemic area such as Southeast Asia or Africa in whom HBV was likely acquired perinatally. As long as patients maintain normal hepatic aminotransferase levels, they are at low risk for progression of liver disease. As this patient ages, she is at increased risk for active hepatitis. Evidence of hepatic inflammation (persistently elevated hepatic aminotransferase levels) indicates active hepatitis; if significant inflammation is seen, liver biopsy should be considered and treatment should be initiated.

Immunization against HBV is not warranted because this patient has already been exposed to the virus, has significant replicating HBV, and has not developed immunity. Vaccination would not result in seroconversion to the antibody to hepatitis B surface antigen–positive state.

Liver biopsy is warranted only if liver chemistry tests become elevated. The presence of significant liver inflammation or fibrosis on biopsy indicates the need for antiviral therapy.

Initiation of antiviral therapy with tenofovir is not warranted in this patient with immune-tolerant HBV infection because she is unlikely to experience progression of liver disease if her hepatic aminotransferase levels are normal. In addition, antiviral therapy may potentially require life-long administration.

Bibliography
Lok AS, McMahon BJ. Chronic hepatitis B [erratum in Hepatology. 2007;45(6):1347]. Hepatology. 2007;45(2):507-539. PMID: 17256718

This question is derived from MKSAP® 16, 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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