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July 21, 2015 Issue


Clinical Practice Points

Medical Knowledge
Patient Care
Interpersonal / Communication Skills

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population. A Cross-sectional Study.

Prescribing antibiotics for acute respiratory infections contributes to overuse. This study evaluated the sources of variation in practice and found that veterans with acute respiratory infections often received antibiotics, regardless of patient, provider, or setting.

Use this study to:

  • Review treatment guidelines for acute respiratory illnesses (e.g., bronchitis and sinusitis). Use the information in ACP Smart Medicine: Acute Bronchitis and Acute Rhinosinusitis to ask your learners when antibiotics are indicated for acute respiratory infections. Which antibiotics should be used when necessary?
  • Ask why a physician might prescribe an antibiotic when not indicated.
  • Role-play conversations with a patient with an acute respiratory infection who requests – and expects –a prescription for an antibiotic that is not required. Ask your learners to explain why they are not prescribing antibiotics. How will they explain the risks of antibiotic use when not required? What will they tell the patient they will do to manage their symptoms? Is it useful to discuss the societal harms of antibiotic overuse with a patient, or to focus only on the risks of harms to the patient?”


Systems-based Practice
Professionalism

Characteristics and Clinical Management of a Cluster of 3 Patients With Ebola Virus Disease, Including the First Domestically Acquired Cases in the United States

This report describes the clinical characteristics and management of a cluster of patients with EVD, including two health care providers who acquired the disease while providing care to an infected patient.

Use this report to:

  • Invite someone from your hospital's administration to discuss your disaster preparedness plan. While most hospitals would not be expected to manage a domestic Ebola outbreak, large-scale biologic or traumatic disasters are a possibility.
  • Ask your learners how they would feel if asked to care for a patient with a highly contagious disease. Would they care for a patient with a disease whose communicability is not yet well understood? Discuss the ethical dilemmas with your learners surrounding the care of the patients in the article. How can they balance dedication to a patient and self- protection?


Medical Knowledge
Patient Care

Borrelia miyamotoi Disease in the Northeastern United States. A Case Series

This is the first description of the clinical and laboratory features of a series of patients with BMD, a newly recognized tick-borne infection. The findings suggest that BMD should be part of the differential diagnosis of febrile patients from areas where deer tick–transmitted infections are endemic.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below.
  • Compare the presentations and therapies of various tick-borne illnesses in the United States. Use the information in a recent In the Clinic: Lyme Disease to discuss how to prevent tick bites, and the differential diagnosis of tick-borne–related illnesses.
  • How will this case series inform your learners' diagnostic and treatment choices for patients with exposures in the Northeast US? How will they counsel patients regarding this (and other tick-borne) illnesses? Use the accompanying editorial to help frame the discussion.


Patient Care
Professionalism
Interpersonal / Communication Skills

Sexual Orientation Identity Disparities in Awareness and Initiation of the Human Papillomavirus Vaccine Among U.S. Women and Girls. A National Survey.

Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians

This research study examined the association between sexual orientation identity and human papillomavirus (HPV) vaccination among U.S. women and girls, and found that adolescent and young adult lesbians may be less likely to initiate HPV vaccination than their heterosexual counterparts. The position paper offers recommendations on how to reduce health disparities for lesbian, gay, bisexual, and transgender (LGBT) persons in the health care system.

Use these papers to:

  • Review the risk factors for HPV transmission and indications for the HPV vaccine.
  • Ask your learners why there might be disparities in the utilization of HPV vaccination. In what other areas are there disparities in health care according to sexual orientation identity? These are reviewed in the ACP Position paper.
  • Review the positions of the ACP. Do your learners agree with them?
  • Ask your learners whether they believe personal religious or cultural beliefs have a place in the practice of medicine. Where might a physician's personal beliefs appropriately inform his or her practice of medicine, and where might it be wrong? What if those beliefs hold that being lesbian, gay, bisexual, or transgender is “wrong”? How would your learners respond to a colleague who objected to participating in care that his or her religious beliefs deem to be “wrong”?


Understanding Research in Health Care

Practice-based Learning / Improvement
High Value Care

Alternatives to Hazard Ratios for Comparing the Efficacy or Safety of Therapies in Noninferiority Studies.

Noninferiority studies are often used to investigate whether a treatment's efficacy or safety profile is acceptable compared with another therapy. When time to a clinical event is of interest, treatment difference is routinely quantified using the hazard ratio (HR). The HR may be difficult to interpret, especially when the proportional hazards assumption is violated, and its precision does not depend directly on exposure times or sample size. This article provides alternative strategies that offer more meaningful interpretations of results.

Use this paper to:

  • Ask your learners to explain the difference between a noninferiority and superiority study. When might a noninferiority study design be chosen?
  • Invite a colleague with expertise in epidemiology and biostatics to review the two examples of clinical trials the authors use to illustrate the importance of how the difference between groups is assessed.
  • Refer to this paper when your journal club reviews a paper using hazard ratios to report outcomes. Ask if the use of HR's was appropriate.


Video Learning

Practice-based Learning / Improvement
Systems-based Practice
Consult Guys logo

The Consult Guys: Hands Up! Did you cleanse your hands?

Watch this short video with your learners as the Consult Guys address the problem of hand cleansing.

Use this video to:

  • Ask your learners to pay attention to whether they cleanse their hands each time they enter and leave a patient's room. Ask why it matters.
  • Is it OK to say, “I don't need to cleanse my hands as I'm not touching anything in the room?” Why or why not? What tone does that set in the hospital? What might others who see an attending not cleanse her hands conclude about what is appropriate practice?
  • Assign your learners to quietly observe an area of your hospital for 10 minutes while pretending to write a note. Record each time a person goes in and out of a patient's room and whether hand cleansing was performed. Then, tally the results of your team. Should you share these results with the caregivers at each location?
  • Ask your hospital's infection control team to discuss what is being done to promote hand cleansing. Is it adequate? What are the barriers to 100% compliance? What ideas do your learners have for improvement? Should incentives be used to promote compliance, or rather punishments for noncompliance?


mksap16

A 22-year-old man is evaluated for a skin eruption on his leg. The patient lives in Virginia and is active outdoors. One week ago, he found a black tick on his lower leg, which his roommate removed with a tweezers. Yesterday he developed diffuse myalgia, neck stiffness, and fatigue. These symptoms have persisted, and today he notes erythema at the site of the previously attached tick.

On physical examination, temperature is 38.1 °C (100.6 °F); other vital signs are normal. There is no nuchal rigidity. Skin findings are shown in the image above.

Which of the following is the most appropriate initial management?

A. Borrelia burgdorferi polymerase chain reaction on skin biopsy specimen
B. Empiric intravenous ceftriaxone
C. Empiric oral doxycycline
D. Serologic testing for Lyme disease

Correct Answer
C. Empiric oral doxycycline

Key Point
Empiric oral doxycycline is the recommended treatment for erythema migrans regardless of the cause.

Educational Objective
Manage a patient with an erythema migrans skin lesion.

The skin lesion shown is consistent with erythema migrans, and oral doxycycline should be started immediately. Erythema migrans may be due to either early localized Lyme disease or Southern tick–associated rash illness. Although these two infections are caused by specific tick vectors with relatively distinct geographic distributions, both ticks are endemic to Virginia. Geographic location is therefore of little value in differentiating between these two syndromes in this patient. However, empiric doxycycline is the recommended treatment for erythema migrans regardless of the cause. Treatment should be given based on the clinical finding of an expansile, target-like skin lesion, particularly at the site of a known tick attachment.

Borrelia burgdorferi polymerase chain reaction testing is not indicated. Although B. burgdorferi may be amplified from erythema migrans skin biopsy specimens if the diagnosis is uncertain, this study is generally not needed because the presence of the characteristic erythema migrans rash, such as is seen in this patient, dictates treatment.

Intravenous ceftriaxone is reserved for patients with cardiac or neurologic manifestations of disseminated Lyme disease.

Serologic testing for B. burgdorferi is not recommended because false-negative antibody assay results may occur in patients with early localized Lyme disease and would be negative in patients with Southern tick–associated rash illness.

Bibliography
Stonehouse A, Studdiford JS, Henry CA. An update on the diagnosis and treatment of early Lyme disease: “focusing on the bull's eye, you may miss the mark”. J Emerg Med. 2010;39(5):e147-151. PMID: 17945460

This question was 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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