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May 5, 2015 Issue


Clinical Practice Points

Medical Knowledge
Patient Care

Fecal Microbiota Transplantation for Clostridium difficile Infection. A Systematic Review

Fecal microbiota transplantation (FMT) is an emerging new therapy for Clostridium difficile infection (CDI). This systematic review assessed the efficacy, comparative effectiveness, and harms of FMT for CDI.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the risk factors, prevention, presentation, and available therapies of CDI. Use In the Clinic: Clostridium difficile Infection to answer such questions as how CDI is acquired and how we can reduce the likelihood of our patients developing CDI.
  • Ask your learners how FMT might be beneficial in CDI. The authors discuss this in the paper’s introduction. What concerns would your learners have before prescribing FMT to their patients?
  • FMT has been recommended for treatment of recurrent CDI by some professional organizations. Yet, this systematic review identified a limited number of randomized controlled trials addressing the effect of FMT for therapy of CDI, although many more case series. Ask your learners what limitations these data impose on our ability to draw firm conclusions. What may or may not be concluded? What more information is needed to assess the effect of FMT and its potential for adverse effects? Use the accompanying editorial to help assess these issues.


Medical Knowledge
Patient Care

Redefining the Chronic Fatigue Syndrome

The Institute of Medicine recently convened an expert committee to examine the evidence base for the chronic fatigue syndrome, develop evidence-based clinical diagnostic criteria, and recommend whether new terminology should be adopted.

Use this paper to:

  • Ask your learners if they know how to diagnose the chronic fatigue syndrome? Do any of their patients report having this diagnosis? On what basis was it made?
  • How should your learners evaluate patients who complain of fatigue? Use the information in ACP Smart Medicine: Chronic Fatigue Syndrome, including tables for differential diagnosis, treatments, scales to use for monitoring, and more.
  • The IOM proposes a new name (systemic exertion intolerance disease) as well as diagnostic criteria. Review the criteria listed in the table and ask your learners whether they feel they can differentiate systemic exertion intolerance disease from other causes of fatigue. How might a change in the name be helpful to patients and clinicians dealing with this problem?

Clinical Guideline


Medical Knowledge
Patient Care
HVC

Screening for Thyroid Dysfunction: U.S. Preventive Services Task Force Recommendation Statement

This updated recommendation from the U.S. Preventive Services Task Force addresses screening for thyroid dysfunction. The Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults.

Use this guideline to:

  • Ask your learners if they send “routine” or “screening” thyroid function tests (e.g., TSH) on their asymptomatic patients. How come?
  • Review with your learners the long-term health consequences of thyroid dysfunction.
  • The Task Force said there was insufficient information, and in particular a lack of evidence that screening nonpregnant adults for thyroid dysfunction reduces cardiovascular disease or related morbidity and mortality. Ask your learners if they feel the absence of strong evidence should always dissuade them from doing something? When should it and when should it not? How should it affect their practice when doing something that lacks robust evidence?
  • Read the accompanying editorial, in which the authors discuss their concerns with the recommendations.


Medical Knowledge
Patient Care
HVC
In the Clinic:

Deep Venous Thrombosis

This eminently practical review discusses the approach to the diagnosis and treatment of this frequently vexing clinical problem.

Use this review to:

  • Use the already prepared teaching slides to help prepare a teaching session.
  • Ask your learners which hospitalized medical and surgical patients require prophylaxis for venous thromboembolism. Should heparin or mechanical compression devices be used? What about pregnant patients? Those with thrombophilic disorders?
  • What should you tell patients embarking on prolonged travel?
  • Review the diagnostic algorithm. Do your learners follow it? Do they understand why it is important to assess the likelihood of DVT before ordering a test (e.g., a D-dimer)? Often, clinicians judge the likelihood of DVT to be low, yet still order more testing despite a normal D-dimer. Why is this a problem? Should a D-dimer test be ordered if DVT is felt to be likely?
  • Use the multiple-choice questions at the end to break up a teaching session. Log on and enter your answers to earn CME for yourself.

Humanism and Professionalism


Professionalism
Medical Knowledge
Patient Care

Annals Graphic Medicine: 50 Shades of Gray Matter

Annals Graphic Medicine

This short, creative video tells the story of how a patient’s terrifying delirium following seizures was ameliorated in the hospital.

Use this video to:

  • Take a few minutes to enjoy watching with your learners.
  • Ask your learners if it was appropriate for the nurse to allow the patient’s partner to stay with him in his bed. When should we “bend the rules"?
  • Use this video to start a teaching session about delirium. Who is at risk? Can your learners recognize hypoactive delirium in addition to hyperactive? What measures help prevent delirium? How can it be treated? Use the recent In the Clinic: Delirium to answer these questions.


Professionalism
Interpersonal and Communication Skills

On Being a Doctor: Not My Place?

Dr. Solomon tells of being haunted that he and his colleagues never felt comfortable asking a hospital employee about his jaundice.

Use this essay to:

  • Ask your learners what they do when noting an important sign of disease (e.g., a dysplastic nevus or melanoma, clubbing, or jaundice) on someone who is not their patient—perhaps a colleague or acquaintance. Do they feel it is appropriate to ask? Are they violating that individual’s privacy?
  • Are we obligated to raise these issues when we are not the person’s physician? Why or why not?

For Program Directors


Systems-based Practice
Professionalism
HVC

A Commitment to High-Value Care Education From the Internal Medicine Community

In this article, the Alliance for Academic Internal Medicine, American Board of Internal Medicine (ABIM), ABIM Foundation, and American College of Physicians formally commit to providing a foundation for high-value care education on which other organizations may build. The article details 5 key targets for high-value care and highlights established programs and others being developed to help educate physicians in high-value care.


mksap16

A 45-year-old man is evaluated for a 1-week history of nonbloody diarrhea that occurs ten times per day and is accompanied by mild abdominal cramping. He has a 5-year history of ulcerative colitis for which he takes mesalamine.

On physical examination, temperature is 37.9 °C (100.2 °F), blood pressure is 110/80 mm Hg (no orthostatic changes), and pulse rate is 100/min. Abdominal examination discloses hyperactive bowel sounds and mild diffuse tenderness but no peritoneal signs.

Laboratory studies:

Hemoglobin Normal
Leukocyte count 23,000/ μµL (23 × 10^9/L)
Platelet count Normal
Blood urea nitrogen 15 mg/dL (5.4 mmol/L)
C-reactive protein 32 mg/dL (320 mg/L)
Creatinine 1.0 mg/dL (88.4 μµmol/L)
Potassium 2.9 meq/L (2.9 mmol/L)

An acute abdominal radiograph series is normal.

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

A. Abdominal CT
B. Colonoscopy
C. Right upper quadrant ultrasound
D. Stool studies for Clostridium difficile

Correct Answer
D. Stool studies for Clostridium difficile

Key Point
Clostridium difficile has become a common problem in patients with inflammatory bowel disease; patients with disease flares should undergo stool studies for routine enteric pathogens, ova and parasites, and C. difficile.

Educational Objective
Manage a flare of ulcerative colitis with testing for Clostridium difficile.

The most appropriate diagnostic test is stool studies for Clostridium difficile. C. difficile has become a common problem in patients with inflammatory bowel disease, and it has a high associated morbidity and mortality. Although the typical clinical scenario for C. difficile colitis is an older hospitalized or institutionalized patient with recent antibiotic use, outpatient C. difficile infection in young people without recent antibiotic use is being described more frequently. Rapid identification is essential to initiate proper antibiotic therapy and to minimize immune suppression during treatment. A classic associated finding is leukocytosis, which can be quite marked. The most serious associated complication is toxic megacolon, which can be assessed with plain abdominal films. Standard treatment is with oral metronidazole; however, oral vancomycin is becoming more frequently recommended for patients with inflammatory bowel disease owing to better clinical response and the patient's already compromised colon. Intravenous metronidazole or vancomycin retention enemas can also be effective if oral intake is not possible. Stool should also be tested for routine enteric pathogens and parasitic infections, because these can mimic or exacerbate a flare of ulcerative colitis and should be appropriately treated.

CT would be recommended in a patient with increasing abdominal pain and distention, rebound tenderness, and hypoactive bowel sounds to evaluate for toxic megacolon or perforation. However, these symptoms are not present in this patient.

Colonoscopy is an appropriate second-line evaluation if the patient does not respond to appropriate therapy for C. difficile, another infection, or a flare of ulcerative colitis. It is not a very good first-line evaluation owing to its invasive nature, the time required to receive biopsy results, and the frequent lack of pseudomembranes during a C. difficile infection in the setting of inflammatory bowel disease. Superimposed cytomegalovirus infection should be considered in patients on long-standing corticosteroid therapy, and in this case colonoscopy could be beneficial to obtain biopsy specimens.

Patients with inflammatory bowel disease have an increased rate of cholelithiasis, but this patient's symptoms are not consistent with gallstone disease and a right upper quadrant ultrasound would not be helpful.

Bibliography
Ananthakrishnan AN, Issa M, Binion DG. Clostridium difficile and inflammatory bowel disease. Gastroenterol Clin North Am. 2009;38(4):711-728. PMID: 19913210

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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