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October 21, 2014 Issue


Clinical Practice Points


Patient Care
Practice Based Learning and Improvement

Do Clinicians Know Which of Their Patients Have Central Venous Catheters? A Multicenter Observational Study

Complications associated with central venous catheters (CVCs) increase over time, and the extent to which clinicians are aware that their patients have a CVC is unknown. This multicenter, cross-sectional study assessed how often clinicians were aware of the presence of triple-lumen or peripherally inserted central catheters in hospitalized patients. The authors found that many interns, residents, and attending physicians were unaware that their patients had indwelling catheters.

Use this study to:

  • Start a teaching session with a multiple-choice question (we’ve provided one below).
  • Ask your learners what the indications are for a CVC. Is the need for frequent phlebotomy an acceptable reason for one?
  • When should catheters be removed? What are the barriers to the prompt removal of CVCs that are no longer needed?
  • What are the complications of CVCs? Do peripherally inserted central catheters pose a risk?
  • Ask how they assess whether a CVC is still needed. Do they do so every day? Does your hospital have in place additional systems to routinely assess whether a CVC is required? How might these systems be improved? Invite a member of your infection control team to join the discussion.
  • An editorialist believes it is unacceptable for physicians to be unaware of their patients’ CVCs. Do you agree? The editorialist also notes that “forms” used to create progress notes should not be permitted to automatically carry forward yesterday’s details and comments. Why might such forms be problematic? Do you agree?


Patient Care
Interpersonal and Communication Skills
Medical Knowledge

A Practical and Evidence-Based Approach to Common Symptoms

This narrative review discusses 4 common epidemiologic questions about a clinical condition (cause, diagnosis, prognosis, and therapy) to promote an evidence-based and practical approach to handling common symptoms. The author points out compelling yet often overlooked truths about symptoms that may help in their management.

Use this review to:

  • Ask your learners what proportion of common symptoms they think lack a clear-cut, disease-based explanation? Are they surprised to learn it is at least one third?
  • Ask your learners if they have heard the expression, “The most important diagnostic tool is your chair.” The patient’s history alone yields 75% of the diagnostic information needed. Why is this so important to the practice of internal medicine?
  • Is it comforting as a clinician to hear that serious causes that are not apparent after initial evaluation seldom emerge later? What does that assume about the adequacy of initial evaluation? At what point can a clinician begin to feel comfortable accepting that a patient’s symptom will not be explained?
  • Ask how your learners interpret the author framing our jobs as frequently managing a problem rather than treating it. Is that difference helpful to them as clinicians? Will understanding this difference be helpful to patients?

Clinical Guideline


Medical Knowledge
Patient Care
Systems-based Practice

Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: U.S. Preventive Services Task Force Recommendation Statement

This updated U.S. Preventive Services Task Force recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known risk factors for cardiovascular disease. It recommends offering or referring such patients to intensive behavioral counseling interventions to promote a healthful diet and physical activity for prevention of cardiovascular disease.

Use this guideline to:

  • Ask your learners what advice they provide to their overweight and obese patients regarding diet and exercise. What should they be telling them? Use the information in this guideline and in In the Clinic: Obesity and ACP Smart Medicine: Obesity.
  • Review what the Task Force concluded regarding the benefits of behavioral counseling interventions. Ask your learners if they know how to get their patients such counseling. How is it paid for?
  • Invite an expert in weight reduction and/or a dietitian to join your discussion.
  • Log on and complete the brief CME quiz to earn credit for yourself.

Our Healthcare System


Systems-based Practice
Professionalism
Patient Care

The U.S. Health Insurance Marketplace: Are Premiums Truly Affordable?

The Affordable Care act aims to expand health care coverage in part by providing subsidies to individuals with low incomes. This study assessed the cost of purchasing the least expensive health insurance plans after accounting for these subsidies. It found that the penalty for not buying health insurance would be lower than buying the least expensive insurance for many individuals and some young persons would pay more than older ones.

Use this study to:

  • Play for your learners the short author insight video that explains quickly how health insurance subsidies are calculated, and why some younger individuals will pay more than older people.
  • Ask your learners if they know what the federal poverty level is for a household (see Table 1). Ask if they think this is more or less than the household income of many of their patients. Ask if they think they would be able to support a family and buy health insurance at this income level.
  • Look at Figure 2, illustrating where the cost of buying the lowest-priced insurance plan available would be more than what is considered “affordable” for an individual whose income is too high to receive federal subsidies. Such individuals would be exempt from the requirement to purchase insurance.
  • Ask your learners if they think the cost of insurance relative to the cost of paying a penalty for not buying it is the only factor people will consider. What value do they get from insurance beyond avoiding the penalty? The authors address this in their discussion.

Video Learning


Medical Knowledge
Professionalism
Consult Guys logo

The Consult Guys: Dressed to Kill? Can Neckties Spread Infection?

Watch this month’s episode of the medical consult talk show as The Consult Guys take on hospital fashion and infection. Before playing the video, ask your learners if they think neckties can be colonized with dangerous bacteria. Can they cause infection? After watching the video, ask your learners if they think it matters how a physician dresses. Are we obligated to dress a certain way, or to avoid certain types of clothing? Why or why not?


Humanism and Professionalism


Professionalism
On Being a Doctor: A Wounded Healer

In her essay, Dr. Lawrence tells of the challenges she has faced as a child and adult, how depression has affected her career, and how she has recovered.

Use this essay to:

  • Play an audio recording, read by Dr. Michael LaCombe.
  • Ask your learners if they know where to turn for help if they need it. What are the symptoms and signs of depression—and would your learners be able to assess their own symptoms and whether they need help?
  • Do they think depression is common among physicians? Would they worry, as Dr. Lawrence did, whether her colleagues and patients would welcome her back after she took time off to help herself to heal?

mksap16

On physical examination, temperature is 39.0 °C (102.2 °F), blood pressure is 90/60 mm Hg, pulse rate is 120/min, and respiration rate is 20/min. There are erythema and purulent drainage at the site of a right subclavian central venous catheter. The rest of the examination is normal.

Laboratory studies indicate a leukocyte count of 16,000/μL (16 × 109/L). Serum creatinine level is 3.6 mg/dL (318.2 µmol/L) compared with a value of 1.2 mg/dL (106.1 μmol/L) at admission. Two sets of blood cultures obtained 2 days ago are growing yeast.

In addition to central venous catheter removal, which of the following is the most appropriate treatment option for this patient?

A. Caspofungin
B. Conventional amphotericin B
C. Fluconazole
D. Liposomal amphotericin B
E. Voriconazole

Correct Answer
A. Caspofungin

Key Point
Antifungal therapy with an echinocandin agent (caspofungin, anidulafungin, or micafungin) is the treatment of choice for critically ill patients with candidemia.

Educational Objective
Treat life-threatening candidemia.

This patient should be treated with caspofungin. She has fungemia, which is most likely caused by Candida species. The most likely source is the central venous catheter, the site of which shows obvious signs of infection including erythema and purulent drainage. She has multiple risk factors for candidemia, including exposure to broad-spectrum antibiotics and having received parenteral nutrition via a central venous catheter. In addition to catheter removal, it is essential that antifungal therapy be instituted promptly. Because she is severely ill, the therapy of choice is an echinocandin agent. The Infectious Diseases Society of America guidelines do not distinguish among the echinocandins; therefore, any of them (caspofungin, anidulafungin, or micafungin) would be appropriate.

Amphotericin B or a lipid formulation of amphotericin B is an alternative choice if there is intolerance to or limited availability of other antifungal agents. This patient has kidney failure, which would be exacerbated by either formulation of amphotericin B.

Fluconazole is recommended for patients who are less critically ill than this patient and who have had no recent exposure to azole antifungal agents. When this patient becomes clinically stable, she can be transitioned from receiving an echinocandin to fluconazole if the isolate is likely to be susceptible to fluconazole.

Voriconazole is effective for the treatment of candidemia, but it offers little advantage over fluconazole and is recommended as step-down oral therapy for selected patients with candidiasis caused by Candida krusei or voriconazole-susceptible Candida glabrata.

Bibliography
Pappas PG, Kauffman CA, Andes D, et al; Infectious Diseases Society of America. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(5):503-535. PMID: 19191635

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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