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Annals for Educators - 2 February 2016Annals for Educators - 2 February 2016 FREE

Darren B. Taichman, MD, PhD
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From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University.


Ann Intern Med. 2016;164(3):ED3. doi:10.7326/AFED201602020
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Patients who have perforated diverticulitis with purulent peritonitis are frequently managed surgically with open colon resection and formation of a stoma. This randomized trial assessed whether management with laparoscopic lavage alone can improve outcomes for these patients, including reducing the need for reoperations.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below.

  • Review with your learners the epidemiology of diverticulosis. Is the consumption of certain foods (e.g., popcorn) associated with an increased risk for diverticulosis or diverticulitis? Use the information in DynaMed Plus – Diverticulitis, a benefit of your ACP membership.

  • Ask your learners what the symptoms of diverticulitis are. What is the differential diagnosis? How is a diagnosis of diverticulitis established? Is a CT scan always needed?

  • When are antibiotics required, and which ones should be used? Which patients require hospital admission?

  • What are the complications of diverticulitis? Ask when a surgical consultation is required. Can recurrent bouts be prevented?

  • The primary end point of this study was the number of “reoperations”—which included stoma reversal. Do your learners think it was appropriate to count stoma reversal (an anticipated sequela of one of the trial's interventions, the Hartmann procedure) as a “reoperation?” Read the authors' thoughts in the Discussion section of their article (pages 142-143), and use the editorialists' comments to help frame your discussion.

  • Although this randomized trial compared surgical approaches to the management of perforated diverticulitis, internists are frequently involved in the care of these patients. Ask what roles a medical consultant might serve in patients with ruptured diverticulitis.

Up to 75% of menopausal women have hot flashes, with considerably diminished quality of life. Although women often turn to alternative therapy, such as acupuncture, for symptom relief, evidence of its efficacy for this purpose is inconsistent. This randomized, controlled trial compared the efficacy of standardized Chinese medicine acupuncture with sham acupuncture for menopausal hot flashes.

Use this study to:

  • Ask your learners what advice they give to their patients who are troubled by hot flashes. Use In the Clinic: Perimenopause to help prepare a teaching session, including multiple-choice questions and already prepared teaching slides.

  • Do your learners ask their patients about the use of “alternative therapies,” such as acupuncture? Do your learners think that they should be asking? Are there possible direct or indirect harms to such practices? How would your learners discuss these issues with their patients?

  • This trial found no benefit to acupuncture as compared with sham acupuncture for the treatment of hot flashes. Review with your learners what the “sham” treatment involved in this trial. In their discussion, the authors note that “noninsertive” acupuncture is not the ideal “control” for such a trial. Why not? Note also that the treating acupuncturists were not blinded to treatment allocation, although the patients and outcome assessors were. What effect(s) might each of these issues have had on the study's results?

Silicone gel breast implants, which were removed from the U.S. market in 1992 due to safety concerns, were reintroduced in 2006. This systematic review of 32 studies examines whether these implants are associated with risk for cancer, rheumatologic and autoimmune diseases, neurologic diseases, or mental health issues. The review found we lack sufficient evidence to draw firm conclusions, and the accompanying editorials discuss the reasons why and what should be done in the future.

Use these papers to:

  • Ask your learners if they are aware of whether their patients have undergone cosmetic surgical procedures. Why might it matter?

  • Do your learners inquire about breast implants in the evaluation of potential rheumatologic or other systemic symptoms? Do they think they should? Why or why not?

  • How would your learners design a registry to help more definitively answer the questions for which available evidence fails to provide confident answers? Read the editorials and the researchers' discussions to provide ideas for discussion. What does the often-cited phrase “Absence of evidence is not evidence of absence” mean? Is that applicable here?

This eminently practical and concise review discussed isolated seizures, epilepsy, evaluation, and treatment.

Use this review to:

  • Ask your learners why it is important to differentiate an isolated seizure from epilepsy. How do the differential diagnoses differ?

  • What evaluation should be pursued following a first seizure? Following a “breakthrough” seizure? When is an electroencephalogram (EEG) needed? When and what imaging is required? What other tests and why?

  • Arrange for a neurologist to review EEG readings with your team.

  • Ask whether epilepsy can be prevented. What treatments are effective? How are pharmacologic therapies chosen? When are other therapies, such as surgery or devices (e.g., vagus nerve stimulators), to be considered? What safety concerns need to be discussed (e.g., precautions related swimming, stairs, street crossing).

  • What responsibilities do physicians have regarding driving restrictions for patients with epilepsy? What are the laws in your state regarding driving by patients with epilepsy?

  • Are your learners familiar with sudden unexpected death in epilepsy (SUDEP)? How should this be discussed? The authors note addressing modifiable risks (e.g., drug adherence).

  • Use the already prepared teaching slides and the multiple-choice questions provided to help introduce new topics as you proceed through a teaching session. Sign on and enter your responses to earn CME for yourself!

The Advisory Committee on Immunization Practices (ACIP) presents the recommended Immunization Schedule for Adults Aged 19 Years or Older for 2016. This schedule has been approved by the ACIP, American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.

Use this paper to:

  • Review the adult immunization schedule with your learners.

  • Ask what is new this year. The authors point these items out in the introduction (e.g., an interval change for the 13-valent pneumococcal conjugate vaccine, serogroup B meningococcal vaccination for persons at increased risk, the addition of 9-valent human papillomavirus vaccine).

  • Who checks on whether patients in your practice are up-to-date with immunizations? Do your learners know where this should be documented? Do your learners think the system works well to ensure your patients are protected? How might they improve it? Which vaccines are stocked in your practice, and how do your learners provide them if not stocked?

A 58-year-old woman is evaluated in the emergency department for a 2-day history of left lower abdominal discomfort. The pain began insidiously and has gradually progressed. She has felt warm but has not had shaking chills, urinary symptoms such as dysuria or urgency, change in bowel habits, or apparent blood in her stool. She is able to eat and drink normally; however, her appetite is decreased. She has never had symptoms like this before. Her medical history is unremarkable.

On physical examination, temperature is 36.6 °C (97.9 °F), blood pressure is 135/68 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. She appears mildly uncomfortable. Mild left lower quadrant abdominal tenderness is noted, with no fullness or mass, guarding, or rebound tenderness.

Laboratory studies are significant for a hemoglobin level of 11.8 g/dL (118 g/L) and a leukocyte count of 10,800/µL (10.8 × 109/L). Serum electrolyte levels and kidney function studies are normal.

Abdominal CT scan shows inflammation of the sigmoid colon and mesentery consistent with acute diverticulitis; no bowel obstruction or abscess is noted.

In addition to antibiotic therapy, which of the following is the most appropriate management?

A. Discharge home with close follow-up

B. Laparoscopic sigmoid resection

C. Percutaneous drainage

D. Urgent colonoscopy

Correct Answer

A. Discharge home with close follow-up

Educational Objective

Manage diverticulitis.

Critique

The most appropriate management for this woman with diverticulitis is treatment with oral antibiotics with home discharge and close clinical follow-up. The therapeutic approach to diverticulitis is dictated by patient-related factors, the severity of clinical features, and the ability to tolerate oral intake. In a healthy, immunocompetent patient with mild symptoms, outpatient therapy is appropriate and should consist of a liquid diet, oral antimicrobial agents that cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole), and as-needed analgesia. Close follow-up is warranted to detect any deterioration as soon as possible. For older, frail, sicker patients, and in those with potential complications of diverticulitis (such as peritonitis or fistula formation), hospitalization is recommended for administration of intravenous antimicrobial agents and observation. This patient with diverticulitis has mild symptoms and is otherwise healthy. She is able to maintain oral intake and can therefore be managed as an outpatient with oral antibiotics and close follow-up.

Surgery is pursued acutely only in patients who have free perforation or peritonitis, or in those for whom medical therapy is unsuccessful. If indicated, both laparoscopic and open procedures are options; laparoscopic treatment is associated with a more rapid recovery time. This patient does not have a current indication for surgical intervention.

Percutaneous drainage is typically indicated in patients with diverticulitis with larger abscesses (often considered to be >3 cm) that are procedurally amenable in those without evidence of peritonitis. Smaller abscesses are usually treated with antibiotics alone and close follow-up. This patient does not have evidence of an abscess on imaging; therefore, percutaneous drainage is not indicated.

Colonoscopy is recommended after recovery because diverticulitis may be precipitated by a sigmoid cancer; however, colonoscopy during an attack is contraindicated because it would be very difficult to insert the colonoscope beyond the area of inflammation and obtain adequate mucosal inspection. In addition, it may cause peritonitis.

Key Point

In a healthy, immunocompetent patient with diverticulitis and mild symptoms, outpatient therapy is appropriate and should consist of a liquid diet, oral antimicrobial agents that cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole), and as-needed analgesia.

Bibliography

Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20.

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