Clinical Practice Points
Expanding treatment for latent tuberculosis infection (LTBI) is important to decrease active disease globally. This study compared treatment completion and safety of self-administered once-weekly isoniazid and rifapentine versus direct observation.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners who should be screened for LTBI. How should screening be performed? What are the treatment options? Use the recent In the Clinic: Tuberculosis to help prepare your teaching session.
What are the risks and benefits of each directly observed and self-administered treatment for LTBI?
Do your learners believe they can identify patients in whom self-administered treatment would be appropriate? What were the inclusion and exclusion criteria for this randomized trial? Do they help guide you?
The prevalence of human papillomavirus (HPV)–positive oropharyngeal cancer is disproportionately high among men. Data from the National Health and Nutrition Examination Survey (2011 to 2014) were used to determine the prevalence of oral HPV infection and the concordance of oral and genital HPV infection among U.S. men and women. This information is critical for designing detection and prevention efforts.
Ask your learners who is at increased risk for HPV infection. Is screening recommended? In whom, and how?
What are the potential complications of HPV infection?
Are your learners surprised by the prevalence estimates for HPV infection among men and women?
What are the recommendations for HPV vaccination? Consult the most recent statement from the Advisory Committee on Immunization Practices. Until what age are men and women to receive vaccination? Might the data from this study be useful in assessing the appropriateness of current recommendations?
Peripheral intravenous catheters (PIVCs) are among the most important and prevalent medical devices in the hospital. However, they have received limited attention in the context of patient safety and health care quality. Substantial attention has been paid to the 3 million central venous catheters placed annually in the United States. The author discusses the relatively limited attention paid to the more than 350 million PIVCs placed.
Ask your learners what your hospital's policy is on the need for PIVCs in inpatients. Are they required for everyone? Are they routinely changed after a set number of days, or only when they are nonfunctional?
Does everyone need a PIVC? Are they harmless?
Do your learners think current practice could be improved? What changes would they consider? What additional information would be desired before making a change? Can your learners propose practical means to gather this information or to study a change in practice?
Working in Our Health Care System
Myriad financial, quality, and service metrics pervade the professional lives of ambulatory care providers. These include measurements from the electronic health record (EHR), which include practice efficiency scores that create a window on the clinician's workflow. In this article, the authors propose a set of EHR-related metrics that provide further insight into the clinician experience.
Ask your learners whether they like or dislike using your system's EHR.
What are the potential benefits of using an EHR? What are the risks to patients and the burdens on health care providers? Can your learners propose ways to minimize or eliminate these risks and burdens?
Do your learners think the “metrics” proposed by the authors of this paper would be useful? What needs to be agreed on regarding how a metric will be used before it is worth measuring it?
Invite a member of your hospital's administration who is responsible for EHR implementation to join your discussion. Ask what metrics your system uses to evaluate how well your EHR functions. Do your learners believe the right areas are being scrutinized?
Video Learning
Howard and Geno (the Consult Guys) help decide whether a procedure requiring anesthesia may proceed after a patient drank a cappuccino.
Take a relaxing and educational break with your learners and watch this 10-minute video.
Ask your learners what the policy is regarding fasting before procedures at your center. What are these policies based on? What are the risks of having food or liquid before anesthesia, and how long do they last?
Answer the multiple-choice questions with your team. Log on and submit your own answers to earn CME/MOC credit for yourself.
Humanism and Professionalism
Dr. Waxman notes that the rewards of helping a patient in the middle of the night come at a price to his family.
Listen to an audio recording of the essay, read by Dr. Michael LaCombe.
Ask your learners if they resent when time caring for patients takes away from time with family and friends. How do they deal with this resentment? Does patient care seem like an inconvenience?
Do any of your learners have children? Do they think the pressures are different in this situation? What other unique situations do your learners face?
How do we balance work and family responsibilities?
Do we talk to our family and friends about these challenges? Do they understand?
MKSAP 17 Question
A 30-year-old woman is evaluated for a reactive tuberculin skin test (TST). She developed 6-mm induration 48 hours after the test was performed. She has no fever, weight loss, or cough, and cannot recall any exposure to tuberculosis. Medical history is notable for psoriasis diagnosed 10 years ago. Her only medication is infliximab. A TST result was negative before initiation of therapy.
On physical examination, vital signs are normal. Stable plaque psoriasis is noted. The lungs are clear, and the remainder of the examination is normal.
Which of the following is the most appropriate next step in the management of this patient?
B. Interferon-γ release assay
C. Rifampin, isoniazid, pyrazinamide, and ethambutol
D. No further intervention
Manage a reactive tuberculin skin test in an immunosuppressed patient.
This patient should undergo chest radiography to exclude active tuberculosis infection. The patient is asymptomatic and is taking infliximab, a tumor necrosis factor α inhibitor, for management of her psoriasis. A tuberculin skin test (TST) reaction of 5-mm or larger induration is interpreted as positive in patients who are immunosuppressed, including those who are taking tumor necrosis factor α inhibitors or the equivalent of at least 15 mg/d of prednisone for 1 month or longer. Other patients for whom 5-mm or larger induration is considered positive include patients with HIV infection, organ transplants, and fibrotic changes on chest radiograph consistent with old tuberculosis, and recent contacts of a person with active tuberculosis. If the chest radiograph is negative, treatment for latent tuberculosis infection, usually consisting of daily isoniazid with pyridoxine (vitamin B6) for 9 months, is recommended to decrease the risk for progression to active disease.
Testing with both the TST and interferon-γ release assay is not routinely recommended. According to the Centers for Disease Control and Prevention, using both tests may be helpful when the result of the initial test is positive and additional validation of infection is required before recommended treatment is initiated, such as in health care professionals who previously received the bacillus Calmette-Guérin vaccine or patients at low risk for infection and progression to active disease. Conversely, both tests may be helpful when the result of the initial test is negative and the risk for infection, active disease, and a poor outcome is increased, such as in patients infected with HIV or children younger than 5 years who have been exposed to a patient with active tuberculosis. Using both tests also may be helpful when the result of the initial test is negative but symptoms, signs, or imaging results are suspicious for TB and evidence of infection with M. tuberculosis is being sought. Because this patient does not fit into one of these categories, interferon-γ release assay would not be indicated.
Rifampin, isoniazid, pyrazinamide, and ethambutol would be recommended as initial therapy for a patient with active tuberculosis. This patient has no symptoms of active infection. Unless the chest radiograph suggests active tuberculosis, beginning four-drug antituberculous therapy is not indicated and would not be appropriate before further evaluation.
No additional intervention, including evaluation or therapy, would be inappropriate for this patient. Although she is asymptomatic, she is at risk for active tuberculosis if untreated for latent tuberculosis infection.
Patients who have a positive reaction to tuberculin skin testing should be further evaluated by chest radiography to rule out active tuberculosis infection.
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