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Annals for Educators - 3 March 2020.
Annals of Internal Medicine ( IF 19.6 ) Pub Date : 2020-03-03 , DOI: 10.7326/awed202003030
Darren B Taichman

Clinical Practice Points

Poxvirus Vectored Cytomegalovirus Vaccine to Prevent Cytomegalovirus Viremia in Transplant Recipients. A Phase 2, Randomized Clinical Trial

Reactivation of latent cytomegalovirus (CMV) in CMV-seropositive recipients of allogeneic hematopoietic stem cell transplant (HCT) is associated with increased morbidity and mortality. This multicenter, double-blind, randomized, placebo-controlled, phase 2 trial evaluated the safety and efficacy of a vaccine to prevent CMV viremia in HCT recipients.
Use this study to:

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

  • Ask your learners what the donor and recipient risk factors for CMV infection after solid organ transplant are. Use the information in DynaMed: CMV Infection in Solid-organ Transplant Recipients, a benefit of your ACP membership.

  • What symptoms and signs should raise concerns about CMV disease?

  • How is a diagnosis established? How is the disease treated?

  • Can CMV infection be prevented?

  • What are the potential long-term complications of CMV infection among transplant recipients?

Sitters as a Patient Safety Strategy to Reduce Hospital Falls. A Systematic Review

This systematic review examines 20 studies that evaluated whether adding sitters to usual care or using alternatives to sitters (such as video monitors or close observation units) reduced falls in adult patients on general wards of acute care hospitals.
Use this study to:

  • Ask your learners how big a problem falls are among inpatients at your hospital.

  • How common are falls among hospitalized patients nationally? What are the personal and health system costs? What are the implications for your hospital of the Centers for Medicare & Medicaid Services deeming a fall a “never event”? Use the editorial to help frame your discussion.

  • What strategies are used at your hospital to identify patients at risk for falling? Who is responsible for identifying patients at risk?

  • What strategies are used to prevent falls? Are they effective? How do you know? What did this study find?

  • Do you use “sitters” at your institution? How about restraints? What are the potential benefits and complications with each approach? Invite a leader from your hospital's nursing department to join your discussion.

  • What is the value of a systematic review that finds that the evidence base for a commonly used intervention is not great? In what ways might that be helpful?

Recommended Adult Immunization Schedule, United States, 2020

This article provides immunization recommendations from the Advisory Committee on Immunization Practices for adults aged 19 years or older.
Use this paper to:

  • Review the immunization recommendations with your learners.

  • Is there a system in place to ensure identification of patients in need of immunizations in your practice? For which immunizations? What is the approach to others?

  • Ask your learners what has changed since last year's recommendations.

  • What is different in the recommendations for pneumococcal vaccination? Are PCV13 and PPSV23 both routinely recommended? Why the change? How would your learners discuss whether to use PCV13 with their patients?

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

This synopsis of a 2019 clinical practice guideline addresses management of chronic insomnia disorder and obstructive sleep apnea.
Use this synopsis to:

  • Ask your learners whether they ask patients about insomnia. Should they?

  • What questions do your learners ask when a patient reports problems sleeping? What evaluation should be performed?

  • What should be the approach to management of insomnia? Is cognitive behavioral therapy useful? How do you arrange for it? When is pharmacologic therapy appropriate? Which drugs should be considered, and what are the benefits and risks?

  • Do all patients with possible sleep apnea require an in-laboratory polysomnogram?

In the Clinic

In the Clinic: Fibromyalgia

Fibromyalgia is estimated to affect 2% to 4% of the general population, and the prevalence exceeds 15% in selected clinical groups. It is underdiagnosed. Are your learners prepared to recognize, evaluate, and treat it?
Use this feature to:

  • Ask your learners what they consider when patients complain of chronic, widespread pain.

  • Should “screening” rheumatologic blood markers be tested?

  • How is a diagnosis of fibromyalgia made?

  • What is the role of cognitive behavioral therapy? What about sleep hygiene?

  • Is referral to a specialist required for diagnosis or management?

  • What is the prognosis?

  • Use the provided multiple-choice questions to help introduce topics for discussion. And, sign on to enter your answers to earn CME/MOC credit for yourself!

Humanism and Professionalism

On Being a Doctor: Meaning at the Fingertips

Dr. Quagliarello recalls feeling pride and guilt when his patient remarked, “You're the only one who touches me.”
Use this essay to:

  • Listen to an audio recording, read by Dr. Michael LaCombe.

  • Ask your learners whether they believe too much emphasis is put on the importance of physical examination.

  • Is there value to examining a patient even when it does not lead to a diagnosis or altered management?

  • How might physical examination be harmful? Can it be “therapeutic”?

Teaching Opportunity/CV Builder

Clinical Skills Proposals Wanted for Internal Medicine Meeting 2022

Interested in teaching procedural, physical examination, or communication skills?
The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2022, which will be held in Chicago, Illinois, April 28-30, 2022. To submit a proposal, please complete the Clinical Skills Proposal. The deadline to submit proposals is April 24, 2020.

MKSAP 18 Question

A 45-year-old man is hospitalized with a 5-day history of fever, bloody diarrhea, and abdominal pain. Medical history is significant for end-stage kidney disease, for which he underwent kidney transplantation 1 year ago. Medications are prednisone, mycophenolate, and tacrolimus.
On physical examination, vital signs are normal. Conjunctival pallor is present. Abdominal palpation elicits diffuse abdominal pain. The remainder of the examination is unremarkable.

Laboratory studies:

Hemoglobin 9.5 mg/dL (95 g/L) 
Leukocyte count 3400/µL (3.4 × 109/L) 
Platelet count 98,000/µL (98 × 109/L) 
Alanine aminotransferase 99 U/L 
Aspartate aminotransferase 88 U/L 
Creatinine 1.5 mg/dL (133 µmol/L) 
Hemoglobin 9.5 mg/dL (95 g/L) 
Leukocyte count 3400/µL (3.4 × 109/L) 
Platelet count 98,000/µL (98 × 109/L) 
Alanine aminotransferase 99 U/L 
Aspartate aminotransferase 88 U/L 
Creatinine 1.5 mg/dL (133 µmol/L) 
Which of the following is the most likely diagnosis?
A. Cytomegalovirus infection
B. Entamoeba histolytica infection
C. Salmonella enteritidis infection
D. Strongyloides stercoralis infection
Correct Answer
A. Cytomegalovirus infection
Educational Objective
Diagnose cytomegalovirus infection in a solid organ transplant recipient with colitis.
Critique
The most likely diagnosis in this patient is cytomegalovirus infection. Approximately 60% to 90% of adults have latent cytomegalovirus infection, with reactivation of disease common in persons who are immunosuppressed (patients with AIDS, transplant recipients, patients taking glucocorticoids). Cytomegalovirus is an important pathogen in kidney transplant recipients, and the risk of cytomegalovirus infection depends on the serologic status of the kidney donor and recipient at the time of transplantation. The highest risk occurs when a seronegative recipient (one who has never had a cytomegalovirus infection) receives a kidney from a seropositive donor. Cytomegalovirus can cause retinitis (especially in persons with AIDS), pneumonitis, hepatitis, bone marrow suppression, colitis with bloody diarrhea, esophagitis, and adrenalitis. This patient recently received a kidney transplant; he has bone marrow suppression (leukopenia and thrombocytopenia), hepatitis (elevated aminotransferase levels), and bloody diarrhea consistent with cytomegalovirus reactivation. Diagnosis relies on isolation of the virus from bodily fluids, such as urine; detection of cytomegalovirus pp65 antigen in leukocytes; cytopathic demonstration of “owl's eye” intracellular inclusions from tissue biopsy (colon in this case) (shown); polymerase chain reaction; and serologic assays. Antiviral treatment is typically indicated in cases of disease reactivation in immunocompromised patients and occasionally in immunocompetent hosts with severe disease. Valganciclovir is the first-line agent and is also used as prophylaxis or pre-emptive therapy in certain transplant patients.
Entamoeba histolytica and Salmonella enteritidis can cause bloody diarrhea, but neither presents with pancytopenia. Therefore, they are unlikely possibilities in a solid organ transplant recipient. Furthermore, E. histolytica would not cause elevated aminotransferase levels in the absence of a liver abscess.
Strongyloides stercoralis is the only parasite that has an autoinfection route (ability to complete its life cycle entirely within the human host) resulting in an increasing burden of parasites that can survive for decades in patients. Disseminated strongyloidiasis after solid organ transplantation can present with abdominal pain and diarrhea, but it is usually nonbloody. Furthermore, disseminated Strongyloides infection may present with sepsis with colonic bacteria, serpiginous rash, meningitis, or eosinophilic pneumonia. All patients scheduled for solid organ transplantation are now screened with a Strongyloides antibody and treated with ivermectin to decrease the incidence of this infection.
Key Point
Latent cytomegalovirus infection is present in 60% to 90% of adults, and patients who are immunosuppressed may experience disease reactivation with retinitis, pneumonitis, hepatitis, bone marrow suppression, colitis with bloody diarrhea, esophagitis, or adrenalitis.
Bibliography
Angarone M, Ison MG. Diarrhea in solid organ transplant recipients. Curr Opin Infect Dis. 2015;28:308-16. doi:10.1097/QCO.0000000000000172
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中文翻译：
教育工作者年鉴-2020年3月3日。

临床实践要点

痘病毒载体化巨细胞病毒疫苗可预防移植受者中的巨细胞病毒病毒血症。第2期，随机临床试验

异基因造血干细胞移植（HCT）的CMV血清反应阳性接受者中潜伏巨细胞病毒（CMV）的重新激活与发病率和死亡率增加相关。这项多中心，双盲，随机，安慰剂对照的2期临床试验评估了预防HCT接受者CMV病毒血症的疫苗的安全性和有效性。
使用此研究可以：

  • 用选择题开始教学课程。我们在下面提供了一个！

  • 询问您的学习者，实体器官移植后CMV感染的供体和受体危险因素是什么。使用DynaMed：实体器官移植接受者中的CMV感染中的信息，这是ACP成员资格的一项好处。

  • 哪些症状和体征应引起对CMV疾病的关注？

  • 如何建立诊断？该病如何治疗？

  • 可以预防CMV感染吗？

  • 移植受者中CMV感染的潜在长期并发症是什么？

保姆作为减少医院跌倒的患者安全策略。系统评价

这项系统评价审查了20项研究，这些研究评估了是否在常规护理中增加保姆或使用替代保姆（例如视频监视器或紧密观察单位）来减少急诊医院普通病房中成年患者的跌倒。
使用此研究可以：

  • 询问您的学习者，您医院的住院患者中有多严重的问题。

  • 全国住院患者中跌倒的情况有多普遍？个人和卫生系统的费用是多少？联邦医疗保险和医疗补助服务中心将跌倒视为“从未发生”会给您的医院带来什么影响？使用社论来帮助您进行讨论。

  • 您的医院使用什么策略来识别有跌倒风险的患者？谁负责识别有风险的患者？

  • 有什么策略可以防止跌倒？他们有效吗？你怎么知道的？这项研究发现了什么？

  • 您在机构中使用“保姆”吗？束缚如何？每种方法的潜在好处和并发症是什么？邀请您医院护理部门的负责人参加您的讨论。

  • 如果发现通常的干预措施的证据基础不完善，那么系统评价的价值何在？在哪些方面有帮助？

推荐的成年人免疫接种时间表，美国，2020年

本文为19岁以上的成年人提供了免疫实践咨询委员会的免疫建议。
使用本文可以：

  • 与您的学习者复习免疫建议。

  • 是否有一个系统可以确保在您的实践中识别需要免疫的患者？哪些免疫？对他人的处理方式是什么？

  • 问您的学习者自去年的建议以来发生了什么变化。

  • 关于肺炎球菌疫苗接种的建议有何不同？是否常规建议同时使用PCV13和PPSV23？为什么要改变？您的学习者将如何与患者讨论是否使用PCV13？

慢性失眠症和阻塞性睡眠呼吸暂停的治疗：2019年美国退伍军人事务部和美国国防部临床实践指南的提要

2019年临床实践指南的概要概述了慢性失眠症和阻塞性睡眠呼吸暂停的管理。
使用此提要可以：

  • 询问您的学习者是否向患者询问失眠情况。应该吗

  • 当患者报告睡眠问题时，您的学习者会问什么问题？应该执行什么评估？

  • 失眠的治疗方法应该是什么？认知行为疗法有用吗？您如何安排呢？什么时候适合药物治疗？应该考虑使用哪种药物，其益处和风险是什么？

  • 是否所有可能出现睡眠呼吸暂停的患者都需要进行实验室多导睡眠图检查？

在诊所

在临床中：纤维肌痛

纤维肌痛估计影响普通人群的2％至4％，在某些临床组中患病率超过15％。未被充分诊断。您的学习者是否准备好认识，评估和对待它？
使用此功能可以：

  • 询问您的学习者，当患者抱怨慢性广泛性疼痛时，他们会考虑什么。

  • 是否应“筛查”风湿性血液标志物？

  • 纤维肌痛如何诊断？

  • 认知行为疗法的作用是什么？睡眠卫生如何？

  • 诊断或管理需要转介专家吗？

  • 预后如何？

  • 使用提供的多项选择题可以帮助介绍讨论主题。并且，登录并输入答案即可自己赚取CME / MOC积分！

人文主义和专业精神

关于当医生：指尖的意义

Quagliarello博士回忆起当他的病人说：“你是唯一触摸我的人”时感到自豪和内feeling的。
使用本文来：

  • 收听录音，由Michael LaCombe博士朗读。

  • 询问您的学习者，他们是否认为过分强调身体检查的重要性。

  • 即使没有导致诊断或改变治疗方法，对患者进行检查是否有价值？

  • 身体检查会如何有害？可以“治疗”吗？

教学机会/简历制作器

希望为2022年内科会议提出临床技能建议

对教学程序，身体检查或沟通技巧感兴趣吗？
ACP正在接受有关动手，互动式研讨会的建议，这些研讨会的重点是获得或提高2022年内科医学的程序技能，体格检查技能和沟通能力，该课程将于2022年4月28日至30日在伊利诺伊州芝加哥举行。要提交建议，请完成临床技能建议。提交提案的截止日期是2020年4月24日。

MKSAP 18问题

一名45岁的男性住院，有5天的发烧，血性腹泻和腹痛史。病史对于晚期肾脏疾病很重要，他在1年前接受了肾脏移植。药物为泼尼松，霉酚酸酯和他克莫司。
经身体检查，生命体征正常。存在结膜苍白。腹部触诊引起腹部弥漫性疼痛。其余的检查效果不明显。

实验室研究：

血红蛋白 9.5毫克/分升（95克/升） 
白细胞计数 3400 / µL（3.4×10 9 /升） 
血小板计数 98,000 / µL（98×10 9 /升） 
丙氨酸氨基转移酶 99单位 
天冬氨酸转氨酶 88 U / L 
肌酐 1.5 mg / dL（133 µmol / L） 
血红蛋白 9.5毫克/分升（95克/升） 
白细胞计数 3400 / µL（3.4×10 9 /升） 
血小板计数 98,000 / µL（98×10 9 /升） 
丙氨酸氨基转移酶 99单位 
天冬氨酸转氨酶 88 U / L 
肌酐 1.5 mg / dL（133 µmol / L） 
以下哪项是最可能的诊断？
A.巨细胞病毒感染
B.溶血性变形杆菌
C.肠炎沙门氏菌感染
D.类固醇类固醇感染
正确答案
A.巨细胞病毒感染
教育目标
诊断患有结肠炎的实体器官移植受者中的巨细胞病毒感染。
批判
该患者最可能的诊断是巨细胞病毒感染。大约60％至90％的成年人患有潜伏性巨细胞病毒感染，并在免疫抑制患者（艾滋病患者，接受移植的患者，服用糖皮质激素的患者）中常见疾病的重新激活。巨细胞病毒是肾移植受者中的重要病原体，巨细胞病毒感染的风险取决于移植时肾脏供体和接受者的血清状况。当血清反应阴性的接受者（从未感染过巨细胞病毒的接受者）从血清反应阳性的供体接受肾脏时，发生最高风险。巨细胞病毒可引起视网膜炎（尤其是在艾滋病患者中），肺炎，肝炎，骨髓抑制，结肠炎伴腹泻，食道炎和肾上腺炎。该患者最近接受了肾脏移植。他患有骨髓抑制（白细胞减少症和血小板减少症），肝炎（转氨酶水平升高）以及与巨细胞病毒重新激活相一致的血性腹泻。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。他患有骨髓抑制（白细胞减少症和血小板减少症），肝炎（转氨酶水平升高）以及与巨细胞病毒重新激活相一致的血性腹泻。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。他患有骨髓抑制（白细胞减少症和血小板减少症），肝炎（转氨酶水平升高）以及与巨细胞病毒重新激活相一致的血性腹泻。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。肝炎（转氨酶水平升高）和血性腹泻与巨细胞病毒重新激活相一致。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。肝炎（转氨酶水平升高）和血性腹泻与巨细胞病毒重新激活相一致。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。诊断依赖于从体液（如尿液）中分离出病毒。检测白细胞中巨细胞病毒pp65抗原；组织活检显示“猫头鹰眼”细胞内包裹物的细胞病变（在这种情况下为结肠）（如图所示）；聚合酶链反应；和血清学检测。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。抗病毒治疗通常在免疫功能低下的患者疾病再激活的情况下使用，有时在具有严重疾病的具有免疫能力的宿主中使用。缬更昔洛韦是一线药物，在某些移植患者中也用作预防或先发疗法。
溶血性变形杆菌和肠炎沙门氏菌可引起血性腹泻，但全血细胞减少症均不存在。因此，它们在实体器官移植受者中不太可能。此外，在不存在肝脓肿的情况下，溶组织性大肠杆菌不会引起氨基转移酶水平升高。
甾体类固醇是唯一具有自身感染途径（完全能够在人类宿主内完成其生命周期的能力）的寄生虫，导致寄生虫负担增加，这些寄生虫可以在患者体内存活数十年。实体器官移植后弥散性圆线虫病可出现腹痛和腹泻，但通常是非血性的。此外，散发的类圆线虫感染可能伴有败血症，并伴有结肠细菌，锯齿状皮疹，脑膜炎或嗜酸性粒细胞性肺炎。现在，所有计划进行实体器官移植的患者均使用抗茎线虫抗体进行筛查，并用伊维菌素进行治疗，以减少这种感染的发生率。
关键
成年人中有60％至90％存在潜在的巨细胞病毒感染，被免疫抑制的患者可能会因视网膜炎，肺炎，肝炎，骨髓抑制，结肠炎并伴有血性腹泻，食管炎或肾上腺炎而重新激活疾病。
参考书目
Angarone M，Ison MG。实体器官移植受者的腹泻。Curr Opin感染疾病。2015; 28：308-16。doi：10.1097 / QCO.0000000000000172
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更新日期：2020-03-03
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