Annals for Educators - 18 October 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives18 October 2016Annals for Educators - 18 October 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201610180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsHuman Trafficking: The Role of Medicine in Interrupting the Cycle of Abuse and ViolenceHuman trafficking, a form of modern slavery, has profound consequences for individuals and society. Victims frequently present to a variety of medical settings while being trafficked. Health care professionals should be trained to recognize the symptoms and signs of trafficking to provide victim-centered, trauma-informed medical care and, when desired, referrals to programs that can help interrupt the cycle of abuse.Use this paper to:Ask your learners to define “human trafficking.” Who is at risk? How common is it? Are your learners shocked by the statistics in the paper's introduction? Had they ever thought about this problem occurring in their communities?What health problems are associated with human trafficking? Use Table 2.What sorts of complaints are these patients commonly seen for by medical professionals?The paper quotes a study that found that >85% of female survivors of exploitation had been evaluated by a medical provider at least once before, without identification of the problem. Might we be missing the clues? What clues might help us identify a victim of trafficking? Review Table 3 with your learners.How should we approach potential victims? Note the author's caution regarding the potential harms of an aggressive pursuit of victim disclosure. What is the best approach? Who should be called to help? Note the resources provided in Table 5.What is “trauma-informed care”? How might our own reactions—even anger—at the “negative” behavior of trauma victims impede the provision of care, and even cause harm?Does your health system have a system to help identify and aid victims of human trafficking? If so, ask someone familiar with this program to talk to your learners about available resources. If not, ask your learners to organize action within your system. How will they start, and how will they set goals to make sure their effort does not “fall through the cracks”?“Nonfunctional” Adrenal Tumors and the Risk for Incident Diabetes and Cardiovascular Outcomes. A Cohort StudyAdrenal tumors are frequent incidental findings on abdominal imaging done for unrelated indications. These tumors are deemed nonfunctional and assumed to be of no consequence if hormone levels are within the normal range. This study evaluated the occurrence of diabetes and cardiovascular outcomes among patients with incidentally noted adrenal tumors that, by current standards, would be deemed nonfunctional on the basis of baseline test results.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask a radiologist to supply images from an abdominal CT in which an adrenal mass is present. See if your learners are able to identify the abnormality.Ask them what, if any, evaluation they would perform if this lesion was identified incidentally in a 35-year-old patient whose CT was obtained for evaluation for possible appendicitis. What is meant by an “incidentaloma”?What tests should be ordered to establish whether an adrenal mass is functional or nonfunctional?Ask your learners how they would design a study to assess whether “nonfunctional” adrenal tumors increase the risk for cardiometabolic outcomes. Now, review how the authors assembled this cohort study (use Figure 1 to help explain).All studies have limitations. What assumptions had to be made in this study's design, and what limitations do they impose on the findings? The authors outline these nicely for you in the paper's discussion section.Review the findings (show Figure 2). How do they change our thinking about “nonfunctional” adrenal tumors? What would your learners suggest be done next to study the potential health implications of such lesions?Public Opinion Regarding Whether Speaking With Patients About Firearms Is Appropriate. Results of a National SurveyMedical and public health organizations advocate counseling by health care professionals to lower the risks associated with household firearms and to promote safe gun storage practices. However, health care professionals do not seem to routinely engage in such counseling, in part due to concerns for whether patients find it acceptable. This nationally representative survey asked adults about the appropriateness of discussions between health care professionals and patients.Use this study to:Ask your learners if they think their patients would be upset if asked about firearms in their homes. Review the results of this study. Do they surprise your learners? Do they think that patients might actually appreciate being asked?Do your learners think they should be asking? Why or why not? Use a recent paper that discusses in whom this should be considered, and how to go about it.Pretend you are a patient and ask your learners to inquire about guns in your home. How will they bring up the subject? How will they respond if you act offended by the question? Are they able to focus the discussion on the health reasons for addressing the issue, rather than on political views?Humanism and ProfessionalismOn Being a Doctor: The Glass WatchersDr. Babbott compares the careful observation of a building's window panes for signs of structural faults that might cause them to fall with the need to observe and monitor ourselves and our profession.Use this essay to:Play an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners what warning signs might signal that a professional colleague might be suffering from burnout. How might physician burnout pose a risk to patients?Ask the same questions for depression and for substance abuse.How should we respond when we think a colleague is in trouble and in need of help? Do we have a right or obligation to prod? What resources are available?MKSAP 17 QuestionA 55-year-old man presents for follow-up of a recent diagnosis of hyperaldosteronism. Medical and family history are unremarkable. Medications are losartan, metoprolol, amlodipine, and chlorthalidone.On physical examination, blood pressure is 150/90 mm Hg and pulse rate is 70/min. The rest of the examination is unremarkable.Additional studies include a noncontrast CT scan of the abdomen that shows a 1.2-cm homogeneous left adrenal lesion with a density of −5 Hounsfield units. Adrenal vein sampling indicates similar ratios of aldosterone to cortisol bilaterally.Which of the following is the most appropriate therapy for this patient?A. Bilateral adrenalectomyB. DexamethasoneC. Left adrenalectomyD. SpironolactoneCorrect AnswerD. SpironolactoneEducational ObjectiveManage primary hyperaldosteronism.CritiqueThe most appropriate treatment for this patient is spironolactone. He has primary hyperaldosteronism (PA) due to a bilateral adrenal source as evidenced by the lack of lateralization on adrenal vein sampling (AVS). Bilateral adrenal hyperplasia is the most common etiology of PA, accounting for approximately 60% of cases, and spironolactone is the treatment of choice. Spironolactone is a mineralocorticoid receptor (MR) antagonist that can improve blood pressure, normalize serum potassium concentration, and reduce excess cardiovascular risk related to hyperaldosteronism. Eplerenone is an alternative MR antagonist that is less likely to cause gynecomastia in men because of greater MR selectivity; however, use of eplerenone for this indication is off-label. Antagonists of the aldosterone-sensitive sodium channel (amiloride) can be used as second-line therapy.Bilateral adrenalectomy is not appropriate for the routine management of PA, as this would risk primary adrenal failure, thus necessitating life-long glucocorticoid and mineralocorticoid therapy.Dexamethasone, a long-acting synthetic glucocorticoid, has a role in treating only a small percentage of patients who have glucocorticoid-remedial hypertension, a very rare autosomal dominant condition resulting from ectopic expression of aldosterone synthase in the cortisol-producing zona fasciculata. Administration of dexamethasone will suppress pituitary adrenocorticotropic hormone (ACTH) secretion in these patients and therefore mineralocorticoid production. However, hyperaldosteronism in most patients is independent of ACTH secretion, and suppression with exogenous glucocorticoid is not an effective therapy.Left adrenalectomy should not be performed because the patient has a bilateral cause of PA. The left adrenal adenoma detected by CT scan is an incidental finding and is likely not the cause of this patient's hyperaldosteronism. Because nonsecreting adrenal adenomas are common, AVS is needed in most patients with hyperaldosteronism to determine the source of aldosterone secretion when imaging studies show an adrenal adenoma to assess its contribution to excess mineralocorticoid production. AVS should be done at a high-volume referral center due to a high risk of complications when significant procedural experience is lacking.Key PointFor patients with primary hyperaldosteronism due to bilateral adrenal hyperplasia, medical therapy with a mineralocorticoid antagonist such as spironolactone is the treatment of choice because of its proven efficacy to lower blood pressure, normalize serum potassium concentration, and reduce cardiovascular risk.BibliographyFunder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008 Sep;93(9):3266-81.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: 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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 18 October 2016Volume 165, Issue 8Page: ED8KeywordsAdrenal tumorsAdrenalectomyAldosteroneBlood pressureComputed axial tomographyGlucocorticoid therapyHealth careHuman traffickingLesionsMineralocorticoids ePublished: 18 October 2016 Issue Published: 18 October 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...