Annals for Educators - 7 June 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives7 June 2016Annals for Educators - 7 June 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201606070 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThe Relationship of Parathyroidectomy and Bisphosphonates With Fracture Risk in Primary Hyperparathyroidism: An Observational StudyThe comparative effectiveness of surgical and medical treatments on fracture risk in primary hyperparathyroidism is unknown. In this retrospective cohort study, the authors sought to determine the effects of parathyroidectomy, bisphosphonates, and observation on skeletal outcomes in patients with primary hyperparathyroidism.Use this study to:Start a teaching session with a multiple-choice question. We've provided 2 below.Review calcium homeostasis. Ask how parathyroid hormone affects serum calcium levels.Ask your learners to list the possible symptoms of hypercalcemia. When is acute management required, and what does it involve? What are the other complications of hyperparathyroidism?How is hyperparathyroidism diagnosed? How is primary hyperparathyroidism differentiated from secondary causes? What are the secondary causes? Use the information from DynaMed Plus: Hyperparathyroidism (sign in with your ACP membership).Ask what the treatment options are for hyperparathyroidism. Will the results of this study influence your learners' opinions regarding whether parathyroidectomy or bisphosphonate therapy should be recommended? What are the potential complications of parathyroidectomy? Of medical therapy?Outcomes in Adults With Acute Liver Failure Between 1998 and 2013. An Observational Cohort StudyWhether changes have occurred in the causes of acute liver failure (ALF), its management, or the survival of patients with the condition with or without liver transplantation is not known. This large cohort of patients with ALF referred to specialized centers evaluated changes in causes, treatment, and survival over 16 years.Use this study to:Ask your learners to generate a differential diagnosis of ALF. How should a patient be evaluated? What tests are needed?What therapies are indicated, and when? What supportive measures are used? When is N-acetylcysteine indicated?What are the indications for liver transplantation? How is an evaluation for liver transplantation initiated, and what does it involve? If your center does not have a transplantation service, where do you refer patients? Review the outcomes of the center where your patients in need would undergo transplantation (available at this link ). What factors contribute to the differences in outcomes among centers?Transplantation centers consider medical and social factors (e.g., ongoing substance use disorders and adherence) when deciding whether to offer organ transplantation. Why? How would your learners explain that to a patient or his/her family with such issues?Beyond the Guidelines: Should We Treat for Subclinical Hypothyroidism?This Grand Rounds summarizes a discussion between 2 experts about treating subclinical hypothyroidism and how they would balance the benefits and harms of treatment both in general and in a specific patient. The feature includes videos of an interview with the patient and the grand rounds discussion, in addition to supplemental slides and a CME/MOC activity.Use this feature to:Ask your learners to define subclinical hypothyroidism.Watch the patient interview with your learners. Then ask if they would recommend treatment for this patient's subclinical hypothyroidism.Review the current evidence and guideline recommendations that are concisely summarized at the beginning of the paper that accompanies this feature.Watch the video of the discussants—one who is in favor of treatment and the other who is not.Now, what would your learners recommend?Breast Cancer Screening and PreventionIn 2016, about 250 000 U.S. women are estimated to develop breast cancer and 40 000 to die of it. Is screening for breast cancer effective?Use this clinical review to:Ask your learners who is at increased risk for breast cancer. What are the options for prevention of breast cancer in woman at high risk? What are their benefits and harms?Who should be screened for breast cancer, when, and how often? Ask your learners if they order digital mammography? What other approaches to screening are there? Is the addition of tomosynthesis (3-D mammography) beneficial? Are there harms?Ask why screening for breast cancer is such a contentious issue. Use a recent editorial to help frame your discussion.Ask your learners to role-play advising a 30-year-old woman at average risk for breast cancer who requests a mammogram because she recently heard on the news that screening might save her life.Break up a teaching session with the multiple-choice questions provided to introduce important topics. Be sure to log on and enter your answers to earn CME for yourself.Download the already-prepared teaching slides to help you prepare a teaching session.Clinical Care and Conflict of InterestMarketing and the Most Trusted Profession: The Invisible Interactions Between Registered Nurses and IndustryConcerns about conflicts of interest among health care workers have focused on interactions between industry representatives and prescribing clinicians. In this qualitative, ethnographic study, the authors sought to describe industry activities targeted at registered nurses and addressed common assumptions about nurses' interactions with industry.Use this study to:Ask your learners to define a conflict of interest.Ask what purposive sampling is. Why did the researchers use such a technique in this study? What are the advantages to this type of qualitative research? What limitations does it impose on the findings?In what ways might interactions between practicing clinicians and representatives from drug or device makers be beneficial? In what ways might they be problematic? Might they cause harm?Do the results of this study surprise your learners? Ask a nurse leader at your institution to discuss whether you have policies that guide nursing interactions with industry representatives. Ask your chief medical officer to explain the policies related to such interactions and physicians.Ask your learners if any of their own activities might be viewed as potentially conflicting with their role in deciding therapies for their patients. Have they ever received anything (a book, a meal, a reprint of an article) from someone who might have a personal stake in what treatments are provided?Do your learners think such activities influence their decisions? An often-heard response to such a question is, “I make my own judgments and interactions with pharmaceutical representatives do not influence my practice.” Do your learners think this is true? If so, why do your learners think drug and device makers spend so much money on these activities?Humanism and ProfessionalismAnnals Graphic Medicine: A Brief Anatomy of My Anxiety: The OCD VarietyIn his art and narrative, Dr. Doan depicts the thoughts that challenge this individual with obsessive-compulsive disorder.Use this feature to:Read the words of this piece aloud to your learners, without showing them the artwork.Now, have your readers look at the graphics.How did it make them feel? Did the pictures alter their reaction to the words?Do your learners have patients with anxiety? Patients with obsessive-compulsive disorder? Did seeing this graphic narrative help them think about how it might affect a patient's daily life?MKSAP 17 Question 1A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril.On physical examination, temperature is 35.8 °C (96.4 °F), blood pressure is 120/68 mm Hg, pulse rate is 62/min, and respiration rate is 14/min. BMI is 32. The remainder of his examination is unremarkable.Laboratory studies:Calcium10.9 mg/dL (2.7 mmol/L)Creatinine0.9 mg/dL (79.6 µmol/L)Parathyroid hormone98 pg/mL (98 ng/L)25-Hydroxyvitamin D19 ng/mL (47.4 nmol/L)Estimated glomerular filtration rate>60 mL/min/1.73 m2A dual-energy x-ray absorptiometry (DEXA) scan shows T-scores of –1.3 in the right femoral neck, –1.0 in the lumbar spine, and –1.4 in the non-dominant forearm. Fracture Risk Assessment Tool (FRAX) score indicates a 13% risk of major osteoporotic fracture and a 1.9% risk of hip fracture over the next 10 years.Which of the following is the most appropriate management of this patient?A. Refer for parathyroidectomyB. Start alendronateC. Start calcitoninD. Start cinacalcetE. Start vitamin D3 (cholecalciferol)Correct AnswerE. Start vitamin D3 (cholecalciferol)Educational ObjectiveTreat primary hyperparathyroidism and concomitant vitamin D deficiency.CritiqueThe most appropriate treatment of this patient is to replete his vitamin D deficiency with a supplement such as vitamin D3 (cholecalciferol). He has primary hyperparathyroidism as shown by his elevated serum calcium and parathyroid hormone levels. However, there is a high prevalence of concurrent vitamin D deficiency and insufficiency in patients with primary hyperparathyroidism, and low levels of 25-hydroxyvitamin D can stimulate parathyroid hormone secretion in non-adenomatous glands. Because of this, measurement of vitamin D levels should be ordered as part of the evaluation of primary hyperparathyroidism, and repletion should be provided if identified. In these patients, it is important to replace their vitamin D to a level of at least 30 ng/dL (75 nmol/L). After this level is reached, the patient should be placed on a vitamin D dosage to maintain that value. The choice to use cholecalciferol versus ergocalciferol is often based on the level of vitamin D deficiency. Since ergocalciferol is more readily available in the 50,000 U form and has a shorter half-life, it is recommended when a patient's vitamin D level is less than 10 ng/mL (25 nmol/L). Cholecalciferol is often used when the level is between 20 and 30 ng/mL (50-75 nmol/L) or for maintenance. Since this patient already has hypercalcemia and low-dose repletion is desired, the lower doses (400 U daily) of vitamin D3 (over-the-counter cholecalciferol) should be used. This patient's serum calcium should be monitored at least monthly.This patient does not meet the threshold for surgery. His serum total calcium level is less than 1 standard deviation from upper limit of normal, his bone density score is not in the osteoporotic or treatment range, he is older than 50 years of age, and his glomerular filtration rate is preserved.Alendronate would be an excellent option for calcium reduction and simultaneous treatment of osteoporosis if his T-scores were lower or Fracture Risk Assessment Tool (FRAX) scores were higher. The FRAX calculator defines the 10-year fracture risk for patients with T-scores in the −1.0 to −2.5 range. The FRAX calculator ( www.shef.ac.uk/FRAX) incorporates multiple risk factors including sex, fracture history, femoral neck bone mineral density, steroid usage, smoking, BMI, age, and alcohol intake to determine projected fracture risk. If the risk of major osteoporotic fracture is greater than or equal to 20% or the risk of hip fracture is greater than or equal to 3%, the patient's benefit from therapy exceeds the risk and treatment should be offered.Calcitonin is an option for reducing his calcium levels, but he is currently asymptomatic and does not warrant calcium lowering.Cinacalcet, a calcimimetic agent, is another option for lowering calcium for symptomatic patients with kidney involvement. This patient has preserved kidney function and no symptoms. Due to the cost and potential side effects of cinacalcet, it would not be indicated at this time.Key PointIn patients with primary hyperparathyroidism and concomitant vitamin D deficiency, 25-hydroxyvitamin D levels should be repleted to at least 30 ng/dL (75 nmol/L) to prevent further parathyroid hormone stimulation.BibliographyHolick MF, Binkley N, Bischoff-Ferrari HA, Gordon C, Hanley D, Heaney R, Weaver C. Evaluation, treatment and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30.MKSAP 17 Question 2A 74-year-old woman is evaluated for a diagnosis of primary hyperparathyroidism made after an elevated serum calcium level was incidentally discovered on laboratory studies. She has no symptoms associated with hypercalcemia. Medical history is significant for hypertension and chronic kidney disease. Her only medication is amlodipine. She has never smoked.On physical examination, temperature is 36.8 °C (98.3 °F), blood pressure is 134/87 mm Hg, pulse rate is 92/min, and respiration rate is 14/min. BMI is 27. The remainder of her examination is unremarkable.Laboratory studies:Calcium11.3 mg/dL (2.8 mmol/L)Creatinine1.3 mg/dL (114.9 µmol/L)Parathyroid hormone76 pg/mL (76 ng/L)Estimated glomerular filtration rate40 mL/min/1.73 m2Dual-energy x-ray absorptiometry (DEXA) scan shows a T-score of −1.3 in the right femoral neck. Her Fracture Risk Assessment Tool (FRAX) score indicates a 2.1% 10-year probability of hip fracture and 17% 10-year probability of any fracture.Which of the following is the most appropriate therapy to recommend to this patient?A. AlendronateB. CinacalcetC. ParathyroidectomyD. Clinical observationCorrect AnswerC. ParathyroidectomyEducational ObjectiveDefine surgical indications for primary hyperparathyroidism.CritiqueThe most appropriate treatment recommendation for this patient is parathyroidectomy. She has primary hyperparathyroidism as shown by her elevated serum calcium and parathyroid hormone levels. She also has evidence of kidney compromise with an elevated creatinine level and decreased estimated glomerular filtration rate (eGFR). Impaired kidney function (defined as eGFR <60 mL/min/1.73 m2, 24-h urine calcium >400 mg/24 h [10 mmol/24 h], or the presence of nephrolithiasis or nephrocalcinosis by radiograph, ultrasound, or CT) is an indication for surgical treatment of hyperparathyroidism in otherwise asymptomatic patients. Other indications for surgery in asymptomatic patients include age younger than 50 years; a serum calcium level greater than or equal to 1 mg/dL (0.25 mmol/L) above upper limit of normal; a T-score of −2.5 or worse at the lumbar spine, total hip, femoral neck, or distal radius; or in those in whom medical surveillance is neither desired nor possible. Patients with these indications are considered to have the highest potential benefit from surgery.A bisphosphonate, such as alendronate, would not be the treatment of choice for this patient as she does not have osteoporosis nor does she meet Fracture Risk Assessment Tool (FRAX) criteria for therapy. The FRAX calculator defines the 10-year fracture risk for patients with T-scores in the −1.0 to –2.5 range. The FRAX calculator ( www.shef.ac.uk/FRAX) incorporates multiple risk factors including gender, fracture history, femoral neck bone mineral density, glucocorticoid usage, smoking, BMI, age, and alcohol intake to determine projected fracture risk. If the risk of major osteoporotic fracture is greater than or equal to 20% or the risk of hip fracture is greater than or equal to 3%, the patient's benefit from therapy exceeds the risk, and she should be offered treatment. Additionally, bisphosphonates should be used with caution in patients with compromised kidney function.If the patient declines surgical intervention, a calcimimetic agent such as cinacalcet would be an appropriate therapy. Cinacalcet has recently been FDA approved as an alternative for patients unable or unwilling to undergo parathyroidectomy. Cinacalcet lowers calcium levels by stimulating the calcium-sensing receptors of the parathyroid glands and inhibiting parathyroid hormone secretion. However, it is expensive and has multiple drug interactions, which make it less desirable in this patient.Because this patient is considered to be at increased risk of complications due to untreated hypercalcemia, clinical observation alone would not be appropriate.Key PointDecreased estimated glomerular filtration rate (<60 mL/min/1.73 m2) is an indication for surgical treatment of primary hyperparathyroidism in otherwise asymptomatic persons.BibliographyBilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the Management of Asymptomatic Primary Hyperparathyroidism: Summary Statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561-9.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. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 7 June 2016Volume 164, Issue 11Page: ED11KeywordsBreast cancerCalciumHyperparathyroidismKidneysParathyroid hormoneParathyroidectomyResearch laboratoriesRisk assessmentsVitamin DVitamin D deficiency ePublished: 7 June 2016 Issue Published: 7 June 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...