<i>Annals</i> for Educators - 5 April 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives5 April 2016Annals for Educators - 5 April 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201604050 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsOral Prednisolone in the Treatment of Acute Gout. A Pragmatic, Multicenter, Double-Blind, Randomized TrialTwo recent randomized, controlled trials showed that oral corticosteroids and nonsteroidal anti-inflammatory drugs were similarly effective in treating acute gout symptoms, but the trials had small samples and other methodological limitations. This large pragmatic trial compared the analgesic effectiveness and safety of oral prednisolone versus indomethacin in the treatment of acute gout.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to describe the pathophysiology of gout. What are the causes of urate overproduction and decreased urate excretion? Use the information in DynaMed Plus: Gout (a benefit of your ACP membership) to help prepare.What are the presentations of acute gout? What is the differential diagnosis, and how is a diagnosis made? How should it be treated? Review the results of this trial.Ask your learners what a pragmatic clinical trial is. How does it differ from an explanatory trial? In which ways is each more (or less) useful in answering clinical questions? Use a brief perspective on this topic to help frame your discussion.What made the enrollment and management of patients in this trial more “real world” (pragmatic)? Prompt your learners by asking if they think the results might have been affected by allowing gout to be defined by the clinician, rather than requiring confirmation of urate crystals in the synovial fluid? How might that have affected the results of the trial?What can be done to prevent recurrent acute attacks of gout?The Effect of Erythropoietin-Stimulating Agents on Health-Related Quality of Life in Anemia of Chronic Kidney Disease. A Systematic Review and Meta-analysisThis meta-analysis of 17 studies examines whether erythropoietin-stimulating agents (ESAs) improve health-related quality of life (HRQOL) in patients with anemia of chronic kidney disease (CKD).Use this study to:Ask your learners to list the potential causes of chronic anemia in a patient with CKD. How should each be managed?What is the role of iron supplementation in patients with CKD? How should it be administered?What are the potential benefits of ESAs in the treatment of patients with CKD? What are the potential harms? When should their use be considered? See what a current clinical guideline recommends. This review concluded that using ESAs to obtain higher hemoglobin targets in patients with CKD does not result in important differences in HRQOL. Ask your learners to define HRQOL. What “domains” might be considered (e.g., physical health, mental health)? What variables affect each domain? How might they be measured?Have your learners complete the SF-36, used in the studies included in this review and one of the most widely used “generic” HRQOL measures. You may get the form at this link. How might a “disease-specific” HRQOL tool differ? Do your learners think the questions addressed by such research tools ask what is important to a patient? Do they think HRQOL is an important outcome in trials of therapy?Multimedia Teaching ToolsBeyond the Guidelines: Should We Screen for Coronary Heart Disease in Asymptomatic Persons? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterMr F. is a 72-year-old man in good health. He has no symptoms to suggest coronary heart disease (CHD). Should he be screened for CHD?Use this program to:Watch the interview of Mr. F with your learners. He worries that tests and the results of screening for CHD might make him nervous. As he puts it, “...candidly maybe a little knowledge is a dangerous thing. I think if I subjected myself to one of those tests and I was informed that there was a moderate possibility that I would have some symptoms of coronary artery disease, that would make me anxious.” Ask what your learners would recommend to Mr. F.Now watch the video of the grand rounds debate regarding whether screening for CHD is beneficial. Or, download the already prepared slides to help summarize the key points made for your learners.Has the discussion altered your learners' thoughts?Given the prevalence of CHD, and the number of trials conducted each year in cardiology, are your learners surprised by the lack of a single, clear-cut answer to the questions posed in this debate? How would they design a study to assess whether screening is beneficial to patients like Mr. F? What outcomes would they want to study?Substance Use DisordersThis eminently practical review is structured around answering key questions related to the prevention, diagnosis, and treatment of substance use disorders.Use this review to:Download the teaching slides. Use the provided multiple-choice questions to introduce topics during a teaching session. Log on to enter your responses and claim CME for yourself.Ask your learners what the most common substance use disorders are. How common are they?Can substance use disorders be prevented? Ask how.How is unhealthy alcohol use defined? How is it diagnosed? Review the questions that may be useful in the Diagnosis section of this review.Ask how withdrawal from alcohol should be approached in the outpatient setting. What about withdrawal from opioids? Benzodiazepines? What interventions are available for each?What is the role of the primary care physician (versus an addiction specialist) in the care of a patient with a substance use disorder?Humanism and Professionalism:Annals Graphic Medicine: Please Don't Use Patient NamesShow this single-panel cartoon to your learners.Ask them:Is it funny? Is it disturbing? Is it ever OK to make jokes about our patients?If we are honest with ourselves, might we be guilty of ever dehumanizing our patients? When and why? What should we do?On Being a Doctor: The Nazi PatientDr. Sussman recalls learning about his patient's past activities as a Nazi soldier as well as his current beliefs and struggles with how he should respond as the patient's physician.Use this essay to: Listen to an audio recording, read by On Being a Doctor associate editor Dr. Michael LaCombe.Ask your learners if there are situations that would make it difficult to continue to provide care to a patient. Is there a limit to our duty to treat all patients?When might it be appropriate to stop being a patient's doctor? How should this be done? Should you arrange for another physician to take over? If so, what should you tell the patient's new physician? How might his or her knowledge of the reasons you need to stop influence care?MKSAP 17 QuestionA 76-year-old man seeks advice regarding dietary modifications to help prevent gout flares. He recently experienced his first episode of podagra. At his initial visit, serum urate level was 7.2 mg/dL (0.42 mmol/L). History is also significant for hypertension, for which he takes losartan.On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 135/80 mm Hg, pulse rate is 80/min, and respiration rate is 15/min. BMI is 27. The remainder of the examination is unremarkable.In addition to meat restriction, increased intake of which of the following may help to decrease this patient's risk of gout flares?A. Leafy green vegetablesB. Low-fat dairy productsC. Red wineD. ShellfishCorrect AnswerB. Low-fat dairy productsEducational ObjectiveManage gout with dietary modifications.CritiqueThe addition of low-fat dairy products is appropriate for this patient with gout. Low-fat dairy products have been shown to decrease the risk of gout flares both through uricosuric and anti-inflammatory properties. He should also be advised to reduce intake of high-fructose beverages such as soft drinks because they are associated with gout flares due to metabolic pathways utilized in the metabolism of fructose, which lead to increased uric acid generation. Obesity is also a risk factor for gout and should be addressed as needed.Some leafy green vegetables are high in purines, the nucleic acid component that is metabolized to uric acid. Thus, a recommendation to increase leafy greens as a dietary approach to gout treatment would be incorrect. However, intake of leafy green vegetables has not been shown to increase the risk of flares in population-based studies.Alcohol is a well-established trigger for gout, probably due to several mechanisms, including uric acid production and kidney urate handling. Although wine has been found less likely to trigger gout flares than beer, alcohol consumption of any sort will increase the risk of flares overall.Shellfish have long been established as a food that is likely to trigger a gout flare due to the high purine load and should therefore be restricted in this patient's diet.Key PointIn patients with gout, lifestyle and dietary modifications, including weight loss if appropriate, reduction of high-fructose and high-purine foods, alcohol restriction, and increased low-fat dairy intake, may help decrease the risk of gout flares.BibliographyChoi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004 Mar 11;350(11):1093-1103.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Darren B. Taichman, MD, PhDFrom 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 5 April 2016Volume 164, Issue 7 Page: ED7 Keywords Alcohols Congenital heart disease Eating Gout Graduate medical education Patients Purines Quality of life Uric acid Wine ePublished: 5 April 2016 Issue Published: 5 April 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...