Annals for Educators - 3 January 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives3 January 2017Annals for Educators - 3 January 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201701030 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsChronic Hepatitis B and C Virus Infection and Risk for Non-Hodgkin Lymphoma in HIV-Infected Patients. A Cohort StudyNon-Hodgkin lymphoma (NHL) is a common AIDS-defining condition. Using data from 18 pooled cohorts, the authors investigated whether chronic infection with hepatitis B or C virus is associated with NHL in patients with HIV who are receiving antiretroviral therapy.Use this study to:Ask your learners whether patients living with HIV and receiving antiretroviral therapy remain at increased risk for cancer. If so, which types of cancer? Use a recent study to help answer these questions.Can your learners think of potential mechanisms by which coinfection with hepatitis B or C virus might increase the risk for NHL among HIV-infected patients?The authors of this study as well as those of the accompanying editorial suggest that immune reconstitution inflammatory syndrome (IRIS) may play a role in the development of NHL in the HIV- and hepatitis-infected patients studied. What is IRIS? What are the potential clinical manifestations?Diagnosis of Acute Gout: A Clinical Practice Guideline From the American College of PhysiciansManagement of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of PhysiciansThese clinical practice guidelines from the American College of Physicians (ACP) provide recommendations about the diagnosis of acute gout in adults with joint inflammation, as well as the management of acute and recurrent gout.Use these guidelines to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how they evaluate a patient with acute joint pain. When should gout be a considered, and what is the differential diagnosis? How should the diagnostic approach proceed? Use the recent In the Clinic: Gout to prepare answers to these and other essential questions.The ACP Clinical Guidelines Committee felt there was insufficient evidence to recommend that clinicians practice a “treatment-to-target” approach to managing patients with gout (i.e., monitoring and using drugs as needed to keep serum uric acid levels below a target level). The American College of Rheumatology (ACR), however, has advocated such an approach. What would your learners want to know before deciding whether such an approach is appropriate? Use the accompanying editorials by members of the ACR and ACP to help frame a discussion of why 2 organizations came to differing recommendations.Ask your learners what is the difference between a clinical practice guideline recommendation and a consensus opinion recommendation.In the absence of high-quality evidence to guide practice, what do your learners think they should do? What are the advantages and disadvantages to their proposed approach?Aortic StenosisCalcific aortic stenosis is the most common cardiac valve lesion in developed countries, and management is changing because of recent advances in diagnostic and treatment strategies. This eminently practical review addresses the assessment of lesion severity, the timing and choice of interventions, and patient outcomes.Use this review to:Download the ready-to-use teaching slides to help prepare for a teaching session.Ask your learners who is at increased risk for aortic stenosis. When and what testing is indicated?Do your learners know what “pseudo aortic stensosis” is and why it is important? See the section on page ITC5.How should patients with mild aortic stenosis be followed? At what point should intervention be considered?Ask a cardiologist to show your team images from a transcatheter aortic valve replacement. When should this be considered (as opposed to surgical aortic valve replacement)?Use the provided multiple-choice questions to help introduce topics during a teaching session. Be sure to log on and enter your answers to earn CME for yourself!Humanism and ProfessionalismAnnals Graphic Medicine - Breach of ConfidentialityThis short graphic piece portrays a colleague doing what he knows he should not be doing—but it's OK.Use this graphic medicine piece to:Ask your learners if they have ever told their family members or friends about their patients. Is this OK?How good are we about not discussing patient information in public places? As long as we don't mention the patient's name, is it OK? Why or why not?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;350:1093-103.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 3 January 2017Volume 166, Issue 1Page: ED1KeywordsGoutGraduate medical educationHepatitis BImmune reconstitution inflammatory syndromeLesionsPurinesStenosisTreatment guidelinesUric acidWine ePublished: 3 January 2017 Issue Published: 3 January 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...