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

Web Exclusives5 January 2016Annals for Educators - 5 January 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201601050 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCharacteristics of Skin Lesions Associated With Anti–Tumor Necrosis Factor Therapy in Patients With Inflammatory Bowel Disease. A Cohort StudyAlthough tumor necrosis factor (TNF) antagonists are effective treatment for inflammatory bowel disease (IBD) that is refractory to conventional therapy, some patients have developed psoriasiform skin lesions, prompting discontinuation of therapy. This large series of patients with IBD initiating anti-TNF therapy evaluated the occurrence of skin lesions, their clinical course, and whether therapy could be continued while the dermatologic problems were managed.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below.Review with your learners the approach to medical therapy for IBD. Which drugs are used, and what are their potential side effects?How is disease severity and response to therapy assessed? When is referral required? When are TNF inhibitors indicated? Invite an expert in IBD to help lead your discussion.Ask what are the dermatologic manifestations of Crohn disease and ulcerative colitis. Review the images of dermatologic lesions seen in this study. What therapies should be tried for each before discontinuation of the TNF inhibitor considered? If the dermatologic problem persists despite therapy, how would your learners weigh the benefits and harms of continued anti-TNF therapy?Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose. A Cohort StudyOpioid treatment patterns after an overdose are unknown. This study using data from a large U.S. health insurer to identify patients presenting to a hospital or an emergency department with a nonfatal opioid overdose found that opioid prescriptions were continued in nearly all of the patients following the overdose.Use this study to:Ask your learners how they monitor their patients who receive opioids for chronic pain. What are the alternatives to the use of opioids?Do your learners know when and how to consider the use of buprenorphine? Invite an expert in chronic pain management to join your discussion.An editorialist hypothesizes that continuation of these patients' opioids after an overdose may, in part, be due to the prescriber not being made aware of the emergency room visit. Have your learners' patients been seen in the emergency department without them being informed? Ask what systems need to be in place to prevent this from occurring. How might patient safety be affected by such lapses?Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications: Best Practice Advice From the Clinical Guidelines Committee of the American College of PhysiciansThe underuse of generic medications is an important example of a situation where unnecessarily expensive therapies are used when less costly, equally effective options are available. In this best practice advice paper, the American College of Physicians recommends that clinicians prescribe generic medications, if possible, rather than more expensive brand-name medications.Use this paper to:Ask your learners what the difference is between “generic substitution” and “therapeutic interchange” (the authors review this on page 42).Ask your learners whether their patients have ever said that a generic drug did not work as well for them, or that it caused problems. How did they respond?Are there any situations in which your learners feel they should prescribe a brand-name formulation of a drug when a less expensive, generic version is available?Role-play with your learners: pretend to be a patient who believes that a generic medicine was “not as strong” or “did not work as well for me.” Perhaps express fear that the “generic medicine” is not as good. What should your learners say, and how will they say it?The History and Future of Treatment of HypothyroidismThis article describes the evolution of and rationale for changes in the treatment of hypothyroidism over the past century and addresses limitations in our knowledge of what constitutes adequate thyroid replacement.Use this paper to:Review the normal regulation of thyroid hormone.Ask your learners what the symptoms of hypothyroidism and hyperthyroidism are.Ask whether thyroid-stimulating hormone (TSH) alone is adequate for evaluation of the patient with newly diagnosed hypothyroidism? What about a patient already on L-thyroxine monotherapy?What are the limitations to what the serum TSH tells us about thyroid replacement?Have your learners encountered patients who report symptoms potentially due to thyroid dysfunction despite a normalized TSH? How do they manage such patients? What are the concerns with increasing the dose of their thyroid replacement?Alcohol UseData from the third National Epidemiologic Survey on Alcohol and Related Conditions indicate that 14% of adults have a current alcohol use disorder and 29% have had an alcohol use disorder over their lifetime, with rates highest among men and younger persons. As such, unhealthy alcohol use is the third leading cause of preventable death and costs the United States over $220 billion each year. Are your learners prepared to address unhealthy alcohol use by their patients?Use this review to:Use the already prepared teaching slides to plan a teaching session, and use the multiple-choice questions to help introduce topics. Be sure to log on and enter your answers to earn CME credit for yourself.Ask your learners whether they screen their patients for unhealthy alcohol use. How do they do it? What screening tools are available?Review the potential adverse health effects of alcohol use. Ask your learners what physical examination findings may suggest unhealthy alcohol use. What laboratory findings might be useful?Ask your learners whether they think certain terms (such as “abuse” or “alcoholic”) are useful when discussing alcohol use with a patient. What language should or should not be used? This is discussed in the review.Humanism and ProfessionalismOn Being a Doctor: A New Pair of LungsDr. Coulehan tells how a patient gave him credit for something he thought he had not done.Use this essay to: Listen to an audio recording, read by Dr. Michael LaCombe, with your learners.Ask your learners if they feel that Dr. Coulehan had been too cautious in recommending against a lung transplant.Have your learners ever personally enjoyed their interactions with a patient so much that they secretly did not want to consider interventions that might alter it? When might such considerations be wrong? How can they be sure never to allow personal desires to hinder making the best decision for their patients?Are your learners surprised to hear that Max and Sam credited Dr. Coulehan with her good outcome following transplantation? What might this tell us about the things that matter most to our patients?MKSAP 17 QuestionA 40-year-old man is evaluated for several ulcers located near his ostomy site. He has a 15-year history of ulcerative colitis and underwent elective proctocolectomy with ostomy placement 3 months ago to decrease his risk of colorectal cancer. His ostomy has functioned well without previous problems. The ulcers, which are moderately painful, developed 1 month ago and have failed to respond to topical care, including barrier methods and changing adhesives. He is otherwise healthy and takes no medications.On physical examination, vital signs are normal. BMI is 19. Skin findings are shown.Which of the following is the most appropriate treatment?A. Replace ostomy to the opposite sideB. RituximabC. Surgical debridementD. Topical clobetasolCorrect AnswerD. Topical clobetasolEducational ObjectiveEducational Objective: Treat pyoderma gangrenosum.CritiqueThis patient has peristomal pyoderma gangrenosum (PG), and a topical potent glucocorticoid, such as clobetasol, is the preferred treatment. PG is an autoimmune ulcerative process that may occur idiopathically or in conjunction with an underlying disease; the most common disease association is inflammatory bowel disease (IBD). This patient has IBD and had recent surgery; 20% to 30% of patients with PG may exhibit “pathergy” or induction of lesions in response to trauma, such as surgery. Peristomal PG is a common manifestation, and early recognition is essential to avoid expansion, thereby limiting ostomy appliance adherence and devastating patients' quality of life. PG ulcers are typically painful, may rapidly expand, and are often exudative. When appropriate therapy is instituted, the lesions often dry out and become less painful over 1 to 2 weeks. Even when the PG inflammation is controlled, patients are left with a large ulcer that must then heal, and local care is critical. PG is treated with glucocorticoids (oral, topical, or intralesional), cyclosporine, or infliximab (a tumor necrosis factor α inhibitor) as first-line therapy for most patients. Active IBD should be treated as well.Replacing the ostomy to the opposite side would entail major surgery, which, in the setting of active PG, could worsen the problem and may lead to PG at the new site. Removing the ostomy would not address the PG ulcer.Rituximab is not indicated for PG, as rituximab targets CD20+ cells (B cells), which have little role in the pathogenesis of PG.Because of the nature of the disease, PG lesions should not be debrided. PG lesions will worsen after debridement. It is not uncommon for PG to be diagnosed after repeated, unsuccessful debridements for a presumed infection result in dramatic worsening of the initial ulcer. Regardless, there is no necrotic tissue here to debride.Key PointKey Point Glucocorticoids (oral, topical, intralesional) are first-line therapy for peristomal pyoderma gangrenosum.BibliographyMiller J, Yentzer BA, Clark A, Jorizzo JL, Feldman SR. Pyoderma gangrenosum: a review and update on new therapies. J Am Acad Dermatol. 2010 Apr;62(4):646-54.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 5 January 2016Volume 164, Issue 1Page: ED1KeywordsAlcoholsHypothyroidismInflammatory bowel diseaseLesionsOpioidsPyodermaThyroidThyroid-stimulating hormoneTumor necrosis factorUlcers ePublished: 5 January 2016 Issue Published: 5 January 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...