<i>Annals</i> for Educators - 4 October 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives4 October 2016Annals for Educators - 4 October 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201610040 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsVariation in Mammographic Breast Density Assessments Among Radiologists in Clinical Practice: Findings From a Multicenter Observational StudyAbout half of U.S. states currently have legislation requiring radiology facilities to disclose information on mammographic breast density to women, and many include language recommending discussion of supplemental screening options. However, breast density assessment, as routinely practiced in the clinical setting, is subjective. The authors performed cross-sectional and longitudinal analyses of prospectively collected observational data to examine variation in breast density assessment across radiologists in clinical practice.Use this study to:Ask your learners why breast density is important. What is the relationship between breast density and risk for breast cancer? What affect does breast density have on the performance of mammography? The authors discuss these in the paper's introduction.Arrange for a radiologist to show your team mammograms from patients with a range of breast tissue densities. Ask the radiologist to discuss the difficulties faced in evaluating breast density. On what bases do they quantify density?Does your state require notification of patients regarding the density of their breasts on mammography? How do your learners think such information should be communicated to patients? How would they explain its importance? How does the variation in radiologists' reading demonstrated in this study affect how they might counsel patients?Ask your learners how they would counsel a patient with dense breast tissue regarding cancer screening. Would their approach to test ordering be different? Use a recent guideline from the U.S. Preventive Services Task Force to help inform the discussion.Prediction Models of Mortality in Acute Pancreatitis in Adults. A Systematic ReviewThis systematic review of 94 studies evaluates the accuracy and utility of 18 severity scoring systems for predicting mortality in adults with acute pancreatitis.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to generate a differential diagnosis of acute pancreatitis.What variables do they consider in evaluating the severity of the patients' conditions? How do they decide whether a patient needs hospital admission? Intensive care? Use the accompanying editorial to help inform your discussion.How do prognostic tools help us? What performance parameters should be considered before using a prognostic tool? Do your learners use any to help explain prognosis to their patients?How should patients with acute pancreatitis be managed? What interventions are helpful? How should they be monitored? What complications may occur, and how are they managed? Use the information in DynaMed Plus: Acute Pancreatitis (a benefit of your ACP membership) to help prepare a teaching session.DepressionWorldwide, unipolar depression is a leading cause of disability and loss of years of productivity. In the United States, depression estimates range from 5% to 10% but can be as high as 40% depending on the population seen in primary care or specialty settings. Only about half of depressed persons receive adequate treatment despite the existence of high-quality, evidence-based therapies.Use this review to:Ask who should be screened for depression. How should one screen for it?What are the diagnostic criteria?Who should be referred for psychotherapy? Behavioral cognitive therapy?Who should start pharmacotherapy, and with which agents? Use the table to compare their indications and possible side effects.How long should therapy continue? How should it be monitored?Download the teaching slides to help prepare for a teaching session. Use the multiple-choice questions provided to help break up a session, and be sure to log in to enter the answers and earn CME credit for yourself!Are physicians at increased risk for depression? What resources are available locally to help (e.g., crisis lines, employee health, counseling)? How might being labeled as “depressed” affect a physician?Humanities and ProfessionalismAnnals Graphic Medicine - Today's Doctor–Patient RelationshipThis artwork begs the question, “Where exactly do we practice medicine?”Use this artwork to:Show it to your learners and ask them for their reactions.What point is the author making? Do your learners agree?Do they feel they spend enough time with their patients? Why or why not? Is this within their control? If not, are there things they may do to improve the situation?Teach at the bedside! Show this picture to some of the patients on your team. Ask what the patients think!On Being a Patient: I Had to Get Cancer to Become a More Empathetic DoctorDr. Norden describes how his understanding of patients' anxiety, the burden of treatment side effects, and problematic health care communications changed as a result of his own experience with cancer.Use this essay to:Listen to an audio recording, read by On Being a Doctor/Patient editor, Dr. Michael LaCombe.Have your learners heard some or all of these lessons before?Do your learners think they do enough to be empathic and avoid the problems Dr. Norden describes in caring for their patients? Why do we seem to require reminders—over and over—of these essential messages? Are there ways to remind ourselves of these essential lessons regularly, and often enough? Do we all need to have been patients to become as compassionate as possible as physicians?Ask your learners to think about their own experiences. Have they ever experienced impersonal care, or care that was not as compassionate as it should have been? Perhaps they recall the experiences of family members. You might not want to ask them to answer aloud, as learners may not wish to share their own stories or reveal medical histories, but you can ask them to think about it.MKSAP 17 QuestionA 35-year-old man is evaluated in the emergency department for a 6-hour history of epigastric abdominal pain that radiates to the back. He also has nausea and occasional bilious vomiting. He has consumed between six and twelve beers daily for 10 to 15 years.On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 110/65 mm Hg, pulse rate is 105/min, and respiration rate is 22/min. Abdominal examination discloses epigastric tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is mild abdominal distention. No jaundice is noted.Laboratory studies reveal a leukocyte count of 14,000/μL (14 × 109/L), a blood urea nitrogen level of 25 mg/dL (8.9 mmol/L), and a serum lipase level of 952 U/L.Abdominal ultrasound shows a normal-appearing gallbladder and no biliary dilation. The patient is admitted to the hospital. Over the next 48 hours, he has ongoing abdominal pain, nausea, and poor appetite despite supportive therapy consisting of pain medication and aggressive intravenous fluid replacement. Subsequent contrast-enhanced CT of the abdomen shows nonenhancing areas of the head and body of the pancreas (consistent with necrosis) and several peripancreatic fluid collections.Which of the following is the most appropriate management?A. Drainage of the fluid collectionsB. Endoscopic retrograde cholangiopancreatographyC. Enteral nutrition by nasojejunal tubeD. Total parenteral nutritionCorrect AnswerC. Enteral nutrition by nasojejunal tubeEducational ObjectiveTreat acute pancreatitis with enteral nutrition.CritiqueEnteral feeding is the most appropriate management. Enteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis. This patient has moderately severe acute pancreatitis based on evidence of pancreatic necrosis and peripancreatic fluid collections. He also has several risk factors for severe disease based on the presence of three of four Systemic Inflammatory Response Syndrome (SIRS) criteria (pulse rate >90/min, leukocyte count >12,000/µL [12 × 109/L], and respiration rate >20/min) and a blood urea nitrogen level greater than 23 mg/dL (8.2 mmol/L). Nasogastric and nasojejunal feeding appear to be comparable in safety and efficacy. The optimal time to start enteral nutrition remains under investigation, but it should commence no later than 72 hours after presentation. In mild acute pancreatitis, oral feeding may start when nausea and vomiting resolve.Drainage of acute peripancreatic fluid collections (APFCs) is not appropriate at this time because most collections resolve without intervention. Asymptomatic APFCs require no treatment. Symptomatic APFCs can be treated medically with bowel rest, jejunal feeding, pancreatic enzymes, octreotide, and rarely pancreatic duct stenting. Rarely, APFCs persist beyond 4 weeks, when they become encapsulated and are labeled a pancreatic pseudocyst. Pseudocysts are amenable to drainage if clinically indicated based on persistent pain despite medical therapy, infected pseudocyst, or obstruction of the gastric outlet or biliary tract.Endoscopic retrograde cholangiopancreatography in acute pancreatitis should be used only in the following clinical scenarios: (1) in a patient with ascending cholangitis (fever, right upper quadrant pain, and jaundice) concomitant with acute pancreatitis, or (2) in a patient with gallstone pancreatitis who is not improving clinically and has worsening liver chemistry test results. Patients with gallstone pancreatitis and no complications should have a cholecystectomy prior to discharge.Key PointEnteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis.BibliographyTenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108:1400-15; 1416. doi:10.1038/ajg.2013.218Do 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 4 October 2016Volume 165, Issue 7Page: ED7KeywordsAbdominal painAcute pancreatitisMortalityNauseaNutritionPatient advocacyRadiologistsRespirationTotal parenteral nutritionVomiting ePublished: 4 October 2016 Issue Published: 4 October 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...