<i>Annals</i> for Educators - 6 September 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives6 September 2016Annals for Educators - 6 September 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201609060 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLong-Term Pioglitazone Treatment for Patients With Nonalcoholic Steatohepatitis and Prediabetes or Type 2 Diabetes Mellitus. A Randomized TrialNonalcoholic steatohepatitis (NASH) is a common chronic liver condition affecting obese patients with prediabetes or type 2 diabetes mellitus (T2DM). Pioglitazone seems to target metabolic defects, such as insulin resistance and adipose tissue dysfunction, that are associated with both NASH and T2DM. This trial examined the efficacy and safety of pioglitazone treatment of NASH in patients with prediabetes or T2DM.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to define nonalcoholic fatty liver disease (NAFLD), steatosis, and NASH. What conditions are associated with NAFLD? What evaluation should be performed to make this diagnosis? Use the information in DynaMed Plus: NAFLD a benefit of your ACP membership.What are the complications of NAFLD? Who is at risk for progression from steatosis to NASH and to cirrhosis? What, if anything, may be done to prevent progression?Arrange for a pathologist to review the histology of normal liver, as well as the changes seen in NAFLD, NASH, and cirrhosis.What is known about the pathophysiology of NASH that might explain why diabetics are at risk? Why might thiazolidinediones be beneficial? These are discussed in the paper's introduction.Are these results ready to be incorporated into clinical practice? Why or why not? What more would your learners like to know? Use the accompanying editorial to help frame your discussion.Transmission of Neurodegenerative Disorders Through Blood Transfusion. A Cohort StudySimilarities with prion diseases and findings in animal models raise concern that certain neurodegenerative disorders, including Alzheimer and Parkinson diseases, might be transmissible through transfusion of blood products. This study used Scandinavian national databases to assess the risk for neurodegenerative diseases among recipients of blood products from donors who were diagnosed with such conditions.Use this study to:Ask your learners to list the acute and chronic risks of blood product transfusions.Invite an expert from your blood bank to discuss what questions are asked of blood donors, who is excluded from donating, and why? For what conditions, and how, are donated products actively tested?What are prion diseases? What pathological characteristic of Alzheimer and Parkinson disease is also seen in prion-transmitted conditions, such as Creutzfeldt–Jakob disease? What are their clinical characteristics?Before reviewing this study, ask your learners how they would use robust long-term national registries of blood donations and transfusions, together with national health records, to design a study to assess whether blood transfusion might be associated with the development of neurodegenerative diseases. What would be the limitations of such a study? What would your learners use as a “positive control” for their study (i.e., to assess whether their study is capable of detecting an infectious risk of blood donation)?Now ask your learners to describe the cohort study design used by these investigators. What were the “exposure” and “outcomes”? What unique challenge was posed by the potential latency between when an individual might donate blood, or receive a blood transfusion, and the development of disease?Hepatitis C VirusHepatitis C virus is the most common blood-borne pathogen in the United States, estimated to infect over 3 million Americans. This eminently practical and concise review answers key questions regarding the evaluation, treatment, and prognosis of patients with hepatitis C virus infection.Use this review to:Introduce specific teaching topics with the multiple-choice questions provided, and log on to enter your answers and earn CME for yourself!Ask what measures help to prevent hepatitis C virus infection. Can a patient who has achieved sustained virologic response from treatment be re-infected?Who should be screened for hepatitis C, and how? How does one interpret serologic testing?How should an infected individual be evaluated? Why is it important to determine whether there is hepatic fibrosis and its severity?How efficacious are hepatitis C therapies? In which patients? How are they used? Does treatment require a specialist?How should treatment be monitored?Download the already-prepared teaching slides to help prepare a session.For Program Directors: Running an Internal Medicine Residency ProgramThe Internal Medicine Reporting Milestones: Cross-sectional Description of Initial Implementation in U.S. Residency ProgramsInternal medicine residency training programs recently began evaluating residents' achievement of the milestones deemed necessary for completion of training. This study assessed the initial evaluations of all U.S. internal medicine residents submitted by program directors in the first year that reporting was required. See how your experiences compare with those of your colleagues.Humanism and ProfessionalismAnnals Graphic Medicine - Judgment CallThis engaging piece relates the angst of a family member facing difficult decisions about her mother's continued care.Use this piece to:Ask your learners to read it. Then, ask for their reactions.Have they ever felt that a family member was being “selfish” for advocating for continued curative therapies for a loved one with a poor prognosis? Do they agree with the comments of the protagonist's uncle?Do your learners think the author made the right decision? How did things turn out? Did it surprise your learners?How would your learners have counseled this patient's family? Since sometimes things turn out differently than expected, how do we balance the known and the unknown when discussing end-of-life care with patients and their families?Teaching Scholarship OpportunityHerbert S. Waxman Clinical Skills Center Teaching ScholarshipAll chief residents who are members of ACP are eligible to apply for a Herbert S. Waxman Clinical Skills Center Teaching Scholarship. The Waxman Center is part of ACP's annual Internal Medicine Meeting, and it provides hands-on, small-group learning opportunities for clinical and procedural skills. Waxman Scholars assist in teaching popular workshops under the guidance and mentorship of expert faculty. Eligible workshops include ultrasound-guided invasive procedures (central line, paracentesis, thoracentesis, and lumbar puncture), arthrocentesis, incision and drainage of abscesses, and skin biopsy. The scholarship includes the cost of meeting registration, travel, and accommodations for the ACP Internal Medicine Meeting 2017 to be held 30 March–1 April 2017, in San Diego, CA.This is an opportunity to build your CV and to gain valuable experience teaching a workshop.Applications may be submitted until 10/3/2016. Don't miss this unique opportunity— complete your application !MKSAP 17 QuestionA 64-year-old man is evaluated in follow-up after recent abnormal findings on intraoperative liver biopsy. Two days ago he underwent right colon resection for a large villous adenoma with high-grade dysplasia. At the time of surgery, an abnormal-appearing liver was noted and biopsy was performed. His medical history is notable for type 2 diabetes mellitus, hypertension, and obesity. Medications are metformin and lisinopril. He drinks two cans of beer daily but does not use tobacco.On physical examination, vital signs are normal; BMI is 38. No jaundice or spider angiomata are noted. Abdominal examination reveals healing laparoscopic scars and hepatomegaly. The spleen is not palpable, and there is no ascites. No peripheral edema is seen.Laboratory studies:Complete blood countNormalINRNormalAlanine aminotransferase79 U/LAspartate aminotransferase68 U/LAlbuminNormalAlkaline phosphatase126 U/LTotal bilirubinNormalLiver biopsy demonstrates a mildly active steatohepatitis without fibrosis. An iron stain is negative.Which of the following is the most appropriate management?A. Bariatric surgeryB. PhlebotomyC. Surveillance for hepatocellular carcinomaD. Weight lossCorrect AnswerD. Weight lossEducational ObjectiveManage nonalcoholic fatty liver disease.CritiqueThe most appropriate management is weight loss. This patient has nonalcoholic fatty liver disease (NAFLD), and weight loss should be recommended. NAFLD is the most common cause of abnormal liver test results in the United States. Approximately 30% of the U.S. population has NAFLD, some of whom have normal liver enzyme levels. Most patients with NAFLD have insulin resistance associated with obesity, hypertriglyceridemia, and/or type 2 diabetes mellitus. Approximately 20% of patients with NAFLD have nonalcoholic steatohepatitis (NASH), which is characterized by hepatic steatosis accompanied by inflammation and often fibrosis. Although NASH requires a liver biopsy for accurate diagnosis, a presumptive diagnosis can be made in a patient with mild abnormalities of aminotransferase levels, risk factors for NAFLD (such as diabetes, obesity, and hyperlipidemia), and imaging features consistent with hepatic steatosis. This patient's liver biopsy is consistent with steatohepatitis, and given his risk factors of obesity and diabetes mellitus, NAFLD is the most likely diagnosis.Patients with NASH who have bariatric surgery and lose weight have improvement in hepatic histology, and bariatric surgery can be considered if conservative attempts at weight loss fail.Patients with NAFLD may have abnormal iron tests, especially serum ferritin. The absence of iron on this patient's liver biopsy excludes significant iron overload, and therefore phlebotomy is unnecessary.Patients with NASH and cirrhosis are at significant risk for hepatocellular carcinoma, and surveillance with imaging should be performed every 6 months; however, surveillance is not necessary in the absence of cirrhosis.Key PointA presumptive diagnosis of nonalcoholic steatohepatitis can be made in a patient with mild abnormalities of aminotransferase levels, risk factors for nonalcoholic fatty liver disease (such as diabetes mellitus, obesity, and hyperlipidemia), and imaging features consistent with hepatic steatosis.BibliographyChalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, et al; American Gastroenterological Association. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology. 2012;142:1592-609.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 6 September 2016Volume 165, Issue 5Page: ED5KeywordsBiopsyBlood banksBlood transfusionCirrhosisLiverNon-alcoholic fatty liver diseaseObesitySteatosisType 2 diabetesWeight loss ePublished: 6 September 2016 Issue Published: 6 September 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...