Annals for Educators - 5 June 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives5 June 2018Annals for Educators - 5 June 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201806050 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLong-Term Effectiveness of Sigmoidoscopy Screening on Colorectal Cancer Incidence and Mortality in Women and Men. A Randomized TrialFour randomized trials found that sigmoidoscopy screening reduces colorectal cancer incidence and mortality. Some also indicated that the effect might be smaller in women than men, but the differences varied by study and outcome (incidence or mortality). This population-based, randomized trial in Norway had longer follow-up and more events, and it reached a clear conclusion.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!What properties are required of a test and a disease to recommend screening?Ask your learners what options are available for colorectal cancer screening. Has each method been proven to reduce mortality from colorectal cancer?What are potential reasons why sigmoidoscopy seems to reduce colorectal cancer incidence and mortality in men but not women? Use the accompanying editorial to help frame your discussion. Does your outpatient practice have a means to remind clinicians and patients about colorectal cancer screening? Does it work? Ask your learners to check the charts of each of the patients they see in the outpatient practice over the next month to confirm whether each is up-to-date with screening. If not, why not? How might that be improved?What is an “intention-to-treat” analysis? Look at the Appendix Figure. What numbers do you look at to assess the intention-to-treat analysis? What is a “per protocol” analysis? Why might a per protocol analysis bias the results? In this study, there was little difference between the two, but why might a per protocol analysis have been helpful? Invite an expert in clinical epidemiology to join your discussion.Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine PatientsThe Centers for Medicare & Medicaid Services requires that hospitals pay financial penalties when they have too many readmissions within 30 days of discharge. This 30-day window has little scientific basis, so others have proposed windows of 3, 7, or 14 days, but no direct evidence was given for these shorter periods. The aim of this study was to determine whether readmissions within 7 days of hospital discharge are more preventable than readmissions 8 to 30 days after discharge.Use this study to:Ask your learners to list common situations in which patients are readmitted to the hospital. What conditions are associated with frequent readmissions? What care process issues?In what ways are readmissions harmful? To whom?Review the results of this study. How would your learners identify a preventable readmission? How did the authors do it? Look at the items listed in Table 3. How might each category increase the risk for an early or late readmission? What variables did the authors identify as being associated with early readmissions and more likely to be preventable by hospital-based interventions?Does your team discuss the potential for readmission when considering whether to discharge a patient? If not, try it with each patient your team plans to discharge this week. What variables put the patient at risk for readmission? Is there anything your team can do to reduce or eliminate that risk? What practices and services are (or should be) in place in your system to help reduce readmissions?Beyond the GuidelinesHow Would You Manage This Patient With Osteoporosis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterTwo endocrinologists debate whether a 71-year-old woman with osteoporosis should have bone density monitoring during and after treatment with an antiresorptive agent. They also review management of osteoporosis and treatment recommendations for a patient whose bone density decreases during or after a 5-year course of alendronate.Use this feature to:Watch the video of the patient interview with your learners.Pose the questions being debated to your learners: Would you monitor a patient with osteoporosis who is receiving a 5-year course of alendronate? If so, how? Would you monitor a patient who has completed a 5-year course of alendronate? If so, how? When and how would you treat a patient whose bone density decreases during or after a 5-year course of alendronate?Watch or read the presentations made at the Grand Rounds.Now ask your learners the same questions. What would they do?Log on and answer the questions to earn CME and MOC credit for yourself!In the Clinic: Heart FailureHeart failure affects more than 6 million people in the United States and incurs a heavy toll in morbidity, mortality, and health care costs. Decades of clinical trials have shown that several medications and interventions are effective for improving outcomes; however, mortality and hospitalization rates remain high. More recently, additional medications and devices have shown promise in reducing the health burden of heart failure. Are your learners up-to-date in their knowledge of heart failure management?Use this paper to:Ask your learners what the risk factors for heart failure are. Will treating these risk factors prevent heart failure?Are diagnostic tests needed in the evaluation of patients with suspected heart failure? If so, when, and which ones? How does each assist management?Which drugs are used for the management of heart failure, and when should others be added?When should inotropic agents be considered? Is there a benefit to anticoagulation in patients with heart failure? When should an intracardiac device be considered?What advice about exercise should your learners give to their patients with heart failure?Use the provided multiple-choice questions and teaching slides to help prepare for a teaching session. And, log on and enter your answers to earn CME and MOC credit for yourself!Department of VisualizationAnnals Graphic Medicine - Finding the Funny: ChemotherapyLaugh, cry, and reflect with your learners at the messages in this series of cartoons by a patient who reflects on her experiences with chemotherapy for breast cancer.Humanism and ProfessionalismOn Being a Doctor: A Difficult PatientDr. Kahn describes several challenging management issues in the care of his patient, although none were the reason why he was “a difficult patient.”Use this essay to:Listen to an audio recording of the essay, read by the Associate Editor for On Being a Doctor, Dr. Michael LaCombe. Ask your learners about their “difficult patients.” What has made each “difficult”?Are the limits in our abilities as “healers” only with regard to curing disease?MKSAP 17 QuestionA 53-year-old woman is evaluated during a preventive health examination. She feels well. She is asymptomatic, and her medical history is unremarkable. She has no family history of colorectal cancer, colon polyps, or gastric cancer. She has not had prior colorectal cancer screening.Vital signs and the remainder of the physical examination are normal.According to the referenced recommendations, which of the following is the best screening strategy for this patient?A. Colonoscopy now and every 5 yearsB. Colonoscopy now and every 10 years or annual fecal immunochemical testingC. CT colonography now and every 5 yearsD. Serum methylated SEPT9 assay now and annuallyCorrect AnswerB. Colonoscopy now and every 10 years or annual fecal immunochemical testingEducational ObjectiveManage colorectal cancer screening in an asymptomatic, average-risk adult.CritiqueColonoscopy now and every 10 years or annual fecal immunochemical testing (FIT) is recommended for this asymptomatic, average-risk patient. According to 2017 recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer, colonoscopy every 10 years or annual FIT should be offered beginning at age 50 years to screen asymptomatic, average-risk patients. For patients who decline this first-tier screening strategy, the second tier Multi-Society Task Force recommendation is CT colonography every 5 years, a combination FIT–fecal DNA test every 3 years, or flexible sigmoidoscopy every 5 to 10 years.Colonoscopy every 5 years is recommended for higher-risk patients with two first-degree relatives with colorectal cancer or an advanced adenoma diagnosed at any age, or colorectal cancer or an advanced adenoma in a single first-degree relative younger than 60 years. In these higher-risk patients, screening should begin at age 40 years or 10 years before the age of diagnosis of the youngest affected first-degree relative.CT colonography every 5 years should be offered only to those patients who decline the strategy of colonoscopy every 10 years or annual FIT, according to the Multi-Society Task Force. Although CT colonography has the advantages of a reduced risk for colon perforation compared with colonoscopy and no need for sedation, the sensitivity of CT colonography for polyps smaller than 1 cm is less than the sensitivity of colonoscopy for these lesions. Additionally, CT colonography entails exposure to radiation.The FDA has approved a blood test for circulating methylated SEPT9 DNA for the detection of colorectal cancer. However, this test is not recommended as a screening strategy by the Multi-Society Task Force. The test has a sensitivity of only 48% for detection of colorectal cancer and no sensitivity for detection of precancerous polyps, and it is expensive relative to FIT. Additionally, the optimal frequency for performing this test is unknown.The Multi-Society Task Force guideline differs from the U.S. Preventive Services Task Force 2016 recommendation statement, which recommends that asymptomatic, average-risk adults aged 50 to 75 years be screened for colorectal cancer but does not endorse any particular screening strategy over another.Key PointThe U.S. Multi-Society Task Force on Colorectal Cancer recommends that colorectal cancer screening of average-risk, asymptomatic patients begin at age 50 years, with colonoscopy every 10 years or annual fecal immunochemical testing.BibliographyRex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153:307-23. doi:10.1053/j.gastro.2017.05.013Do 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 June 2018Volume 168, Issue 11Page: ED11KeywordsBone densityColonoscopyColorectal cancerColorectal cancer screeningComputed axial tomographyHeart failureMortalityOsteoporosisOutpatientsRandomized trials ePublished: 5 June 2018 Issue Published: 5 June 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...