Annals for Educators - 2 October 2018
Authors: Christine Laine
Journal: Annals of Internal Medicine (2018)

Web Exclusives2 October 2018Annals for Educators - 2 October 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201810020 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Understanding Clinical ResearchAnnals Understanding Clinical Research: Interpreting Results With Large P ValuesRelying solely on P values to interpret study results is widely recognized as suboptimal, but it remains the dominant method of study interpretation in biomedicine. This tutorial discusses issues to consider and misinterpretations to avoid when encountering P values greater than 0.05.Use this paper to:Ask your learners to define a P value. Is it easy to do?What are type I and type II errors?Read the brief description of the clinical trial and its results to your learners. Ask them whether the results are “negative.” Do they exclude a benefit from the in-home occupational therapy intervention? What else do your learners need to know to answer the question?What is the meaning of a “clinically meaningful change” in this context? How does knowing what the investigators defined as a clinically meaningful change affect how one interprets the study results?What do confidence intervals tell us?What is the difference between “absence of evidence” and “evidence of absence”?Review the key questions to ask when interpreting a clinical study, which are listed in the Table.Invite an expert in epidemiology to join your discussion.Clinical Practice PointsPrevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016Given the rapid adoption of e-cigarettes despite unclear benefits and harms, understanding use patterns, together with those of combustible cigarettes, is important for efforts to safeguard public health. This nationally representative survey assessed demographic patterns of e-cigarette and combustible cigarette use.Use this paper to:Ask your learners whether use of e-cigarettes is harmful. What are the physiologic effects and harms of nicotine?In whom might e-cigarettes be beneficial?Do your learners think the growing use of e-cigarettes (e.g., JUUL) among young people who have never used combustible cigarettes is a problem? What might be the risks?Do your learners agree with the editorialist that the use of e-cigarettes among people who have never used combustible cigarettes is “negligible”? Do your learners ask patients whether they use e-cigarettes? Do the forms completed by new patients at your learners' outpatient practices inquire about them? Should they? Why or why not?Treatments of Primary Basal Cell Carcinoma of the Skin. A Systematic Review and Network Meta-analysisThis network meta-analysis examines the comparative effectiveness and safety of 18 interventions for primary basal cell carcinoma in adults.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners whether they check their patients' skin for suspicious lesions when they perform a routine physical examination.Do your learners know how to recognize suspicious lesions? What about basal cell carcinoma or melanoma? To whom do your learners refer patients for biopsy?Teach at the bedside! Review images of benign and suspicious lesions with your team, or identify willing patients on your service with lesions that would be useful for teaching rounds. Consider inviting a dermatologist to join you.Beyond the GuidelinesShould This Woman With Dense Breasts Receive Supplemental Breast Cancer Screening? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe sensitivity of mammography for breast cancer screening is reduced in women with dense breasts. Guidelines differ with regard to the benefits and harms of adding supplemental breast ultrasonography and magnetic resonance imaging for screening in these women. Here, a general internist and a radiologist debate the use of supplemental breast cancer screening for women with dense breasts in general, as well as for a specific patient.Use this feature to:Watch the interview with your learners of Ms. C, a 47-year-old woman who was informed that dense breast tissue was seen on her mammogram.Ask your learners how they would advise Ms. C.Watch the grand rounds presentation, or assign learners to summarize the arguments made by the primary care physician and the radiologist in the published paper.Now ask your learners again how they would advise Ms. C. How would they explain the clinical meaning of dense breasts to a patient? Should it affect her care?Use the multiple-choice questions to help teach, and log on to enter your answers and earn CME and MOC credit for yourself.In the Clinic: Clostridioides difficile InfectionClostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care–associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to prevent infection. This article provides updated recommendations on the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.Use this review to:Ask your learners to name risk factors for C difficile infection.Ask what clinicians can do to prevent infection.Ask what symptoms and signs should raise concern about C difficile infection. What is the differential diagnosis? What tests should be performed? How are the results interpreted?What is the approach to treatment?What are the potential complications of infection? When might surgery be required?Should fecal transplant be considered? If so, when?Use the multiple-choice questions to help introduce new topics during a teaching session. Be sure to log on and enter your answers to earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: A Strawberry MilkshakeDr. Dohlman recalls the daily ritual of helping her patient enjoy her strawberry milkshake.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners whether they have had connections with patients that are analogous to the daily milkshake in Dr. Dohlman's experience with her patient.Do your learners feel guilty when they don't think they have sufficient time to show they care? How do they handle this? How do they show the patient that they do care? Does it relieve their feelings of guilt?MKSAP 18 Question 1An 83-year-old man is seen in the office for routine follow-up. He has a history of hypertension and atrial fibrillation. Medications are hydrochlorothiazide and warfarin.On physical examination, vital signs are normal. During lung auscultation, a 0.4 × 0.4-cm pink pearly papule with telangiectasias on his back is found.Biopsy of the lesion reveals a basal cell carcinoma with low-risk histology.Which of the follow is the most appropriate treatment?A. Electrodesiccation and curettageB. Mohs micrographic surgeryC. RadiationD. VismodegibCorrect AnswerA. Electrodesiccation and curettageEducational ObjectiveTreat low-risk basal cell carcinoma.CritiqueElectrodesiccation and curettage (ED&C) is a widely used treatment for noninfiltrating basal cell carcinomas on low-risk anatomic sites (trunk and extremities). Treatment of basal cell carcinomas depends on many factors, including the histologic subtype, location, size, cosmetic considerations, and patient's age and comorbidities. Nodular and superficial basal cell carcinomas on the trunk and extremities are often treated with ED&C. Infiltrative and micronodular basal cell carcinomas, especially on the face, are not appropriate for ED&C. For this patient, his lesion is a small, histologically low-risk subtype of basal cell carcinoma on the back that can be treated with ED&C.Mohs micrographic surgery is a specialized surgical procedure that provides margin control while sparing as much normal skin as possible. Indications for Mohs micrographic surgery include tumors with aggressive histologic subtypes (micronodular, morpheaform, infiltrative, perineural involvement); high-risk and cosmetically sensitive locations (face, genitals); large tumors or tumors arising in scar tissue; and tumors in patients who are immunosuppressed. This patient's lesion would not be an appropriate use of Mohs surgery.Radiation therapy for skin cancers is appropriate for patients who refuse surgery or are not optimal surgical candidates. The patient will be able to tolerate an ED&C without any difficulty.Vismodegib is an oral medication that inhibits the hedgehog signaling pathway; this signaling pathway is aberrant in most basal cell carcinomas. It is reserved for locally advanced or metastatic basal cell carcinomas.This content was last updated in August 2018.Key PointNoninfiltrating basal cell carcinomas on low-risk areas such as the trunk and extremities are best treated with electrodesiccation and curettage.BibliographyConnolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, et al; American Academy of Dermatology. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg. 2012;38:1582-603. doi:10.1111/j.1524-4725.2012.02574.xMKSAP 18 Question 2A 63-year-old woman is evaluated for a lesion on her nose that is slowly enlarging and nonhealing. She is otherwise in good health and takes no medications.On physical examination, vital signs are normal. The skin examination demonstrates a 0.8 × 0.6-cm pearly ulcerated papule with arborizing telangiectasias. The remainder of the examination is normal.Biopsy of the lesion demonstrates basal cell carcinoma with high-risk micronodular and infiltrative histologic features.Which of the following is the most appropriate treatment of this lesion?A. CryotherapyB. Electrodesiccation and curettageC. Mohs micrographic surgeryD. Topical 5-fluorouracilE. VismodegibCorrect AnswerC. Mohs micrographic surgeryEducational ObjectiveTreat high-risk basal cell carcinoma.CritiqueThe most appropriate treatment for this lesion is Mohs micrographic surgery. Mohs micrographic surgery is a specialized surgical procedure that provides margin control while sparing as much normal skin as possible. Indications for Mohs micrographic surgery include tumors with aggressive histologic subtypes (micronodular, morpheaform, infiltrative, perineural involvement), high-risk and cosmetically sensitive locations (face, genitals), large tumors or tumors arising in scar tissue, and in patients who are immunosuppressed. Because this patient has a high-risk tumor that is located in a cosmetically sensitive location, Mohs surgery is the most appropriate treatment.Small noninfiltrating basal cell carcinomas can be treated with cryotherapy; however, other surgical methods are more commonly used. To treat basal cell carcinomas appropriately with cryotherapy, the target temperature is −50 °C using liquid nitrogen as the cryogen and this requires local anesthesia. Hypopigmentation is often seen after cryotherapy. The histologic subtype and location of the basal cell carcinoma make cryotherapy inappropriate for this patient.Electrodesiccation and curettage is a widely used treatment for noninfiltrating basal cell carcinomas on low-risk anatomic sites (trunk and extremities). High-risk infiltrative and micronodular basal cell carcinomas are not appropriate for electrodesiccation and curettage. Additionally, because it may result in a cosmetically unappealing scar on the nose, it should not be used for this patient.Topical therapies including 5-fluorouracil and imiquimod are most effective for superficial basal cell carcinomas. Superficial basal cell carcinomas are well-demarcated, irregularly bordered red patches; they tend to enlarge radially rather than invading into deeper structures. Topical therapies are not effective for more aggressive histologic subtypes of basal cell carcinomas.Vismodegib is an oral medication that inhibits the hedgehog signaling pathway. It is reserved for locally advanced or metastatic basal cell carcinomas. There are significant side effects including dysgeusia, alopecia, and muscle cramps.This content was last updated in August 2018.Key PointMohs surgery, a form of margin-controlled surgery that minimizes loss of normal tissue, is particularly useful for basal cell tumors in areas such as the head and neck, for large or recurrent tumors, for histologically high-risk tumors, or when cosmetic outcome is crucial.BibliographyConnolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, et al; American Academy of Dermatology. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg. 2012;38:1582-603. doi:10.1111/j.1524-4725.2012.02574.xDo 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 Cited byDefining key design elements of registry-based randomised controlled trials: a scoping review 2 October 2018Volume 169, Issue 7Page: ED7KeywordsBasal cell carcinomasBiopsyDermatologyGraduate medical educationHead and neck tumorsLesionsRadiologistsScarsSurgeryVital signs ePublished: 2 October 2018 Issue Published: 2 October 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...