Annals for Educators - 18 June 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives18 June 2019Annals for Educators - 18 June 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201906180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRisk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty. A Cohort StudyPatients, particularly those with rheumatoid arthritis (RA), are at increased risk for infection after major surgery. In this analysis, the authors examined risk for infection across different biologic medications and with exposure to glucocorticoids in a large sample of patients with RA who underwent a primary or revision total knee or hip arthroplasty.Use this study to:Ask your learners what risks are associated with surgery among patients with RA.What do your learners know about the risks of neck manipulation and intubation in patients with RA? Do they know the significance of cervical subluxation?What are the potential benefits and risks of biologic therapies in patients with RA?What advice would your learners provide with regard to perioperative management of immunosuppression for a patient with RA? What if any special considerations might be necessary in patients receiving glucocorticoids?Poststreptococcal Myalgia and MyositisThis case report presents a 34-year-old man with recurrent bouts of debilitating myositis after a sore throat.Use this report to:Ask your learners what the potential complications of streptococcal pharyngitis are.Why is it important to identify infection with Streptococcus pyogenes (group A Streptococcus)? Why is antimicrobial therapy important?How does acute rheumatic fever present? Scarlet fever? Reactive arthritis? Glomerulonephritis? What are the suppurative complications? How is each diagnosed and treated?Review the Jones criteria. When and how might antistreptolysin O titers be helpful?Cardiovascular Events and Mortality in White Coat Hypertension. A Systematic Review and Meta-analysisThis systematic review and meta-analysis examines cardiovascular and mortality risks associated with untreated white coat hypertension and treated white coat effect.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to define normotension, sustained hypertension, white coat hypertension, and masked hypertension. What is white coat effect?Why do recent guidelines emphasize use of ambulatory and home blood pressure monitoring? How do the results of this study inform such practice? Do they suggest that ambulatory monitoring is more or less important, and how? Use the accompanying editorial to help frame your discussion. How do your learners arrange for ambulatory blood pressure monitoring in their patients? Do they do so when it is indicated? Why or why not?What are the potential limitations of the studies that were included in this meta-analysis, and how might they affect what may be concluded? The editorialists discuss these issues.Humanism and ProfessionalismPhysician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of PhysiciansThis ACP position paper, which is informed by an environmental scan of the literature, provides advice to clinicians and health care institutions on how to respond to physicians who may be impaired.Use this paper to:Ask your learners how they would define “physician impairment.”Why do the authors of this paper distinguish between “functional impairment” and “potentially impairing illness”?What are our responsibilities with regard to recognition and reporting of potential impairment in ourselves or our colleagues? To whom should we turn when there is concern about impairment?What are the barriers to such reporting?What professional challenges remain for a physician who has successfully recovered from impairment?Use the accompanying editorial to help frame your discussion. On Being a Doctor: Girl Meets TumorMs. Li recalls, “On one especially humid afternoon, we learned the head and neck examination. Then, my classmates and I learned I had a tumor.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners how we might treat a colleague's privacy differently than that of nonphysician patients. Why might this happen?How can we avoid such behavior?How should Ms. Li's teachers have handled this situation? What should others in the room have done? Would students or residents have had the confidence to speak up in such a situation?On Being a Doctor: Providence in MedicineDr. Kelly recalls being alone in her car and calling out loud to her dying patient. “We had witnessed a power we could not understand or explain, but it was real. I felt deep stirrings of faith that I hadn't experienced since childhood.”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have experienced events that are inexplicable in the care of patients.Do your learners believe that miracles occur? Have they ever discussed such things with patients? Why or why not?On Being a Doctor: A Time to DieDr. Gianakos asks himself, “How could I be so wrong about this? Am I possibly ending her life prematurely?”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask whether your learners have ever questioned their assessment of a patient's terminal status.Have they reconsidered prognostic assessments when patients do better than expected?What should prompt such thoughts? What might prevent us from doing so as frequently as we should? What might be the harms to a patient if done too frequently?MKSAP 18 QuestionA 24-year-old woman is evaluated during a follow-up visit for elevated blood pressure measurements found on two separate occasions. The measurements were 144/94 mm Hg and 142/92 mm Hg. She states that going to the doctor makes her nervous, so she had her blood pressure measured at the local pharmacy, which was <130/80 mm Hg. Review of systems is otherwise unremarkable. She has no other pertinent personal or family history. She takes no medications.On physical examination, the average of three blood pressure measurements is 143/93 mm Hg, and pulse rate is 80/min; other vital signs are normal. BMI is 21. The remainder of the examination is normal.Laboratory studies show a serum creatinine level of 0.8 mg/dL (70.7 µmol/L), and a urine albumin-creatinine ratio is undetectable; pregnancy test results are negative.Electrocardiogram is normal.Which of the following is the most appropriate next step in management?A. Begin hydrochlorothiazideB. Obtain echocardiographyC. Perform 24-hour ambulatory blood pressure monitoringD. Recheck blood pressure in 3 monthsCorrect AnswerC. Perform 24-hour ambulatory blood pressure monitoringEducational ObjectiveDiagnose white coat hypertension using ambulatory blood pressure monitoring.CritiqueThe most appropriate next step is to evaluate for white coat hypertension using 24-hour ambulatory blood pressure monitoring (ABPM). ABPM uses a continuously worn device that can be programmed to measure blood pressure every 15 to 20 minutes during the day and every 30 to 60 minutes at night. White coat hypertension refers to elevated blood pressure measured in the office, but normal out-of-office blood pressure averages. According to the American College of Cardiology/American Heart Association blood pressure guideline, in adults with untreated systolic blood pressure >130 mm Hg but <160 mm Hg or diastolic blood pressure >80 mm Hg but <100 mm Hg, it is reasonable to screen for white coat hypertension using either ABPM (the gold standard) or home blood pressure monitoring. Before white coat hypertension is diagnosed, it needs to be confirmed that the out-of-office measurements are reliable; for example, the patient's home blood pressure monitor should be calibrated against the office sphygmomanometer or, preferably, blood pressure should be measured by ABPM. If white coat hypertension is confirmed, lifestyle modification and careful monitoring are indicated because there is risk for future development of hypertension.Before initiating hydrochlorothiazide, 24-hour ABPM or home blood pressure monitoring should be performed to rule out white coat hypertension.Screening echocardiography is not the correct next step in diagnosis, although it may be considered if the diagnosis of hypertension remains in doubt in order to evaluate for left ventricular hypertrophy. The presence of confirmed left ventricular hypertrophy will necessitate treatment with antihypertensive medication.The patient's blood pressure has been elevated in the office on three different occasions, and it is unlikely that another measurement in 3 months' time will produce a different result. The issue at hand is the diagnosis of white coat hypertension, which will require out-of-office blood pressure measurements.This content was last updated in August 2018.Key PointWhite coat hypertension refers to elevated blood pressure measured in the office, but normal out-of-office blood pressure averages; diagnosis requires confirmation using 24-hour ambulatory blood pressure monitoring (gold standard) or home blood pressure monitoring.BibliographyPierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens. 2011;24:52-8.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 18 June 2019Volume 170, Issue 12Page: ED12KeywordsBiologicsBlood pressureEchocardiographyGraduate medical educationHypertensionLeft ventricular hypertrophySurgerySystematic reviewsTotal hip arthroplastyVital signs ePublished: 18 June 2019 Issue Published: 18 June 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...