Annals for Educators - 7 August 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives7 August 2018Annals for Educators - 7 August 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201808070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMedication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality. A Cohort StudyPatients who survive an opioid overdose are at increased risk for subsequent nonfatal and fatal events. This study evaluated overdose survivors to determine whether use of medications for opioid use disorder (MOUDs) was associated with reduced mortality.Use this paper to:Ask your learners what steps are required immediately in the management of a patient with an opioid overdose. What interventions should be considered after management of acutely life-threatening issues?Ask your learners what options are available for patients with opioid use disorder. How do methadone, buprenorphine, and naltrexone work? How are they prescribed? Who may prescribe them, and what monitoring is required? How effective are they at reducing risk for subsequent overdose and/or death?How would your learners arrange for outpatient care of patients presenting with an opioid overdose? How often is this actually done at your center?Why do your learners think MOUDs are underused? What are the legal barriers to their use? Should these be changed? Review a recent ACP position paper to help frame your discussion. The editorialists believe that the persistent belief that MOUDs “substitute a new addiction for an old one” is part of the problem. What are reasonable concerns regarding MOUDs? Do the benefits outweigh the risks? Invite a specialist in substance abuse to join your discussion. Prognostic Implications of Single-Sample Confirmatory Testing for Undiagnosed Diabetes. A Prospective Cohort StudyCurrent clinical guidelines require repeated testing (“2-sample testing”) to confirm an elevated fasting glucose or hemoglobin A1c level and reduce the possibility of a false-positive diagnosis of diabetes mellitus. In this study, the authors examined the prognostic performance of a single-sample confirmatory definition of undiagnosed diabetes in identifying persons who subsequently developed diabetes or related complications.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how a diagnosis of diabetes is established. How do they do it? Do they confirm an abnormal glycemic test result on a separate sample? If not, why not?Should the results of this study alter how we diagnose diabetes? Why or why not? What are the study's limitations?What properties should we require of a diagnostic test?Given that diagnosing diabetes with tests performed on a single blood sample would be easier for patients and clinicians, why not take this approach now? Use the accompanying editorial to help frame your discussion. Storing and Disposing of Opioid Analgesics: What Does Our Medicine Tell Us?Medication diversion represents the largest source of misused opioid analgesics. Unused opioid analgesics are seldom safely stored or disposed of, creating a large supply for diversion. This brief research report assessed how often the package inserts of opioids contain information about the safe storage and disposal of the drug.Use this study to:Ask your learners if they know how patients should dispose of unused opioids. How should this be done?Do your learners ever talk about safe storage of opioids and what to do with the remaining supply after the drug is no longer needed for the reason it was prescribed? Have they ever discussed with their patients the potential for the drug's diversion and the role that might play in harming others?How would your learners counsel their patients? What specific advice would they provide?Beyond the GuidelinesWhat Should Be the Target Blood Pressure for This Older Patient With Hypertension? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe optimum threshold above which to begin antihypertensive therapy as well as the optimum target blood pressure to achieve with medication are areas of controversy, especially in older adults. Two guidelines published in 2017 address this issue. In this Beyond the Guidelines, 2 experts debate application of these guidelines to the care of a 79-year-old man with hypertension.Use this feature to:Watch the short video of the patient's interview.Ask your learners what criteria should determine eligibility for antihypertensive treatment in persons aged 60 years or older. What should their target blood pressure be? Which antihypertensive agents are preferable?Watch the grand rounds presentation with your learners. Now how would they answer these questions?How would your learners discuss with a patient whether to initiate antihypertensive treatment?Be sure to answer the multiple-choice questions to earn CME/MOC credit for yourself!In the Clinic: Herpes ZosterPrimary care providers and hospitalists frequently encounter older or immunocompromised patients with herpes zoster accompanied by debilitating pain. Atypical presentations and zosteriform herpes simplex may present diagnostic challenges to clinicians. Are your learners prepared to prevent herpes zoster, diagnose it, and treat the complications?Use this feature to:Ask your learners who is at risk for herpes zoster.Who should be vaccinated against varicella zoster virus? How effective is the vaccine?Is laboratory testing required to diagnose herpes zoster? What is the differential diagnosis?When should an ophthalmologist or an otolaryngologist be consulted?How is herpes zoster treated? When is intravenous treatment needed?Use the multiple-choice questions to help introduce topics for discussion with your team, and log on to enter your answers to earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: A Beautiful DeathDr. Weatherly recalls her patient's grace when he was the only one who knew he was about to die.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask what a “good death” is.What is our role in a patient's death? How would your learners have responded when this patient indicated with a smile that he would die that day?MKSAP 17 QuestionA 55-year-old man is evaluated following a screening for type 2 diabetes mellitus. He is asymptomatic. He has a history of hypertension and hyperlipidemia. There is no history of anemia, liver disease, or kidney disease. Medications are lisinopril and rosuvastatin.On physical examination, blood pressure is 123/76 mm Hg and pulse rate is 72/min. BMI is 28. The remainder of the examination is unremarkable.Laboratory studies:Hematocrit45.6%Creatinine1.0 mg/dL (88.4 µmol/L)Glucose, fasting128 mg/dL (7.1 mmol/L)Hemoglobin A1c5.6%Which of the following is the most appropriate diagnostic test to perform next?A. Fasting plasma glucoseB. Hemoglobin A1cC. Oral glucose tolerance testD. Random blood glucoseCorrect AnswerA. Fasting plasma glucoseEducational ObjectiveDiagnose type 2 diabetes mellitus.CritiqueA fasting plasma glucose measurement is the most appropriate diagnostic test for this patient. Diabetes mellitus can be diagnosed with an abnormal result of one screening test performed on two separate occasions. Although the hemoglobin A1c is normal in this patient, the fasting plasma glucose is abnormally elevated within the diagnostic range for diabetes mellitus. When discrepant results occur among different screening tests for diabetes, the American Diabetes Association recommends repeating the abnormal screening test. If the repeat fasting plasma glucose measurement is abnormal, the diagnosis of diabetes is confirmed. Screening for type 2 diabetes should begin in all asymptomatic patients at age 45 years. In adult patients with a BMI greater than or equal to 25, screening should occur at any age if one or more additional risk factors for diabetes is present.Use of the hemoglobin A1c as an initial screening test in this patient is appropriate as there is no evidence for anemia or kidney or liver disease that could decrease the reliability of the test. The value was normal and does not warrant a repeat measurement as the next diagnostic test to perform in this scenario.A 2-hour 75-g oral glucose tolerance test can be used as a screening tool for diagnosing diabetes. Since this test was not initially used for screening in this patient, it is most appropriate to repeat the abnormal screening test (fasting plasma glucose) that was already used for comparison.A random blood glucose measurement would be useful in this patient if he presented with classic hyperglycemic symptoms in the setting of a blood glucose level of 200 mg/dL (11.1 mmol/L) or above, as that would be diagnostic of diabetes. This patient is not symptomatic.Key PointWhen discrepant results occur among different screening tests for diabetes mellitus, the American Diabetes Association recommends repeating the abnormal screening test.BibliographyAmerican Diabetes Association. (2) Classification and diagnosis of diabetes. In: Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015;38 Suppl 1:S8-16.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 7 August 2018Volume 169, Issue 3Page: ED3KeywordsBlood plasmaBlood pressureDiabetes mellitusDrugsGlucoseHemoglobinOpioidsRenal diseasesResearch laboratoriesType 2 diabetes ePublished: 7 August 2018 Issue Published: 7 August 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...