Annals for Educators - 3 April 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives3 April 2018Annals for Educators - 3 April 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201804030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsTreatment-Free Remission After Second-Line Nilotinib Treatment in Patients With Chronic Myeloid Leukemia in Chronic Phase. Results From a Single-Group, Phase 2, Open-Label StudyFor patients with chronic myeloid leukemia (CML) who achieve sustained deep molecular response (DMR) after treatment with the tyrosine kinase inhibitor imatinib, treatment-free remission (TFR) is possible. A single-group, phase 2 clinical trial investigated TFR in patients who achieved sustained DMR only after switching from imatinib to nilotinib.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what the Philadelphia chromosome is. Why was its discovery an important event in the history of oncology? How did the discovery of the BCR-ABL1 tyrosine kinase lead to remarkable progress in CML treatment?What are the 3 phases of CML? How do tyrosine kinase inhibitors prolong survival?How is therapy for CML monitored?What are the toxicities of tyrosine kinase inhibitors, and why would TFR be desirable? What is DMR, and why is it a prerequisite for achievement of TFR?Invite an oncologist with expertise in the treatment of CML to join your discussion.Beyond the GuidelinesShould This Patient Receive Prophylactic Medication to Prevent Delirium? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterA psychiatrist and a geriatrician debate whether Mr. W, a 79-year-old man at high risk for postoperative delirium, should receive prophylactic antipsychotics with his next surgery. They review risk factors, appropriate evaluation, and potential benefits and harms of the various medications often used in this setting.Use this feature to:Watch a video with your team of Mr. W telling his story.Ask your learners each of the questions posed to the discussants: What risk factors predispose patients (and Mr. W specifically) to delirium in the perioperative setting? If Mr. W experiences delirium, what short-term evaluations should he have? What would you recommend to prevent delirium with Mr. W's next surgery?Now, watch the video of the Grand Rounds presentations, or assign members of your team to read and summarize the points made by the psychiatrist and the geriatrician.Review Table 2 with your learners and ask whether they routinely consider each of the listed categories when evaluating a patient with delirium. Do they review and consider whether to continue each of a patient's outpatient medications?What do your learners recommend be done to prevent delirium in a patient like Mr. W? Will they use antipsychotics for prevention?In the Clinic: PsoriasisPsoriasis, an inherited disorder of the immune system, presents most commonly in the skin and joints but is also associated with cardiovascular, metabolic, and neuropsychiatric effects. Treatments include topical therapy for mild disease; phototherapy and oral therapy, such as retinoids and immunomodulating agents; and targeted biologic therapies that have revolutionized treatment of psoriasis and psoriatic arthritis. Are your learners aware of the systemic associations of psoriasis and the treatments available for this disorder?Use this feature to:Ask your learners how psoriasis most commonly presents. In what other ways may the disease manifest? What is the differential diagnosis? Use the Table to help answer these questions.Ask what organ systems beyond the skin may be involved. How is psoriatic arthritis diagnosed? When is arthrocentesis needed? What is the Koebner phenomenon?How is the severity of disease assessed, and how should clinicians choose between topical and systemic treatment for psoriasis? What topical and systemic treatments are available? What are their potential toxicities? What is the role of phototherapy?Should your learners choose therapy? When should they consult a specialist?Use the provided CME/MOC questions to help introduce new topics as you teach, and be sure to log on and enter your responses to earn credit for yourself. Download the prepared teaching slides to help prepare for a teaching session.Humanism and ProfessionalismHidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of PhysiciansHidden curricula are lessons learned that are embedded in culture and are not explicitly intended. In the field of medicine, the hidden curriculum powerfully influences student and resident norms and values. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum and identifies challenges, opportunities, and strategies for optimizing learning environments.Use this position paper to:Prompt discussion among teachers and learners regarding your center's culture. Do your educators believe they model appropriate attitudes and behavior to their learners? Do you? What unintended messages might our day-to-day behaviors be modeling?Use the accompanying editorial to help frame your discussion. How can you get honest feedback from your learners regarding what they see and learn from your and other teachers' behaviors and attitudes? Do they feel secure expressing their impressions and concerns?Review the vignettes in Appendix Table 1 with your learners. How would they have reacted in each situation?Ask your learners whether they feel empowered to speak up when something is not right. Do they?Do your learners serve as role models for others (such as other residents or students)? Do they think that they model appropriate attitudes and behavior?Does the model of care at your institution foster more attention to the “iPatient” than the patient?On Being a Doctor: Politics in the Exam RoomDr. Imber considers the increased frequency with which political issues are raised in her daily medical practice and wonders what the best response is.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners whether patients have raised political issues during their appointments. How have your learners responded?Dr. Imber wonders to what degree it is acceptable or even important to express political views to patients. What do your learners think?Is it okay to draw on our experiences and authority as medical professionals to try to change the political opinion of people with whom we disagree, even when those people are patients?Will knowing that you might hold different political beliefs affect the trust a patient places in you? Does letting patients know that you disagree with them politically go against our ethical responsibility to place patients' welfare above our own self-interests?Do your learners think it is appropriate to display a sign such as the one Dr. Imber did in her exam room? Why or why not?Just For FunAnnals Graphic Medicine - The Cure Is at HandTake a minute's break and enjoy this month's brief look at a humorous side of medical practice.MKSAP 17 QuestionA 34-year-old man is evaluated for a 3-month history of fatigue, early satiety, and a 10-kg (22 lb) weight loss. Medical history is notable for hypertension, which is well controlled with hydrochlorothiazide.On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 135/81 mm Hg, pulse rate is 114/min, and respiration rate is 13/min. Cardiac and pulmonary examinations are normal, and no lymphadenopathy is noted. The spleen is palpable 10 cm below the costal margin.Laboratory studies show a hemoglobin level of 8.4 g/dL (84 g/L), leukocyte count of 314,000/µL (314 × 109/L), and platelet count of 622,000/µL (622 × 109/L).A peripheral blood smear is shown.Which of the following is the most likely genetic mutation to explain this patient's findings?A. BCR-ABLB. IGH/CD1C. JAK2 V617FD. PML-RARCorrect AnswerA. BCR-ABLEducational ObjectiveDiagnose chronic myeloid leukemia.CritiqueThis patient is most likely to have a BCR-ABL genetic mutation predisposing him to chronic myeloid leukemia (CML). He has the classic presentation for CML with the insidious onset of fatigue; early satiety and progressive weight loss associated with splenomegaly; and a peripheral blood smear demonstrating myelocytes, metamyelocytes, and basophils. The peripheral blood smear of CML is commonly described as mimicking a bone marrow aspirate. Basophilia is a general clue to the presence of a myeloproliferative neoplasm (MPN).IGH/CD1 is the mutation associated with mantle cell lymphoma (MCL). MCL can present with hyperleukocytosis and massive splenomegaly, but myeloid precursors and basophilia would not be seen on peripheral blood smear.The JAK2 gene mutation is associated with polycythemia vera, essential thrombocytosis (ET), and primary myelofibrosis but not CML. Because CML is a more likely diagnosis, especially because of the prominence and degree of leukocytosis, BCR-ABL mutation should be excluded first in this patient.PML-RAR protein mutation is associated with acute promyelocytic leukemia (APL). APL does not demonstrate basophilia or transitional myeloid precursors on the peripheral blood smear. Additionally, it is clinically associated with disseminated intravascular coagulation and thrombocytopenia rather than thrombocytosis, and splenomegaly is uncommon in APL.Key PointPatients with suspected chronic myeloid leukemia should be tested for an underlying BCR-ABL mutation.BibliographyTefferi A, Vardiman JW. Classification and diagnosis of myeloproliferative neoplasms: the 2008 World Health Organization criteria and point-of-care diagnostic algorithms. Leukemia. 2008 Jan;22(1):14-22.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 Cited byDefining key design elements of registry-based randomised controlled trials: a scoping review 3 April 2018Volume 168, Issue 7Page: ED7KeywordsBehaviorBloodChronic myeloid leukemiaDeliriumPsoriasisSplenomegalyToxicityTyrosine kinase inhibitorsWeight loss ePublished: 3 April 2018 Issue Published: 3 April 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...