Annals for Educators - 3 October 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives3 October 2017Annals for Educators - 3 October 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201710030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsLow-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome. A Randomized TrialComplex regional pain syndrome (CRPS) is a rare posttraumatic pain condition with few effective treatment options. This randomized placebo-controlled trial evaluated the effectiveness of low-dose intravenous immunoglobulin (IVIg) in reducing pain during a 6-week period in adults with long-standing CRPS.Use this study to:Ask your learners how patients with CRPS present. How is it diagnosed? What is the differential diagnosis? Use the information in DynaMed Plus: Complex Regional Pain Syndrome (a benefit of your ACP membership) to help prepare. What is known about the pathophysiology of CRPS? This is discussed by the editorialists. How did understanding the pathophysiology prompt the hypothesis that IVIg might be effective therapy? How is IVIg derived, and for which conditions does it work? Do we know how it works?The editorialists do not believe that this trial should end a focus on immune regulation as an approach to CRPS therapy. What do your learners think?How is CRPS treated now? How effective are these interventions? What do your learners think it means to have a rare disease for which we lack reliable therapy? How can we help these patients avoid despair and hopelessness?Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults. A National Cohort StudyAlthough total sedentary time has been associated with increased mortality, most studies have relied on participant recall to report activity. Whether longer or shorter bouts of inactivity are associated with different outcomes is not known. This large cohort study objectively measured physical activity to assess total as well as shorter and longer bouts of sedentary time.Use this study to:Ask your learners how much of their day is spent sitting. How many engage in routine physical exercise? How intense is it?Do the results of this study alter how your learners think about the importance of physical activity? Does engaging in moderate-to-vigorous physical activity alter the association between sedentary time and mortality? Does it “protect” us from our sedentary habits?In addition to total sedentary time, the authors examined longer and shorter bouts of sedentary time. Why? What did they find? How might these variables alter the risk for death? Use the accompanying editorial to help frame your discussion. Teach at the bedside! Ask patients on your service what their daily activities involve and how much of their time is sedentary. Would they be able to alter that if they wanted to? What could be recommended? Should we make recommendations based on this study?Ask your learners what confounding is and how it might be important in an observational study such as this. The authors quantified the potential effect of an “unmeasured confounder” on their findings. What is an unmeasured confounder? How do the results of this sensitivity analysis help to provide confidence in the authors' conclusions? Use a recent editorial to help frame your discussion. Beyond the GuidelinesShould We Screen This Patient for Carotid Artery Stenosis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterIn this grand rounds discussion, a vascular surgeon and a primary care physician share perspectives on whether a 74-year-old man with risk factors for cardiovascular disease should be screened for carotid artery stenosis (CAS).Use this feature to:Watch the video interview with Mr. O, a 74-year-old man who has undergone carotid ultrasound. After watching, ask your learners whether they think patients like Mr. O should be screened for CAS. Why or why not?Who is at risk for CAS, and does pharmacotherapy affect its natural history? Does carotid endarterectomy (CEA) reduce the risk for stroke in asymptomatic patients? What level of risk from CEA is acceptable?Evaluate the answers to these questions provided by the discussants. Watch the video of the grand rounds discussion, ask your learners to read it before your teaching session, or assign individuals or teams to summarize the arguments made by the primary care physician and the vascular surgeon. Use the provided slide sets to help.After reviewing the points made, ask whether your learners have changed their minds. Will they suggest screening to their patients? If so, how will they discuss its potential benefits and harms?Regarding his past carotid studies, Mr. O comments, “Why not? I mean the more information the better, right?” Is he right? Is more information always better?In the Clinic: Urinary Tract InfectionUrinary tract infections (UTIs) are common in both inpatient and outpatient settings. This eminently practical review provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention structured around answering key questions that arise in daily practice. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.Use this review to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether we should screen for UTI or asymptomatic bacteriuria.In which patients with asymptomatic bacteriuria is prevention of symptomatic UTI recommended?Should women with recurrent symptomatic UTI receive antibiotic prophylaxis? If so, how? How successful are interventions?What is the differential diagnosis of acute cystitis? How is each condition diagnosed and treated?When is consultation with an infectious disease specialist or a urologist appropriate?Use the accompanying multiple-choice questions and teaching slides to help introduce topics for discussion. Be sure to log on and enter your answers to claim CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: A Night to RememberDr. Ricanati recalls the horrible circumstances and her emotions as she watched the examination of a young woman who had been raped.Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood.Ask your learners whether they have ever helped care for a victim of sexual assault. Did it scare them?How do our own fears of being on the other side of the examination table make us better doctors?Do your learners ask their patients about sexual abuse? Do they know what to do when a patient reports having been the victim of sexual abuse?For Medical EducatorsDiagnostic Reasoning: An Endangered Competency in Internal Medicine TrainingIn this essay, the authors describe several initiatives at their institution to foster the development of diagnostic reasoning skills among internal medicine residents.MKSAP 17 QuestionA 53-year-old woman is evaluated during a follow-up visit for recurrent urinary tract infections. She has been treated for three episodes of urinary tract infection with Klebsiella over the past 4 months. Despite an initial response to antibiotics, her urinary tract symptoms return once the antibiotics are stopped. She has no systemic symptoms, including fever or chills. Medical history is otherwise unremarkable. She currently takes no medications.On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 124/74 mm Hg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 22. There is no costovertebral angle tenderness to palpation. The remainder of the examination is unremarkable.Urine dipstick reveals a pH of 9.0 and is positive for leukocyte esterase and nitrites; urine microscopy shows 8-10 leukocytes/hpf and many coffin-lid–shaped crystals consistent with struvite.Kidney ultrasound shows a 1.2-cm irregularly shaped stone in the left renal pelvis.Which of the following is the most appropriate next step in management?A. Chronic antibiotic therapyB. Low phosphate dietC. Stone removalD. Urine acidificationCorrect AnswerC. Stone removalEducational ObjectiveTreat a patient with struvite nephrolithiasis by removing the stone.CritiqueThe most appropriate next step in management is to remove the struvite stone in the left renal pelvis. Struvite stones are composed of magnesium ammonium phosphate and occur only when ammonium production is increased, which elevates the urine pH and decreases the solubility of phosphate. This is most commonly a consequence of chronic upper urinary tract infection (UTI) with a urease-producing organism, such as Proteus or Klebsiella. Struvite stones can grow rapidly and become large, filling the entire renal pelvis and taking on a characteristic “staghorn” shape. Although struvite stones affect less than 10% of patients with kidney stones, they occur more commonly in women and in patients predisposed to chronic or recurrent UTI, including those with urologic diversions or neurogenic bladder.Although treatment of the initial upper UTI is important to prevent struvite stone development, once struvite stones are formed, they are difficult to treat medically, including with chronic antibiotics. Antibiotics may not penetrate the stone, and colonizing bacteria may create an alkaline environment within the stone that promotes continued or recurrent UTI, stone growth, and chronic inflammatory damage to the kidney. Because of this, stone removal is indicated in most cases, and kidney outcomes have been shown to be improved when struvite stones are removed compared with medical therapy. Removal is commonly by percutaneous nephrolithotomy, shock wave lithotripsy, or a combination of both procedures.Dietary phosphate reduction and urine acidification would be expected to discourage struvite stone formation but are of minimal effectiveness once struvite stones have developed.Key PointIn most patients with known struvite stones, removal of the stones is indicated.BibliographyFrassetto L, Kohlstadt I. Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011 Dec 1;84(11):1234-42.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 3 October 2017Volume 167, Issue 7Page: ED7KeywordsAntibioticsC-reactive proteinsExerciseKidney stonesPelvisPhosphatesSurgeonsUltrasound imagingUrine ePublished: 3 October 2017 Issue Published: 3 October 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...