Annals for Educators - 4 April 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives4 April 2017Annals for Educators - 4 April 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201704040 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMaintenance After Initiation of Nutrition Training. A Randomized TrialDespite the efficacy of behavioral weight loss initiation programs, maintenance has remained the holy grail of weight loss research. In this randomized usual care–controlled trial, investigators examined the efficacy of a low-cost intervention for maintaining weight loss.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners why it is often difficult for patients to maintain weight loss after initial positive results.What do your learners advise their patients with regard to maintenance of weight loss? Use In the Clinic: Obesity to review dietary and physical activity recommendations.The authors note that interventions to maintain weight loss in prior studies have been modestly successful but resource-intensive. Review the intervention used in this study. Do your learners think such an intervention could be readily provided to large groups of patients? Note the costs in the last section of the results. Do your learners think such costs are worth the reported results in maintenance of weight loss?What are the limitations of this study? How closely do the study's participants match those your learners typically see? Do they think the results of this study apply to their patients?Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansSystemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice GuidelineNonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice GuidelinePatients frequently seek assistance from their physicians for relief of low back pain. These systematic reviews evaluate available evidence regarding the efficacy of both pharmacologic and nonpharmacologic treatments, and the guideline from the American College of Physicians provides advice to treating physicians.Use these papers to:Ask your learners how they evaluate patients with low back pain. What history and signs do they use to determine whether testing is necessary? Use the information in DynaMed Plus: Acute Low Back Pain and Chronic Low Back Pain (a benefit of your ACP membership) to help prepare and inform your teaching session.Review the ACP recommendations. Do your learners routinely recommend acetaminophen? Will they continue to do so?The authors of the guideline stress the importance of explaining to patients the likely course of acute back pain with and without intervention. Why is this important? How do your learners explain this to their patients?Do your learners recommend nonpharmacologic interventions, such as yoga, acupuncture, or mindfulness? How do they do so? Where do they recommend their patients seek such care?The editorial notes that the trials included in the systematic reviews and used to inform the clinical guideline may not mimic care provided in real-world practice. How might they differ? Does this affect your learners' approach?In the Clinic - MigraineMigraine affects around 15% of adults in the United States and accounts for more than 90% of patients with recurrent headache presenting to primary care offices and emergency departments. Use this eminently practical review to plan a teaching session organized around answering the key clinical questions posed.Use this review to:Review the diagnostic criteria for migraine and symptoms suggesting more serious causes of headache (they are presented in the boxes on page ITC51).When should your learners order tests? Which ones?What interventions should be tried first? What are their contraindications? When is consultation recommended? Use the table and algorithm to help review with your learners.What special considerations are necessary for pregnant patients?How should patients be followed? When should interventions for prevention be considered, and which ones?Use the multiple-choice questions to break up a teaching session by introducing new topics for discussion. And, log on to enter your answers and earn CME credit for yourself!Download the already-prepared slides to help with teaching.Beyond the GuidelinesHow Would You Manage Opioid Use in These Three Patients? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe Centers for Disease Control and Prevention published a comprehensive guideline in 2016 to help clinicians with opioid prescribing for chronic pain. In this Grand Rounds, the guideline is reviewed and an expert discusses its application to 3 very different patients prescribed opioids to treat chronic pain.Use this feature to:Review the brief histories presented for each of the 3 patients. Then, watch the patient interviews with your learners.Divide your learners into 3 groups, and assign each to discuss how they would approach the use of opioids in 1 of the 3 patients. Then, have each group present what they discussed. Did they agree with the approaches suggested by the expert consultant in the Grand Rounds presentation?Alternatively, summarize the 3 patients on the board together with your group. Then, discuss how the differences among these patients should influence what your learners would recommend for each.How would your learners discuss therapeutic options with these patients? What if the patient insisted on an approach with which your learner did not agree? Have your learners role-play these discussions.Log on and answer the multiple-choice questions to earn CME and MOC credit for yourself!Humanism and ProfessionalismAnnals Graphic Medicine: Code BlueWith only a few words and powerful images, Michael Natter takes us to the bedside of his first “code blue” during a medical clerkship.Use this feature to:Ask your learners if they recall the first time they witnessed a death. Was CPR performed? Were they scared? For themselves, or only for the patient?Have their emotions at “codes” changed over time? How? Do they find they are no longer as disturbed by an unsuccessful code as in the past? Why or why not? Does this bother them in any way?After a code, have your learners discussed their own actions and emotions with their residents, medical students, or attendings? Why might doing so be helpful? In what ways should we be particularly cautious in these discussions so as to be helpful and not hurtful?MKSAP 17 QuestionA 27-year-old woman is evaluated for overweight. Her weight has steadily increased over the past 10 years, and she has attempted weight loss through commercial diets and increased physical activity. Additionally, she has met with a dietician for nutritional guidance. She frequently eats fast food, and she snacks at work, before meals, and especially when she is under stress. She currently exercises 30 minutes daily. She does not smoke and rarely consumes alcohol. Medical history is otherwise unremarkable, and she takes no medications.On physical examination, the patient is afebrile, blood pressure is 138/74 mm Hg, and pulse rate is 76/min. BMI is 29. Waist circumference is 92 cm (36 in). Head, neck, lung, and heart examinations are normal. The abdomen is obese without striae.Laboratory studies, including fasting plasma glucose, total cholesterol, and thyroid-stimulating hormone levels, are normal.In addition to calorie restriction and continued regular exercise, which of the following is the most appropriate next step to help this patient achieve sustained weight loss?A. Behavioral therapyB. Laparoscopic adjustable gastric bandingC. OrlistatD. PhentermineCorrect AnswerA. Behavioral therapyEducational ObjectiveTreat an overweight patient with behavioral therapy.CritiqueThe most appropriate additional treatment for this patient is behavioral therapy. With a BMI of 29, this patient is overweight, and her waist circumference of 92 cm (36 in) is independently associated with increased cardiovascular risk. According to the American College of Cardiology, American Heart Association, and The Obesity Society, all overweight and obese patients should be offered a comprehensive lifestyle intervention (comprised of diet, physical activity, and behavioral treatments) for weight loss. Behavioral therapy includes providing patients with strategies to facilitate a shift from personal maladaptive eating patterns toward healthful eating and exercise, particularly in this patient who acknowledges eating to reduce stress and suboptimal dietary choices. Such strategies are associated with weight loss and reduced risk for developing diabetes mellitus and hypertension. Although best conducted by a trained therapist, behavioral therapy can be initiated by internists. Specifically, internists can emphasize the behavioral therapy components of self-monitoring, stimulus control, goal setting, and social support. Given this patient's eating patterns and previous dieting attempts, she should be offered behavioral therapy.Bariatric surgery, such as laparoscopic adjustable gastric banding, should be considered in all patients with a BMI of 40 or higher and in patients with a BMI of 35 or higher with obesity-related comorbid conditions; it is therefore not indicated in this patient.Pharmacologic agents, such as orlistat or phentermine, are used along with diet, physical activity, and behavioral treatments in patients with a BMI of 30 or higher or in patients with a BMI of 27 or higher with overweight- or obesity-associated comorbidities. This patient does not currently meet the criteria for pharmacologic therapy.Key PointAll overweight and obese patients should be offered a comprehensive lifestyle intervention for weight loss including diet, physical activity, and behavioral therapy.BibliographyJensen MD, Ryan DH, Apovian CM, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2985-3023. Erratum in: J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):3029-3030.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 4 April 2017Volume 166, Issue 7Page: ED7KeywordsBody mass indexDietEatingExerciseHeartLower back painMigraineObesityOverweightWeight loss ePublished: 4 April 2017 Issue Published: 4 April 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...