Annals for Educators - 7 March 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives7 March 2017Annals for Educators - 7 March 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201703070 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPhysician Decision Making and Clinical Outcomes With Laboratory Polysomnography or Limited-Channel Sleep Studies for Obstructive Sleep Apnea. A Randomized TrialDespite increased use in clinical practice, whether in-home sleep studies lead to similar diagnostic and therapeutic decisions and similar patient outcomes compared with full laboratory polysomnography (PSG) is not known. This randomized trial compared diagnoses made by physicians and their confidence in them as well as patient outcomes when physicians were presented with full PSG results or the more limited information available from in-home studies.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners if they know how to order a “sleep study.”What types of sleep studies are available and what are they used for? Which ones are most appropriate for the evaluation of patients in whom sleep apnea is suspected? What is a type I study? What are split-night studies? Invite an expert in sleep apnea to review the appropriate uses of available studies.What are the strengths and weaknesses of this randomized trial? Do your learners think that the results are generalizable to the use of data derived from at-home sleep studies?The accompanying editorial notes that in an effort to reduce costs as reimbursement falls, some sleep programs are reducing the availability of technicians to teach patients about sleep apnea treatment. Why might this be important? Do your learners know how to counsel a patient who reports problems using CPAP?Arrange a visit to your center's sleep laboratory. Do your learners think that a more accurate evaluation of a patient's sleep would be obtained here or at home? Are the higher fidelity and greater number of monitors with additional information of an in-laboratory study warranted?Breast Cancer Screening in Denmark. A Cohort Study of Tumor Size and OverdiagnosisEffective breast cancer screening should detect early-stage cancer and prevent advanced disease. Using unique data from screening programs launched in Denmark from 1991 to 2007, the authors assessed the association between screening and the size of detected tumors. They estimated that a substantial proportion of tumors represents overdiagnosis—tumors found during screening that would not become clinically relevant in a lifetime.Use this study to:Ask your learners to define “overdiagnosis” as it relates to breast cancer.How could overdiagnosis be harmful? Are the risks only psychological? What are the physical risks?Ask your learners why they think it may be difficult for some to accept that overdiagnosis may be a real issue in breast cancer, and that screening may cause substantial harm to some individuals. Use the accompanying editorial to help frame your discussion. What does the editorialist mean by, “…considering all small breast lesions to be deadly and aggressive types of cancer is the pathologic equivalent of racial profiling”?Do your learners think that all women should undergo breast cancer screening at all ages? Who should not undergo screening? Role-play scenarios in which your learners need to discuss the potential benefits and harms of screening with patients of different ages and with different risks.Atrial FibrillationAtrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia and a major cause of morbidity, mortality, and health care expenditure. In the United States, 2.3 million persons have AF, and this number is expected to increase to 5.6 million by 2050. Are your trainees prepared?Use this review article to:Ask your learners what other electrocardiographic arrhythmias may be confused with AF. Can they differentiate AF from sinus rhythm with premature atrial contractions? Present Figures 2 and 3 to your learners and ask them to identify the rhythms.What laboratory studies should be ordered in a patient with newly identified AF?When should immediate cardioversion be considered, and who requires hospitalization?How should rate and rhythm control be approached? Use the table to review pharmacologic options. What about electrophysiological approaches?Find the answers to these and other essential questions in this practical review. And download the already prepared teaching slides to help prepare a teaching session.Use the multiple-choice questions to help introduce topics during your teaching, and be sure to log on to enter your answers to earn CME for yourself!Humanities and ProfessionalismAnnals Graphic Medicine: Something StrangeIs there an unexpected explanation for the lack of effect of your treatments?Use this feature to:Show the cartoon to your learners.Do your learners routinely ask their patients to describe exactly how they use their medications? How about inhalers? Injectable medicines? Do they ask the patient to demonstrate how they use their medications? Do your learners feel qualified to teach appropriate use?Ask if they have ever discovered a “strange” explanation for a patient's problem.On Being a Doctor: City on FireDr. Suave describes the harrowing and chaotic experience of evacuating a hospital surrounded by fire, and his 8-hour bus trip working to help patients survive the trip to safety.Use this essay to:Listen to an audio recording of the story, read by Dr. Michael LaCombe.Ask your learners if they have ever felt their own life was in danger while caring for others. How did they react?What factors would your learners consider if they had to choose which patients should receive a limited supply of oxygen or other life-sustaining therapies? Likelihood of survival? Age? Would they take oxygen (or another therapy) away from someone already receiving it to provide it to someone with a perceived greater need, or potential benefit?MKSAP 17 QuestionA 73-year-old man is evaluated for sleep difficulties. He notes unrefreshing sleep that is sometimes interrupted by nocturia, and he occasionally experiences episodes of shortness of breath that awaken him. He thinks he might snore but has no regular bed partner to provide confirmation. His normal sleep schedule is 10:30 PM to 6:30 AM. Most days of the week he feels sleepy during the daytime and naps for 45 minutes. He has a history of chronic atrial fibrillation and heart failure with stable exertional dyspnea. His medications are lisinopril, atorvastatin, warfarin, and metoprolol.On physical examination, temperature is 36.6 °C (97.9 °F), blood pressure is 118/70 mm Hg, pulse rate is 76/min, and respiration rate is 14/min; BMI is 27. Respiratory examination shows a low-lying soft palate and clear lung fields. Cardiac examination discloses an irregularly irregular rhythm but no murmurs.Which of the following is the most appropriate next step in management?A. Auto-titrating positive airway pressure (APAP)B. In-laboratory polysomnographyC. Out-of-center sleep testingD. Overnight pulse oximetryCorrect AnswerB. In-laboratory polysomnographyEducational ObjectiveDiagnose suspected obstructive sleep apnea or central sleep apnea.CritiqueThe most appropriate next step is in-laboratory polysomnography. This patient has risk factors for both obstructive sleep apnea (OSA) (male gender, snoring, overweight) and central sleep apnea (CSA) (heart failure and atrial fibrillation). The lack of history from a bed partner hampers determination of pretest probability. Although out-of-center (performed outside of a sleep laboratory or at home) sleep testing is appropriate for patients with a high pretest probability of uncomplicated moderate to severe OSA, those with heart failure or advanced pulmonary disease or those at risk for CSA should undergo in-laboratory polysomnographic diagnostic testing. In-laboratory polysomnography allows more detailed analysis of the possible underlying disorder than out-of-center methods. Once the type of apnea is clarified during the diagnostic portion of the in-laboratory study, the technician may then utilize the most appropriate mode of positive airway pressure (PAP) therapy and assess the response to treatment. Treatment options include continuous positive airway pressure (CPAP) for OSA, adaptive servoventilation (ASV) for CSA, and the addition of supplemental oxygen, if needed, for gas exchange abnormalities due to chronic heart failure or lung disease.In this patient, auto-titrating positive airway pressure (APAP) would not be appropriate before diagnostic testing is performed to clarify the predominant type of apnea. APAP is indicated for treatment of OSA but is unlikely to be an effective treatment for CSA or complex sleep apnea, if present.Out-of-center sleep testing should be used in patients without comorbid cardiopulmonary disease who are likely to have OSA of at least moderate severity, such as in an obese middle-aged man who snores loudly, pauses breathing, and gasps during sleep.This patient has symptoms of interrupted sleep and daytime sleepiness, which are strong indications for treatment of sleep-disordered breathing. Further screening with overnight pulse oximetry is unlikely to add reliably important diagnostic information, and it will not alter the decision to treat.Key PointAlthough out-of-center sleep testing is appropriate for patients with a high pretest probability of uncomplicated moderate to severe obstructive sleep apnea, those with heart failure or advanced pulmonary disease or those at risk for central sleep apnea should undergo in-laboratory polysomnographic diagnostic testing.BibliographyEpstein LJ, Kristo D, Strollo PJ Jr, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun 15;5(3):263-76.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 March 2017Volume 166, Issue 5Page: ED5KeywordsAtrial fibrillationContinuous positive airway pressureHeart failureObstructive sleep apneaOxygenPolysomnographyResearch laboratoriesSleepSleep apneaTechnicians ePublished: 7 March 2017 Issue Published: 7 March 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...