Annals for Educators - 16 October 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives16 October 2018Annals for Educators - 16 October 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201810160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRelationship of Interleukin-1β Blockade With Incident Gout and Serum Uric Acid Levels. Exploratory Analysis of a Randomized Controlled TrialStudies suggest that interleukin-1β (IL-1β), a proinflammatory cytokine, is involved in acute gout attacks. Although IL-1β inhibitors have been shown to shorten the duration of an attack, whether they can prevent gout is unknown. This exploratory analysis of a randomized controlled trial examined whether canakinumab, an IL-1β inhibitor, was associated with reduced risk for gout attacks.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to explain the role of uric acid in the pathophysiology of gout.Do your learners monitor uric acid levels when treating gout? Should they? Why is this controversial? What do professional organizations recommend? Use a recently published guideline and 2 editorials ( here and here) to help frame your discussion. Listen to the recent Annals On Call podcast, “ The Gout Wars: When Guidelines Collide,” to get yourself up to speed on the debate! Briefly describe the CANTOS trial on which this analysis was based. Were patients randomly assigned according to a history of gout or uric acid levels? Why is that important to consider when interpreting the results of this analysis?What are the limitations to what may be concluded from an “exploratory” analysis of a randomized controlled trial?Are there potential sources of bias that might have influenced the results of this study? Does it matter that gout attacks were self-reported by participants? The authors note that assessors in the trial were blinded and that reports of gout attacks were collected in an identical fashion in both groups. Might that alleviate concern for bias?Interpreting Clinical ScienceResearcher Requests for Inappropriate Analysis and Reporting: A U.S. Survey of Consulting BiostatisticiansThis survey of consulting biostatisticians in the United States asked about the frequency with which they received requests for inappropriate analysis and reporting from researcher colleagues. It also asked respondents to rate the perceived severity of 18 predefined inappropriate requests.Use this study to:Review the list of “violation requests” noted in Table 1. Ask your learners how each might affect the reported result of a clinical study or its interpretation. How might each affect how the medical community applies the results of a clinical trial?What might be the reasons for inappropriate statistical practices? Use the authors' discussion of their results for potential answers.What training have your learners received in epidemiologic and statistical methods? If they have participated or plan to participate in research, who will be mentoring them?What ethical obligations do researchers have when deciding how to analyze and report their study results? Does it matter if the inappropriate use of statistical methods was due to malfeasance or lack of knowledge on the part of the investigators?The authors note that they could not tell whether the inappropriate requests were honored. If not, does the request matter?Use the accompanying editorial to help frame your discussion. Video LearningAnnals Consult Guys – Should Your Patient's Surgery Be Stopped for Hypertension? The Pressure Is OnIn this episode of the consultative medicine talk show, the Consult Guys dissect the evidence regarding whether and when surgery should be delayed because of hypertension.Use this feature to:Ask your learners whether the presence of hypertension in the OR should cancel or delay surgery. If so, what degree of hypertension should stop a procedure?Now, take a break and watch the short video with your learners.Have your learners' answers changed?Log on and answer the brief multiple-choice questions to help teach and to earn CME/MOC credit for yourself!Teaching RoundsA Student Reflection on Doctoring With Confidence: Mind the GapThis commentary discusses ways in which the field of medicine can work to close the “confidence gap,” the discrepancy in confidence between male and female physicians and trainees.Use this paper to:Ask your learners whether they feel comfortable expressing uncertainty when “presenting” on rounds.In what circumstances might sounding more or less confident be beneficial or harmful?How does sounding confident differ from being confident? Might the difference be dangerous in clinical care?Is a lack of confidence viewed or judged differently in women than in men?Ask others who teach if they judge learners according to how confident they appear to be. Are male and female learners judged on the same criteria?Why might fostering a culture that acknowledges uncertainty be beneficial? Are there potential dangers?Paying for Medical EducationMedical Education and the Public Service Loan Forgiveness Program: Unnecessary UncertaintiesIn this commentary, the authors discuss how the federal Public Service Loan Forgiveness program affects affordability of medical school and distribution of the physician workforce. It also considers the possible effect of proposed changes, including elimination of the program.Use this paper to:Ask your learners whether financial concerns are dictating their plans for residency or fellowship training.Are financial concerns affecting where they plan to practice?Are concerns about their future loan repayments causing your learners stress? Do they require assistance to help them deal with uncertainty and to plan? To whom may they turn for advice and support?Do your learners believe that more physicians would pursue careers in primary care and/or in underserved communities if financial issues were not a consideration? Do your learners have accurate information on the incomes they might expect (or need) in different fields and locations?Humanism and ProfessionalismOn Being a Doctor: The Jumbo Man in the Jumbo MartDr. Fitzgerald recalls being uncertain of whether to approach a stranger in a store to check if he was aware of his life-threatening condition.Use this essay to:Listen to an audio recording, read by Annals' Associate Editor for the On Being a Doctor series, Dr. Michael LaCombe. Ask your learners if they have had similar experiences. What did they see that caused them concern? What did they do?Should we approach strangers when we are concerned about a potential medical malady of which they might be unaware? Should we be concerned that we might be seen as invading the stranger's privacy?What about when we know the person?Is it our duty to check, or to inform everyone we see with a concerning physical finding?MKSAP 18 QuestionA 76-year-old man is evaluated for fever and a swollen, painful left knee. He was hospitalized 7 days ago for heart failure and appropriately treated. However, he developed fevers up to 38.0 °C (100.4 °F). On examination, lungs were clear to auscultation. The left knee was hot and swollen; 60 mL of turbid fluid was drained from the knee. Gram stain of the synovial fluid was negative; microscopy revealed needle-shaped intracellular crystals. Gout was diagnosed and the knee was drained again, followed by an injection of 80 mg of methylprednisolone, without improvement. Intravenous methylprednisolone, 60 mg/d for 3 days, did not improve the knee or the fevers. History is also significant for hypertension and gout. Other medications are furosemide, lisinopril, metoprolol, subcutaneous heparin, and morphine as needed.On physical examination today, temperature is 38.0 °C (100.4 °F), blood pressure is 148/92 mm Hg, pulse rate is 116/min, and oxygen saturation is 97% on ambient air. The left knee is warm, swollen, and tender.Blood, urine, and synovial fluid cultures are negative.Which of the following is the most appropriate treatment for the knee?A. AnakinraB. ColchicineC. IbuprofenD. VancomycinCorrect AnswerA. AnakinraEducational ObjectiveTreat refractory acute gout.CritiqueAnakinra is the most appropriate treatment for this patient's knee. He has a persistent fever due to a severe acute gouty attack. Synovial fluid analysis permits definitive diagnosis and can rule out other conditions. Under polarized light, monosodium urate crystals are needle shaped and negatively birefringent. Whereas extracellular crystals confirm a chronic gout diagnosis, crystals within neutrophils define active, gout-induced inflammation. Even in the setting of acute gout, Gram stain and cultures must be obtained to exclude infection because acute gout and joint infection occasionally coexist. This patient has not responded favorably to glucocorticoid therapy, which characterizes some severe acute episodes. In a case such as this, an interleukin-1 inhibitor such as anakinra should be provided as a reliable (although expensive) off-label treatment.Colchicine is unlikely to be effective for an established attack of greater than 12 to 24 hours' duration. It is also unlikely to be useful when intravenous and intra-articular glucocorticoids have been ineffective.The absence of a response to intra-articular or intravenous glucocorticoids necessitates an alternative treatment; however, NSAIDs would not be as effective as the two previously provided failed alternatives. Additionally, NSAIDs have numerous side effects that might be even more likely to occur during critical illness, and they are relatively contraindicated in a patient with heart failure.Blood, urine, and synovial fluid cultures have all been negative, the pneumonia is resolving, and there is no clinical evidence of infection. Vancomycin for methicillin-resistant staphylococcus is unnecessary.Key PointFor patients with severe and refractory gouty attacks or with contraindications to other treatments, off-label use of interleukin-1 inhibitors (anakinra or canakinumab) can be considered.BibliographyThueringer JT, Doll NK, Gertner E. Anakinra for the treatment of acute severe gout in critically ill patients. Semin Arthritis Rheum. 2015;45:81-5. doi:10.1016/j.semarthrit.2015.02.006Do 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 16 October 2018Volume 169, Issue 8Page: ED8KeywordsFeversGoutHypertensionKneesStatistical methodsSurgerySynovial fluidUric acidUrineVancomycin ePublished: 16 October 2018 Issue Published: 16 October 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...