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

Web Exclusives4 July 2017Annals for Educators - 4 July 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201707040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Welcoming Your New Interns!Annals Graphic Medicine - July PlungeAnnals Graphic Medicine - InternshipA Letter to New InternsTwo Annals Graphic Medicine pieces (cartoons!) depict some of the emotions your new interns are probably feeling as they embark on their postgraduate training, and the editorialists implore us all to ask for help when we need it throughout our medical careers.Use these pieces to:Ask your learners to look at the cartoons and to read the list of emotions in the second paragraph of the editorial. Do your learners share these feelings? What others are they experiencing as they start their internships?The editorialists welcome our new colleagues and remind them to share their feelings with others and to ask for help when needed. Why should such a reminder be necessary? Is there anything about the culture of medical practice that makes it difficult for us to admit that we need help?What can we do in our residency programs to help ensure that we all pay attention to the potential for depression and suicidality? Are we afraid to discuss these issues? What do your interns and residents think they need to do for themselves and others? What are the risks of not paying attention?Do your learners know who they may turn to for help and what types of support are available? Why might they worry about asking for help? What consequences might they fear? How can you reassure them so that they will ask for help if needed?Clinical Practice PointsTriple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis. A Cost-Effectiveness AnalysisThis study uses data from a recently published randomized controlled trial to examine the cost-effectiveness of triple therapy versus adding etanercept to methotrexate as a first-line strategy in patients with rheumatoid arthritis not controlled by methotrexate monotherapy.Use this study to:Ask your learners what the therapeutic options are for the treatment of rheumatoid arthritis. What is the initial therapy? What are the goals? Use the information in DynaMed Plus: Rheumatoid Arthritis (a benefit of your ACP membership) to help prepare a teaching session. How is the response to therapy assessed, and what should the next step be in patients with insufficient disease control?Ask your learners what the purpose of a cost-effectiveness analysis (CEA) is. How does such a study's focus differ from that of a report of a randomized trial? What is meant by the “perspective” that the CEA takes? What are quality-adjusted life-years and incremental cost-effectiveness ratios? The editorialists contend that being aware of the value of a therapy is critical because providing expensive therapy when less expensive but similarly effective regimens could be used may free up resources for other treatments that save lives and improve quality of life. Do your learners agree? Would they choose a more expensive therapy if they expected at least some incremental benefit, even if at a higher cost? Invite an expert in CEAs and a rheumatologist to join your discussion and ask whether their perspectives on the study's results differ.Growth and Rupture Risk of Small Unruptured Intracranial Aneurysms. A Systematic ReviewSmall intracranial aneurysms are sometimes detected incidentally on brain imaging. This systematic review of 26 observational studies assesses and summarizes evidence about the growth and rupture risk of small and very small intracranial aneurysms.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask a radiologist to show your team images of unruptured intracranial aneurysms.How is an intracranial aneurysm's risk for rupture assessed? What are the potential consequences of rupture, and why do these lesions appear to account for a disproportionate amount of the morbidity and mortality from strokes?This review concluded that the available evidence was of low quality. On what basis was this determined? See Appendix Table 6. In what ways are the results still valuable even if available evidence is limited? How might these results alter your learners' practices? What will they tell a patient with a small unruptured intracranial aneurysm? How will they explain what is and is not known? How would they help a patient decide whether to undergo therapy?Ask your learners why the risks from small intracranial aneurysms are hard to study. What are the challenges to performing a randomized trial in this population? Why have such studies had problems with recruitment and retention? Use the editorial to help frame your discussion. In the Clinic - Management of Newly Diagnosed HIV InfectionArguably, no field in medicine has moved as swiftly as HIV/AIDS over the past 35 years. Because of the rapid turnover of key information, this In the Clinic focuses on essential principles of care for newly diagnosed adults with HIV-1 infection and how to prevent infection in persons at risk. To ensure continued usefulness, future directions in therapy and how to access updated information on a continuous basis are emphasized.Use this paper to:Ask your learners who should be screened for HIV infection, how often, and how.What signs and symptoms should prompt evaluation for potential acute or chronic HIV infection? What should clinicians do if they suspect HIV infection but test results are negative?What treatment should be initiated for newly diagnosed HIV infection? What immunizations are necessary? How does pregnancy alter these answers? These and other questions are answered in this article.Download the teaching slides to help prepare for a teaching session. Use the CME questions provided to help introduce new topics as you move through the teaching session. Be sure to log on and enter your answers to earn CME and MOC credit for yourself!Medicine and ProfessionalismOn Being a Doctor: Incidental Findings in Research Studies: One Student's ExperienceDr. Canady's brain tumor might have been treated earlier if the results of a research study performed years earlier had been brought to his attention and used for clinical care.Use this essay to:Take a break with your learners and listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners why the results of studies performed for research might not be routinely used for clinical care. What might be the barriers to doing so? How might routinely planning to do so hinder the research enterprise?Do your learners agree that this is acceptable? Why? How might the problems that are raised be addressed?MKSAP 17 QuestionA 52-year-old man comes to the office to discuss results of a recent magnetic resonance angiogram (MRA). A 4-mm left posterior communicating artery aneurysm was diagnosed 3 years ago, and he has had yearly brain MRAs since that time. Previous imaging has shown no changes in size or appearance of the aneurysm. He has had no headaches or neurologic symptoms. The patient has hypertension, dyslipidemia, and a 20-pack-year smoking history; he stopped smoking 3 years ago. He has no family history of aneurysms or subarachnoid hemorrhage. Medications are amlodipine, hydrochlorothiazide, and atorvastatin.On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 132/68 mm Hg, pulse rate is 72/min, and respiration rate is 12/min; BMI is 29. Visual acuity is 20/30 in both eyes; pupillary dilation is noted, with the left pupil 5 mm in diameter and poorly reactive to light and the right pupil 3 mm in diameter and reactive to light. Results of eye movement and visual field testing are normal. No nuchal rigidity, corneal injection, erythema, or proptosis is noted, and all cranial nerve and motor findings are normal.His most recent MRA shows an 8-mm left posterior communicating artery aneurysm. An MRI of the brain is normal.Which of the following is the most appropriate treatment?A. ClonidineB. MRA of the neckC. Repeat MRA of the brain in 1 yearD. SurgeryCorrect AnswerD. SurgeryEducational ObjectiveTreat an unruptured intracranial aneurysm.CritiqueThe patient should have surgery. His asymptomatic intracranial aneurysm now has several features predictive of a high risk of rupture. The aneurysm has increased in size over the past year from 4 mm to 8 mm in the posterior circulation; aneurysms of 7 mm and greater in the posterior circulation are typically treated with surgery in the absence of contraindications. Additionally, the patient now has dilation of the pupil that is likely due to external compression of the oculomotor nerve (cranial nerve III) from the enlarging aneurysm. These high-risk features in the absence of prohibitive medical comorbidities, such as coronary artery disease or an end-stage medical illness with limited (<1 year) survival, make surgical treatment of the aneurysm appropriate. The patient may undergo either endovascular coiling to occlude the aneurysm or open surgical clipping. Both modalities are associated with a high success rate; the optimal approach is dictated by the morphology of the aneurysm and local experience in performing either modality on at least 20 patients per year. Long-term follow up of treated aneurysms does not show significant differences in functional status. Coiling has a small risk of incomplete occlusion of the aneurysm, and postoperative morbidity may be higher with surgical clipping.The patient's main risk factor for the presence and growth of the aneurysm is hypertension. Close monitoring of blood pressure is indicated to prevent aneurysmal growth or rupture. The patient's current blood pressure is already less than 140/80 mm Hg, which is the target blood pressure to reduce the risk of rupture and aneurysmal expansion.A neck MRA would rule out a carotid dissection in a patient with a headache and Horner syndrome. The patient's pupillary abnormality, however, is not consistent with Horner syndrome, in which ptosis and a decrease in the size of the pupil (myosis) are expected.Because of the increase in size of the aneurysm and clinical signs of a third nerve palsy, definitive treatment of the aneurysm now, rather than repeat screening with an MRA in 1 year, is required in this patient. After treatment, yearly MRAs of the brain are indicated to follow the treated aneurysm and to evaluate for new aneurysms or growth of other small ones that may not have been evident on previous MRAs.Key PointRecent guidelines recommend surgery for patients with an asymptomatic intracranial aneurysm in the posterior circulation when the aneurysm shows rapid growth to greater than 7 mm in size and clinical signs consistent with an enlarging aneurysm.BibliographyThompson BG, Brown RD Jr, Amin-Hanjani S, et al. Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Aug; 46(8):2368-400. Epub 2015 Jun 18.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. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 4 July 2017Volume 167, Issue 1Page: ED1KeywordsAneurysmsBlood pressureBrainEmotionsHIV infectionsMagnetic resonance angiographyResidencyRheumatoid arthritisStrokeSurgery ePublished: 4 July 2017 Issue Published: 4 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...