Annals for Educators - 20 November 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives20 November 2018Annals for Educators - 20 November 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201811200 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice Pointsβ-Blocker Use in Pregnancy and the Risk for Congenital Malformations. An International Cohort Studyβ-Blockers are among the most commonly used antihypertensive medications during pregnancy, but concerns have been raised about their potential teratogenic effects. These authors analyzed data from nationwide health registries in 5 Nordic countries and the U.S. Medicaid population to examine the risk for congenital malformations in offspring of women with hypertension who were exposed to β-blockers during the first trimester of pregnancy.Use this study to:Ask your learners where they get information regarding the safety of drugs for use in pregnancy. Review the FDA classification. What about for women who are breastfeeding?How common is hypertension during pregnancy? Why might uncontrolled maternal hypertension be harmful to the fetus?The authors note that to reduce the potential for confounding by indication, they restricted their analysis to pregnancies with a diagnosis of hypertension. Ask your learners to define “confounding.” What is “confounding by indication”? Why might that be applicable here?How frequent were congenital malformations in the exposed and unexposed groups of mothers (look at Table 2)? While it is good that overall the “end points” occur infrequently, what challenge does that pose for epidemiologic studies such as this? Hint: Why are the confidence intervals around the point estimates for risk wide in this study? How are the confidence intervals to be interpreted?How will your learners treat hypertension in pregnant women? Use the accompanying editorial to help frame your discussion.On-Demand Sildenafil as a Treatment for Raynaud Phenomenon. A Series of n-of-1 TrialsRaynaud phenomenon (RP) characteristically occurs during exposure to cold. Using a series of randomized, double-blind, n-of-1 trials, the authors assessed the efficacy and safety of on-demand sildenafil as an alternative to daily treatment for RP.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to describe RP.What is meant by primary and secondary RP? What are potential causes of secondary RP? Use the information at DynaMed Plus: Raynaud Phenomenon to help prepare for teaching, a benefit of your ACP membership.What should the evaluation of a patient with RP include? What are the potential complications?How should patients with RP be managed? What advice should they be given? Invite a rheumatologist to join your discussion.Medicine and SocietyReducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of PhysiciansWhat Can I Do as a Physician to Prevent Firearm Injury?Firearm-related injuries continue to threaten public health in the United States. This position paper provides policy recommendations from the ACP aimed at reducing firearm-related morbidity and mortality. The editorialist describes how and why he asks his patients about firearm safety.Use these papers to:Ask your learners if they know when to consider the risk for firearm injury to their patients or those around them. Use a recent, concise paper to begin learning.How often do your learners see patients with alcohol use disorder, at risk for intimate partner violence, suicidality, other poorly controlled severe mental illness, or serious life stressors? How about patients with children or grandchildren in the home?Do they ask each about the presence of firearms and whether they are stored safely?Do your learners know how to counsel patients? Use the concise information at this Web site to help learn how.Whether firearm injury is “in our lane” as physicians has recently been a topic of national interest and in the news. What do your learners think? Should the ACP and other physician organizations be involved? Why?Ask your learners whether they think they should commit to discussing firearm safety with their patients when risks for harm are present. Consider taking such a pledge with your learners.Humanism and ProfessionalismWhat Can Medicine Learn From Social Science Studies of Sexual Harassment?The medical profession is not immune from sexual harassment, and culture change is needed. The authors discuss taxonomies and findings from the social sciences that merit consideration by the medical profession as it strives to change culture to prevent sexual harassment.Use this essay to:Consider whether your training program has assessed how frequently and in what forms your learners are subject to sexual harassment. Talk to others involved in teaching at your institution.Are your learners asked if and in what ways they have been harassed, recalling that sexual harassment may occur in ways other than sexual coercion, as is explained in the essay? How often does gender harassment occur at your program? Would the leadership of your program know about it?What can be done to prevent it?Do your learners know from whom they should seek advice and help if they are the victims of harassment?On Being a Doctor: The Privilege of GriefDr. Kittleson reflects on how she has learned to manage her grief over patients' bad outcomes, and how to use them to make herself a better doctor.Use this essay to:Listen to an audio recording , read by Dr. Virginia Hood.Ask your learners whether a mistake in a patient's care has “haunted” them. Tell your learners about your own experience, and share a cartoon from Annals Graphic Medicine to help them feel comfortable sharing their stories.How have they dealt with their grief? Do they feel guilty? How might these experiences be helpful or harmful? Dr. Kittleson describes examples of both.With whom do your learners discuss poor patient outcomes and their emotions surrounding them? How about lesson learned? Do your learners feel safe discussing such issues?Does your program have a structured mechanism to help clinicians support each other and grieve together? Should it? What might be discussed at such events? Who should lead them?MKSAP 17 QuestionA 24-year-old woman is evaluated for a 6-month history of color change in her hands and feet, which is worse during stress. She is a nonsmoker. Family history is negative.On physical examination, temperature is normal, blood pressure is 116/72 mm Hg, pulse rate is 64/min, and respiration rate is 12/min. BMI is 22. There is mild reversible discoloration of the fingertips upon exposure to cold. Cool tips of the fingers without digital pits are noted. Cardiopulmonary examination is normal. Muscle strength and reflexes are normal. There is no rash. The remainder of the examination is normal.Laboratory studies, including complete blood count and chemistry panel, are normal. Nailfold capillary examination is normal.Which of the following is the most appropriate next step in management?A. Measure antinuclear and anti-U1-ribonucleoprotein antibodiesB. Measure antiphospholipid antibody panel and cryoglobulinsC. Obtain digital arteriographyD. Clinical observationCorrect AnswerD. Clinical observationEducational ObjectiveEducational Objective: Evaluate a patient with primary Raynaud phenomenon.CritiqueClinical observation is the most appropriate next step in management. This patient's presentation is suggestive of primary Raynaud phenomenon, a common occurrence in young women that may be seen in up to 30% of women who are white. Raynaud phenomenon may also be the initial symptom of an underlying fibrosing connective tissue disease (CTD) such as mixed connective tissue disease or systemic sclerosis; the predictors/features include severe and prolonged episodes of vasospasm, asymmetric involvement of the digits, and abnormal nailfold capillary examination and/or digital pitting. This patient has none of these features, has a negative family history for CTD, and has undergone nailfold capillary examination, which is normal. She is at a low risk for progressing to a CTD, should be reassured, and can be followed periodically. In these patients, most episodes of Raynaud phenomenon are self-limiting and do not require treatment. Persistently symptomatic patients can be treated with a peripherally acting calcium channel blocker such as nifedipine or amlodipine. Sildenafil and endothelin-1 blockers can be used in refractory cases.This patient's likelihood of developing a CTD is low, and measuring antinuclear and anti-U1-ribonucleoprotein antibodies would be of extremely low yield and would not be cost-effective.Similarly, obtaining an antiphospholipid antibody panel and cryoglobulins in a patient who has no history or evidence of thrombosis, pregnancy loss, or vasculitis is unnecessary and not cost-effective.Digital arteriography is an invasive test and is usually normal in patients with Raynaud phenomenon. Obtaining this study would be appropriate if thromboangiitis obliterans (“Buerger disease”) were suspected, which is a nonatherosclerotic vascular inflammatory disease affecting the medium and small vessels of the extremities and digits that has a strong association with smoking and male gender.Key PointRaynaud phenomenon may be the initial symptom of an underlying connective tissue disease; the predictors/features include severe and prolonged vasospastic episodes, asymmetric involvement of the digits, and abnormal nailfold capillary examination and/or digital pitting.BibliographyLambova SN, Müller-Ladner U. The role of capillaroscopy in differentiation of primary and secondary Raynaud's phenomenon in rheumatic diseases: a review of the literature and two case reports. Rheumatology Int. 2009 Sep;29(11):1263-71.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 20 November 2018Volume 169, Issue 10Page: ED10KeywordsAntibodiesCapillariesDrug safetyFire safetyFirearm injuriesGraduate medical educationHypertensionPregnancySexual identityVascular diseases ePublished: 20 November 2018 Issue Published: 20 November 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...