Annals for Educators - 6 March 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives6 March 2018Annals for Educators - 6 March 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201803060 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRisk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms. A Population-Based Cohort StudyPatients with myeloproliferative neoplasms (MPNs) have been reported to be at increased risk for thrombotic events, but no population-based study has estimated this excess risk compared with matched control participants. This study analyzed data on patients reported to the Swedish Cancer Register between 1987 and 2009 to assess risk for arterial and venous thrombosis among those with MPNs compared with matched control participants.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners if they can name the 3 major subtypes of MPNs.In what ways do patients with each of these MPNs present? How is each diagnosed? Use the information in the DynaMed Plus sections on polycythemia vera, essential thrombocythemia, and primary myelofibrosis (a benefit of your ACP membership!). What is the relationship between JAK2 and each MPN subtype? The accompanying editorial explains this. What does this study tell us about risk for thrombotic events in patients with MPNs?Look at Figure 3. What change in the risk for venous thrombosis has occurred with time? The authors believe this is likely due to improved management. How are patients with MPNs treated? In addition to the risk for thrombosis, what other complications occur?Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke. A Systematic Review and Meta-analysisPercutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale. A Systematic Review and Meta-analysisThese meta-analyses of recent landmark trials examined the benefits and harms of percutaneous closure of patent foramen ovale (PFO) compared with medical therapy alone in patients with cryptogenic stroke.Use these papers to:PFOs are highly prevalent. What are the potential complications?What should the poststroke work-up include? The authors of the second review provide a concise list in their paper's discussion.When should closure of a PFO be considered? What patients were included in the trials used for these meta-analyses (i.e., were they patients with incidentally noted PFOs or those who had experienced 1 or recurrent strokes)? Why does that matter when considering which patients should undergo PFO closure?How is PFO closure accomplished? Invite an interventional cardiologist to join your discussion and to show films of the procedure.What are the potential complications of PFO closure? What more do we need to know? Should these papers alter practice? Use the accompanying editorial to inform your discussion. The Hypertension Guidelines (Again!)Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension GuidelineThe 2017 American College of Cardiology/American Heart Association Hypertension Guideline: A Resource for Practicing CliniciansHypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood PressureThe recent American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline differs substantially from its predecessor and from the guidelines of other organizations. It is more than 100 pages long and includes 106 recommendations. The guideline developers present a synopsis of the most important changes and recommendations. Here, a commentary discusses why the new guideline is helpful, and the editorialists discuss why they believe it falls short in weighing potential benefits and harms, particularly for adults older than 60 years.Use these papers to:Ask your learners how the updated ACC/AHA guideline differs from the prior version and from guidelines from other organizations, such as the American College of Physicians and the American Academy of Family Physicians. Why are these differences so important?Look at the figures in the guideline synopsis. Do your learners believe they should use home and ambulatory blood pressure measurements more often than they do?What limitations in what is known about the risks and outcomes related to hypertension and its treatment are noted by the editorialists? What are the limitations of the clinical trials on which guidelines are based? Why might these be important?What approach will your learners take to diagnosing patients with and treating hypertension?In the Clinic: Palliative CarePalliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This eminently practical review addresses these essentials and provides an overview of current evidence to support patient-centered palliative care.Use this paper to:Ask your learners what the differences are between palliative care and hospice care. Who is eligible for each?Why might patients' perceptions, misconceptions, and fears of hospice care influence their interest in palliative care? How would your learners discuss this with their patients? Look at the Patient Information sheet at the end. Would this be helpful to your patients?When do your learners consider consultation with a palliative care team? What should they expect from such a consultation? Invite a member of your institution's palliative care service to join your discussion.Do your learners use a systematic approach to evaluating and managing pain? In what ways should the approach differ according to the cause? How should adverse effects of opioids be managed?Are your learners comfortable prescribing narcotics for patients with dyspnea? When is it appropriate? How much?How do your learners ask patients about their goals of care? Are they comfortable doing so? How might the manner in which they pose questions matter? Use Table 4 to help spark discussion.Download the teaching slides, and use the multiple-choice questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Note to an Oncology FellowDr. Vettese answers why she discussed hospice care with her patient instead of encouraging palliative chemotherapy and implores her colleague to ask patients what they would be willing to give up to live longer.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Why does the author suggest that we ask our patients what they would never give up?How do your learners react to this essay? Is this an issue of “older” versus “younger” doctors?Have your learners ever felt that other physicians have failed to adequately consider a patient's circumstances and desires? Have others ever suggested that your learners have done so? Why do such differences in opinion occur? Are they harmful to patients?Annals Graphic Medicine - Is This What Depression Looks Like?The author/artist imagines what depression looks like inside himself and wonders, “Is this the black dog of depression I've read about?”Use this feature to:Show the graphic to your learners. How do they react?Do the images make them think differently about patients with depression? How? Does it alter their impressions of what is and is not within the control of the patient?Do such graphic depictions help us to foster our sense of empathy in ways that differ from other experiences?Might sharing these images with a patient who has depression be helpful? Might it be hurtful?MKSAP 17 QuestionA 27-year-old woman is evaluated during a follow-up visit. She was evaluated 3 months previously for symptoms of fatigue of 9 months' duration and a craving for ice. She experiences heavy, irregular menstrual cycles, but has no history of other bleeding. Medications are oral contraceptive pills and daily iron, which were initiated 3 months ago.On physical examination, vital signs are normal; BMI is 31. No splenomegaly is noted.Laboratory studies:3 Months Ago2 Months AgoCurrentFerritin6 ng/mL (6 µg/L)16 ng/mL (16 µg/L)45 ng/mL (45 µg/L)Hemoglobin8.7 g/dL (87 g/L)10.1 g/dL (101 g/L)13 g/dL (130 g/L)Mean corpuscular volume71 fL77 fL88 fLPlatelet count800,000/µL (800 × 109/L)790,000/µL (790 × 109/L)775,000/µL (775 × 109/L)Which of the following is the most appropriate diagnostic test to perform next?A. BCR-ABL genetic analysisB. JAK2 V617F analysisC. Prothrombin time and activated partial thromboplastin timeD. von Willebrand factor antigenCorrect AnswerB. JAK2 V617F analysisEducational ObjectiveDiagnose essential thrombocythemia.CritiqueMutational analysis for JAK2 V617F should be conducted. The patient presented with iron deficiency anemia and thrombocytosis. Thrombocytosis is often associated with iron deficiency anemia, particularly if bleeding is the cause of the anemia. However, when the patient's anemia was corrected with oral iron and oral contraceptive pills for better regulation of menstruation, thrombocytosis persisted, suggesting a disorder in platelet regulation. Iron deficiency is the most common cause of reactive thrombocytosis, which corrects within weeks of correcting the iron deficiency. Infection, inflammation, and malignancy are other causes. With iron deficiency ruled out as a cause and no other causes clinically apparent, essential thrombocythemia (ET) becomes more probable. Her lack of splenomegaly is fairly typical. The JAK2 activating mutation is present in 50% of patients with ET, so a negative result would not exclude the diagnosis, but a positive result supports the diagnosis of a myeloproliferative neoplasm (polycythemia vera, ET, or primary myelofibrosis).BCR-ABL testing, then bone marrow aspiration and biopsy, would be performed if the platelet count remained persistently elevated after correction of serum iron levels with a negative JAK2 mutation status, because myeloproliferative neoplasms other than ET can less commonly elevate the platelet count. In ET, general hypercellularity and megakaryocyte hyperplasia would be seen on the bone marrow examination.Testing the prothrombin and activated partial thromboplastin times would not be the most appropriate choice, because it focuses the diagnosis on a bleeding diathesis rather than thrombocytosis. Similarly, von Willebrand factor antigen testing does not address the patient's persistently elevated platelet count.Key PointA patient with iron deficiency and isolated thrombocytosis that persists after correction of iron deficiency should undergo JAK2 V617F mutational analysis as part of the evaluation for essential thrombocythemia.BibliographyTefferi A. Polycythemia vera and essential thrombocythemia: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol. 2013 Jun;88(6):507-16.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 6 March 2018Volume 168, Issue 5Page: ED5KeywordsFactor analysisHemorrhageHypertensionIron deficiencyIron deficiency anemiaPalliative carePlateletsPolycythemia veraThrombocytosisThrombosis ePublished: 6 March 2018 Issue Published: 6 March 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...