Annals for Educators - 17 July 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives17 July 2018Annals for Educators - 17 July 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201807170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPercutaneous Ablation Versus Partial and Radical Nephrectomy for T1a Renal Cancer. A Population-Based AnalysisPercutaneous ablation is an image-guided, nephron-sparing, nonsurgical treatment for small renal tumors. In an observational cohort analysis, the authors compared survival, complications, and incidence of renal insufficiency after percutaneous ablation, partial nephrectomy, or radical nephrectomy.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners who is at risk for renal cell carcinoma. Use the information in DynaMed Plus: Renal Cell Carcinoma, a benefit of your ACP membership. How does renal cell carcinoma usually present? What laboratory abnormalities might be seen?How is it diagnosed? What is the most appropriate imaging study, and how does the choice differ according to clinical variables? Is biopsy always needed before surgery?Do all patients require surgery? How should the choice among radical nephrectomy, partial nephrectomy, and percutaneous ablation be made? What variables should be used when deciding? How do the results of this observational study help inform that decision? What are the limitations of this study?When might active surveillance be appropriate?Invite experts in interventional radiology, nephrology, surgery, and/or oncology to join your discussion. Consider planning a multidisciplinary case conference discussion on the approach to diagnosing and managing renal cell carcinoma.Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants. A Qualitative StudyNearly half of undocumented immigrants with end-stage kidney disease in the United States receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure (“emergency-only hemodialysis” [EOHD]). Little is known about how providing EOHD affects the clinicians involved. This qualitative study used semistructured interviews to understand the experiences and perspectives of interdisciplinary clinicians providing direct care for undocumented patients who rely on EOHD.Use this study to:Ask your learners whether they have provided care to undocumented immigrants. What unique challenges did this present in planning care? How did this differ from caring for other patients who lack insurance?Review the major themes that describe the clinicians' experiences providing dialysis to undocumented immigrants and the quotes provided in Table 2. Have your learners had analogous experiences?Ask your learners whether they have ever had to exaggerate findings or otherwise be less than completely honest in how they have reported the severity of a clinical situation in order to get a patient the care they felt was needed. How did it make your learners feel? Is it better to “play strictly by the rules,” even if that means providing less than what you believe is optimal care for your patient? Is there a line to be drawn?How do your learners think the situation addressed in this article might be improved? Do they agree with the approach suggested by the editorialist? Medical Practice: Maintenance of CertificationAssociations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set (HEDIS) Process MeasuresWhether patient care is improved by physicians maintaining their American Board of Internal Medicine (ABIM) certification is not known. This study assessed how often physicians who had maintained their certification met a group of performance measures compared with those who had not maintained their certification.Use this study to:Ask your learners whether they plan to take the ABIM certification examination at the end of their internal medicine training. Why or why not?Ask if they know what will be required of them to maintain their certification thereafter. How do the requirements differ from and/or overlap with the requirements for maintaining their state medical licenses?Do your learners believe that certification and maintenance of certification requirements are a good thing? Is completing an internal medicine–accredited residency and/or specialty training enough?What are the goals of a professional certification system? How would your learners design a system to achieve these goals?How do your learners interpret the results of this study? How good are HEDIS performance measures at evaluating the care provided by a physician? What is the significance of the differences this study identified in performance on HEDIS measures between physicians who maintained their certification and those who did not?Read the accompanying editorial. Do your learners agree with the editorialist's assessment? Why or why not? Video LearningAnnals Consult Guys - A Stumper: How Much Spent for How Much Prevention?Howard and Geno challenge us to think about what is known and what is not known about what we might assume to be well-established preventive therapy. Can your team get the right answer?Use this feature to:Take a short break for a relaxing way to learn—watch the video together.Pause when Howard asks you to name the intervention. What do your learners think?Log on and answer the multiple-choice questions to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: The LetterDr. Pischel recalls waiting to open the letter that arrived after her patient died and calling the patient's husband.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether they have had contact with the family of a patient who has died. Have they remained in touch?Should we call family members after a patient has died? Once? More than once? Who might benefit from such calls?Do your learners believe that our medical training aims to teach us to “compartmentalize” the death of a patient and just move on?MKSAP 17 Question 1A 78-year-old man is evaluated for headaches, blurred vision, facial flushing, and mild right midback discomfort. The patient is a lifelong nonsmoker.On physical examination, blood pressure is 150/95 mm Hg; other vital signs are normal. Oxygen saturation is 99% on ambient air. Facial plethora is present. There is no hepatosplenomegaly. The remainder of the examination is unremarkable.Laboratory studies:Erythropoietin150 mU/mL (150 U/L)Hematocrit55.2%Hemoglobin18.2 g/dL (182 g/L)Leukocyte count8200/µL (8.2 × 109/L)Platelet count312,000/µL (312 × 109/L)Urinalysis reveals microscopic hematuria.Which of the following diagnostic studies should be performed next?A. Bone marrow biopsyB. CT of the abdomen and pelvisC. JAK2 mutation testingD. Peripheral blood flow cytometryCorrect AnswerB. CT of the abdomen and pelvisEducational ObjectiveDiagnose renal cell carcinoma in a patient with erythrocytosis and a high serum erythropoietin level.CritiqueThis patient requires CT of the abdomen and pelvis to detect possible renal cell carcinoma. The findings of a markedly elevated serum erythropoietin level due to secondary erythrocytosis plus vague midback pain and microscopic hematuria suggest the presence of an underlying renal cell carcinoma. Renal cell carcinoma is associated with secondary erythrocytosis in about 1% to 3% of patients. Polycythemia vera (PCV), a myeloproliferative neoplasm that results in excessive and unregulated erythrocyte production, is associated with very low serum erythropoietin levels. In contrast, an elevated serum erythropoietin level indicates the presence of secondary erythrocytosis. Although the most common causes of secondary erythrocytosis are chronic hypoxia and elevated carboxyhemoglobin concentrations due to tobacco use, an important cause is an erythropoietin-producing tumor. Other tumors commonly associated with secondary erythrocytosis include hepatocellular carcinoma and pheochromocytoma.Bone marrow biopsy is not indicated because of this patient's markedly elevated serum erythropoietin level, which suggests external erythropoietin production and not a bone marrow disorder as a cause of this patient's polycythemia.JAK2 mutation testing, which would be appropriate to rule out PCV in a patient with a very low serum erythropoietin level, is not indicated for this patient who has a markedly elevated level that is not compatible with a diagnosis of PCV.Peripheral blood flow cytometry would not add useful information because this patient has isolated polycythemia and no evidence of abnormal lymphocytes. Flow cytometry is best used to help establish a diagnosis when evaluating for a malignancy that would reveal a monoclonal population of cells with a specific phenotype.This content was last updated in August 2015.Key PointThe finding of a markedly elevated serum erythropoietin level in a patient with vague midback pain and microscopic hematuria suggests the presence of an underlying renal cell carcinoma.BibliographyKremyanskaya M, Mascarenhas J, Hoffman R. Why does my patient have erythrocytosis? Hematol Oncol Clin North Am. 2012 Apr;26(2):267-83, vii-viii.MKSAP 17 Question 2A 42-year-old man is evaluated during a follow-up visit for chronic kidney disease due to vesicoureteral reflux that progressed to end-stage kidney disease 10 years ago; he has been receiving hemodialysis for 5 years. He is anuric but feels well and reports no other symptoms. Medical history is otherwise unremarkable.On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 145/95 mm Hg, pulse rate is 85/min, and respiration rate is 14/min. BMI is 26. The lungs are clear. The abdominal examination is normal, and there is no costovertebral angle tenderness. The remainder of the examination is normal.An abdominal ultrasound was recently performed to evaluate a complaint of abdominal discomfort, which has since resolved. This study was remarkable for bilateral small echogenic kidneys with innumerable cysts and a 4-cm mass in the right renal parenchyma.Which of the following is the most likely diagnosis?A. Hemorrhagic kidney cystB. Renal angiomyolipomaC. Renal cell carcinomaD. Transitional cell carcinomaCorrect AnswerC. Renal cell carcinomaEducational ObjectiveDiagnose acquired cystic kidney disease and renal cell carcinoma in a patient with end-stage kidney disease.CritiqueThe most likely diagnosis is renal cell carcinoma. The patient has acquired cystic kidney disease (ACKD), which becomes more common and progresses during the course of end-stage kidney disease (ESKD); the incidence of ACKD rises dramatically as time on dialysis increases. Patients with ACKD typically have a large number of small bilateral kidney cysts and reduced kidney size. For unclear reasons, patients with ACKD have an approximately 30-fold increased risk for developing renal cell carcinoma; despite this, routine screening for this malignancy is not recommended. However, clinicians should have a high level of suspicion for renal cell carcinoma in patients with ESKD who have flank pain or hematuria that may be suggestive of the diagnosis. Despite the relatively high prevalence of renal cell carcinoma in patients with ACKD, it is an uncommon cause of death in patients with ESKD.The hallmark of autosomal dominant polycystic kidney disease (ADPKD) is large kidneys with multiple kidney cysts, usually originating in the renal collecting duct. Most patients with ADPKD have a positive family history for cystic kidney disease and/or chronic kidney disease. Diagnosis may be complicated by the fact that a hemorrhagic kidney cyst is usually indistinguishable from a solid renal mass on ultrasound. However, in this patient without a family history, small kidneys on ultrasound, and cysts scattered throughout the renal parenchyma, ADPKD with a hemorrhagic renal cyst is unlikely.Renal angiomyolipomas and bilateral renal cysts are associated with tuberous sclerosis complex (TSC). However, because this is an autosomal dominant disease, there is almost always a positive family history. Additionally, TSC is a systemic disorder with lesions typically present in various organs and tissues and would be a far less common cause of kidney tumors in a patient with ESKD.Transitional cell or urothelial carcinomas arise from the mucosal surfaces of the urethra, bladder, and ureters and may also occur in the renal pelvis and calyces; in the upper urinary tract, transitional cell carcinomas also tend to be multifocal and only uncommonly form mass lesions within the kidney. This patient's mass is located in the renal parenchyma, and there is not an increased risk of transitional cell carcinoma with ACKD, making this a less likely diagnosis.Key PointAcquired cystic kidney disease is associated with a large number of small bilateral kidney cysts, reduced kidney size, and a markedly increased risk for developing renal cell carcinoma.BibliographySinganamala S, Brewster UC. Should screening for acquired cystic disease and renal malignancy be undertaken in dialysis patients? Semin Dial. 2011 Jul-Aug;24(4):365-6.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 17 July 2018Volume 169, Issue 2Page: ED2KeywordsCellsErythropoietinKidneysNephrectomyPatientsPelvisPolycythemiaRenal cell carcinomaRenal diseasesRenal failure ePublished: 17 July 2018 Issue Published: 17 July 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...