Annals for Educators - 1 August 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives1 August 2017Annals for Educators - 1 August 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201708010 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsBenefits and Risks of Antithrombotic Therapy in Essential Thrombocythemia. A Systematic ReviewThis systematic review examines current evidence about the benefits and risks of antiplatelet therapy for adults with essential thrombocythemia (ET), a disorder associated with high risk for both thrombosis and hemorrhage.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to generate a differential diagnosis of thrombocytosis. How might ET present? Is it often an “incidental finding” in asymptomatic patients?Ask your learners to list the myeloproliferative disorders. How does ET differ from polycythemia vera? Use the information in DynaMed Plus: Essential thrombocythemia, a benefit of your ACP membership. What are the major complications of ET? What is the justification for antiplatelet therapy in ET? The editorialist notes that the benefit of antiplatelet therapy in a randomized trial of patients with polycythemia vera makes “the temptation…almost irresistible” to start antiplatelet therapy in patients with ET. What are the potential pitfalls of such an approach? What do the results of this systematic review tell us about the use of antiplatelet therapy? How might a systematic review that concludes that the current state of evidence is insufficient to guide therapy still be useful to clinicians and the research community?What advice would your learners give to a patient with ET with regard to the balance of risks and benefits of antiplatelet therapy? How would they explain these in light of the results of this systematic review?Would the presence of a JAK2 mutation be helpful in deciding what to do? Invite a hematologist to join your discussion.Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy. A Systematic ReviewThis systematic review of 67 studies examines the effectiveness of 8 strategies to reduce or discontinue long-term opioid therapy in adults with chronic pain.Use this study to:Ask your learners what the risks of long-term opioid use are. What are the barriers to discontinuation? Is dose reduction useful?What are the challenges to dose reduction, and what are the potential unintended consequences (both medical and to the physician–patient relationship)? Use the accompanying editorial to help frame your discussion. Do the barriers lie only with the patient? Are we sufficiently motivated to take the time required to assist patients in this process? How was dose reduction accomplished in the studies included in this systematic review? Are we prepared to do what was done in these programs? The editorialist suggests identifying and starting with a few motivated patients in one's practice. Why?The authors and editorialists note the importance of obtaining patient buy-in. How might motivational interview techniques help? What are they? Role-play with your learners to practice.Explore the resources available from the Centers for Disease Control and Prevention (reference 9 of the editorial). Will these be helpful to your learners or your patients?What other members of the health care team are important in helping patients to reduce the dose of long-term opioid therapy?The editorialist disagrees with the attitude that, “In the realm of opioid therapy, patient safety and pain relief have often been framed as conflicting and mutually exclusive goals.” Do your learners agree?Beyond the GuidelinesShould This Patient Receive an Antidepressant? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThis Beyond the Guidelines reviews a recent clinical practice guideline and includes a discussion between 2 experts on how they would apply it to a 64-year-old man with depression who is reluctant to begin taking medication. They review the data on which the guideline is based, discuss the limitations of applying the data to real-world settings, review how they would incorporate patient preferences when making treatment decisions, and outline options for patients in whom first-line therapy has failed.Use this feature to:Watch the patient interview video with your learners, then ask them what they would recommend to this patient. Are there other questions or topics they would want to discuss with the patient to help him decide what to do?Review the evidence supporting the use of therapies for depression. You might watch the grand rounds presentation with your learners, download and use the prepared slides to help present the material yourself, or assign your learners to summarize the points made by the primary care physician and the psychiatrist.The discussants note the potential use of nonpharmacologic approaches to treating depression. What are they? How does one refer a patient for cognitive behavioral therapy? What is involved?Use the multiple-choice questions provided to help break up a teaching session, and be sure to log on and enter your answers to earn CME and MOC credit for yourself!In the Clinic: OsteoporosisOsteoporosis is a common systemic skeletal disorder resulting in bone fragility and increased fracture risk. However, management of osteoporosis and fracture prevention strategies are often not addressed by primary care clinicians, even in older patients with recent fractures. Are your learners prepared to do so?Use this eminently practical review to:Ask your learners how often adults should be screened for osteoporosis. When should screening be stopped?How much vitamin D is it appropriate for adults to take each day? In addition to adequate vitamin D, what else is recommended to prevent osteoporosis?How are Z scores on dual-energy x-ray absorptiometry interpreted? In which patients should secondary causes of osteoporosis be evaluated, and which tests should be ordered? Is consultation with a specialist needed?Which patients are candidates for pharmacologic treatment, and how does one choose among treatments? Use the table to review their adverse effects and risks. How long should therapy be continued?Share the patient information sheet with your learners. Would this be helpful for their patients? Does your practice have such reading materials readily available for your patients? If not, should your learners suggest this one be made available? Where should it be kept, and whose job should it be to remember to provide it to patients with osteoporosis? Is there anything missing from this information that they would have included?Use the prepared teaching slides to help with a teaching session. Use the multiple-choice questions to introduce topics, and be sure to log on to enter your answers and earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: CrutchesDr. Karkowsky senses there is something else going on in his patient's life that prompted the visit.Use this essay to:Listen to an audio recording with your learners, read by Dr. Michael LaCombe.Dr. Karkowsky was busy and had fit this patient into his schedule when he noticed something more might be behind the visit than concern about hypertension. Do your learners think that in such a situation, perhaps short on time, they might have ignored such a signal and simply increased the patient's antihypertensive medications?How comfortable would your learners be talking about such personal issues with their patients? How would it make your learners feel to know their patient looked to them for such counsel? Would they draw on personal experience when trying to provide advice? How comfortable (or uncomfortable) would they be doing so?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 1 August 2017Volume 167, Issue 3Page: ED3KeywordsAntiplatelet therapyHemorrhageIron deficiencyOpioidsOsteoporosisPlateletsPolycythemia veraSystematic reviewsThrombocytosisTreatment guidelines ePublished: 1 August 2017 Issue Published: 1 August 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...