Annals for Educators - 2 July 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives2 July 2019Annals for Educators - 2 July 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201907020 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAccess to Office-Based Buprenorphine Treatment in Areas With High Rates of Opioid-Related Mortality. An Audit StudyDespite increased attention on opioid addiction and overdose, most persons with opioid use disorder have not received care in the past year. This study assesses how often and how quickly callers posing as patients seeking care for heroin use were offered appointments by publicly listed buprenorphine prescribers.Use this study to:Ask your learners whether they have cared for patients to whom medications for opioid use disorder (e.g., buprenorphine) were or should have been offered. What are the indications? Are there contraindications?When medication for opioid use disorder is indicated, how is it accessed? Do your learners know what is involved in receiving a waiver to prescribe these medications in nonspecialty settings? Is there a limit to the number of patients a provider may treat?How do patients get appointments with such health care providers?What is an audit study (“secret shopper” study), and what kind of questions does it help to answer? What are the limitations of such a study?Teach at the bedside! Ask a patient who has received medication for opioid use disorder what challenges were involved in initiating and continuing to receive medication and care.Why do your learners think more “patients” who were paying for care out of pocket were offered appointments in this study than those receiving Medicare? Use the accompanying editorial to help frame your discussion. Use of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease. A Prospective Cohort StudyGuidelines from professional societies recommend that clinicians avoid placing peripherally inserted central catheters (PICCs) in patients with chronic kidney disease (CKD). This study used data from a multi-institutional quality collaborative in Michigan on a sample of hospitalized patients who received PICCs to describe the frequency and characteristics of placement in patients with CKD.Use this study to:Ask your learners why national guidelines recommend avoidance of PICC placement in patients with advanced CKD.What did this study find? Why do your learners think PICC placement among patients with CKD remains so common? Use the accompanying editorial to help frame your discussion. What are the alternatives to PICC placement?The authors note that being unable to assess whether PICC placement had been approved by a nephrologist was a limitation of their study. How is this a limitation?What variables might have confounded the study's findings? How did the authors attempt to control for them?Long-Term Drug Therapy and Drug Discontinuations and Holidays for Osteoporosis Fracture Prevention. A Systematic ReviewNational Institutes of Health Pathways to Prevention Workshop: Research Gaps for Long-Term Drug Therapies for Osteoporotic Fracture PreventionThis systematic review of 48 studies examined the benefits and harms of long-term drug treatment for osteoporosis as well as the benefits and harms of treatment discontinuation and holidays. The workshop assessed available evidence on long-term use of drug therapies to prevent osteoporotic fractures and identified research gaps and needs for advancing the field.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what the benefits are to use of drug therapies for osteoporosis. Do the benefits differ among the available drugs? Over what time frame are the benefits realized?What are the potential harms? What is an atypical femoral fracture? What is osteonecrosis of the jaw? How common are they?How long should drug therapy for osteoporosis be? What is the rationale for “drug holidays”? How strong is the evidence for such a practice? What did the systematic review find?What are the gaps in our knowledge, and why do they matter? Use the accompanying editorial to help frame your discussion. In the Clinic: Care of the Transgender PatientBarriers to accessing appropriate and culturally competent care contribute to health disparities in transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Thus, it is important that clinicians understand the specific medical issues that are relevant to this population.Use this feature to:Ask your learners whether they know the criteria for establishing that a patient is transgender or gender-incongruent.Ask how transgender medical interventions should be considered.What are the options for transfeminine and transmasculine hormone therapies? What are the potential complications?What surgical procedures are available?Does insurance cover these therapies?What barriers to the care of transgender patients exist at your health center? How might the experiences of transgender and cisgender patients in your hospital differ?Are the questions on forms completed by patients in your practice problematic for transgender persons? How might they be changed? What about in your EHR?Use the multiple-choice questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: FamilyMs. Rahman ponders, “When the scenarios we learn in class replay in our lives, I don't know which person I should be: the family member or the medical trainee.”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have found themselves involved in medical discussions about their own family members and wondered whether their role in the dynamic should be altered by their medical training.The author notes the problems posed by the conflicting agendas of family members and her own goals for a family meeting. Have your learners experienced such conflict? How should these issues be negotiated to help the patient and his or her family?MKSAP 18 QuestionA 74-year-old woman is seen in follow-up for osteoporosis diagnosed 5 years ago. She has been taking alendronate (70 mg weekly) without adverse effect for 5 years. Medical history is otherwise unremarkable. Alendronate is her only medication.On physical examination, vital signs are normal. She has no kyphosis or height loss, and the remainder of her examination is also normal.Her recent bone mineral density by dual-energy x-ray absorptiometry (DEXA) scan showed a lumbar spine T-score of −2.2 and femoral neck T-score of −2.4.Which of the following is the most appropriate management?A. C-terminal peptide of type 1 collagen (CTx) measurementB. Continue alendronate for 5 additional yearsC. Decrease alendronate doseD. Discontinue alendronateCorrect AnswerD. Discontinue alendronateEducational ObjectiveManage a patient who has completed 5 years of oral bisphosphonate therapy.CritiqueThe most appropriate management of this patient is to discontinue alendronate. The Fracture Intervention Trial Long-term Extension (FLEX) trial showed that continuing alendronate treatment for 10 years compared with stopping after 5 years resulted in a small decrease in the incidence of clinical vertebral fractures but not nonvertebral fractures. Subject characteristics most predictive of incident fracture after alendronate discontinuation were age older than 76 years, current femur neck T-score below −2.5, and prior osteoporotic fracture. Importantly, women with femur neck T-score below −3.5 or who fractured during the initial 5 years of alendronate therapy were not included in the FLEX trial. The authors concluded that patients at high risk of fracture may benefit from continuing alendronate therapy for up to 10 years. There is inconsistency among expert groups regarding the need to monitor bone mineral density during osteoporosis therapy and at 5 years to inform decision making about discontinuation of therapy. Contrary to other groups, the American College of Physicians recommends against monitoring because data from several studies showed that women treated with antiresorptive treatment benefit from reduced fractures even if BMD did not increase.The antiresorptive effect of alendronate can be assessed by bone turnover markers including serum C-terminal peptide of type 1 collagen (CTx). However, neither CTx levels on alendronate nor change with discontinuation predict which patients will fracture if alendronate is discontinued. Furthermore, serum CTx levels in patients taking alendronate vary widely and cannot be reliably interpreted without pretreatment values.The FLEX trial included postmenopausal women who had taken 5 years of alendronate 5 mg daily (equivalent to 35 mg weekly) or 10 mg daily (equivalent to 70 mg weekly). There was no difference in outcomes based on alendronate dose. Therefore, the management decision to be made after 5 years of alendronate therapy is to continue or discontinue rather than to modify the dose.This content was last updated in August 2018.Key PointFor low-risk osteoporotic women, treatment with antiresorptive therapy for 5 years is sufficient.BibliographyQaseem A, Forciea MA, McLean RM, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a Clinical Practice Guideline Update from the American College of Physicians. Ann Intern Med. 2017;166:818-839. Epub 2017 May 9.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 2 July 2019Volume 171, Issue 1Page: ED1KeywordsBone densityDrug therapyDrugsGraduate medical educationOpioid use disorderOsteoporosisPatientsPeripherally inserted central cathetersPhoton absorptiometrySystematic reviews ePublished: 2 July 2019 Issue Published: 2 July 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...