Annals for Educators - 5 May 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives5 May 2020Annals for Educators - 5 May 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202005050 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsIsradipine Versus Placebo in Early Parkinson Disease. A Randomized TrialSeveral studies have suggested that treatment with dihydropyridine calcium-channel blockers, such as isradipine, may be associated with a reduced risk for Parkinson disease. This randomized controlled trial examined the effect of isradipine on disease progression among patients with a relatively recent diagnosis of Parkinson disease.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how Parkinson disease presents. What symptoms should prompt consideration? How is the diagnosis made? How does Parkinson disease progress, and what complications may occur? Use the information in In the Clinic: Parkinson Disease. What can be done to manage the symptoms and complications of Parkinson disease? Do any therapies halt or delay disease progression?Why did the authors of this study believe isradipine might halt disease progression?Why were the outcome assessments made both ON and OFF antiparkinsonian medications? The authors explain this in the Methods section under “Outcomes and Follow-up.”Why might this study have failed to demonstrate a benefit? What might help guide the design or assessment of future trials? Use the accompanying editorial to help frame your discussion. Case Report: Unilateral Facial Paralysis During an Airline FlightThis brief report describes the presentation, physical findings, and outcome of a young man with acute unilateral facial weakness during an airline flight.Use this report to:Read the case report to your learners, stopping before the author indicates his clinical impression. Ask your learners what they would have considered in the differential diagnosis.What would your learners have done if they were “the doctor on board”? What are the possible causes of Bell palsy? Use the information in DynaMed: Bell Palsy, a benefit of your ACP membership. Read what happened in this case. Do your learners think the author did the right thing? Would they have instructed that the plane be landed as soon as possible? Do they think it would have been reasonable to ask that the plane be landed, or was it truly unnecessary?Annals Clinical Decision Making: Weighing Evidence to Inform Clinical DecisionsDeciding when recently published evidence should alter practice can be daunting. This article in the Annals Clinical Decision Making series discusses the care of a patient with a common problem and recently published studies to illustrate an approach to weighing new evidence not yet considered by practice guidelines that conflicts with existing recommendations.Use this feature to:Ask your learners to investigate the clinical question posed in the case presentation (whether to use steroids for therapy in a patient with pneumonia). How do they go about finding relevant information? What variables do they use to assess whether each source of information is reliable and sufficiently updated?Do your learners use clinical guidelines to inform their care? How do they assess their quality? Use this editorial to help frame your discussion. How do they decide whether the results of a recently published study should alter their plans of care? What variables do they consider?How do they assess validity? Use the Figure. What is the difference between the internal and external validity of a study?What variables should be considered when deciding whether to apply the results of a study to the care of an individual patient?In the Clinic: Eosinophilic EsophagitisEosinophilic esophagitis (EoE) is a relatively new disease, with its earliest recognition and understanding in the 1990s. It is driven by food allergies and leads to chronic esophageal inflammation, fibrosis, and stricture. Are your learners prepared to recognize and evaluate patients with EoE?Use this review to:Ask your learners what is known about the cause of EoE.In what ways does EoE present? How does it typically differ between pediatric and adult patients? What “compensatory” behaviors might be present? Review Table 1.How is the diagnosis made? What is the differential diagnosis? What are the endoscopic findings? When should pH monitoring or esophagography be considered?What are the potential complications of EoE?What is the therapeutic approach? What are “The 3 D's”? Do your learners think they could adhere to the 6-food elimination diet? What pharmacologic interventions are effective?Who requires long-term maintenance therapy?When is referral to a specialist appropriate, and which ones?Humanism and ProfessionalismOn Being a Doctor: Love in the Time of CoronaDr. Benatti reflects that, “One of the most painful aspects of this pandemic is the irremediable separation of patients from their families at the end of their lives.”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners to share their experiences communicating with families who are unable to see their loved ones in the hospital. How have the restrictions imposed in this pandemic affected your learners' emotions? Has it altered their pride in what they do? Has it caused frustration? Has it changed their view of their roles as physicians?What does the author mean when she writes, “Where medical science fails, medicine can still succeed. After all, this and nothing else is the driving force of medicine's progress across centuries”?MKSAP 18 QuestionA 59-year-old woman comes to the office for a follow-up evaluation of Parkinson disease, which was diagnosed 8 years ago and has been treated with carbidopa-levodopa, amantadine, and rasagiline. Primary symptoms are tremor, slowness, shuffling of the feet, and intermittent freezing of gait, which has caused her to fall several times; the tremor and slowness substantially improve after administration of carbidopa-levodopa, but she exhibits prominent involuntary, nonpatterned, dance-like movements for approximately 2 hours after a dose. She has tried increasing the carbidopa-levodopa dosage but could not tolerate the resultant nausea and orthostatic hypotension.On initial physical examination, which takes place before she takes her scheduled dose of carbidopa-levodopa, a prominent tremor is noted. The patient's spontaneous and repetitive movements are very slow, and she has difficulty taking more than a few steps before needing assistance to maintain balance. A repeat examination performed 1 hour after she takes the medication reveals suppression of the tremor, remarkable improvement of speed and gait, and the presence of diffuse high-amplitude flowing involuntary movements in all extremities.An MRI of the brain is unremarkable.Which of the following is the most appropriate next step in her treatment?A. ApomorphineB. Deep brain stimulationC. DroxidopaD. Rotigotine patchCorrect AnswerB. Deep brain stimulationEducational ObjectiveTreat advanced Parkinson disease.CritiqueThis patient should have deep brain stimulation, which is indicated for patients with advanced Parkinson disease who derive a continued benefit from carbidopa-levodopa but experience medication-related complications. The patient has two common levodopa-related complications: motor fluctuations (caused by the wearing off of the beneficial effects of the medication before the next dose is administered) and medication-induced dyskinesia (involuntary choreic movements). Attempting to increase the dose of levodopa to mitigate the “wearing-off” phenomenon resulted in dyskinesia, nausea, and hypotension. Deep brain stimulation enables a persistent motor benefit and reduction of the total levodopa dosage, which would diminish the levodopa-induced adverse effects, including dyskinesia, nausea, and orthostatic hypotension.Apomorphine is a fast-acting subcutaneous dopamine agonist that is indicated for rapid relief of symptoms caused by sudden wearing off of a Parkinson medication. It is inappropriate for this patient, who experiences predictable episodes of wearing off of the carbidopa-levodopa benefit before she takes the next dose. Apomorphine also does not address the dyskinesia or nausea.Droxidopa has been approved for management of neurogenic orthostatic hypotension in Parkinson disease. This treatment, however, would not improve the wearing off of the dopaminergic medication before the next dose or the patient's other symptoms of gait freezing, dyskinesia, and medication-induced nausea.Rotigotine, a dopamine agonist, can worsen both nausea and orthostatic hypotension. Additionally, an overall increase in dopaminergic medication dosing is likely to aggravate dyskinesia.Key PointDeep brain stimulation is appropriate for patients with Parkinson disease who derive a continued benefit from carbidopa-levodopa but experience medication-related complications.BibliographyOkun MS. Deep-brain stimulation for Parkinson's disease. N Engl J Med. 2012;367:1529-38. doi:10.1056/NEJMct1208070Do 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 5 May 2020Volume 172, Issue 9Page: ED9KeywordsDecision makingDeep brain stimulationDopamineDopaminergicsGraduate medical educationHypotensionLevodopaNauseaParalysisParkinson disease ePublished: 5 May 2020 Issue Published: 5 May 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...