Annals for Educators - 21 July 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives21 July 2020Annals for Educators - 21 July 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202007210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsA Dangerous Myth: Does Speaking Imply Breathing?The belief that a person's ability to speak precludes the possibility of suffocation is false and can have fatal consequences. This commentary reviews basic respiratory physiology and highlights the clinician's role in educating the public against relying on speech as a sign of adequate respiration, especially when this misconception is used to propagate injustice or violence.Use this essay to:Ask your learners if they have heard it said that the ability to speak means a person is breathing. Have they heard this in reference to assessing a choking victim?Review the relevant physiology of air movement and oxygen exchange, which is explained clearly in the second and third paragraphs of this essay. Use the simple, single-panel visual abstract to help explain and reinforce the message. The authors note that the medical profession has a duty to educate the public about the commonly held myth that phonation indicates an ability to breathe. Do your learners agree? What about the duty to speak out against the purposeful induction of respiratory distress?Long-Term Colorectal Cancer Incidence and Mortality After a Single Negative Screening ColonoscopyThe current colorectal cancer screening guidelines recommend colonoscopy every 10 years for an average-risk population. However, this recommendation is based on limited indirect evidence. This study quantified the long-term risk for colorectal cancer incidence and mortality after a single negative result on screening colonoscopy. It also evaluated the associations between the quality of the baseline colonoscopy and the subsequent risk for colorectal cancer incidence and mortality.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to explain the mechanism by which colonoscopy might reduce colorectal cancer incidence and mortality.Why do they think the reductions observed for cancer in the distal colon have not been seen in the proximal colon?How has the recommended interval between screening colonoscopies been established? Do your learners think the interval is likely too long, too short, or about right? What do the results of this study suggest?Why are the results different from high- and low-quality colonoscopic examinations? How might each of the elements used to determine study quality (cecal intubation rate, adequate bowel preparation, and the endoscopist's adenoma detection rate) contribute to this difference?Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States. A Qualitative StudyMental and substance use disorders are common, but access to behavioral health services is often challenging for patients and their clinicians. Despite financial incentives and the encouragement of professional organizations, efforts to integrate behavioral health clinicians into physician practices have been limited. This study assessed variables that influence physician practices' integration of behavioral health services.Use this study to:Note that 1 in 5 adults has a clinically significant mental health or substance use disorder. Ask your learners how they access behavioral health services for their patients. Is it easy to arrange?When their patients are seen by a behavioral health specialist, is there effective communication with your learners?Is behavioral health integrated into physician practices at your center? Why or why not? Invite a leader of the outpatient practices and of behavioral health services at your center to participate in your discussion.Use the accompanying editorial to help frame the discussion. What barriers to integration were identified in this study? Are these same issues present at your center? How might they be addressed?Risk for Nephrogenic Systemic Fibrosis After Exposure to Newer Gadolinium Agents. A Systematic ReviewThis systematic review compares the risk for nephrogenic systemic fibrosis after exposure to newer versus older gadolinium-based contrast agents.Use this review to:Ask your learners what the clinical manifestations of nephrogenic systemic fibrosis are.Who is thought to be at risk? Use the information in DynaMed: Complications of Chronic Kidney Disease, a benefit of your ACP membership. What did this study find regarding the risk with newer gadolinium-based contrast agents? What limitations did the authors find regarding data available to answer this question?The authors note several potential risks for bias in the available data (see the “Quality Assessment” subheadings for key questions 1 and 2 in the Results). How might each of these affect the estimates of risk?What kind of gadolinium-based contrast agent is used at your institution? When is gadolinium useful? Invite a radiologist to join your discussion.Humanism and ProfessionalismOn Being a Doctor: Silver Alert: Lost-and-Found DadDr. Parshley recalls the growing panic of trying to find her father, a retired physician who has dementia and is lost on the grounds of his old medical center.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether, like Dr. Parshley, they have felt embarrassed when having to explain the actions of an ill family member to other health care professionals. Why do we react this way to being on “the other side” of health care delivery?Dr. Parshley notes that this health care facility was ill equipped to help find patients with dementia who have wandered off. Are things better at your institution? What can be done to make things safer?MKSAP 18 QuestionA 55-year-old woman is evaluated after screening colonoscopy showed three polyps at the rectosigmoid junction. The three polyps were 3 mm, 5 mm, and 6 mm in size. All three polyps were completely excised and pathology showed them to be hyperplastic. Colonoscopy preparation was excellent and the procedure was complete to the cecum. Family history is significant for colon cancer diagnosed in her paternal grandfather at age 80 years.All physical examination findings, including vital signs, are normal.When should this patient next undergo colonoscopy?A. 1 yearB. 3 yearsC. 5 yearsD. 10 yearsCorrect AnswerD. 10 yearsEducational ObjectiveManage follow-up colonoscopy for hyperplastic polyps.CritiqueThis patient should undergo colonoscopy in 10 years. Serrated polyps are classified into three histologic types: hyperplastic polyps, sessile serrated polyps, and traditional serrated adenomas. Hyperplastic polyps are the most common type of serrated polyp. They are non-neoplastic and are composed of normal mucosal elements; small hyperplastic polyps, often found in the rectosigmoid colon, are believed to have no clinical significance. As a result, the interval until the next screening examination is 10 years, the same as for patients who do not have polyps found on baseline examination. Sessile serrated polyps (also known as sessile serrated adenomas) and traditional serrated adenomas are both neoplastic and are precursors to colorectal cancer; they should be completely excised. Substantial variability has been demonstrated in the ability of a pathologist to differentiate a hyperplastic polyp from a sessile serrated polyp; therefore, guidelines recommend managing large (>10 mm) hyperplastic polyps as if they are sessile serrated polyps.The patient's family history of a second-degree relative with colon cancer diagnosed at age 80 years does not increase her risk for colon cancer or indicate the need for more frequent or early colonoscopy.A 1-year surveillance interval is not appropriate for this patient. It is indicated in patients with more than 10 adenomas found on colonoscopy, those with a diagnosed polyposis syndrome, or those with Lynch syndrome. Lynch syndrome is the term used to describe patients who meet the Amsterdam II criteria for hereditary nonpolyposis colorectal cancer and have an identified germline mutation in one of the four mismatch repair genes (MLH1, MSH2, MSH6, PMS2) or the epithelial cell adhesion molecule gene (EPCAM).A 3-year surveillance interval is recommended for patients who have three or more adenomas (or sessile serrated polyps) found on baseline colonoscopy, one adenoma larger than 10 mm in size, or an adenoma with any degree of villous or high-grade dysplasia.A surveillance interval of 5 years is recommended for patients with two or fewer adenomas (or sessile serrated polyps) found on baseline colonoscopy and for patients with a first-degree relative with colon cancer diagnosed at an age younger than 60 years. Sessile serrated polyps are more frequently found in the proximal colon and may be difficult to detect on colonoscopy due to their flat appearance. Like tubular adenomas, surveillance colonoscopy is based on size and presence of dysplasia.Key PointPatients with small (<10 mm) hyperplastic polyps on baseline colonoscopic examination should undergo surveillance colonoscopy in 10 years.BibliographyLieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR; United States Multi-Society Task Force on Colorectal Cancer. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.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 21 July 2020Volume 173, Issue 2Page: ED2KeywordsAdenomasColonColonoscopyColorectal cancerFibrosisHealth careHereditary nonpolyposis colorectal cancerMedical servicesMortalitySystematic reviews ePublished: 21 July 2020 Issue Published: 21 July 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...