Annals for Educators - 7 May 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives7 May 2019Annals for Educators - 7 May 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201905070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsB-Lymphocyte Depletion in ε Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. A Randomized, Double-Blind, Placebo-Controlled TrialClinical observations and a series of small trials suggested that patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) had an improvement in their symptoms when they received cancer therapy. This multicenter, randomized, controlled trial compared rituximab infusions versus placebo infusions over 12 months in patients with ME/CFS.Use this study to:Ask your learners ε what symptoms should prompt consideration of ME/CFS.How is the diagnosis of ME/CFS established?What observations in patients with ME/CFS prompted these investigators to hypothesize that altering B-cell function might improve symptoms in ME/CFS? Use the paper's discussion and the accompanying editorial to help frame your discussion. What do the results of this study, in conjunction with prior experience of rituximab use in ME/CFS, tell us about the potential role of placebo effects?The Chylomicronemia Syndrome Is Most Often Multifactorial. A Narrative Review of Causes and TreatmentThe chylomicronemia syndrome is a constellation of findings that occurs with extreme elevations in plasma triglyceride levels. This narrative review describes the 3 causes of the syndrome and important differences in treatment, depending on the underlying cause.Use this review to:Ask your learners to list the potential clinical manifestations of hypertriglyceridemia.Review the normal physiology of triglyceride transport and metabolism. What are the causes of chylomicronemia syndrome?What factors may contribute to severe hypertriglyceridemia in persons with a genetic predisposition? Use the Table to prepare for a teaching session.What is the “buttock shelf” in the Köbberling type of partial lipodystrophy? Show Figure 2 to your learners.How is chylomicronemia syndrome treated? Review the algorithm provided.Cases in Precision Medicine: When Patients Present With Direct-to-Consumer Genetic Test ResultsAs direct-to-consumer (DTC) genetic testing grows in popularity, physicians must anticipate that patients will increasingly bring the results to them for interpretation. This article discusses DTC genetic testing in the context of a married couple who ask their primary care physician to explain the implications of the findings for their own health and that of any future children.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!What are the potential harms and benefits of DTC genetic testing?Ask your learners whether patients have asked for interpretation of DTC genetic test results.What information do DTC genetic tests provide? How reliable are the results?Are 23andMe test results comprehensive?Why is the positive predictive value of 23andMe results limited?When should your learners refer patients for genetic counseling?Do your learners believe it is their responsibility to provide counseling on the results of tests they did not order or recommend?Reassessment of Risk for Stroke During Follow-up of Patients With Atrial FibrillationThis brief research report assesses changes in patients' CHA2DS2-VASc scores over time to determine how frequently the scores go from below to above the threshold for recommended anticoagulation.Use this study to:Ask your learners how they decide whether a patient with atrial fibrillation should receive anticoagulant therapy.How is the CHA2DS2-VASc score calculated? At what score is anticoagulation recommended in men and women? Why?Have your learners ever considered how often the CHA2DS2-VASc score changes? Should they? What do the results of this study suggest? How often do your learners think CHA2DS2-VASc scores should be recalculated?In the Clinic: HypertensionRecent guidelines on diagnosis and management of high blood pressure (BP) include substantial changes and several new concepts compared with previous guidelines. Are your learners familiar with the new diagnostic thresholds, out-of-office BP monitoring, intensified treatment goals, and an appropriate approach to resistant hypertension?Use this review to:Ask your learners why we screen for hypertension.How should BP be measured? Are you sure your learners do it correctly? Observe them, and use the information in the Box to assess how well they do.Ask your learners about the process for BP measurement in their practice. Who does it, and how? Are they sure it is done correctly? Ask them to quietly observe and report back on whether the measurements are being done correctly.Which definition of hypertension do your learners use?What is masked hypertension?When should ambulatory monitoring be used? How do your learners arrange for this?What laboratory testing should be ordered in patients with newly diagnosed hypertension?How does the American Heart Association approach to treatment differ between stage 1 and stage 2 hypertension?Use the provided multiple-choice questions to help introduce topics for teaching. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismAnnals Graphic Medicine – Dr. Mom: Haven't Seen the Doc YetDr. Farris's comic shows how a patient viewed (or did not view) her.Use this comic to:Provide a copy to your learners to enjoy, or show it to them at a workstation, on your phone, or on your tablet.Ask if patients have failed to recognize or acknowledge that your learners are physicians. Why does this happen? Does it happen more frequently to women physicians?How should we respond when it occurs? Should we be offended?Although this situation is comically portrayed here, might it pose a problem for patient care? What about for physician well-being? What can be done to remedy the situation?MKSAP 18 QuestionA 46-year-old man seeks advice on whether he should undergo prostate cancer screening. He recently underwent direct-to-consumer genetic testing, which revealed that his risk for prostate cancer is 33% higher than that of the average person. He is asymptomatic. Medical history is unremarkable. Family history is significant for prostate cancer diagnosed in his paternal grandfather at age 72 years. He takes no medications.On physical examination, vital signs and the remainder of the examination are normal.Which of the following is the most appropriate management?A. Digital rectal examination (DRE)B. Serum prostate-specific antigen level measurementC. Serum prostate-specific antigen level measurement and DRED. Patient education and no further testingCorrect AnswerD. Patient education and no further testingEducational ObjectiveManage a patient who has undergone direct-to-consumer genetic testing.CritiqueThis patient should be advised that no further testing is necessary and should be educated on the limitations of direct-to-consumer (DTC) genetic testing. DTC genetic testing is a commercial service that allows patients to obtain genetic information for a low cost and without referral from a physician. These tests estimate the risk for many common medical conditions by genotyping polymorphic nucleotides. Single-nucleotide polymorphisms (SNPs) that are disproportionately found in affected individuals are identified, and odds ratios for each SNP are determined. The SNPs are usually common but have low penetrance (that is, most people with an SNP do not develop disease). Individually, SNPs contribute very little to overall disease risk; most SNPs have an odds ratio of less than 1.5. Because counseling or education is not typically provided before or after the DTC genetic test is obtained, patients are generally unable to accurately interpret the results and may request guidance or additional testing from their physicians. This patient's absolute risk for developing prostate cancer based on the test results is extremely small; therefore, no further testing is required.Screening for prostate cancer in asymptomatic, average-risk men is controversial, and recommendations vary among professional organizations and frequently change. However, no guidelines support performing a digital rectal examination (DRE) to screen for prostate cancer. The overall sensitivity of DRE does not exceed 60%, whereas the specificity is greater than 90%; the positive predictive value of an abnormal DRE is 28%. As such, there is no indication for this test either alone or in combination with serum prostate-specific antigen (PSA) level measurement.The U.S. Preventive Services Task Force recommends that clinicians discuss potential benefits and harms of PSA-based screening for prostate cancer in men aged 55 to 69 years. The decision to proceed with PSA level measurement should be individualized based on the patient's beliefs and values. In this 46-year-old patient, obtaining a serum PSA level is not indicated. The patient's family history of prostate cancer at an advanced age does not significantly increase his risk for cancer. He has a low pretest probability of prostate cancer, and a positive test result will likely be a false positive. Nevertheless, patients with positive test results often undergo biopsy with the attendant risks of infection, bleeding, pain, and anxiety.Key PointPatients who undergo direct-to-consumer genetic testing should be advised of the risks and limitations of these tests, including the possibility for misinterpretation.BibliographyBurke W, Trinidad SB. The deceptive appeal of direct-to-consumer genetics. Ann Intern Med. 2016;164:564-5.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 7 May 2019Volume 170, Issue 9Page: ED9KeywordsAntigensCancer screeningDigital rectal examinationGenetic testingGeneticsHypertensionOdds ratioPositive predictive valueProstate cancerSingle nucleotide polymorphism ePublished: 7 May 2019 Issue Published: 7 May 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...