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

Web Exclusives21 January 2020Annals for Educators - 21 January 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202001210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsTestosterone Treatment in Adult Men With Age-Related Low Testosterone: A Clinical Guideline From the American College of PhysiciansThis clinical guideline from the American College of Physicians provides recommendations about testosterone treatment in adult men with age-related low testosterone.Use this guideline to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what symptoms should prompt consideration of hypogonadism in men. How should patients be evaluated? Use the information in DynaMed: Hypogonadism in Men, a benefit of your ACP membership. For what symptoms should testosterone replacement therapy (TRT) be considered? What does the ACP recommend? Why should TRT not be used to improve energy, vitality, or cognition?What are the potential risks with TRT? How should patients be monitored during therapy?Review Figure 2. How would your learners discuss the potential benefits and harms with a patient considering TRT? How would they explain the “certainty of evidence”?Use the accompanying editorial to help frame your discussion. Hospital-Level Care at Home for Acutely Ill Adults. A Randomized Controlled TrialHospital-level care provided in the patient's home may have beneficial effects on outcomes, but few trials of home hospital care have been done in the United States. This randomized controlled trial compared the effects of home hospital versus usual hospital care on direct costs and other outcomes among patients who required hospital admission.Use this study to:Ask your learners whether they think any of the patients on your service might have been safely treated at home rather than in the hospital. What would the potential benefits and risks be with care at home instead of hospitalization?Review the results of this randomized trial.What are the limitations of the study? Use the accompanying editorial to help frame your discussion. Why does it matter that so many eligible patients declined to participate? What do your learners believe are the consequences of hospitals' need to keep their beds occupied? Does it create good and/or bad incentives? How might caring for patients at home instead of in the hospital affect these issues? These issues are discussed in the editorial. Video LearningAnnals Consult Guys - Ouch! Imaging and the Prevention of Kidney StonesGeno and Howard (the Consult Guys) look to break up a fight over the evaluation of nephrolithiasis.Use this feature to:Start by posing the provided CME question to quiz your learners.Ask what symptoms suggest a diagnosis of nephrolithiasis. What is the differential diagnosis?Watch the short video with your team.Invite a urologist to discuss how to approach management of a stone and what can be done to prevent recurrence.Humanism and ProfessionalismAnnals Graphic Medicine - W.O.W.A cartoon (yes, a cartoon in a serious medical journal) assesses the state of hospital practice and where patients “fit in.”Use this feature to:Show the cartoon to your team.Ask whether what is depicted rings true at your hospital.How can we structure our practices to ensure that what is depicted here is not the reality?Show this issue's other Annals Graphic Medicine features ( here and here) and those at the Web Exclusives collection to your learners. Do your learners have an artistic flair? Encourage them to submit their own work. On Being a Doctor: A Very Persistent ColdDr. Faustinella describes how, “A feeling of helplessness came over me, penetrating into my bones just like the cold air outside.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners how much they know about their patients' home situations. How often might our medical plans for a patient's care be thwarted by social barriers?Do we ask our patients about their living conditions frequently enough? What should prompt us to do so? Do we worry that patients will be embarrassed to tell us? Do we worry that we won't know how to handle what we hear?On Being a Doctor: An MD Made in AmericaDr. Genao shares her story to encourage other immigrants not to give up on their dreams.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners how a story like Dr. Genao's affects them.Do your learners feel “privileged” to be physicians? Do we often forget how fortunate we are in the midst of the work and fatigue of training and medical practice?How can stories like this make us better physicians?MKSAP 18 QuestionA 71-year-old man is evaluated for headaches of 2 months' duration. He reports no shortness of breath and has a good energy level. Medical history is significant for hypertension, hypothyroidism, and hypogonadism; he has never smoked. Medications are lisinopril, levothyroxine, and testosterone injections.On physical examination, vital signs are normal except for a blood pressure of 160/92 mm Hg; BMI is 19. He has facial plethora. Cardiopulmonary examination is normal. No hepatosplenomegaly is noted.Laboratory studies:Erythropoietin40 mU/mL (40 U/L)Hematocrit56%Hemoglobin18.9 g/dL (189 g/L)Leukocyte count7000/µL (7 × 109/L) with normal differentialPlatelet count300,000/µL (300 × 109/L)Which of the following is the most likely cause of this patient's findings?A. LevothyroxineB. LisinoprilC. Polycythemia veraD. TestosteroneCorrect AnswerD. TestosteroneEducational ObjectiveDiagnose testosterone supplementation as a secondary cause for polycythemia.CritiqueThis patient's polycythemia is likely caused by testosterone injections. Polycythemia is a common adverse effect of testosterone (and anabolic steroid) supplementation, and evaluating the hematocrit level at initiation, 3 to 6 months after testosterone initiation, and annually thereafter is recommended by Endocrine Society guidelines. Guidelines also recommend interrupting the testosterone supplementation if the hematocrit value is greater than 54%. Secondary polycythemia can cause symptoms, such as headaches and elevated blood pressure, and increase the risk of thromboembolism. The risk of venous thromboembolic disease is directly related to hematocrit level. In this patient, stopping the testosterone supplementation until his polycythemia improves and restarting at a lower dose is recommended. In patients with severe symptoms, phlebotomy can also be considered. Testosterone supplementation can also exacerbate undiagnosed sleep apnea, and evaluation for an underlying sleep disorder should be performed in these patients with polycythemia.Anemia rather than erythrocytosis may be seen in patients with both hyperthyroidism and hypothyroidism, and levothyroxine, even if given at inappropriately high or low doses, does not cause polycythemia.Lisinopril does not cause polycythemia. ACE inhibitors, such as lisinopril, are actually used to treat secondary polycythemia after kidney transplantation. Posttransplant erythrocytosis occurs in up to 15% of patients after kidney transplantation. ACE inhibitors reduce erythrocytosis in 90% of patients in a dose-response manner. The mechanism is unknown, but apoptosis of the erythroid precursors has been suggested as well as renin-angiotensin system inhibition that may decrease erythropoietin production.Polycythemia vera (PV) is a disorder of the myeloid and erythroid stem cells that causes erythropoietin-independent proliferation of erythrocytes and splenomegaly. PV should be considered in all patients with polycythemia; however, in this patient who is receiving testosterone supplementation, has an elevated erythropoietin level, and does not have splenomegaly, PV is unlikely. If PV is suspected, mutational analysis for JAK2 V617F should be performed.Key PointPolycythemia is a common adverse effect of testosterone injections, and testosterone supplementation should be interrupted if the hematocrit level exceeds 54%.BibliographyBhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, et al; Task Force, Endocrine Society. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95:2536-59. doi:10.1210/jc.2009-2354Do 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 January 2020Volume 172, Issue 2Page: ED2KeywordsHematocritHypogonadismHypothyroidismPolycythemiaPolycythemia veraRenal transplantationSplenomegalyTestosteroneThyroxineTreatment guidelines ePublished: 21 January 2020 Issue Published: 21 January 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...