Annals for Educators - 3 November 2020
Authors: Christine Laine
Journal: Annals of Internal Medicine (2020)

Web Exclusives3 November 2020Annals for Educators - 3 November 2020FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202011030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThree-Year Outcomes of Bariatric Surgery in Patients With Obesity and Hypertension. A Randomized Clinical TrialAssociation Between Bariatric Surgery and All-Cause Mortality: A Population-Based Matched Cohort Study in a Universal Health Care SystemThe first study involved patients with obesity and hypertension and compared the effects of Roux-en-Y gastric bypass versus medical therapy on antihypertensive medication use and blood pressure control after 3 years. The findings show that Roux-en-Y gastric bypass is an effective strategy for hypertension control. The second study compared risk for death among patients who had bariatric surgery versus nonsurgical obesity management and examined this relationship across subgroups based on age and other characteristics. Across most subgroups, bariatric surgery was associated with substantially lower all-cause, cardiovascular, and cancer mortality. The largest absolute effects were for men and patients aged 55 years or older.Use these studies to:Start a teaching session with a multiple-choice question. We provide one below!Review the definitions of overweight, obesity, and morbid obesity with your learners.Ask your learners to identify the types of patients for whom they might recommend bariatric surgery.Review the different bariatric procedures and discuss the advantages and disadvantages of each.Read the editorial and discuss whether these data suggest that early surgical intervention is better than a stepwise approach to managing cardiometabolic consequences of obesity. Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries. A Systematic Review and Network Meta-analysis of Randomized TrialsNonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family PhysiciansThe network meta-analysis of 207 trials summarizes evidence about benefits and harms of therapies for acute pain from non–low back, musculoskeletal injuries. The guideline provides recommendations for nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adult outpatients.Use the evidence review and clinical guideline to:Ask your learners what duration of symptoms distinguishes acute from chronic musculoskeletal pain.Discuss the types of nonpharmacologic therapies that patients report using to manage musculoskeletal pain. What is known about the effectiveness and harms of those interventions?Ask your learners which pharmacologic therapies they typically prescribe for patients with acute, non–low back musculoskeletal pain. Review the evidence for the benefits and harms of topical NSAIDs, oral NSAIDs, acetaminophen, and opioids.Role play a discussion with a patient who is seeking opioid therapy for acute, non–low back musculoskeletal pain.In the Clinic: Care of the Patient Using CannabisOver the past 2 decades, legal access to cannabis in the United States has increased, and the population of cannabis users, especially daily users, has grown significantly. An estimated 4.5 million to 7 million persons in the United States now meet criteria for cannabis use disorder each year. This article focuses on the effects of cannabis use, intoxication, and withdrawal while also reviewing the developmental pathways of cannabis use disorder as well as evidence-based pharmacologic and psychosocial treatments.Use this review to:Ask your learners whether they routinely ask patients about cannabis use when taking a medical history.Ask your learners about the definition of cannabis use disorder.Review the management of cannabis use disorder.Watch a brief video and discuss perioperative management of a patient with regular cannabis use. Use the provided multiple-choice questions to introduce topics for discussion during a teaching session, and sign in to earn CME/MOC credit for yourself.Humanism and ProfessionalismA Dangerous Myth: Does Speaking Imply Breathing?This article reviews basic respiratory physiology and highlights the clinician's role in discouraging the public from relying on speech as a sign of adequate respiration, especially to propagate injustice or violence.Use this article to:Review the visual abstract accompanying this article with your learners. Review the physiology behind the fallacy that speech indicates effective breathing.Have your learners read a recent ACP position paper on racism and health in the United States. Open a discussion with your learners about their thoughts on physicians and structural racism. Can they identify structural racism within the health care system? Do they think that physicians have a role in addressing structural racism? If so, what are some positive actions that physicians might take?MKSAP 18 QuestionA 27-year-old man is evaluated during a routine follow-up visit for obesity. On his previous two visits, he had a BMI of 38. Despite enrollment in a 6-month comprehensive supervised weight loss program that included nutritional counseling, he has gained 2.3 kg (5.0 lb). He briefly tried orlistat but discontinued this medication because of gastrointestinal side effects. Medical history is significant for type 2 diabetes mellitus and hypertension. Medications are liraglutide, lisinopril, and metformin.On physical examination, blood pressure is 146/91 mm Hg; other vital signs are normal. BMI is 39. The remainder of the physical examination is unremarkable.Laboratory studies reveal a hemoglobin A1c value of 8.2%.Which of the following is the most appropriate management?A. Bariatric surgeryB. LorcaserinC. Referral to a dieticianD. Very-low-calorie dietCorrect AnswerA. Bariatric surgeryEducational ObjectiveTreat a patient with obesity with bariatric surgery.CritiqueThis patient with obesity-related comorbid conditions and no weight loss success after a trial of comprehensive lifestyle modifications meets the criteria for referral for bariatric surgery. Bariatric surgery should be considered for patients who do not lose weight with lifestyle modifications, with or without pharmacologic therapy, and have a BMI of 40 or greater or a BMI of 35 or greater with obesity-related comorbid conditions, such as type 2 diabetes mellitus, coronary artery disease, obstructive sleep apnea, or osteoarthritis. Studies comparing bariatric surgery with nonsurgical treatment (diet, exercise, behavioral modification, and medications) have shown that participants randomly assigned to bariatric surgery lost more weight and were more likely to experience remission of type 2 diabetes and metabolic syndrome, improved quality of life, and reduced medication use. Evidence suggests that bariatric surgery is also associated with reduced mortality and improvement of obstructive sleep apnea, osteoarthritis, and other conditions.Lorcaserin is approved as adjunctive therapy to comprehensive lifestyle modification in the treatment of overweight and obesity. This patient is already taking liraglutide, another approved pharmacologic agent for obesity, and has tried but not responded to a third approved agent, orlistat. He is unlikely to benefit from the addition of lorcaserin to his medication regimen.Behavioral therapy for obesity may include the use of a trained interventionist, such as a nutritionist or dietician. This patient is already participating in a comprehensive behavioral therapy plan that includes nutritional counseling; a separate referral to a dietician is unnecessary. Behavioral therapy is also less likely than bariatric surgery to be successful in this patient.Very-low-calorie diets are recommended when rapid weight loss is medically indicated. Their use requires close medical supervision with frequent office visits and laboratory monitoring. In this patient, there is no indication for rapid weight loss that would warrant the use of a very-low-calorie diet.Key PointBariatric surgery should be considered in patients who do not lose weight with lifestyle modifications and have a BMI of 40 or greater, or a BMI of 35 or greater with obesity-related comorbid conditions, such as type 2 diabetes mellitus, coronary artery disease, obstructive sleep apnea, or osteoarthritis.BibliographyJensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129:S102-38. doi:10.1161/01.cir.0000437739.71477.eeDo 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: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 3 November 2020Volume 173, Issue 9Page: ED9KeywordsBariatric surgeryBody mass indexCannabis useHypertensionLower back painMusculoskeletal injuryObesityPain managementType 2 diabetesWeight loss ePublished: 3 November 2020 Issue Published: 3 November 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...