Annals for Educators - 16 June 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives16 June 2020Annals for Educators - 16 June 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202006160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsEffect of Acupuncture for Postprandial Distress Syndrome. A Randomized Clinical TrialFunctional dyspepsia is a common condition leading to significantly impaired quality of life. Its most common subtype, postprandial distress syndrome, is characterized by bothersome postprandial fullness or early satiation. The objective of this sham-controlled, randomized trial from China was to evaluate the effect of acupuncture on symptoms related to postprandial distress syndrome.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what functional dyspepsia syndrome is. What are the 2 subcategories? Use DynaMed: Functional Dyspepsia, a benefit of your ACP membership. Review the Rome IV criteria for diagnosis.What evaluation should be considered in patients with symptoms that are potentially consistent with functional dyspepsia to exclude structural or motility abnormalities?What were this study's end points? Do your learners agree they are good end points for evaluation of therapeutic efficacy? What did the study find?What limitations are created by the self-reported nature of the outcome? Are they avoidable given the nature of the condition? Review the other limitations noted by the authors in the paper's discussion section (e.g., sham acupuncture, substantial participant dropout). How might each have biased the results?Rifabutin-Based Triple Therapy (RHB-105) for Helicobacter pylori Eradication. A Double-Blind, Randomized, Controlled TrialAll patients with Helicobacter pylori infection should be offered eradication therapy. However, antimicrobial resistance has undermined the success rate of most current eradication therapies. This clinical trial assessed the effectiveness of a novel rifabutin-based therapy for H. pylori eradication.Use this study to:Ask your learners what diseases are associated with H. pylori infection.What are the mechanisms by which H. pylori infection contributes to gastric ulceration?Why is eradication of H. pylori recommended even in the absence of symptoms?What mechanisms are proposed regarding its role in the development of gastric cancer?What is the prevalence of antibiotic resistance among H. pylori in your community? How would your learners find out? What is the recommended treatment?Why were participants of Asian ancestry excluded from this trial?What follow-up is recommended after a course of treatment for H. pylori? Who is responsible for ensuring that follow-up testing to confirm eradication is pursued?Video LearningAnnals Consult Guys - Should We Elect to Replace a 93-Year-Old's Hip?In this episode of the consultative medicine talk show, Howard and Geno (“The Guys”) tackle the challenge of hip surgery in an elderly patient.Use this feature to:Take a break and watch the short, engaging video discussion with your learners.Ask them what they would consider when deciding whether to recommend surgery. What are the risks and benefits?Do your learners believe the benefits outweigh the risks for surgery in this patient? How would they engage the patient to decide whether to proceed?Use the provided multiple-choice questions to prompt discussion. And, be sure to sign in and enter your responses to earn CME/MOC credit for yourself!For Program DirectorsA Cautionary Tale: The 2019 Orphaning of Hahnemann's Graduate Medical TraineesHahnemann University Hospital provided care for Philadelphians starting in 1848, but financial turmoil culminated in its rapid closure in summer 2019, exposing vulnerabilities in graduate medical education. As the hospital shut its doors to patients, it also orphaned 583 medical trainees. In this firsthand account of the situation, the program director, department chair, and designated institutional official reflect on lessons learned that may help leaders at other institutions mitigate the inevitable difficulties that arise when academic hospitals close.Humanism and ProfessionalismResident Response During Pandemic: This Is Our TimeThis commentary discusses the value of residents during the COVID-19 pandemic. The author also evaluates the role of program leadership and administration during this health crisis.Use this essay to:Now several months into this pandemic, ask your learners if they feel they have received the support the author calls for. Has their physical health been consistently protected? Their mental health?The author hopes, “May we rise to the occasion, upholding the oath and honor of our profession.” Do your learners believe they have done so?The author further concludes, “This is our time.” Do your learners agree? Have their individual and collective contributions during this pandemic been a source of pride to them?On Being a Doctor: Vicarious Trauma: The Hazard and Joy of Caring for RefugeesDr. Fabreau learned that he and his colleagues were experiencing classic symptoms of “vicarious trauma.”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have heard of “vicarious trauma.” Do they think that some of what they have experienced in their training may affect them in this manner?Can we prevent the toll that these experiences took on the author and his colleagues while still providing care to patients in need?The author notes the powerful effect sharing his experience with colleagues had on them. Do your learners feel they could do the same?What is “vicarious resilience”?Invite an expert in providing emotional support to caregivers to join your discussion.MKSAP 18 QuestionA 55-year-old woman is evaluated for a 6-month history of throbbing and sometimes burning epigastric pain. The pain occurs 2 to 3 times per week and often subsides with eating. She reports no weight loss, nausea, or vomiting, and no bowel symptoms. She tested negative for Helicobacter pylori infection. Her pain did not respond to a 4-week trial of omeprazole. The patient also has anxiety, hypothyroidism, and type 2 diabetes mellitus controlled by diet. Her family medical history is unremarkable. Her medications are lorazepam and levothyroxine.On physical examination, vital signs are normal. Epigastric tenderness to palpation is noted. Other findings are normal.A complete blood count, liver chemistry tests, and thyroid-stimulating hormone level are normal. Hemoglobin A1c level is 6.7%.Upper endoscopy findings are normal. Gastric and small-bowel biopsies are normal.Which of the following is the most appropriate next step in management?A. CT scan of the abdomenB. Gastric emptying testC. Initiation of a tricyclic antidepressantD. Twice-daily proton pump inhibitor therapyE. Ultrasonography of the right upper quadrantCorrect AnswerC. Initiation of a tricyclic antidepressantEducational ObjectiveTreat functional dyspepsia.CritiqueStarting a trial of a tricyclic antidepressant is the most appropriate next step in the management of this patient. The patient has functional dyspepsia meeting the diagnostic criteria for epigastric pain syndrome: (1) bothersome postprandial fullness; (2) early satiety; (3) epigastric pain; and/or (4) epigastric burning for at least 3 days per week. These criteria should be met for the 3 months leading up to diagnosis, with symptoms starting at least 6 months before diagnosis and with no evidence of structural disease to explain the symptoms. The absence of an underlying organic disease is demonstrated by this patient's normal upper endoscopy, including gastric and small-bowel biopsies, as well as normal laboratory testing and the lack of alarm features such as vomiting, weight loss, or family history of gastrointestinal malignancy. Because she tested negative for Helicobacter pylori infection and her symptoms did not respond to a trial of once-daily omeprazole for a minimum of 4 weeks, the recommended next step in the treatment of functional dyspepsia is a trial of a tricyclic antidepressant. In the treatment of functional dyspepsia, this class of antidepressants was found to be more effective than other classes, including selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors.Given this patient's absence of alarm symptoms and normal laboratory test results, further structural testing with CT imaging or abdominal ultrasonography is likely to be of low yield; therefore, such testing is neither clinically indicated nor cost effective.A gastric emptying test is used to evaluate suspected gastroparesis. Gastroparesis commonly presents with symptoms of early satiety, postprandial fullness, nausea, vomiting, upper abdominal pain, bloating, and weight loss; this patient's lack of compatible symptoms makes the diagnosis unlikely.There is no evidence that a higher dose of a proton pump inhibitor performs better in the treatment of functional dyspepsia than once-daily omeprazole, which did not alleviate the patient's symptoms.Key PointFirst-line treatment for functional dyspepsia is once-daily omeprazole for at least 4 weeks; if symptoms do not respond, a tricyclic antidepressant is the next recommended treatment.BibliographyMoayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112:988-1013. doi:10.1038/ajg.2017.154Do 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 16 June 2020Volume 172, Issue 12Page: ED12KeywordsAcupunctureGraduate medical educationHelicobacter pylori infectionPainProton pump inhibitorsSurgeryTricyclic antidepressantsUltrasound imagingVomitingWeight loss ePublished: 16 June 2020 Issue Published: 16 June 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...