Annals for Educators - 2 June 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives2 June 2020Annals for Educators - 2 June 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202006020 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsResidual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence. A Prospective Cohort StudyRecent evidence has demonstrated the efficacy of patent foramen ovale (PFO) closure in preventing recurrent stroke. Residual shunt, however, may be observed after percutaneous closure. This study evaluated the long-term association of residual shunt with recurrent neurologic events after percutaneous PFO closure.Use this study to:Ask your learners to list the potential complications of a PFO.When should PFO closure be considered? What are the options for how that is accomplished?How is percutaneous closure performed? Invite an interventional cardiologist to join your discussion, or arrange to discuss this at the cardiac catheterization lab where fluoroscopic films of a PFO closure may be shown to your learners.How should patients be monitored after PFO closure? Do they require long-term anticoagulation?Should the results of this study alter the approach to PFO closure or follow-up care? Use the accompanying editorial to help frame your discussion. L-Thyroxine Therapy for Older Adults With Subclinical Hypothyroidism and Hypothyroid Symptoms. Secondary Analysis of a Randomized TrialRandomized clinical trials have shown that L-thyroxine does not improve hypothyroid symptoms among adults with subclinical hypothyroidism. This secondary analysis of data from the TRUST trial, which compared L-thyroxine versus placebo among persons aged 65 years or older with persistent subclinical hypothyroidism, examines whether L-thyroxine improved hypothyroid symptoms among patients with the greatest symptom burden before treatment.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!What is “subclinical hypothyroidism”? What symptoms may be present? What are the diagnostic criteria?What are the causes of hypothyroidism and subclinical hypothyroidism?Should subclinical hypothyroidism be treated? Why or why not? What are the potential benefits and risks?What did this study find? Will the results alter your learners' approach?How do your learners respond to patients on thyroid replacement therapy who continue to have bothersome symptoms despite thyroid function tests that do not suggest hypothyroidism?Annals Clinical Decision Making: Using a Diagnostic TestDiagnostic testing is an essential tool in clinical decision making. This article in the Annals Clinical Decision Making series reviews core principles underlying the approach to choosing and interpreting diagnostic tests for individual patients.Use this feature to:Read the short presentation of case 1 to your learners (a patient with cough, anorexia, and fever). What went wrong here?The authors note, “Because nearly all tests are imperfect, errors in interpretation most often arise from overestimating the effect of a test result on the posttest probability of a condition.” Can your learners explain why this is true?What is posttest probability? How does it differ from the sensitivity of a test? Review the 2 examples provided in Table 2 to be sure your learners understand.Now review case 2. What testing should be considered?What are the tradeoffs between performing tests and treating empirically? How might they differ according to the condition and the test? Use Table 3 and Figure 2 to guide the discussion.Review the algorithm for approaching diagnostic testing in Table 1. Do your learners think they follow an approach such as this in their practices? Should they?Beyond the GuidelinesShould You Recommend Inhaled Corticosteroids for This Patient With Chronic Obstructive Pulmonary Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe mainstay of treatment for chronic obstructive pulmonary disease (COPD) is inhaled bronchodilators, whereas the role of inhaled corticosteroids (ICSs), which have substantial risks, is less clear. Here, 2 pulmonologists discuss the care of a patient with severe COPD and consider the indications for ICSs in COPD, when ICSs should be withdrawn, and what other treatments are available.Use this feature to:Watch the video of Ms. J, who has severe COPD with frequent exacerbations, a history of recurrent pneumonia, and profound exercise limitation.Ask your learners what classes of medications are used to treat COPD.Why might ICS therapy be helpful? Why might it be harmful? Would your learners recommend it be continued in Ms. J?Review the major points made by the 2 discussants in favor of or against using ICS therapy here. Alternatively, assign members of your team to summarize one or the other point of view.What would your learners recommend now? How would they discuss this with a patient?Do your learners refer patients with COPD for physical rehabilitation? Should they?In the Clinic: Systemic Lupus ErythematosusSystemic lupus erythematosus (SLE) is characterized by aberrant activity of the immune system, leading to variable clinical symptoms. Diagnosing, treating, and identifying novel therapies for SLE is challenging because of its genetic and phenotypic heterogeneity. Are your learners prepared?Use this review to:Ask your learners who is at risk for SLE.Should we screen for SLE in at-risk patients? Why or why not? What characteristics are needed to make screening for a disease appropriate?What symptoms might be attributable to SLE? Can your learners list the potential manifestations of SLE in each of the major organ systems?What studies should be ordered in the evaluation, and how is a diagnosis made? Is referral to a specialist required to make a diagnosis of SLE?How should treatment be initiated? What are the options for maintenance therapy? What are their benefits? What are their potential harms?How might a “flare” of SLE manifest, and how is it managed?Teach at the bedside! Ask a patient with SLE if she or he would be willing to discuss how SLE and its treatments have affected her or his life. Has it altered her or his outlook?Use the provided multiple-choice questions to introduce topics for discussion during a teaching session, and sign in to enter your answers to earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: Three (Not So) Easy PiecesDr. Bordley reflects that, “By the time I became an attending, my memory of the terror of that first bedside presentation was completely lost to me.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask the members of your team whether any of them can recall feeling nervous presenting patients to others. Be careful not to embarrass more junior members of your team, or to “put them on the spot.” Indeed, consider whether this discussion should only include the more senior members of your team.How do they support less experienced members of the team (especially medical students) when they present patients to more experienced clinicians? In what ways can we ensure they feel safe? Can we help them to feel proud of what they can do while learning how to improve, confident that they will?Do your learners try to create a safe learning environment for those they are helping to teach?MKSAP 18 QuestionA 45-year-old man is seen for follow-up evaluation for depression and to review the results of laboratory testing. He was seen 1 month ago for a 6-month history of depressed mood, difficulty sleeping, decreased appetite, 2.3-kg (5-lb) weight loss, and fatigue. Major depressive disorder was diagnosed, and escitalopram was prescribed. Today the patient reports a significant improvement in his mood, appetite, and the quality of his sleep since starting treatment.On physical examination, vital signs and physical examination are normal. Screening laboratory studies from 1 month ago show a thyroid-stimulating hormone (TSH) level of 7 µU/mL (7 mU/L) and a free thyroxine (T4) level of 1.0 ng/dL (12.9 pmol/L).Which of the following is the most appropriate management?A. Measure thyroid peroxidase antibodiesB. Measure thyrotropin receptor antibodiesC. Measure serum triiodothyronine (T3) levelD. Prescribe levothyroxineE. Repeat serum TSH testing in 2 monthsCorrect AnswerE. Repeat serum TSH testing in 2 monthsEducational ObjectiveManage subclinical hypothyroidism.CritiqueThis patient has subclinical hypothyroidism, and the most appropriate management is to repeat serum thyroid-stimulating hormone (TSH) testing in 2 months. Free thyroxine (T4) and thyroid peroxidase antibodies could also be measured at that time. Subclinical hypothyroidism is an early form of primary hypothyroidism affecting up to 10% of the population and is characterized by a serum TSH level above the upper limit of the reference range and normal free T4 level. Before making this diagnosis; however, transient elevation of serum TSH levels should be ruled out by repeating the measurement of TSH in 2 to 3 months.Thyroid peroxidase (TPO) antibodies are frequently seen in the setting of Hashimoto thyroiditis, the most common cause of hypothyroidism in the United States. TPO antibody positivity would support a diagnosis of primary hypothyroidism, predict risk of progression to overt hypothyroidism, and may impact treatment decisions accordingly. However, the most appropriate next step in the management of this patient is to confirm the diagnosis of subclinical hypothyroidism by documenting persistent serum TSH elevation.Thyrotropin receptor antibodies would be more consistent with Graves disease and testing for these antibodies would not be appropriate in this setting.Measurement of serum triiodothyronine (T3) in patients with known or suspected primary hypothyroidism is generally not indicated. Elevation of serum TSH is the earliest biochemical change observed in the setting of primary hypothyroidism. Reductions in serum T3 are not usually seen until after free T4 levels are low. Measuring serum T3 has little to no impact on diagnosis or management decisions.More severe subclinical hypothyroidism, serum TSH greater than 10 µU/mL (10 mU/L), may increase the risk of coronary artery disease and heart failure, whereas serum TSH levels below 7 to 10 µU/mL (7-10 mU/L) are not associated with increased morbidity or mortality. Treatment with levothyroxine would be considered if the patient's serum TSH is similar or higher on reassessment, but this is not the most appropriate next step in management.Key PointSubclinical hypothyroidism is characterized by a serum thyroid-stimulating hormone (TSH) level above the upper limit of the reference range and normal free thyroxine (T4) level; before making this diagnosis, however, transient elevation of serum TSH should be ruled out by repeating the measurement of TSH in 2 to 3 months.BibliographyPeeters RP. Subclinical hypothyroidism. N Engl J Med. 2017 Jun 29;376(26):2556-2565. doi:10.1056/NEJMcp1611144Do 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 2 June 2020Volume 172, Issue 11Page: ED11KeywordsAntibodiesDecision makingHypothyroidismPeroxidasesResearch laboratoriesStrokeThyroidThyroid-stimulating hormoneThyroxineTriiodothyronine ePublished: 2 June 2020 Issue Published: 2 June 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...