Annals for Educators - 7 July 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives7 July 2020Annals for Educators - 7 July 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202007070 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThe Unrecognized Prevalence of Primary Aldosteronism. A Cross-sectional StudyPrimary aldosteronism has traditionally been perceived as a rare cause of hypertension, but recent evidence suggests that its prevalence may be higher than previously believed. This study used gold-standard diagnostic approaches to characterize abnormal renin-independent aldosterone production and biochemically overt primary aldosteronism among patients across a continuum of blood pressures.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!When do guidelines recommend evaluating hypertensive patients for primary aldosteronism? Do your learners follow these guidelines? Have they looked?How should a diagnosis be made?What did this study find regarding the prevalence of primary aldosteronism? Are the findings on the sensitivity and negative predictive value of the aldosterone–renin ratio concerning?What are the potential implications of this study? Do your learners believe we are doing an adequate job of addressing hypertension and the risks of primary aldosteronism? Use the accompanying editorial to help frame your discussion. Watch the short author insight video, in which the editorialist walks you through a brief review of the problem, the study's findings, and why they matter. Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services InitiativeScreening for Anxiety in Adolescent and Adult Women. A Systematic Review for the Women's Preventive Services InitiativeThis recommendation statement from the Women's Preventive Services Initiative addresses screening for anxiety in adolescent girls and adult women. The systematic review evaluates evidence about the effectiveness of screening, the accuracy of screening instruments, and the benefits and harms of treatments.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how common anxiety disorders are. Do the numbers in the guideline's introduction surprise you?What are the different anxiety disorders? How do they differ? Invite a mental health expert in this area to join your discussion.The guideline recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Why?How should we screen? Are the available tools sufficiently useful?How should patients with anxiety be managed? Is cognitive behavioral therapy available to your patients? How do they arrange for it? When are medications appropriate, which ones, and how should treatment be monitored?Use the accompanying editorial to prompt discussion about the availability of mental health services and its effect on the benefits of screening. In the Clinic: HypothyroidismBecause most of the clinical features of hypothyroidism are nonspecific, the diagnosis requires laboratory testing. Are your learners prepared to recognize when and how to evaluate for it?Use this review to:Ask your learners why screening for hypothyroidism is not recommended.Ask what symptoms should suggest possible hypothyroidism.What is the differential diagnosis? How is a diagnosis made?What is subclinical hypothyroidism, and what do we know about whether there is a benefit to treating it?Are there important differences among the various thyroid replacement formulations? Is there an advantage to combination LT4/LT3 therapy?What are the potential consequences of excessive thyroid replacement?How is myxedema recognized, and how should it be managed?Use the accompanying multiple-choice questions to introduce topics for discussion in a teaching session. Log on to enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Patient: Sounds for a Waking Coma PatientMs. Green shares that, “The most important sound in the world, to my mind, is the rhythmic huffing of a ventilator in an intensive care unit.”Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Ask your learners whether they have ever thought about how the world looks and sounds to a patient who wakes up in a hospital bed.What is Ms. Green hearing that sounds like the grunting of a pig?Can thinking about how things appear and sound from the patient's perspective help us to be better physicians?Teach at the bedside! Ask a patient who has had a long stay in intensive care whether she or he would be willing, or even would appreciate, talking to your team about periods where what was happening did not seem clear. Ask about other experiences during their ICU or hospital stay.MKSAP 18 Question 1A 58-year-old man is evaluated for resistant hypertension. He was first diagnosed with hypertension 10 years ago, and his blood pressure has been increasingly difficult to control. Testing for secondary causes of hypertension will be undertaken. Medical history is otherwise unremarkable. Medications are lisinopril, spironolactone, hydrochlorothiazide, and metoprolol.On physical examination, blood pressure is 149/93 mm Hg. Other vital signs are normal. BMI is 29. The remainder of the physical examination is unremarkable.Which of the following should be discontinued prior to screening for secondary causes of hypertension?A. HydrochlorothiazideB. LisinoprilC. MetoprololD. SpironolactoneCorrect AnswerD. SpironolactoneEducational ObjectiveRecognize medications that interfere with screening for primary aldosteronism.CritiqueSpironolactone can significantly interfere with interpretation of the plasma aldosterone-plasma renin ratio (ARR) and therefore should be discontinued approximately 6 weeks prior to screening for primary aldosteronism. Treatment-resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which is a diuretic. Possible situations in which screening for secondary causes of hypertension include: severe or resistant hypertension; young age of onset (in childhood or adolescence), especially in the absence of family history; abrupt worsening of blood pressure in a previously well-controlled patient; or clinical features of an underlying disorder associated with hypertension (for example, cushingoid features). Hyperaldosteronism, usually from an aldosterone-producing adenoma or bilateral idiopathic hyperaldosteronism, may be present in up to 10% of patients with hypertension. Testing for primary aldosteronism should be considered in all patients with difficult to control hypertension. It should also be performed in patients with hypertension and an incidentally noted adrenal mass or spontaneous or diuretic-induced hypokalemia. Spironolactone and eplerenone cause elevation of renin levels and hence can result in a false-negative ARR. On stopping a mineralocorticoid antagonist, the patient may develop hypokalemia if the underlying diagnosis is primary aldosteronism. Potassium should be replaced accordingly prior to screening for primary aldosteronism, as hypokalemia results in lowering of aldosterone levels and hence impacts the ARR.In general, most antihypertensive agents can be continued during screening for primary aldosteronism except for spironolactone, eplerenone, and high-dose amiloride therapy. Specifically, verapamil, doxazosin, and hydralazine have minimal impact on the ARR and, therefore, can be continued during screening for primary aldosteronism.Other antihypertensive agents that have minor effects on the ARR can also be continued during screening for primary aldosteronism as long as the results of the ARR are interpreted with these effects in mind. The hallmark of primary aldosteronism is a suppressed renin level. Any medication that increases renin can result in a false-negative result. On the other hand, a suppressed renin in the presence of a medication that usually would raise renin (an ACE inhibitor) raises the suspicion for primary aldosteronism.Key PointSpironolactone and eplerenone can significantly interfere with interpretation of the plasma aldosterone-plasma renin ratio (ARR) and therefore should be discontinued approximately 6 weeks prior to screening for primary aldosteronism.BibliographyFunder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101:1889-916. doi:10.1210/jc.2015-4061MKSAP 18 Question 2A 30-year-old woman is evaluated for a 1-year history of severe anxiety about multiple aspects of her life, including her marriage, work, and health. She also reports irritability, poor sleep, and difficulty concentrating, and she finds it difficult to complete her daily home and occupational tasks. She has had multiple visits with her internist for various symptoms, including atypical chest pain, shortness of breath, palpitations, and intermittent diarrhea. She does not use alcohol, tobacco, or recreational drugs. She drinks one cup of coffee every morning. Her Generalized Anxiety Disorder 7-item scale score is 15, corresponding to severe anxiety.Laboratory studies reveal a normal serum thyroid-stimulating hormone level.Which of the following is the most appropriate long-term pharmacologic treatment?A. AmitriptylineB. ClonazepamC. LithiumD. SertralineCorrect AnswerD. SertralineEducational ObjectiveTreat generalized anxiety disorder with pharmacologic therapy.CritiqueThe most appropriate long-term pharmacologic treatment for this patient with generalized anxiety disorder (GAD) is sertraline. GAD is characterized by excessive anxiety about activities or events (occupation, school) occurring more days than not for at least 6 months and causing significant functional impairment. Patients with GAD also experience difficulty concentrating, irritability, muscle tension, restlessness, and sleep disturbance. A useful tool for identifying and assessing the severity of GAD is the Generalized Anxiety Disorder 7-item scale (GAD-7), which asks patients to rate seven items on a scale of 0 to 3 based on increasing severity. A score of 5 to 9 indicates mild anxiety, 10 to 14 moderate anxiety, and 15 to 21 severe anxiety. The GAD-7 can be used to monitor symptom severity over time, allowing clinicians to monitor treatment effectiveness. Treatment options for GAD include cognitive behavioral therapy (CBT) and pharmacologic therapy, such as with a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI). Patients with GAD often have comorbid mood and anxiety disorders, which often make SSRIs (such as sertraline) and SNRIs (such as venlafaxine) preferred because of their broad therapeutic applicability. CBT is the most effective psychotherapy for GAD; trials have shown it is as effective as pharmacologic therapy and can be used as monotherapy or in combination with drugs. The choice between pharmacologic therapy and CBT is often based on patient preference and the presence of comorbid disorders. Another consideration may be costs of treatment, both direct and indirect (due to time away from work or school). Depending on the particular agent, antidepressant therapy costs $100 to $300 per year, with low indirect costs. On average, annual costs for CBT are three to four times higher than for antidepressant therapy and also require significant time away from work or school to attend therapy.Tricyclic antidepressants, such as amitriptyline, are considered second-line therapy for GAD because of a higher incidence of side effects with their use.Benzodiazepines, such as clonazepam, are useful for controlling severe anxiety symptoms, especially before the benefits of CBT or other pharmacologic therapy take effect. These agents should be used only for short periods (<4-6 weeks) because of the potential for dependency.Lithium and other mood stabilizers are appropriate treatment for bipolar disorder but are not indicated for the treatment of anxiety disorders.Key PointTreatment options for generalized anxiety disorder include cognitive behavioral therapy and pharmacologic therapy with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor.BibliographyPatel G, Fancher TL. In the clinic. Generalized anxiety disorder. Ann Intern Med. 2013;159:ITC6-1–ITC6-11; quiz ITC6-12.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 July 2020Volume 173, Issue 1Page: ED1KeywordsAbsolute risk reductionAdolescentsAnxietyAnxiety disordersBlood pressureCognitive behavior therapyDrug therapyGeneralized anxiety disorderHypertensionHypothyroidism ePublished: 7 July 2020 Issue Published: 7 July 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...