Annals for Educators - 20 October 2020
Authors: Christine Laine
Journal: Annals of Internal Medicine (2020)

Web Exclusives20 October 2020Annals for Educators - 20 October 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202010200 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Focus on Diagnostic ErrorAnnals Clinical Decision Making: Avoiding Cognitive Errors in Clinical Decision MakingDiagnostic errors are common and are frequently the result of failures in our cognitive processes. This paper in the Annals Clinical Decision Making series discusses biases that predispose us to these errors and strategies to avoid them.Use this paper to:Ask your learners to define “diagnostic error.” Does every instance of an incorrect diagnosis represent a diagnostic error?What is a “heuristic”? How do we use them in medical decision making? Are they useful? Are they dangerous?What is “confirmation bias”? What is the “availability heuristic”? Review the terms in the glossary. Use the patient scenarios presented to make sure your learners understand each.Review the admission evaluation and subsequent daily plans of a few patients who have been on your team's service for several days. Can your team identify instances when they may have failed to think through all the available evidence, including what fit and what did not fit with the diagnostic label attached to the patient's problem?What do the authors suggest as tools to prevent falling into the cognitive traps outlined in the glossary?How can we use the process of writing an admission or progress note to avoid cognitive errors? Do we currently use our notes this way? See a recent call to improve how we use this important tool. Annals Graphic Medicine - Bed BlockerThis cartoon tells the story of a near miss in the emergency department and quite literally illustrates how one physician's thought process avoided the cognitive errors of another and thus prevented a disaster.Use this feature to:Plan to use this piece as a fun review of what you learned in the Annals Clinical Decision Making piece on diagnostic error discussed above.Ask your learners to read through the comic—the first time without the accompanying annotations.Now, ask your learners to dissect the errors that the resident made and how they were corrected.Then, read the annotations provided in each of the pop-out balloons on the PDF.Clinical Practice PointsEffects of Interleukin-1β Inhibition on Incident Hip and Knee Replacement. Exploratory Analyses From a Randomized, Double-Blind, Placebo-Controlled TrialOsteoarthritis is a common inflammatory disorder with no disease-modifying therapies. This exploratory analysis of a randomized trial assessed whether inhibition of interleukin-1β (IL-1β) can reduce the consequences of large-joint osteoarthritis.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners what they recommend to their patients with knee or hip osteoarthritis. What is the role of weight loss? Physical therapy? Pharmacologic interventions? How well do they work? Use the information in DynaMed (a benefit of your ACP membership) on osteoarthritis of the hip and osteoarthritis of the knee. Why did the authors hypothesize that inhibition of IL-1β might be beneficial in hip or knee osteoarthritis? Use the paper's discussion section and the editorial to help frame your discussion. What is an “exploratory analysis”? Does the strength of the findings differ from those of the a priori–planned analyses of a randomized trial?The authors note that radiographic studies were not obtained to assess arthritis outcomes. Why is this considered a limitation? What outcomes did they assess? Which is more important?Should the results of this study alter practice? Why or why not? What should be done next?Delayed Denosumab Injections and Fracture Risk Among Patients With Osteoporosis. A Population-Based Cohort StudyDenosumab is an effective antiresorptive drug prescribed for treatment of osteoporosis, but its effects are reversed and there is an increased risk for fracture after its use is discontinued. Nearly half of patients treated for several years experience an injection delay of more than 4 months. This study evaluated whether delays in denosumab treatments were associated with increased fracture risk.Use this study to:Ask your learners how they approach the treatment of osteoporosis. What nonpharmacologic recommendations do they provide to their patients? What drugs are available, and what are their benefits and potential harms? Use the information in DynaMed on osteoporosis to help prepare for teaching. When is denosumab used for treatment of osteoporosis? Why was there concern about an increased risk for fracture if there were delays in dosing (e.g., beyond the recommended 6-month interval)?Review the design of this observational study. Do your learners understand why the investigators aimed to emulate a randomized trial to the extent possible?The authors and the editorialists note that residual confounding remains a concern. What is residual confounding, and what specifically might be a confounder in this study? To examine the effect of unmeasured confounding, the authors calculated an E-value. How is this value interpreted? Use this editorial to help understand and explain this simple approach to assessing unmeasured confounding. Point-of-Care Ultrasonography, Primary Care, and PrudenceThere is substantial and growing enthusiasm for diagnostic point-of-care ultrasonography (POCUS) in primary care. This commentary discusses the limitations in what is known, why POCUS may not perform well in this setting, and why it matters.Use this study to:Ask your learners whether they have used POCUS in the hospital. How about in their outpatient practices? What training did they receive?What monitoring is performed to assess whether decisions based on POCUS in your practices are accurate?Why is POCUS popular? What are its potential advantages in patient care? What are its potential dangers? Have these been adequately studied?Are there possible conflicts of interest that drive the popularity of POCUS? Whose?The author points out why disease prevalence and severity can affect the performance of a test (e.g., when used in the emergency department versus a primary care office). Do your learners understand the points being made?How do your learners think POCUS should be taught and used and its benefits or harms assessed at your medical center's inpatient and outpatient practices?MKSAP 18 Question 1A 58-year-old man is evaluated for a 3-year history of left knee stiffness, which was intermittent but has become more persistent in the past 4 months. He reports no daily pain but has knee stiffness for 10 minutes in the morning and when he sits for an extended period of time. He reports no swelling and no knee buckling or locking. History is significant for gastroesophageal reflux disease and peptic ulcer disease diagnosed 6 months ago now treated with omeprazole. He prefers not to take medications for his knee symptoms.On physical examination, vital signs are normal. BMI is 24. Crepitus and medial joint line tenderness to palpation are noted. There is no redness, effusion, or signs of knee instability.Left knee radiograph shows mild medial joint space narrowing and spiking of the tibial spines.Which of the following is the most appropriate management?A. IbuprofenB. Intra-articular glucocorticoidsC. Left knee MRID. Physical therapyCorrect AnswerD. Physical therapyEducational ObjectiveTreat knee osteoarthritis with physical therapy and exercise.CritiquePhysical therapy and a graduated leg muscle strengthening exercise program are appropriate for this patient with knee osteoarthritis. For patients with osteoarthritis, an individualized management plan includes education on osteoarthritis and joint protection, an exercise regimen, weight loss, proper footwear, and assistive devices as appropriate. Physical activity includes graduated aerobic exercise and strength training, with attention paid to bolstering strengthening periarticular structures and minimizing injury. The patient's main symptom is stiffness, not pain, and he prefers nonpharmacologic therapy at this time, which is most appropriate from a management perspective as well. Muscle weakness is common in knee osteoarthritis, possibly related to disuse, and muscle strengthening has been associated with reduced pain and improved function. All treatment guidelines agree that a muscle strengthening exercise program should be part of the patient's management plan.Because the patient has a history of peptic ulcer disease, ibuprofen is not advisable. He also chooses not to take medication for his knee symptoms, and it is unclear whether ibuprofen would help his main symptom of stiffness.Intra-articular glucocorticoids are useful agents in knee osteoarthritis, particularly as second-line therapies. Similar to ibuprofen, it is unclear whether this treatment would help the patient with his stiffness.A knee MRI is not indicated in a patient without knee buckling or locking or signs of instability, all of which may indicate an unstable meniscal tear that needs surgical management. Incidental meniscal tears are common MRI findings in the middle-aged population, and especially in patients with knee osteoarthritis. Studies have shown that patients with knee osteoarthritis and meniscal tears experience similar long-term improvements in pain and function with physical therapy compared with arthroscopic surgery, and that arthroscopic surgery may even pose higher harms.Key PointTreatment guidelines recommend that a muscle strengthening exercise program should be part of the management plan for knee osteoarthritis.BibliographyMcAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22:363-88. doi:10.1016/j.joca.2014.01.003MKSAP 18 Question 2A 73-year-old woman is evaluated for a 10-year history of osteoarthritis affecting multiple joints over the years, including the distal joints of her fingers, bases of the thumbs, knees, and cervical and lower lumbar spines. She has chronic daily pain in at least one joint. She has tried nonpharmacologic measures, and she had minimal benefit from intra-articular glucocorticoid and hyaluronic acid injections to her knees. She was recently diagnosed with peptic ulcer disease. History is also significant for coronary artery disease, diabetes mellitus, and hypertension. Medications are enalapril, carvedilol, metformin, atorvastatin, pantoprazole, and low-dose aspirin.On physical examination, vital signs are normal. Heberden nodes and squaring of the bilateral carpometacarpal joints are present. Crepitus and limited extension of the cervical spine are noted. Bilateral knee varus deformity and bony enlargement are present, with crepitus on range of motion.Which of the following is the most appropriate treatment?A. DuloxetineB. GabapentinC. IbuprofenD. Topical capsaicinCorrect AnswerA. DuloxetineEducational ObjectiveTreat osteoarthritis with duloxetine.CritiqueDuloxetine, a serotonin and norepinephrine reuptake inhibitor with central nervous system effects, is a good treatment option for this patient with generalized osteoarthritis (OA). Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee OA pain, implicating the role of central sensitization in OA pain modulation. This patient has already tried multiple nonpharmacologic measures, as well as intra-articular glucocorticoid and hyaluronic injections, all with insufficient symptomatic relief. Duloxetine is a reasonable choice given the patient's comorbidities and generalized musculoskeletal pain.Gabapentin and pregabalin are more effective than placebo in the treatment of neuropathic pain conditions such as postherpetic neuralgia and diabetic neuropathy. These drugs are expensive and both are associated with dose-dependent dizziness and sedation. There is no evidence of their effectiveness specifically for chronic OA pain.NSAIDs inhibit cyclooxygenase (COX) enzymes, blocking the generation of the lipid prostaglandin E2 (PGE2). PGE2 stimulates inflammation, vasodilation, smooth muscle contraction, pain, and fever. However, PGE2 also maintains gastric mucosa and promotes kidney sodium excretion and glomerular filtration. Other COX products include thromboxane A2, a prothrombotic regulator of platelets, and prostacyclin, an antithrombotic and vasodilatory lipid. Because NSAIDs inhibit all of these, the consequences of COX inhibition are complex and accompanied by multiple potential side effects. Side-effect risk is increased in older patients and those with preexisting comorbidities. Therefore, ibuprofen is not an advisable choice in an elderly patient with peptic ulcer disease, hypertension, and heart disease.Topical capsaicin may benefit localized OA (for example, knee only) but is impractical in this case given the multiple areas of involvement. Furthermore, duloxetine is more likely to be efficacious given how many treatments this patient has tried and failed.Key PointDuloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee osteoarthritis pain.BibliographyMcAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22:363-88. doi:10.1016/j.joca.2014.01.003Do 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 20 October 2020Volume 173, Issue 8Page: ED8KeywordsDecision makingExerciseExercise therapyIbuprofenKneesLower back painMusclesOsteoarthritisOsteoporosisStiffness ePublished: 20 October 2020 Issue Published: 20 October 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...