Annals for Educators - December 2021
Authors: Christine Laine
Journal: Annals of Internal Medicine (2021)

Web ExclusivesDecember 2021Annals for Educators - December 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202112210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsIdentifying Equitable Screening Mammography Strategies for Black Women in the United States Using Simulation ModelingMoving Beyond Race-Based MedicineEvidence suggests that Black women may need different breast cancer screening schedules to achieve outcomes similar to those among White women. This article identifies screening schedules that provide Black women with benefit–harm ratios similar to those in White women who are screened biennially from ages 50 to 74 years. The accompanying editorial discusses the complexity of factoring race into clinical decision making.Use this article and the editorial to:Review current clinical guidelines for breast cancer screening. This ACP guidance statement can help focus the discussion. Discuss some of the factors that might contribute to the differences in breast cancer outcomes by race/ethnicity observed in the United States. Which of these factors would earlier initiation of screening help to mitigate?Whether to consider race/ethnicity in screening decisions, diagnostic criteria, prognostic indices, and treatment recommendations is a topic of vigorous debate. Ask your learners to name clinical situations in which race/ethnicity has been a consideration and to discuss the potential benefits and harms of considering race/ethnicity in clinical decision making.The editorial calls for more sophisticated ways to identify race and other potential social determinants of health in medicine. Ask your learners to brainstorm ideas for how this might be achieved—for example, in health care databases that are often used in research.Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults. A Retrospective Observational StudyHow to Intensify Treatment in Older Patients With Hypertension: Is There a Single Answer?Evidence is lacking on intensifying antihypertensive treatment when initial therapy does not lead to satisfactory blood pressure control. This observational study compared maximizing doses of existing medications versus adding a new medication before maximizing doses. The accompanying editorial discusses the findings and why there is no single best strategy for intensifying antihypertensive therapy.Use this article and the editorial to:Start your teaching session with a multiple-choice question. We provide one below.Present several examples of patients seen in your learners' outpatient practice setting who had inadequate blood pressure control on a single medication. What was the approach to treatment intensification for each patient? Was the approach optimal in light of the findings of the current study?Read the editorial, and then ask your learners to list patient factors that would lead them to maximize the dose of the existing drug rather than adding a second drug for a patient who has suboptimal blood pressure control on a single agent that is not at the maximum dose.Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults. A Cohort StudyThe Supplemental Nutrition Assistance Program: Improving Health by Decreasing Food InsecurityThe Supplemental Nutrition Assistance Program (SNAP) provides assistance to reduce food insecurity. This cohort study examined the effect of SNAP enrollment on health care use for older adults dually enrolled in Medicare and Medicaid in North Carolina. The accompanying editorial discusses the findings and argues that “SNAP is medicine.”Use this article and the editorial to:Invite a social worker to your session to discuss the eligibility criteria and process for enrollment in SNAP.Ask your learners to name common chronic medical conditions that are adversely affected by food insecurity.Ask your learners whether they routinely ask patients about food insecurity.Discuss effective and respectful strategies to screen patients for food insecurity that could be implemented in your learners' clinical setting.Poll your learners about whether they think enrollment in SNAP should be automatic for patients who meet eligibility criteria.Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019During the past 2 decades in the United States, outpatient visits to primary care practices have increased much less than outpatient visits to specialty practices. This article describes these changes and some of their immediate consequences.Use this article to:Ask your learners to estimate the number of different physician specialists seen by their typical patient over age 65. Compare their estimates with what this study found.Ask your learners to describe some of the challenges that are present when one patient receives care from many different specialists in addition to their primary care physician.Discuss whether there are systems-based processes that could improve care coordination for patients cared for by a number of different physicians.Are there actions that individual primary care physicians could take to foster better care coordination?Measuring the COVID-19 Mortality Burden in the United States. A Microsimulation StudyData: The Lifeblood of the Public Health Response to COVID-19The burden of COVID-19 mortality can be estimated in many ways. The authors used a microsimulation model to account for years of life lost and quality-of-life differences and projected 3 cases with different assumptions about who was most affected by COVID-19. The accompanying editorial discusses why data are the lifeblood of any public health response to the pandemic.Use this article and the editorial to:Ask your learners which of the 3 scenarios considered in the model they think best reflects their own observations during the COVID-19 pandemic.Given the model's findings, what actions might the United States have taken earlier in the pandemic to mitigate the disparities noted?Discuss the implications of the model's findings for future management of COVID-19.The editorial comments on the failures of the U.S. public health system to report basic data on infections, hospitalizations, and death. How might data collection and reporting be improved in future health crises?Beyond the GuidelinesHow Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterIn this article, a general internist and a pulmonologist present their views on the application of guidelines on community-acquired pneumonia to the management of a specific patient presenting to the emergency department with community-acquired pneumonia.Use this article to:Watch the patient video, and then ask your learners how they would manage this patient.Ask your learners to name factors that would lead them to hospitalize a patient with community-acquired pneumonia.Watch the video of the Grand Rounds discussion that accompanies this article as a group.Complete the quiz at the end of the article. How did the group do?Smoking CessationTobacco dependence is the leading cause of preventable death in the United States, and its harms are well established. Physicians have more evidence-based resources at their disposal than ever before to effectively treat this deadly addiction, including new uses and combinations of FDA-approved pharmacotherapies and expanded community programs. Alternative products, such as electronic nicotine delivery systems, are potential treatment tools, but their safety and efficacy need to be established. Priority groups of tobacco users, such as those with cancer diagnoses or hospitalized smokers, may benefit from particular attention to their tobacco use.Use this article to:Ask your learners to name the health conditions with definite links to smoking combustible cigarettes.Ask your learners to name the short- and long-term health benefits that smokers who quit can anticipate.Review the pharmacologic interventions that are approved to assist patients with smoking cessation.Debate whether physicians should recommend that patients who smoke combustible cigarettes switch to e-cigarettes if they are having difficulty with smoking cessation.ProfessionalismOne of Many“Terrified by my own thoughts, I finally reached out to colleagues for help and found something surprising. And beautiful. And devastating.”Use this article to:Read the essay aloud to the group.Ask your learners to reflect on the author's experience. Have they had similar stressful periods? What helped them cope with the situation?Discuss ways that we and our institutions can help our colleagues who are experiencing distress.MKSAP 19 QuestionA 45-year-old woman is evaluated during a follow-up visit for newly diagnosed severe hypertension. She began low-dose hydrochlorothiazide and amlodipine therapy 1 month ago. There is no family history of hypertension. She has no other medical problems and takes no other medications.On physical examination, blood pressure is 164/100 mm Hg in both arms, pulse rate is 76/min, and respiration rate is 18/min. BMI is 24. The remainder of the examination is normal.Laboratory studies:Bicarbonate30 mEq/L (30 mmol/L)Creatinine0.9 mg/dL (79.6 µmol/L)Potassium2.9 mEq/L (2.9 mmol/L)Sodium138 mEq/L (138 mmol/L)UrinalysisNo blood or proteinWhich of the following is the most appropriate diagnostic test to perform next?A. Plasma aldosterone concentration/plasma renin activity ratioB. Plasma fractionated metanephrines measurementC. Renal artery CT angiographyD. 24-Hour urine free cortisol measurementCorrect AnswerA. Plasma aldosterone concentration/plasma renin activity ratioEducational ObjectiveDiagnose primary hyperaldosteronism as a secondary cause of hypertension.CritiqueThe most appropriate diagnostic test to perform next is the plasma aldosterone concentration/plasma renin activity ratio (Option A). Primary hyperaldosteronism, in which aldosterone production cannot be suppressed with sodium loading, is the most common cause of secondary hypertension in middle-aged adults and an important cause of resistant hypertension. A triad of resistant hypertension, metabolic alkalosis, and hypokalemia (including in patients treated with low-dose thiazide diuretics) should raise suspicion. Screening is recommended if any of the following are present: resistant hypertension; hypokalemia (spontaneous or substantial, if diuretic induced); incidentally discovered adrenal mass; family history of early-onset hypertension; moderately severe hypertension (>160/100 mm Hg); or stroke at age <40 years. It is common for patients with primary hyperaldosteronism to have normal serum potassium levels; a high index of suspicion is therefore required. This patient has substantial hypokalemia (serum potassium level of 2.9 mEq/L [2.9 mmol/L]) with initiation of low-dose hydrochlorothiazide and persistent, moderately severe hypertension. The patient also has a metabolic alkalosis.Plasma fractionated metanephrines (Option B) are obtained to screen for a pheochromocytoma. The absence of episodic palpitations, headaches, and tachycardia and the presence of metabolic alkalosis and hypokalemia make pheochromocytoma a less likely diagnosis for this patient.Renal artery CT angiography (Option C) is an appropriate screening test for renovascular disease, including fibromuscular dysplasia. Older patients with renovascular hypertension often have other manifestations of atherosclerosis, including the presence of coronary artery, cerebrovascular, or peripheral vascular disease. Lateralizing abdominal bruits may be auscultated. Abrupt onset of hypertension in patients <35 years of age suggests fibromuscular dysplasia. None of these clinical findings is present to suggest the diagnosis of renovascular disease.The 24-hour urine free cortisol (Option D) is a frequently used screening test for hypercortisolism. In adults, hypercortisolism may manifest as hypertension and hypokalemia, but it is relatively rare compared with primary hyperaldosteronism. In the absence of Cushingoid facies, central obesity, proximal muscle weakness, and ecchymosis, Cushing syndrome is a very unlikely cause of this patient's hypertension.Key PointPrimary hyperaldosteronism is the most common cause of secondary hypertension and should be suspected in patients with resistant hypertension, hypokalemia, family history of early-onset hypertension, blood pressure >160/100 mm Hg, or stroke at age <40 years. The plasma aldosterone concentration/plasma renin activity ratio is the recommended screening test for primary hyperaldosteronism.BibliographyLee FT, Elaraj D. Evaluation and management of primary hyperaldosteronism. Surg Clin North Am. 2019;99:731-745. doi:10.1016/j.suc.2019.04.010Do 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 December 2021Volume 174, Issue 12Page: ED12 ePublished: 21 December 2021 Issue Published: December 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...