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

Web ExclusivesMarch 2021Annals for Educators - March 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202103160 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsTesting for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans. A Retrospective Cohort StudyPrimary aldosteronism is a common cause of treatment-resistant hypertension, but evidence suggests low rates of testing for primary aldosteronism. The authors used Veterans Health Administration data to evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.Use this article to:Start your session by listening to the Annals On Call interview with an author of the study. Ask your learners to define resistant hypertension.Discuss the clinical scenarios in which clinicians should consider primary aldosteronism as a potential diagnosis.Review how to diagnose primary aldosteronism.Discuss the appropriate treatment for hypertension in the setting of primary aldosteronism.Recommended Adult Immunization Schedule, United States, 2021This article provides immunization recommendations from the Advisory Committee on Immunization Practices (ACIP) for adults aged 19 years or older, including the use of COVID-19 vaccines that have received Emergency Use Authorization.Use this article to:Ask your learners to describe the role of the ACIP.Review the changes in the 2021 recommendations compared with the 2020 recommendations.Ask your learners whether they regularly ask their adult patients about vaccinations.Discuss the ACIP recommendations for COVID-19 vaccination.Review the FDA vaccine approval process by viewing Dr. David Kessler's presentation in the video included with this article. Cases in Precision Medicine: The Role of Polygenic Risk Scores in Breast Cancer Risk AssessmentThis article discusses the potential clinical utility of polygenic risk scores in assessing breast cancer risk and the optimal method for communicating implications of the results to patients.Use this article to:Start your session with a multiple-choice question. We provide one below.Ask your learners whether they have had patients ask about genetic testing.What would your learners do if a patient came to them with results from a commercial home genetic test, such as 23andMe?Discuss the process at your institution for referring patients for genetic testing.Invite a genetic counselor to join your group to discuss appropriate scenarios in which to refer patients for genetic testing to determine breast cancer risk.InsomniaInsomnia is common in adults and can be acute, intermittent, or chronic. It is often comorbid with mood and anxiety disorders and with chronic health conditions. Appropriate treatment of the problem “insomnia” requires evaluation—largely history—to distinguish among various conditions associated with insomnia. Cognitive behavioral therapy (CBT) for insomnia is the preferred treatment approach, but pharmaceutical treatments are widely used for insomnia symptoms.Use this article to:Ask your learners to define insomnia.Discuss medical conditions associated with insomnia as either the cause or a sequela of difficulty sleeping.Ask your learners to describe the behavioral advice they should provide to patients with insomnia.Invite a psychologist or psychiatrist to join your group to describe CBT.Explore a free CBT app developed by the VA and discuss whether this might be a useful approach if in-person CBT is difficult to access. Public HealthEffectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers. A Randomized Controlled TrialThe Role of Masks in Mitigating the SARS-CoV-2 Pandemic: Another Piece of the PuzzleThe DANMASK-19 investigators reported the results of a unique randomized controlled trial of mask wearing in the community to mitigate SARS-CoV-2 infection. The editorialists discuss how the findings add to what we know about mask wearing in the community and risk for SARS-CoV-2 infection.Use this article and the editorial to:Ask your learners to explain the difference between masks as an intervention for source control and for personal protection.Discuss the current CDC recommendations on mask use and the data used to support them.Discuss the primary result of this trial and why the findings are inconclusive.Review the available evidence on the effectiveness of masks in preventing transmission of SARS-CoV-2 infection provided in this living systematic review. Strategies for Clinical Discussions About Climate ChangeThis commentary links the climate crisis with the COVID-19 pandemic in how both are the subject of campaigns to cast doubt on the science. The authors discuss the clear role clinicians have in countering misinformation.Use this article to:Ask your learners if they believe climate change is a public health issue.Review the ways in which climate affects health. This article provides a useful overview. Use the suggestions provided in the article to role-play conversations with patients who have conditions such as asthma that have adverse associations with the effects of climate change.Ethics and ProfessionalismAre Financial Payments From the Pharmaceutical Industry Associated With Physician Prescribing? A Systematic ReviewFinancial payments from the drug industry to physicians are common in the United States. This systematic review of 36 studies examines associations between industry payments and physician prescribing.Use this article to:Ask your learners if they are surprised by the findings of this review.Do your learners think that physicians should inform patients when prescribing a drug marketed by an entity that the physician has a financial relationship with?Should health care organizations allow clinicians to have industry relationships?WellnessAnnals Graphic Medicine - Dr. Mom: Things I Took for Granted PrepandemicIn this Annals Graphic Medicine piece, Dr. Farris reflects on the activities she took for granted before the COVID-19 pandemic.Use this Annals Graphic Medicine feature to:Ask your learners to share something they took for granted before the pandemic.Hand out paper and pencils and have your learners draw what they missed. Assemble the drawings into your group's own graphic medicine piece.Discuss the strategies your learners have found helpful in dealing with pandemic-related stress.Discuss the resources available to your learners if they or a colleague is suffering from anxiety, depression, or burnout.MKSAP 18 QuestionA 26-year-old woman is interested in genetic testing for BRCA1 and BRCA2 gene mutations based on her family history. Her mother was diagnosed with triple-negative breast cancer at age 53 years and died at age 55 years. Her maternal aunt was diagnosed with ovarian cancer at age 48 years and is still alive but is not interested in genetic testing. Her maternal and paternal relatives are of Ashkenazi Jewish descent. The patient is premenopausal and takes no medications.On physical examination, vital signs are normal. Breast and gynecologic examination findings are normal.Which of the following is the most appropriate management?A. Recommend a direct-to-consumer genetic testB. Recommend against genetic testingC. Recommend genetic testing for the three BRCA1 and BRCA2 mutations most common in patients of Ashkenazi Jewish ethnicityD. Refer to a genetic counselorCorrect AnswerD. Refer to a genetic counselorEducational ObjectiveRecommend genetic counseling to an asymptomatic patient with a family history of BRCA-related cancers.CritiqueThe most appropriate management for this patient is referral to a genetic counselor. This patient has a family history suggestive of an inherited breast and ovarian cancer susceptibility gene and is interested in genetic testing. Both her mother and maternal aunt had cancers suggestive of a BRCA1 or BRCA2 mutation. Women with triple-negative breast cancers diagnosed before age 60 years are recommended to have BRCA1 and BRCA2 genetic testing, as are women with ovarian cancer diagnosed at any age. Referral to a genetic counselor or other suitably trained health care provider is the best option for genetic risk assessment. The U.S. Preventive Services Task Force has published guidelines for risk assessment and recommends referral to a genetic counselor for asymptomatic women who have not been diagnosed with a BRCA-related cancer but have a family history of BRCA-related cancers. These guidelines include screening tools designed to identify a family history that may be associated with an increased risk for BRCA1 or BRCA2 mutations. Family history factors suggesting an increased likelihood of BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in one or more male family members, multiple cases of breast cancer in the family, one or more family member with two primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity. Genetic counseling should always occur before any genetic test is performed. The essential components of counseling include informing the patient of the test purpose, implications of diagnosis, alternative testing options (including foregoing testing), and any possible risks and benefits. The National Society of Genetic Counselors Web site can be used to locate a genetic counselor. Direct-to-consumer tests may not include the appropriate type of genetic testing. In addition, genetic testing should be done after pretest genetic counseling, which is not always available in patients being tested by direct-to-consumer commercial genetic tests.Although BRCA1 and BRCA2 testing for the three mutations most common in the Ashkenazi Jewish population (called multisite testing) is recommended for Ashkenazi Jewish women with breast cancer diagnosed at any age, comprehensive BRCA1 and BRCA2 testing is recommended if additional criteria for BRCA1/2 testing are met.Key PointAsymptomatic patients with a family history of BRCA-related cancers should receive genetic counseling for genetic risk assessment.BibliographyMoyer VA; U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:271-81.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: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics March 2021Volume 174, Issue 3Page: ED3KeywordsBreast cancerCOVID-19Cancer geneticsGenetic counselingGenetic testingHereditary nonpolyposis colorectal cancerInsomniaMutationRisk assessmentsSystematic reviews ePublished: 16 March 2021 Issue Published: March 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...