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

Web ExclusivesAugust 2021Annals for Educators - August 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202108170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAssociation Between Mortality and Levels of Autonomous Cortisol Secretion by Adrenal Incidentalomas. A Cohort StudyMany patients with adrenal incidentalomas have biochemical signs of cortisol hypersecretion, which is associated with increased mortality. To advance understanding about which tumors should be considered for surgical removal, this observational study identified levels of secretion that are associated with increased mortality.Use this article to:Start your educational session with a MKSAP question. We provide one below!Invite an endocrinologist to join your teaching session and review the various diagnostic procedures that can be helpful in determining the appropriate care for a patient with an adrenal incidentaloma.Present 1 to 3 patients with adrenal incidentalomas, and discuss what the appropriate evaluation would be in each.Effects of Tai Chi or Conventional Exercise on Central Obesity in Middle-Aged and Older Adults. A Three-Group Randomized Controlled TrialThis randomized, controlled, assessor-blinded trial sought to examine the therapeutic efficacy of tai chi versus conventional exercise for management of central obesity in adults aged 50 years or older.Use this article to:Ask your learners to discuss which weight loss interventions they have observed to be successful in the patients they have encountered.If there is someone in your community who practices tai chi, invite them to lead a brief exercise session with your learners. If no such person is available, find one of the many free instructional videos online.Discuss the relative value of body mass index and waist circumference in determining health risks in various patient groups.The Evidence Behind Robot-Assisted Abdominopelvic Surgery. A Systematic ReviewThis systematic review assesses the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults.Use this article to:Ask your learners to describe the differences among open, laparoscopic, and robot-assisted surgery.Invite a surgeon who does robotic surgery to join your session and describe performance of the same abdominopelvic procedure via laparoscopy versus with robotic assistance.After reviewing the article, ask your learners whether they would opt for open, laparoscopic, or robot-assisted surgery if they needed a cholecystectomy. What if they needed a bowel resection for inflammatory bowel disease?Clinical GuidelinesThe Development of Living, Rapid Practice Points: Summary of Methods From the Scientific Medical Policy Committee of the American College of PhysiciansRapid and Living Guidance for COVID-19In response to the COVID-19 pandemic, ACP's Scientific Medical Policy Committee began developing “practice points” to provide clinical advice based on the best available evidence. This article describes the methods for development and maintenance of living, rapid practice points to provide evidence-based responses to pressing clinical questions about COVID-19. The accompanying editorial discusses the challenges of developing high-quality, up-to-date, evidence-based recommendations and how rapid and living reviews and guidelines can help to translate research evidence into improved health outcomes.Use this article and the accompanying editorial to:Review the standards for trustworthy clinical guidelines discussed in this article and this article. Ask your learners to discuss the pros and cons of guideline panels providing clinical recommendations in the absence of high-quality evidence to support them.Review the ACP living practice points on remdesivir in the treatment of COVID-19 and subsequent updates for an example of how ACP implemented the process described in the article. Discuss the challenges of developing guidelines on topics with rapidly emerging evidence.Beyond the GuidelinesHow Would You Manage This Male Patient With Hypogonadism? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterIn 2020, ACP published a clinical guideline on whether to initiate testosterone treatment in men. In this article, a generalist and an endocrinologist debate the management of a patient with sexual symptoms and a low serum testosterone level.Use this article to:Watch the video of the patient interview and ask your learners whether they would prescribe testosterone to this patient.Ask your learners to describe the potential adverse effects of testosterone supplementation in patients such as the one described in this article.Discuss how testosterone should be prescribed if a decision were made to prescribe it.Discuss what the indications for discontinuing therapy would be if testosterone were prescribed.Low Back PainLow back pain is a leading cause of disability. Evaluation should focus on identification of factors indicating a serious underlying condition and increased risk for developing persistent disabling symptoms. When serious underlying conditions are not the cause, nonpharmacologic therapies, including exercise and psychological therapy, are preferred for most patients and may be supplemented with adjunctive drug therapies. Surgery and interventional procedures are options in a minority of patients who do not respond to noninvasive treatments.Use this article to:Ask whether any of your learners are willing to share their own experiences with low back pain. What brought it on? Did it limit their normal activities? What interventions alleviated the pain? How long did it last?Ask your learners what factors would cause them to be concerned about serious underlying illness in a patient with acute low back pain.Discuss the hierarchy of pharmacologic treatments that should be considered if nonpharmacologic interventions are not helpful.Discuss when, if ever, prescription of opioids would be appropriate for treatment of low back pain.Academia and the ProfessionMedical Schools as Racialized Organizations: A PrimerIn this article, the authors apply the theory of racialized organizations to medical schools and explore how organizational structures affect racial and ethnic minorities in their ability to succeed in medicine.Use this article to:Ask your learners to define structural racism.Discuss what the authors mean by a racialized organization.Ask your learners to identify policies or practices at your institution that might contribute to structural racism.Brainstorm actions that individual physicians, trainees, and students can take to reduce structural racism.MKSAP 18 QuestionA 58-year-old woman is evaluated after the incidental discovery of an adrenal adenoma. A CT scan was performed last week to evaluate renal colic; findings were negative. The remainder of the medical history is unremarkable, and she takes no medication.On physical examination, vital signs and the remainder of the examination are unremarkable.Laboratory studies show normal serum electrolytes.Evaluation for which of the following conditions is most appropriate in this patient?A. Glucocorticoid and mineralocorticoid deficiencyB. Primary hyperaldosteronism and hyperandrogenismC. Subclinical Cushing disease and pheochromocytomaD. No additional testing is necessaryCorrect AnswerC. Subclinical Cushing disease and pheochromocytomaCritiqueThe patient should be evaluated for primary subclinical Cushing disease and pheochromocytoma. An adrenal incidentaloma is defined as an adrenal mass greater than 1 cm in diameter that is detected on imaging performed for reasons other than suspicion of adrenal disease. The prevalence of adrenal incidentaloma increases with age and is estimated to be approximately 10% in persons aged 70 years or older. Most lesions are benign, nonfunctioning adenomas, but approximately 10% to 15% secrete excess hormones. The finding of an incidental adrenal mass prompts two main questions: (1) Is it secreting excess hormone (aldosterone, cortisol, or catecholamines)? and (2) Is it benign or malignant? Biochemical testing for pheochromocytoma, such as a 24-hour urine total metanephrine measurement, should be undertaken in all patients with adrenal incidentaloma, even in the absence of typical symptoms or hypertension. Hypertension associated with pheochromocytoma/paraganglioma can show a sustained pattern, with or without paroxysms, or occur as paroxysms only. Some patients (10% to 15%) remain normotensive. The classic triad of palpitations, headache, and diaphoresis is seen in fewer than 50% of patients with pheochromocytoma. All patients with incidental adrenal mass should also be evaluated for subclinical Cushing syndrome, a condition characterized by adrenocorticotropic hormone–independent cortisol secretion that may cause metabolic (hyperglycemia and hypertension) and bone (osteoporosis) effects of hypercortisolism, but not the more specific clinical features of Cushing syndrome, such as supraclavicular fat pads, wide violaceous striae, facial plethora, and proximal muscle weakness.Primary adrenal insufficiency is a life-threatening disorder that often presents with insidious onset of symptoms, making diagnosis a challenge. Potential symptoms of glucocorticoid and mineralocorticoid deficiency may include fatigue, weakness, low-grade fever, weight loss, anorexia, and hypotension. This patient has no symptoms to suggest adrenal insufficiency. Furthermore, while an adrenal adenoma may be nonfunctioning, it would not be associated with findings of adrenal insufficiency.Primary aldosteronism is a common cause of secondary hypertension. Identification of patients with primary aldosteronism is important because aldosterone has deleterious effects on the cardiovascular system, and treatment prevents progression and can sometimes reverse changes. Screening for primary aldosteronism is unnecessary in the absence of hypertension. Androgen-producing adrenal tumors are rare and lead to menstrual irregularities and virilization in women, including hirsutism, voice-deepening, increased muscle mass, increased libido, and clitoromegaly. This patient has no findings to suggest androgen excess and screening for androgen-producing tumors is therefore not indicated.Although this patient is asymptomatic, performing no further testing may result in a missed diagnosis of subclinical Cushing disease or pheochromocytoma and is therefore inappropriate.BibliographyFassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016;175:G1-G34. doi:10.1530/EJE-16-0467Do 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 August 2021Volume 174, Issue 8Page: ED8 ePublished: 17 August 2021 Issue Published: August 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...