Annals for Educators - 18 September 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives18 September 2018Annals for Educators - 18 September 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201809180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Humanism and ProfessionalismOn Being a Doctor: Murky WaterDr. Lapedis recalls the horror the day her medical school classmate died. “My worst fears were realized: suicide.”Use this essay to:Listen to an audio recording of this essay with your team, read by Dr. Virginia Hood. Allow time for quiet after the reading. Ask your learners whether they have experienced pressures similar to those Dr. Lapedis describes.Why might we—as medical students, as residents, or after training—feel we are not good enough? What actions increase the stress? How do our own words regarding “success” or “competence” affect ourselves and those around us?Do your learners know how to help themselves to stay well? Do they know how to recognize when they need help, or when others need help? How do they get it?What does your program do to safeguard the mental health of your learners? Is it enough? Is this monitored? Is it discussed?Share this essay with your colleagues. Do you think there is more you should be doing at your program to help prevent what happened to Sarah?Clinical Practice PointsTransfusion-Transmitted Plasmodium falciparum in a Patient With Sickle Cell HemoglobinopathyThis report describes how recognition of the presence of malaria infection was key to saving the life of a patient whose clinical course seemed explicable on the basis of known sickle cell anemia.Use this paper to:Ask your learners to list the potential complications of sickle cell disease.In what ways can vaso-occlusive crisis present? How is it diagnosed and treated?What is the differential diagnosis of hemolysis?What might have happened to this patient had the findings on a blood smear been overlooked?How is malaria treated?Review the pathogenesis of malaria infection. Ask your learners how sickle cell disease and malaria are believed to be connected.Real-Time Use of Artificial Intelligence in Identification of Diminutive Polyps During Colonoscopy. A Prospective StudyConfident identification during colonoscopy of polyps that do not require resection could reduce costs. This study evaluated the performance of real-time computer-aided diagnosis with endocytoscopes in differentiating nonneoplastic from neoplastic colorectal polyps during colonoscopy.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Review the progression of lesions in the pathogenesis of colorectal cancer. What are the different histologic types of polyps? Which need to be removed, and why?Ask your learners by what mechanism colonoscopy is believed to reduce mortality from colorectal cancer. Is it only in detecting lesions early?What are the benefits and risks of attempting to remove all polyps during colonoscopy? How might the approach used in this study help? Invite an endoscopist to join your discussion. Would it be feasible for your team to observe a colonoscopy?What does “generalizability” mean in relation to the results of a clinical research study? What might limit the generalizability of approaches such as the one used in this study to perform colonoscopy? How did the authors try to assess this issue? Use the accompanying editorial to help frame your discussion. HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015. A Cohort StudyUnderstanding trends and predictors of HIV viral suppression is essential for optimal outcomes and prevention efforts and is imperative to inform public health policy. This observational cohort study of patients treated at 8 HIV clinics across the United States evaluated viral suppression trends in people living with HIV, including the relationship of associated factors, such as demographic characteristics and use of integrase strand transfer inhibitors.Use this study to:Invite a clinician who cared for HIV-positive patients in the 1980s and 1990s to describe to your learners what it was like.Ask your learners what HIV treatment goals and targets are. How well are they achieved in your learners' patients? Identify as many patients with HIV as possible who are on your service or have been seen by your learners in the past few months. Had they achieved viral suppression? Alternatively, are such data available for the HIV specialty practice at your center?What variables do your learners think influence whether patients achieve viral suppression? What was found in this study?How might the findings of this study help further efforts toward achieving the United Nations' “90-90-90” targets (diagnosis, therapy, viral suppression)? Use the accompanying editorial to help frame your discussion. Video LearningAnnals Consult Guys – Pros and Cons of Therapy to Increase Bone Mineral DensityThe Guys (Howard and Geno) take on a tough one: Will calcium supplementation increase the risk for cardiovascular disease, and should it be avoided in a patient with aortic stenosis?Use this feature to:Take a break with your team to watch this short episode of the consultative medicine talk show.Pause the video after Geno reads the viewer's letter. What do your learners think?Do your learners evaluate bone mineral density in their male patients?What will they do in the future?Answer the brief multiple-choice questions. Be sure to log on to claim CME/MOC credit for yourself!MKSAP 18 QuestionA 52-year-old man is evaluated after screening colonoscopy revealed three polyps in the descending colon, measuring 5 mm, 8 mm, and 3 mm in size. Colonoscopy preparation was excellent, and the procedure was complete to the cecum. The polyps were completely excised, and pathology showed all three to be tubular adenomas. The patient has no personal or family history of colorectal cancer. He reports no symptoms and takes no medication.All physical examination findings, including vital signs, are normal.Based on his colonoscopy findings, when should this patient next undergo surveillance colonoscopy?A. 1 yearB. 3 yearsC. 5 yearsD. 10 yearsCorrect AnswerB. 3 yearsEducational ObjectiveManage colonoscopy surveillance following polypectomy.CritiqueThis patient should undergo surveillance colonoscopy in 3 years. Current recommendations emphasize that an adequate bowel preparation and a high-quality colonoscopy that reaches and examines the cecum are required for an adequate screening examination. Screening colonoscopy studies demonstrate that polyps are detected in approximately 60% of average-risk individuals. The prevalence of polyps on average-risk screening colonoscopy is 22% to 25% for adenomas, 12% for hyperplastic polyps, and 0.6% for sessile serrated polyps. The degree of dysplasia in a polyp is reported as high or low. Adenomatous polyps are neoplastic lesions and, therefore, have malignant potential; most colorectal cancers arise from adenomatous polyps. Adenomatous polyps are further defined by their glandular architecture: tubular, villous, or a combination of both. The most common pattern is tubular, followed by tubulovillous, with the least common pattern being villous. After neoplastic polyps (adenomas, sessile serrated polyps, or traditional serrated adenomas) are completely resected, postpolypectomy colonoscopy should be performed; the surveillance interval depends on the size, number, and pathology of the polyp. This patient was found to have three tubular adenomas smaller than 1 cm in size. The presence of three or more adenomas, any adenoma greater than or equal to 1 cm in size, or any adenoma with villous features or high-grade dysplasia has been associated with increased risk for metachronous neoplasia (multiple primary tumors developing at different time intervals), warranting a 3-year surveillance interval.Guidelines recommend screening average-risk individuals beginning at age 50 years. Repeat colonoscopy is based on initial findings. Individuals with no adenomas should have a repeat colonoscopy in 10 years. Individuals who have two or fewer tubular adenomas are also considered low-risk for colon cancer and should repeat screening in 5 to 10 years. Appropriate follow-up recommendations after screening colonoscopy, including avoidance of inappropriate use of colonoscopy after removal of adenomatous polyps, are core gastroenterology quality measures.High-risk findings include more than 10 polyps on baseline colonoscopic examination, which should prompt consideration for a polyposis syndrome. These individuals should have a follow-up colonoscopy in less than 3 years, depending on polyp burden and polyposis syndrome. Any patient who has a polyp removed piecemeal should return within 3 to 6 months for repeat colonoscopy, especially if there is any concern for incomplete polyp removal.This content was last updated in August 2018.Key PointPatients with three or more adenomas on screening colonoscopy should undergo surveillance colonoscopy in 3 years.BibliographyLieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR; United States Multi-Society Task Force on Colorectal Cancer. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57. doi:10.1053/j.gastro.2012.06.001Do 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 18 September 2018Volume 169, Issue 6Page: ED6KeywordsAdenomasColonoscopyColorectal cancerHIVLesionsMalariaPathogenesisPolypectomiesPrevention, policy, and public healthSickle cell disease ePublished: 18 September 2018 Issue Published: 18 September 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...