Darren B. Taichman, MD, PhD
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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.
Taichman D.; Annals for Educators - 19 January 2016. Ann Intern Med. 2016;164:ED2. doi: 10.7326/AFED201601190
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Published: Ann Intern Med. 2016;164(2):ED2.
Medical and behavioral strategies are available for managing osteoarthritis, but some recommended therapies are underused. This randomized trial evaluated the effect of providing treatment recommendations to physicians in addition to telephone-based support to patients with knee or hip osteoarthritis.
Use this study to:
Teach at the bedside! Osteoarthritis is a common problem in both inpatients and outpatients, even if it is not the presenting complaint. Review with your learners the essential history and physical examination elements for osteoarthritis of the hip, knee, and hand. Practice examining the joints. Use the information in Table 1 of a recent In the Clinic: Osteoarthritis to help prepare.
Ask your learners what the major risk factors are for osteoarthritis. Can it be prevented, and which modifiable risk factors are most important to address? What is the differential diagnosis of osteoarthritis? The answers may also be found in In the Clinic: Osteoarthritis.
The investigators of this trial found that although participants in the intervention group more often received referrals for specific osteoarthritis treatments, the number of participants who actually received these treatments did not increase. Why do your learners think that may have happened? What are the barriers?
The “intervention” in this trial combined actions directed at health providers and the patients. Implementing interventions found to be effective can be costly. Ask your learners if the design of this study allows one to discern between the effects of the patient and the provider interventions. How would they design a follow-up study to do that? Discuss what a “2×2 trial” involves.
Although recommendations for the diagnosis of latent tuberculosis infection include tuberculin skin testing or an interferon-γ release assay, the authors discuss why important differences in these tests need to be considered and why they are not always equivalent.
Use this paper to:
Review how to place a purified protein derivative (PPD). If permissible, have your learners practice on each other using normal saline. How deep should the infiltration be made?
How is a PPD test read? When? Review how to interpret the results. How do the cutoffs for positive results differ according to the patient's risk factors?
Ask your learners when they place a PPD, and whether they have ordered an interferon-γ release assay. What do the results of each indicate? Review the limitations of each, as outlined in this paper. Which test do your learners think they should use when evaluating a patient for possible latent tuberculosis?
What is the purpose of screening for latent tuberculosis? Does the PPD have a role in the evaluation of possible active tuberculosis?
Information on the presence of cardiac abnormalities among adult survivors of childhood cancer is limited. This large, prospective study evaluated asymptomatic adult survivors of childhood cancer exposed to cardiotoxic therapies for evidence of cardiac abnormalities.
Start a teaching session with a multiple-choice question! We've provided one below. What information regarding a patient's history and treatment of a childhood cancer is needed to provide appropriate care in adulthood? Use In the Clinic: Care of the Adult Cancer Survivor to find the answers.
This study found a substantial number of adult survivors of childhood cancer had asymptomatic cardiac abnormalities. Although further study is required to assess whether screening for cardiac abnormalities will result in improved outcomes, should the results of this study alter your learners' approach to monitoring patients with a history of childhood cancer?
In addition to cardiac conditions, what pulmonary, cognitive, bone health, sexual, and reproductive issues should your learners consider in these patients? What is the risk for secondary cancer, and how should this be addressed? These issues are also discussed in In the Clinic: Care of the Adult Cancer Survivor.
Intersperse your teaching session with the other multiple-choice questions provided with In the Clinic: Care of the Adult Cancer Survivor to introduce important topics for discussion. Be sure to log in and enter your answers to claim CME for yourself!
The U.S. health care system is transitioning from fee-for-service payment models to compensating physicians based on the quality of care they provide. This article describes several principles of behavioral economics that health systems may use in developing incentives to encourage physicians to provide high-value care to patients.
Teach your learners the meaning of several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Each is defined in the paper's table.
Ask your learners what the current incentives are in the provision of care.
Break your learners into 2 groups and have them debate the pros and cons of a fee-for-service model and reimbursements based on the quality of care. What are the benefits and the potential unintended consequences of each?
Take a break and watch this short video with your learners, in which Howard Weitz and Geno Merli (The Consult Guys) tackle the anxiety-provoking question of whether to hunt for a malignancy when a patient has an apparently unprovoked venous thromboembolic event. Be sure to answer the CME question provided (and log on to enter your answer to earn CME!).
A 27-year-old woman is admitted to the hospital with a 1-week history of worsening exertional substernal chest pressure relieved by rest. She was admitted after 30 minutes of chest pain relieved with sublingual nitroglycerin tablets. Medical history is significant for Hodgkin lymphoma 7 years ago, treated with high-dose (90 Gy) chest radiation therapy. She reports a history of cocaine use. There is no history of fever or rash. She takes no medications.
On physical examination, temperature is normal, blood pressure is 110/50 mm Hg, pulse rate is 98/min, and respiration rate is 14/min. Cardiopulmonary and peripheral vascular examinations are normal.
Serum toxicology screen is negative. Serum troponin I level is 0.01 ng/mL (0.01 µg/L). Prothrombin and activated partial thromboplastin time are normal.
Electrocardiogram during chest pain at the time of admission indicates ST-segment depression in leads V1 to V4. Cardiac catheterization shows 60% ostial narrowing of the left main coronary artery and 60% narrowing of the proximal left anterior descending coronary artery.
Which of the following is the most likely cause of this patient's chest pain?
A. Antiphospholipid syndrome
B. Cocaine-induced coronary artery vasospasm
C. Coronary artery disease
D. Kawasaki disease
Diagnose premature coronary artery disease in a cancer survivor with previous radiation therapy.
This young woman's chest pain is most likely caused by coronary artery disease (CAD). She has chest pain consistent with unstable angina. In a patient with a history of chest irradiation who is young and free from conventional risk factors, CAD can be attributed to the effects of the irradiation. Coronary obstructions from previous chest radiation typically occur in ostial or proximal sites. Pathologic examination of the coronary vessels shows intimal proliferation that consists of fibrous tissue without extracellular lipid deposits. The fibrous nature of radiation-induced coronary lesions makes them poor candidates for interventional dilatation procedures.
The antiphospholipid antibody typically prolongs the activated partial thromboplastin time or the prothrombin time. These antibodies are paradoxically associated with an increased risk for venous and arterial thromboembolism and pregnancy loss. The antiphospholipid syndrome is unlikely in a patient with normal coagulation and a more compelling alternative reason for CAD.
Cocaine-induced coronary artery vasospasm is a reasonable consideration in this patient with a history of cocaine use. However, the negative screen for cocaine makes it an unlikely cause of her chest pain. In addition, vasospasm of epicardial coronary vessels is more apt to cause ST-segment elevation than depression.
Kawasaki disease is characterized by fever, conjunctivitis, erythema of the oral mucous membranes, erythema or edema of the extremities, cervical lymphadenopathy, coronary aneurysms, and coronary artery thrombosis and occlusion. It occurs mainly in childhood. However, coronary artery aneurysms from the disease may be seen in adulthood. This patient has no history of Kawasaki disease and no angiographic findings of coronary aneurysms.
The fibrous nature of radiation-induced coronary lesions makes them poor candidates for interventional dilatation procedures.
Darby SC, Cutter DJ, Boerma M, et al. Radiation-related heart disease: current knowledge and future prospects. Int J Radiat Oncol Biol Phys. 2010;76(3):656-665.
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Cardiology, Hematology/Oncology, Infectious Disease, Cancer Survivorship, Mycobacterial Infections.
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