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December 16, 2014 Issue


Clinical Practice Points

Patient Care
Medical Knowledge
Systems-based Practice

Racial Disparities in Colon Cancer Survival

The incidence of colon cancer is highest among black persons, and there are racial disparities in survival. This matched cohort study found that disparity in colon cancer survival seemed more related to characteristics of the patients at presentation than to differences in subsequent cancer treatment.

Use this study to:

  • Review the risk factors for colon cancer with your learners. Who should be screened for colorectal cancer, and how? How often? Use the information in a recent In the Clinic: Colorectal Cancer Screening to help you teach—including teaching slides and multiple-choice questions.
  • The study found that most of the disparity in colon cancer survival between black and white patients is explained by poorer health at the time of diagnosis among black patients, with more advanced disease and comorbidities. What do your learners know about completion rates for colorectal cancer screening? Are they different among blacks and whites? Do your learners think there are disparities among racial groups in your center’s practices?
  • Are there racial differences in the prevalence of colon cancer? Why might the presenting characteristics be different among races? How might the disparities at presentation be addressed by physicians or the health care system?


Systems-based Practice
Professionalism

The Importance of Purpose: Moving Beyond Consent in the Societal Use of Personal Health Information

Corporate Research Ethics: Whose Responsibility?

These 2 papers address research ethics and participants’ consent in the electronic age. In the first, a national survey explored public support for the use of electronic health information for research for differing purposes and under varying consent scenarios. The second paper discusses the recent experiment conducted by Facebook to see if manipulating the amount of positive or negative material users saw altered their emotional states, as measured by their own posts.

Use these papers to:

  • Review the wording of HIPPA legislation. Discuss the intentions of this legislation with your learners. What does HIPPA say (or not say) about the use of your patients’ electronic health information for research. Do your learners think the provisions are appropriate?
  • Review the proposed uses of available electronic health information in the first paper's scenarios. Which ones would your learners be comfortable with for themselves?
  • Do restrictions on the use of patients’ electronic health information pose problematic (and needless) restrictions on research? What are the risks to allowing greater access to these records without consent? What are the potential benefits to society?
  • Do your learners think companies such as Facebook should be allowed to do what it did?
  • An editorialist discusses these issues and the problems and limitations to current research consent processes and outlines some changes that might help.


Patient Care
Medical Knowledge

Association Between Emphysema-like Lung on Cardiac Computed Tomography and Mortality in Persons Without Airflow Obstruction

Although spirometric findings are known to predict mortality, the prognostic importance of CT findings of emphysema is uncertain. This study examined mortality among individuals without airflow obstruction on spirometry who did and did not have pulmonary emphysematous changes on cardiac CT. The results suggest that emphysematous lung changes on cardiac CT are associated with increased mortality, particularly among smokers.

Use this study to:

  • Review how the diagnosis of COPD is made. Use the information in ACP Smart Medicine: Chronic Obstructive Pulmonary Disease. What spirometric changes are required for a diagnosis of COPD? Ask one of your center’s pulmonologists to bring and help interpret the PFTs from patients with normal findings, as well as obstructive and restrictive lung disease.
  • Discuss the management of COPD. Are there any interventions that reduce mortality? Does this study change the way your learners think about patients at risk for COPD?
  • Review the indications for cardiac CT. If emphysema is incidentally noted on a cardiac CT of one of their patients, what will they tell the patient?

Clinical Guidelines


Medical Knowledge
Patient Care

Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement

Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement

The first of these recommendations addresses behavioral counseling interventions to prevent STIs, including those targeting risky sexual behaviors in persons of any sexual orientation or level of reported sexual activity. It recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. The second guideline recommends screening for chlamydia and gonorrhea in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. Current evidence is insufficient to assess the balance of benefits and harms of screening in men.

Use these guidelines to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners if and how they discuss the prevention of STIs with their patients. Do they do so with all their sexually active patients?
  • Ask if they screen for chlamydia and gonorrhea? Ask what the symptoms of chlamydia and gonorrhea are? How are they treated? What other STIs need to be considered? Use the recent In the Clinic: Chlamydia and Gonorrhea to help prepare a teaching session, including tables and slides addressing physical examination findings, differential diagnosis, and treatment.

Drugs and Doctors


Professionalism

California’s Proposition 46 and Mandatory Physician Drug Testing: A Cause for Concern

California’s Proposition 46: A Wolf in Sheep’s Wool

A recent ballot proposal in California included a requirement that hospitals perform drug and alcohol testing of physicians. The authors of these short essays discuss the potential problems with such a mandate, as well as the unanticipated consequences.

Use these papers to:

  • Ask your learners if they think random drug testing of physicians would be appropriate?
  • What are the potential benefits and harms?
  • Do they know what to do if they suspect a colleague has a problem that might impair his or her ability to safely practice medicine?

Video Learning


Medical Knowledge
Consult Guys logo

The Consult Guys: Balancing the Medication Portfolio 5 Years After a Heart Attack

What drugs should be initiated following a myocardial infarction, and why? How long should they be continued? In this episode of The Consult Guys, the consultative medicine talk show, Geno and Howard tackle these questions and set the record straight. Watch with your learners. Then, see if they can answer the multiple-choice questions provided.




mksap16

An 18-year-old woman is evaluated in the emergency department for a 3-day history of fever and rash accompanied by joint pain and swelling that initially involved only the left elbow before progressing to the left wrist. Medical history is unremarkable. She receives a depot medroxyprogesterone acetate injection every 12 weeks for contraception.

On physical examination, temperature is 38.1 °C (100.6 °C); other vital signs are normal. The left wrist is erythematous and swollen, and pain is induced with active range of motion. The left elbow is also swollen and painful. Scattered lesions are present on the left hand and both feet.

Appropriate cultures are taken.

Definitive diagnosis can be accomplished by which of the following?

A. Blood cultures
B. Gram stain and culture of left elbow joint
C. Culture of cervix, urethra, or rectum
D. Biopsy, Gram stain, and culture of peripheral skin lesion

Correct answer:
C. Culture of cervix, urethra, or rectum

This patient most likely has disseminated gonococcal infection (DGI). DGI may cause septic or sterile immune-mediated arthritis and tenosynovitis and frequently involves the knees, hips, and wrists but not the spine. Dermatitis associated with sparse peripheral necrotic pustules also is common. A characteristic prodrome of migratory arthralgia and tenosynovitis may precede the settling of the synovitis in one or several joints.

 Genitourinary symptoms associated with DGI usually are absent in women, and genital infection in women may have occurred long before systemic dissemination. Rectal and pharyngeal Neisseria gonorrhoeae infection are commonly asymptomatic. In persons in whom DGI is clinically suspected, evaluation of the exposed mucosal sites including culture or nucleic acid amplication testing (NAAT) of the cervix, rectum, or pharynx, , is indicated. The sensitivity of NAATs for the detection of gonorrhea is superior to culture at nongenital anatomic sites but can vary by NAAT type with gonorrhea. Blood cultures, aspiration of joint fluid or peripheral lesions can also be performed, but the diagnostic yield at these sites is lower than at mucosal sites.

 Prompt evaluation for additional sexually transmitted diseases, including Chlamydia, syphilis and HIV, is indicated. Gonococcal infection is frequently asymptomatic in sex partners of those with DGI. Sexual partners of patients with DGI also should be evaluated and treated.


This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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