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Annals for Educators - 20 September 2016Annals for Educators - 20 September 2016 FREE

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.


Ann Intern Med. 2016;165(6):ED6. doi:10.7326/AFED201609200
© 2016 American College of Physicians
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Hearing loss affects about 30 million persons in the United States. The National Academies of Sciences, Engineering, and Medicine recently released a report on hearing health care for adults. This commentary summarizes findings and recommendations from that report that are particularly relevant for physicians.

Use this paper to:

  • Have some of your learners insert cotton balls into their external ear canals (not too far!), and bring in commercial hearing protectors for a few others to wear. Now, ask your learners to generate a differential diagnosis of hearing loss. Be sure to ask those with the cotton balls and hearing protectors questions. Ask them how this made them feel? Were they less sure of themselves when participating in a discussion? Were they frustrated? Were they embarrassed when you asked them questions? Can such an exercise be used to help improve our empathy and attention to such disabilities?

  • Ask your learners to list the ways in which hearing loss may impair physical and mental health.

  • Ask what evaluation is appropriate for patients with hearing loss. Use the information in In the Clinic: Hearing Loss to help review, including the already prepared teaching slides.

  • How do your learners arrange for hearing aids when appropriate for their patients? What services/devices are available, and are they covered by insurance? Invite an expert from ENT and/or audiology to help review with your team what they need to know about arranging care for their patients.

  • Teach at the bedside! There are likely patients on your service with varying degrees of hearing loss, albeit not like the reason for hospital admission. Has anyone asked them about it? Ask patients during morning rounds about their hearing. Did your team learn anything they did not know? How might hearing impairment affect each patient's health care and quality of life?

The best treatment options for binge-eating disorder are unclear. This systematic review summarizes trial evidence on the benefits and harms of various treatment options for binge-eating disorder, including cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants.

Use this paper to:

  • Start a teaching session with a multiple-choice question. We've provided one below!

  • Ask your learners to define binge eating, bulimia nervosa, and anorexia. What differentiates them? How are they related? The diagnostic criteria for binge-eating disorder are provided in the appendix of this paper.

  • What are the potential medical complications of each of these eating disorders? What history and physical examination findings may suggest their presence?

  • Use the information in DynaMed Plus: Anorexia nervosa and Bulimia nervosa or In the Clinic: Eating Disorders to help with teaching.

  • Ask your learners how we can encourage healthy weight loss among our overweight and obese patients without reinforcing the feeling of guilt that might contribute to an eating disorder. Might our counseling have unintended consequences? Can we avoid them? Use the accompanying editorial to help frame your discussion.

On 2 March 2016, the National Academies of Science, Engineering, and Medicine released a congressionally mandated report on the state of research on ovarian cancer and its subtypes. This commentary summarizes selected findings and recommendations of key relevance to internists.

Use this paper to:

  • Ask your learners to list the possible presentations and physical findings in a patient with ovarian cancer.

  • Should we screen for ovarian cancer? Why not? What are the potential benefits and harms? What characteristics must a potential screening test demonstrate to make it appropriate for use for disease screening? Review the recommendations from the U.S. Preventive Services Task Force

  • Use the information at DynaMed Plus: Ovarian Cancer and Ovarian Cancer Screening a benefit of your ACP membership

  • Are there patients at sufficiently increased risk for ovarian cancer such that screening is appropriate? How should they be managed? Use this paper to help frame your discussion.

Use this feature to help select papers from Annals of Internal Medicine and other journals that are useful in your learners' practices. ACP Journal Club provides concise synopses and expert commentaries on papers chosen by practicing clinicians for their relevance to clinical care. This month's ACP Journal Club discusses articles on secondary prevention of ischemic stroke or TIA, transcatheter aortic valve implantation, omega-3 highly unsaturated fatty acids for depression, and more.

A 17-year-old teenager is evaluated during an office visit. She is brought in by her mother who is concerned about her focus on diet and weight. The patient states that she believes that she is obese and feels as though she needs to diet to achieve a more appropriate body weight. She also reports exercising on a daily basis to help her lose weight. Dietary history suggests that most of the time she consumes very little food, but at least twice per week she will eat large amounts of high-calorie desserts over the course of 1 to 2 hours. She describes feeling guilty after doing so and will make herself vomit. Medical history is otherwise unremarkable, although she indicates that her menstrual periods are highly irregular.

On physical examination, vital signs are normal. BMI is 23. The parotid glands are enlarged, but the remainder of the examination is unremarkable.

Which of the following is the most likely diagnosis?

A. Anorexia, purging subtype

B. Anorexia, restricting subtype

C. Binge eating disorder

D. Bulimia nervosa

Correct Answer

D. Bulimia nervosa

Educational Objective

Diagnose bulimia nervosa.

Critique

The most likely diagnosis is bulimia nervosa. It is important to differentiate between types of eating disorders as the treatment varies depending on the diagnosis. Bulimia nervosa is characterized by frequent episodes (≥1 per week) of binge eating followed by inappropriate compensatory behaviors (self-induced vomiting or misuse of laxatives, diuretics, and enemas) due to fear of weight gain. Physical examination may reveal erosion of dental enamel, parotid gland swelling, xerosis, and Russell sign (scarring or calluses on the dorsum of the hand if used to induce vomiting). This patient meets diagnostic criteria for bulimia nervosa because she has recurrent episodes of binge eating with recurrent purging to try to compensate for the intake of calories.

Anorexia nervosa is characterized by persistent caloric intake restriction leading to significantly low body weight, a distorted body image, and an intense fear of gaining weight or becoming fat. Subtypes include restricting type (no binge eating or purging behaviors) and binge eating/purging type (purging with or without binging). The differentiating factor between bulimia nervosa and the purging subtype of anorexia nervosa is BMI. Because both purging and laxative abuse are ineffective in removing calories (although they may cause loss of water weight), patients with bulimia nervosa tend to be normal weight to slightly overweight, as seen in this patient. Conversely, the diagnostic criteria for anorexia require that the patient be underweight, generally with a BMI less than 18.5. Menstrual irregularities occur in both anorexia nervosa and bulimia nervosa and are present in approximately one half to one third of patients with bulimia. Although amenorrhea previously was a requirement for the diagnosis of anorexia nervosa, it has been removed from the diagnostic criteria in the DSM-5. Many experts consider anorexia nervosa and bulimia nervosa as a continuum, as one condition often develops from the other.

Binge eating disorder is defined as episodes of eating significantly more food in a short period than most people at least once per week over 3 months, while feeling a lack of control, and is often accompanied by feelings of disgust or guilt afterward but without attempted compensatory behaviors for excessive caloric intake.

Key Point

Bulimia nervosa is characterized by frequent episodes (≥1 per week) of binge eating followed by inappropriate compensatory behaviors (self-induced vomiting or misuse of laxatives, diuretics, and enemas) due to fear of weight gain.

Bibliography

Attia E. In the clinic: Eating disorders. Ann Intern Med. 2012;156(7):ITC4-1-16.

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