Annals for Educators - 3 October 2017,Annals of Internal Medicine

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Annals for Educators - 3 October 2017
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2017-10-03 , DOI: 10.7326/afed201710030
Darren B. Taichman

Clinical Practice Points

Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome. A Randomized Trial

Complex regional pain syndrome (CRPS) is a rare posttraumatic pain condition with few effective treatment options. This randomized placebo-controlled trial evaluated the effectiveness of low-dose intravenous immunoglobulin (IVIg) in reducing pain during a 6-week period in adults with long-standing CRPS.

Use this study to:

Ask your learners how patients with CRPS present. How is it diagnosed? What is the differential diagnosis? Use the information in DynaMed Plus: Complex Regional Pain Syndrome (a benefit of your ACP membership) to help prepare.
What is known about the pathophysiology of CRPS? This is discussed by the editorialists.
How did understanding the pathophysiology prompt the hypothesis that IVIg might be effective therapy? How is IVIg derived, and for which conditions does it work? Do we know how it works?
The editorialists do not believe that this trial should end a focus on immune regulation as an approach to CRPS therapy. What do your learners think?
How is CRPS treated now? How effective are these interventions? What do your learners think it means to have a rare disease for which we lack reliable therapy? How can we help these patients avoid despair and hopelessness?

Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults. A National Cohort Study

Although total sedentary time has been associated with increased mortality, most studies have relied on participant recall to report activity. Whether longer or shorter bouts of inactivity are associated with different outcomes is not known. This large cohort study objectively measured physical activity to assess total as well as shorter and longer bouts of sedentary time.

Use this study to:

Ask your learners how much of their day is spent sitting. How many engage in routine physical exercise? How intense is it?
Do the results of this study alter how your learners think about the importance of physical activity? Does engaging in moderate-to-vigorous physical activity alter the association between sedentary time and mortality? Does it “protect” us from our sedentary habits?
In addition to total sedentary time, the authors examined longer and shorter bouts of sedentary time. Why? What did they find? How might these variables alter the risk for death? Use the accompanying editorial to help frame your discussion.
Teach at the bedside! Ask patients on your service what their daily activities involve and how much of their time is sedentary. Would they be able to alter that if they wanted to? What could be recommended? Should we make recommendations based on this study?
Ask your learners what confounding is and how it might be important in an observational study such as this. The authors quantified the potential effect of an “unmeasured confounder” on their findings. What is an unmeasured confounder? How do the results of this sensitivity analysis help to provide confidence in the authors' conclusions? Use a recent editorial to help frame your discussion.

Beyond the Guidelines

Should We Screen This Patient for Carotid Artery Stenosis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

In this grand rounds discussion, a vascular surgeon and a primary care physician share perspectives on whether a 74-year-old man with risk factors for cardiovascular disease should be screened for carotid artery stenosis (CAS).

Use this feature to:

Watch the video interview with Mr. O, a 74-year-old man who has undergone carotid ultrasound. After watching, ask your learners whether they think patients like Mr. O should be screened for CAS. Why or why not?
Who is at risk for CAS, and does pharmacotherapy affect its natural history? Does carotid endarterectomy (CEA) reduce the risk for stroke in asymptomatic patients? What level of risk from CEA is acceptable?
Evaluate the answers to these questions provided by the discussants. Watch the video of the grand rounds discussion, ask your learners to read it before your teaching session, or assign individuals or teams to summarize the arguments made by the primary care physician and the vascular surgeon. Use the provided slide sets to help.
After reviewing the points made, ask whether your learners have changed their minds. Will they suggest screening to their patients? If so, how will they discuss its potential benefits and harms?
Regarding his past carotid studies, Mr. O comments, “Why not? I mean the more information the better, right?” Is he right? Is more information always better?

In the Clinic

In the Clinic: Urinary Tract Infection

Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This eminently practical review provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention structured around answering key questions that arise in daily practice. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.

Use this review to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners whether we should screen for UTI or asymptomatic bacteriuria.
In which patients with asymptomatic bacteriuria is prevention of symptomatic UTI recommended?
Should women with recurrent symptomatic UTI receive antibiotic prophylaxis? If so, how? How successful are interventions?
What is the differential diagnosis of acute cystitis? How is each condition diagnosed and treated?
When is consultation with an infectious disease specialist or a urologist appropriate?
Use the accompanying multiple-choice questions and teaching slides to help introduce topics for discussion. Be sure to log on and enter your answers to claim CME/MOC credit for yourself!

Humanism and Professionalism

On Being a Doctor: A Night to Remember

Dr. Ricanati recalls the horrible circumstances and her emotions as she watched the examination of a young woman who had been raped.

Use this essay to:

Listen to an audio recording of the essay, read by Dr. Virginia Hood.
Ask your learners whether they have ever helped care for a victim of sexual assault. Did it scare them?
How do our own fears of being on the other side of the examination table make us better doctors?
Do your learners ask their patients about sexual abuse? Do they know what to do when a patient reports having been the victim of sexual abuse?

For Medical Educators

Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

In this essay, the authors describe several initiatives at their institution to foster the development of diagnostic reasoning skills among internal medicine residents.

MKSAP 17 Question

A 53-year-old woman is evaluated during a follow-up visit for recurrent urinary tract infections. She has been treated for three episodes of urinary tract infection with Klebsiella over the past 4 months. Despite an initial response to antibiotics, her urinary tract symptoms return once the antibiotics are stopped. She has no systemic symptoms, including fever or chills. Medical history is otherwise unremarkable. She currently takes no medications.

On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 124/74 mm Hg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 22. There is no costovertebral angle tenderness to palpation. The remainder of the examination is unremarkable.

Urine dipstick reveals a pH of 9.0 and is positive for leukocyte esterase and nitrites; urine microscopy shows 8-10 leukocytes/hpf and many coffin-lid–shaped crystals consistent with struvite.

Kidney ultrasound shows a 1.2-cm irregularly shaped stone in the left renal pelvis.

Which of the following is the most appropriate next step in management?

A. Chronic antibiotic therapy

B. Low phosphate diet

C. Stone removal

D. Urine acidification

Correct Answer

C. Stone removal

Educational Objective

Treat a patient with struvite nephrolithiasis by removing the stone.

Critique

The most appropriate next step in management is to remove the struvite stone in the left renal pelvis. Struvite stones are composed of magnesium ammonium phosphate and occur only when ammonium production is increased, which elevates the urine pH and decreases the solubility of phosphate. This is most commonly a consequence of chronic upper urinary tract infection (UTI) with a urease-producing organism, such as Proteus or Klebsiella. Struvite stones can grow rapidly and become large, filling the entire renal pelvis and taking on a characteristic “staghorn” shape. Although struvite stones affect less than 10% of patients with kidney stones, they occur more commonly in women and in patients predisposed to chronic or recurrent UTI, including those with urologic diversions or neurogenic bladder.

Although treatment of the initial upper UTI is important to prevent struvite stone development, once struvite stones are formed, they are difficult to treat medically, including with chronic antibiotics. Antibiotics may not penetrate the stone, and colonizing bacteria may create an alkaline environment within the stone that promotes continued or recurrent UTI, stone growth, and chronic inflammatory damage to the kidney. Because of this, stone removal is indicated in most cases, and kidney outcomes have been shown to be improved when struvite stones are removed compared with medical therapy. Removal is commonly by percutaneous nephrolithotomy, shock wave lithotripsy, or a combination of both procedures.

Dietary phosphate reduction and urine acidification would be expected to discourage struvite stone formation but are of minimal effectiveness once struvite stones have developed.

Key Point

In most patients with known struvite stones, removal of the stones is indicated.

Bibliography

Frassetto L, Kohlstadt I. Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011 Dec 1;84(11):1234-42.

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中文翻译：

教育家年鉴-2017年10月3日

临床实践要点

低剂量静脉免疫球蛋白治疗长期存在的复杂区域性疼痛综合征。随机试验

复杂区域性疼痛综合征（CRPS）是一种罕见的创伤后疼痛状况，几乎没有有效的治疗选择。这项随机安慰剂对照试验评估了小剂量静脉免疫球蛋白（IVIg）在具有CRPS长期存在的成年人中在6周内减轻疼痛的有效性。

使用此研究可以：

问您的学习者CRPS患者的病情如何。如何诊断？什么是鉴别诊断？使用DynaMed Plus：复杂的区域性疼痛综合症（您的ACP会员资格所带来的好处）中的信息来帮助您进行准备。
关于CRPS的病理生理学知识是什么？社论者对此进行了讨论。
对病理生理学的了解如何提示IVIg可能是有效治疗的假说？IVIg是如何得出的，在什么条件下起作用？我们知道它是如何工作的吗？
评论家认为，该试验不应以免疫调节作为CRPS治疗的方法而结束。您的学习者怎么看？
CRPS现在如何治疗？这些干预效果如何？您的学习者认为患有罕见疾病而我们缺乏可靠的治疗方法意味着什么？我们如何帮助这些患者避免绝望和绝望？

美国中老年人的久坐行为和死亡率模式。全国队列研究

尽管久坐时间与死亡率增加有关，但大多数研究都依靠参与者的回忆来报告活动。不知道更长或更短的不运动是否与不同的结果相关。这项大型队列研究客观地测量了身体活动，以评估久坐时间的总长短。

使用此研究可以：

询问您的学习者，他们每天有多少时间花在坐上。有多少人参加日常体育锻炼？有多强烈？
这项研究的结果是否会改变您的学习者对体育锻炼重要性的看法？进行中度到剧烈运动会改变久坐时间和死亡率之间的联系吗？它会“保护”我们免于久坐的习惯吗？
除了总的久坐时间外，作者还检查了久坐时间的长短。为什么？他们发现了什么？这些变量如何改变死亡风险？使用随附的社论来帮助您进行讨论。
在床边教书！在您的服务中询问患者日常活动涉及什么，以及他们久坐的时间是多少。如果他们愿意的话，他们能够改变它吗？可以推荐什么？我们应该根据这项研究提出建议吗？
问您的学习者什么是混淆，以及混淆在诸如此类的观察性研究中可能有何重要性。作者量化了“无法衡量的混杂因素”对他们的发现的潜在影响。什么是无法衡量的混杂因素？敏感性分析的结果如何帮助建立对作者结论的信心？使用最新的社论来帮助您进行讨论。

超越准则

我们应该筛查该患者的颈动脉狭窄吗？贝丝以色列女执事医疗中心举行的大回合讨论

在这一轮大讨论中，一名血管外科医师和一名初级保健医生分享了有关是否应筛查患有心血管疾病危险因素的74岁男性颈动脉狭窄（CAS）的观点。

使用此功能可以：

观看视频采访O先生，他是一名74岁的接受过颈动脉超声检查的男子。观看后，问您的学习者是否认为像O先生这样的患者应该接受CAS筛查。为什么或者为什么不？
谁有CAS的风险，药物治疗会影响其自然病史吗？颈动脉内膜切除术（CEA）是否可以减少无症状患者中风的风险？CEA带来的风险等级是可以接受的？
评估讨论者提供的这些问题的答案。观看大回合讨论的视频，要求您的学习者在您的教学之前阅读它，或指派个人或团队对初级保健医生和血管外科医师的论点进行总结。使用提供的幻灯片组来提供帮助。
在复习所提出的观点之后，请问您的学习者是否改变了主意。他们会建议对患者进行筛查吗？如果是这样，他们将如何讨论其潜在的利弊？
关于他过去的颈动脉研究，O先生评论说：“为什么不呢？我是说，信息越多越好，对吗？他说的对吗？更多信息总是更好吗？

在诊所

在诊所：尿路感染

尿路感染（UTI）在住院和门诊患者中都很常见。这项杰出的实践综述提供了有关UTI管理的循证，临床相关概述，包括围绕回答日常实践中出现的关键问题而进行的筛查，诊断，治疗和预防。涵盖的疾病包括急性膀胱炎（不复杂和复杂），与导管相关的尿路感染和男女无症状菌尿。

使用此评论可以：

从选择题开始教学。我们在下面提供了一个！
询问您的学习者我们是否应该筛查UTI或无症状菌尿。
在哪些无症状菌尿患者中建议预防有症状的尿路感染？
复发性有症状性尿路感染的妇女应该接受抗生素预防吗？如果是这样，怎么办？干预效果如何？
急性膀胱炎的鉴别诊断是什么？如何诊断和治疗每种疾病？
什么时候与传染病专家或泌尿科医师会诊是合适的？
使用随附的多项选择题和教学幻灯片来帮助介绍要讨论的主题。请务必登录并输入答案，以为自己申请CME / MOC积分！

人文主义和专业精神

关于当医生：一个值得纪念的夜晚

Ricanati博士回顾了她看着被强奸的年轻女子的体检过程，回顾了可怕的环境和她的情绪。

通过这篇文章可以：

聆听弗吉尼亚·胡德（Virginia Hood）博士朗读的论文录音。
询问您的学习者，他们是否曾经帮助照顾过性侵犯的受害者。吓到他们了吗？
我们自己担心自己被排在检查台的另一侧，如何使我们成为更好的医生？
您的学习者是否向患者询问性虐待？他们知道患者报告曾遭受性虐待时该怎么办吗？

对于医学教育者

诊断推理：内科培训中的危险能力

在本文中，作者描述了其机构中促进内科住院医师诊断推理能力发展的若干举措。

MKSAP 17问题

在随访期间对一名53岁妇女进行了尿路复发感染评估。在过去的4个月中，她已接受克雷伯菌（Klebsiella）的三个尿路感染治疗。尽管最初对抗生素有反应，但是一旦停止使用抗生素，她的尿道症状就会恢复。她没有全身症状，包括发烧或发冷。病史不明显。她目前不吃药。

身体检查时，温度为37.1°C（98.8°F），血压为124/74 mm Hg，脉搏频率为72 / min，呼吸频率为12 / min。BMI为22。触诊没有肋椎角压痛。其余的检查效果不明显。

尿液试纸的pH值为9.0，对白细胞酯酶和亚硝酸盐呈阳性。尿液镜检显示8-10个白细胞/ hpf和许多与鸟粪石一致的棺盖形晶体。

肾脏超声检查显示，左肾盂中有一块1.2厘米不规则形状的结石。

以下哪项是管理中最合适的下一步？

A.长期抗生素治疗

低磷饮食

C.清除石头

D.尿液酸化

正确答案

C.清除石头

教育目标

取下结石，治疗鸟粪石肾结石症患者。

批判

治疗中最合适的下一步是去除左肾盂的鸟粪石。鸟粪石由磷酸铵镁组成，仅在铵盐产量增加时才会出现，这会增加尿液的pH值并降低磷酸盐的溶解度。这最常见的结果是产生尿素酶的生物（如变形杆菌或克雷伯菌）慢性上尿路感染（UTI）的结果。鸟粪石可以迅速生长并变大，填满整个肾盂，并具有特征性的“鹿角”形状。尽管鸟粪石结石对肾结石患者的影响不到10％，但它们更常见于女性和易患慢性或复发性UTI的患者，包括泌尿系统转移或神经源性膀胱炎的患者。

尽管最初的上尿路感染的治疗对于预防鸟粪石结石很重要，但是一旦鸟粪石结石形成，它们就很难用药物治疗，包括使用慢性抗生素治疗。抗生素可能无法穿透结石，并且定居细菌可能在结石内形成碱性环境，从而促进持续或反复发生的尿路感染，结石生长以及对肾脏的慢性炎症损害。因此，在大多数情况下，建议去除结石，与药物治疗相比，去除鸟粪石结石可改善肾脏结局。通常通过经皮肾镜取石术，冲击波碎石术或两种方法的结合进行切除。

饮食中磷酸盐的减少和尿液的酸化会阻止鸟粪石结石的形成，但是一旦鸟粪石结石发展，其效果就很小。

重点

在大多数已知鸟粪石结石的患者中，建议去除结石。

参考书目

Frassetto L，Kohlstadt I.肾结石的治疗和预防：更新。我是家庭医生。2011年12月1日； 84（11）：1234-42。

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更新日期：2017-10-03

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