Annals for Educators - 2 January 2018.,Annals of Internal Medicine

Clinical Practice Points

Effect of Several Negative Rounds of Human Papillomavirus and Cytology Co-testing on Safety Against Cervical Cancer. An Observational Cohort Study

The optimal interval for concurrent high-risk human papillomavirus (HPV) and cytology testing (co-testing) to detect cervical cancer and its precursors is a question of great interest. Data from a large regional integrated health system were analyzed to determine whether a history of negative high-risk HPV and cytology co-testing results at 3 or 5 years has an effect on such detection.

Use this study to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners what the risk factors for cervical cancer are. What is the role of HPV in the pathogenesis?
What are your learners' approaches to screening their patients for cervical cancer? Whom do they screen? How? How often?
What do guidelines recommend? Use the information at DynaMed Plus: Cervical Cancer Screening (a benefit of your ACP membership).
Do your learners use HPV testing and/or cytology testing? Do they perform co-testing? How might the results of this study help inform future cervical cancer screening guidelines with regard to the necessary frequency of screening? Use the accompanying editorial to help frame your discussion.

Preventing Cognitive Impairment and Dementia

Physical Activity Interventions in Preventing Cognitive Decline and Alzheimer-Type Dementia. A Systematic Review

Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia. A Systematic Review

Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia. A Systematic Review

Does Cognitive Training Prevent Cognitive Decline? A Systematic Review

These systematic reviews evaluate several types of interventions that have been proposed to help prevent the development or progression of mild cognitive impairment or dementia.

Use these studies to:

Ask your learners whether they assess their patients for mild cognitive impairment or dementia. How is each diagnosed? What tools are available to help in the evaluation?
Have your team list possible interventions to prevent the development or progression of cognitive impairment. Does their list include the approaches studied in these systematic reviews (physical activity, medications, over-the-counter supplements, and cognitive training)? Have their patients expressed concern about preventing cognitive decline? Do your learners recommend any of these approaches to prevention?
Assign individuals to briefly summarize the findings of these systematic reviews at your next session so that each is reviewed for the group.
After hearing each presentation, ask whether your team believes anything can be done to prevent cognitive decline. Why do they think that finding solutions to this enormous problem is so difficult? Use the accompanying editorial to help frame your discussion.
The editorialist suggests recommendations that might prevent cognitive decline later in life. Each recommendation is something we should already be doing but are less than perfect at adhering to. Do your learners think that the possibility of delaying or preventing cognitive decline will be a better incentive to exercise or quit smoking than the reasons we already give our patients? How would your learners explain these recommendations to their patients?

In the Clinic

In the Clinic: Travel Medicine

Primary care physicians are frequent sources of health advice for U.S. international travelers. In addition, returned travelers who have become ill may seek care in primary care settings. Thus, physicians need to be familiar with destination-specific disease risks, travel and routine vaccines, chemoprophylaxis regimens, and self-treatment regimens for infectious and noninfectious illnesses. Are your learners ready?

Use this review to:

Invite a member of your institution's travel clinic to join your discussion. What services do they provide? What questions do they ask?
Ask your learners whether they ask patients about planned travel. What immunizations are required? How can your learners arrange for these immunizations for their patients?
Who requires malaria prophylaxis, and what are the options?
What should your learners tell their patients about preventing travelers' diarrhea? Should they provide antibiotics in case they are needed? What should travelers pack in a traveler's kit? Review the Box (Travel Health Kit for International Travelers).
What advice should your learners give their patients in case they become ill during travel?
Answer these and the other questions addressed in this eminently practical review.
Download the teaching slides to help run a teaching session. Use the provided multiple-choice questions to introduce new topics along the way, and be sure to log on and enter your answers to earn CME/MOC credit for yourself!

Annals Graphic Medicine and Annals Story Slam

Annals Graphic Medicine - Back to Work

Dr. Farris recalls the trying moments of being “Doctor Mom.”

Use this feature to:

Before the teaching session, ask your learners who are parents whether they would like to discuss the challenges they have faced with their colleagues. Make sure they are comfortable saying no or setting limits on what they will discuss.
Share the comic with your learners.
Watch some of the Annals Story Slam videos from July 2017, in which physicians discuss their experiences being “Doctor Mom.”
What specific challenges are faced by mothers as they balance being a parent with being a physician? Are the challenges different than for fathers? Do your learners think that your program is sufficiently helpful in supporting physicians who are parents? How could it be improved?

MKSAP 17 Question

A 26-year-old woman is evaluated during a routine examination. Her last Pap smear was performed 1 year ago and was normal. She has received a complete human papillomavirus (HPV) quadrivalent vaccine series. Medical history is unremarkable. Family history is noncontributory. She takes no medications.

On physical examination, temperature is normal, blood pressure is 110/72 mm Hg, and pulse rate is 78/min. The remainder of the physical examination is normal.

Which of the following is the most appropriate management of this patient's cervical cancer screening?

A. Obtain HPV testing in 2 years

B. Obtain Pap smear in 2 years

C. Obtain Pap smear and HPV testing now

D. Obtain Pap smear and HPV testing in 2 years

Correct Answer

B. Obtain Pap smear in 2 years

Educational Objective

Screen for cervical cancer in a young woman.

Critique

This patient should receive a Pap smear in 2 years. According to the U.S. Preventive Services Task Force and the American Congress of Obstetricians and Gynecologists, women aged 21 to 65 years should be screened for cervical cancer every 3 years with cytology (Pap smear). Performing screening more frequently adds little benefit while significantly increasing harms. Harms can include evaluation and treatment of transient lesions as well as false-positive screening results, which may lead to unnecessary colposcopies and emotional distress. Screening for cervical cancer is not recommended in women younger than 21 years, women age 65 years and older who are not at high risk and have had adequate prior Pap smears, and women who have had a hysterectomy with removal of the cervix with no previous history of a precancerous lesion. This patient had a normal Pap smear 1 year ago; therefore, she will be due for her next Pap smear in 2 years.

Owing to poor specificity, screening with human papillomavirus (HPV) DNA testing alone is not recommended. HPV testing is not recommended in women younger than 30 years, as HPV is not only highly prevalent but is also more likely to resolve without treatment in this age group. In women aged 30 to 65 years who want to lengthen the screening interval, a combination of cytology and HPV testing can be performed every 5 years. Women should be informed that there is an increased likelihood of receiving a positive screening result with HPV testing and cytology than with cytology alone. A positive HPV test result likely requires additional immediate testing and also involves more frequent surveillance.

All females aged 11 to 26 years should be vaccinated against HPV. HPV vaccination status does not alter recommendations for cervical cancer screening.

Key Point

Women aged 21 to 65 years should be screened for cervical cancer every 3 years with cytology (Pap smear); in women aged 30 to 65 years who want to lengthen the screening interval, a combination of cytology and human papillomavirus testing can be performed every 5 years.

Bibliography

Moyer VA; U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jun 19;156(12):880-91, W312.

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临床实践要点

几轮阴性的人乳头瘤病毒和细胞学共同测试对宫颈癌安全性的影响。观察性队列研究

并发高危型人乳头瘤病毒（HPV）和细胞学测试（共同测试）以检测子宫颈癌及其前体的最佳间隔是一个引起人们极大兴趣的问题。分析来自大型区域综合卫生系统的数据，以确定3或5年高阴性HPV阴性史和细胞学联合检查结果是否对此类检测有影响。

使用此研究可以：

从选择题开始教学。我们在下面提供了一个！
询问您的学习者宫颈癌的危险因素是什么。HPV在发病机理中的作用是什么？
您的学习者对患者进行子宫颈癌筛查的方法是什么？他们筛选谁？如何？多常？
准则建议什么？使用DynaMed Plus：宫颈癌筛查中的信息（ACP会员资格的一项好处）。
您的学习者是否使用HPV测试和/或细胞学测试？他们是否执行共同测试？这项研究的结果如何在必要的筛查频率方面为将来的子宫颈癌筛查指南提供参考？使用随附的社论来帮助您进行讨论。

预防认知障碍和痴呆

预防认知能力下降和阿尔茨海默氏型痴呆症的体育活动干预措施。系统评价

预防认知能力下降，轻度认知障碍和临床阿尔茨海默氏型痴呆症的药物干预。系统评价

非处方药补充剂可预防认知功能下降，轻度认知障碍和临床阿尔茨海默氏型痴呆症。系统评价

认知训练可以防止认知能力下降吗？系统评价

这些系统的评价评估了已提出的几种类型的干预措施，以帮助预防轻度认知障碍或痴呆症的发生或发展。

使用这些研究可以：

询问您的学习者，他们是否评估患者的轻度认知障碍或痴呆症。如何分别诊断？哪些工具可用于评估？
让您的团队列出可能的干预措施，以防止认知障碍的发生或发展。他们的清单中是否包括在这些系统评价中研究的方法（体力活动，药物，非处方药和认知训练）？他们的患者是否对防止认知能力下降表示关注？您的学习者是否推荐这些预防方法中的任何一种？
指派个人在您的下届会议上简要总结这些系统评价的结果，以便每个人对该小组进行评价。
听完每个演示文稿后，询问您的团队是否认为可以采取任何措施来防止认知能力下降。他们为什么认为找到解决这个巨大问题的解决方案是如此困难？使用随附的社论来帮助您进行讨论。
社论者提出了一些建议，这些建议可能会阻止以后的认知能力下降。每个建议都是我们应该已经做的事情，但在坚持方面还不够完善。您的学习者是否认为，比我们已经给予患者的理由，延迟或预防认知能力下降的可能性会更好地刺激运动或戒烟？您的学习者将如何向患者解释这些建议？

在诊所

在诊所：旅行医学

初级保健医生经常为美国国际旅行者提供健康建议。此外，生病返回的旅客可能会在初级保健场所寻求护理。因此，医生需要熟悉针对特定目的地的疾病风险，旅行和常规疫苗，化学预防方案以及传染性和非传染性疾病的自我治疗方案。您的学习者准备好了吗？

使用此评论可以：

邀请您所在机构旅行诊所的成员参加您的讨论。他们提供什么服务？他们问什么问题？
询问您的学习者是否询问患者计划旅行。需要什么疫苗？您的学习者如何为患者安排这些免疫接种？
谁需要预防疟疾，有哪些选择？
您的学习者应如何告知患者预防旅行者的腹泻？他们是否应提供抗生素以备不时之需？旅行者应在旅行者工具包中包装什么？查看包装箱（国际旅行者旅行保健工具包）。
如果学生在旅途中生病，您的学习者应该给他们什么建议？
回答本杰出实践评论中解决的这些以及其他问题。
下载教学幻灯片以帮助进行教学。使用提供的多项选择题来介绍新话题，并确保登录并输入答案以自己赚取CME / MOC积分！

年鉴图形医学和年鉴故事大满贯

年鉴图形医学-重返工作

法里斯博士回忆起身为“妈妈医生”的艰辛时刻。

使用此功能可以：

在授课之前，请问作为父母的学习者是否愿意与同事讨论他们所面临的挑战。确保他们愿意说不或对讨论内容设置限制。
与您的学习者分享漫画。
观看2017年7月的一些Annals Story Slam视频，医生在其中讨论他们作为“ Motor Doctor”的经历。
母亲在兼顾父母与医生之间面临着哪些具体挑战？挑战与父亲不同吗？您的学习者是否认为您的计划对支持父母的医师足够有帮助？如何改善？

MKSAP 17问题

在例行检查期间对一名26岁的女性进行了评估。她的上一次子宫颈抹片检查是1年前进行的，很正常。她已经收到完整的人类乳头瘤病毒（HPV）四价疫苗系列。病史不明显。家族史无贡献。她不吃药。

经身体检查，体温正常，血压为110/72 mm Hg，脉搏率为78 / min。其余的身体检查是正常的。

以下哪项是该患者宫颈癌筛查的最合适的管理方法？

A.在2年内获得HPV测试

B. 2年内获得子宫颈抹片检查

C.立即获得子宫颈抹片检查和HPV检测

D.在两年内获得子宫颈抹片检查和HPV检测

正确答案

B. 2年内获得子宫颈抹片检查

教育目标

筛查一名年轻女子的宫颈癌。

批判

该患者应在2年内接受子宫颈抹片检查。根据美国预防服务工作队和美国妇产科医生大会，应每3年对21至65岁的女性进行细胞学检查（子宫颈抹片检查）以筛查子宫颈癌。更频繁地进行筛查几乎没有带来任何好处，同时也大大增加了危害。危害可能包括评估和治疗短暂性病变以及假阳性筛查结果，这可能会导致不必要的阴道镜和情绪困扰。不建议在21岁以下的女性，65岁及以上且风险不高，既往有子宫颈抹片检查的女性以及进行了子宫切除术并切除了子宫颈且没有既往史的女性中筛查子宫颈癌癌前病变。该患者1年前的子宫颈抹片检查正常；因此，她将在2年内进行下一次子宫颈抹片检查。

由于特异性差，不建议仅使用人乳头瘤病毒（HPV）DNA检测进行筛查。不建议在30岁以下的女性中进行HPV检测，因为在这个年龄段，HPV不仅非常流行，而且如果不进行治疗也很可能会消退。对于要延长筛查间隔的30至65岁的女性，可以每5年进行一次细胞学检查和HPV检测相结合的检查。应告知妇女，与单独进行细胞学检查相比，通过HPV检测和细胞学检查获得阳性筛查结果的可能性更高。阳性的HPV检测结果可能需要立即进行其他检测，并且还需要进行更频繁的监视。

所有11至26岁的女性均应接种HPV疫苗。HPV疫苗接种状况不会改变宫颈癌筛查的建议。

重点

对于年龄在21至65岁之间的女性，应每3年进行一次细胞学检查（子宫颈抹片检查），以筛查子宫颈癌；对于希望延长筛查间隔的30至65岁女性，可以每5年进行一次细胞学检查和人乳头瘤病毒测试。

参考书目

Moyer VA; 美国预防服务工作队。宫颈癌筛查：美国预防服务工作队推荐声明。安实习生。2012年6月19日； 156（12）：880-91，W312。

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