Annals for Educators - 6 March 2018,Annals of Internal Medicine

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Annals for Educators - 6 March 2018
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2018-03-06 , DOI: 10.7326/afed201803060
Darren B. Taichman

Clinical Practice Points

Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms. A Population-Based Cohort Study

Patients with myeloproliferative neoplasms (MPNs) have been reported to be at increased risk for thrombotic events, but no population-based study has estimated this excess risk compared with matched control participants. This study analyzed data on patients reported to the Swedish Cancer Register between 1987 and 2009 to assess risk for arterial and venous thrombosis among those with MPNs compared with matched control participants.

Use this study to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners if they can name the 3 major subtypes of MPNs.
In what ways do patients with each of these MPNs present? How is each diagnosed? Use the information in the DynaMed Plus sections on polycythemia vera, essential thrombocythemia, and primary myelofibrosis (a benefit of your ACP membership!).
What is the relationship between JAK2 and each MPN subtype? The accompanying editorial explains this.
What does this study tell us about risk for thrombotic events in patients with MPNs?
Look at Figure 3. What change in the risk for venous thrombosis has occurred with time? The authors believe this is likely due to improved management. How are patients with MPNs treated? In addition to the risk for thrombosis, what other complications occur?

Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke. A Systematic Review and Meta-analysis

Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale. A Systematic Review and Meta-analysis

These meta-analyses of recent landmark trials examined the benefits and harms of percutaneous closure of patent foramen ovale (PFO) compared with medical therapy alone in patients with cryptogenic stroke.

Use these papers to:

PFOs are highly prevalent. What are the potential complications?
What should the poststroke work-up include? The authors of the second review provide a concise list in their paper's discussion.
When should closure of a PFO be considered? What patients were included in the trials used for these meta-analyses (i.e., were they patients with incidentally noted PFOs or those who had experienced 1 or recurrent strokes)? Why does that matter when considering which patients should undergo PFO closure?
How is PFO closure accomplished? Invite an interventional cardiologist to join your discussion and to show films of the procedure.
What are the potential complications of PFO closure? What more do we need to know? Should these papers alter practice? Use the accompanying editorial to inform your discussion.

The Hypertension Guidelines (Again!)

Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline

The 2017 American College of Cardiology/American Heart Association Hypertension Guideline: A Resource for Practicing Clinicians

Hypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood Pressure

The recent American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline differs substantially from its predecessor and from the guidelines of other organizations. It is more than 100 pages long and includes 106 recommendations. The guideline developers present a synopsis of the most important changes and recommendations. Here, a commentary discusses why the new guideline is helpful, and the editorialists discuss why they believe it falls short in weighing potential benefits and harms, particularly for adults older than 60 years.

Use these papers to:

Ask your learners how the updated ACC/AHA guideline differs from the prior version and from guidelines from other organizations, such as the American College of Physicians and the American Academy of Family Physicians. Why are these differences so important?
Look at the figures in the guideline synopsis. Do your learners believe they should use home and ambulatory blood pressure measurements more often than they do?
What limitations in what is known about the risks and outcomes related to hypertension and its treatment are noted by the editorialists? What are the limitations of the clinical trials on which guidelines are based? Why might these be important?
What approach will your learners take to diagnosing patients with and treating hypertension?

In the Clinic

In the Clinic: Palliative Care

Palliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This eminently practical review addresses these essentials and provides an overview of current evidence to support patient-centered palliative care.

Use this paper to:

Ask your learners what the differences are between palliative care and hospice care. Who is eligible for each?
Why might patients' perceptions, misconceptions, and fears of hospice care influence their interest in palliative care? How would your learners discuss this with their patients? Look at the Patient Information sheet at the end. Would this be helpful to your patients?
When do your learners consider consultation with a palliative care team? What should they expect from such a consultation? Invite a member of your institution's palliative care service to join your discussion.
Do your learners use a systematic approach to evaluating and managing pain? In what ways should the approach differ according to the cause? How should adverse effects of opioids be managed?
Are your learners comfortable prescribing narcotics for patients with dyspnea? When is it appropriate? How much?
How do your learners ask patients about their goals of care? Are they comfortable doing so? How might the manner in which they pose questions matter? Use Table 4 to help spark discussion.
Download the teaching slides, and use the multiple-choice questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME and MOC credit for yourself!

Humanism and Professionalism

On Being a Doctor: Note to an Oncology Fellow

Dr. Vettese answers why she discussed hospice care with her patient instead of encouraging palliative chemotherapy and implores her colleague to ask patients what they would be willing to give up to live longer.

Use this essay to:

Listen to an audio recording of the essay, read by Dr. Michael LaCombe.
Why does the author suggest that we ask our patients what they would never give up?
How do your learners react to this essay? Is this an issue of “older” versus “younger” doctors?
Have your learners ever felt that other physicians have failed to adequately consider a patient's circumstances and desires? Have others ever suggested that your learners have done so? Why do such differences in opinion occur? Are they harmful to patients?

Annals Graphic Medicine - Is This What Depression Looks Like?

The author/artist imagines what depression looks like inside himself and wonders, “Is this the black dog of depression I've read about?”

Use this feature to:

Show the graphic to your learners. How do they react?
Do the images make them think differently about patients with depression? How? Does it alter their impressions of what is and is not within the control of the patient?
Do such graphic depictions help us to foster our sense of empathy in ways that differ from other experiences?
Might sharing these images with a patient who has depression be helpful? Might it be hurtful?

MKSAP 17 Question

A 27-year-old woman is evaluated during a follow-up visit. She was evaluated 3 months previously for symptoms of fatigue of 9 months' duration and a craving for ice. She experiences heavy, irregular menstrual cycles, but has no history of other bleeding. Medications are oral contraceptive pills and daily iron, which were initiated 3 months ago.

On physical examination, vital signs are normal; BMI is 31. No splenomegaly is noted.

Laboratory studies:

	3 Months Ago	2 Months Ago	Current
Ferritin	6 ng/mL (6 µg/L)	16 ng/mL (16 µg/L)	45 ng/mL (45 µg/L)
Hemoglobin	8.7 g/dL (87 g/L)	10.1 g/dL (101 g/L)	13 g/dL (130 g/L)
Mean corpuscular volume	71 fL	77 fL	88 fL
Platelet count	800,000/µL (800 × 10⁹/L)	790,000/µL (790 × 10⁹/L)	775,000/µL (775 × 10⁹/L)

	3 Months Ago	2 Months Ago	Current
Ferritin	6 ng/mL (6 µg/L)	16 ng/mL (16 µg/L)	45 ng/mL (45 µg/L)
Hemoglobin	8.7 g/dL (87 g/L)	10.1 g/dL (101 g/L)	13 g/dL (130 g/L)
Mean corpuscular volume	71 fL	77 fL	88 fL
Platelet count	800,000/µL (800 × 10⁹/L)	790,000/µL (790 × 10⁹/L)	775,000/µL (775 × 10⁹/L)

Which of the following is the most appropriate diagnostic test to perform next?

A. BCR-ABL genetic analysis

B. JAK2 V617F analysis

C. Prothrombin time and activated partial thromboplastin time

D. von Willebrand factor antigen

Correct Answer

B. JAK2 V617F analysis

Educational Objective

Diagnose essential thrombocythemia.

Critique

Mutational analysis for JAK2 V617F should be conducted. The patient presented with iron deficiency anemia and thrombocytosis. Thrombocytosis is often associated with iron deficiency anemia, particularly if bleeding is the cause of the anemia. However, when the patient's anemia was corrected with oral iron and oral contraceptive pills for better regulation of menstruation, thrombocytosis persisted, suggesting a disorder in platelet regulation. Iron deficiency is the most common cause of reactive thrombocytosis, which corrects within weeks of correcting the iron deficiency. Infection, inflammation, and malignancy are other causes. With iron deficiency ruled out as a cause and no other causes clinically apparent, essential thrombocythemia (ET) becomes more probable. Her lack of splenomegaly is fairly typical. The JAK2 activating mutation is present in 50% of patients with ET, so a negative result would not exclude the diagnosis, but a positive result supports the diagnosis of a myeloproliferative neoplasm (polycythemia vera, ET, or primary myelofibrosis).

BCR-ABL testing, then bone marrow aspiration and biopsy, would be performed if the platelet count remained persistently elevated after correction of serum iron levels with a negative JAK2 mutation status, because myeloproliferative neoplasms other than ET can less commonly elevate the platelet count. In ET, general hypercellularity and megakaryocyte hyperplasia would be seen on the bone marrow examination.

Testing the prothrombin and activated partial thromboplastin times would not be the most appropriate choice, because it focuses the diagnosis on a bleeding diathesis rather than thrombocytosis. Similarly, von Willebrand factor antigen testing does not address the patient's persistently elevated platelet count.

Key Point

A patient with iron deficiency and isolated thrombocytosis that persists after correction of iron deficiency should undergo JAK2 V617F mutational analysis as part of the evaluation for essential thrombocythemia.

Bibliography

Tefferi A. Polycythemia vera and essential thrombocythemia: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol. 2013 Jun;88(6):507-16.

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中文翻译：

教育家通志-2018年3月6日

临床实践要点

骨髓增生性肿瘤患者发生动脉和静脉血栓形成的风险。基于人群的队列研究

据报道患有骨髓增生性肿瘤（MPN）的患者发生血栓形成事件的风险增加，但是与对照对照组相比，没有一项基于人群的研究估计这种过高的风险。这项研究分析了1987年至2009年间向瑞典癌症登记处报告的患者数据，以评估MPN患者和相匹配的对照组参与者发生动脉和静脉血栓形成的风险。

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！
询问您的学习者是否可以命名MPN的3个主要子类型。
患有这些MPN的患者以何种方式出现？如何分别诊断？使用DynaMed Plus部分中有关真性红细胞增多症，原发性血小板增多症和原发性骨髓纤维化的信息（这是ACP会员的好处！）。
JAK2和每个MPN子类型之间有什么关系？随附的社论对此进行了解释。
这项研究告诉我们有关MPN患者血栓形成事件的风险？
请看图3。随着时间的流逝，静脉血栓形成的风险发生了什么变化？作者认为，这可能是由于改善了管理。MPN患者如何治疗？除了形成血栓的风险外，还会发生其他哪些并发症？

封闭装置与单独的医学疗法一起治疗深源性中风患者的卵圆孔未闭。系统评价和荟萃分析

经皮封闭与药物治疗卵圆孔未闭的卒中患者的关系。系统评价和荟萃分析

这些近期标志性试验的荟萃分析检查了隐源性中风患者与单独药物治疗相比，经皮闭合卵圆孔未闭（PFO）的利弊。

使用这些文件可以：

PFO非常普遍。潜在的并发症是什么？
中风后检查应包括哪些内容？第二篇评论的作者在他们的论文讨论中提供了一个简要清单。
什么时候应该考虑终止PFO？这些荟萃分析的试验中包括哪些患者（即，他们是那些偶然注意到PFO的患者，还是经历过1次或复发性中风的患者）？在考虑哪些患者应进行PFO封闭治疗时，这为何重要？
如何关闭PFO？邀请介入心脏病专家参加您的讨论并放映该过程的电影。
PFO封堵的潜在并发症有哪些？我们还需要知道什么？这些论文应该改变实践吗？使用随附的社论为您的讨论提供信息。

高血压指南（再次！）

成人高血压的预防，检测，评估和管理：2017年美国心脏病学会/美国心脏协会高血压指南的内容提要

2017年美国心脏病学会/美国心脏协会高血压指南：执业医生的资源

高血压凌波：在降低血压门槛之前，要平衡收益，危害和患者的喜好

最近的美国心脏病学会（ACC）/美国心脏协会（AHA）高血压指南与之前的指南和其他组织的指南有很大不同。它的长度超过100页，包含106条建议。指南制定者介绍了最重要的更改和建议。在这里，有一篇评论讨论了新指南为何有所帮助的原因，而社论主义者则讨论了为什么他们认为该指南在权衡潜在的利益和危害方面存在不足，尤其是对于60岁以上的成年人而言。

使用这些文件可以：

询问您的学习者，更新后的ACC / AHA指南与先前版本以及其他组织（例如，美国内科医师学会和美国家庭内科医师学会）的指南有何不同。为什么这些差异如此重要？
查看指南提要中的数字。您的学习者是否认为他们应该比他们更频繁地使用家庭和门诊血压测量？
编辑者指出，在与高血压及其治疗有关的风险和结果方面，已知的哪些限制？指导原则所依据的临床试验的局限性是什么？为什么这些很重要？
您的学习者将采用哪种方法诊断和治疗高血压患者？

在诊所

在诊所：姑息治疗

姑息治疗在整个严重疾病过程中始终将症状管理和生活质量放在首位。无论是住院治疗还是门诊治疗，无论是初级护理还是专科护理，对有效沟通，症状管理和临终护理的基本知识都有扎实的了解至关重要。这项杰出的实践回顾解决了这些要点，并概述了当前证据以支持以患者为中心的姑息治疗。

使用本文可以：

问您的学习者姑息治疗和临终关怀治疗之间的区别是什么。谁有资格参加？
为什么患者的观念，误解和对临终关怀的恐惧会影响他们对姑息治疗的兴趣？您的学习者将如何与患者讨论此问题？查看末尾的患者信息表。这对您的患者有帮助吗？
您的学习者何时考虑与姑息治疗小组进行咨询？他们从这种咨询中期望得到什么？邀请您所在机构的姑息治疗服务成员参加您的讨论。
您的学习者是否使用系统的方法来评估和管理疼痛？该方法应根据原因在哪些方面有所不同？阿片类药物的不良反应应如何处理？
您的学习者是否愿意为呼吸困难的患者开出麻醉药？什么时候合适？多少？
您的学习者如何向患者询问他们的护理目标？他们这样做舒服吗？他们提出问题的方式有多重要？使用表4有助于引发讨论。
下载教学幻灯片，并使用多项选择题来帮助介绍要讨论的主题。请务必登录并输入答案，以自己赚取CME和MOC积分！

人文主义和专业精神

关于当医生：肿瘤学同仁

Vettese博士回答了为什么她与患者讨论临终关怀而不是鼓励姑息性化疗的问题，并恳请她的同事问患者他们愿意放弃更长寿的意愿。

通过这篇文章可以：

收听迈克尔·拉康姆（Michael LaCombe）博士朗读的论文录音。
为什么作者建议我们问患者他们永远不会放弃什么？
您的学习者对这篇文章有何反应？这是“老年”医生还是“年轻”医生的问题？
您的学习者是否曾经感到其他医师未能充分考虑患者的情况和愿望？是否有其他人建议您的学习者这样做？为什么会出现这种意见分歧？它们对患者有害吗？

年鉴图形医学-这是抑郁症的模样吗？

这位作家/艺术家想象自己内心的抑郁症是什么，他想知道：“这是我读过的抑郁症的黑狗吗？”

使用此功能可以：

向学习者显示图形。他们如何反应？
这些图像是否使他们对抑郁症患者有不同的看法？如何？是否会改变他们对患者控制范围之内或之外的印象？
这样的图形描绘是否有助于我们以与其他经历不同的方式来培养我们的同理心？
可能与抑郁症患者分享这些图像会有所帮助吗？可能会受伤吗？

MKSAP 17问题

在随访期间对一名27岁的女性进行了评估。3个月前对她进行了9个月持续疲劳症状和对冰的渴望评估。她的月经周期很沉重，但没有其他出血史。药物是口服避孕药和每日铁剂，这是3个月前开始的。

经身体检查，生命体征正常。BMI为31。没有发现脾肿大。

实验室研究：

	3个月前	2个月前	当前的
铁蛋白	6 ng / mL（6微克/升）	16 ng / mL（16微克/升）	45 ng / mL（45微克/升）
血红蛋白	8.7克/分升（87克/升）	10.1克/分升（101克/升）	13克/分升（130克/升）
平均红细胞体积	71升	77升	88升
血小板计数	800,000 / µL（800×10 ⁹ / L）	790,000 / µL（790×10 ⁹ /升）	775,000 / µL（775×10 ⁹ /升）

	3个月前	2个月前	当前的
铁蛋白	6 ng / mL（6微克/升）	16 ng / mL（16微克/升）	45 ng / mL（45微克/升）
血红蛋白	8.7克/分升（87克/升）	10.1克/分升（101克/升）	13克/分升（130克/升）
平均红细胞体积	71升	77升	88升
血小板计数	800,000 / µL（800×10 ⁹ / L）	790,000 / µL（790×10 ⁹ /升）	775,000 / µL（775×10 ⁹ /升）

以下哪一项是接下来执行的最合适的诊断测试？

A. BCR-ABL基因分析

B. JAK2 V617F分析

C.凝血酶原时间和活化的部分凝血活酶时间

D.von Willebrand因子抗原

正确答案

B. JAK2 V617F分析

教育目标

诊断原发性血小板增多症。

批判

JAK2 V617F的变异分析应该进行。该患者表现为缺铁性贫血和血小板增多症。血小板增多症通常与缺铁性贫血有关，特别是如果出血是贫血的原因。但是，当通过口服铁剂和口服避孕药纠正患者的贫血以更好地调节月经时，血小板增多症持续存在，提示血小板调节紊乱。铁缺乏症是反应性血小板增多的最常见原因，可在纠正铁缺乏症后数周内纠正。感染，炎症和恶性肿瘤是其他原因。由于排除了铁缺乏症，并且没有其他任何临床上明显的原因，因此原发性血小板增多症（ET）的可能性更高。她缺乏脾肿大是很典型的。该JAK2 活化突变存在于50％的ET患者中，因此阴性结果不能排除诊断，但阳性结果支持对骨髓增生性肿瘤（真性红细胞增多症，ET或原发性骨髓纤维化）的诊断。

如果在校正具有JAK2突变状态的血清铁水平后血小板计数仍持续升高，则将进行BCR-ABL测试，然后进行骨髓穿刺和活检，因为除ET以外的骨髓增生性肿瘤通常不会增加血小板计数。在ET中，在骨髓检查中会发现普遍的细胞增生和巨核细胞增生。

测试凝血酶原和活化的部分凝血活酶时间不是最合适的选择，因为它将诊断重点放在出血的素质而不是血小板的生成上。同样，von Willebrand因子抗原检测不能解决患者持续升高的血小板计数。

重点

患有铁缺乏症且孤立的血小板增多症的患者在纠正铁缺乏症后仍然存在，应进行JAK2 V617F突变分析，作为评估原发性血小板增多症的一部分。

参考书目

Tefferi A.真性红细胞增多症和原发性血小板增多症：2013年有关诊断，风险分层和管理的最新信息。我是J Hematol。2013年6月; 88（6）：507-16。

你喜欢读《教育家年鉴》吗？直接将其接收到您的收件箱。立即注册“教育者年鉴”警报。

更新日期：2018-03-06

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