Annals of Internal Medicine ( IF 19.6 ) 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
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
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
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
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
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?
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
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) |
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
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
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
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
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
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?
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
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) |