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Annals for Educators - 20 March 2018
Annals of Internal Medicine ( IF 19.6 ) Pub Date : 2018-03-20 , DOI: 10.7326/afed201803200
Darren B. Taichman

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Clinical Practice Points

Hydroxychloroquine Effectiveness in Reducing Symptoms of Hand Osteoarthritis. A Randomized Trial

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Osteoarthritis is a common form of arthritis, affecting up to 31% of adults older than 70 years. Effective treatment options are limited and are often associated with adverse effects. This double-blind, placebo-controlled trial examined the efficacy of hydroxychloroquine, a well-established therapy for rheumatoid arthritis, for treatment of osteoarthritis of the hand.
Use this study to:
  • Start a teaching session with a multiple-choice question. We've provided one below!

  • Ask your learners what the clinical characteristics of hand osteoarthritis are. How should they be evaluated? What is the differential diagnosis? Use the information in In the Clinic: Osteoarthritis to help prepare for teaching.

  • What are the risk factors for osteoarthritis?

  • How do your learners treat patients with hand osteoarthritis? Do they use anti-inflammatory drugs? Which ones? Do they work?

  • Do the results of this randomized trial indicate that inflammation is not important in the pathophysiology of hand osteoarthritis? Why or why not? Use the accompanying editorial to help frame your discussion.

  • What are the potential causes of a “negative” trial? What factors need to be considered when evaluating whether negative findings indicate that a therapeutic approach should not be pursued?

Antithyroid Drugs and Congenital Malformations. A Nationwide Korean Cohort Study

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Using a national database of nearly 3 million completed pregnancies, the authors analyzed the risk for congenital malformations associated with different antithyroid drugs used to treat Graves disease during the first trimester.
Use this study to:
  • Start a teaching session with a multiple-choice question. We've provided one below!

  • Ask your learners whether they always review the drugs of pregnant patients to assess whether any are potentially teratogenic. Where do they look?

  • Do your learners know the FDA pregnancy categories? What do they mean? Which categories of drugs do they feel comfortable prescribing to pregnant patients? When should they consult an obstetrician?

  • How do your learners assess whether a drug is safe when a mother is breastfeeding?

  • Ask your learners how hyperthyroidism should be treated during pregnancy.

Clinical Guideline

Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update

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This synopsis of the updated Kidney Disease: Improving Global Outcomes guideline, published in 2017, focuses on recommendations for diagnosis and testing for chronic kidney disease–mineral and bone disorder in adults with chronic kidney disease (CKD) and those receiving long-term dialysis. Recommendations address management of phosphate levels, calcium levels, and secondary hyperparathyroidism.
Use this guideline to:
  • Ask your learners how CKD is classified. Use the figure in the paper's appendix to review.

  • What mineral and bone disorders are of particular concern among patients with CKD? Who is at risk?

  • Which patients with CKD should undergo dual-energy x-ray absorptiometry (DXA) testing?

  • How should serum phosphate and calcium levels be managed? When and how should phosphate levels be lowered?

  • What dietary recommendations should your learners make to their patients with CKD?

  • When and why should parathyroid hormone levels be measured?

  • How should osteoporosis be treated in patients with CKD?

  • Invite a nephrologist to join your discussion.

Humanism and Professionalism

On Being a Patient: Lessons From a Year With Breast Cancer: An Academic Physician's Perspective

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Dr. Trautner reflects on the lessons learned since being diagnosed with breast cancer, observing that she knew them before but has put them more fully into practice since her diagnosis.
Use this essay to:
  • Listen to an audio recording, read by Dr. Virginia Hood.

  • Ask your learners whether the 3 lessons Dr. Trautner describes are “new.” If not, why do we seem to need constant reminders to practice them?

  • Ask a patient (or a few) whether they would be willing or even would enjoy talking with your team about the lessons they have learned since they became ill. Then, ask your patient to tell your team about these lessons during teaching rounds.

  • What did you learn? Can your learners draw inspiration from asking their patients about such lessons? Should we do so regularly? How might such questions be helpful to our patients?

Opportunities for Educators

Clinical Skills Proposals Wanted for Internal Medicine 2020

Interested in teaching procedural, physical examination, or communication skills?
The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2020, which will be held in Los Angeles, California, on April 23-25, 2020. To submit a proposal, please complete the Clinical Skills Proposal. The deadline to submit proposals is April 27, 2018.

MKSAP 17 Question 1

A 50-year-old woman is evaluated for slowly worsening joint pain in her fingers for the past 5 years. She notes swelling, morning stiffness lasting 10 minutes, and pain that is worse after housework or typing. She has no other joint pain and otherwise feels well. She reports no fevers, weight loss, rashes, alopecia, oral ulcers, dyspnea, chest pain, or abdominal pain. The patient takes no medications.
On physical examination, vital signs are normal. There is squaring, crepitus, and tenderness of the first carpometacarpal joints. Bony enlargement and tenderness over all distal interphalangeal (DIP) joints are present. Limited range of motion of the thumbs and DIP joints is noted. There is no joint warmth, redness, or effusions. The remainder of the joint examination is normal.
Which of the following is the most appropriate next step in management?
A. Anti–double-stranded DNA antibody testing
B. Antinuclear antibody testing
C. Radiography of the hands
D. Rheumatoid factor testing
E. No further testing
Correct Answer
E. No further testing
Educational Objective
Clinically diagnose osteoarthritis of the hands.
Critique
No further testing is necessary for this patient who clinically appears to have hand osteoarthritis. Osteoarthritis is a clinical diagnosis, and the cardinal symptom is pain with activity that is relieved with rest. Affected patients also typically experience morning stiffness that lasts for less than 30 minutes daily. Bony hypertrophy is commonly detected in the fingers, and Heberden and Bouchard nodes may be easily palpated. Osteoarthritis also may cause squaring or boxing of the carpometacarpal joint at the base of the thumb.
This patient has no clinical signs or symptoms suggestive of a systemic inflammatory disease and therefore does not require diagnostic testing with antinuclear antibodies (ANA) or anti–double-stranded DNA antibodies. A positive ANA test result has low predictive value when the pretest probability of systemic lupus erythematosus or a related disease is low. Therefore, this test should not be used to screen indiscriminately for the presence of rheumatologic disease. The American College of Rheumatology recommends not testing ANA subserologies such as anti–double-stranded DNA without the combination of a positive ANA and elevated clinical suspicion of autoimmune disease, which is not present in this patient.
Radiography is not needed to confirm the diagnosis of osteoarthritis in patients with a history and physical examination compatible with this condition. Clinical examination is more sensitive and specific for the diagnosis of hand osteoarthritis compared with radiography.
The key features of rheumatoid arthritis (RA) are swelling and tenderness in and around the joints. Prominent morning stiffness that usually lasts more than 1 hour characterizes early RA. Rheumatoid factor positivity is characteristic of RA, although rheumatoid factor has a low specificity for diagnosis of RA. Rheumatoid factor may be present in healthy persons, especially at older ages. Because this patient has no clinical evidence of RA, testing for rheumatoid factor is unnecessary.
Key Point
Additional testing such as autoantibody measurements or radiography is unnecessary in patients with clinically diagnosed hand osteoarthritis.
Bibliography
Hunter DJ. In the clinic. Osteoarthritis. Ann Intern Med. 2007 Aug 7;147(3):ITC8-1-16.

MKSAP 17 Question 2

A 32-year-old woman is evaluated during a follow-up visit. She indicates that she and her husband are contemplating pregnancy, and she discontinued her oral contraceptive 2 months ago. Medical history is significant for hypertension, type 2 diabetes mellitus, and severe depression, which is currently in remission. Medications are lisinopril, metformin, atorvastatin, and sertraline. She does not smoke or use alcohol or illicit drugs. A normal Pap smear was obtained 1 year ago, no high-risk behaviors are identified, and her vaccinations are up to date.
On physical examination, blood pressure is 114/70 mm Hg. BMI is 24. The remainder of the examination is unremarkable.
A urine pregnancy test is negative.
Her lisinopril is discontinued, and she is started on a prenatal vitamin with folate.
Which of the following medications also needs to be discontinued?
A. Atorvastatin
B. Metformin
C. Sertraline
D. No additional changes needed
Correct Answer
A. Atorvastatin
Educational Objective
Adjust medications in a woman who may become pregnant.
Critique
Discontinuation of atorvastatin is indicated in this patient who is planning pregnancy. Statin medications should be avoided in pregnancy due to the potential risk for congenital abnormalities. In patients actively planning pregnancy, dyslipidemia is best managed with diet and lifestyle modification for the duration of the pregnancy. Because the effects of statin use during breastfeeding are not known, their use during nursing should be discouraged.
ACE inhibitors and angiotensin receptor blockers are also contraindicated due to potential risk of teratogenicity and should be discontinued in women who are planning pregnancy, as was done in this patient. Her hypertension should be followed and treated, if needed, with another agent known to be safe in pregnancy, such as β-blockers, calcium channel blockers, or methyldopa.
Oral antidiabetic agents should be continued in women contemplating pregnancy to maintain control of diabetes mellitus. Metformin is an FDA pregnancy category B medication (no definitive studies in pregnant women but no animal studies showing risk to the fetus) and is a reasonable option for controlling this patient's hyperglycemia before pregnancy. Evidence suggests that metformin and sulfonylureas are acceptable during pregnancy; however, further management decisions are best made through co-management of medical and obstetric issues with a high-risk obstetrician.
In the treatment of depression, medication discontinuation may not be appropriate in women with a history of major or recurrent depression. Some selective serotonin reuptake inhibitors (SSRIs), including sertraline and fluoxetine, are FDA pregnancy category C (no definitive studies in pregnant women but evidence of potential harm in animal reproduction studies, although potential benefits may warrant use despite potential risks), and their use must be determined on an individual basis. Such agents may be continued if needed, but the risks and benefits of treatment, taking into account severity of depressive symptoms, stage of gestation, and associated circumstances, should be evaluated by a psychiatrist or high-risk obstetrician. SSRIs should not be stopped precipitously.
Because this patient is on a known medication classified as FDA pregnancy category X (atorvastatin), continued treatment with this agent would be inappropriate.
Key Point
Statins, ACE inhibitors, and angiotensin receptor blockers are teratogenic and should be discontinued in women planning pregnancy.
Bibliography
Callegari LS, Ma EW, Schwarz EB. Preconception care and reproductive planning in primary care. Med Clin North Am. 2015 May;99(3):663-82.
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中文翻译:

教育家年鉴-2018年3月20日

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临床实践要点

羟氯喹对减轻手部骨关节炎症状的有效性。随机试验

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骨关节炎是关节炎的一种常见形式,可影响多达31%的70岁以上的成年人。有效的治疗选择是有限的,并且通常与不良反应有关。这项双盲,安慰剂对照试验研究了羟氯喹(一种成熟的类风湿关节炎疗法)治疗手部骨关节炎的功效。
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!

  • 问您的学习者手部骨关节炎的临床特征是什么。应该如何评估它们?什么是鉴别诊断?使用“诊所:骨关节炎”中的信息来帮助准备教学。

  • 骨关节炎的危险因素有哪些?

  • 您的学习者如何治疗手部骨关节炎患者?他们使用抗炎药吗?哪个?做他们的工作?

  • 这项随机试验的结果是否表明炎症在手部骨关节炎的病理生理中并不重要?为什么或者为什么不?使用随附的社论来帮助您进行讨论。

  • “阴性”审判的潜在原因是什么?在评估阴性结果是否表明不应该采用治疗方法时,需要考虑哪些因素?

抗甲状腺药物和先天性畸形。全国韩国队列研究

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作者使用了将近300万次完整妊娠的国家数据库,分析了妊娠早期三个月中与用于治疗Graves疾病的不同抗甲状腺药物相关的先天性畸形的风险。
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,他们是否总是检查孕妇的药物以评估是否有潜在的致畸性。他们在哪里看?

  • 您的学习者知道FDA怀孕类别吗?他们的意思是什么?他们对怀孕的患者开哪种药感到舒服?他们什么时候应该咨询产科医生?

  • 当母亲母乳喂养时,您的学习者如何评估药物是否安全?

  • 询问您的学习者在怀孕期间应如何治疗甲状腺功能亢进症。

临床指南

慢性肾脏病-矿物质和骨疾病的诊断,评估,预防和治疗:肾脏疾病的提要:改善全球疗效2017临床实践指南更新

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2017年发布的最新版《肾脏疾病:改善全球结局指南》的内容提要着重于慢性肾脏病(CKD)成人和接受长期透析的成年人的慢性肾脏疾病-矿物质和骨骼疾病的诊断和测试建议。建议涉及磷酸盐水平,钙水平和继发性甲状旁腺功能亢进的管理。
使用此准则可以:
  • 询问您的学习者CKD如何分类。使用本文附录中的图进行检查。

  • CKD患者应特别关注哪些矿物质和骨骼疾病?谁有危险?

  • 哪些CKD患者应接受双能X射线吸收测定(DXA)测试?

  • 应如何管理血清磷酸盐和钙水平?何时以及如何降低磷酸盐水平?

  • 您的学习者应该为CKD患者提供哪些饮食建议?

  • 什么时候以及为什么应该测量甲状旁腺激素水平?

  • CKD患者应如何治疗骨质疏松症?

  • 邀请肾科医生参加您的讨论。

人文主义和专业精神

关于成为患者:一年乳腺癌的经验教训:学术医师的观点

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Trautner博士回顾了自被诊断出患有乳腺癌以来所汲取的经验教训,观察到她以前已经知道这些经验,但自诊断以来已将其更充分地付诸实践。
通过这篇文章可以:
  • 收听录音,由弗吉尼亚·胡德博士(Virginia Hood)朗读。

  • 询问您的学习者Trautner博士描述的3课是否是“新的”。如果没有,为什么我们似乎需要不断的提醒来练习它们?

  • 询问患者(或几位患者),他们是否愿意,甚至乐于与您的团队讨论自患病以来所学到的经验教训。然后,请您的患者在教学轮次中告诉您的团队有关这些课程的信息。

  • 你学到了什么?您的学习者可以从向患者询问此类课程中汲取灵感吗?我们应该定期这样做吗?这样的问题如何对我们的患者有帮助?

教育者的机会

2020年内科药物临床技能建议书

对教学程序,身体检查或沟通技巧感兴趣吗?
ACP正在接受有关动手,交互式研讨会的提案,这些研讨会的重点是获得或提高2020年内科医学的程序技能,身体检查技能和沟通能力,该活动将于4月23日至25日在加利福尼亚州洛杉矶举行,2020年。要提交建议,请完成临床技能建议。提交提案的截止日期为2018年4月27日。

MKSAP 17问题1

在过去的5年中,对一名50岁的女性的手指关节疼痛进行了逐步加重评估。她注意到肿胀,早晨僵硬持续10分钟,做家务或打字后疼痛更重。她没有其他关节疼痛,否则感觉良好。她没有发烧,体重减轻,皮疹,脱发,口腔溃疡,呼吸困难,胸痛或腹痛。病人不服药。
经身体检查,生命体征正常。第一掌掌关节有方形,松脱和压痛。存在所有远端指间(DIP)关节的骨增大和压痛。注意到拇指和DIP关节的活动范围有限。没有关节发热,发红或积水。其余的联合检查是正常的。
以下哪项是管理中最合适的下一步?
A.抗双链DNA抗体检测
B.抗核抗体检测
C.手部放射照相
D.类风湿因子测试
E.无需进一步测试
正确答案
E.无需进一步测试
教育目标
临床诊断为手骨关节炎。
批判
对于该临床上看来患有手部骨关节炎的患者,无需进行进一步的检查。骨关节炎是临床诊断,主要症状是疼痛,活动可缓解。受影响的患者通常还会经历早晨僵硬,每天持续不到30分钟。骨骼肥大通常在手指中检测到,Heberden和Bouchard结节很容易触诊。骨关节炎也可能会导致拇指掌骨的腕掌骨出现方眼或方眼。
该患者没有提示全身性炎性疾病的临床体征或症状,因此不需要使用抗核抗体(ANA)或抗双链DNA抗体进行诊断测试。当系统性红斑狼疮或相关疾病的预检概率较低时,ANA检测结果阳性的预测值较低。因此,该测试不应被用来无差别地筛查风湿病的存在。美国风湿病学院建议不要在没有阳性ANA和临床上怀疑自身免疫性疾病相结合的情况下测试ANA亚型,例如抗双链DNA,这在该患者中是不存在的。
病史和体格检查均与这种情况相符的患者无需进行放射线照相以确认骨关节炎的诊断。与放射线照相相比,临床检查对手部骨关节炎的诊断更加敏感和特异。
类风湿关节炎(RA)的主要特征是关节内和周围的肿胀和压痛。通常持续超过1小时的突出的早晨僵硬是早期RA的特征。类风湿因子阳性是RA的特征,尽管类风湿因子对RA的诊断特异性较低。类风湿因子可能存在于健康人中,尤其是在老年人中。由于该患者没有RA的临床证据,因此无需测试类风湿因子。
重点
在临床诊断为手部骨关节炎的患者中,无需进行其他检查,例如自身抗体测量或X线摄影。
参考书目
猎人DJ。在诊所。骨关节炎。安实习生。2007年8月7日; 147(3):ITC8-1-16。

MKSAP 17问题2

在随访期间对一名32岁的女性进行了评估。她表示她和她的丈夫正在考虑怀孕,并且在两个月前停止口服避孕药。病史对于高血压,2型糖尿病和目前正在缓解的严重抑郁症具有重要意义。药物为赖诺普利,二甲双胍,阿托伐他汀和舍曲林。她不抽烟或使用酒精或违禁药物。1年前获得了正常的子宫颈抹片检查,未发现高危行为,并且她的疫苗接种是最新的。
经身体检查,血压为114/70 mm Hg。身体质量指数(BMI)为24。其余的检查无异常。
尿液妊娠试验为阴性。
她的赖诺普利停药了,她开始使用含叶酸的产前维生素。
下列哪些药物也需要停药?
A.阿托伐他汀
B.二甲双胍
舍曲林
D.无需其他更改
正确答案
A.阿托伐他汀
教育目标
调整可能怀孕的女性的药物。
批判
计划怀孕的患者应停用阿托伐他汀。由于先天性异常的潜在风险,应在妊娠期避免使用他汀类药物。在积极计划怀孕的患者中,血脂异常最好在妊娠期间通过饮食和生活方式的改变得到控制。由于母乳喂养期间他汀类药物的使用效果尚不清楚,因此不建议在哺乳期使用他汀类药物。
ACE抑制剂和血管紧张素受体阻滞剂也有禁忌症,因为有致畸性的潜在风险,因此,与该患者一样,计划怀孕的妇女应停用ACE抑制剂和血管紧张素受体阻滞剂。应当跟踪她的高血压,并在需要时用已知在妊娠中安全的另一种药物治疗,例如β受体阻滞剂,钙通道阻滞剂或甲基多巴。
打算怀孕的妇女应继续口服降糖药,以控制糖尿病。二甲双胍是FDA怀孕的B类药物(对孕妇没有确定的研究,但没有对胎儿有风险的动物研究),并且是控制该患者妊娠前高血糖的合理选择。有证据表明二甲双胍和磺脲类药物在怀孕期间是可以接受的。但是,最好与高风险的产科医生共同管理医疗和产科问题,以做出进一步的管理决策。
在抑郁症的治疗中,停药对于患有重度或复发性抑郁史的女性可能不适合。一些选择性的5-羟色胺再摄取抑制剂,包括舍曲林和氟西汀,是FDA怀孕的C类药物(在孕妇中没有确定的研究,但在动物生殖研究中有潜在危害的证据,尽管尽管有潜在风险也可能需要使用其潜在的益处),以及它们的使用必须根据个人情况确定。如果需要,可以继续使用此类药物,但应考虑由抑郁症状的严重程度,妊娠阶段和相关情况引起的治疗风险和益处,应由精神科医生或高危产科医生评估。不应该立即停止SSRI。
由于该患者正在使用已知分类为FDA妊娠X类药物(阿托伐他汀)的药物,因此继续用该药物治疗是不合适的。
重点
他汀类药物,ACEI抑制剂和血管紧张素受体阻滞剂具有致畸性,在计划怀孕的妇女中应停用。
参考书目
Callegari LS,Ma EW,Schwarz EB。初级保健中的孕前保健和生殖计划。Med Clin North Am。2015年5月; 99(3):663-82。
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更新日期:2018-03-20
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