Annals of Internal Medicine ( IF 19.6 ) Pub Date : 2021-08-17 , DOI: 10.7326/awed202108170 Christine Laine
Clinical Practice Points
Association Between Mortality and Levels of Autonomous Cortisol Secretion by Adrenal Incidentalomas. A Cohort Study
Many patients with adrenal incidentalomas have biochemical signs of cortisol hypersecretion, which is associated with increased mortality. To advance understanding about which tumors should be considered for surgical removal, this observational study identified levels of secretion that are associated with increased mortality.
Use this article to:
Start your educational session with a MKSAP question. We provide one below!
Invite an endocrinologist to join your teaching session and review the various diagnostic procedures that can be helpful in determining the appropriate care for a patient with an adrenal incidentaloma.
Present 1 to 3 patients with adrenal incidentalomas, and discuss what the appropriate evaluation would be in each.
Effects of Tai Chi or Conventional Exercise on Central Obesity in Middle-Aged and Older Adults. A Three-Group Randomized Controlled Trial
This randomized, controlled, assessor-blinded trial sought to examine the therapeutic efficacy of tai chi versus conventional exercise for management of central obesity in adults aged 50 years or older.
Use this article to:
Ask your learners to discuss which weight loss interventions they have observed to be successful in the patients they have encountered.
If there is someone in your community who practices tai chi, invite them to lead a brief exercise session with your learners. If no such person is available, find one of the many free instructional videos online.
Discuss the relative value of body mass index and waist circumference in determining health risks in various patient groups.
The Evidence Behind Robot-Assisted Abdominopelvic Surgery. A Systematic Review
This systematic review assesses the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults.
Use this article to:
Ask your learners to describe the differences among open, laparoscopic, and robot-assisted surgery.
Invite a surgeon who does robotic surgery to join your session and describe performance of the same abdominopelvic procedure via laparoscopy versus with robotic assistance.
After reviewing the article, ask your learners whether they would opt for open, laparoscopic, or robot-assisted surgery if they needed a cholecystectomy. What if they needed a bowel resection for inflammatory bowel disease?
Clinical Guidelines
The Development of Living, Rapid Practice Points: Summary of Methods From the Scientific Medical Policy Committee of the American College of Physicians
Rapid and Living Guidance for COVID-19
In response to the COVID-19 pandemic, ACP's Scientific Medical Policy Committee began developing “practice points” to provide clinical advice based on the best available evidence. This article describes the methods for development and maintenance of living, rapid practice points to provide evidence-based responses to pressing clinical questions about COVID-19. The accompanying editorial discusses the challenges of developing high-quality, up-to-date, evidence-based recommendations and how rapid and living reviews and guidelines can help to translate research evidence into improved health outcomes.
Use this article and the accompanying editorial to:
Review the standards for trustworthy clinical guidelines discussed in this article and this article.
Ask your learners to discuss the pros and cons of guideline panels providing clinical recommendations in the absence of high-quality evidence to support them.
Review the ACP living practice points on remdesivir in the treatment of COVID-19 and subsequent updates for an example of how ACP implemented the process described in the article.
Discuss the challenges of developing guidelines on topics with rapidly emerging evidence.
Beyond the Guidelines
How Would You Manage This Male Patient With Hypogonadism? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
In 2020, ACP published a clinical guideline on whether to initiate testosterone treatment in men. In this article, a generalist and an endocrinologist debate the management of a patient with sexual symptoms and a low serum testosterone level.
Use this article to:
Watch the video of the patient interview and ask your learners whether they would prescribe testosterone to this patient.
Ask your learners to describe the potential adverse effects of testosterone supplementation in patients such as the one described in this article.
Discuss how testosterone should be prescribed if a decision were made to prescribe it.
Discuss what the indications for discontinuing therapy would be if testosterone were prescribed.
Low Back Pain
Low back pain is a leading cause of disability. Evaluation should focus on identification of factors indicating a serious underlying condition and increased risk for developing persistent disabling symptoms. When serious underlying conditions are not the cause, nonpharmacologic therapies, including exercise and psychological therapy, are preferred for most patients and may be supplemented with adjunctive drug therapies. Surgery and interventional procedures are options in a minority of patients who do not respond to noninvasive treatments.
Use this article to:
Ask whether any of your learners are willing to share their own experiences with low back pain. What brought it on? Did it limit their normal activities? What interventions alleviated the pain? How long did it last?
Ask your learners what factors would cause them to be concerned about serious underlying illness in a patient with acute low back pain.
Discuss the hierarchy of pharmacologic treatments that should be considered if nonpharmacologic interventions are not helpful.
Discuss when, if ever, prescription of opioids would be appropriate for treatment of low back pain.
Academia and the Profession
Medical Schools as Racialized Organizations: A Primer
In this article, the authors apply the theory of racialized organizations to medical schools and explore how organizational structures affect racial and ethnic minorities in their ability to succeed in medicine.
Use this article to:
Ask your learners to define structural racism.
Discuss what the authors mean by a racialized organization.
Ask your learners to identify policies or practices at your institution that might contribute to structural racism.
Brainstorm actions that individual physicians, trainees, and students can take to reduce structural racism.
MKSAP 18 Question
A 58-year-old woman is evaluated after the incidental discovery of an adrenal adenoma. A CT scan was performed last week to evaluate renal colic; findings were negative. The remainder of the medical history is unremarkable, and she takes no medication.
On physical examination, vital signs and the remainder of the examination are unremarkable.
Laboratory studies show normal serum electrolytes.
Evaluation for which of the following conditions is most appropriate in this patient?
A. Glucocorticoid and mineralocorticoid deficiency
B. Primary hyperaldosteronism and hyperandrogenism
C. Subclinical Cushing disease and pheochromocytoma
D. No additional testing is necessary
Correct Answer
C. Subclinical Cushing disease and pheochromocytoma
Critique
The patient should be evaluated for primary subclinical Cushing disease and pheochromocytoma. An adrenal incidentaloma is defined as an adrenal mass greater than 1 cm in diameter that is detected on imaging performed for reasons other than suspicion of adrenal disease. The prevalence of adrenal incidentaloma increases with age and is estimated to be approximately 10% in persons aged 70 years or older. Most lesions are benign, nonfunctioning adenomas, but approximately 10% to 15% secrete excess hormones. The finding of an incidental adrenal mass prompts two main questions: (1) Is it secreting excess hormone (aldosterone, cortisol, or catecholamines)? and (2) Is it benign or malignant? Biochemical testing for pheochromocytoma, such as a 24-hour urine total metanephrine measurement, should be undertaken in all patients with adrenal incidentaloma, even in the absence of typical symptoms or hypertension. Hypertension associated with pheochromocytoma/paraganglioma can show a sustained pattern, with or without paroxysms, or occur as paroxysms only. Some patients (10% to 15%) remain normotensive. The classic triad of palpitations, headache, and diaphoresis is seen in fewer than 50% of patients with pheochromocytoma. All patients with incidental adrenal mass should also be evaluated for subclinical Cushing syndrome, a condition characterized by adrenocorticotropic hormone–independent cortisol secretion that may cause metabolic (hyperglycemia and hypertension) and bone (osteoporosis) effects of hypercortisolism, but not the more specific clinical features of Cushing syndrome, such as supraclavicular fat pads, wide violaceous striae, facial plethora, and proximal muscle weakness.
Primary adrenal insufficiency is a life-threatening disorder that often presents with insidious onset of symptoms, making diagnosis a challenge. Potential symptoms of glucocorticoid and mineralocorticoid deficiency may include fatigue, weakness, low-grade fever, weight loss, anorexia, and hypotension. This patient has no symptoms to suggest adrenal insufficiency. Furthermore, while an adrenal adenoma may be nonfunctioning, it would not be associated with findings of adrenal insufficiency.
Primary aldosteronism is a common cause of secondary hypertension. Identification of patients with primary aldosteronism is important because aldosterone has deleterious effects on the cardiovascular system, and treatment prevents progression and can sometimes reverse changes. Screening for primary aldosteronism is unnecessary in the absence of hypertension. Androgen-producing adrenal tumors are rare and lead to menstrual irregularities and virilization in women, including hirsutism, voice-deepening, increased muscle mass, increased libido, and clitoromegaly. This patient has no findings to suggest androgen excess and screening for androgen-producing tumors is therefore not indicated.
Although this patient is asymptomatic, performing no further testing may result in a missed diagnosis of subclinical Cushing disease or pheochromocytoma and is therefore inappropriate.
Bibliography
Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016;175:G1-G34. doi:10.1530/EJE-16-0467
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中文翻译：
教育工作者年鉴 - 2021 年 8 月
临床实践要点
死亡率与肾上腺偶发瘤自主皮质醇分泌水平之间的关联。队列研究
许多肾上腺偶发瘤患者有皮质醇分泌过多的生化迹象，这与死亡率增加有关。为了进一步了解哪些肿瘤应该考虑手术切除，这项观察性研究确定了与死亡率增加相关的分泌水平。
使用这篇文章：
以 MKSAP 问题开始您的教育课程。我们提供以下之一！
邀请内分泌学家参加您的教学课程，并回顾各种诊断程序，这些程序有助于确定对肾上腺偶发瘤患者的适当护理。
介绍 1 至 3 名患有肾上腺偶发瘤的患者，并讨论对每个患者进行适当的评估。
太极拳或常规运动对中老年人中枢性肥胖的影响。三组随机对照试验
这项随机、对照、评估者盲法的试验旨在检验太极拳与传统运动在治疗 50 岁或以上成人向心性肥胖方面的疗效。
使用这篇文章：
请您的学习者讨论他们观察到的哪些减肥干预措施在他们遇到的患者中取得了成功。
如果您所在社区有人练习太极拳，请邀请他们与您的学习者进行简短的练习。如果没有这样的人，请在线查找众多免费教学视频之一。
讨论体重指数和腰围在确定不同患者群体健康风险方面的相对价值。
机器人辅助腹盆腔手术背后的证据。系统回顾
本系统评价评估了机器人辅助手术与成人腹腔镜手术和开放手术的证据质量和结果。
使用这篇文章：
让您的学习者描述开腹手术、腹腔镜手术和机器人辅助手术之间的区别。
邀请进行机器人手术的外科医生加入您的课程，并描述通过腹腔镜检查与机器人辅助相同的腹盆腔手术的表现。
阅读文章后，询问您的学习者，如果他们需要胆囊切除术，他们是否会选择开腹手术、腹腔镜手术或机器人辅助手术。如果他们因炎症性肠病需要进行肠切除术怎么办？
临床指南
生活、快速实践点的发展：来自美国内科医师学会科学医疗政策委员会的方法总结
COVID-19 快速生活指南
为应对 COVID-19 大流行，ACP 的科学医疗政策委员会开始制定“实践要点”，以根据最佳可用证据提供临床建议。本文描述了开发和维护活生生的快速实践点的方法，以对有关 COVID-19 的紧迫临床问题提供循证响应。随附的社论讨论了制定高质量、最新、循证建议的挑战，以及快速、实时的评论和指南如何帮助将研究证据转化为改善的健康结果。
使用本文和随附的社论来：
查看本文和本文中讨论的值得信赖的临床指南的标准。
请您的学习者讨论在缺乏高质量证据支持的情况下提供临床建议的指南小组的利弊。
查看瑞德西韦治疗 COVID-19 的 ACP 生活实践要点和后续更新，以举例说明 ACP 如何实施文章中描述的过程。
讨论在迅速出现证据的主题上制定指南的挑战。
超越指南
您将如何管理这名患有性腺功能减退症的男性患者？贝斯以色列女执事医疗中心的盛大讨论
2020 年，ACP 发布了关于是否开始男性睾酮治疗的临床指南。在这篇文章中，一位多面手和一位内分泌学家讨论了一名有性症状和血清睾酮水平低的患者的治疗方法。
使用这篇文章：
观看患者访谈的视频并询问您的学习者他们是否会给该患者开睾丸激素。
请您的学习者描述补充睾酮对患者的潜在不良影响，例如本文中描述的患者。
讨论如果决定开处方睾酮，应如何开处方。
讨论如果开出睾酮，停止治疗的指征是什么。
腰背疼痛
腰痛是导致残疾的主要原因。评估应侧重于识别表明存在严重潜在疾病和持续致残症状风险增加的因素。当严重的潜在疾病不是病因时，大多数患者首选非药物治疗，包括运动和心理治疗，并可能辅以辅助药物治疗。手术和介入手术是少数对无创治疗无反应的患者的选择。
使用这篇文章：
询问您的学习者是否愿意分享他们自己的腰痛经历。是什么引起的？这是否限制了他们的正常活动？哪些干预措施减轻了疼痛？它持续了多久？
询问您的学习者哪些因素会导致他们担心急性腰痛患者的严重潜在疾病。
讨论如果非药物干预无效时应考虑的药物治疗等级。
讨论何时，如果有的话，阿片类药物处方适合治疗腰痛。
学术界和专业
作为种族化组织的医学院：入门
在本文中，作者将种族化组织理论应用于医学院，并探讨组织结构如何影响种族和少数民族在医学上取得成功的能力。
使用这篇文章：
请您的学习者定义结构性种族主义。
讨论作者所说的种族化组织是什么意思。
请您的学习者确定您所在机构可能导致结构性种族主义的政策或做法。
集思广益，个别医生、受训人员和学生可以采取哪些行动来减少结构性种族主义。
MKSAP 18 问题
一名 58 岁女性在偶然发现肾上腺腺瘤后接受了评估。上周进行了 CT 扫描以评估肾绞痛；结果是否定的。其余病史无明显异常，她也未服用任何药物。
体格检查时，生命体征和其余检查均无异常。
实验室研究显示血清电解质正常。
评估以下哪种情况最适合该患者？
A. 糖皮质激素和盐皮质激素缺乏症
B. 原发性醛固酮增多症和雄激素过多症
C. 亚临床库欣病和嗜铬细胞瘤
D. 不需要额外的测试
正确答案
C. 亚临床库欣病和嗜铬细胞瘤
批判
应评估患者的原发性亚临床库欣病和嗜铬细胞瘤。肾上腺偶发瘤被定义为直径大于 1 cm 的肾上腺肿块，在影像学检查中发现的不是由于怀疑肾上腺疾病的原因。肾上腺偶发瘤的患病率随着年龄的增长而增加，估计在 70 岁或以上的人群中约为 10%。大多数病变是良性的、无功能的腺瘤，但大约 10% 至 15% 会分泌过量的激素。偶然发现肾上腺肿块会引发两个主要问题：(1) 是否分泌过多的激素（醛固酮、皮质醇或儿茶酚胺）？(2) 是良性还是恶性？所有肾上腺偶发瘤患者都应进行嗜铬细胞瘤的生化检测，例如 24 小时尿总变肾上腺素检测，即使没有典型症状或高血压。与嗜铬细胞瘤/副神经节瘤相关的高血压可以显示出持续的模式，有或没有阵发性，或仅作为阵发性发生。一些患者（10% 至 15%）保持正常血压。不到 50% 的嗜铬细胞瘤患者会出现典型的心悸、头痛和出汗三联征。所有偶发肾上腺肿块的患者还应评估亚临床库欣综合征，这种情况的特征是不依赖促肾上腺皮质激素的皮质醇分泌，可能导致皮质醇增多症的代谢（高血糖和高血压）和骨骼（骨质疏松症）影响，但不是更具体的临床特征库欣综合征，如锁骨上脂肪垫、宽紫罗兰纹、面部过多和近端肌肉无力。
原发性肾上腺皮质功能减退症是一种危及生命的疾病，通常表现为隐匿的症状，使诊断成为一项挑战。糖皮质激素和盐皮质激素缺乏的潜在症状可能包括疲劳、虚弱、低烧、体重减轻、厌食和低血压。该患者没有提示肾上腺功能不全的症状。此外，虽然肾上腺腺瘤可能无功能，但它不会与肾上腺功能不全的发现相关联。
原发性醛固酮增多症是继发性高血压的常见原因。识别原发性醛固酮增多症患者很重要，因为醛固酮对心血管系统有有害影响，治疗可以防止进展，有时可以逆转变化。在没有高血压的情况下，没有必要筛查原发性醛固酮增多症。产生雄激素的肾上腺肿瘤很少见，会导致女性月经不调和男性化，包括多毛症、声音变深、肌肉量增加、性欲增加和阴蒂肥大。该患者没有发现表明雄激素过多，因此不需要筛查产生雄激素的肿瘤。
尽管该患者无症状，但不进行进一步检查可能会导致漏诊亚临床库欣病或嗜铬细胞瘤，因此是不合适的。
参考书目
Fassnacht M、Arlt W、Bancos I 等。肾上腺偶发瘤的管理：欧洲内分泌学会临床实践指南与欧洲肾上腺肿瘤研究网络合作。Eur J 内分泌学。2016 年；175：G1-G34。doi:10.1530/EJE-16-0467
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