Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information.
In the largest and longest study of its kind published to date, more than 300 patients were followed for one year Chronic or recurrent back pain cost the U.S. health care system billions of dollars each year, and is one of the most common reasons people visit their doctor. Researchers conducted a trial to determine whether offering a 12-week yoga program to adults with chronic or recurrent low back pain could improve back function better than usual care (back pain education booklet and continuation of treatments patients were already receiving). More than 300 participants were randomly assigned to either a 12-session, 3-month yoga program (n = 156) or usual care (n = 157). Patients reported back function at 3, 6, and 12 months by filling out the Roland Morris Disability Questionnaire (RMDQ) that rated symptoms such as function and pain on a scale of 0 (best) to 24 (worst). The yoga group reported better back function but similar back pain and general health scores throughout the trial. Improvements in back function were most pronounced at 3 months, immediately after the intervention, but confidence in performing normal activities despite pain improved more in the yoga group than in the usual care group at 3 and 6 months. Eight participants reported adverse events, such as increased pain, that were may have been related to yoga. The researchers conclude that yoga may be a safe and effective treatment for patients with chronic low back pain.
Venous thromboembolism (VTE), comprised of pulmonary embolism (PE) and deep venous thrombosis (DVT), is a serious, common clinical problem. Because most hospitalized patients have at least one VTE risk factor, many hospitals routinely give patients blood thinners. However, these medications increase the risk of bleeding. In a new clinical practice guideline, the American College of Physicians (ACP) recommends that doctors assess the risk of thromboembolism and bleeding in patients hospitalized for medical illnesses, including stroke, before initiating therapy to prevent VTE. If a patient is at risk for VTE, ACP recommends that physicians prescribe heparin or related blood thinners, unless the assessed risk of bleeding outweighs likely benefits. Prevention with heparin is associated with a statistically significant reduction in PE events. In most cases, the clinical benefit of reducing PE events will outweigh the harm of increased risk of bleeding events, the guideline states. No differences in benefits or harms were found between the types of heparin used. If a patient is at risk for VTE and bleeding from blood thinners, ACP does not recommend using graduated compression stockings. The evidence showed that they were not effective in preventing VTE or reducing death, and resulted in clinically important lower extremity skin damage. ACPís recommendations do not apply to patients hospitalized for surgery.
Implanted cardiac rhythm devices (ICRDs) use small bursts of electricity to regulate a patientís heart beat. Some electronic devices, like the metal detectors used for security screening at airports, create magnetic fields that could interfere with the function of ICRDs. Researchers sought to determine if hand-held metal detectors used in airports could cause ICRDs to malfunction. The investigators scanned 388 patients (209 with pacemakers and 179 with ICDs) presenting for routine follow-up using two of the most common types of hand-held metal detectors. After researchers documented initial ICRD settings, patients were scanned over the chest area while lying supine. Devices were monitored continuously using ECG. The researchers observed no device malfunction during or after exposure to this screening. They conclude that use of common hand-held metal detectors in security screening of patients with pacemakers and cardioverter-defibrillators is probably safe, but caution that the findings require confirmation with a broader array of devices in real-world security screening settings.
Patients with advanced cancer struggle with emotional distress. Oncologists often miss opportunities to empathize with patients, and may instead exhibit behaviors that block feelings and create emotional distance. Oncologists can take courses teaching them how to respond appropriately to emotions, but these courses are expensive and take time to complete. Researchers tested whether a brief, computerized intervention could improve oncologist responses to patient expressions of negative emotions. Forty-eight oncologists were enrolled in the study. Researchers first audio recorded clinic visits between the oncologists and their patients with advanced cancer to serve as examples of communication behaviors. These examples were used to create an intervention CD-ROM tailored to the individual physicianís needs. The oncologist were then randomly assigned to either a standard lecture or a lecture and the intervention CD-ROM. After physicians heard the lecture, or heard the lecture and reviewed the CD-ROM, their visits with another set of patients were recorded. One week later, patients were surveyed about their trust in their oncologist and the quality of communication. The patients reported that oncologists in the lecture plus CD-ROM group demonstrated a two-fold increase in empathic statements used at the appropriate time. After one month, patients reported that physicians were still using more empathetic statements and were more likely to respond appropriately to patientsí negative comments. This degree of behavior change among physicians is similar to that seen in intensive multiday courses that use small-group teaching.