Effectiveness of Nonpharmacologic Treatments for Chronic Low Back Pain: A Sequential, Multiple-Assignment, Randomized Trial: Annals of Internal Medicine: Vol 179, No 6

Background: Many treatments are recommended for chronic low back pain (cLBP), but comparative effectiveness and adaptive interventions have not been adequately studied. Objective: To compare the effectiveness of physical therapy (PT) and cognitive behavioral therapy (CBT) as first-stage treatment and switching treatments versus mindfulness as second-stage treatment. Design: Multisite sequential, multiple-assignment, randomized trial with 52-week follow-up. (ClinicalTrials.gov: NCT03859713) Setting: Three health care systems. Participants: Adults with cLBP. Intervention: Eight weeks of PT or CBT in stage I. Nonresponders were randomly assigned again to 8 weeks of stage II treatment. Measurements: Co-primary outcomes were function measured with the Oswestry Disability Index (ODI; range, 0 to 100) and pain intensity (range, 0 to 10) at 10 (stage I), 26, and 52 (stage II) weeks. Results: The sample comprised 749 participants. After 10 weeks, there was greater improvement in function in the PT group (adjusted mean ODI difference, 2.8 [96% CI, 0.38 to 5.1]) and no difference in pain intensity (adjusted mean difference, 0.32 [99% CI, −0.07 to 0.71]). The mean difference in ODI was below the minimum important difference of 6. After 52 weeks, there were no differences in stage II treatments for nonresponders for either function (adjusted mean ODI difference, 0.43 [96% CI, −0.29 to 2.4]) or pain intensity (adjusted mean difference, −0.05 [96% CI, −0.58 to 0.48]). Limitations: Treatment initiation was lower than expected, particularly for CBT and for nonresponders. Participants were not blinded. Sample size was reduced due to the COVID-19 pandemic. Conclusion: Patients with cLBP may benefit from PT as first-line treatment. Among nonresponders, there were no differences in second-stage treatment with mindfulness or switching. Primary Funding Source: Patient-Centered Outcomes Research Institute (PCORI).

Annals Guide to Journal Club - Medication-Induced Weight Change Across Common Antidepressant Treatments

Improving the Health of and Access to Health Care for People With Disabilities: A Position Paper From the American College of Physicians

In the United States, people with disabilities experience disparities in health and health care. Disparities stem from inadequate insurance coverage, physically and culturally inaccessible health care facilities, pervasive harmful misconceptions about disability, and incomprehensive epidemiologic data regarding disability. In this position paper, the American College of Physicians offers recommendations to alleviate health disparities among people with disabilities through policy changes in areas such as health insurance coverage, accessibility of health care facilities, health professional education, research participation, and data collection.

Fostering Support and Inclusion for Physicians, Postgraduate Trainees, and Medical Students With Disabilities: A Position Paper From the American College of Physicians

Over the past several decades, federal laws have instituted sweeping antidiscrimination protections to foster inclusion for people with disabilities in education and employment, but substantial barriers remain to full and meaningful inclusion in the practice of medicine. In this position paper, the American College of Physicians (ACP) highlights the barriers to entering medicine and offers policy recommendations to improve the accessibility of medical schools, training programs, and the practice of medicine. ACP affirms that a diverse physician workforce, inclusive of disability, is a key component of reducing disparities in health and health care.

Behind the Seen: Searching for Peace in a House With Violence

Iron Deficiency Anemia

Iron deficiency anemia (IDA) is caused by iron deficiency, a common yet underrecognized clinical entity. Populations at greatest risk include children, menstruating and pregnant persons, and people of low socioeconomic status. Timely diagnosis and management of iron deficiency are key to preventing IDA and require thorough assessment of the underlying cause and appropriate iron repletion through either oral or parenteral therapy. Blood transfusion does not provide adequate elemental iron but is sometimes indicated along with iron therapy in patients with cardiovascular compromise, active bleeding, or severe anemia where more rapid correction is warranted. Alternative causes of anemia can be differentiated by red blood cell morphology and reticulocyte count and should be considered if anemia persists despite adequate repletion of iron stores.

Annals for Educators - October 2025

Proximal Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in the OSPREY Study: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 179, No 6

Background: Hypoglossal nerve stimulation (HGNS) is used to treat obstructive sleep apnea (OSA); however, evidence is limited for patients who cannot tolerate positive airway pressure therapy. Proximal HGNS (pHGNS) provides multicontact stimulation of proximal nerve portions, with easier electrode implantation than distal nerve stimulation. Objective: To evaluate the efficacy and safety of pHGNS in patients with moderate-to-severe OSA. Design: 7-month randomized controlled trial followed by a 6-month open-label extension. (ClinicalTrials.gov: NCT04950894) Setting: 23 U.S. health centers. Patients: Adults aged 22 years or older with moderate-to-severe OSA. Intervention: All patients underwent implantation with pHGNS at baseline and were randomly assigned in a 2:1 ratio to treatment or control. Therapy began at month 1 (treatment) or month 7 (control). Measurements: Assessments included the proportion of patients achieving greater than 50% improvement from baseline in the apnea–hypopnea index (AHI) and AHI below 20 events/h at month 7 (primary end point), improvements in oxygen desaturation index (ODI) and patient-reported outcomes (for example, Epworth Sleepiness Scale [ESS]), and safety. Results: The 104 randomly assigned patients had a mean age of 55.6 years (SD, 9.0), body mass index of 30.6 kg/m2 (SD, 3.0), a preimplantation AHI of 35.7 events/h (SD, 12.8), and a preimplantation ODI of 36.7 events/h (SD, 13.4). At month 7, 58.2% (95% CI, 45.5% to 70.2%) of patients assigned to treatment (n = 67) versus 13.5% (CI, 4.5% to 28.8%) assigned to control (n = 37) achieved the primary end point, and ODI was reduced by at least 25% in 68.7% (CI, 56.2% to 79.4%) versus 37.8% (CI, 22.5% to 55.2%) of patients, respectively. Median ESS score improved from baseline to month 7 in the treatment group (10.0 [IQR, 7.0 to 14.0] to 6.0 [IQR, 5.0 to 9.0]) but not in the control group (9.0 [IQR, 7.0 to 11.0] to 9.0 [IQR, 6.0 to 11.0]). No serious procedure-related adverse events were reported. Limitations: Lack of blinding, small sample size, and short follow-up. Conclusion: pHGNS for OSA yielded clinically significant responses versus control at month 7, supporting pHGNS as a therapeutic option for OSA. Primary Funding Source: LivaNova PLC.

Frailty

Frailty is a syndrome of decreased reserve across multiple physiologic systems that is associated with greater risk for hospitalizations, disability, institutionalization, and other adverse outcomes, including mortality. Patients with frailty, most of whom are older adults, may be more likely to experience adverse outcomes due to iatrogenic causes, such as higher-risk medications or procedures. Guidelines recommend frailty screening for both chronic disease management and in-hospital care, as identification of frailty allows for risk mitigation and alignment of care with patients’ goals. In addition, some interventions may delay or reverse frailty, thus increasing physiologic reserve and improving day-to-day function. This article reviews frailty definitions, approaches to assessment in different care settings, and management.

New GRADE Evidence-to-Decision Framework for Pairwise and Multiple Comparisons (GRADE Guidance 45)

Evidence-based decision making in health often requires comparison of multiple options for a given condition. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision (EtD) framework provides a structured approach for moving from evidence to decisions but was originally designed for pairwise comparisons. Hence, there is a need to accommodate decision making based on multiple comparisons, especially with the increasing use of systematic reviews and network meta-analyses in guideline development. Furthermore, since the original EtD framework was developed, further relevant GRADE guidance has been developed. The aim of this work was to develop a new EtD framework to accommodate multiple comparisons and reflect current GRADE guidance. The new EtD framework was revised and developed through iterative discussion, feedback, and refinement by the GRADE EtD Project Group and the GRADE Working Group. Experiences and examples from guideline developers, methodological experts, and other stakeholders informed improvements in its structure and usability for multiple comparisons and were subsequently approved by the GRADE Working Group. This article describes the new EtD framework, which now includes 2 corresponding parts for reviews of pairwise and multiple comparisons. The authors describe application to a review with multiple comparisons for the different parts of the EtD framework: the question definition, which now includes the presentation of values of health outcomes and decision thresholds; the assessment section, where the new “net effect” criterion has been included; and the conclusion section, which includes an adaptation for multiple comparisons. The article provides examples and suggestions for presentation of findings. The framework does have limitations, in that its usability has not been tested across a broad spectrum of guideline development contexts.