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Search Results for "chronic back pain management"
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Displaying 41 - 50 of 365 in Policy Library
Displaying 41 - 50 of 1297 in Annals of Internal Medicine
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Should You Recommend Inhaled Corticosteroids for This Patient With Chronic Obstructive Pulmonary Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 172, No 11
Approximately 12 million adults in the United States receive a diagnosis of chronic obstructive pulmonary disease (COPD) each year, and it is the fourth leading cause of death. Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow obstruction and a constellation of symptoms, including cough, sputum production, and shortness of breath. The main risk factor for COPD is tobacco smoke, but other environmental exposures also may contribute. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2020 Report aims to provide a nonbiased review of the current evidence for the assessment, diagnosis, and treatment of patients with COPD. To date, no conclusive evidence exists that any existing medications for COPD modify mortality. The mainstay of treatment for COPD is inhaled bronchodilators, whereas the role of inhaled corticosteroids is less clear. Inhaled corticosteroids have substantial risks, including an increased risk for pneumonia. Here, 2 experts, both pulmonologists, reflect on the care of a woman with severe COPD, a 50–pack-year smoking history, frequent COPD exacerbations, and recurrent pneumonia. They consider the indications for inhaled corticosteroids in COPD, when inhaled corticosteroids should be withdrawn, and what other treatments are available.
Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 1
Background: Few studies have examined primary care management for acute sciatica, including referral to physical therapy. Objective: To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica. Design: Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350) Setting: 2 health care systems in Salt Lake City, Utah. Patients: 220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation. Intervention: All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy. Measurements: The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays. Results: Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, −5.4 points [95% CI, −9.4 to −1.3 points]; P = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, −4.8 points [CI, −8.9 to −0.7 points]) and back pain intensity (relative difference, −1.0 points [CI, −1.6 to −0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays. Limitation: The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined. Conclusion: Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC. Primary Funding Source: Agency for Healthcare Research and Quality.
Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians
Description: The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP. Methods: This guideline is based on a systematic evidence review on the comparative efficacy and safety of nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. We evaluated the following clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events. Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with acute pain from non–low back, musculoskeletal injuries. Recommendation 1: ACP and AAFP recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient's treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence). Recommendation 2a: ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain (Grade: conditional recommendation; moderate-certainty evidence). Recommendation 2b: ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain (Grade: conditional recommendation; low-certainty evidence). Recommendation 3: ACP and AAFP suggest against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).
Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study: Annals of Internal Medicine: Vol 171, No 4
Background: Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has examined long-term physical health in women with unwanted pregnancies after abortion versus childbirth. Objective: To examine the physical health of women who seek and receive or are denied abortion. Design: Prospective cohort study. Setting: 30 U.S. abortion facilities from 2008 to 2010. Participants: Of 1132 women seeking abortion who consented to participate, 874 were included in this analysis (328 who had first-trimester abortion, 383 who had second-trimester abortion, and 163 who gave birth). Measurements: Self-reported overall health; chronic abdominal, pelvic, back, and joint pain; chronic headaches or migraines; obesity; asthma; gestational and nongestational hypertension and diabetes; and hyperlipidemia were assessed semiannually for 5 years. Mortality was assessed by using verbal autopsy and public records. Results: No significant differences were observed in self-rated health or chronic pain after first-trimester versus second-trimester abortion. At 5 years, 27% (95% CI, 21% to 34%) of women who gave birth reported fair or poor health compared with 20% (CI, 16% to 24%) of women who had first-trimester abortion and 21% (CI, 18% to 25%) who had second-trimester abortion. Women who gave birth also reported more chronic headaches or migraines and joint pain, but experienced similar levels of other types of chronic pain and obesity. Gestational hypertension was reported by 9.4% of participants who gave birth. Eight of 1132 participants died during follow-up, 2 in the postpartum period. Maternal mortality did not differ statistically by group. Limitation: Self-reported outcome measures, uncertain generalizability, and 41% loss to follow-up at 5 years. Conclusion: Although some argue that abortion is detrimental to women's health, these study data indicate that physical health is no worse in women who sought and underwent abortion than in women who were denied abortion. Indeed, differences emerged suggesting worse health among those who gave birth. Primary Funding Source: An anonymous foundation.
Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 166, No 11
Background: Mindfulness-based stress reduction (MBSR) is frequently used to treat pain-related conditions, but its effects on low back pain are uncertain. Purpose: To assess the efficacy and safety of MBSR in patients with low back pain. Data Sources: Searches of MEDLINE/PubMed, Scopus, the Cochrane Library, and PsycINFO to 15 June 2016. Study Selection: Randomized controlled trials (RCTs) that compared MBSR with usual care or an active comparator and assessed pain intensity or pain-related disability as a primary outcome in patients with low back pain. Data Extraction: Two reviewers independently extracted data on study characteristics, patients, interventions, outcome measures, and results at short- and long-term follow-up. Risk of bias was assessed using the Cochrane risk-of-bias tool. Data Synthesis: Seven RCTs involving 864 patients with low back pain were eligible for review. Compared with usual care, MBSR was associated with short-term improvements in pain intensity (4 RCTs; mean difference [MD], −0.96 point on a numerical rating scale [95% CI, −1.64 to −0.34 point]; standardized mean difference [SMD], −0.48 point [CI, −0.82 to −0.14 point]) and physical functioning (2 RCTs; MD, 2.50 [CI, 0.90 to 4.10 point]; SMD, 0.25 [CI, 0.09 to 0.41 point]) that were not sustained in the long term. Between-group differences in disability, mental health, pain acceptance, and mindfulness were not significant at short- or long-term follow-up. Compared with an active comparator, MBSR was not associated with significant differences in short- or long-term outcomes. No serious adverse events were reported. Limitation: The number of eligible RCTs was limited; only 3 evaluated MBSR against an active comparator. Conclusion: Mindfulness-based stress reduction may be associated with short-term effects on pain intensity and physical functioning. Long-term RCTs that compare MBSR versus active treatments are needed in order to best understand the role of MBSR in the management of low back pain. Primary Funding Source: None.
Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults
Background: There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time. Objective: To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions. Design: Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes. Setting: United States, 2008 to 2019. Patients: 7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain. Measurements: Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month. Results: Laws were associated with small-in-magnitude and non–statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids. Limitations: Results may not be generalizable to non–commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments. Conclusion: This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws. Primary Funding Source: National Institute on Drug Abuse.
In acute low back pain, adding oxycodone/acetaminophen or cyclobenzaprine to naproxen did not improve pain or function
Source Citation Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314:1572-80. 26501533
Displaying 41 - 50 of 90 in Annals of Internal Medicine: Clinical Cases
Isolated Bilateral Adrenal Histoplasmosis With Addisonian Crisis in an Immunocompetent Host | Annals of Internal Medicine: Clinical Cases
Bilateral adrenal histoplasmosis presenting as an adrenal crisis and being the only site of demonstrable disease in an immunocompetent adult is a rare presentation. The adrenal gland is frequently involved in disseminated histoplasmosis but commonly presents as unilateral mass; isolated bilateral involvement in an immunocompetent patient is rare. We describe a patient case of 38-year-old man presenting with epigastric pain, intermittent low-grade fever, nausea and vomiting, skin darkening, generalized weakness, and weight loss for 6 months. Investigations suggested primary adrenal insufficiency. On imaging, patient was found to have bilateral adrenal masses. The histopathological examination revealed Histoplasma species.
The Pacemaker Cable as an Unexpected Cause of Recurrent Pulmonary Embolism | Annals of Internal Medicine: Clinical Cases
Recurrent pulmonary embolism (PE) is uncommon. We report a 39-year-old man with a pacemaker who developed recurrent PEs while receiving rivaroxaban, warfarin, and therapeutic enoxaparin. Evaluation for autoimmunity and thrombophilia was negative. Each episode was preceded by fever, malaise, and myalgia. During admission, 18-fluorodeoxyglucose positron emission tomography–computed tomography (18FDG PET/CT) showed focal uptake (maximum standardized uptake value, 2.3) along the right-ventricular pacemaker lead, suggesting device-related infection or thrombosis. Transvenous extraction failed; subsequently, surgical removal was performed. Cultures remained negative. This case highlights pacemaker-associated infection as a treatable cause of septic embolization and underscores the diagnostic value of 18FDG PET/CT in recurrent PE.
A Case of Turmeric-Induced Liver Injury | Annals of Internal Medicine: Clinical Cases
Turmeric spice and its active ingredient, curcumin, are becoming more commonly used, despite a simultaneous increase in reports of turmeric-induced hepatotoxicity. Our report demonstrates an additional case of turmeric-induced liver injury with concurrent ingestion of bioavailability-increasing substances. Despite known underreporting, a significant proportion of documented drug-induced liver injuries are secondary to herbal and dietary supplements. There are also high variabilities in supplement dosage and delivery, as well as lack of regulation in the supplements industry. Our case highlights the importance of discussing supplement-specific medical histories and educating patient on the risks for unregulated supplement use.
A Rare Observation of Silicone-Associated Scleroderma-Like Syndrome: How to Recognize and Diagnose Similar Cases | Annals of Internal Medicine: Clinical Cases
Although silicone breast implants are generally considered safe medical devices, implant ruptures and silicone leakage are not uncommon. In this brief report, we describe an unusual case of a woman with ruptured breast implants and long-standing unexplained systemic symptoms. She developed an atypical and localized scleroderma-like syndrome, with a rare observation of histopathologically confirmed silicone depositions in distant sclerotic cutaneous biopsies. This observation with silicone-specific modified oil-red-o staining strongly suggests a direct inflammatory reaction to the distant (sub)cutaneous silicone depositions from her ruptured breast implants. We propose clinical recommendations on how to recognize and diagnose possible similar cases.
Incidental Krukenberg Tumor During Cesarean Section | Annals of Internal Medicine: Clinical Cases
We present the case of a 29-year-old woman in her 30th week of pregnancy admitted for preterm contractions. She had an emergent cesarean delivery and was noted to have a large ovarian mass diagnosed on pathology as a Krukenberg tumor. Subsequent upper gastrointestinal endoscopy revealed gastric signet ring cell adenocarcinoma as the primary cancer. The patient received palliative chemotherapy and immunotherapy and is pending clinical trial participation. Pregnancy-associated gastric cancer is a rare condition with a poor prognosis as most symptoms may be attributed to a normal pregnancy. This misinterpretation often leads to a late diagnosis and poor outcomes.
Atypical Epigastric Pain Reveals Obstructive Urosepsis in a Horseshoe Kidney | Annals of Internal Medicine: Clinical Cases
A 61-year-old woman presented with 2 days of nausea, vomiting and severe mid- to upper abdominal pain radiating to the right flank without any urinary symptoms. She was hypotensive, with leukocytosis and pyuria. Contrast-enhanced computed tomography demonstrated a horseshoe kidney and a 12- × 8- × 18-mm right ureteropelvic junction stone causing mild to moderate hydronephrosis. Blood and urine cultures were obtained before administration of antibiotics and remained negative. She received intravenous crystalloid therapy, ceftriaxone, and emergent percutaneous nephrostomy, with rapid hemodynamic recovery and normalization of leukocytosis by hospital day 1. This case highlights atypical presentations of obstructive urosepsis and the importance of early decompression.
Tics in the Small Intestine: An Unusual Case of Jejunal Diverticulitis | Annals of Internal Medicine: Clinical Cases
Small bowel (SB) diverticulosis is rare and usually has an asymptomatic presentation. Diverticular microperforations provoke inflammation and diverticulitis. Given the disease rarity, no current treatment guidelines exist. Little is known regarding malignancy-associated SB diverticulitis and screening with endoscopic procedures, capsule endoscopy, or radiographic imaging may be difficult or inadequate. In this case, we report on a 64-year-old woman who presented with abdominal pain secondary to jejunal diverticulitis, received antibiotics with radiographic disease resolution, and will undergo malignancy screening with balloon enteroscopy.
Renal Cell Carcinoma Metastasis to Esophagus 45 Years After Nephrectomy: A Case Report | Annals of Internal Medicine: Clinical Cases
Renal cell carcinoma (RCC) is a common malignancy, often discovered incidentally with abdominal imaging modalities. Metastasis of RCC to the esophagus is extremely rare. In this case, a patient presented with melena and dysphagia and was found to have an isolated metastasis of RCC in the proximal esophagus on endoscopy. He was previously treated for RCC 45 years ago, making this case the longest relapse of RCC documented in the literature to the best of our knowledge.
Coin in the Bronchus Intermedius for 25 Years: Complication of Chronic Foreign Body Aspiration | Annals of Internal Medicine: Clinical Cases
Chronic bronchial obstructions from inhaled objects are uncommon in the adult population. Long-term complications of foreign body aspiration have included hemoptysis, recurrent pneumonia, empyema, and abscess formation. We report the patient case of a 66-year-old man, with an accidental inhalation of a coin 25 years ago that was never retrieved, who presented with progressive shortness of breath and was found to have an infected lung bulla in the setting of giant bullous emphysema secondary to the chronic right bronchial foreign body.
Incidentally Detected Chronic Left Ventricular Pseudoaneurysm After Subacute Inferior–Posterior Myocardial Infarction | Annals of Internal Medicine: Clinical Cases
We describe a 69-year-old man with subacute inferior myocardial infarction who had surgical repair for a left ventricular (LV) pseudoaneurysm incidentally detected by routine 6-month follow-up echocardiography. Although LV pseudoaneurysm is a rare complication after myocardial infarction, the delayed diagnosis and management can cause adverse patient outcomes. The present case suggests that patients with multiple risk factors for LV pseudoaneurysms, including advanced age, late presentation, and delayed revascularization, should receive intensive blood pressure control and closer examination using a multimodal imaging approach for early detection of aneurysmal formation and complications.