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Search Results for "low back pain"
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Displaying 61 - 70 of 448 in Policy Library
Displaying 61 - 70 of 1899 in Annals of Internal Medicine
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Stable Supportive Footwear for Self-managing Hip Osteoarthritis Pain: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 179, No 4
Background: Few effective nonsurgical treatments exist for hip osteoarthritis. Footwear influences hip forces and may be a promising novel approach. Objective: To evaluate whether stable supportive shoes are more effective than flat flexible shoes for hip pain. Design: 2-group, pragmatic, comparative effectiveness, superiority randomized trial. (Australian New Zealand Clinical Trials Registry: ACTRN12621001532897) Setting: Community. Participants: 120 people with hip osteoarthritis pain. Intervention: Off-the-shelf stable supportive (n = 60) or flat flexible (n = 60) shoes that met prespecified criteria. Participants chose from options in their randomly assigned shoe group and were instructed to wear selected shoes at least 6 hours per day for 6 months. Measurements: The primary outcome was 6-month change in average hip pain on walking in the previous week (11-point scale; range, 0 to 10, with higher scores indicating worse pain). Secondary outcomes included other measures of pain, symptoms, function in daily living, function in sport and recreation, quality of life, physical activity, global improvement, and adverse events. Results: A total of 120 participants were randomly assigned, and 116 (97%) completed 6-month primary outcomes. Stable supportive shoes did not differ from flat flexible shoes in improving hip pain (mean difference [MD], −0.5 point [95% CI, −1.3 to 0.2 point]; P = 0.163). Few secondary outcomes differed by shoe type, but flat flexible shoes showed greater improvement in the Hip Disability and Osteoarthritis Outcome Score symptom subscale (MD, 6.6 points [CI, 1.4 to 11.7 points]) and quality-of-life subscale (MD, 7.8 points [CI, 1.1 to 14.4 points]), whereas stable supportive shoes showed more improvement in contralateral foot or ankle pain (MD, 0.8 point [CI, 0.0 to 1.5 points]). There were fewer adverse events in the stable supportive shoe group (n = 7 [12%]) than the flat flexible shoe group (n = 18 [31%]; relative risk, 0.39 [CI, 0.18 to 0.86]). Limitation: Unblinded participants. Conclusion: Stable supportive shoes were not superior to flat flexible shoes for improving hip osteoarthritis pain while walking. Primary Funding Source: National Health and Medical Research Council.
Rapid Evaluation of Artificial Intelligence Technology Used for Ambient Dictation in Primary Care: Comparing the Quality of Documentation of Artificial Intelligence–Generated and Human-Produced Clinical Notes
Background: Ambient artificial intelligence (AI) scribes can reduce the burden of administrative documentation. Prior evaluations have been vendor specific and not focused on measures of documentation quality. Objective: To compare the quality of AI-generated clinical notes with that of human-produced notes. Design: Cross-sectional evaluation of notes generated from standardized primary care clinical cases. Setting: Veterans Health Administration (VHA). Participants: 11 AI scribe tools, 18 human note takers, and 30 human raters. Intervention: Five standardized primary care cases were audio recorded using standardized patients (for example, new patient, back pain, chest pain, pharmacy, and nurse care manager). Vendors and human clinicians generated encounter notes from the audio files. Measurements: Blinded raters assessed all notes using the modified Physician Documentation Quality Instrument (PDQI-9), which measures 10 domains of note quality on a 5-point Likert scale (maximum score 50). Results: Across all 5 clinical cases, human-generated notes received higher overall modified PDQI-9 scores than AI-generated notes. The largest difference was seen in the acute low back pain case (human: 43.8 [95% CI, 37.4 to 50.3] vs. AI: 20.3 [CI, 15.4 to 25.2]; difference −23.5 [CI, −29.2 to −17.9]). Pooled domain analysis showed lower AI scores across all 10 domains, with the largest deficits in domains related to being thorough (−1.23 [CI, −1.82 to −0.65]), organized (−1.06 [CI, −1.65 to −0.47]), and useful (−1.03 [CI, −1.61 to −0.44]). Limitation: Cases were simulated; human-generated notes were not generated under real-world constraints. Conclusion: Notes generated by AI had lower-quality scores than human-generated notes across 5 standardized care cases. Although ambient AI scribes hold promise for reducing clinician burden, independent, vendor-neutral evaluations of note quality are essential before large-scale clinical deployment. Primary Funding Source: VHA.
What Would You Recommend for This Patient Interested in a Total Knee Joint Arthroplasty? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Fourteen million people in the United States have symptomatic knee osteoarthritis (OA), a number that is expected to rise with an aging population. Patients with OA can benefit from nonoperative treatment. However, none of these treatments are disease modifying, and many patients eventually require total joint arthroplasty (TJA). The American College of Rheumatology and the American Association of Hip and Knee Surgeons recently issued a guideline on the optimal timing of TJA in patients with symptomatic moderate-to-severe OA for whom nonoperative therapy has been ineffective. In this article, 2 experts review the available evidence and discuss options for nonoperative treatment and the indications for and timing of operative therapy.
Quality Indicators for Pain in Adults: A Review of Performance Measures by the American College of Physicians
Pain is a debilitating symptom generally caused by injuries or various conditions. It can be acute, subacute, or chronic and can have a significant impact on a patient’s quality of life. The goal of managing pain is to relieve or reduce suffering and improve patient functioning. Several performance measures that address the treatment of pain are used in payment, public reporting, or accountability programs. The American College of Physicians (ACP) embraces performance measurement as a means to improve quality of care. ACP believes that a performance measure must be methodologically sound and evidence-based to be considered for inclusion in payment, accountability, or reporting programs. However, a plethora of performance measures that provide minimal or no value to patient care have inundated physicians, practices, and systems with the burden of collecting and reporting data. ACP’s Performance Measurement Committee (PMC) reviews performance measures using a validated process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. There is a need for a higher standard for a performance measure when reputation and reimbursement are on the line. This paper aims to present a review of current performance measures for pain to inform physicians, payers, and policymakers in their selection and use of performance measures. The PMC reviewed 6 performance measures for pain relevant to internal medicine physicians, of which 3 were considered valid at their intended levels of attribution (“Use of Imaging for Low Back Pain,” “Use of Opioids at High Dosage in Persons Without Cancer,” and “Use of Opioids From Multiple Providers in Persons Without Cancer”). This paper also proposes a performance measure concept to address a quality-of-care gap based on the current clinical guideline from ACP and the American Academy of Family Physicians, “Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–low Back, Musculoskeletal Injuries in Adults.”
Obesity
The role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (medications, sleep deprivation), and solicit patient motivation for weight loss. Internists should assess these factors and emphasize the importance of weight loss for the individual patient. All patients wishing to lose weight should be encouraged to monitor their diet and physical activity and should be referred to high-intensity behavioral programs. Some patients with obesity may also benefit from pharmacotherapy or bariatric surgery.
Displaying 61 - 70 of 85 in Annals of Internal Medicine: Clinical Cases
Spontaneous Resolution of Myocardial Inflammation in Cardiac Sarcoidosis: A Case Report | Annals of Internal Medicine: Clinical Cases
Sarcoidosis is a multisystem disease characterized by granulomatous inflammation of virtually any organ or tissue. Atrioventricular block, arrhythmias, cardiomyopathies, and sudden cardiac death are known manifestations of cardiac sarcoidosis (CS), and, thus, diagnosis of CS is considered an absolute indication to initiate treatment of sarcoidosis with disease-modifying anti-inflammatory immunosuppressives. To our knowledge, spontaneous resolution of CS has not been documented. Here, we report what we believe is the first documented case of spontaneous-resolution CS-related myocardial inflammation without corticosteroid or other immunosuppressive therapy for nearly 5 years following initial presentation.
Vitamin C Deficiency as a Mimicker of Vasculitis: A Case | Annals of Internal Medicine: Clinical Cases
Scurvy causes poor wound healing, hemarthrosis, petechiae, perifollicular hemorrhages, and nonspecific myalgia. Although studies report that scurvy can mimic vasculitis on physical examination, the disease lacks the laboratory evidence for vasculitis. We introduce a patient with scurvy whose clinical presentation and laboratory findings mimicked vasculitis, which led to a delayed diagnosis and high resource expenditure. This case highlights the importance of early dietary history in patients with concern for vasculitis. Early dietary history and involvement of the nutrition team can significantly decrease invasive and costly testing procedures and improve diagnosis and patient outcomes.
RS3PE: A Rheumatic Presentation of Lung Malignancy | Annals of Internal Medicine: Clinical Cases
We describe a previously well 56-year-old man who presented with symmetrical inflammatory polyarthralgia associated with bilateral lower limb swelling and left hand puffiness. He had noticed blood steaks in his productive cough for half a year but reported no constitutional symptoms. Inflammatory markers were elevated, whereas rheumatoid factor was negative. Imaging of the chest showed a mass in the right upper zone, which was confirmed via biopsy to be ALK-positive lung adenocarcinoma. The patient was diagnosed with paraneoplastic remitting seronegative symmetrical synovitis with pitting edema, representing one of the first descriptions of lung adenocarcinoma–associated RS3PE.
Apathetic Thyrotoxicosis Presenting With New-Onset Pulmonary Hypertension | Annals of Internal Medicine: Clinical Cases
Apathetic thyrotoxicosis is a distinct clinical entity of hyperthyroidism that occurs in elderly patients. Manifestations include depression, weight loss, mild tachycardia, and symptoms of heart failure. Noteworthy is the absence of typical hyperkinetic motor symptoms. Pulmonary hypertension is an often-overlooked manifestation of thyrotoxicosis. Here, we present a case of a 67-year-old woman who presented to the clinic with complaints of dyspnea on exertion, orthopnea, leg edema, and 20-lb weight loss. Further work-up revealed pulmonary hypertension with thyrotoxicosis, without the typical sympathetic symptoms. After achieving a euthyroid state with methimazole therapy, she experienced resolution of her symptoms, and her pulmonary artery pressures normalized.
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.
When Community-Acquired Pneumonia Guidelines Provide Misguided Guidance | Annals of Internal Medicine: Clinical Cases
Limited diagnostic testing and empirical antimicrobial therapy are recommended in practice guidelines for adults with community-acquired pneumonia (CAP). Although following CAP guidelines is cost-effective with high cure rates, consideration should be given to the possibility that CAP is caused by pathogens not effectively treated by the recommended antibiotic regimens. Expanding the differential diagnosis based on potential pathogen exposures and comorbid conditions can prevent delays in diagnosis and appropriate treatment. As an example, mucormycosis should be considered in a patient presenting with pneumonia in the setting of diabetic ketoacidosis.
Sandwich-Associated Lactic Acidosis: A Case Report of a Young Adult With Pyruvate Dehydrogenase Complex Deficiency | Annals of Internal Medicine: Clinical Cases
Pyruvate dehydrogenase complex deficiency is a rare genetic disorder that can lead to severe metabolic consequences. We present the case of a young adult with pyruvate dehydrogenase complex deficiency who presented with progressive shortness of breath and subsequently required intubation in the setting of severe lactic acidemia. After resuscitation and extubation, a targeted history identified that the patient had eaten 3 grilled cheese sandwiches just before admission. In these rarely encountered cases, both detailed clinical history-gathering as well as multidisciplinary provider coordination is essential in ultimately implementing specialized dietary recommendations and thus preventing accelerated morbidity and mortality.
Reversible Improvement of Arterial Stenosis and Wall Thickness in Takayasu Arteritis Through Treatment With Tocilizumab | Annals of Internal Medicine: Clinical Cases
Early diagnosis and initiation of treatment in Takayasu arteritis (TA) is important to prevent irreversible arterial changes. A 39-year-old female was diagnosed with active TA. Subcutaneous administration of tocilizumab (162 mg/week) was initiated in combination with prednisolone (30 mg/d). After 21 months, the carotid arterial stenosis and wall thickness had normalized with only slight plaque on echocardiography. After 23 months, computed tomography showed normalization of the overall aortic stenosis and wall thickness. The prednisolone dosage could be reduced to 2 mg/d without relapse for >2 years. Early combination treatment of TA with tocilizumab prevented and normalized vascular stenosis and wall thickness.
Iatrogenic Hyperkalemia Induced by Hypermagnesemia From Administration of Laxatives in a Patient With Gastroparesis | Annals of Internal Medicine: Clinical Cases
Magnesium-containing drugs such as magnesium citrate are popular over-the-counter laxatives used to treat constipation. Although generally well tolerated, excessive intake can result in potentially dangerous electrolyte abnormalities. Of these abnormalities, hyperkalemia is one that is heavily underreported. We report an elderly woman who presented for gastroparesis flare-up and constipation. She was given magnesium citrate and subsequently developed hypermagnesemia, which resulted in hyperkalemia. By presenting this case, we hope to increase awareness of this heavily underreported side effect of magnesium-based laxatives, especially in the setting of gastrointestinal disturbances that may affect the absorption of these electrolytes.
Uphill and Downhill Esophageal Varices Secondary to Pulmonary Hypertension | Annals of Internal Medicine: Clinical Cases
Downhill esophageal varices (EVs) are rare endoscopic findings and coincide with superior vena cava (SVC) obstruction. Historically, downhill EVs have been associated with malignancy, thrombosis, or iatrogenic SVC obstruction. Few cases of “benign obstruction”, as in pulmonary hypertension (PH) with tricuspid regurgitation (TR), have been reported. Downhill EV can result in life-threatening bleeds; however, there are no current guidelines regarding treatment or surveillance endoscopy. We report a case of both uphill and downhill EV due to benign obstruction from PH and TR, leading to the diagnosis of decompensated cirrhosis.