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In critically ill adults, accuracy of pulse oximeters for detecting hypoxemia varied by skin tone
Clinical Impact Ratings GIM/FP/GP: 6 out of 7 Critical Care: 6 out of 7 Pulmonology: 5 out of 7
Atopic Dermatitis
Atopic dermatitis affects approximately 10% of the U.S. population and is more common in children than adults. Up to 99% of physician visits for atopic dermatitis are in primary care. Most cases can be managed successfully with topical treatments, including moisturizers and prescription anti-inflammatory treatments, such as corticosteroids, calcineurin inhibitors, phosphodiesterase-4 inhibitors, Janus kinase (JAK) inhibitors, and aryl hydrocarbon receptor agonists. For more refractory or severe atopic dermatitis, ultraviolet phototherapy and systemic treatments, usually prescribed by specialists, can be used. Systemic treatments include older off-label immunomodulators, such as methotrexate. Since 2017, multiple on-label injectable biologics and oral JAK inhibitors have been approved.
Efficacy, Comparative Effectiveness, and Harm of Respiratory Syncytial Virus Vaccines in Adults Who Are Not Pregnant or Immunocompromised: A Rapid Review for the American College of Physicians
Background: Respiratory syncytial virus (RSV) causes respiratory disease with a high disease burden in older adults and people with comorbid conditions. Purpose: To analyze the efficacy, comparative effectiveness, and harm of RSV vaccines in nonpregnant adults who are not immunocompromised. Data Sources: Ovid Medline, Embase, and ClinicalTrials.gov between January 2023 and October 2025; a recently published Cochrane review to identify studies published before 2023. Study Selection: Two independent reviewers screened all references on the abstract and full-text levels. Data Extraction: Two independent reviewers assessed the risk of bias (RoB). One reviewer extracted data and assessed the certainty of evidence (CoE); a second reviewer verified extractions and assessments. For studies carried forward from the Cochrane review, reported data and RoB assessments were used. Data Synthesis: The review included 7 randomized controlled trials and 1 nonrandomized study. In older adults (≥60 years), RSV protein subunit vaccines probably reduce RSV-related hospitalizations (vaccine efficacy [VE], 83.3% [95% CI, 42.9% to 96.9%]; moderate CoE) and severe RSV illness (VE, 94.1% [CI, 62.4% to 99.9%]; moderate CoE) but have no effect on all-cause mortality (risk ratio [RR], 1.07 [CI, 0.68 to 1.68]; high CoE). They probably do not differ from placebo or no vaccination in serious adverse events (SAEs) (RR, 0.96 [CI, 0.75 to 1.23]; moderate CoE). Messenger RNA (mRNA) vaccines for RSV showed no difference in the incidence of SAEs compared with placebo in older adults (RR, 1.09 [CI, 0.83 to 1.45]; high CoE). Limitation: Evidence on RSV vaccines in younger adults and on the efficacy of mRNA vaccines remains insufficient. Conclusion: Protein subunit vaccines for RSV decrease the risk for hospitalization and severe illness in older adults. Primary Funding Source: American College of Physicians. (PROSPERO: CRD420251145237)
“Never More Than 15 Feet From the Respirator”: Housestaff Research During the 1955 Boston Polio Epidemic
In July 1955, a devastating polio epidemic struck Massachusetts only 3 months after the licensing of the Salk vaccine. One of the last major polio epidemics in the United States, it overwhelmed the local health care system. At Massachusetts General Hospital, 2 assistant residents—the equivalent of today's postgraduate year 2 trainees—were assigned to oversee a hastily organized polio ward and a rising second-year medical student was charged with setting up and running an adjoining laboratory. There, they and other residents conducted original patient-oriented research while providing round-the-clock care for patients, most in iron lungs, under crisis conditions. Their work was facilitated by a strong preexisting culture of bedside research at the hospital. Extremely long work hours ensured constant, close patient observation. A lack of role boundaries between the physician as researcher and as clinician and an absence of formal requirements for patient consent to research in that era also facilitated the studies, which were of similar methodological sophistication and ethical consideration to contemporaneous studies of other diseases. There is evidence that this experience influenced their subsequent careers. The autonomy granted these trainees contrasts sharply with the restricted roles permitted to medical students and residents during the initial surge of the recent COVID-19 pandemic.
Reforming 340B to Promote Program Integrity and Better Serve Vulnerable Populations: An American College of Physicians Policy Brief
The United States pays some of the highest prices for prescription drugs in the world, with drug prices and overall spending increasing year-over-year. Ballooning prescription drug costs can result in low rates of medication adherence, negatively affecting public health and straining national health care systems and resources. The 340B Drug Pricing Program (340B Program), which allows health care safety-net settings to purchase prescription drugs at deep discounts, has long sought to function as a bulwark against increasing drug prices for institutions serving those most vulnerable in society. Savings from the program have facilitated expanded access to health care services for low-income and uninsured patients. However, shortcomings in the program’s design, implementation, and oversight obscure to what degree low-income and uninsured patients are realizing program benefits and create incentives for institutions to undertake profit-seeking behaviors at the expense of patients. To strengthen the 340B Program and ensure it is best serving its intended audience, reforms are needed within the program to promote transparency in how drug savings are reinvested into patient care and mandate demonstrated benefit to low-income and uninsured populations. Access to contract pharmacies—that is, the specialty or community-based pharmacies that 340B Program “covered entities” have an agreement with to distribute medications to patients—should be preserved, with appropriate guardrails to prevent unauthorized diversion. Federal regulators should be empowered with the resources and clear statutory authority necessary to engage in meaningful oversight of all program participants.
Screening for Breast Cancer in Asymptomatic, Average-Risk Adult Females: A Guidance Statement From the American College of Physicians (Version 2)
Description: The purpose of this updated guidance statement is to guide internal medicine physicians and other clinicians on screening for breast cancer in asymptomatic, average-risk adult females. Methods: The American College of Physicians updated its guidance statement on screening for breast cancer using high-quality clinical guidelines from national guideline developers around the world. Guidance Statement 1: In asymptomatic, average-risk females aged 40 to 49 years, clinicians should discuss the female’s risk of breast cancer, values and preferences, and uncertainty around benefits and harms of screening for breast cancer. Following shared decision making, if a female in this population prefers to get screened for breast cancer, clinicians should then initiate screening mammography every 2 years (biennial). Guidance Statement 2: In asymptomatic, average-risk females aged 50 to 74 years, clinicians should use biennial mammography for screening for breast cancer. Guidance Statement 3: In asymptomatic, average-risk females aged 75 years or older or asymptomatic, average-risk females with a limited life expectancy, clinicians should discuss discontinuation of breast cancer screening based on shared decision making that includes the female’s risk of breast cancer, values and preferences, and uncertainty around benefits and harms of screening for breast cancer. Guidance Statement 4: In asymptomatic, average-risk adult females with breast density of Breast Imaging Reporting and Data System (BI-RADS) category C or D, clinicians should consider using supplemental digital breast tomosynthesis based on benefits, harms, additional radiation exposure, availability, values and preferences, and cost. Guidance Statement 5: In asymptomatic, average-risk adult females with breast density of BI-RADS category C or D, clinicians should not use supplemental magnetic resonance imaging or ultrasound.
Continuing Glucagon-Like Peptide-1 Receptor Agonists Into the First Trimester of Pregnancy and Pregnancy Outcomes: A Target Trial Emulation Study Using Claims Information: Annals of Internal Medicine: Vol 0, No 0
Background: Glucagon-like peptide-1 receptor agonist (GLP-1RA) use has increased among women of reproductive age, but limited data exist on safety in pregnancy. Objective: To estimate the risk for nonlive birth, abnormal fetal growth, and major congenital malformation (MCM) with GLP-1RA dispensing in early pregnancy. Design: In an observational cohort of pregnant women aged 16 to 55 years with a GLP-1RA dispensation in the 90 days before the last menstrual period (LMP), a target trial with 2 treatment strategies was emulated: continuation of dispensing into the first trimester (≥1 further dispensation), or noncontinuation. Setting: Merative MarketScan U.S. insurance claims data (2011 to 2024). Participants: 3572 pregnancies (41.1% [n = 1467] among women with type 2 diabetes). Measurements: Risk for nonlive birth was estimated using a weighted Kaplan–Meier estimator. Among live-birth pregnancies linked to infants, the weighted prevalence of MCM, small for gestational age (SGA), and large for gestational age (LGA) was estimated. Results: The weighted risk for nonlive birth was 29.7% with continuation and 27.1% with noncontinuation (adjusted risk ratio, 1.09 [95% CI, 0.98 to 1.23]). Among 2529 live-birth pregnancies, 1443 (57.1%) received at least 1 GLP-1RA dispensation after LMP and 1499 (829 continuers) were linked to an infant. Weighted prevalence ratios for continuation versus noncontinuation were 1.29 (CI, 0.82 to 2.06) for SGA, 1.08 (CI, 0.84 to 1.40) for LGA, and 1.21 (CI, 0.83 to 1.82) for MCM. Limitation: Potential residual confounding by prior glycemic control. Conclusion: Risks for nonlive birth, SGA, LGA, and MCM were not definitively higher with continuation of GLP-1RAs into early pregnancy. However, estimates for MCM and SGA were imprecise and were compatible with both no increased risk and clinically relevant differences in risk. Primary Funding Source: National Institutes of Health.
Telemedicine Policy and Practice: A Position Paper From the American College of Physicians
In response to the COVID-19 pandemic, federal policymakers temporarily lifted long-standing restrictions on telemedicine, resulting in an unprecedented and rapid expansion of virtual care across video, audio, and asynchronous modalities. When integrated into longitudinal care relationships, telemedicine can increase access, reduce patient burden, and support continuity for people facing geographic, mobility, or socioeconomic barriers. However, telemedicine also introduces new clinical, regulatory, equity, and safety challenges that require deliberate policy design. Beyond its clinical considerations, telehealth offers environmental and logistical benefits, including reduced travel time and cost, decreased fuel consumption, lower transportation expenses, and lower greenhouse gas emissions. In this position paper, the American College of Physicians updates its previous policy paper on telemedicine to reflect changes in payment policy, licensure, prescribing authority, and utilization patterns that have occurred over the past decade and accelerated during the COVID-19 public health emergency. This paper focuses on access, payment policy, licensure, prescribing practices, equity, and patient safety across federal and state programs and private payers and emphasizes the conditions under which telemedicine should be integrated into clinical practice. Key developments addressed include the expansion and partial lapse of Medicare telemedicine waivers, evolving U.S. Drug Enforcement Administration rules governing prescribing, increased reliance on interstate practice, and normalization of telemedicine by private payers.
Comparative Effectiveness and Harm of Seasonal Influenza Vaccines in Adults Who Are Not Pregnant or Immunocompromised: A Rapid Review for the American College of Physicians
Background: Seasonal influenza is a contagious viral respiratory illness that causes yearly epidemics. Purpose: To assess the comparative effectiveness and harm of standard and newer and enhanced influenza vaccines in nonpregnant, nonimmunocompromised adults. Data Sources: Medline and Embase between May 2023 and July 2025, and a systematic review by the European Centre for Disease Prevention and Control (ECDC) to identify studies published before May 2023. Study Selection: Two investigators independently selected English-language randomized controlled trials (RCTs) and nonrandomized studies of interventions (NRSIs). Data Extraction: For newly included studies, one reviewer extracted data and assessed certainty of evidence (CoE), which was verified by a second reviewer; 2 reviewers independently assessed risk of bias. For studies from the ECDC report, original data and risk-of-bias assessments were used. Data Synthesis: The review included 35 RCTs and 5 NRSIs. Compared with standard vaccines, high-dose vaccines reduced laboratory-confirmed influenza in adults aged 65 years or older (high CoE) but increased the risk for fever in this group (high CoE). High-dose vaccines probably caused fewer serious adverse events in all adults and those aged 65 years or older (moderate CoE). Recombinant vaccines reduced laboratory-confirmed influenza in all adults and those younger than 65 years compared with standard vaccines (high CoE). Evidence from 2 RCTs indicated that mRNA vaccines may increase serious adverse events in all adults and those younger than 65 years compared with standard vaccines (low CoE). Limitations: RCTs evaluating laboratory-confirmed influenza and influenza-related hospitalization or death are limited. Evidence was lacking for several comparisons and outcomes. Broad definitions of serious adverse events may have inflated risk estimates. Conclusion: High-dose and recombinant vaccines improve protection compared with standard vaccines, but high-dose vaccines increase fever risk. Evidence for mRNA vaccines is limited and should be cautiously interpreted. Primary Funding Source: American College of Physicians. (PROSPERO: CRD420251114496)
Physicians Are Not Providers: The Ethical Significance of Names in Health Care: A Policy Paper From the American College of Physicians
More than 25 years ago, Pellegrino and Relman noted the increasing commercialization of the learned professions, anticipating what many physicians are increasingly experiencing today: an impairment of their ability to practice in accordance with standards of medical ethics and professionalism. These hurdles to the physician’s ability to do right by the patient contribute to what leaders in medicine and the American College of Physicians have called deprofessionalization. An example is the use of the term provider to describe physicians and other health professionals. The use of this terminology has been reviewed in medical journal articles but has not been adequately explored as a matter of ethics and professionalism. Through that lens, this paper examines the trends, significance, and implications for patients, physicians, and health care of the use of the term provider.