The Changing Face of Ambulatory Medicine - Reimbursing Physicians for Computer-Based Care

The Patient Centered Medical Home Neighbor: The Interface of the Patient Centered Medical Home with Specialty/Subspecialty Practices

Beyond the Referral: Principles of Effective, Ongoing Primary and Specialty Care Collaboration

ACP Comment Letter to CMS Regarding CY 2018 Medicare Physician Fee Schedule Proposed Rule

ACP Letter of Support for the Ensuring Access to Lower-Cost Medicines for Seniors Act

Patient-Centered, Physician-Guided Care for the Chronically Ill: The American College of Physicians Prescription for Change

ACP Comments on 2026 Physician Fee Schedule, Medicare Shared Savings Program, and Medicare Prescription Drug Inflation Rebate Program Proposed Rule

ACP Comment Letter Regarding the Physician Fee Schedule Proposed Rule for CY 2017

Medicare Shared Savings Program Comments and Recommendations to CMS in Response to Proposed Policy and Payment Changes

ACP Comments on 2022 Physician Fee Schedule and Quality Payment Program Proposed Rule

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 175, No 11

Background: The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. Purpose: To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. Data Sources: Electronic databases and registries from inception to 7 February 2022. Study Selection: Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. Data Extraction: Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Data Synthesis: Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. Limitations: Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. Conclusion: The risk–benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit–risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. Primary Funding Source: None. (PROSPERO: CRD42021275293)

Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy: A Randomized Trial: Annals of Internal Medicine: Vol 166, No 8

Background: Active discopathy is associated with a specific phenotype of chronic low back pain (LBP). Local inflammation has a role in active discopathy–associated symptoms. Objective: To assess the efficacy of a single glucocorticoid intradiscal injection (GC IDI) in patients with chronic LBP with active discopathy. Design: Prospective, parallel-group, double-blind, randomized, controlled study. (ClinicalTrials.gov: NCT00804531) Setting: 3 tertiary care centers in France. Patients: 135 patients with chronic LBP with active discopathy on magnetic resonance imaging (MRI). Intervention: A single GC IDI (25 mg prednisolone acetate) during discography (n = 67) or discography alone (n = 68). Measurements: The primary outcome was the percentage of patients with LBP intensity less than 40 on an 11-point numerical rating scale (0 [no pain] to 100 [maximum pain] in 10-point increments) in the previous 48 hours at 1 month after the intervention. The main secondary outcomes were LBP intensity and persistent active discopathy on MRI at 12 months and spine-specific limitations in activities, health-related quality of life, anxiety and depression, employment status, and use of analgesics and nonsteroidal anti-inflammatory drugs at 1 and 12 months. Results: All randomly assigned patients were included in the primary efficacy analysis. At 1 month after the intervention, the percentage of responders (LBP intensity <40) was higher in the GC IDI group (36 of 65 [55.4%]) than the control group (21 of 63 [33.3%]) (absolute risk difference, 22.1 percentage points [95% CI, 5.5 to 38.7 percentage points]; P = 0.009). The groups did not differ in LBP intensity at 12 months and in most secondary outcomes at 1 and 12 months. Limitation: Tertiary care setting. Conclusion: In chronic LBP associated with active discopathy, a single GC IDI reduces LBP at 1 month but not at 12 months. Primary Funding Source: French Ministry of Health.

High- Versus Low-Dose Exercise Therapy for Knee Osteoarthritis

Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Hyperlipasemia Due to Duodenal Obstruction Secondary to Gastrostomy Tube Migration | Annals of Internal Medicine: Clinical Cases

A nonverbal woman with cerebral palsy and a chronic gastrostomy tube presented with nonbilious vomiting of tube feeds and abdominal pain. Initial work-up showed elevated lipase; however, computed tomography imaging revealed duodenal obstruction from gastrostomy tube migration as the cause of her symptoms. This case represents alternative causes to hyperlipasemia, such as bowel obstruction.

A Rare Case of Bivalvular Infective Endocarditis and Mural Vegetation Caused by Bartonella quintana | Annals of Internal Medicine: Clinical Cases

Bartonella quintana is a rare but increasingly recognized cause of culture-negative infective endocarditis. We report a patient who presented with features of congestive heart failure without associated fever or detectable bacteremia. Diagnostic work-up revealed infective endocarditis due to B. quintana causing a large right atrial mural vegetation along with severe mitral regurgitation and severe aortic regurgitation, for which the patient had surgical valve replacements. The case highlights the indolent nature of the disease, leading to late presentation and challenging management, especially in a vulnerable patient population.

A Case of Daptomycin-Induced Eosinophilic Pneumonia | Annals of Internal Medicine: Clinical Cases

Daptomycin is commonly used for methicillin-resistant Staphylococcus aureus infections, but 1 rarely reported adverse reaction for its use is daptomycin-induced eosinophilic pneumonia. It is unclear how or why the drug produces this reaction. Workup includes ruling out other infectious causes and discontinuing daptomycin, and bronchoscopy showing more than 25% eosinophils is diagnostic. Here, we report a rarely described patient case of daptomycin-induced eosinophilic pneumonia and discuss its management.

Report of Concomitant Intracranial Cysts in Unrelated Patients With Heterozygous Germline NF1 Pathogenic Variants | Annals of Internal Medicine: Clinical Cases

Neurofibromatosis 1 (NF1) is one of the most common genetic diseases of the central nervous system. The nature of intracranial lesions that are associated with NF1 are yet to be fully defined. Arachnoid, velum interpositum, and odontogenic cysts are among the more common intracranial cystic lesions that can be congenital. Although odontogenic cysts are well known to be associated with Gorlin–Goltz syndrome, the possibilities of other genetic disorders in patients with odontogenic and other intracranial cystic lesions have continued to stir research interests. Here, we report 2 cases of unrelated patients, each patient having concurrent intracranial cystic lesions in the setting of a diagnosis of NF1. Individual I had concomitant arachnoid and odontogenic cysts in parallel with a novel heterozygous germline NF1 pathogenic frameshift variant, NF1 [NM_000267.3] c.40del (p.Val14Serfs*10). Individual II had concomitant arachnoid and vellum interpositum cysts in the context of a heterozygous likely pathogenic NF1 germline variant [NF1 (NM_000267.3) c.4265C>T, p.(Ser1422Leu)]. Our observations suggest that clinicians should consider NF1 among the differential diagnosis for intracranial cystic lesions such as arachnoid, vellum interpositum, and odontogenic cysts.

Blastic Plasmacytoid Dendritic Cell Neoplasm Mimicking Erythema Nodosum: A Case Report | Annals of Internal Medicine: Clinical Cases

Blastic plasmacytoid dendritic cell neoplasm (BPDCN), previously known as blastic natural killer cell lymphoma, is a rare, difficult-to-diagnose, and aggressive hematologic malignancy. Skin lesions are the initial presentation of BPDCN in 64% to 77% of cases, characterized by brown to purple nodular or bruised macular lesions in solitary or multiple locations. Here, we report the case of a 57-year-old man who initially presented with refractory erythema nodosum symptoms, including fever, arthritis, and painful erythema, and was finally diagnosed with BPDCN after a second skin biopsy. This case illustrates that skin lesions caused by BPDCN mimic ordinary erythema nodosum.

Dermatomyositis Presenting as Pseudo-angioedema | Annals of Internal Medicine: Clinical Cases

Dermatomyositis is an autoimmune inflammatory myopathy that has a heterogeneous clinical presentation, which can make it difficult to diagnose. We present the first case report of Wong-type dermatomyositis presenting with pseudo-angioedema. A 65-year-old man presented with several months of facial swelling, dysphagia, and dysarthria. The patient developed a diffuse cutaneous rash, periorbital swelling, and proximal muscle weakness. Skin biopsy was consistent with a diagnosis of Wong-type dermatomyositis.

Multiple Organ Dysfunction Syndrome Secondary to Multiple Wasp Stings: A Case Report | Annals of Internal Medicine: Clinical Cases

Wasp sting is common in resource-limited countries like Viet Nam. Symptoms can range from mild (itching, urticaria, and angioedema) to severe (multiorgan dysfunction), which increases mortality. Rhabdomyolysis and acute respiratory distress syndrome are rare complications but yield a high risk of death, thus requiring emergent interventions. We present a case of a 32-year-old man suffering from multiple wasp stings. The patient manifested several swollen, erythematous, and tender stings, and then developed a high fever, dyspnea, and reddish urine. He was diagnosed with multiple organ dysfunction syndrome, including severe hemolysis, acute kidney injury, liver injury, and acute respiratory distress syndrome.

Hypoglossal Nerve Paralysis Caused by Diffuse Idiopathic Skeletal Hyperostosis | Annals of Internal Medicine: Clinical Cases

Diffuse idiopathic skeletal hyperostosis (DISH) is a rare disease characterized by bony overgrowth of the spine. If severe enough, it can lead to dysphagia from many different mechanisms. These most commonly include mechanical obstruction, inflammation, or vocal cord paralysis. In our patient case, DISH caused paralysis of the hypoglossal nerve, which contributed to his dysphagia. Paralysis of the hypoglossal nerve as a result of DISH has not yet been reported in the literature.

Stress Cardiomyopathy in Chronic Obstructive Pulmonary Disease and Asthma Exacerbations: A Narrative Literature Review | Annals of Internal Medicine: Clinical Cases

In patients with asthma or chronic obstructive pulmonary disease exacerbations, the association between use of β-adrenergic agonists and stress cardiomyopathy is becoming increasingly recognized. Considering the emergence of this association, we sought to consolidate information from the existing body of literature to derive observational trends. One case series and 8 case reports were reviewed. Sex, age, ethnicity, comorbid conditions, presenting symptoms, electrocardiogram findings, troponin values, amount and type of β-agonist used, and time to resolution of cardiomyopathy were examined.

Point-of-Care Ultrasound: An Emerging Tool for Diagnosing Calciphylaxis | Annals of Internal Medicine: Clinical Cases

Calciphylaxis is a disease involving medial calcification of dermal arterioles, resulting in cutaneous necrosis. Diagnosis is typically clinical, but it is frequently misdiagnosed. Skin biopsy, the gold standard diagnostic test, is hindered by risk, patient refusal, and difficulties with histologic evaluation. This case series investigates using soft tissue point-of-care-ultrasound (POCUS) to aid in diagnosis. It describes ultrasound images obtained from patients diagnosed with calciphylaxis. These potentially pathognomonic sonographic findings in the proper clinical context include superficial hyperechoic foci lining small-caliber vessels with posterior acoustic shadowing. This demonstrates the diagnostic potential of POCUS in evaluating patients with possible calciphylaxis.

Thriving at the annual meeting in your early-career years

MKSAP Quiz: Evaluation for worsening choking

Opioid use declined in chronic pain patients with no increase in nonpharmacologic therapy

Federation of State Medical Boards updates guidelines for chronic use of opioids

PASC defined, analyzed by latest COVID-19 studies

Complementary, integrative health services increasing in VA system

MKSAP Quiz: Evaluation for stiffness and pain

MKSAP Quiz: 10-year history of chronic pain

In older adults, psychological therapies have small benefits for treating chronic pain, review finds

Extended-release morphine didn't improve breathlessness in COPD

Catching postop problems | ACP Hospitalist

Reducing returns to the ED | ACP Hospitalist

Cases from the University of Massachusetts | ACP Hospitalist

Cases from Legacy Health | ACP Hospitalist

Helping hip fracture patients | ACP Hospitalist

A collection of individual cases | ACP Hospitalist

Cases from the Medical College of Wisconsin | ACP Hospitalist

Troponin levels in chronic kidney disease | ACP Hospitalist

New antibiotic, report on drug shortages | ACP Hospitalist

The risky rise of gabapentinoids | ACP Hospitalist