Solutions to the Challenges Facing Primary Care Medicine: Comprehensive Strategies from ACP

Rural Primary Care

The Role of International Medical Graduates in the U.S. Physician Workforce

Reforming the Medical Professional Liability Insurance System

Physician Practice Expenses: What Does the Independent Research Show?

The Paperless Medical Office: Digital Technology's Potential for the Internist

Medicare Integrity Program Contracting Initiatives and Proposed Regulations to Implement the Medicaid Managed Care Provisions of the Balanced Budget Act of 1997. Statement to the Practicing Physicians Advisory Council.

Human Immunodeficiency Virus (HIV) Infection

Five Prescriptions for Ensuring the Future of Primary Care

Ethical Considerations for Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid & Beyond

In gluteal tendinopathy, education + exercise improved outcomes vs corticosteroid injection or wait strategy

Source Citation Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662. 29720374

Physiotherapy reduced recurrent headaches linked to neck pain and dysfunction in older adults

Source Citation Uthaikhup S, Assapun J, Watcharasaksilp K, Jull G. Effectiveness of physiotherapy for seniors with recurrent headaches associated with neck pain and dysfunction: a randomized controlled trial. Spine J. 2016 Aug 4. [Epub ahead of print]. 27497890

In non–low back musculoskeletal injuries, NSAIDs and acetaminophen reduce acute pain

Source Citation Busse JW, Sadeghirad B, Oparin Y, et al. Management of acute pain from non-low back, musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials. Ann Intern Med. 2020;173:730-8. 32805127

Annals Story Slam - When You Know What Is Right, There Is No Decision: The Case of a Surgeon Needing Help at Another Hospital

Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable Angina

The Relationship of Obesity to Hospice Use and Expenditures

Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis

Annals Graphic Medicine - Helpless

Chess Lessons: Harnessing Collective Human Intelligence and Imitation Learning to Support Clinical Decisions

Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials: Annals of Internal Medicine: Vol 173, No 9

Background: Patients and clinicians can choose from several treatment options to address acute pain from non–low back, musculoskeletal injuries. Purpose: To assess the comparative effectiveness of outpatient treatments for acute pain from non–low back, musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs). Data Sources: MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020. Study Selection: Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non–low back, musculoskeletal injuries. Data Extraction: Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Data Synthesis: The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (≤2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence). Limitations: Only English-language studies were included. The number of head-to-head comparisons was limited. Conclusion: Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit–harm ratio for patients with acute pain from non–low back, musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms. Primary Funding Source: National Safety Council. (PROSPERO: CRD42018094412)

Cryoglobulinemic Glomerulonephritis Presenting as Acute Kidney Injury on Chronic Kidney Disease in Rheumatoid Arthritis | Annals of Internal Medicine: Clinical Cases

Cryoglobulinemic vasculitis (CV) is one of the manifestations of rheumatoid arthritis (RA). Here, we present a case of a 69-year-old woman with uncontrolled long-standing RA who presented with heart failure exacerbation and had an incidental finding of persistent acute kidney injury, which led to the diagnosis of CV. The rarity of its co-occurrence with RA and the serious consequences from progressive kidney damage makes this case a key learning encounter.

Atypical Hemolytic Uremic Syndrome Precipitated by Recurrent Pancreatitis | Annals of Internal Medicine: Clinical Cases

Atypical hemolytic uremic syndrome presents with negative direct antiglobulin test microangiopathic hemolytic anemia, acute kidney injury, and thrombocytopenia in the absence of diarrhea. Atypical hemolytic uremic syndrome may be triggered by drugs, infections, systemic lupus erythematosus, or, rarely, pancreatitis. Furthermore, recurrent hemolytic uremic syndrome should raise suspicion for complement-mediated atypical hemolytic uremic syndrome treated with eculizumab, an anti-C5 monoclonal antibody. Here, we report a case of complement-mediated atypical hemolytic uremic syndrome likely precipitated by recurrent alcohol-induced pancreatitis.

Antibiotic and Surgical Treatment of a Ventriculoperitoneal Shunt-Related Soft Tissue Abscess Caused by Brucella melitensis | Annals of Internal Medicine: Clinical Cases

We report on the antibiotic and surgical treatment of a woman who presented with an abscess caused by Brucella melitensis related to a ventriculoperitoneal shunt, which is an atypical presentation of brucellosis. There were no signs of neurologic, osteoarticular, or peritoneal infection. The abscess initially healed after ultrasound-guided drainage and antibiotic treatment with gentamycin/doxycycline for 5 days, followed by doxycycline/ciprofloxacin for 8 weeks, allowing shunt preservation. Three months after treatment ended, however, a relapse occurred that required partial surgical shunt revision and readministration of antibiotics. Seven months after surgery and 12 months after the initial diagnosis, the patient's remission status has been maintained.

Uncommon Presentation of Autoimmune Pancreatitis With Refractory Ulcerative Colitis | Annals of Internal Medicine: Clinical Cases

Patients diagnosed with autoimmune pancreatitis (AIP) are at significantly higher risk for ulcerative colitis (UC), and the concurrent diagnoses continue to be a challenge to recognize. A previously healthy symptomatic 23-year-old man was diagnosed with type II AIP with UC and, despite aggressive treatment with steroids and infliximab, ultimately had a total colectomy. This patient case illustrates the association between AIP and UC and proposes that a concomitant diagnosis suggests a worse prognosis. Determining the relationship between these 2 pathologies and early diagnosis will allow physicians to escalate therapy more quickly and improve outcomes in patients.

Spontaneous Hemopericardium: A Lesson on Risk-Benefit Profile of Contemporary Oral Anticoagulant Therapy Prompted by an Uncommon Occurrence | Annals of Internal Medicine: Clinical Cases

Anticoagulation therapy is of paramount importance in atrial fibrillation (AF) because of the substantial risk for stroke associated with high morbidity and mortality. The current therapeutic options include vitamin K antagonists and novel oral anticoagulant agents. Despite meticulous therapy selection, the risk for bleeding remains with all forms of anticoagulation and has infrequently been reported in the form of hemopericardium. We highlight a patient case of an 84-year-old man with a history of permanent atrial fibrillation on warfarin who presented with shortness of breath and was found to have a massive hemopericardium.

Lymphoid Interstitial Pneumonia Associated With Hashimoto Thyroid Disease | Annals of Internal Medicine: Clinical Cases

Lymphoid interstitial pneumonia (LIP) refers to the diffuse infiltration and accumulation of lymphocytes within the alveolar interstitium and may be associated with multiple autoimmune diseases, most notably Sjögren syndrome. Only rare cases of LIP have been reported in patients with Hashimoto thyroiditis. In these cases, the patients also had at least 1 additional autoimmune disease. We report a case of LIP in a 70-year-old woman whose only autoimmune disease was Hashimoto thyroiditis. This case supports the hypothesis that Hashimoto thyroiditis alone may instigate the development of LIP.

Aortic Stenosis: A New Physiologic Approach With the Stress Aortic Valve Index | Annals of Internal Medicine: Clinical Cases

The stress aortic valve index is a new validated way for grading the severity of aortic stenosis. These measurements are based on physiologic (stress) conditions, rather than the traditional resting indices, used in echocardiography. The essence of these measurements is described in this case report.

Radiation Therapy for Endobronchial Chronic Lymphocytic Leukemia Causing Extrinsic Airway Compression—A Novel Treatment Strategy | Annals of Internal Medicine: Clinical Cases

Here, we report a case of a very rare manifestation of chronic lymphocytic leukemia (CLL)—lobar lung collapse and partial airway occlusion from direct endobronchial involvement of the disease, complicated by bacterial infections requiring antibiotics. Because this was the only symptomatic site of disease, the patient was not treated systemically, which is the typical treatment strategy for CLL, but with focal radiation therapy, resulting in good symptomatic improvement. Radiation therapy for endobronchial CLL has never been reported, to our knowledge, and given the patient's good clinical outcome, could be a feasible alternative to avoid the side effects of systemic therapy for similar cases in the future.

COVID-19–Mediated Electrical Storm Managed With Milrinone in a Vaccinated Patient | Annals of Internal Medicine: Clinical Cases

SARS-CoV-2 infection (COVID-19) can lead to an inflammatory response affecting multiple organs. Ventricular arrhythmias, including ventricular tachycardia and ventricular fibrillation (VF), have been reported in otherwise-healthy individuals who have not been vaccinated. A young, otherwise-healthy man who was vaccinated and recently diagnosed with COVID-19 was admitted for refractory VF. Common pharmaceutical agents for VF were given to no avail. VF resolved with use of low-dose milrinone infusion. An inotropic agent usually used in patients with heart failure, milrinone also possesses proven anti-inflammatory effects, which may have allowed it to succeed where the traditional agents failed.

A Case of Adult-Onset Still Disease Masquerading as Dermatomyositis | Annals of Internal Medicine: Clinical Cases

Adult-onset Still disease (AOSD) is a systemic autoinflammatory disorder characterized by quotidian fevers, arthralgia/arthritis, and an evanescent rash. To our knowledge, we are reporting the first U.S. case presenting with the triad of dermatomyositis-like rash, proximal muscle weakness, and muscle atrophy without inflammatory myositis. Although AOSD and dermatomyositis are distinct clinical entities, both converge on the downstream JAK-STAT signaling pathway, a therapeutic target in refractory disease. A literature review suggests that dermatomyositis-like rashes represent an atypical AOSD variant more common in the Asia-Pacific region. Recognition of these rashes is essential, as they are linked to delayed diagnosis, refractory disease, and increased mortality.

Vitamin D did not lower fracture risk in generally healthy patients, study finds

No additional benefit seen for self-monitored blood glucose with community health worker support

NIH adds another antibody to recommended treatments, studies look at early cases, racial disparities

MKSAP Quiz: 1-year history of progressive fatigue, dyspnea, edema

Latest COVID-19 guidelines come out against bamlanivimab, remdesivir

HCV treatment by NPs, PCPs appears safe, effective as that provided by subspecialists

MKSAP quiz: Evaluation for recurrent nephrolithiasis

Diagnostic follow-up after positive lung cancer screening often falls short

Low-molecular-weight heparin may not prevent VTE after knee arthroscopy or lower-leg casting, studies find

Fish oil may lower rate of serious cardiovascular events for those undergoing hemodialysis, study finds

Managing neutropenic fever in oncology patients | ACP Hospitalist

Fighting the subconscious biases that lead to health care disparities | ACP Hospitalist

The problem with pulse ox | ACP Hospitalist

Little plastic Santa | ACP Hospitalist

10th Annual Top Hospitalists issue | ACP Hospitalist

POCUS cases from Mayo Clinic | ACP Hospitalist

A code for improving transitions of care | ACP Hospitalist

Readmission impossible | ACP Hospitalist

A different score and factor to consider before surgery | ACP Hospitalist

Candidemia became more common, more deadly from 2015 to 2024 | ACP Hospitalist