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Displaying 31 - 40 of 448 in Policy Library
Displaying 31 - 40 of 1899 in Annals of Internal Medicine
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How Would You Manage This Patient With Benign Prostatic Hyperplasia?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 4
Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common in older patients assigned male sex at birth, regardless of gender identity, and treatment of these symptoms is therefore common in primary care practice. In 2021, the American Urological Association published guidelines for management of BPH. They recommend using a standardized scoring system such as the International Prostate Symptom Score to help establish a diagnosis and to monitor the efficacy of interventions, α-blockers as the first-choice pharmacotherapy option, and 5α-reductase inhibitors for patients with prostate size estimated to be at least 30 cc. Tadalafil is another option regardless of erectile dysfunction. Combination therapies with α-blockers and 5α-reductase inhibitors, anticholinergic agents, or β3-agonists are effective options. A surgical referral is warranted if the BPH results in chronic kidney disease, refractory urinary retention, or recurrent urinary tract infections; if there is concern for bladder or prostate cancer; or if symptoms do not respond to medical therapy. In this article, a general internal medicine physician and a urologist discuss the treatment options and how they would apply their recommendations to a patient who wishes to learn more about his options.
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)
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.
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.
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).
What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria
The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.
How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 169, No 11
Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a “treat-to-target” approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks (“treat-to-avoid-symptoms”) with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.
Displaying 31 - 40 of 85 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.
Acute Anterior Uveitis Following Intravenous Zoledronate for Osteoporosis | Annals of Internal Medicine: Clinical Cases
Postmenopausal osteoporosis is a common health issue clinicians encounter in practice for which bisphosphonates are commonly prescribed with success. However, these agents may cause intolerable gastrointestinal side effects when administered orally. In such cases, intravenous (IV) bisphosphonates may be prescribed. Post-infusion transient side effects are common, but more uncommon severe adverse effects may develop. We report a case of acute anterior uveitis following the use of IV zoledronate.
Recurrent Strokes in a Hypertensive Smoker: An Atypical Case and Review of Thrombotic Thrombocytopenic Purpura | Annals of Internal Medicine: Clinical Cases
Thrombotic thrombocytopenic purpura (TTP) can present with neurologic symptoms before the development of typical hematologic abnormalities. We describe a patient presenting with decreased grip strength in his right hand who was found to have an ischemic stroke from acute TTP. In the setting of subtle hematologic abnormalities, detection of severely decreased ADAMTS13 activity aided in early diagnosis and prompt initiation of plasmapheresis. Hence, we emphasize the need for high clinical suspicion for TTP in patients with recurrent and cryptogenic strokes, especially in the setting of subtle hematologic findings, as early treatment decreases mortality rate by almost 90%.
A Case of Hyperviscosity Syndrome in Rheumatoid Arthritis | Annals of Internal Medicine: Clinical Cases
Hyperviscosity syndrome (HVS) is a rare complication of both monoclonal and polyclonal disorders associated with elevation of immunoglobulins. Here, we describe a female patient who presented with shortness of breath and a history of seropositive rheumatoid arthritis with deformities, significant barriers to care, and poor therapeutic adherence. Her rheumatoid factor titer was greater than 1000 kIU/L, and she had an elevated serum viscosity level with her presentation consistent with HVS which improved significantly after therapeutic plasmapheresis. Our case highlights the presentation of rare but potentially life-threatening HVS that can occur in patients with systemic autoimmune rheumatic disorder.
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.
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.
Laryngeal Histoplasmosis in an Immunocompromised Host | Annals of Internal Medicine: Clinical Cases
Laryngeal histoplasmosis is a rare manifestation of histoplasmosis infection and presents as a diagnostic challenge. It has been documented to occur in immunocompromised and immunocompetent hosts. This is a case of laryngeal histoplasmosis in a patient with idiopathic CD4 lymphocytopenia, an immunocompromising condition that presents similarly to HIV. There is no known cause or standardized treatment of idiopathic CD4 lymphocytopenia, which leaves patients at risk for opportunistic infections and malignancy.
Successful Extracorporeal Membrane Oxygenation After a Challenging Cannulation in a Pregnant Patient With COVID-19 | Annals of Internal Medicine: Clinical Cases
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for fulminant COVID-19 pneumonia in a person with a viable pregnancy is controversial because many experts recommend delivery of the fetus before maternal ECMO. We describe V-V ECMO use for COVID-19 in a pregnant person at 28 weeks gestation. An inability to pass a guidewire from the jugular vein to the inferior vena cava complicated bedside ECMO cannulation, mandating a jugular-femoral 2-cannula approach that involves risk near a gravid uterus. In this case, procedural flexibility and multispecialty collaboration led to good maternal and fetal outcomes after 6 days of ECMO support.
Hydroxychloroquine-Induced Dilated Cardiomyopathy: A Case Report | Annals of Internal Medicine: Clinical Cases
Hydroxychloroquine (HCQ) cardiomyopathy (CM) usually presents with a hypertrophic or restrictive pattern. We present a patient case of dilated HCQ-CM with normal wall thickness in young woman with systemic lupus erythematosus and end-stage kidney disease. In patients undergoing renal replacement therapy, the daily dose should be lower than recommended by the manufacturer to avoid toxic effects.