Annals for Educators - 19 January 2021
Authors: Christine Laine
Journal: Annals of Internal Medicine (2021)

Web ExclusivesJanuary 2021Annals for Educators - January 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202101190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPhysical Therapy Referral From Primary Care for Acute Back Pain With Sciatica. A Randomized Controlled TrialEarly Referral to Physical Therapy: A Reasonable Choice for Primary Care Patients With SciaticaThis randomized controlled trial examined the effects of early referral to physical therapy plus a single educational session versus a single educational session alone on disability among patients with acute sciatica. The accompanying editorial discusses the need to identify patients most likely to benefit from physical therapy and what it should include.Use this article and the accompanying editorial to:Start your session with a multiple-choice question. We provide one below.Ask your learners whether and when they consider referring patients with sciatica to physical therapy.Ask your learners what signs and symptoms would cause them to obtain an imaging study in a patient with low back pain and sciatica.Invite a physiatrist or physical therapist to participate in the session and discuss the information they like physicians to provide when referring a patient with sciatica for physical therapy.Patient Trajectories Among Persons Hospitalized for COVID-19. A Cohort StudyThis retrospective analysis determines factors at hospital admission that are predictive of severe disease or death from COVID-19 and describes patient trajectories and outcomes categorized using the World Health Organization's COVID-19 disease severity scale.Use this article to:Ask your learners what factors present at the time of hospitalization make them worried that a patient with COVID-19 is not going to do well.Invite a critical care physician to participate in the session and discuss the criteria at your institution that determine the need for ICU transfer of patients with COVID-19.Go to this site and have your learners enter data for several patients with COVID-19 they have cared for. Discuss whether your institution uses any of the risk calculators described in this article or a similar tool to inform clinical and resource allocation for patients with COVID-19. If not, discuss the advantages and disadvantages of using a tool like the COVID-19 Inpatient Risk Calculator.Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension. A Systematic Review and Individual Participant–based Meta-analysisWhether intensive blood pressure–lowering treatment in adults with hypertension causes orthostatic hypotension is unclear. This systematic review and meta-analysis examined risk for orthostatic hypotension before and in the setting of intensive treatment.Use this article to:Ask your learners about the optimal blood pressure targets they typically aim for when treating patients with hypertension.Ask your learners to define orthostatic hypotension, and have someone demonstrate how to assess for orthostasis during an outpatient encounter.Discuss the eligibility criteria for trials that showed benefit of intensive blood pressure lowering. How often do patients in their practices meet these criteria?Recent Trends in Cannabis Use in Older AmericansThis article describes recent trends in cannabis use among Americans aged 55 years or older.Use this article to:Ask your learners whether they routinely ask patients about cannabis use, regardless of age.Discuss the laws regarding cannabis use for medical and recreational purposes in the states where your patients generally reside.Are there conditions for which your learners recommend cannabis to patients? Discuss the data supporting this.Health PolicyA Health Opportunity Cost Threshold for Cost-Effectiveness Analysis in the United StatesThe Patient Not in the RoomThis study evaluates one way to establish a cost-effectiveness threshold for U.S. policy considerations by estimating how many years of life people lost when they gave up health insurance because of an increase in the policy's price. The accompanying editorial discusses how this work will facilitate dialogue about value and fairness in U.S. health care.Use this article and the accompanying editorial to:Ask your learners whether they think the U.S. health care system and insurers should factor cost-effectiveness into coverage decisions.What are the benefits and harms of considering cost-effectiveness in such decisions?Do the thresholds for cost-effectiveness identified in this study seem reasonable to your learners?Sickle Cell DiseaseSickle cell disease is characterized by hemolytic anemia, significant chronic end-organ damage, and early death. This review provides an overview of the fundamentals of sickle cell disease diagnosis, the acute and chronic clinical manifestations, and the management of the disease and its most common complications.Use this article to:Ask your learners about their experiences caring for patients with sickle cell disease.What specific screening and diagnostic tests should be done in adults suspected of having sickle cell disease or sickle cell trait?Discuss the appropriate management of a painful sickle cell crisis.Discuss the circumstances that warrant referral of a patient with sickle cell disease to a specialist. What specialty resources for caring for patients with sickle cell disease are available in your area?Are there health implications for patients who have sickle trait?Humanism and ProfessionalismTime Out Before Talking: Communication as a Medical ProcedureThis article explains how taking a medical history, delivering bad news, and discussing care goals might be improved by considering how clinicians prepare for invasive technical interventions.Use this article to:Start the session with a role-play of a physician delivering bad news about a cancer diagnosis to a patient.Have your learners critique the communication demonstrated during the role-play. What worked well, and what could have improved the interaction?Ask your learners what they think about the argument put forth in this commentary—will thinking of communication as a procedure improve their interactions with patients?Medical Interventions That Take Less Than 8 Minutes and 46 SecondsIn 8 minutes and 46 seconds, you can see that your patients' health is not an isolated variable that can be thought of solely in the abstract.Use this article to:Start the session by listening to the audio recording of this On Being a Doctor essay. Ask your learners to identify social determinants of health.Discuss the challenges that social determinants of health present in the care of their patients.Discuss whether physicians should play a role in combating racism and other social determinants of health. If so, what actions can they take?MKSAP 18 QuestionA 38-year-old woman is evaluated for low back pain that began 7 days ago when she bent over to pick up a piece of paper. She describes the pain as moderate aching that is localized to the right lower back. A sharp pain intermittently radiates down the lateral aspect of the right leg. She has not had bowel or bladder dysfunction, fevers, leg weakness, night sweats, saddle anesthesia, or weight loss. She has no history of trauma, and she does not use intravenous drugs.On physical examination, vital signs are normal. BMI is 21. Musculoskeletal and neurologic examinations are normal.Which of the following is the most appropriate initial treatment?A. AcetaminophenB. DuloxetineC. Nonpharmacologic modalitiesD. OxycodoneCorrect AnswerC. Nonpharmacologic modalitiesEducational ObjectiveTreat a patient with acute low back pain with nonpharmacologic modalities.CritiqueThe most appropriate initial treatment of this patient's low back pain is nonpharmacologic therapy. According to a 2017 clinical practice guideline issued by the American College of Physicians, clinicians should choose nonpharmacologic treatments as first-line therapy for acute low back pain. Options include superficial heat, acupuncture, massage, and spinal manipulation. The quality of evidence supporting individual nonpharmacologic measures is moderate or low. Recommendations for their use are based on the fact that most patients with acute low back pain will improve over time (most within 4 weeks), regardless of the treatment chosen. Harms of nonpharmacologic interventions were seldom and minor. Superficial heat was associated with increased risk for skin flushing, and massage and spinal manipulation were associated with muscle soreness.Recent evidence, including a Cochrane review, has demonstrated that acetaminophen is not effective in treating acute low back pain. As such, it would be inappropriate to recommend its use in this patient.The FDA has approved the use of duloxetine in chronic back pain (pain lasting >12 weeks), as studies have demonstrated its effectiveness. However, no evidence supports its use for acute low back pain.Guidelines recommend that opioids should be the last treatment option considered for chronic back pain and should be considered only in patients in whom other therapies have failed, as these drugs are associated with substantial harms. Harms of short-term opioid therapy include increased constipation, dizziness, dry mouth, nausea, somnolence, and vomiting. Studies assessing opioids for the treatment of chronic low back pain did not address the risk for addiction, abuse, or overdose, although observational studies have shown a dose-dependent relationship between opioid use for chronic pain and serious harms. A 2018 randomized trial demonstrated that treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function for chronic back pain. In addition, pain intensity was significantly improved in the nonopioid group. There are no studies of opioids for the treatment of acute back pain, but given their questionable effect and substantial harms as well as the self-limited nature of acute nonspecific back pain, opioids should likely be avoided entirely.Key PointFirst-line treatment of acute low back pain is nonpharmacologic therapy, including acupuncture, massage, spinal manipulation, and superficial heat; most patients will improve over time, regardless of the treatment chosen.BibliographyQaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics January 2021Volume 174, Issue 1Page: ED1KeywordsBlood pressureCOVID-19Cannabis useHypotensionLower back painOpioidsPatientsSickle cell diseaseSystematic reviewsTreatment guidelines ePublished: 19 January 2021 Issue Published: January 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...