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1.
Ann Intern Med ; 177(6): 800-811, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38857499

ABSTRACT

Nearly 15% of U.S. adults have diabetes; type 2 diabetes (T2D) accounts for more than 90% of cases. Approximately one third of all patients with diabetes will develop chronic kidney disease (CKD). All patients with T2D should be screened annually for CKD with both a urine albumin-creatinine ratio and an estimated glomerular filtration rate. Research into strategies to slow the worsening of CKD and reduce renal and cardiovascular morbidity in patients with T2D and CKD has evolved substantially. In 2022, a consensus statement from the American Diabetes Association and the Kidney Disease: Improving Global Outcomes recommended prioritizing the use of sodium-glucose cotransporter-2 inhibitors and metformin and included guidance for add-on therapy with glucagon-like peptide 1 receptors agonists for most patients whose first-line therapy failed. It also recommended nonsteroidal mineralocorticoid receptor antagonists for patients with hypertension that is not adequately controlled with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Here, an endocrinologist and a nephrologist discuss the care of patients with T2D and CKD and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD.


Subject(s)
Diabetes Mellitus, Type 2 , Renal Insufficiency, Chronic , Sodium-Glucose Transporter 2 Inhibitors , Humans , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/drug therapy , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/drug therapy , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Hypoglycemic Agents/therapeutic use , Mineralocorticoid Receptor Antagonists/therapeutic use , Teaching Rounds , Diabetic Nephropathies/drug therapy , Metformin/therapeutic use , Glucagon-Like Peptide-1 Receptor/agonists , Glomerular Filtration Rate , Male
2.
Ann Intern Med ; 176(12): 1656-1665, 2023 12.
Article in English | MEDLINE | ID: mdl-38079640

ABSTRACT

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.


Subject(s)
Heart Failure , Sodium-Glucose Transporter 2 Inhibitors , Teaching Rounds , Infant, Newborn , Humans , Aged , Heart Failure/diagnosis , Heart Failure/drug therapy , Stroke Volume , Ventricular Function, Left , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use
3.
Ann Intern Med ; 176(4): 545-555, 2023 04.
Article in English | MEDLINE | ID: mdl-37037036

ABSTRACT

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 ß3-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.


Subject(s)
Prostatic Hyperplasia , Teaching Rounds , Female , Infant, Newborn , Humans , Male , Aged , Prostatic Hyperplasia/complications , Prostatic Hyperplasia/diagnosis , Prostatic Hyperplasia/drug therapy , Drug Therapy, Combination , Gender Identity , 5-alpha Reductase Inhibitors/therapeutic use , Adrenergic alpha-Antagonists/therapeutic use , Oxidoreductases/therapeutic use , Treatment Outcome
4.
Ann Intern Med ; 175(12): 1746-1753, 2022 12.
Article in English | MEDLINE | ID: mdl-36508740

ABSTRACT

Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. The American Academy of Sleep Medicine (AASM) published recent guidelines on behavioral and psychological treatment as well as pharmacologic therapy for chronic insomnia disorder. Regarding behavioral and psychological approaches, the only intervention strongly recommended was multicomponent cognitive behavioral therapy for insomnia. Regarding pharmacologic treatment, the AASM, based on weak evidence, suggested a limited number of medications that might be useful and others that probably are not. Here, 2 clinicians with expertise in sleep disorders-one a clinical psychologist and the other a physician-debate the management of a patient with chronic insomnia who has been treated with medications. They discuss the role of behavioral and psychological interventions and pharmacologic therapy for chronic insomnia and how the primary care practitioner should approach such a patient.


Subject(s)
Cognitive Behavioral Therapy , Sleep Initiation and Maintenance Disorders , Teaching Rounds , Humans
5.
Ann Intern Med ; 175(6): 862-872, 2022 06.
Article in English | MEDLINE | ID: mdl-35696686

ABSTRACT

Cardiovascular disease (CVD) is the leading cause of death in the United States. Hypercholesterolemia is a principal modifiable risk factor for the primary prevention of CVD. In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. A useful strategy to identify candidates for statins is to estimate the 10-year risk for CVD through the use of a validated risk calculator. Commonly used calculators include the Framingham risk score and the pooled cohort equation. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. Two recent guidelines have proposed an approach to the use of statins in primary prevention of CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans Affairs guidelines form the basis for this discussion. The guidelines differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin. In this paper, 2 experts, a preventive cardiologist and a general internist, discuss their approach to the use of statins for primary prevention of CVD and how they would apply the guidelines to an individual patient.


Subject(s)
Cardiovascular Diseases , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Teaching Rounds , Cardiovascular Diseases/prevention & control , Cholesterol, LDL , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Primary Prevention , Risk Assessment , Risk Factors , United States
6.
Ann Intern Med ; 174(8): 1133-1142, 2021 08.
Article in English | MEDLINE | ID: mdl-34370516

ABSTRACT

Male hypogonadism is defined as an abnormally low serum testosterone concentration or sperm count. As men age, often in the context of obesity and other comorbid conditions, serum testosterone levels may decrease. Normalizing serum testosterone levels in male adults with hypogonadism may improve symptoms related to androgen deficiency, but controversies exist regarding the long-term benefits and risks of hormone supplementation in this setting. In 2020, the American College of Physicians published a clinical guideline for the use of testosterone supplementation in adult men based on a systematic review of available evidence. Among their recommendations were that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function and not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition. Here, two clinicians with expertise in this area, one a generalist and the other an endocrinologist, debate the management of a patient with sexual symptoms and a low serum testosterone level. They discuss the diagnosis of male hypogonadism, the indications for testosterone therapy, its potential benefits and risks, how it should be monitored, and how long it should be continued.


Subject(s)
Hypogonadism/diagnosis , Hypogonadism/drug therapy , Testosterone/deficiency , Testosterone/therapeutic use , Adult , Humans , Male , Teaching Rounds
7.
Ann Intern Med ; 174(2): 237-246, 2021 02.
Article in English | MEDLINE | ID: mdl-33556279

ABSTRACT

Cannabis includes 140 active cannabinoid compounds, the most important of which are tetrahydrocannabinol and cannabidiol (CBD). Tetrahydrocannabinol is primarily responsible for the intoxicating effects of cannabis; CBD has potential therapeutic effects, including reduction in chronic pain. Recent legislative changes have resulted in the legal availability of cannabinoids in all 50 states, as well as a marked increase in patients' interest in their use. Despite an abundance of data, albeit of varied quality, clinicians may feel poorly prepared to counsel patients seeking advice on the suitability of CBD products for various indications, particularly chronic neuropathic pain. In 2018, on the basis of a systematic review of the literature, a Canadian Evidence Review Group published a guideline with recommendations for clinicians on prescribing cannabinoids in primary care practice. The overall quality of evidence was low to very low. In a meta-analysis of 15 randomized trials of medical cannabis for treating chronic pain, 39% of patients achieved at least a 30% reduction in pain. The corresponding value for placebo-treated patients was 30%; the number needed to treat was 11. More evidence exists for neuropathic pain than for other types of noncancer pain. Here, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature to make recommendations for a patient with painful diabetic neuropathy, including counseling on both potential benefits and harms.


Subject(s)
Cannabinoids/therapeutic use , Diabetic Neuropathies/drug therapy , Aged , Analgesics/adverse effects , Analgesics/therapeutic use , Cannabinoids/adverse effects , Chronic Pain/drug therapy , Female , Humans , Practice Guidelines as Topic , Treatment Outcome
8.
Am J Med ; 134(5): 626-636.e2, 2021 05.
Article in English | MEDLINE | ID: mdl-33130125

ABSTRACT

BACKGROUND: Coffee is one of the most widely consumed beverages globally. A substantial number of observational data suggest an inverse relationship between coffee consumption and the risk for cardiovascular disease. The basis for this association is not clear. In this review, we specifically study the impact of coffee on inflammatory biomarkers as one potential mechanistic basis for this observation. Our objective was to systematically review randomized controlled trials that examined the effects of coffee consumption on selected cardiovascular biomarkers. METHODS: We systematically reviewed bibliographic databases including PubMed (NCBI), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Clarivate Analytics), Cochrane Central Register of Controlled Trials (EBSCO), and CAB Abstracts (Clarivate Analytics). We searched for randomized controlled trials that studied the effect of drinking coffee on inflammatory markers of cardiovascular risk. RESULTS: The search of electronic databases returned 1631 records. After removing duplicate records and ineligible studies, we examined a total of 40 full-text documents, 17 of which were eligible for further analysis. In our review, boiled coffee, in particular, appeared to raise total and low-density lipoprotein cholesterol and apolipoprotein B, but evidence suggests no similar effect for filtered coffee. One study showed a significant increase in blood interleukin 6 levels among individuals who drank caffeinated coffee, compared with individuals consuming no coffee. CONCLUSION: Based on our systematic review of randomized controlled studies, we cannot confidently conclude that an anti-inflammatory effect of coffee is a major contributing factor to the lower all-cause mortality reported in observational studies.


Subject(s)
Cardiovascular Diseases/prevention & control , Coffee , Biomarkers/blood , Cardiovascular Diseases/blood , Cardiovascular Diseases/epidemiology , Coffee/metabolism , Heart Disease Risk Factors , Humans , Inflammation/blood , Randomized Controlled Trials as Topic
9.
Ann Intern Med ; 173(7): 563-571, 2020 10 06.
Article in English | MEDLINE | ID: mdl-33017547

ABSTRACT

In recent years, the number of patients choosing to have direct-to-consumer (DTC) genetic testing without involving their clinicians has increased substantially. For example, the number of subscribers to a commonly used testing site has grown to more than 10 million. These services have been heavily marketed in the United States and often include information about ancestry; genetic traits; and, increasingly, disease risk. In clinical care, genetic testing by a physician is accompanied by both pre- and posttest counseling by a trained genetic counselor. However, there are not enough genetic counselors to meet the needs of all persons contemplating DTC genetic testing. Formal genetic counseling includes preparation of a family pedigree; a discussion about potential benefits, the possibility that some information might be stressful to receive or difficult to understand, and the potential for disclosure of genetic information; and a detailed informed consent process. Some DTC tests for genetic susceptibilities look for only a few known mutations in a particular gene (such as BRCA1); a negative test result does not exclude the possibility of a clinically important mutation. A positive DTC genetic test result that might change clinical management should be followed by a confirmatory test through a genetics laboratory. Here, 2 expert physicians-a general internist and a medical oncologist with genetics experience-discuss an approach to counseling a patient who is considering DTC testing to learn more about his ancestry and his risk for metabolic syndrome.


Subject(s)
Direct-To-Consumer Screening and Testing , Genetic Testing/methods , Adult , Evidence-Based Medicine , Genetic Counseling , Humans , Male , Practice Guidelines as Topic , Referral and Consultation , Teaching Rounds , United States
10.
Ann Intern Med ; 172(11): 735-742, 2020 06 02.
Article in English | MEDLINE | ID: mdl-32479149

ABSTRACT

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.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , Pulmonary Disease, Chronic Obstructive/drug therapy , Administration, Inhalation , Adrenal Cortex Hormones/administration & dosage , Adrenal Cortex Hormones/adverse effects , Aged , Female , Humans , Practice Guidelines as Topic , Smoking/adverse effects , Treatment Outcome
11.
Ann Intern Med ; 171(11): 828-836, 2019 12 03.
Article in English | MEDLINE | ID: mdl-31791056

ABSTRACT

Atrial fibrillation (AFib) is the most common type of cardiac arrhythmia, affecting 2.7 million to 6.1 million persons in the United States. Although some persons with AFib have no symptoms, others do. For those without symptoms, AFib may be detected by 12-lead electrocardiogram (ECG), single-lead monitors (such as ambulatory blood pressure monitors and pulse oximeters), or consumer devices (such as wearable monitors and smartphones). Pulse palpation and heart auscultation also may detect AFib. In a systematic review, screening with ECG identified more new cases of AFib than no screening. Atrial fibrillation is an important cause of stroke, and without anticoagulant treatment, patients with AFib have approximately a 5-fold increased risk for stroke. The U.S. Preventive Services Task Force reviewed the benefits and harms of ECG screening for AFib in adults aged 65 years or older and found inadequate evidence that ECG identifies AFib more effectively than usual care. This conclusion is in contrast to guidelines from the European Society of Cardiology and the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, which found that active screening for AFib in patients older than 65 years may be useful. Here, 2 cardiologists discuss the risks and benefits of screening for AFib, if and when they would recommend screening, and whether they would recommend anticoagulation for a patient with screen-detected AFib.


Subject(s)
Atrial Fibrillation/diagnosis , Patient Selection , Diagnosis, Differential , Humans
12.
Ann Intern Med ; 171(7): 505-513, 2019 10 01.
Article in English | MEDLINE | ID: mdl-31569249

ABSTRACT

In the United States, 9.4% of all adults-and 25% of those older than 65 years-have diabetes. Diabetes is the leading cause of blindness and end-stage renal disease and contributes to both microvascular and macrovascular complications. The management of patients with type 2 diabetes (T2D) is a common and important activity in primary care internal medicine practice. Measurement of hemoglobin A1c (HbA1c) provides an estimate of mean blood sugar levels and glycemic control. The optimal HbA1c target level among various persons with T2D is a subject of controversy. Guidelines regarding HbA1c targets have yielded differing recommendations. In 2018, the American College of Physicians (ACP) published a guideline on HbA1c targets for nonpregnant adults with T2D. In addition to a recommendation to individualize HbA1c target levels, the ACP proposed a level between 7% and 8% for most patients. The ACP also advised deintensification of therapy for patients who have an HbA1c level lower than 6.5% and avoidance of HbA1c-targeted treatment for patients with a life expectancy of less than 10 years. This guidance contrasts with a recommendation from the American Diabetes Association to aim for HbA1c levels less than 7% for many nonpregnant adults and to consider a target of 6.5% if it can be achieved safely. Here, 2 experts, a diabetologist and a general internist, discuss how to apply the divergent guideline recommendations to a patient with long-standing T2D and a current HbA1c level of 7.8%.


Subject(s)
Diabetes Mellitus, Type 2/blood , Diabetes Mellitus, Type 2/drug therapy , Glycated Hemoglobin/analysis , Hypoglycemic Agents/therapeutic use , Diabetes Mellitus, Type 2/complications , Female , Guideline Adherence , Humans , Hypoglycemia/chemically induced , Hypoglycemic Agents/adverse effects , Middle Aged , Obesity/complications , Practice Guidelines as Topic , Risk Assessment , Teaching Rounds
13.
Ann Intern Med ; 170(11): 770-778, 2019 06 04.
Article in English | MEDLINE | ID: mdl-31158876

ABSTRACT

Prostate cancer is the third most common cancer type in the United States overall, accounting for 9.5% of new cancer cases and 5% of cancer deaths. The goal of prostate-specific antigen (PSA)-based screening is to identify early-stage disease that can be treated successfully. The U.S. Preventive Services Task Force (USPSTF) reviewed evidence on the benefits and harms of PSA-based screening and treatment of screen-detected prostate cancer. It found that PSA-based screening in men aged 55 to 69 years prevents approximately 1.3 deaths from prostate cancer over 13 years per 1000 men screened and 3 cases of metastatic cancer per 1000 men screened, with no reduction in all-cause mortality. No benefit was found for PSA-based screening in men aged 70 years and older. On the basis of its review, the USPSTF concluded that the decision for men aged 55 to 69 years to have PSA-based screening should be an individual one and should include a discussion of the potential benefits and harms. Here, 2 experts-an internist and a urologist-discuss the key points of a shared decision-making conversation about PSA-based prostate cancer screening, the PSA-based screening strategy that optimizes benefit and minimizes harm, and the PSA threshold at which they would recommend further diagnostic testing.


Subject(s)
Early Detection of Cancer , Prostate-Specific Antigen/blood , Prostatic Neoplasms/diagnosis , Aged , Decision Making, Shared , Humans , Internal Medicine , Male , Practice Guidelines as Topic , Referral and Consultation , Risk Assessment , Teaching Rounds , Urology
14.
Ann Intern Med ; 169(7): 474-484, 2018 10 02.
Article in English | MEDLINE | ID: mdl-30285208

ABSTRACT

Breast cancer will develop in 12% of women during their lifetime and is the second leading cause of cancer death among U.S. women. Mammography is the most commonly used tool to screen for breast cancer. Considerable uncertainty exists regarding the age at which to begin screening and the optimal screening interval. Breast density is a risk factor for breast cancer. In addition, for women with dense breasts, small tumors may be missed on mammography and the sensitivity of screening is diminished. At the time of publication, 35 states had passed laws mandating that breast density be reported in the letters that radiologists send to women with their mammogram results. The mandated language may be challenging for patients to understand, and such reporting may increase worry for women who are told that their risk for breast cancer is higher than average on the basis of breast density alone. The U.S. Preventive Services Task Force and the American College of Radiology (ACR) have each issued guidelines that address breast cancer screening for women with dense breasts. Both organizations found insufficient evidence to recommend for or against magnetic resonance screening, whereas the ACR advises consideration of ultrasonography for supplemental screening. In this Beyond the Guidelines, 2 experts-a radiologist and a general internist-discuss these controversies. In particular, the discussants review the role of supplemental breast cancer screening, including breast ultrasonography or magnetic resonance imaging for women with dense breasts. Finally, the experts offer specific advice for a patient who finds her mammography reports confusing.


Subject(s)
Breast Density , Breast Neoplasms/diagnosis , Early Detection of Cancer , Breast/pathology , Breast Neoplasms/diagnostic imaging , Breast Neoplasms/pathology , Female , Humans , Mammography , Middle Aged , Risk Factors , Teaching Rounds
15.
Ann Intern Med ; 169(3): 175-182, 2018 08 07.
Article in English | MEDLINE | ID: mdl-30083717

ABSTRACT

Hypertension is prevalent and the most important risk factor for cardiovascular disease. Controversy exists regarding the optimum threshold above which to begin antihypertensive therapy and the optimum target blood pressure once medication is begun. This controversy is particularly true for older patients, who may be more likely to benefit from treatment because of their higher risk for cardiovascular events, but may also be more at risk for adverse effects of treatment. Two guidelines published in 2017 address this issue. The American College of Physicians/American Academy of Family Physicians guideline recommends initiating antihypertensive therapy for older patients (aged 60 years or older) if systolic blood pressure is 150 mm Hg or higher and to treat to the same target. They recommend a lower threshold for starting treatment and a lower target systolic blood pressure (140 mm Hg) for patients with cerebrovascular disease and potentially those at high risk for cardiovascular events. The American College of Cardiology/American Heart Association guideline, which is based primarily on SPRINT (Systolic Blood Pressure Intervention Trial), advises a target systolic blood pressure of 130 mm Hg for community-dwelling ambulatory patients aged 65 years or older. This article presents the case of a 79-year-old man who is contemplating antihypertensive therapy. Two experts discuss the optimal approach for the patient and suggest how to apply the 2 guidelines to his care.


Subject(s)
Blood Pressure , Hypertension/drug therapy , Aged , Antihypertensive Agents/therapeutic use , Humans , Middle Aged , Practice Guidelines as Topic , Teaching Rounds , Treatment Outcome
16.
Ann Intern Med ; 168(11): 801-808, 2018 06 05.
Article in English | MEDLINE | ID: mdl-29868815

ABSTRACT

Osteoporosis is a skeletal disorder characterized by reduced bone strength that increases the risk for fracture. Approximately 10 million men and women in the United States have osteoporosis, and more than 2 million osteoporosis-related fractures occur annually. In 2016, the American Association of Clinical Endocrinologists issued the "Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis," and in 2017, the American College of Physicians issued the guideline "Treatment of Low Bone Density or Osteoporosis to Prevent Fracture in Men and Women." Both guidelines agree that patients diagnosed with osteoporosis should be treated with an antiresorptive agent, such as alendronate, that has been shown to reduce hip and vertebral fractures. However, there is no consensus on how long patients with osteoporosis should be treated and whether bone density should be monitored during and after the treatment period. In this Beyond the Guidelines, 2 experts discuss management of osteoporosis in general and for a specific patient, the role of bone density monitoring during and after a 5-year course of alendronate, and treatment recommendations for a patient whose bone density decreases during or after a 5-year course of alendronate.


Subject(s)
Bone Density Conservation Agents/therapeutic use , Clinical Decision-Making , Osteoporosis, Postmenopausal/drug therapy , Absorptiometry, Photon , Aged , Alendronate/therapeutic use , Bone Density , Diphosphonates/therapeutic use , Drug Administration Schedule , Female , Humans , Osteoporosis, Postmenopausal/diagnostic imaging , Osteoporosis, Postmenopausal/physiopathology , Osteoporotic Fractures/prevention & control , Practice Guidelines as Topic
18.
Cleve Clin J Med ; 84(11): 863-872, 2017 Nov.
Article in English | MEDLINE | ID: mdl-29173248

ABSTRACT

The authors performed a MEDLINE search to identify articles published between January 2016 and April 2017 that had significant impact on perioperative care. They identified 6 topics for discussion.


Subject(s)
Perioperative Care/methods , Aged, 80 and over , Atrial Fibrillation/drug therapy , Blood Vessel Prosthesis Implantation , Drug-Eluting Stents , Frail Elderly , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Perioperative Period , Sleep Apnea, Obstructive/diagnosis , Surgical Procedures, Operative/adverse effects , Surgical Procedures, Operative/methods
19.
Ann Intern Med ; 167(7): 484-492, 2017 10 03.
Article in English | MEDLINE | ID: mdl-28973212

ABSTRACT

In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were -2.0% (95% CI, -3.3% to -0.7%) and -3.5% (CI, -5.1% to -1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.


Subject(s)
Carotid Stenosis/diagnostic imaging , Mass Screening , Aged , Asymptomatic Diseases , Carotid Arteries/diagnostic imaging , Carotid Stenosis/complications , Carotid Stenosis/drug therapy , Carotid Stenosis/surgery , Endarterectomy, Carotid/adverse effects , Humans , Male , Postoperative Complications , Practice Guidelines as Topic , Risk Factors , Stroke/etiology , Stroke/prevention & control , Ultrasonography
20.
Ann Intern Med ; 167(3): 192-199, 2017 08 01.
Article in English | MEDLINE | ID: mdl-28761956

ABSTRACT

Depression is a major public health problem and a common cause of disability. To help physicians choose among available treatment options, the American College of Physicians recently issued a guideline titled "Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder." The evidence review done for the guideline found no statistically significant difference in the efficacy of second-generation antidepressants (SGAs) versus most other treatments for this disorder. However, rates of adverse events and discontinuation were generally higher in patients treated with SGAs. This Beyond the Guidelines reviews the guideline and includes a discussion between 2 experts on how they would apply it to a 64-year-old man with depression who is reluctant to begin medication. They review the data on which the guideline is based, discuss the limitations of applying the data to real-world settings, review how they would incorporate patient preferences when making treatment decisions, and outline options for patients in whom first-line therapy has failed.


Subject(s)
Antidepressive Agents, Second-Generation/therapeutic use , Depressive Disorder/drug therapy , Antidepressive Agents, Second-Generation/adverse effects , Cognitive Behavioral Therapy , Comparative Effectiveness Research , Complementary Therapies , Depressive Disorder/diagnosis , Depressive Disorder/therapy , Evidence-Based Medicine , Humans , Male , Middle Aged , Psychotherapy
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