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Gert Bronfort, DC, PhD; Maria A. Hondras, DC, MPH; Craig A. Schulz, DC, MS; Roni L. Evans, DC, PhD; Cynthia R. Long, PhD; and Richard Grimm, MD, PhD

Patients with back-related leg pain are often treated with prescription medications, injections, and surgical approaches, which has led to concern about their overuse, costs, and safety. This randomized trial compared spinal manipulative therapy plus home exercise and advice with home exercise and advice alone for reducing back-related leg pain. It found that spinal manipulative therapy improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks, but these benefits were not sustained at 52 weeks.

Topics: back pain, exercise, lower limb pain, manipulation, spinal
Daniel B. Mark, MD, MPH; J. David Knight, MS; Eric J. Velazquez, MD; Jaroslaw Wasilewski, MD, PhD; Jonathan G. Howlett, MD; Peter K. Smith, MD; John A. Spertus, MD, MPH; Miroslaw Rajda, MD; Rakesh Yadav, DM; Baron L. Hamman, MD; Marcin Malinowski, MD; Ajay Naik, MD, DM, DNB; Gena Rankin, MPH; Tina M. Harding, RN, BSN; Laura A. Drew, RN, BSN; Patrice Desvigne-Nickens, MD; and Kevin J. Anstrom, PhD

This randomized trial compared a strategy of routine coronary artery bypass grafting (CABG) with guideline-based medical therapy in patients with ischemic left ventricular dysfunction, a group not represented in earlier clinical trials. It found that CABG plus medical therapy produced clinically important improvements in several health status domains compared with medical therapy alone.

Topics: ischemia, coronary artery bypass surgery, chest pain, ventricular dysfunction, left, heart failure, ...
Joshua J. Gagne, PharmD, ScD; Niteesh K. Choudhry, MD, PhD; Aaron S. Kesselheim, MD, JD, MPH; Jennifer M. Polinski, ScD, MPH; David Hutchins, MBA, MHSA; Olga S. Matlin, PhD; Troyen A. Brennan, MD; Jerry Avorn, MD; and William H. Shrank, MD, MSHS

Statins are the most frequently prescribed drugs in the United States, but evidence suggests that patients do not fully adhere to statin therapy. This observational study of a large cohort of Medicare beneficiaries examined whether patients were more adherent to therapy with generic versus brand-name statins and whether this resulted in differences in health outcomes. The results suggest that initiation of a generic statin was associated with lower out-of-pocket costs, greater adherence to therapy, and improved clinical outcomes.

Topics: myocardial infarction, hypercholesterolemia, statins, antilipemic agents, cerebrovascular accident, ischemic stroke, drug costs, ...
Mary Butler, PhD, MBA; Edward Ratner, MD; Ellen McCreedy, MPH; Nathan Shippee, PhD; and Robert L. Kane, MD

Many severely or terminally ill patients do not have advance directives, but decision aids are available to help patients consider health care options. This article describes several decision aids that are available to guide adults in advance care planning, identifies a framework for future research, and summarizes published studies that used a decision aid as an intervention.

Topics: end-of-life care, terminal patient care, decision support techniques, terminally ill, terminal illness, ...
Helen R. Stagg, PhD; Dominik Zenner, MD; Ross J. Harris, MSc; Laura Muñoz, MD; Marc C. Lipman, MD; and Ibrahim Abubakar, MBBS, PhD

This network meta-analysis of 53 trials addresses the benefits and harms of 15 regimens aimed at preventing active tuberculosis in patients with latent infection. It found that therapies containing rifamycin, given for 3 months or more, were reasonably well-tolerated and efficacious. Such regimens containing rifamycin may be effective alternatives to isoniazid monotherapy.

Topics: antitubercular agents, mycobacterium tuberculosis, tuberculosis, latent tuberculosis, hepatotoxicity, isoniazid, rifamycins
Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Mary Ann Forciea, MD, MS; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians

This American College of Physicians (ACP) guideline on the nonsurgical management of urinary incontinence (UI) in women recommends pelvic floor muscle training in women with stress UI, bladder training in women with urgency UI, and both in women with mixed UI. It also recommends against systemic pharmacologic therapy for stress UI but recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful.

Topics: pharmacotherapy, weight reduction, exercise, urinary incontinence, women, urge incontinence, pelvic floor exercises, ...
Andrew J. Vickers, PhD; Kelly Edwards, PhD; Matthew R. Cooperberg, MD, MPH; and Alvin I. Mushlin, MD, ScM

Prostate-specific antigen (PSA) screening for prostate cancer is a problematic aspect of primary care. Most guidelines recommend informed decision making by the patient after a discussion with a physician, but how to best implement such decision making is unclear. The authors propose an approach for informed decision making about PSA testing that is evidence-based, facilitates a discrete decision, and is appropriate for primary care settings.

Topics: decision making, prostate-specific antigen, prostate cancer, prostate cancer screening, schema, prostate-specific antigen ...
Shyam Kottilil, MD, PhD; Mary Wright, MD, MPH; Michael A. Polis, MD, MPH; and Henry Masur, MD

Treatment of hepatitis C virus infection has entered a new era in which the cure of individual patients is eminently feasible and community-wide eradication is conceivable. This commentary evaluates the role of internists in initiating and managing treatment of this condition.

Topics: hepatitis c, chronic, hepatitis c, hepatitis c virus

On 30 April 2014, the Medicare Evidence Development&Coverage Advisory Committee issued a vote of low confi-dence about whether the benefits of low-dose computed tomography (LDCT) screening for lung cancer would out-weigh harms among Medicare beneficiaries in a community setting. This commentary discusses potential strategies to implement lung cancer screening with LDCT in a responsible manner that avoids overzealous screening.

Topics: lung cancer, lung cancer screening, low-dose spiral ct

In this issue, Gagne and colleagues' observational study examined whether the use of generic versus brand-name statins affected patients' adherence to therapy and health outcomes. The editorialists discuss the findings and stress the importance of economic factors in medication adherence.

Topics: myocardial infarction, statins, patient compliance, antilipemic agents, cerebrovascular accident, ischemic stroke, drug ...

In this issue, Stagg and colleagues' network meta-analysis compares treatment regimens for Mycobacterium tuberculosis infection to identify which options provide the optimal balance of efficacy and tolerability. The editorialists discuss the findings and conclude that it is time to switch focus to short-course, rifamycin-containing regimens.

Topics: antitubercular agents, isoniazid, mycobacterium tuberculosis, tuberculosis, rifamycins, latent tuberculosis, hepatotoxicity
Inginia Genao, MD
Includes: Audio/Video

Early morning, I got the news of my mother's admission to the hospital. My drive to see her was quiet and solemn. The trees were leaning forward with the weight of snow.

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Walter C. Willett, MD, DrPH; Meir J. Stampfer, MD, DrPH; and Frank M. Sacks, MD
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Christine Dawczynski, PhD; Marcus E. Kleber, PhD; Winfried März, PhD; Gerhard Jahreis, PhD; and Stefan Lorkowski, PhD
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Bonnie F. Liebman, MS; Martijn B. Katan, PhD; and Michael F. Jacobson, PhD
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Lisa Te Morenga, PhD; Jim Mann, PhD, DM; and Murray Skeaff, PhD
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Lukas Schwingshackl, MSc, BSc; and Georg Hoffmann, PhD
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Connie Diekman, MEd, RD, CSSD, LD, FAND; Gerard Hornstra, PhD Med; Bethold V. Koletzko, MD, PhD; Anna Lartey, PhD; and Joyce Nettleton, DSc
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Johanna M. Geleijnse, PhD; Ingeborg A. Brouwer, PhD, MSc; and Daan Kromhout, PhD, MSc
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Adrienne O’Neil, BA Hons, PhD; and Catherine Itsiopoulos, BSc (Hons), Grad Dip Diet, MPH, PhD, APD, AN
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Emanuele Di Angelantonio, MD, MSc, PhD; Rajiv Chowdhury, MD, PhD; Nita G. Forouhi, PhD; and John Danesh, FRCP
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Woods Nash, MPH, PhD
Includes: Audio/Video
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Topics: benzodiazepines, benzodiazepine dependence, elderly, benzodiazepine withdrawal, benzodiazepine adverse effects
Topics: benzodiazepines, primary health care, benzodiazepine withdrawal, benzodiazepine adverse effects
Topics: mediterranean diet, fat-restricted diet, diabetes mellitus, type 2, hypoglycemic agents
Topics: calcium, fracture, postmenopause, vitamin d, elderly, prevention
Topics: influenza, influenza virus vaccine, orthomyxoviridae, vaccination, vaccines adverse reaction, flu-like illness
Topics: acute coronary syndromes, angina pectoris, myocardial infarction, fatty acids, dietary supplements, coronary ...
Topics: heparin, pulmonary embolism, hemodynamics, pulmonary embolism, massive, acute, tenecteplase, ischemic stroke, decompensation ...
Topics: pulmonary embolism, thrombolytic therapy, hemorrhage, mortality
Topics: anticoagulants, oral, hemorrhage, kidney failure, chronic, drug potency, vitamin k antagonist
Topics: erythrocyte transfusion, nosocomial infection
Topics: hiv, isoniazid, mycobacterium tuberculosis, anti-retroviral agents, active tuberculosis, tuberculosis
Topics: aspirin, pregnancy, live birth, pregnancy loss

The Consult Guys bring a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations.

Topics: heart
Topics: back pain, exercise, manipulation, spinal, lower limb pain
Topics: angina pectoris, ischemia, coronary artery bypass surgery, chest pain, ventricular dysfunction, left, ...
Topics: myocardial infarction, hypercholesterolemia, statins, antilipemic agents, cerebrovascular accident, ischemic stroke, drug costs, ...
Topics: pharmacotherapy, urinary incontinence, urinary incontinence, stress, women, oxybutynin chloride, clinical practice guideline, ...
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