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Jeffrey L Jackson

Publications and source records attributed to Jeffrey L Jackson.

At least 19 recordsLinked to original sources
PubMed2026

Systematic Review of Pharmacologic Treatment for Migraine Prevention in Adults: Report of the AAN Guidelines Subcommittee and the American Headache Society.

BACKGROUND AND OBJECTIVES: This systematic review (SR) provides updated evidence-based conclusions regarding the use of pharmacologic migraine prevention in adults to inform a new joint American Academy of Neurology (AAN) and American Headache Society practice guideline. METHODS: A multidisciplinary panel conducted an SR following the 2017 AAN Clinical Practice Guideline Process Manual. Randomized controlled trials evaluating pharmacologic preventive treatments for adults with episodic or chronic migraine were included. Searches encompassed MEDLINE, Embase, and ClinicalTrials.gov from database inception through June 6, 2024. Studies were screened in duplicate, with dual independent risk-of-bias assessment. Outcomes included change in monthly headache days, ≥50% responder rate, and validated patient-reported quality of life (QOL) measures. Raw mean differences, standardized mean differences, and risk ratios were calculated. A modified Grading of Recommendations Assessment, Development, and Evaluation process was used to classify certainty of evidence. RESULTS: A total of 217 studies met inclusion criteria. For episodic migraine, high-confidence evidence showed that galcanezumab and erenumab are more effective than placebo in reducing headache frequency. Moderate-confidence evidence supported benefit from atogepant, eptinezumab, fremanezumab, propranolol, topiramate, and valproate. Several additional oral agents including amitriptyline, bisoprolol, flunarizine, fluoxetine, levetiracetam, metoprolol, nifedipine, pizotifen, and telmisartan had low-confidence evidence suggesting possible benefit. For chronic migraine, high-confidence evidence supported reductions in headache frequency with fremanezumab, galcanezumab, and onabotulinumtoxinA. Moderate-confidence evidence supported benefit from atogepant, eptinezumab, erenumab, topiramate and valproate. Across both episodic and chronic migraine populations, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant, topiramate and onabotulinumtoxinA demonstrated improvements in patient-reported QOL outcomes on validated instruments. Evidence comparing active treatments was limited and generally of low or very low confidence, restricting conclusions about comparative effectiveness. DISCUSSION: This SR provides a comprehensive synthesis of evidence on pharmacologic migraine prevention in adults. High- and moderate-confidence findings confirm the efficacy of several established and newer preventive therapies and demonstrate improvements in patient-reported outcomes across multiple validated measures. These conclusions informed the development of evidence-based recommendations, presented in a companion publication, to guide clinicians in selecting preventive medications for adults with episodic and chronic migraine.

Humans↗
PubMed2006

The effect of early, intensive statin therapy on acute coronary syndrome: a meta-analysis of randomized controlled trials.

BACKGROUND: In addition to well-established secondary prevention benefits for atherosclerotic coronary artery disease, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are hypothesized to have short-term benefit in acute coronary syndrome (ACS), yet the data are inconsistent, with some trials underpowered to demonstrate therapeutic benefit. Our objective was to determine the effects of early, intensive statin therapy for ACS. DATA SOURCES: Studies found in the PubMed, MEDLINE, EMBASE, BIOSIS, SciSearch, PASCAL, and International Pharmaceutical Abstracts (IPA) databases and the Cochrane Controlled Trials Register published between January 1974 and May 2006. STUDY SELECTION: Randomized controlled trials of statins begun within 14 days of hospitalization for ACS were included. DATA EXTRACTION: Two investigators independently abstracted study quality, characteristics, and outcomes. DATA SYNTHESIS: Thirteen randomized controlled trials published before May 2006 were available, involving 17 963 adults (median number of patients, 135; median follow-up, 6 months). Early, intensive statin therapy for ACS decreased the rate of death and cardiovascular events over 2 years of follow-up (hazard ratio, 0.81 [95% confidence interval, 0.77-0.87]) (Q(3) = 58.54; P<.001; I(2) = 95%). Survival curves revealed that this benefit begins to occur between 4 and 12 months, achieving statistical significance by 12 months. There was no evidence of publication bias, and sensitivity analyses did not identify a dominating study or study characteristic. CONCLUSIONS: Early, intensive statin therapy reduces death and cardiovascular events after 4 months of treatment. The validity of this finding would be strengthened by an analysis of individual patient data.

Humans↗
PubMed2006

Meta-analysis: convalescent blood products for Spanish influenza pneumonia: a future H5N1 treatment?

BACKGROUND: Studies from the Spanish influenza era reported that transfusion of influenza-convalescent human blood products reduced mortality in patients with influenza complicated by pneumonia. Treatments for H5N1 influenza are unsatisfactory, and convalescent human plasma containing H5N1 antibodies could be an effective therapy during outbreaks and pandemics. PURPOSE: To determine whether transfusion with influenza-convalescent human blood products reduced the risk for death in patients with Spanish influenza pneumonia. DATA SOURCES: Manual search of English-language journals from 1918 to 1925. Citations from retrieved studies were also searched. STUDY SELECTION: Published English-language studies that had at least 10 patients in the treatment group, used convalescent blood products to treat Spanish influenza pneumonia in a hospital setting, and reported on a control or comparison group. DATA EXTRACTION: Two investigators independently extracted data on study characteristics, outcomes, adverse events, and quality. DATA SYNTHESIS: Eight relevant studies involving 1703 patients were found. Treated patients, who were often selected because of more severe illness, were compared with untreated controls with influenza pneumonia in the same hospital or ward. The overall crude case-fatality rate was 16% (54 of 336) among treated patients and 37% (452 of 1219) among controls. The range of absolute risk differences in mortality between the treatment and control groups was 8% to 26% (pooled risk difference, 21% [95% CI, 15% to 27%]). The overall crude case-fatality rate was 19% (28 of 148) among patients who received early treatment (after <4 days of pneumonia complications) and 59% (49 of 83) among patients who received late treatment (after > or =4 days of pneumonia complications). The range of absolute risk differences in mortality between the early treatment group and the late treatment group was 26% to 50% (pooled risk difference, 41% [CI, 29% to 54%]). Adverse effects included chill reactions and possible exacerbations of symptoms in a few patients. LIMITATIONS: Studies were few and had many methodologic limitations. No study was a blinded, randomized, or placebo-controlled trial. Some pertinent studies may have been missed. CONCLUSIONS: Patients with Spanish influenza pneumonia who received influenza-convalescent human blood products may have experienced a clinically important reduction in the risk for death. Convalescent human H5N1 plasma could be an effective, timely, and widely available treatment that should be studied in clinical trials.

Antibodies, Viral↗
PubMed2006

Meta-analysis: the effect of statins on albuminuria.

BACKGROUND: Albuminuria is an independent risk factor for cardiovascular and renal disease with limited therapeutic options. Data on the effects of statins on albuminuria are conflicting. PURPOSE: To determine whether and to what degree statins affect albuminuria. DATA SOURCES: English-language and non-English-language studies found in PubMed, MEDLINE, EMBASE, BIOSIS, SciSearch, PASCAL, and International Pharmaceutical Abstracts (IPA) databases and the Cochrane Central Register of Controlled Trials that were published between January 1974 and November 2005. STUDY SELECTION: Randomized, placebo-controlled trials of statins reporting baseline and follow-up measurements of albuminuria or proteinuria measured by 24-hour urine collection or the urinary albumin-to-creatinine ratio. DATA EXTRACTION: Two investigators independently abstracted study quality, characteristics, and outcomes. DATA SYNTHESIS: Fifteen studies involving a total of 1384 patients and averaging 24 weeks in duration were included. Meta-analysis of the proportional reduction in proteinuria showed that statins reduced albuminuria (11 studies) and proteinuria (4 studies) in 13 of 15 studies. The reduction in excretion was greater among studies with greater baseline albuminuria or proteinuria: change of 2% (95% CI, -32% to 35%) for those with excretion less than 30 mg/d, -48% (CI, -71% to -25%) for those with excretion of 30 to 300 mg/d, and -47% (CI, -67% to -26%) for those with excretion more than 300 mg/d. Statistical heterogeneity was evident only in the group with excretion greater than 300 mg/d (excretion < 30 mg/d, I2 = 23% [P = 0.27]; excretion of 30 to 299 mg/d, I2 = 0% [P = 0.64]; excretion > or = 300 mg/d, I2 = 63% [P = 0.020]). LIMITATIONS: Published studies were not of high quality on average and varied markedly in effect size, as well as in characteristics of the cohorts. Unpublished studies showing no effect could impact these results. CONCLUSION: Statins may have a beneficial effect on pathologic albuminuria. The validity of this finding, and whether this effect translates into reduction of cardiovascular or end-stage renal disease, requires larger studies.

Albuminuria↗
PubMed2006

The Epworth sleepiness scale: relationship to sleep and mental disorders in a sleep clinic.

BACKGROUND AND PURPOSE: Both sleep disorders and mental disorders are associated with excessive daytime sleepiness as measured by the Epworth sleepiness scale (ESS). We sought to assess the relationship between the ESS scores and mental disorders in a sleep clinic. METHODS: One hundred sixty-five consecutive new referrals to a sleep clinic completed the ESS prior to their initial visit. Mental disorders (major depression, minor depression, anxiety not otherwise specified, and panic disorder) were diagnosed with the primary care evaluation of mental disorders (PRIME-MD) questionnaire, a reliable and valid instrument. Nearly all sleep diagnoses (95%) were made by polysomnography. RESULTS: The mean ESS for the cohort was 12.3 (standard deviation (SD) 5.1). There was no difference in the mean ESS for those with and without mental disorders (12.8 vs. 12.2, P=0.48) or sleep-disordered breathing (SDB) (12.3 vs. 12.3, P=0.99). ESS scores were not different between patients with a comorbid mental disorder and SDB compared with the presence of a mental disorder or SDB alone (combination: 13.0 vs. mental disorder: 11.5 vs. SDB: 12.2, P=0.70). There was also no relationship between ESS scores and the respiratory disturbance index (RDI) (P=0.63). CONCLUSIONS: We found no relationship between ESS scores and mental disorders among referrals to a sleep clinic. ESS cannot be used to screen for mental disorders among sleep clinic patients.

Adolescent↗
PubMed2006

Provider preferences for DVT prophylaxis.

BACKGROUND: Patients admitted to medicine wards are typically elderly with multiple co-morbidities, placing them at significant risk for venous thromboembolic (VTE) disease. Standard guidelines to help physicians assess risk and institute prophylaxis do not currently exist for this patient population. Our purpose was to assess how clinicians would rate a patient's risk for VTE and what recommendations they would make for prophylaxis. METHODS: Internal medicine residents and staff at a tertiary care medical center were asked to identify risk factors, evaluate VTE risk, and recommend a method of prophylaxis for patients described in eight clinical vignettes created by the authors. Each vignette was designed to represent a patient at a specific level of risk. RESULTS: 35 physicians returned the survey. Responders were able to identify some risk factors and weigh them appropriately when assigning an overall risk level. There was good agreement on risk level among responders (k=0.62) and moderate agreement comparing responders with our pre-defined gold standard (GS) (k=0.42). Compared to the GS they underestimated the level of risk almost 50% of the time. The risk level they assigned affected the type of prophylaxis recommended, with fewer low risk patients receiving any type of heparin and more high risk patients receiving low-molecular weight heparin (LMWH). CONCLUSIONS: Although internal medicine physicians are able to identify some risk factors for in-hospital VTE, they consistently underestimate the overall risk, leading to less aggressive preventative measures. Continuing education is essential to combating this preventable inpatient complication.

Adolescent↗
PubMed2006

Antidepressants and cognitive-behavioral therapy for symptom syndromes.

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.

Antidepressive Agents↗
PubMed2006

The impact of the Stanford Faculty Development Program on ambulatory teaching behavior.

CONTEXT: Faculty development has received considerable investment of resources from medical institutions, though the impact of these efforts has been infrequently studied. OBJECTIVE: To measure the impact of the Stanford Faculty Development Program in Clinical Teaching on ambulatory teaching behavior. DESIGN: Pre-post. SETTING AND PARTICIPANTS: Eight internal medicine faculty participating in local faculty development. INTERVENTION: Participants received 7 2-hour sessions of faculty development. Each session included didactic, role-play, and videotaped performance evaluation. MAIN OUTCOME MEASURE: Before and after the intervention, faculty were video-taped during a case presentation from a standardized learner, who had been trained to portray 3 levels of learners: a third-year medical student, an intern, and a senior medical resident. Teacher and learner utterances (i.e, phrases) were blindly and randomly coded, using the Teacher Learner Interaction Analysis System, into categories that capture both the nature and intent of the utterances. We measured change in teaching behavior as detected through analysis of the coded utterances. RESULTS: Among the 48 videotaped encounters, there were a total of 7,119 utterances, with 3,203 (45%) by the teacher. Examining only the teacher, the total number of questions asked declined (714 vs 426, P=.02) with an increase in the proportion of higher-level, analytic questions (44% vs 55%, P<.0001). The quality of feedback also improved, with less "minimal" feedback (87% vs 76%, P<.0005) and more specific feedback (13% vs 22%) provided. CONCLUSIONS: Teaching behaviors improved after participation in this faculty development program, specifically in the quality of questions asked and feedback provided.

Ambulatory Care↗
PubMed2005

Meta-analysis: computed tomographic colonography.

BACKGROUND: Computed tomographic (CT) colonography, also called virtual colonoscopy, is an evolving technology under evaluation as a new method of screening for colorectal cancer. However, its performance as a test has varied widely across studies, and the reasons for these discrepancies are poorly defined. PURPOSE: To systematically review the test performance of CT colonography compared to colonoscopy or surgery and to assess variables that may affect test performance. DATA SOURCES: The PubMed, MEDLINE, and EMBASE databases and the Cochrane Controlled Trials Register were searched for English-language articles published between January 1975 and February 2005. STUDY SELECTION: Prospective studies of adults undergoing CT colonography after full bowel preparation, with colonoscopy or surgery as the gold standard, were selected. Studies had to have used state-of-the-art technology, including at least a single-detector CT scanner with supine and prone positioning, insufflation of the colon with air or carbon dioxide, collimation smaller than 5 mm, and both 2-dimensional and 3-dimensional views during scan interpretation. The evaluators of the colonogram had to be unaware of the findings from use of the gold standard test. Data on sensitivity and specificity overall and for detection of polyps less than 6 mm, 6 to 9 mm, and greater than 9 mm in size were abstracted. Sensitivities and specificities weighted by sample size were calculated, and heterogeneity was explored by using stratified analyses and meta-regression. DATA SYNTHESIS: 33 studies provided data on 6393 patients. The sensitivity of CT colonography was heterogeneous but improved as polyp size increased (48% [95% CI, 25% to 70%] for detection of polyps <6 mm, 70% [CI, 55% to 84%] for polyps 6 to 9 mm, and 85% [CI, 79% to 91%] for polyps >9 mm). Characteristics of the CT colonography scanner, including width of collimation, type of detector, and mode of imaging, explained some of this heterogeneity. In contrast, specificity was homogenous (92% [CI, 89% to 96%] for detection of polyps <6 mm, 93% [CI, 91% to 95%] for polyps 6 to 9 mm, and 97% [CI, 96% to 97%] for polyps >9 mm). LIMITATIONS: The studies differed widely, and the extractable variables explained only a small amount of the heterogeneity. In addition, only a few studies examined the newest CT colonography technology. CONCLUSIONS: Computed tomographic colonography is highly specific, but the range of reported sensitivities is wide. Patient or scanner characteristics do not fully account for this variability, but collimation, type of scanner, and mode of imaging explain some of the discrepancy. This heterogeneity raises concerns about consistency of performance and about technical variability. These issues must be resolved before CT colonography can be advocated for generalized screening for colorectal cancer.

Aged↗
PubMed2005

Hydroxymethylglutaryl-coenzyme A reductase inhibitors and osteoporosis: a meta-analysis.

Studies determining the association between hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) and bone metabolism are mixed. We conducted a systematic review to assess the potential impact of statins on fractures, bone mineral density and bone markers. We searched Medline, Embase, the Cochrane Library, and Federal Research in Progress (FEDRIP). Inclusion criteria consisted of human studies with measurable outcomes, which were rated as good or fair according to the United States Preventive Services Task Force (USPSTF) criteria. The effects of statins on bone mineral density (BMD), bone markers and fracture risk were independently extracted by two reviewers and were combined by use of a random-effects model. The 31 analyzed studies included 24 observational studies and seven randomized controlled trials. Overall, statin use was associated with fewer hip fractures (OR 0.60, 95% CI 0.45-0.78) and improved hip BMD (Z score 0.12, 95% CI 0.05-0.19), with a non-significant reduction in vertebral fractures and no effect on vertebral BMD. In subgroup analysis of studies that involved only women there was a reduction in hip fractures (OR 0.75, 95% CI 0.60-0.95) and improvement in hip BMD (Z score 0.11, 95% CI 0.04-0.18). Vertebral BMD was unchanged, and only one study reported on vertebral fractures, finding improvement. Statins had only small effects on bone markers, with a decrease in alkaline phosphatase [standardized mean difference (SMD) -0.18, 95% CI -0.34 to -0.01], an increase in NTX (SMD 0.39, 95% CI 0.07-0.71), with no effect on osteocalcin or CTX. The statistically significant improvement in hip fracture risk was seen only in case-control trials, not in either the eight prospective trials or the two randomized controlled trials (RCTs). Statins may have a beneficial impact on bone metabolism and fracture risk; randomized controlled trials are needed to explore this association.

Bone Density↗
PubMed2005

Communication about symptoms in primary care: impact on patient outcomes.

BACKGROUND AND PURPOSE: Good communication is an integral part of a healing relationship. Our study's purpose was to explore the relationship between patient-doctor communication about physical symptoms and patient outcomes METHODS: Five hundred (500) consecutive adults presenting with physical symptoms were surveyed. Previsit surveys assessed for patient symptom characteristics, illness worry, stress, expectations, functional status (MOS SF-6), and mental disorders (PRIME-MD). Immediately postvisit, patients were asked about their satisfaction (Rand-9), the presence of unmet expectations, and what the clinicians did for them; clinicians were asked what they did for the patients and also completed a 10-item measure of how difficult the encounter was from their perspective (DDPRQ). At 2 weeks, patient surveys assessed symptom outcome, functional status (MOS SF6), and satisfaction. RESULTS: There was a high degree of agreement between clinician and patient reports about concrete actions during the encounter, such as prescription writing, diagnostic test ordering, or providing referrals. However, there was little agreement about whether clinicians discussed the symptom's diagnosis (k = 0.18) or prognosis (k = 0.27). Encounters in which patients' reported receiving such information were associated with greater satisfaction ( DIAGNOSIS: 2.1, 95% CI: 1.5-3.1; PROGNOSIS: 2.0, 95% CI: 1.4-2.9), fewer unmet expectations ( DIAGNOSIS: 0.41, 95% CI: 0.24-0.71; PROGNOSIS: 0.75, 95% CI: 0.52-0.98), less postvisit worry that their symptom( s) could be serious ( DIAGNOSIS: 0.41, 95% CI: 0.29-0.64; PROGNOSIS: 0.53, 95% CI: 0.36-0.79), and better 2-week symptom outcomes ( DIAGNOSIS: 1.7, 95% CI: 1.1-2.5; PROGNOSIS: 1.9, 95% CI: 1.3-3.0). CONCLUSIONS: Patients and clinicians disagreed about whether or not communication about symptom diagnosis and prognosis occurred during their encounter. Patient reports of receiving such information were associated with greater satisfaction, less worry, fewer unmet expectations, and better 2-week symptom outcomes.

Adult↗
PubMed2005

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Clinical Medicine↗
PubMed2005

The feasibility, reliability, and validity of a program director's (supervisor's) evaluation form for medical school graduates.

PURPOSE: To determine the feasibility, reliability, and validity of the supervisor's evaluation form for first-year residents as an outcome measure for programmatic evaluation. METHOD: Prospective feedback has been sought from supervisors for the Uniformed Services University of the Health Sciences (USUHS) graduates during their internship year. Supervisors are sent yearly evaluation forms with up to three additional mailings. Using a six-point scale, supervisors rate residents on 18 items. The authors used evaluation data from 1993 to 2002. Feasibility was estimated by response rate. Internal consistency was assessed by calculating Cronbach's alpha and analyzing scores on a year-to-year and interrater basis. Validity was determined by exploratory factor analysis with oblique rotations, comparing ratings with end-of-medical school GPA and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (Pearson correlations), and by analyzing the range of scores to include the percentage of scores below acceptable level. RESULTS: A total of 1,247 evaluations were collected for the 1,559 USUHS graduates (80%). Cronbach's alpha was .96 with no significant difference in scores by supervisor specialty or year. Factor analysis found that the evaluation form collapsed into two domains accounting for 68% of the variance: professionalism and expertise. End-of-medical school GPA and USMLE Step 1 and 2 scores correlated with expertise but not with professionalism. Mean scores across items were 3.5-4.31 with a median of 4.0 for all items (SD .80-1.21). Four percent of graduates received less-than-satisfactory ratings. CONCLUSIONS: This evaluation form has high feasibility and internal consistency. Factory analysis revealed two complimentary domains supporting its validity. Correlation with end-of-medical school measurements and analysis of range of scores supports the form's validity.

Education, Medical, Undergraduate↗
PubMed2005

Impact of national low back pain guidelines on clinical practice.

OBJECTIVES: The purpose of this study was to assess the impact of the 1994 Agency for Health Research and Quality (AHRQ) clinical practice guidelines on the management of acute low back pain. METHODS: From the National Ambulatory Medical Care Service database, the authors abstracted data on patients being seen in primary care settings, presenting with low back pain as their primary reason for visit, and aged between 20 and 55 years. Patients with an inflammatory or secondary diagnosis to explain their back pain were excluded. Using the sampling weights assigned by the National Ambulatory Medical Care Service, we assessed the medications prescribed, referrals for physiotherapy, and radiography usage for 3 years before (1991 to 1993) and after (1995 to 1997) release of the back pain guidelines. RESULTS: During these 6 years, more than 10 million ambulatory office visits were available for analysis, 5.2 million visits between 1991 to 1993 and 5.0 million visits between 1995 to 1997. The most common diagnosis was lumbago, present in 21% of these visits. Acetaminophen use increased 20-fold from 0.1 to 2%, nonsteroidal use increased from 40 to 43%, muscle relaxant use decreased from 29 to 20%, radiography ordering increased slightly from 15.4 to 19.4%, and physical therapy referrals declined from 27 to 22%. There was no evidence of a trend toward increased compliance with the AHRQ guidelines over time. CONCLUSIONS: The AHRQ clinical practice guidelines for the management of acute low back pain had a modest impact on physician behavior, increasing the use of acetaminophen and nonsteroidals and decreasing the use of muscle relaxants and physical therapy referrals.

Acute Disease↗
PubMed2005

The outcomes among patients presenting in primary care with a physical symptom at 5 years.

BACKGROUND: Symptoms are common and often remain medically unexplained. OBJECTIVE: To assess 5-year symptom outcomes, determine how often symptoms remain unexplained and assess their relationship with mental disorders. DESIGN: Prospective cohort study. PARTICIPANTS: Five hundred consecutive patients presenting to a medicine clinic with physical symptoms. MEASUREMENTS PREVISIT: Mental disorders, symptom characteristics, stress, expectations, illness worry, and functional status. Postvisit (immediately, 2 weeks, 3 months, 5 years): unmet expectations, satisfaction, symptom outcome, functional status, and stress. RESULTS: While most subjects (81%) experienced symptom improvement by 5 years, resolution rates were lower (56%), with 35% of symptoms remained medically unexplained. Most patients with medically unexplained symptoms (MUS) did not have a mental disorder. Mood or anxiety disorders were not associated with MUS (relative risks [RR]: 0.94, 95% confidence interval [CI]: 0.79 to 1.13), or with lower rates of symptom improvement (RR: 1.14, 95% CI: 0.60 to 2.2). In contrast, most patients with somatoform disorders had MUS and were unlikely to improve. Worse functioning (RR: 0.95, 95% CI: 0.91 to 0.99), longer duration of symptom at presentation (RR: 0.5, 95% CI: 0.28 to 0.87), illness worry at presentation (RR: 0.56, 95% CI: 0.35 to 0.89), or lack of resolution by 3 months (RR: 0.47, 95% CI: 0.26 to 0.86) reduced the likelihood of symptom improvement at 5 years. CONCLUSIONS: More than half of patients presenting with a physical symptom resolve by 5 years, while a third remain medically unexplained. Most patients whose symptom remained unexplained had no mental disorder. While mood and anxiety disorders were not associated with MUS or worse outcomes, most patients with somatoform disorders had MUS and were unlikely to improve.

Anxiety↗