CHA Family Medicine Residency

Tufts family medicine residents have "the best of both worlds"


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Early Imaging for Back Pain

Today we discussed early imaging in back pain.

Jarvik JG et al. “Association of Early Imaging for Back Pain with Clinical Outcomes in Older Adults.” JAMA 2015; 313 (11): 1143-1153.

Population: 5k patients who are, according to the #’s, mostly white, over 65, with a high school or higher education, but with a smattering of other races and educational levels thrown in. Drawn from Harvard Vanguard, Kaiser Permanente of NoCA, and Henry Ford health systems.
Excluded: people with cancer or back surgery

Intervention: early back imaging < 6 weeks from “index visit”

Control: propensity-matched controls that did NOT undergo imaging

Outcome: Patient self-reported pain/function/depression at different intervals, mainly 3-, 6-, and 12-month intervals. Basically, 1300-1500 dollars more usage per patient in those who undergo early imaging. The short version is: early imaging largely results in same outcomes with more health care costs. Proportion of cancer diagnoses were not statistically different between the two groups!

Limitations of study: patient-reported data and a morass of CPT, ICD9, and RVU data pulled from medical records. How to account for osteoporotic patients?

Short version: you can safely avoid getting early (< 6 weeks) imaging in older folks who present with your basic back pain visit without worrying about “missing something.”

Why did this study matter? Most back pain literature is based on younger < 65 year old peeps.

Questions? Concerns? Comments?
-Danielle

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Synergy Conference: 9/18/14

“Synergy Conference” is a morning resident conference that reviews the common lab and imaging results AFTER a visit to discuss the next steps in the plan, the part that can often be hidden from preceptors.  Faculty contribute with their suggestions and everyone looks up the best-practices and evidence-based decisions for these situations.
35 y/o M presented with 2wks pedal edema, PND, orthopnea, noticed sugars were a little high – restarted Januvia a couple weeks ago
Initially thought maybe his Januvia or amlodipine were causing edema
But then…! Labs showed Cr =14, albumin 2.7, K 5.7
BNP 35,000
Thought to be due to cardio-renal syndrome
Dialysis recommended but pt has declined multiple times
Biggest concern is hyperkalemia -> risk of fatal arrhythmia

38 y/o F s/p gastric bypass with H/H 6.8/26 microcytic
Iron, ferritin low, TIBC high end of normal -> Consistent with IDA
Patient not compliant with PO iron and might not have great absorption of it due to bypass, so IV iron recommended
To set up IV iron transfusions – talk to Drs. Misra or Taylor to get assistance in setting up pts to get IV iron at transfusion center. Have to write Rx for what you want and fax it to transfusion center
However, pt also had low B12
Gastric bypass pts have poor absorption of PO vit B12 due to lack of intrinsic factor -> best Tx is monthly IM B12 shots
Of note, B12 supplementation in patients with low-normal B12 can help with neuropathic pain
However, very high B12 levels (>1200) can also cause neuropathy and other toxic effects

41 y/o F with incidental pancytopenia
WBC 3.3
H/H 9/26
Plts 60
Had h/o IDA, not currently taking iron
Felt a little tired
No EtOH use
Does take a lot of Reglan, which can cause agranulocytosis
Causes to consider: post-viral marrow suppression, hematologic cancer, medication effects, B12 deficiency
Viral marrow suppression should resolve or improve within a couple weeks after viral infection
Plan: add on manual diff, repeat labs, review meds, consider heme referral if pancytopenia persists without clear cause

59 y/o male who said he had a “thyroid problem” in the past
Initial TSH 6.3, normal T4, no sxs
Repeat 4mos later: TSH 22, normal T4, no sxs
Technically supposed to Tx when TSH >10
Plan: Trial of low-dose levothyroxine (25mcg) and see if pt subjectively feels better. Repeat labs 6wks after starting levothyroxine.

-Lauren

We didn’t get into retic counts much – but that could have helped in the two anemia cases. Retic count in the pancytopenia patient could help confirm marrow suppression, if low, or lead to the consideration of hemolysis if high.
PO B12 supplementation always works, except when it doesn’t. People with gastric bypass in particular may not absorb po B12 because of lack of intrinsic factor. There are plenty of B12 1,000mcg capsules, pills, sublingual – but I write it as a prescription so insurance will pay.
Our nurses generally give the B12 shots subcut. It can be given daily in severe deficiency, but usually is weekly for a month then monthly – 1,000mcg.

-George