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Back Pain Addiction

SECTION ONE: GENERAL TREATMENT APPROACHES TO LOW BACK PAIN

Your patient with chronic back pain returns for follow-up after having visited a therapist who performed spinal

manipulation. He is happy with the result and asks about using manipulation to prevent further pain episodes. Which

one of the following should you tell him?  (check one)

 A. Evidence supports use of spinal manipulation to prevent further episodes of back pain. 

 B. Spinal manipulation is useful for prevention only if performed by a chiropractor. 

 C. Spinal manipulation is no more effective than sham therapy and the benefit he experienced is likely a placebo

effect.  D. Evidence does not support using spinal manipulation to

prevent exacerbations.  E. Evidence supports prevention, but spinal manipulation is

not as effective as massage. 

Answer

•  D. Evidence does not support using spinal manipulation to prevent exacerbations. 

• Evidence does not support using spinal manipulation to prevent acute exacerbations in the setting of chronic back pain. See page 13.

SECTION ONE: GENERAL TREATMENT APPROACHES TO LOW BACK PAIN

Which one of the following is the role of exercise for patients with back pain?  (check one)

 A. Improves overall fitness but has no effect on back pain. 

 B. Reduces pain and improves function in adults with chronic back pain. 

 C. Reduces pain and improves function in adults with acute back pain. 

 D. Exacerbates pain in patients with back pain, so it should be minimized. 

 E. Increases pain but improves function in patients with acute and chronic back pain. 

Answer

•  B. Reduces pain and improves function in adults with chronic back pain. 

• A Cochrane review concluded that exercise can reduce pain and improve function in adults with chronic back pain and is as effective as either no treatment or other conservative treatments for acute low back pain. See pages 13-14 and Table 1.

SECTION ONE: GENERAL TREATMENT APPROACHES TO LOW BACK PAIN

Your patient who works as a baker is experiencing continued back pain since lifting a heavy sack of flour 2 weeks ago. She

finds exercise too painful and asks about acupuncture treatment recommended by a friend. Which one of the

following is true of acupuncture for this patient?  (check one)

 A. It is not effective for acute episodes of back pain.  B. It might be effective but is associated with high rates of

adverse events.  C. It is not effective for any type of back pain. 

 D. It is more effective than sham acupuncture for chronic back pain. 

 E. It has been proven to be effective for acute back pain. 

Answer

•  A. It is not effective for acute episodes of back pain. 

• Although not shown to be effective in acute back pain, acupuncture appears to be an option for chronic back pain. See page 15.

SECTION ONE: GENERAL TREATMENT APPROACHES TO LOW BACK PAIN

Your patient who is a factory worker e-mails you asking whether he should use a back brace to prevent back pain. He has intermittent episodes of low back pain and his employer has encouraged him to use a brace. What advice should you

offer?  (check one)

 A. A back brace can effectively prevent episodes of pain.  B. A back brace may be effective for prevention but should

be professionally fitted.  C. Back braces only show benefit for short-term pain

reduction during an episode of pain.  D. A back brace will be effective in prevention and in

managing painful episodes.  E. Back braces are not effective for pain prevention in

patients with low back pain. 

Answer

• E. Back braces are not effective for pain prevention in patients with low back pain. 

• There is moderate evidence against use of bracing devices for preventing pain among patients with low back pain. See page 15.

SECTION ONE: GENERAL TREATMENT APPROACHES TO LOW BACK PAIN

Which one of the following is a conclusion of the American Society of Interventional Pain Physicians regarding use of

opioids to treat chronic back pain?   (check one)

 A. Opioid therapy is safe and effective long term for most patients with chronic back pain. 

 B. Opioid therapy should be provided with caution and evidence is variable on the effectiveness of long-term use. 

 C. If providing opioid therapy, the strongest evidence supports use of hydrocodone. 

 D. Family physicians who use opioid therapy for patients with chronic back pain can follow evidence-based guidelines

to select appropriate patients for therapy.  E. Opioid drug use to treat chronic pain has decreased in the

past 10 years. 

Answer•  B. Opioid therapy should be provided with

caution and evidence is variable on the effectiveness of long-term use.

• Based on best evidence, the American Society of Interventional Pain Physicians stated that opioid therapy should be provided with caution and that evidence is variable on the effectiveness of long-term (6 months or more) opioid use in reducing pain and improving functional status. See page 16.

SECTION TWO: ACUTE LUMBAR DISK PAINYour patient returns for follow-up for persistent sciatica. He underwent magnetic resonance imaging study last week and the results indicate a lumbar disk herniation. Which one of

the following is true of the association between disk herniation and sciatica?  (check one)

 A. Most patients with acute sciatica will have disk herniation on imaging. 

 B. It is rare to find disk herniation in an asymptomatic patient. 

 C. Most disk herniations occur in patients older than 60 years with sciatica. 

 D. Sciatica is more likely to be due to a disk herniation if pain is worse in the leg than in the back. 

 E. None of the above. 

Answer•  D. Sciatica is more likely to be due to a disk

herniation if pain is worse in the leg than in the back. 

• Three symptoms increase the specificity that the cause of the sciatica is from a lumbar disk herniation: pain is worse in the leg as opposed to the back, neurologic symptoms (eg, paresthesias, numbness) follow a typical dermatome distribution, and pain worsens with the Valsalva maneuver. See page 17.

SECTION TWO: ACUTE LUMBAR DISK PAIN

Which one of the following symptoms should trigger a clinician to consider emergent/early

referral for imaging in a patient with sciatica?  (check one)

 A. Pain for more than 2 weeks.  B. Bowel or bladder dysfunction (ie, suspected cauda equina syndrome).  C. Pain and numbness in the foot. 

 D. New-onset pain with a history of cancer.  E. Both B and D. 

Answer•  E. Both B and D. 

• If cauda equina syndrome is suspected, emergent magnetic resonance imaging study should be performed with immediate surgical referral. Immediate erythrocyte sedimentation rate and x-ray should be obtained if major cancer risk (new-onset pain with history of cancer, multiple risk factors for cancer, or strong clinical suspicion of cancer) are present. See page 19 and Table 2.

SECTION TWO: ACUTE LUMBAR DISK PAINWhile pursuing a course of watchful waiting, your patient with subacute sciatica telephones asking for treatment for

pain. She has heard about an injection that might help. Which one of the following should you tell her about epidural steroid

injection?  (check one)

 A. It may improve short-term pain but not long-term pain.  B. It may improve function and decrease need for surgery. 

 C. Intradiscal steroid injection may improve short-term pain.  D. Intradiscal steroid injection may improve function and

decrease need for surgery.  E. It is not associated with any benefit. 

Answer

• A. It may improve short-term pain but not long-term pain. 

• Epidural steroid injections may improve pain in the short term (less than 6 weeks) but they do not influence long-term pain relief, average impairment of function, or the need for surgery. See page 19.

SECTION TWO: ACUTE LUMBAR DISK PAINYour patient with sciatica for the past 4 weeks

telephones to ask about a referral to physical therapy (PT). Which one of the following is true of formal

PT for sciatica?  (check one)

 A. It is effective during acute episodes of sciatica.  B. It is more effective than conservative care. 

 C. It is more effective than manipulation.  D. It has not been proven effective. 

 E. It increases pain and delays healing during acute episodes of sciatica. 

Answer

•  D. It has not been proven effective.

• Formal physical therapy programs directed by a physical therapist have not been proven effective for sciatica, and are no more cost-effective than conservative care without physical therapy. See page 19.

SECTION TWO: ACUTE LUMBAR DISK PAINYour patient with severe sciatica has not benefited from 6 weeks of conservative management and wants to discuss surgical treatment options. He does not have severe or

progressive neuromotor deficits, or cauda equina syndrome. Which one of the following should you tell him about surgery

for sciatica?  (check one)

 A. He should consider surgery now because over time the condition is unlikely to improve without it. 

 B. Early surgery is likely to improve his disability scores and level of recovery at 1 year. 

 C. Early surgery is likely to provide faster pain relief and result in less disability at 1 year. 

 D. He should not pursue surgery because it is too dangerous.  E. Early surgery has potential for earlier relief but has similar

outcomes compared with nonsurgical treatment. 

Answer•  E. Early surgery has potential for earlier relief but

has similar outcomes compared with nonsurgical treatment. 

• For most patients with persistent sciatica, a discussion about surgical and nonsurgical treatment should include the severity of symptoms, the potential for earlier relief but similar long-term outcomes, patient aversion to surgical risks, and patient willingness to wait for spontaneous healing. See page 20.

SECTION THREE: LUMBAR SPINAL STENOSIS

Your 78-year-old patient with intermittent back pain presents with a worsening episode of back pain, this time associated with bilateral burning leg pain. You

suspect lumbar spinal stenosis. Which one of the following signs or symptoms, if present, would most

increase your suspicion of this diagnosis?   (check one)

 A. Wide-based gait.  B. Vibration deficit.  C. Pinprick deficit. 

 D. Numbness in the lower extremities.  E. Abnormal Romberg test result. 

Answer

•  A. Wide-based gait.

• Certain aspects of the history and physical examination can be used to support a diagnosis of lumbar spinal stenosis. The most suggestive features are a wide-based gait and absence of pain while seated. See page 21 and Table 3.

SECTION THREE: LUMBAR SPINAL STENOSISA 68-year-old man presents with difficulty walking as well as burning pain in the buttocks and associated lower extremity

numbness. To confirm the diagnosis of lumbar spinal stenosis (LSS), you consider obtaining x-rays of the lumbar spine.

Which one of the following describes the role of x-rays in the diagnosis of LSS?  (check one)

 A. They are useful for confirming the diagnosis of LSS.  B. They are useful for excluding diagnoses such as

degenerative joint disease.  C. They have no role in the evaluation of LSS. 

 D. They are routinely recommended before additional testing. 

 E. They are recommended for medicolegal reasons. 

Answer

• B. They are useful for excluding diagnoses such as degenerative joint disease. 

• Although it might be reasonable to obtain an x-ray to exclude conditions in the differential diagnosis of lumbar spinal stenosis (eg, compression fractures, severe degenerative joint disease), in general, x-rays are not useful. See page 21.

Answer

•  B. They are useful for excluding diagnoses such as degenerative joint disease. 

• Although it might be reasonable to obtain an x-ray to exclude conditions in the differential diagnosis of lumbar spinal stenosis (eg, compression fractures, severe degenerative joint disease), in general, x-rays are not useful. See page 21.

SECTION THREE: LUMBAR SPINAL STENOSIS

Based on North American Spine Society recommendations, which one of the following is the

most appropriate noninvasive test for imaging of degenerative lumbar spinal stenosis?  (check one)

 A. Computed tomography (CT) scan.  B. Magnetic resonance imaging (MRI) study. 

 C. X-ray.  D. Electromyogram. 

 E. Combination CT scan and MRI study. 

Answer

•  B. Magnetic resonance imaging (MRI) study.

• The North American Spine Society recommends magnetic resonance imaging study as the most appropriate noninvasive test for imaging degenerative lumbar spinal stenosis. See page 21.

SECTION THREE: LUMBAR SPINAL STENOSISYour patient with lumbar spinal stenosis returns for follow-up after no benefit from 1 month of conservative treatment. He

wishes to discuss surgery. The patient is worried about surgical risks but wants to know if he should go for surgery and if there are risks in delaying surgery to try alternative

treatment. Which one of the following should you advise?  (check one)

 A. Early surgery is likely to improve long-term outcomes.  B. Delaying surgery is likely dangerous. 

 C. Early surgery may result in early benefit, but delaying surgery is not harmful. 

 D. Almost all patients do well with medical treatment and few require surgery. 

 E. Results of surgery are uniformly good, regardless of when it is performed. 

Answer

•  C. Early surgery may result in early benefit, but delaying surgery is not harmful. 

• In cases of lumbar spinal stenosis, patients may achieve greater early benefit from surgery, but results are not uniformly good and delaying surgical treatment is unlikely to result in neurologic deterioration. See page 23.

SECTION THREE: LUMBAR SPINAL STENOSISYour patient is waiting for a surgical consultation for lumbar spinal stenosis and asks about an epidural steroid injection.

Which one of the following should you tell her?  (check one)

 A. It is no more effective than sham injection.  B. It is likely to provide long-term relief. 

 C. It can be recommended based on strong evidence.  D. It may provide short-term symptom relief. 

 E. It is not effective for patients with mechanical spinal nerve root compression. 

Answer

•  D. It may provide short-term symptom relief. 

• Steroid injections appear to provide short-term symptom relief, especially if there is a radiculopathy, for lumbar spinal stenosis. See page 23.

SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURESWhich one of the following describes the current recommendations from

the US Preventive Services Task Force for osteoporosis screening?  (check one)

 A. Screen all women older than 50 years with dual-energy x-ray absorptiometry (DXA). 

 B. The evidence is insufficient to recommend screening.  C. Screen only women with risk factors with DXA. 

 D. Screen only women older than 65 years with DXA.  E. Screen women 65 years and older and younger women with risk

factors. 

Answer•  E. Screen women 65 years and older and younger

women with risk factors. • Because screening for osteoporosis and preventive

treatment may have a positive effect on fracture prevention, the US Preventive Services Task Force, the National Osteoporosis Foundation, and the American College of Obstetricians and Gynecologists recommend dual-energy x-ray absorptiometry screening for osteoporosis among women 65 years or older and for younger women with risk factors. See page 24.

SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURES

Your patient presents after onset of acute upper back pain. An x-ray shows a vertebral

compression fracture. Which one of the following characteristics would help to

confirm that this is likely a recent fracture?   (check one)

 A. Pain with forward flexion.  B. Pain with extension. 

 C. Pain with side bending.  D. Pain on percussion of the spine. 

 E. Pain when sitting. 

Answer•  D. Pain on percussion of the spine.• Two characteristics that might help determine

whether a fracture is old or new are pain on percussion of the spine (closed-fist percussion sign; sensitivity = 87.5%, specificity = 90%, positive likelihood ratio [LR] = 8.7, negative LR = 0.14) and inability to lie supine on a couch (sensitivity = 81%, specificity = 93%, positive LR = 11.6, negative LR = 0.20). See page 24. 

SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURES

A 74-year-old woman with upper back pain returns for follow-up reporting continued pain despite rest and

acetaminophen. Neurologic examination results are normal. You suspect an osteoporotic compression fracture of the vertebra. Which one of the following would you do to

confirm the diagnosis, based on the American College of Radiology Appropriateness Criteria® guideline?  (check one)

 A. No further testing is needed; initiate treatment for osteoporosis. 

 B. Obtain x-ray.  C. Obtain x-ray and dual-energy x-ray absorptiometry

(DXA).  D. Obtain x-ray and consider computed tomography scan

and DXA.  E. Obtain magnetic resonance imaging study. 

Answer•  C. Obtain x-ray and dual-energy x-ray

absorptiometry (DXA). 

• The American College of Radiology Appropriateness Criteria® guideline recommends dual-energy x-ray absorptiometry and a spine x-ray for diagnosis of a suspected osteoporotic vertebral fracture in a patient with a clinical history, height loss, or steroid use. See page 24.

SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURES

The US Preventive Services Task Force has found sufficient evidence that drug therapies reduce facture risk in

postmenopausal women with osteoporosis detected on screening. Which one of the following treatments, in addition to calcium and vitamin D, would you consider for a woman

with osteoporosis but no fracture who is recently menopausal?   (check one)

 A. Calcitonin.  B. Hormone therapy.  C. A bisphosphonate. 

 D. Denosumab.  E. B or C. 

Answer

•  E. B or C. 

• Estrogen/hormone therapy is approved for osteoporosis and fracture prevention as well as relief of menopause-associated vasomotor symptoms and vulvovaginal atrophy. Bisphosphonates have been shown to significantly reduce the incidence of new vertebral fractures. See page 27.

SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURES

Your patient with a painful vertebral compression fracture that occurred 2 weeks ago has persistent severe pain despite

use of oral pain drugs and calcitonin. She asks about surgery. Which one of the following should you tell her about

vertebroplasty?  (check one)

 A. It is clearly of benefit for pain relief and long-term function. 

 B. It is controversial, with 2 trials showing no differences in effectiveness of vertebroplasty and sham control. 

 C. It is not of benefit, according to all recent studies.  D. It is more effective than kyphoplasty. 

 E. None of the above.

Answer•  B. It is controversial, with 2 trials showing no

differences in effectiveness of vertebroplasty and sham control. 

• In 2009, the use of this procedure was questioned when 2 randomized controlled trials using sham control groups showed no differences between treated and untreated patients. These studies sparked controversy regarding the efficacy of vertebroplasty and drew national media attention. See page 30

SECTION ONE: ALCOHOL USE DISORDERS

Which one of the following is most sensitive for detecting alcohol use disorders?  (check

one)

 A. Carbohydrate-deficient transferrin.  B. Elevated gamma-glutamyl transferase. 

 C. Macrocytosis on hemogram.  D. Screening questionnaires. 

Answer

• D. Screening questionnaires. 

SECTION ONE: ALCOHOL USE DISORDERS

Which one of the following counts as 1 standard drink of alcohol?  (check one)

 A. 12-oz bottle of malt liquor.  B. 12-oz bottle of regular beer. 

 C. 2 shots of hard liquor.  D. 8-oz glass of wine. 

Answer

•  B. 12-oz bottle of regular beer. 

SECTION ONE: ALCOHOL USE DISORDERSYou are treating a patient for alcohol withdrawal.

The symptoms are severe enough to warrant pharmacotherapy. The patient has been drinking for years and has moderately impaired liver function.

Which one of the following drugs would be preferred for this patient?  (check one)

 A. Chlordiazepoxide.  B. Diazepam.  C. Oxazepam. 

 D. Valproic acid.

Answer

•  C. Oxazepam. 

• Benzodiazepines are the first-line drugs for alcohol withdrawal for inpatient and outpatient treatment. Short-acting benzodiazepines (eg, lorazepam, oxazepam) are preferred in elderly patients or in patients with impaired liver function. See page 17.

SECTION ONE: ALCOHOL USE DISORDERSWhich one of the following statements is correct

about naltrexone for treatment of alcohol dependence?   (check one)

 A. It is contraindicated in patients with markedly elevated liver function test results. 

 B. It must be administered by injection.  C. The Food and Drug Administration has not approved naltrexone for treatment of alcohol

dependence.  D. The patient must stop drinking before naltrexone

can be started.

Answer

•  A. It is contraindicated in patients with markedly elevated liver function test results. 

• Naltrexone is contraindicated in patients with active liver disease, when liver function test results are greater than 3 times the upper limit of normal, and in patients requiring opioids. See page 18.

SECTION TWO: PRESCRIPTIONSTIMULANT AND METHAMPHETAMINE

USE DISORDERSWhich one of the following statements is correct

about use of prescription stimulants by undergraduate college students?  (check one)

 A. More students have reported nonmedical use than students reporting medical use. 

 B. The leading source of illicit stimulants is forged prescriptions. 

 C. The majority of college students report nonmedical use of stimulants at least once. 

 D. Use is highest on the East Coast of the United States. 

Answer

•  A. More students have reported nonmedical use than students reporting medical use. 

• In an online survey of 9,161 undergraduate students at a Midwestern university, more students reported illicit use of prescription stimulants than students who reported medical use for attention-deficit/hyperactivity disorder. See page 21.

SECTION TWO: PRESCRIPTIONSTIMULANT AND

METHAMPHETAMINE USE DISORDERS

Which one of the following is a nonstimulant drug approved by the Food and Drug

Administration for treatment of attention-deficit/hyperactivity disorder?  (check one)

 A. Atomoxetine.  B. Methylphenidate. 

 C. Dexmethylphenidate.  D. Bupropion. 

Answer

•  A. Atomoxetine. 

Answer•  A. Atomoxetine. • Drugs for attention-deficit/hyperactivity disorder

(ADHD) treatment that have lower abuse potential include nonstimulant drugs such as atomoxetine, bupropion, guanfacine, and clonidine. Atomoxetine and extended-release formulations of guanfacine and clonidine are Food and Drug Administration-approved for ADHD treatment, but bupropion is not. See page 22.

SECTION TWO: PRESCRIPTIONSTIMULANT AND METHAMPHETAMINE USE DISORDERSYour patient, a long-term user of methamphetamine, presents to your

office seeking treatment for substance abuse. Which one of the following statements is correct about Food and Drug Administration (FDA)-

approved drugs for amphetamine dependence?  (check one)

 A. Aripiprazole is FDA-approved for treatment of amphetamine dependence. 

 B. Modafinil is FDA-approved for treatment of amphetamine dependence. 

 C. Selective serotonin reuptake inhibitors are FDA-approved for treatment of amphetamine dependence. 

 D. Tricyclic antidepressants are FDA-approved for treatment of amphetamine dependence. 

 E. There are currently no drugs approved by the FDA for treatment of amphetamine dependence. 

Answer

•  E. There are currently no drugs approved by the FDA for treatment of amphetamine dependence. 

• . There are currently no drugs approved by the FDA for treatment of amphetamine dependence. 

•

SECTION THREE: PRESCRIPTION OPIOID USE DISORDERS

Which one of the following is the role of urine drug screens when caring for a patient who receives long-term opioid

therapy for chronic nonmalignant pain?  (check one)

 A. Routine urine drug tests will detect all Food and Drug Administration-approved opioids. 

 B. They are not indicated if there is a good patient-physician relationship. 

 C. They should be performed at every visit if feasible, or randomly. 

 D. Although many physicians perform them, they are not recommended in the Federation of State Medical Boards

policy statement on long-term opioid therapy.

Answer

•  C. They should be performed at every visit if feasible, or randomly. 

• If drug testing is not feasible at every patient visit, random drug testing can still be of benefit. See page 29.

FP Essentials - #383 - Connective Tissue DiseasesQuestion 2 of 20

Which statement is correct regarding anticyclic citrullinated peptide antibody testing in the

evaluation of patients with suspected rheumatoid arthritis (RA)?   (check one)

 A. If results are positive, it typically means the patient will have less severe RA. 

 B. If results are negative, it increases the likelihood that the patient does not have RA. 

 C. The test has no value in the evaluation of patients with suspected RA. 

 D. The test results are typically positive later in the course of RA. 

Answer

•  B. If results are negative, it increases the likelihood that the patient does not have RA.

• Anticyclic citrullinated peptide antibodies have similar sensitivity but higher specificity than rheumatoid factor in diagnosis of rheumatoid arthritis. See page 17 and Table 3.

A patient being evaluated for symptoms of a connective tissue disease has a positive anti-

Smith antibody test result. Which one of the following is the most likely

diagnosis?   (check one)

 A. Systemic lupus erythematosus.  B. Polymyositis.  C. Scleroderma. 

 D. Sjögren syndrome.

Answer• A. Systemic lupus erythematosus. • The only highly specific tests for connective tissue disease

detection are anti-double-stranded DNA (anti-dsDNA) and anti-Smith (anti-Sm) antibody, which are specific for systemic lupus erythematosus (SLE), and antiproteinase 3, which is specific for Wegener granulomatosis. Anti-Sm antibodies are present in approximately 40% of patients with SLE. But when present, anti-Sm antibodies are similar to anti-dsDNA antibodies in that they are highly specific for SLE. See pages 14, 18, and Table 3.

Your 76-year-old patient presented to the emergency department, reporting axial pain, stiffness, and weakness that has been present for weeks. The

emergency department physician prescribed steroids. By the time the patient visits your office 3 days later, the symptoms have completely resolved. Which one of the following is the likely diagnosis?  (check one)

 A. Ankylosing spondylitis.  B. Polymyalgia rheumatica. 

 C. Polymyositis.  D. Vertebral rheumatoid arthritis.

Answer

• B. Polymyalgia rheumatica. 

• In polymyalgia rheumatica, an elderly patient with symptoms of axial pain, stiffness, or subjective weakness might experience complete symptom resolution within a few days of beginning daily therapy with 15 mg of prednisone, thus confirming the diagnosis. See page 20.

SLOWING GLOBAL WARMING: BENEFITS FOR PATIENTS AND THE PLANET

Which one of the following is a recommendation that would mutually benefit cardiovascular health and climate

change?  (check one)

 A. The target level of daily meat consumption should be 12 oz. 

 B. Meat intake should remain at current average levels of consumption. 

 C. Average daily meat consumption should decrease to 3 oz, and less than one-half of that should be red meat. 

 D. The target level of daily meat consumption should be 8 oz. 

Correct.

Answer

•  C. Average daily meat consumption should decrease to 3 oz, and less than one-half of that should be red meat. 

SLOWING GLOBAL WARMING: BENEFITS FOR PATIENTS AND THE PLANET

Which of the following health conditions are likely to increase with expected climate

change?  (check all that apply)

 A. Mental illness related to extreme weather events. 

 B. Allergies.  C. Asthma. 

 D. Vector-borne disease. 

Answer

•  A. Mental illness related to extreme weather events.  B. Allergies.  C. Asthma.  D. Vector-borne disease. 

Clinical recommendationEvidence ratingReferences• Physicians should advise patients to reduce their dietary meat consumption,

especially red meat, to improve individual health.• C• Physicians should advise patients to reduce their dietary meat consumption,

especially red meat, to help reduce greenhouse gas emissions and improve public health.

• C• Physicians should recommend that patients use more active transportation

methods, such as walking and bicycling, to improve individual health.• C• Physicians should recommend that patients use more active transportation

methods, such as walking and bicycling, to help reduce greenhouse gas emissions and improve public health.

• C

TREATMENT OF NONGENITAL CUTANEOUS WARTS

Which one of the following statements about cryotherapy for the treatment of cutaneous warts is

correct?  (check one)

 A. It is more effective than salicylic acid.  B. It should not be used for more than three

months.  C. It should clear hand warts with two freeze-thaw

cycles.  D. It requires more applications than salicylic acid. 

Answer

• B. It should not be used for more than three months

Nongenatial Warts• Numerous treatments for nongenital cutaneous warts are available, although no single

therapy has been established as completely curative. • Watchful waiting is an option for new warts because many resolve spontaneously. • However, patients often request treatment because of social stigma or discomfort. • Ideally, treatment should be simple and inexpensive with low risk of adverse effects. • Salicylic acid has the best evidence to support its effectiveness, but it is slow to work and

requires frequent application for up to 12 weeks. • Cryotherapy with liquid nitrogen is a favorable option for many patients, with cure rates

of 50 to 70 percent after three or four treatments. • For recalcitrant warts, Candida or mumps skin antigen can be injected into the wart

every three to four weeks for up to three treatments. • More expensive treatments for recalcitrant warts are offered in many dermatology 

offices. • Photodynamic therapy with aminolevulinic acid has the best evidence of effectiveness

compared with pulsed dye laser, intralesional bleomycin, and surgical removal using curettage or cautery.

Nongenatial Warts• Salicylic acid and cryotherapy with liquid nitrogen are first-line treatments for cutaneous warts.• A• Aggressive cryotherapy (10 to 30 seconds) is more effective than less aggressive cryotherapy.• B• Best results of cryotherapy can be achieved when the patient is treated every two or three weeks. There is no therapeutic

benefit beyond three months.• B• When using cryotherapy for plantar warts, paring the wart before treatment can increase the clearance rate.• B• Intralesional injection with Candida or mumps skin antigen has moderate effectiveness for treatment of recalcitrant warts

in patients with a positive skin antigen pretest.• B• Photodynamic therapy with aminolevulinic acid plus topical salicylic acid is a moderately effective option for treatment of

recalcitrant warts.• B• Although preliminary studies were promising, duct tape is not effective for wart treatment.• B• Pulsed dye laser or intralesional injection with bleomycin can be considered for treatment of recalcitrant warts, although

the effectiveness is unproven.• B

TREATMENT OF NONGENITAL CUTANEOUS WARTS

Which one of the following treatments for cutaneous warts is usually administered by a

dermatologist?  (check one)

 A. Salicylic acid.  B. Cryotherapy. 

 C. Photodynamic therapy.  D. Topical fluorouracil. 

Answer

•  C. Photodynamic therapy.

TREATMENT OF NONGENITAL CUTANEOUS WARTS

Which of the following statements about treatment of asymptomatic warts are correct?  (check all that

apply)

 A. Paring plantar warts before cryotherapy may be beneficial. 

 B. Pulsed dye laser is the treatment of choice for plantar warts. 

 C. Combining salicylic acid with cryotherapy may be more effective than using either treatment alone.  D. Watchful waiting is reasonable for new warts. 

Answer

•  A. Paring plantar warts before cryotherapy may be beneficial.  C. Combining salicylic acid with cryotherapy may be more effective than using either treatment alone.  D. Watchful waiting is reasonable for new warts. 

DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN ADULTS

Which one of the following is considered a risk factor for constipation?  (check

one)

 A. Male sex.  B. High caloric intake. 

 C. Use of a large number of medications. 

 D. High educational level. 

Answer

•  C. Use of a large number of medications. 

DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN ADULTS

Which one of the following statements about the initial diagnostic evaluation of patients with chronic constipation is

correct?  (check one)

 A. All patients should have their thyroid-stimulating hormone level measured. 

 B. Patients with alarm signs or symptoms should undergo endoscopy to rule out serious secondary causes of

constipation.  C. Patients with alarm signs or symptoms should undergo abdominal computed tomography to rule out malignancy. 

 D. All patients should undergo manometric testing of pelvic floor function.

Answer

•  B. Patients with alarm signs or symptoms should undergo endoscopy to rule out serious secondary causes of constipation.

DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN ADULTS

Which of the following statements about slow transit constipation are correct?  (check all that apply)

 A. Symptoms include an infrequent “call to stool,” bloating, and abdominal discomfort. 

 B. Prolonged colonic transit time can be confirmed with radiopaque markers that are delayed on motility study. 

 C. Prolonged colonic transit time is defined as four or more markers visible on a plain abdominal radiograph taken 120

hours after ingesting one Sitzmarks capsule.  D. Treatment with fiber supplementation or laxatives is

ineffective in patients with severe slow transit constipation. 

Answer

•  A. Symptoms include an infrequent “call to stool,” bloating, and abdominal discomfort.  B. Prolonged colonic transit time can be confirmed with radiopaque markers that are delayed on motility study.  D. Treatment with fiber supplementation or laxatives is ineffective in patients with severe slow transit constipation.

Constipation• A history and physical examination should be performed in patients with

constipation to identify alarm signs or symptoms.• C• Routine use of blood tests, radiography, or endoscopy in patients with constipation

who do not have alarm signs or symptoms is not recommended.• C• Patients with alarm signs or symptoms should undergo endoscopy to rule out

malignancy.• C• The initial management of noncomplicated constipation should include a high-fiber

diet, increased water intake, and exercise.• B• Biofeedback is recommended for treating symptoms of pelvic floor dysfunction.• B

COCHRANE FOR CLINICIANS: PUTTING EVIDENCE INTO PRACTICE

SELF-MONITORING AND SELF-MANAGEMENT OF ANTICOAGULATION THERAPY

Compared with standard care, self-monitoring of anticoagulation therapy reduces the incidence of

which of the following outcomes?  (check all that apply)

 A. Thromboembolism.  B. Minor hemorrhage.  C. Major hemorrhage.  D. All-cause mortality.

Answer

•  A. Thromboembolism.  B. Minor hemorrhage.  C. Major hemorrhage.  D. All-cause mortality. 

GERIATRIC ASSISTIVE DEVICESA front-wheeled walker has which one of the

following advantages over other walkers?  (check one)

 A. It is lifted with each step.  B. It is the most stable type of walker. 

 C. It has a small turning arc.  D. It helps maintain a normal gait pattern.

Answer

•  D. It helps maintain a normal gait pattern. 

GERIATRIC ASSISTIVE DEVICESCorrect use of a cane involves which one of the

following?  (check one)

 A. With the patient standing upright with arms relaxed at his or her sides, the handle should be at

the level of the patient’s elbow crease.  B. A cane should be held contralateral to a weak or

painful lower extremity.  C. A cane should be advanced alternating with

movement of the affected leg.  D. Patients should advance the unimpaired

extremity first when going down stairs.

Answer

•  B. A cane should be held contralateral to a weak or painful lower extremity. 

GERIATRIC ASSISTIVE DEVICESWhich of the following caveats should be considered

when recommending assistive devices?  (check all that apply)

 A. They may cause osteoarthritis and other musculoskeletal conditions. 

 B. They can be destabilizing.  C. They have been associated with worsening

osteoporosis.  D. They may worsen cardiorespiratory function. 

Answer

•  A. They may cause osteoarthritis and other musculoskeletal conditions.  B. They can be destabilizing.

Assistive Devices• Assistive devices can be prescribed to improve balance, reduce pain, and increase

mobility and confidence.

• C

• Because most patients obtain their assistive device without recommendations or instructions from a medical professional, assistive devices should be evaluated routinely for proper fit and use.

• C

• When only one upper extremity is needed for balance or weight bearing, a cane is preferred. If both upper extremities are needed, crutches or a walker is more appropriate.

• C

• The correct height of a cane or walker is at the level of the patient's wrist crease, as measured with the patient standing upright with arms relaxed at his or her sides. When holding the device at this height, the patient's elbow is naturally flexed at a 15- to 30-degree angle.

• C

Assistive devices• Disability and mobility problems increase with age. • Assistive devices such as canes, crutches, and walkers can be used to increase a patient's base of support, improve

balance, and increase activity and independence, but they are not without significant musculoskeletal and metabolic demands.

• Most patients with assistive devices have never been instructed on the proper use and often have devices that are inappropriate, damaged, or are of the incorrect height.

• Selection of a suitable device depends on the patient's strength, endurance, balance, cognitive function, and environmental demands.

• Canes can help redistribute weight from a lower extremity that is weak or painful, improve stability by increasing the base of support, and provide tactile information about the ground to improve balance.

• Crutches are useful for patients who need to use their arms for weight bearing and propulsion and not just for balance.

• Walkers improve stability in those with lower extremity weakness or poor balance and facilitate improved mobility by increasing the patient's base of support and supporting the patient's weight.

• Walkers require greater attentional demands than canes and make using stairs difficult. • The top of a cane or walker should be the same height as the wrist crease when the patient is standing upright

with arms relaxed at his or her sides. • A cane should be held contralateral to a weak or painful lower extremity and advanced simultaneously with the

contralateral leg. • Clinicians should routinely evaluate their patients' assistive devices to ensure proper height, fit, and maintenance,

and also counsel patients on correct use of the device.

TREATMENT OPTIONS FOR LOCALIZED PROSTATE CANCER

A 74-year-old man in the bottom quartile of health has stage T2a prostate cancer with a Gleason score of 6. His prostate-specific antigen (PSA) level is 9 ng per mL (9 mcg per L). Which one of the following treatment options would best

align with the recommendations of the National Comprehensive Cancer Network?  (check one)

 A. Active surveillance.  B. Surgery. 

 C. External beam radiation therapy.  D. Brachytherapy.

Answer

• A. Active surveillance. 

TREATMENT OPTIONS FOR LOCALIZED PROSTATE CANCER

Which of the following is part of the Canadian protocol for active surveillance of prostate cancer?  (check all that apply)

 A. PSA testing and digital rectal examination every three months for two years. 

 B. 10 to 12 core biopsies one year after diagnosis, then every three years until 80 years of age. 

 C. Intervention if the PSA doubles in less than three years.  D. Intervention for progression to a Gleason score of 7 (4+3)

or higher. 

Answer•  A. PSA testing and digital rectal examination

every three months for two years.  B. 10 to 12 core biopsies one year after diagnosis, then every three years until 80 years of age.  C. Intervention if the PSA doubles in less than three years.  D. Intervention for progression to a Gleason score of 7 (4+3) or higher. 

Treatment for localized prostate cancer should be recommended for higher-risk patients. Risk can be estimated by using an index of cancer stage and grade, prostate-specific

antigen level, and comorbidity-adjusted life expectancy.B

Patients can be counseled that surgery and external beam radiation therapy are almost equally effective in treating

prostate cancer.B

Brachytherapy is an option for monotherapy in low-risk patients.

BActive surveillance is a reasonable option for low-risk and

very low-risk patients.B

EXERCISE-INDUCED BRONCHOCONSTRICTION: DIAGNOSIS AND MANAGEMENT

A 21-year-old college basketball player presents with symptoms suggestive of exercise-induced

bronchoconstriction (EIB). After performing a workup, you confirm a diagnosis of EIB and discuss treatment options

with her. She is concerned about choosing a treatment prohibited by the National Collegiate Athletic Association (NCAA). Which one of the following drug classes requires proof of prescription under NCAA regulations? (check one)

 A. Mast cell stabilizers.  B. Inhaled corticosteroids. 

 C. Leukotriene receptor antagonists.  D. Inhaled beta2 agonists.

• Screening for abdominal aortic aneurysmThe USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.B