primary health care

Management of Shoulder Pain in Primary Care

Nathan Hinkle — Fri, 09 Oct 2026 05:00:00 +0000

Date Added:

October 9, 2026

Journal/Publication:

JAMA Intern Med

Publisher:

Journal of the American Medical Society

Publication Date:

August 17, 2026

Issue:

Volume:

186

Pages:

1256-1268

URL:

Management of Shoulder Pain in Primary Care A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi:10.1001/jamainternmed.2026.3135

Keywords

Shoulder Pain

primary care

soft-tissue disorders

MeSH

RPR Commentary: Guidance regarding when to refer patients with shoulder pain (and when not to). James W. Mold, MD, MPH

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Importance Shoulder pain is a common and disabling condition most often managed in primary care. This review provides an evidence-based update on the diagnosis and management of shoulder pain to support clinical decision-making and improve patient outcomes.

Observations Shoulder pain arises from benign, self-limiting soft-tissue disorders or rare but serious causes. In primary care, most cases are nontraumatic and involve periarticular soft tissues. The subacromial region is the most frequent source of pain, and the term subacromial pain is preferred over overlapping and inconsistently defined labels such as rotator cuff tendinopathy or tear, impingement syndrome, or subacromial bursitis. Less commonly, pain originates from the glenohumeral joint, as in glenohumeral osteoarthritis or adhesive capsulitis. Assessment should focus on a detailed history and physical examination to assess pain patterns and movement limitation and to exclude serious causes, such as infection, malignant neoplasm, or nonshoulder referred pain. Once these are excluded, first-line treatment is similar for most patients and aligns with recommended care for other regional musculoskeletal concerns: education about the favorable natural history, symptom relief and activity modification if needed, and watchful waiting. Early imaging is not indicated in the absence of significant trauma or suspicious features, such as fever, unexplained weight loss, or history of malignant neoplasm, as structural abnormalities often do not correlate with symptoms, rarely alter management, and may lead to overdiagnosis and overtreatment. Specialist referral should be reserved for suspected serious pathology, such as infection, malignant neoplasm, fracture, or dislocation; significant functional or neurologic deficit; features suggestive of systemic inflammatory disease; or persistent or worsening pain and debility. High-certainty evidence indicates that subacromial pain does not benefit from surgical intervention.

Conclusions and Relevance Shoulder pain is the third most common musculoskeletal presentation in primary care. Although causes vary, the initial management is largely the same once serious conditions have been excluded. Most patients with subacromial pain will fully recover with minimal intervention and can be safely treated with supportive care. Imaging and referral to surgical subspecialists should be reserved for rare and carefully selected cases to avoid unnecessary intervention.

Author/s:

Romi Haas, Thomas Ibounig, Rachelle Buchbinder

Cervical Cancer Screening Updates—Focus on Self-Collected Primary Human Papillomavirus Testing

Mary Cervantes — Fri, 28 Aug 2026 01:36:17 +0000

Date Added:

August 27, 2026

Journal/Publication:

JAMA Internal Medicine: Clinical Insights

Publisher:

JAMA Internal Medicine

Publication Date:

August 24, 2026

URL:

Cervical Cancer Screening Updates—Focus on Self-Collected Primary Human Papillomavirus Testing

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.3980

Keywords

cervical cancer

Cervical Cancer Screening

Papillomavirus Testing

Screening Updates

Women's Health

MeSH

early detection of cancer

Early Detection of Cancer / standards

Early Detection of Cancer* / methods

American Cancer Society

Gynecologists

Papillomavirus Infections

uterine cervical neoplasms

Uterine Cervical Neoplasms* / diagnosis

primary health care

female

An update to the cervical cancer screening guidelines from the USPSTF. James W. Mold, MD, MPH

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The incidence and mortality of cervical cancer have fallen since the adoption of widespread screening, but it still disproportionately affects underserved populations in the US. Expanding access to screening, especially in primary care settings, may reduce these disparities and improve women’s health. This Clinical Insights article summarizes cervical cancer screening recommendations for patients with average and higher than average risk, including recommendations for self-collected human papillomavirus (HPV) testing. It highlights statements by the US National Cancer Institute–sponsored Enduring Guidelines Committee, which was established to continuously evaluate new technologies for cervical cancer screening, management, and surveillance.

Author/s:

Hunter K. Holt, MD, MAS, Yasaswi Kislovskiy, MSc, George F Sawaya

Management of Shoulder Pain in Primary Care: A Review

Mary Cervantes — Wed, 19 Aug 2026 17:54:00 +0000

Date Added:

August 19, 2026

Journal/Publication:

JAMA Internal Medicine

Publisher:

JAMA Intern Med

Publication Date:

August 17, 2026

URL:

Management of Shoulder Pain in Primary Care: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.3135

Keywords

Internal Medicine

Internal Medicine Practice

MeSH

clinical decision-making

Physical Examination

Physical Examination / methods

Overtreatment

primary health care

referral and consultation

Tendinopathy

A review of the management of patients with shoulder pain. James W. Mold, MD, MPH

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Author/s:

Romi Haas, Thomas Ibounig, MD, Buchbinder, Rachelle

Management of Shoulder Pain in Primary Care

Mary Cervantes — Wed, 19 Aug 2026 17:36:50 +0000

Date Added:

August 19, 2026

Journal/Publication:

JAMA Internal Medicine

Publisher:

JAMA, JAMA Network, JN Learning, AMA Ed Hub

Publication Date:

August 17, 2026

URL:

Management of Shoulder Pain in Primary Care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Video

Keywords

MeSH

Physical Therapy Modalities

primary health care

A 15-minute audio-review of the management of shoulder pain in primary care. James W. Mold, MD, MPH

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From the JAMA Network, this is JAMA Internal Medicine Author Interviews. Conversations with authors exploring the latest clinical research, reviews, and opinions featured in JAMA Internal Medicine.

Author/s:

Romi Haas, MPH, PhD, Michael A. Incze, Eve Rittenberg, MD

Approach to Fatigue in Primary Care: A Practical Diagnostic Framework for General Practitioners

Megan George — Fri, 29 May 2026 19:27:45 +0000

Date Added:

May 29, 2026

Journal/Publication:

Cureus

Publication Date:

May 13, 2026

URL:

Approach to Fatigue in Primary Care: A Practical Diagnostic Framework for General Practitioners

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7759/cureus.108764

Keywords

Fatigue

acute fatigue

Chronic Fatigue Syndrome

MeSH

A set of recommendations based upon a systematic literature review for the evaluation of patients presenting with fatigue in primary care. James W. Mold, MD, MPH

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Fatigue is one of the most common presenting complaints in primary care and poses a significant diagnostic challenge due to its multifactorial aetiology. While the majority of cases are benign and self-limiting, fatigue may also represent an early manifestation of serious underlying pathology. This review distinguishes between acute fatigue, typically transient and associated with intercurrent illness or lifestyle factors, and chronic fatigue, defined as fatigue persisting for six or more weeks, which is more likely to be multifactorial in origin.

This narrative review aims to provide a practical and structured diagnostic framework for general practitioners to evaluate and manage fatigue effectively in the primary care setting.

A narrative review of the literature was conducted using PubMed and Google Scholar. Searches were limited to articles published in English from 2010 onwards. Search terms included "fatigue," "primary care," "chronic fatigue," "myalgic encephalomyelitis," "post-viral fatigue," "sleep disorders," and "functional somatic syndromes." Seminal references predating 2010 were retained where no suitable replacement was available. This review did not employ a formal systematic search strategy, and no risk-of-bias assessment was performed, consistent with the narrative review format.

Fatigue arises from a wide range of physical, psychological, and lifestyle-related causes, best understood through a three-tier classification: primary/idiopathic, secondary, and psychosocial. A systematic approach incorporating thorough history-taking, focused clinical examination, and judicious use of investigations is essential. Identification of red flag symptoms is critical to exclude serious conditions, including malignancy and chronic infections.

A structured, patient-centred approach enables general practitioners to manage fatigue effectively while minimising unnecessary investigations and ensuring timely identification of serious disease.

Author/s:

Omar Elbaroumi

Hypertension and alcohol: a cross-sectional study comparing PEth with AUDIT and AUDIT-C in primary care

Megan George — Mon, 16 Feb 2026 17:36:14 +0000

Date Added:

February 16, 2026

Journal/Publication:

Family Practice

Publication Date:

February 1, 2026

URL:

Hypertension and alcohol: a cross-sectional study comparing PEth with AUDIT and AUDIT-C in primary care

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1093/fampra/cmaf097

Keywords

alcohol use disorder

cardiovascular disorders

PMID (1):

41511884

MeSH

Alcohol Drinking* / epidemiology

Antihypertensive Agents / therapeutic use

lycerophospholipids* / blood

Hypertension* / drug therapy

Hypertension* / epidemiology

Alcoholism* / diagnosis

primary health care

The results of this study suggest that patients with poorly controlled BP should be further evaluated for alcohol use disorders even if the brief screening questions are negative. James W. Mold, MD, MPH

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Background: This cross-sectional study aimed to describe proportions of patients with indications of alcohol consumption using phosphatidylethanol (PEth), the Alcohol Use Disorders Identification Test (AUDIT), and its consumption-focused version (AUDIT-C), in relation to blood pressure (BP) control, overall and by sex.

Methods: A total of 270 hypertensive primary care patients (ICD-10: I10.9) were stratified into BP control groups: controlled (<140/90 mmHg), uncontrolled (≥140/90 mmHg), and apparent treatment-resistant hypertension (aTRH; ≥140/90 mmHg with ≥3 antihypertensive drugs). A randomized sample from each stratum was invited, baseline data were collected. Alcohol consumption using predefined categories for PEth and AUDIT, and hazardous use (PEth ≥ 0.122 µmol/L; AUDIT ≥ 8; AUDIT-C ≥ 5 for men, ≥4 for women), were analyzed in relation to BP control groups.

Results: Mean age was 67 ± 11 years; 42% were women. PEth indicated high and regular alcohol consumption in 6.4% of controlled, 5.3% of uncontrolled, and 19.2% of aTRH patients (controlled vs. aTRH, P = .027; uncontrolled vs. aTRH, P = .013). AUDIT showed no significant differences in hazardous use between BP groups (P = .865). AUDIT-C identified slightly higher proportions of hazardous use than PEth, across BP groups and sexes. No significant differences were found between BP groups for hazardous use by PEth (P = .339) or AUDIT-C (P = .150).

Conclusions: PEth revealed significantly higher alcohol use in the aTRH group, undetected by AUDIT. AUDIT-C and PEth identified more hazardous use than AUDIT, suggesting their potential to prompt alcohol-related discussions and support evidence-based hypertension care. PEth correlated more strongly with AUDIT-C than with AUDIT.

Clinical trial registration: Retrospectively registered in Clinical Trials, SLSO2022-0143, 2022-12-10.

Keywords: alcohol use disorder; cardiovascular disorders (hypertension/DVT/atherosclerosis); hypertension (high blood pressure); prevention; primary care; screening.

Author/s:

Åsa Thurfjell, Maria Hagströmer, Charlotte Ivarsson, Anders Norrman, Johanna Adami, Lena Lundh, Jan Hasselström

2024 edition of the Rourke Baby Record

Hope Smashey — Sat, 13 Sep 2025 19:21:41 +0000

Date Added:

September 13, 2025

Journal/Publication:

Canadian Family Physician

Publication Date:

September 13, 2025

Issue:

Volume:

Pages:

553-561

URL:

2024 edition of the Rourke Baby Record

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.7109553

Keywords

child

infant

Baby

PMID (1):

40940145

MeSH

Culturally Competent Care

primary health care

Vegetarians

Eating

This is an article explaining and updating a tool used in many Canadian practices that care for babies and their mothers. The actual Baby Record can b downloaded free at https://www.rourkebabyrecord.ca

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Objective: To assist busy primary care providers caring for infants and young children and their families by providing them with the most recent recommendations and supportive evidence included in the 2024 edition of the Rourke Baby Record (RBR).

Quality of evidence: Articles from pediatric preventive care literature (January 2019 to March 2023) were reviewed for relevance and quality of evidence. When available, evidence from systematic reviews, relevant clinical guidelines, and clinical trials were incorporated. In the absence of high-level evidence, observational studies and expert opinion on the topic were included. Primary research studies were reviewed and critically appraised using a modified protocol.

Main message: Notable updates in the 2024 edition of the RBR include the promotion of early relational health for families; identification of targeted support and resources as opposed to labelling of high-risk groups; guidance on culturally safe care; clarification and evidence-based adjustments of the age of achievement of some developmental surveillance milestones; recommendations on plant-based beverages, vegetarian, and vegan diets; screening considerations for iron deficiency; dangers of ingestion of button batteries and cannabis edibles; literacy and socioemotional benefits of reading, singing, and storytelling; the importance of unstructured outdoor play; the environment's effect on children's health; the significance of sentinel injuries; acholic stools; and the normal presence and abnormal persistence of developmental (primitive) reflexes.

Conclusion: Building on its 40-year history, the 2024 RBR provides freely available, evidence-informed recommendations to guide clinicians in providing effective, up-to-date, and comprehensive preventive pediatric care. Despite the challenging and evolving landscape of primary health care delivery, the RBR will continue to support primary care providers.

Author/s:

Anne Rowan-Legg, Patricia Li, Bruce Kwok, Leslie Rourke, Denis Leduc, James Rourke, Imaan Bayoumi

2024 edition of the Rourke Baby Record

Hope Smashey — Sat, 13 Sep 2025 19:21:20 +0000

Date Added:

September 13, 2025

Journal/Publication:

Canadian Family Physician

Publication Date:

September 13, 2025

Issue:

Volume:

Pages:

553-561

URL:

2024 edition of the Rourke Baby Record

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.7109553

Keywords

child

infant

Baby

PMID (1):

40940145

MeSH

Culturally Competent Care

primary health care

Vegetarians

Eating

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Author/s:

Anne Rowan-Legg, Patricia Li, Bruce Kwok, Leslie Rourke, Denis Leduc, James Rourke, Imaan Bayoumi

Approach to Obesity Treatment in Primary Care: A Review

Erin Blanchette — Tue, 19 Mar 2024 17:28:36 +0000

Date Added:

March 19, 2024

Journal/Publication:

JAMA Internal Medicine

Publisher:

American Medical Association

Publication Date:

March 11, 2024

URL:

Approach to Obesity Treatment in Primary Care: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2023.8526

Keywords

PMID (1):

38466272

MeSH

A review of current recommended primary care approaches for helping patients lose weight and keep it off. James W. Mold, MD, MPH

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Importance: More than 40% of US adults have obesity, which increases the risks for multiple chronic diseases and premature mortality. Historically, nonsurgical interventions often have not led to sufficient weight loss and maintenance to improve health, but highly effective antiobesity medications (AOMs) have recently become available, and additional effective therapeutics are under development. Given that most medical care for adults with obesity is delivered in primary care settings, guidance for integrating weight-management approaches is needed.

Observations: Lifestyle interventions can lead to a mean weight loss of 2% to 9% of initial weight at 1 year and increase the likelihood of weight loss of 5% or more, but weight regain over time is common even with continued treatment. Adjunctive treatments, including AOMs and surgical approaches, can lead to larger, more sustained weight loss and improvements in numerous obesity-associated medical conditions. Highly effective AOMs, including nutrient-stimulated hormone-based therapies, induce mean weight loss of 15% or more. Barriers to intervention, including access to care, have a disproportionate influence on populations most affected by obesity and its consequences.

Conclusions and relevance: Primary care clinicians play a vital role in the assessment, management, and support of patients with obesity. With careful clinical assessment and shared decision-making, a flexible treatment plan can be developed that reflects evidence of treatment efficacy, patient preference, and feasibility of implementation. Adjunctive therapies to lifestyle interventions, including more effective pharmacotherapeutics for obesity, offer hope to patients and the potential for considerable improvements in health and quality of life.

Author/s:

Susan Z Yanovski, Jack A Yanovski

Project nature: promoting outdoor physical activity in children via primary care

Erin Blanchette — Tue, 12 Mar 2024 16:22:18 +0000

Date Added:

March 12, 2024

Journal/Publication:

BMC Primary Care

Publisher:

Springer Nature

Publication Date:

February 23, 2024

Issue:

Volume:

Pages:

URL:

Project nature: promoting outdoor physical activity in children via primary care

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1186/s12875-024-02297-5

Keywords

behavior therapy

children

children's health

preschool-age children

PMID (1):

38395776

MeSH

A simple primary care-based intervention to increase the outdoor physical activities of children. James W. Mold, MD, MPH

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Background

Families face a range of barriers in supporting their children’s active play in nature including family circumstances, environmental constraints, and behavioral factors. Evidence-based strategies to address these barriers are needed. We aimed to develop and pilot test a primary care-based family-centered behavioral intervention to promote active outdoor play in 4–10 year-old children.

Methods

Project Nature, a provider-delivered intervention that provides informational resources and an age-appropriate toy for nature play, was initially developed for children ages 0–3. With stakeholder input, we adapted existing materials for 4–10 year-olds and conducted usability testing at an urban clinic serving families from diverse backgrounds. Subsequently, we conducted a mix-methods pilot study to evaluate intervention feasibility and acceptability. Parents of 4–10 year-olds completed pre- and post-surveys (n = 22), and a purposive subset (n = 10) completed qualitative interviews. Post-intervention, pediatric providers (n = 4) were interviewed about their implementation experiences.

Results

The majority (82%) of parents liked the information provided and the remaining (18%) were neutral. Qualitatively, parents reported that: the toy provided a tangible element to help children and parents be active, they did not use the website, and they wished the intervention emphasized strategies for physical activity during cold and wet seasons. Providers felt the materials facilitated discussion about behavior change with families. There were no statistically significant changes in PA and outdoor time pre- and post-intervention.

Conclusions

Project Nature was welcomed by providers and families and may be a practical intervention to promote outdoor active play during well-child visits. Providing an age-appropriate nature toy seemed to be a critical component of the intervention, and may be worth the additional cost, time and storage space required by clinics. Building from these results, Project Nature should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial.

Author/s:

Georgia M Griffin, Carolina Nieto, Kirsten Senturia, Marshall Brown, Kimberly Garrett, Elizabeth Nguyen, Danette Glassy, Emily Kroshus, Pooja Tandon

Perinatal Depression: A Guide to Detection and Management in Primary Care

Linda Fowler — Fri, 19 Jan 2024 17:34:34 +0000

Date Added:

January 19, 2024

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

January 5, 2024

Issue:

Volume:

Pages:

1071-1086

URL:

Perinatal Depression: A Guide to Detection and Management in Primary Care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2023.230061R1

Keywords

breast feeding

Interpersonal Psychotherapy

Lactation

Postpartum

Postpartum Depression

Pregnancy

Psychiatry

Psychosocial Intervention

selective serotonin reuptake inhibitors

Surveys and Questionnaires

PMID (1):

37704392

MeSH

Depression / drug therapy

Sertraline / therapeutic use

Depressive Disorder, Major*

An evidence-based summary of the recognition and treatment of patients with peripartum depression. James W. Mold, MD, MPH

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Introduction: Existing guidelines for primary care clinicians (PCCs) on the detection and management of perinatal depression (PD) contain important gaps. This review aims to provide PCCs with a summary of clinically relevant evidence in the field.

Methods: A narrative literature review was conducted by searching PubMed and PsycINFO for articles published between 2010 to 2023. Guidelines, systematic reviews, clinical trials, and/or observational studies were all examined.

Results: Screening with the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 followed by a diagnostic evaluation for major depressive disorder in probable cases can enhance PD detection. At-risk individuals and mild to moderate PD should be referred for cognitive behavioral therapy or interpersonal psychotherapy when available. Selective serotonin reuptake inhibitors should be used for moderate to severe PD, with sertraline, escitalopram, or citalopram being preferred first. Using paroxetine or clomipramine in pregnancy, and fluoxetine or doxepin during lactation is generally not preferred. Gestational antidepressant use is associated with a small increase in risk of reduced gestational age at birth, low birth weight, and lower APGAR scores, though whether these links are causal is unclear. Sertraline and paroxetine have the lowest rate of adverse events during lactation. Consequences of untreated PD can include maternal and offspring mortality, perinatal complications, poor maternal-infant attachment, child morbidity and maltreatment, less breastfeeding, and offspring developmental problems.

Conclusions: These clinically relevant data can support the delivery of high-quality care by PCCs. Risks and benefits of PD treatments and the consequences of untreated PD should be discussed with patients to support informed decision making.

Author/s:

Manish H Dama, Ryan J Van Lieshout

Gold 2023: Highlights for Primary Care

Linda Fowler — Wed, 10 Jan 2024 14:21:54 +0000

Date Added:

January 10, 2024

Journal/Publication:

npj Primary Care Respiratory Medicine

Publisher:

npj

Publication Date:

July 31, 2023

Issue:

Volume:

URL:

Gold 2023: Highlights for Primary Care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1038/s41533-023-00349-4

Keywords

chronic obstructive pulmonary disease

gold

primary health care

Humans

PMID (1):

37524724

MeSH

pulmonary disease, chronic obstructive

Gold

Humans

primary health care

A summary for primary care clinicians of the 2023 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines. James W. Mold, MD, MPH

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The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has issued its 2023 annual report1. Compared with former versions, it has been significantly updated. Here, we summarize the most relevant changes for a Primary Care audience. The complete document can be downloaded for free from the GOLD web page (www.goldcopd.org), together with a “pocket guide” and a “teaching slide set”.

Author/s:

Alvar Agustí, Antoni Sisó-Almirall, Miguel Roman, Claus F. Vogelmeier

Referred otalgia: Common causes and evidence-based strategies for assessment and management

Erin Blanchette — Mon, 27 Nov 2023 18:39:54 +0000

Date Added:

November 27, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

November 14, 2023

Issue:

Volume:

Pages:

757-761

URL:

Referred otalgia: Common causes and evidence-based strategies for assessment and management

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.6911757

Keywords

PMID (1):

37963787

MeSH

A concise summary of the various causes of nonotologic ear pain (referred from other structures). James W. Mold, MD, MPH

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Objective: To provide family physicians and general otolaryngologists with a practical, evidence-based, and comprehensive approach to the management of patients presenting with suspected referred otalgia.

Sources of information: The approach described is a review based on the authors' clinical practices along with research and clinical review articles published between 2000 and 2020. MEDLINE and PubMed were searched using the terms otalgia, referred otalgia, and secondary otalgia. Current guidelines for the management of referred otalgia were also reviewed.

Main message: Otalgia is defined as pain localized to the ear. It is one of the most common head and neck presentations in primary care, otolaryngology, and emergency medicine. Secondary otalgia arises from nonotologic pathology and represents nearly 50% of otalgia cases. Otalgia in the absence of other otologic symptoms is highly indicative of a secondary cause. A thorough assessment of patients presenting with referred otalgia requires an understanding of the possible causes of this condition, including dental and oral mucosal pathologies, temporomandibular joint disorders, cervical spine pathology, sinusitis, upper airway infection, and reflux, as well as head and neck malignancy. This paper aims to highlight the most common causes of referred otalgia, their presentations, and initial options for assessment and management.

Conclusion: The prevalence of referred otalgia makes this an important condition for family physicians to be able to assess, manage, and triage based on patient presentation and examination. Understanding the common causes of referred otalgia will help reduce wait times for specialist assessment and allow ease and speed of access to management options for patients in community clinics.

Author/s:

Fatemeh Ramazani, Charmaine Szalay-Anderson, Arthur Volpato Batista, Phillip Park, Euna Hwang, Justin Chau, Justin Lui

Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial

Erin Blanchette — Tue, 21 Nov 2023 20:21:34 +0000

Date Added:

November 21, 2023

Journal/Publication:

The Lancet

Publisher:

Elsevier

Publication Date:

November 11, 2023

Issue:

10414

Volume:

402

Pages:

1773-1785

URL:

Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/S0140-6736(23)01523-4

Keywords

amitriptyline

Irritable Bowel Syndrome

primary health care

antidepressive agents

PMID (1):

37858323

MeSH

Irritable Bowel Syndrome* / drug therapy

primary health care

Amitriptyline / adverse effects

antidepressive agents

antidepressive agents, tricyclic

amitriptyline

Irritable Bowel Syndrome

General Practitioners

Low-dose amitriptyline can be an effective and well-tolerated treatment option for patients with irritable bowel syndrome. James W. Mold, MD, MPH

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Background: Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies for IBS are ineffective, the UK National Institute for Health and Care Excellence guideline suggests considering low- dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown, and they are infrequently prescribed in this setting.

Methods: This randomised, double-blind, placebo-controlled trial (Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment [ATLANTIS]) was conducted at 55 general practices in England. Eligible participants were aged 18 years or older, with Rome IV IBS of any subtype, and ongoing symptoms (IBS Severity Scoring System [IBS-SSS] score ≥75 points) despite dietary changes and first-line therapies, a normal full blood count and C-reactive protein, negative coeliac serology, and no evidence of suicidal ideation. Participants were randomly assigned (1:1) to low-dose oral amitriptyline (10 mg once daily) or placebo for 6 months, with dose titration over 3 weeks (up to 30 mg once daily), according to symptoms and tolerability. Participants, their general practitioners, investigators, and the analysis team were all masked to allocation throughout the trial. The primary outcome was the IBS-SSS score at 6 months. Effectiveness analyses were according to intention-to-treat; safety analyses were on all participants who took at least one dose of the trial medication. This trial is registered with the ISRCTN Registry (ISRCTN48075063) and is closed to new participants.

Findings: Between Oct 18, 2019, and April 11, 2022, 463 participants (mean age 48·5 years [SD 16·1], 315 [68%] female to 148 [32%] male) were randomly allocated to receive low-dose amitriptyline (232) or placebo (231). Intention-to-treat analysis of the primary outcome showed a significant difference in favour of low-dose amitriptyline in IBS-SSS score between groups at 6 months (-27·0, 95% CI -46·9 to -7·10; p=0·0079). 46 (20%) participants discontinued low-dose amitriptyline (30 [13%] due to adverse events), and 59 (26%) discontinued placebo (20 [9%] due to adverse events) before 6 months. There were five serious adverse reactions (two in the amitriptyline group and three in the placebo group), and five serious adverse events unrelated to trial medication.

Interpretation: To our knowledge, this is the largest trial of a tricyclic antidepressant in IBS ever conducted. Titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. General practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial.

Funding: National Institute for Health and Care Research Health Technology Assessment Programme (grant reference 16/162/01).

Author/s:

Alexander C Ford, Alexandra Wright-Hughes, Sarah L Alderson, Pei-Loo Ow, Matthew J Ridd, Robbie Foy, Gina Bianco, Felicity L Bishop, Matthew Chaddock, Heather Cook, Deborah Cooper, Catherine Fernandez, Elspeth A Guthrie, Suzanne Hartley, Amy Herbert, Daniel Howdon, Delia P Muir, Taposhi Nath, Sonia Newman, Thomas Smith, Christopher A Taylor, Emma J Teasdale, Ruth Thornton, Amanda J Farrin, Hazel A Everitt, ATLANTIS trialists

Approach to atrial fibrillation: Essentials for primary care

Aubrey Delammermore — Sat, 22 Apr 2023 05:00:00 +0000

Date Added:

April 22, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

April 1, 2023

Issue:

Volume:

Pages:

245-256

URL:

Approach to atrial fibrillation: Essentials for primary care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.6904245

Keywords

PMID (1):

37072207

MeSH

Anticoagulants / therapeutic use

Atrial Fibrillation* / diagnosis

chronic disease

Stroke* / etiology

primary health care

A very nice summary of current knowledge and recommendations regarding the prevention and management of atrial fibrillation. James W. Mold, MD, MPH

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Objective: To support family physicians in preventing atrial fibrillation (AF) in patients at risk and in identifying and managing those with established AF; and to summarize key recommendations for ideal screening and care of patients.

Sources of information: The 2020 Canadian Cardiovascular Society and Canadian Heart Rhythm Society comprehensive guidelines for the management of AF, based on current evidence and clinical experience related to AF.

Main message: Atrial fibrillation, which is estimated to affect at least 500,000 Canadians, is associated with high risks of stroke, heart failure, and death. Primary care clinicians occupy a central role in the management of this chronic condition, focusing on the challenges of preventing AF and identifying, diagnosing, treating, and following patients with AF. Evidence-based guidelines that provide optimal management strategies have been published by the Canadian Cardiovascular Society and Canadian Heart Rhythm Society to assist in these tasks. Messages critical to primary care are offered to support effective knowledge translation.

Conclusion: Most patients with AF can be managed effectively in primary care. Family physicians not only play an important role in ensuring patients with AF receive timely diagnoses, but they are also key to providing initial and ongoing care, especially in patients with comorbid conditions.

Author/s:

Bell, A., Andrade, J. G., Macle, L., Connelly, K. A., LaBine, L., Singer, A. G.