clinical decision-making

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, MD, Buchbinder, Rachelle

Topical Therapies for Atopic Dermatitis

Rowan Hutchins — Sun, 12 Nov 2023 21:20:37 +0000

Date Added:

November 12, 2023

Journal/Publication:

JAMA

Publisher:

AMA

Publication Date:

October 27, 2023

URL:

Topical Therapies for Atopic Dermatitis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2023.17719

Keywords

Atopic Dermatitis

guidelines

allergy and clinical immunology

PMID (1):

37889498

MeSH

Dermatitis, Atopic

dermatology

Practice Guidelines as Topic / standards*

clinical decision-making

A summary of current topical treatment options for atopic dermatitis. James W. Mold, MD, MPH

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Atopic dermatitis (AD) is a chronic inflammatory skin condition affecting approximately 10% of the US population. AD often occurs as a childhood disease in conjunction with allergies and asthma, but it can also persist into or arise de novo in adulthood. AD negatively affects quality of life, social interactions, and work productivity, with annual US health care costs exceeding $5.3 billion.1 The current guideline provides recommendations on the management of AD in adults with both nonpharmacologic and pharmacologic topical therapies

Author/s:

Amy Z. Xu, Jason T. Alexander

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices

Brian Desmarais — Tue, 14 Jan 2020 15:17:31 +0000

Date Added:

January 14, 2020

Journal/Publication:

Morbidity and Mortality Weekly Report

Publisher:

U.S. Department of Health and Human Services

Publication Date:

August 16, 2019

URL:

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

http://dx.doi.org/10.15585/mmwr.mm6832a3

MeSH

Centers for Disease Control and Prevention, U.S.

Data Collection

vaccination

Papillomaviridae

clinical decision-making

public health

Papillomavirus Infections

Middle Aged

child

United States

HPV vaccination appears to be both safe and effective in adults 27-45 years of age. While the public health impact of routine HPV vaccination of adults would be small, some high-risk individuals could benefit significantly. James W. Mold, MD, MPH

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Summary

What is already known about this topic?

Vaccination against human papillomavirus (HPV) is routinely recommended at age 11 or 12 years. Catch-up recommendations apply to persons not vaccinated at age 11 or 12 years.

What is added by this report?

After reviewing new evidence, CDC updated HPV vaccination recommendations for U.S. adults.

What are the implications for public health practice?

Routine recommendations for HPV vaccination of adolescents have not changed. Catch-up HPV vaccination is now recommended for all persons through age 26 years. For adults aged 27 through 45 years, public health benefit of HPV vaccination in this age range is minimal; shared clinical decision-making is recommended because some persons who are not adequately vaccinated might benefit.

Author/s:

Meites, E., Szilagyi, P., Chesson, H.W., Unger, E.R., Romero, J.R., Markowitz, L.E.

Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices

John Bayhi — Fri, 22 Nov 2019 15:07:10 +0000

Date Added:

November 22, 2019

Journal/Publication:

Morbidity and Mortality Weekly Report

Publisher:

Centers for Disease Control and Prevention

Publication Date:

November 22, 2019

Issue:

Volume:

Pages:

1069-1075

URL:

Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices

Type:

Public Health Announcements

Format:

Article

DOI (1):

10.15585/mmwr.mm6846a5

Keywords

Pneumococcal Vaccines

vaccination

pneumonia

PMID (1):

31751323

MeSH

child

Adult

Humans

Heptavalent Pneumococcal Conjugate Vaccine

Cochlear Implants

Serogroup

Advisory Committees

clinical decision-making

long-term care

13-valent pneumococcal vaccine

Pneumococcal Vaccines

23-valent pneumococcal capsular polysaccharide vaccine

Pneumococcal Infections

Updated recommendations from the ACIP regarding pneumococcal vaccination of patients > 65 years of age. James W. Mold, MD, MPH

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Two pneumococcal vaccines are currently licensed for use in adults in the United States: a 13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13, Pfizer, Inc.]) and a 23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23, Merck and Co., Inc.]). In 2014, the Advisory Committee on Immunization Practices (ACIP)* recommended routine use of PCV13 in series with PPSV23 for all adults aged ≥65 years based on demonstrated PCV13 safety and efficacy against PCV13-type pneumonia among adults aged ≥65 years (1). At that time, ACIP recognized that there would be a need to reevaluate this recommendation because it was anticipated that PCV13 use in children would continue to reduce disease burden among adults through reduced carriage and transmission of vaccine serotypes from vaccinated children (i.e., PCV13 indirect effects). On June 26, 2019, after having reviewed the evidence accrued during the preceding 3 years (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html), ACIP voted to remove the recommendation for routine PCV13 use among adults aged ≥65 years and to recommend administration of PCV13 based on shared clinical decision-making for adults aged ≥65 years who do not have an immunocompromising condition,† cerebrospinal fluid (CSF) leak, or cochlear implant, and who have not previously received PCV13. ACIP recognized that some adults aged ≥65 years are potentially at increased risk for exposure to PCV13 serotypes, such as persons residing in nursing homes or other long-term care facilities and persons residing in settings with low pediatric PCV13 uptake or traveling to settings with no pediatric PCV13 program, and might attain higher than average benefit from PCV13 vaccination. When patients and vaccine providers§ engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for a particular person, considerations might include both the person's risk for exposure to PCV13 serotypes and their risk for developing pneumococcal disease as a result of underlying medical conditions. All adults aged ≥65 years should continue to receive 1 dose of PPSV23. If the decision is made to administer PCV13, it should be given at least 1 year before PPSV23. ACIP continues to recommend PCV13 in series with PPSV23 for adults aged ≥19 years with an immunocompromising condition, CSF leak, or cochlear implant (2).

Author/s:

Matanock, A, Lee, G, Gierke, R, Kobayashi, M, Leidner, A, Pilishvili, T

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices

Brian Desmarais — Mon, 19 Aug 2019 12:55:58 +0000

Date Added:

August 19, 2019

Journal/Publication:

Morbidity and Mortality Weekly Report

Publication Date:

August 16, 2019

Issue:

Volume:

Pages:

698-702

URL:

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices

Type:

Public Health Announcements

Format:

Article

DOI (1):

10.15585/mmwr.mm6832a3

Keywords

MeSH

clinical decision-making

Advisory Committees

Papillomavirus Infections

Updated recommendations on HPV vaccination from the CDC. You can skip down to the “recommendations” section. James W. Mold, MD, MPH

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Vaccination against human papillomavirus (HPV) is recommended to prevent new HPV infections and HPV-associated diseases, including some cancers. The Advisory Committee on Immunization Practices (ACIP)* routinely recommends HPV vaccination at age 11 or 12 years; vaccination can be given starting at age 9 years. Catch-up vaccination has been recommended since 2006 for females through age 26 years, and since 2011 for males through age 21 years and certain special populations through age 26 years. This report updates ACIP catch-up HPV vaccination recommendations and guidance published in 2014, 2015, and 2016 (1-3). Routine recommendations for vaccination of adolescents have not changed. In June 2019, ACIP recommended catch-up HPV vaccination for all persons through age 26 years. ACIP did not recommend catch-up vaccination for all adults aged 27 through 45 years, but recognized that some persons who are not adequately vaccinated might be at risk for new HPV infection and might benefit from vaccination in this age range; therefore, ACIP recommended shared clinical decision-making regarding potential HPV vaccination for these persons.

Author/s:

Meites, E, Szilagyi, P.G., Chesson, H.W., Unger, E.R., Romero, J.R., Markowitz, L.E.

Diagnosis of Celiac Disease: Current State of the Evidence

Tracy Ashby — Tue, 23 Oct 2018 05:00:00 +0000

Date Added:

October 23, 2018

Journal/Publication:

AHRQ Comparative Effectiveness Reviews

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

July 26, 2016

URL:

Diagnosis of Celiac Disease: Current State of the Evidence

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

celiac disease

sensitivity and specificity

clinical decision-making

PMID (1):

27583323

MeSH

celiac disease

sensitivity and specificity

clinical decision-making

This is a summary of the evidence regarding how to diagnose celiac disease.

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This is a summary of a systematic review evaluating the evidence regarding the comparative accuracy (the balance of sensitivity and specificity) and possible adverse consequences (both direct and indirect) of various methods used to diagnose celiac disease. The systematic review included 60 individual studies and 13 previous systematic reviews published from January 1990 through March 2015. The full report, listing all studies and reviews, is available at www.effectivehealthcare.ahrq.gov/celiac-disease. This summary is provided to assist in informed clinical decisionmaking. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Author/s:

John M. Eisenberg Center for Clinical Decisions and Communications Science