Disability examinations: a look at the Social Security Disability Income System.

Disability income protection is an important part of a worker's safety net. U.S. workers who pay into Social Security are eligible for coverage under the federal government, and additional coverage is available in the free market. However, the costs to taxpayers and disability insurance policyholders are high, and a great deal of responsibility rests on the physician providing information on disability issues. A neutral attitude toward a patient requesting disability allows the physician to collect the facts regarding the patient's impairments. A history of the patient's work duties helps the examiner determine the basis for setting limitations or restrictions at work or home. The physician's knowledge base of treatment options assists in determining maximal medical improvement. Records released to the adjudicating body should contain a thorough history, pertinent physical findings, and a review of previous medical records, all of which are to be separated from the opinion of the examiner regarding specific limitations and restrictions. The physician should be aware of symptom magnification and depression as confounders to the patient's perception of disability.

Asthma: a brief overview.

Asthma, a common chronic inflammatory disease of the airways characterized by reversible airway obstruction, is a substantial health problem without regard for age, gender, or ethnicity. Guidelines have been established to provide clinicians with evidence-based recommendations to assist in the diagnosis and management of asthma. This review offers a brief overview of the current understanding of the pathogenesis and definition of asthma, the diagnosis and classification of asthma, and the pharmacologic therapy of asthma in adults. Further studies are required to determine whether the development of new targeted treatments will be effective in the management of asthma.

Low back pain.

Low back pain is a very common condition, with about 80% of people suffering from it at some point in their lives. It is usually self-limited, resolving in 4 to 8 weeks in more than 50% of patients, yet the recurrence rate is high, about 85%. Because of the complexity of the bony, muscular ligamentous, and neural elements of the back, a specific anatomic diagnosis often cannot be made. Evaluation should include a careful history and physical examination, paying particular attention to alarm symptoms or "red flags" mentioned in the text. Imaging procedures are usually not necessary because of the lack of specificity and the high rate of early, spontaneous remission. Exceptions to this include history of recent trauma, presence of red flags or chronic unremitting course. Many treatment modalities, including physical therapy, ultrasound, thermal therapy, and local injection have been tried, but most studies are inconclusive as to their effectiveness. Prolonged bed rest is not indicated. Nonsteroidal anti-inflammation agents, judicious use of muscle relaxers, and patient education about the cause and prognosis are justified.

Quality of care in diabetes: understanding the guidelines.

We are in the midst of a global pandemic of diabetes. Despite the increasing burden of the disease, measurements of quality repeatedly show poor adherence to or implementation of current guidelines for diabetes care. This article will provide a brief review of the most significant randomized controlled clinical trials relevant to the current guidelines and then discuss essential treatment goals and the evidence that supports them. Several practical clinical questions related to the implementation of modern diabetes guidelines will be raised and answered. Finally, reasons for the poor quality performance observed will be examined.

Malpractice risk prevention for primary care physicians.

The recent medical malpractice "crisis" has seen skyrocketing liability premiums and increasing fear of liability. Primary care physicians, especially family medicine and internal medicine physicians, have historically experienced low rates of malpractice claims, both in number and amount of payment. This can be attributed to several factors: the esteem held by internal medicine and family medicine physicians in their communities, relatively low numbers of invasive procedures, reluctance of patients to include "their" primary care physician in any potential litigation, and, probably most importantly, the atmosphere of mutual trust and communication between the internist or family physician and the patient. Recent years have seen this trend erased, as insurance industry data suggest primary care physicians presently face significant potential exposure for medical malpractice claims. It is imperative that primary care physicians take steps to insure they are adequately covered in case of a malpractice claim and that they practice aggressive but appropriate risk management to lessen the likelihood of a claim.

Hyperaldosteronism: the internist's hypertensive disease.

Primary aldosteronism (PA) is a disorder typically characterized by resistant hypertension, hypokalemia, alkalosis and suppressed plasma renin activity, and excessive aldosterone production. A true estimate of the prevalence of the disorder is difficult to estimate because its detection is dependent on the awareness of the healthcare provider to the disorder, but it has generally been felt to be a rare occurrence. Its frequency of detection began to change when Hiramatsu suggested calculating the ratio of plasma aldosterone/plasma renin activity as a screening tool for the disorder. He found a ratio greater than 75 as a sensitive indicator for aldosterone-producing adenomas. Using the ratio, several investigators have found prevalence ranging from 3 to 9%. Two major classifications of PA exist: aldosterone-producing adrenal adenoma (APA) and zona glomerulosa hyperplasia (IHA). Distinguishing between these 2 entities is important clinically, because removal of a unilateral aldosterone-producing adenoma may result in correction of elevated blood pressure and hypokalemia. Thus, when evaluating hypertensive patients, PA should be suspected in those with moderate to severe hypertension or with hypertension refractory to standard treatment or in hypertensive patients with disease onset at an early age. The aldosterone-to-renin ratio is an easy, inexpensive, and rapid means of screening for the disorder. The ratio is the screening test of choice, but further confirmatory testing is required to clinch the diagnosis. Frequently employed confirmatory tests include urinary aldosterone excretion on a high-salt diet, aldosterone suppression after a saline infusion, and the fludrocortisone suppression test, which is considered the most sensitive confirmatory maneuver. Both high-resolution CT and MRI scans appear to have similar ability to differentiate between APA and IHA. As with essential hypertension, the goal of treatment is to prevent the long-term sequela of hypertension. The underlying pathology resulting in PA dictates the treatment strategy. The drug of choice is spironolactone. Surgical intervention should be entertained in those patients with PA in whom imaging studies suggest an adenoma.

Proteinuria as a mortality risk.

This case report examines the factors involved in the mortality risk of low-grade proteinuria. Proteinuria and microalbuminuria are defined and the use of the protein-creatinine ratio is discussed. Studies from the medical literature suggest that albuminuria complements risk selection in diabetics and nondiabetics and may parallel or adversely modify other cardiovascular risk factors.