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We sought to summarize current recommendations for the diagnosis of diarrhea-predominant irritable bowel syndrome (IBS-D) and describe available management options, highlighting a newer US Food and Drug Administration (FDA)-approved agent, eluxadoline.Literature on IBS-D was assessed up to January 2020 using PubMed, with key search terms including "IBS-D diagnosis", "IBS-D management", and "eluxadoline".IBS is a common gastrointestinal disorder affecting up to 14% of US adults and is particularly prevalent in women and those aged under 50. Symptoms include abdominal pain associated with altered bowel habits (i.e. diarrhea and/or constipation subtyped based on the predominant stool pattern). As IBS-D is challenging to manage with varying symptom severity, effective treatment requires a personalized management approach. Evidence-based therapeutic options endorsed by the American Gastroenterological Association and the American College of Gastroenterology can be used to effectively guide treatment. Dietary and lifestyle modifications, including adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake may lead to symptom improvement. Over-the-counter medications such as loperamide are frequently recommended and may improve stool frequency and rectal urgency; however, for the outcome of abdominal pain, mixed results have been observed. Several off-label prescription medications are useful in IBS-D management, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics. Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin.IBS-D can be effectively managed in the primary care setting in the absence of alarm features. Benefits and risks of pharmacologic interventions should be weighed during treatment selection.

Few meaningful changes have been made to reduce medical student mistreatment despite years of interventions undertaken based on data regarding mistreatment gathered annually in the Association of American Medical College’s (AAMC) Medical School Graduation Questionnaire (GQ). No studies to date have compared clerkship-specific mistreatment to identify problems unique to individual learning environments. The purpose of this study was to investigate medical student mistreatment during third-year clerkships at a university-based medical school and to evaluate specific mistreatment patterns by clerkship. In the 2012–2013 academic year, 122 third-year medical students were surveyed using the AAMC GQ questions on mistreatment behaviors witnessed or experienced during medical school. During each of their clerkships, students were asked to report mistreatment and to specify the individuals responsible for it. Public humiliation was the most commonly reported form of mistreatment. This was more prominent on Surgery (23.8%), Obstetrics and Gynecology (15.2%), and Internal Medicine (12.4%) versus Neurology (4.8%), Psychiatry (4.3%), Pediatrics (2.1%), and Family Medicine (0%). Faculty (36–64%) and residents (29–50%) were primarily responsible for mistreatment. Students identified many instances of mistreatment in the operating room. More students reported being denied opportunities based solely on gender during Obstetrics and Gynecology than all other clerkships (12 versus 0–2%). Students reported higher incidences of mistreatment on Surgery, Obstetrics and Gynecology, and Internal Medicine. Operating room culture may contribute to medical student mistreatment. Gender-specific mistreatment occurs during the Obstetrics and Gynecology clerkship, which may affect the educational experience of male students. We recommend a clerkship-specific approach to evaluate mistreatment to successfully identify and address mistreatment across learning environments.

Men's mental health and how they think about their health are critical to the future of men's health. Poor health choice patterns are established under age 50, when men are twice as likely to die than women. As the future of medicine focuses on quality and value, a better understanding of the social determinants of men's health will identify areas for improvement. The presentation of a man to a clinician's office with a sexual health complaint presents an opportunity for more complete evaluation. The future of men's health will be well served by integrated men's health centers that focus on the entire man.

PURPOSE: Electronic application (app)-based treatment is promising for common diseases with good conservative management options, such as urinary incontinence (UI) in women, but its effectiveness compared with usual care is unclear. This study set out to determine if app-based treatment for women with stress, urgency, or mixed UI was noninferior to usual care in the primary care setting. METHODS: The URinControl trial is a pragmatic, noninferiority randomized controlled trial in Dutch primary care including adult women with 2 episodes of UI per week. From July 2015 to July 2018, we screened 350 women for eligibility. A stand-alone app-based treatment with pelvic floor muscle and bladder training (URinControl) was compared with usual care according to the Dutch general practitioner guideline for UI treatment. Outcomes measured were change in symptom severity score from baseline to 4 months (primary outcome), impact on disease-specific quality of life, patient-perceived improvement, and number of UI episodes. Noninferiority (

Phenomenon: Existing research provides little specific evidence regarding the association between public and private medical school curricular settings and the proportion of medical students matching into family medicine careers. Institutional differences have been inadequately investigated, as students who match into family medicine are often consolidated into the umbrella of primary care along with those matching in internal medicine and pediatrics. However, understanding medical school contexts in relation to career choice is critical toward designing targeted strategies to address the projected shortage of family physicians. This study examines factors associated with family medicine residency match rates and the extent to which such factors differ across medical school settings.We combined data from a survey of 123 departments of family medicine with graduate placement rates reported to the American Academy of Family Physicians over a 2-year period. Chi-square/Fisher's Exact texts, t tests, and linear regression analyses were used to identify factors significantly associated with average match rate percentages.The resulting data set included 85% of the U.S. medical schools with Departments of Family Medicine that reported 2011 and 2012 residency match rates in family medicine. Match rates in family medicine were higher among graduates of public than private medical schools-11% versus 7%, respectively, t(92) = 4.00, p.001. Using a linear regression model and controlling for institutional type, the results indicated 2% higher match rates among schools with smaller annual clerkship enrollments (p = .03), 3% higher match rates among schools with clerkships lasting more than 3 to 4 weeks (p = .003), 3% higher match rates at schools with at least 1 family medicine faculty member in a senior leadership role (p = .04), and 8% lower match rates at private medical schools offering community medicine electives (p.001, R(2) = .48), F(6, 64) = 9.95, p.001. Three additional factors were less strongly related and varied by institutional type-informal mentoring, ambulatory primary care learning experiences, and institutional research focus. Insights: Educational opportunities associated with higher match rates in family medicine differ across private and public medical schools. Future research is needed to identify the qualitative aspects of educational programming that contribute to differences in match rates across institutional contexts. Results of this study should prove useful in mitigating physician shortages, particularly in primary care fields such as family medicine.

INTRODUCTION: Millions of patients take prescription medications each year for common urological conditions. Generic and brand-name drugs have widely divergent pricing despite similar therapeutic benefit and side effect profiles. We examined prescribing patterns across provider types for generic and brand-name drugs used to treat 3 common urological conditions, and estimated economic implications for Medicare Part D spending. METHODS: We extracted 2014 prescription claims and payments from Medicare Part D and categorized oral medications used to treat 3 urological conditions, namely benign prostatic hyperplasia, erectile dysfunction and overactive bladder. We examined claims and payments for each medication among urologists and nonurologists. Lastly, we estimated potential savings by selecting a low cost or generic drug as a cost comparator for each class. RESULTS: There were significant differences in prescribing patterns across these conditions, with urologists prescribing more brand-name and expensive medications (p

PURPOSE:The purpose of this guideline is to provide a clinical strategy for the diagnosis and treatment of erectile dysfunction. MATERIALS AND METHODS:A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of erectile dysfunction. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. RESULTS:The American Urological Association has developed an evidence-based guideline on the management of erectile dysfunction. This document is designed to be used in conjunction with the associated treatment algorithm. CONCLUSIONS:Using the shared decision-making process as a cornerstone for care, all patients should be informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments. For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice.

Introduction: The irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are associated with substantial symptom and disease burden. Although typically classified as distinct diseases, symptoms frequently overlap. Aim: The objective of this study was to characterize symptom and disease burden in IBS-C and CIC sufferers and examine a subset of CIC sufferers with abdominal symptoms. Methods: In a US population-based survey, respondents meeting the Rome III criteria for IBS-C or CIC rated symptom frequency and bothersomeness, missed work and disrupted productivity, and degree of obtaining and satisfaction with physician care. CIC respondents were analyzed in two subgroups: those with abdominal symptoms ≥once weekly (CIC-A) and those without (CIC-NA). Results: Of the 10,030 respondents, 328 met the criteria for IBS-C and 552 for CIC (363 CIC-A; 189 CIC-NA). All symptoms were significantly more frequent in IBS-C vs. CIC respondents (P

Background: Primary care providers inevitably care for prostate cancer survivors. However, few comprehensive resources exist to aid them in providing the most up-to-date and evidence-based care. To meet this clinical need, we examined and updated the Michigan Cancer Consortium prostate cancer survivorship guidelines. Methods: Using an expert panel and focus groups comprised of prostate cancer stakeholders, we updated the Michigan Cancer Consortium's 2009 Guidelines for the Primary Care Management of Prostate Cancer Post-Treatment Sequelae. Results: The guideline recommendations were modified to serve as a point-of-care resource and to facilitate care transitions between specialty and primary care. The modified recommendations were approved by the Michigan Cancer Consortium and now include the following elements: (1) patient-reported symptom assessment, (2) distinctions between medical and self-management strategies for prostate cancer treatment-related side effects, (3) recommendations for involv...

Testosterone replacement therapy (TRT) has been used in millions of men worldwide to treat diminished libido and erectile dysfunction, and to improve strength and physical function. The estimated likelihood of adverse effects of long-term TRT is still essentially unknown, as overall high-quality evidence based upon prospective randomized trials to recommend for or against its use in most men with testosterone deficiency (TD) is lacking. Evidence to suggest that TRT increases cardiovascular morbidity and mortality risks is poor, as results vary across study populations and their baseline comorbidities. While TRT may increase serum prostate-specific antigen levels in some men, it often remains within clinically acceptable ranges, and has not been shown to increase the risk of prostate cancer. Current literature supports that TRT does not substantially worsen lower urinary tract symptoms, and may actually improve symptoms in some men. Limited evidence suggests that TRT may initially worsen obstructive sleep apnea in some men, but that this is not a longstanding effect. TRT may result in erythrocytosis in some men, however long-term studies have not reported significant adverse events (e.g. cerebrovascular accident, vascular occlusive events, venous thromboembolisms). Future research will require dedicated focus on evaluation of large, multiethnic cohorts of men through prospective trials to better elucidate both risk and hazard ratios of TRT as it relates to cardiovascular disease, prostate cancer, lower urinary tract symptoms, obstructive sleep apnea, erythrocytosis, and other to-be-determined theoretical risks in men both with and without cardiovascular risk equivalents.

One of my third-year medical students recently commented, “Why do you see somuch psych in your practice? Why don’t you just refer all of these patients with depression, anxiety, and stress to a psychiatrist”? The same student later commented, “I’m impressed that you spent time motivating your patient to take better care of himself in managing his diabetes and metabolic syndrome—when do we learn those techniques in medical school”? As in many of my previous forewords for the Primary Care: Clinics in Office Practice series, I have stated the challenges of teaching the necessary tools and knowledge to address many complex medical and psychosocial issues within 4 years of medical school and 3 years of primary care residency. While this continues to be a formidable challenge, the proverbial bar becomes raised even higher day after day in meeting the needs of our patients—without simply referring our patients to a specialist when we can be well equipped to diagnose and treat common psychiatric conditions. Appropriate psychiatric treatment requires longitudinal care, sequential assessments, hours of compassionate listening, and the ability to motivate people to make positive changes in their lives. Primary care providers are poised to accept this challenge. This issue of Primary Care: Clinics in Office Practice dedicated to psychiatric care in the primary care setting highlights many salient components of psychiatric care requisite for daily practice. The issue commences with detailing the important conceptual framework of how psychiatric care is integrated through multidisciplinary teams, a necessary construct to understand and utilize relative to our resources. Articles outlining motivational interviewing techniques, cognitive behavioral therapy, and mindfulness techniques contain strategies that clinicians can easily implement and teach that will improve outcomes. Many of the common psychiatric diagnoses seen in primary care are explored in detail, including depression, anxiety, bipolar disorder, personality disorders, autism spectrum disorders, and psychiatric emergencies. A dedicated article highlighting pharmacotherapy is rich in practical information that is always evolving.

Over one-third of men over the age of 45 years in the United States have defined testosterone deficiency based upon decreased serum testosterone levels and related symptoms. This clinical entity has been associated with specific sexual signs and symptoms including decreased libido, erectile dysfunction, and loss of spontaneous erections. It is also associated with cardiometabolic health and overall declining physical and cognitive function in the aging male. Yet no single sign or symptom defines testosterone deficiency. Substantial controversy exists relative to the benefits and risks of testosterone replacement therapy. This chapter will include a review of the integrated pathophysiology and the current guidelines for treatment of testosterone deficiency, as well as a detailed review of the current literature highlighting the relationship between testosterone and cardiometabolic syndrome and benefits versus risks of treatment. Additional comorbid disorders related to testosterone deficiency will also be discussed.

Proton pump inhibitors are highly effective acid suppressants with decades of use highlighting positive outcomes in millions of patients worldwide, and they offer minimal risk of adverse events. PPIs are considered overutilised when prescribed without an appropriate indication, when patients are left on them 'indefinitely' without appropriate indications and when they are continued after being utilised for most cases of hospital SUP. While several adverse outcomes have been linked to PPI therapy, most data are from retrospective observational studies that may be subject to confounding and bias.

Proton pump inhibitors (PPIs) are superior to histamine-2 receptor antagonists for the treatment of gastroesophageal reflux disease (GERD) and erosive esophagitis. Antisecretory therapy (AST), however, accounts for significant cost expenditure in the United States including over-the-counter and prescription formulations. Moreover, emerging data illustrate the potential risks associated with long-term PPI therapy including variations in bioavailability of common medications, vitamin B12 deficiency, Clostridium difficile-associated diarrhea, community-acquired pneumonia, and hip fracture. For these reasons, it is imperative to use the lowest dose of drug necessary to achieve desired therapeutic goals. This may entail the use of step-down, step-off, or on-demand PPI therapy for the treatment of GERD. In addition, PPIs are the most commonly used medications for stress ulcer prophylaxis (SUP), despite little evidence to support their use. Compounding this problem is evidence that patients erroneously administered SUP are often discharged on long-term PPI therapy. Pharmacy-driven step-down orders, limitation of the use of PPIs for SUP in non-ICU settings, and meticulous chart review to ensure that hospitalized patients are not discharged home on a PPI without an appropriate indication are interventions that can ensure proper PPI utilization with minimal of risk and optimization of cost-effectiveness.

Background: Due to their broad-spectrum activity and oral bioavailability, fluoroquinolone antibiotics are commonly prescribed to adults aged >60 years for many common community-acquired infections. The association between fluoroquinolone use and Achilles tendinitis is well established but sometimes missed in clinical practice. Older patients and patients with renal dysfunction are at particularly increased risk for this complication. Case summary: We present a case of Achilles tendinitis in a 77-year-old patient with renal dysfunction and a urinary tract infection (UTI) treated with ciprofloxacin 250 mg PO QD. Tendinitis developed within several days of the start of treatment and improved within 2 days of treatment cessation, without the need for intervention. The likelihood of ciprofloxacin having caused this reaction was probable (Naranjo score, 7). Early diagnosis and treatment cessation might have prevented tendon rupture, and the tendinitis resolved completely with subsequent physical therapy. Conclusion: Based on this outcome in this patient with UTI, fluoroquinolones should be used with caution, particularly in patients with risk factors predisposing to tendinitis, including advanced age and renal dysfunction.

Veterans Affairs Center for Clinical Management Research; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; and Division of Gastroenterology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada

The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of Peyronie's disease.A systematic review of the literature using the PubMed®, EMBASE® and Cochrane databases (search dates 1/1/1965 to 1/26/15) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of PD. The review yielded an evidence base of 303 articles after application of inclusion/exclusion criteria.The systematic review was used to create guideline statements regarding treatment of PD. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional consensus statements related to the diagnosis of PD are provided as Clinical Principles and Expert Opinions due to insufficient published evidence.There is a continually expanding literature on PD; the Panel notes that this document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to PD evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Although administration of stress ulcer prophylaxis (SUP) has been recommended for specific patients in the intensive care unit (ICU) setting, this practice has been extrapolated to care of non-ICU patients without evidence to support need or efficacy.To examine the practice of SUP in non-ICU patients in a university hospital setting, with specific attention to resource utilization.Retrospective chart review of adult non-ICU admissions to one family medicine and five general internal medicine teaching services over a consecutive 4-month period. Proportion of patients prescribed SUP was ascertained after exclusion of patients admitted on antisecretory therapy (AST) or prescribed AST for non-SUP indications. Annual cost estimates were calculated assuming full compliance.Of 1,769 patient admissions, 22% received SUP and 54% of these were discharged home on AST. None of these patients met evidence-based criteria for appropriate SUP. Inpatient SUP cost Dollars 11,024 over the 4 months of the study (Dollars 44,096 annually), and outpatient costs based on discharge prescriptions were Dollars 16,924 (Dollars 67,695 annually), yielding a total cost expenditure of Dollars 27,948 (Dollars 111,791 annually).SUP is overutilized in the non-ICU setting, and patients are often discharged unnecessarily on AST, resulting in significant cost expenditure. Interventions to ensure appropriate use of SUP should decrease resource expenditures without detrimental impact on quality of care.

Proton pump inhibitors (PPIs) remain the superior choice worldwide in antisecretory therapy in the evidence-based treatment of upper gastrointestinal disorders including gastroesophageal reflux disease, erosive esophagitis, dyspepsia and peptic ulcer disease. PPI overutilization in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. Nonjudicious use of PPIs creates both preventable financial as well as medical concerns. PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients, as well as those on chronic hemodialysis and concomitant PPI therapy. No current evidence recommends routine screening or supplementation for these potential vitamin and mineral deficiencies in patients on either short- or long-term PPI therapy. Reducing inappropriate prescribing of PPIs can minimize the potential risk of vitamin and mineral deficiencies.