Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

OBJECTIVES

Dizziness often happens in patients with chronic neck pain with only cervical disc degeneration but without cervical radiculopathy or myelopathy. We prospectively selected a series of patients who showed cervical disc degeneration with concomitant chronic neck pain and intractable dizziness who did not respond to conservative treatment to test a new diagnostic method for this dizziness, to analyze the results of anterior cervical discectomy and fusion (ACDF) surgery based on the test, and to explore its pathogenesis.

METHODS

Seventy-seven patients who had a transient neck pain and dizziness relief after injection of bupivacaine into a suspected disc were included in the study. In total, 52 underwent ACDF as surgery group, and 25 refused surgery and accepted conservative treatments as conservative group from June, 2015 to October, 2016 with subsequent follow-up to 1 year. The outcomes were visual analogue scale for neck pain, Neck Disability Index, and intensity and frequency of dizziness. During ACDF, the 72 specimens of degenerative cervical discs were collected to determine the innervation in degenerative cervical discs immunohistochemically.

RESULTS

After surgery, the patients experienced a significant reduction in neck pain and dizziness. Symptomatic relief in surgery group was obviously better than conservative group at each time point of follow-up (P = 0.001). Ruffini corpuscles and substance P-positive free nerve fibers were obviously increased in the number and deeply ingrown into the inner degenerative cervical discs.

CONCLUSIONS

Current clinical and immunohistochemical studies strongly suggest that chronic neck pain and intractable dizziness in this series of patients stem from the degenerative cervical discs.

Incorporating PROMIS Symptom Measures into Primary Care Practice-a Randomized Clinical Trial

BACKGROUND

Symptoms account for more than 400 million clinic visits annually in the USA. The SPADE symptoms (sleep, pain, anxiety, depression, and low energy/fatigue) are particularly prevalent and undertreated.

OBJECTIVE

To assess the effectiveness of providing PROMIS (Patient-Reported Outcome Measure Information System) symptom scores to clinicians on symptom outcomes.

DESIGN

Randomized clinical trial conducted from March 2015 through May 2016 in general internal medicine and family practice clinics in an academic healthcare system.

PARTICIPANTS

Primary care patients who screened positive for at least one SPADE symptom.

INTERVENTIONS

After completing the PROMIS symptom measures electronically immediately prior to their visit, the 300 study participants were randomized to a feedback group in which their clinician received a visual display of symptom scores or a control group in which scores were not provided to clinicians.

MAIN MEASURES

The primary outcome was the 3-month change in composite SPADE score. Secondary outcomes were individual symptom scores, symptom documentation in the clinic note, symptom-specific clinician actions, and patient satisfaction.

KEY RESULTS

Most patients (84%) had multiple clinically significant (T-score ≥ 55) SPADE symptoms. Both groups demonstrated moderate symptom improvement with a non-significant trend favoring the feedback compared to control group (between-group difference in composite T-score improvement, 1.1; P = 0.17). Symptoms present at baseline resolved at 3-month follow-up only one third of the time, and patients frequently still desired treatment. Except for pain, clinically significant symptoms were documented less than half the time. Neither symptom documentation, symptom-specific clinician actions, nor patient satisfaction differed between treatment arms. Predictors of greater symptom improvement included female sex, black race, fewer medical conditions, and receiving care in a family medicine clinic.

CONCLUSIONS

Simple feedback of symptom scores to primary care clinicians in the absence of additional systems support or incentives is not superior to usual care in improving symptom outcomes.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02383862.

Sex differences in spontaneous reports on adverse drug events for common antihypertensive drugs

Purpose

To explore sex differences in spontaneously reported adverse drug events (ADEs) for antihypertensives in routine care.

Methods

A cross sectional analysis combining number of reports from the national pharmacovigilance database with data from the Swedish Prescribed Drug Register, from 2005 to 2012 for ACE inhibitors (ACE-I) and angiotensin receptor blockers (ARB), with or without thiazide, diuretics (thiazides, potassium-sparing agents, sulfonamides, aldosterone antagonists), selective betablockers, and dihydropyridine calcium-channel-blockers (DHPs). The total number of reports was adjusted to exposed patients and dispensed DDDs among women and men. Dose exposures, co-medications, and co-prescriptions were also analyzed.

Results

In women, a higher prevalence of ADE-reports was seen in ACE-I (odds ratio, OR 1.21; 95% CI 1.09–1.35), ACE-I-combinations (OR 1.61; 1.44–1.79), ARB-combinations (OR 2.12; 1.47–3.06), thiazides (OR 1.78; 1.33–2.39), diuretics and potassium-sparing agents (OR 1.62; 1.22–2.17), and DHPs (OR 1.40; 1.17–1.67), with a potential linkage to dose exposure. For aldosterone antagonists, we observed a higher prevalence of ADE reports in men (OR 0.75; 0.59–0.97) but without any sex difference in dose exposure.

Conclusions

This ecological study of reported ADEs showed a higher prevalence of reports in women in six out of ten groups of antihypertensive drugs, and this may potentially be linked to dose exposure. Aldosterone antagonists was the only group with a higher prevalence of ADE-reports in men with a similar dose exposure between women and men.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2480-y) contains supplementary material, which is available to authorized users.

The Outpatient Physical Examination

The physical examination in the outpatient setting is a valuable tool. Even in settings where there is lack of evidence, such as the annual physical examination of an asymptomatic adult, the physical examination is beneficial for the physician-patient relationship. When a patient has specific symptoms, the physical examination-in addition to a thorough history-can help narrow down, or in many cases establish, a diagnosis. In a time where imaging and laboratory tests are easily available, but are expensive and can be invasive, a skilled physical examination remains an important component of patient evaluation.

Why Bioethics Should Be Concerned With Medically Unexplained Symptoms

Biomedical diagnostic science is a great deal less successful than we've been willing to acknowledge in bioethics, and this fact has far-reaching ethical implications. In this article I consider the surprising prevalence of medically unexplained symptoms, and the term's ambiguous meaning. Then I frame central questions that remain answered in this context with respect to informed consent, autonomy, and truth-telling. Finally, I show that while considerable attention in this area is given to making sure not to provide biological care to patients without a need, comparatively little is given to the competing, ethically central task of making sure never to obstruct access to biological care for those with diagnostically confusing biological conditions. I suggest this problem arises from confusion about the philosophical value of vagueness when it comes to the line between biological and psychosocial needs.

Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia

INTRODUCTION

We assessed if patients with known hypoglycaemia present on other occasions with non-specific symptoms associated with (but not diagnosed as) hypoglycaemia, potentially representing missed hypoglycaemia.

METHODS

335 primary care records (5/2/12-4/2/13) from patients aged >65 (79 on insulin, 85 on sulphonylureas, 121 on metformin only, 50 without diabetes) were assessed for hypoglycaemia episodes and consultations with non-specific symptoms, "hypo clues".

RESULTS

27/79(34%) insulin-treated patients had >1 documented hypoglycaemia episode, compared to 4/85(5%) sulphonylurea-treated patients, 2/121(2%) metformin-only treated patients, and none without diabetes, p<0.001. "Hypo clue" consultations were common: 1.37 consultations/patient/year in insulin-treated patients, 0.98/patient/year in sulphonylurea-treated, 0.97/patient/year in metformin only-treated, and 0.78/patient/year in non-diabetic patients, p=0.34. In insulin-treated patients with documented hypoglycaemia, 20/27(74%) attended on another occasion with a "hypo clue" symptom, compared to 21/52(40%) of those without hypoglycaemia, p=0.008. No significant difference in the other treatment groups. Nausea, falls and unsteadiness were the most discriminatory symptoms: 7/33(21%) with hypoglycaemia attended on another occasion with nausea compared to 14/302(5%) without hypoglycaemia, p=0.002; 10/33(30%) vs 36/302(12%) with falls, p=0.007; and 5/33(15%) vs 13/302(4%) with unsteadiness, p=0.023.

CONCLUSIONS

Non-specific symptoms are common in those >65 years. In insulin-treated patients at high hypoglycaemia risk, nausea, falls and unsteadiness should prompt consideration of hypoglycaemia.

Gender Differences in Prevalence of Somatoform Disorders in Patients Visiting Primary Care Centers

The aim of this study was to examine the gender differences in the prevalence of somatoform disorders among a sample of Qatari patients who were visiting primary health care centers and to investigate the severity of diagnostic categories and the most frequent somatic symptoms in these patients. The first stage of the study was conducted with the help of general practitioners, using the somatic symptom module of the Patient Health Questionnaire 12-item General Health Questionnaire. Overall, 2320 subjects were approached, and a total of 1689 patients, of whom 892 were men and 797 were women, agreed to participate in the study. The prevalence rate of somatoform disorders among the total screened sample was 23.9%. The prevalence rate was slightly higher in Qatari women (24.2%) than in Qatari men (23.7%). Housewives (43.5%) and men in administrative posts (37.9%) reported higher somatic symptoms compared to other professions. Prolonged depressive reaction was significantly higher in women compared to men ( P = .003). There was a significant gender difference in certain psychiatric diagnostic categories such as depressive episode, recurrent depressive disorder, dysthymia, and brief depressive reaction. Backache was the most common reported symptom in men, whereas headache was more common in women. The present study revealed that the prevalence of somatoform disorders in Qatar is as high as the overall prevalence reported in prior studies done in other primary care settings. The prevalence of somatoform disorders was slightly higher in Qatari women than in men.

Liaison Psychiatry for the 21st Century: A Review

The development of liaison psychiatry services over the last 20 years is briefly reviewed--sophisticated liaison services have been confined to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals.

Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review

BACKGROUND

Dizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care.

METHODS

We systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms 'dizziness' or 'vertigo' as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates.

RESULTS

We identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière's disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life.

CONCLUSION

There is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.

Gulf War syndrome – has it gone away?

‘Gulf War syndrome’ was a phrase coined after the 1991 Gulf War. This article looks at the variety of hypotheses that have been put forward about the origins of the concept and the studies attempting to characterise the health manifestations of Gulf service and the lasting effects on veterans. It also serves to bring readers up to date with research on the present deployment in Iraq. Finally, consideration is given to how Gulf War syndrome compares with the rich historical literature of post-conflict medical syndromes and how sociological factors may interact with symptom attribution in veterans.

Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting

Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.

REMAP-a Resilience Resources Measure for Prediction and Management of Somatic Symptoms

PURPOSE

Patients with symptoms but without an identified disease are a challenge to primary care providers. A 22-item measure is introduced and evaluated to offer medical care providers with an instrument to assess and discuss possible deficiencies in resilience resources that may contribute to symptoms without identifiable pathology. This instrument highlights psychosocial and lifestyle resources that serve as buffers to life's stressors rather than focusing on stress and its related symptoms.

METHODS

The measure included items from five resilience domains-relational engagement, emotional sensibility, meaningful action, awareness of self and others, and physical health behaviors (REMAP). Its structure and function were evaluated using two different samples.

RESULTS

Results suggest that scores from the REMAP have reasonable psychometric properties. Higher REMAP scores were predictive of fewer health symptoms in a sample representative of the US population. In a second sample, REMAP was positively associated with perceived resilience, ego strength and mindfulness attention and negatively related to perceived stress, depression, sleep disturbances, and loneliness, providing evidence of convergent and divergent validity. Furthermore, the REMAP scale was sensitive to change following a life style intervention.

CONCLUSION

This suggests that REMAP can be a useful tool in practice settings for counseling patients with unexplained symptoms. With insight into the biopsychosocial aspect of their symptoms, patients may become more receptive to cognitive behavioral options to improve their resilience resources and lifestyle choices.

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms

PURPOSE

To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors.

METHOD

A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms).

RESULTS

Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior.

CONCLUSION

Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

Negative affect as mediator between emotion regulation and medically unexplained symptoms

BACKGROUND

Research on emotion regulation (ER) in medically unexplained physical symptoms (MUS) is rare.

PURPOSE

The goal of this study was to compare ER skills between MUS-patients without comorbid depression, MUS-patients with comorbid depression (MUS+MDD), patients with major depressive disorder (MDD), and healthy controls. Additionally, we examined the mediating effect of depression and anxiety on the relationship between ER and somatization.

METHODS

The Emotion-Regulation Skills Questionnaire (ERSQ) and other self-report measures were completed by 138 MUS-patients, 114 MUS+MDD-patients, 106 MDD-patients, and 100 healthy controls. Multiple mediation analyses were applied to investigate the role of depression and anxiety as potential mediators.

RESULTS

A MANCOVA and post-hoc test with age, sex and education as covariates indicated that ER skills of the MUS-group were lower than the controls (p<0.001-p=0.047), but higher than the MDD- and MUS+MDD-group (p<0.001-p=0.042). ER skills of the MDD-group and MUS+MDD-group did not differ (p=0.78-p=0.99), but were lower than controls (p<0.001-p=0.011). In the MUS-groups depression and anxiety had a mediating effect on the relationship between ER and somatization (b=-0.23, 95% bias-corrected CI: -0.30, -0.17). The direct effect of ER on somatization was no longer significant when controlling for the mediating variables (b=0.07, p=0.083).

CONCLUSIONS

Our study reveals that patients with MUS+MDD have higher deficits in ER skills than MUS patients without MDD. Additionally, deficits in ER in MUS-patients are influenced by depression and anxiety. This indicates that MUS-patients with comorbid mental disorders might benefit from an emotion regulation training.

Somatic symptom profiles in the general population: a latent class analysis in a Danish population-based health survey

Purpose

The aim of this study was to identify and describe somatic symptom profiles in the general adult population in order to enable further epidemiological research within multiple somatic symptoms.

Methods

Information on 19 self-reported common somatic symptoms was achieved from a population-based questionnaire survey of 36,163 randomly selected adults in the Capital Region of Denmark (55.4% women). The participants stated whether they had been considerably bothered by each symptom within 14 days prior to answering the questionnaire. We used latent class analysis to identify the somatic symptom profiles. The profiles were further described by their association with age, sex, chronic disease, and self-perceived health.

Results

We identified 10 different somatic symptom profiles defined by number, type, and site of the symptoms. The majority of the population (74.0%) had a profile characterized by no considerable bothering symptoms, while a minor group of 3.9% had profiles defined by a high risk of multiple somatic symptoms. The remaining profiles were more likely to be characterized by a few specific symptoms. The profiles could further be described by their associations with age, sex, chronic disease, and self-perceived health.

Conclusion

The identified somatic symptom profiles could be distinguished by number, type, and site of the symptoms. The profiles have the potential to be used in further epidemiological studies on risk factors and prognosis of somatic symptoms but should be confirmed in other population-based studies with specific focus on symptom burden.

A window-based time series feature extraction method

This study proposes a robust similarity score-based time series feature extraction method that is termed as Window-based Time series Feature ExtraCtion (WTC). Specifically, WTC generates domain-interpretable results and involves significantly low computational complexity thereby rendering itself useful for densely sampled and populated time series datasets. In this study, WTC is applied to a proprietary action potential (AP) time series dataset on human cardiomyocytes and three precordial leads from a publicly available electrocardiogram (ECG) dataset. This is followed by comparing WTC in terms of predictive accuracy and computational complexity with shapelet transform and fast shapelet transform (which constitutes an accelerated variant of the shapelet transform). The results indicate that WTC achieves a slightly higher classification performance with significantly lower execution time when compared to its shapelet-based alternatives. With respect to its interpretable features, WTC has a potential to enable medical experts to explore definitive common trends in novel datasets.

Current Psychosomatic Practice

Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

Dizziness in a community hospital: central neurological causes, clinical predictors, and diagnostic yield and cost of neuroimaging studies

Objectives: Neuroimaging is contributing to the rising costs of dizziness evaluation. This study examined the rate of central neurological causes of dizziness, relevant clinical predictors, and the costs and diagnostic yields of neuroimaging in dizziness assessment. Methods: We retrospectively reviewed the records of 521 adult patients who visited the hospital during a 12-month period with dizziness as the chief complaint. Clinical findings were analyzed using Fisher's exact test to determine how they correlated with central neurological causes of dizziness identified by neuroimaging. Costs and diagnostic yields of neuroimaging were calculated. Results: Of the 521 patients, 1.5% had dizziness produced by central neurological causes. Gait abnormalities, limb ataxia, diabetes mellitus, and the existence of multiple neurological findings predicted central causes. Cases were associated with gait abnormalities, limb ataxia, diabetes mellitus, and the existence of multiple neurological findings . Brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed in 42% and 9.5% of the examined cases, respectively, with diagnostic yields of 3.6% and 12%, respectively. Nine cases of dizziness were diagnosed from 269 brain scans, costing $607 914. Conclusion: Clinical evaluation can predict the presence of central neurological causes of dizziness, whereas neuroimaging is a costly and low-yield approach. Guidelines are needed for physicians, regarding the appropriateness of ordering neuroimaging studies. Abbreviations: OR: odds ratio; CI: confidence interval; ED: emergency department; CT: computed tomography; MRI: magnetic resonance imaging; HINTS: Head impulse, Nystagmus, Test of skew.

The Somatic Symptom Disorder - B Criteria Scale (SSD-12): Factorial structure, validity and population-based norms

PURPOSE

The Somatic Symptom Disorder - B Criteria Scale (SSD-12) assesses the psychological features of DSM-5 Somatic Symptom Disorder (SSD). The present study investigates the dimensionality and psychometric properties in a general population sample and provides norm values.

METHOD

Test dimensionality was evaluated via confirmatory factor analysis and nonparametric item response theory. Correlational analyses and logistic regression models based on related measures (SSS 8, PHQ-2, GAD-2, Health Care Utilization) were used to derive predictive validity. Age and gender specific norms were derived via quantile regression.

RESULTS

The SSD-12 has good item characteristics and excellent reliability (Cronbach's α=0.95). Confirmatory factor analyses revealed a high correlation between the three proposed psychological subscales interpreted as cognitive, affective and behavioral aspects, indicating a general factor model of the SSD-12 in the general population (n=2362, CFI=0.99, TLI=0.998, RMSEA=0.09, 90% CI: 0.09-0.1). SSD-12 total sum-score was significantly associated with somatic symptom burden (r=0.73, p<0.001), general anxiety (r=0.63, p<0.001) and depressive symptoms (r=0.64, p<0.001). Patients with a higher SSD-12 symptom burden reported higher general physical and mental health impairment and a significantly higher health care use.

CONCLUSION

The SSD-12 is a reliable and valid self-report measure of the psychological characteristics of DSM-5 Somatic Symptom Disorder. The provided norms enable researchers and clinicians to compare SSD-12 scores with reference values of a general population sample.

An Attachment-Based Model of the Relationship Between Childhood Adversity and Somatization in Children and Adults

OBJECTIVE

An attachment model was used to understand how maternal sensitivity and adverse childhood experiences are related to somatization.

METHODS

We examined maternal sensitivity at 6 and 18 months and somatization at 5 years in 292 children in a longitudinal cohort study. We next examined attachment insecurity and somatization (health anxiety, physical symptoms) in four adult cohorts: healthy primary care patients (AC1, n = 67), ulcerative colitis in remission (AC2, n = 100), hospital workers (AC3, n = 157), and paramedics (AC4, n = 188). Recall of childhood adversity was measured in AC3 and AC4. Attachment insecurity was tested as a possible mediator between childhood adversity and somatization in AC3 and AC4.

RESULTS

In children, there was a significant negative relationship between maternal sensitivity at 18 months and somatization at age 5 years (B = -3.52, standard error = 1.16, t = -3.02, p = .003), whereas maternal sensitivity at 6 months had no significant relationship. In adults, there were consistent, significant relationships between attachment insecurity and somatization, with the strongest findings for attachment anxiety and health anxiety (AC1, β = 0.51; AC2, β = 0.43). There was a significant indirect effect of childhood adversity on physical symptoms mediated by attachment anxiety in AC3 and AC4.

CONCLUSIONS

Deficits in maternal sensitivity at 18 months of age are related to the emergence of somatization by age 5 years. Adult attachment insecurity is related to somatization. Insecure attachment may partially mediate the relationship between early adversity and somatization.

Central Sensitization Inventory as a Predictor of Worse Quality of Life Measures and Increased Length of Stay Following Spinal Fusion

BACKGROUND

Central sensitization is abnormal and intense enhancement of pain mechanism by the central nervous system. Patients with central sensitization may be at higher risk of poor outcomes after spinal fusion. The Central Sensitivity Inventory (CSI) was developed to identify and quantify key symptoms related to central sensitization.

METHODS

In 664 patients who underwent thoracic and/or lumbar fusion, we evaluated retrospectively pretreatment CSI as a predictor of postoperative quality of life measures, length of stay, and discharge status.

RESULTS

Preoperative Pain Disability Questionnaire scores, Patient Health Questionnaire-9 scores, and EuroQol-5 Dimensions index scores were significantly worse in patients with preoperative CSI ≥40 compared with patients with preoperative CSI <40 (P < 0.0001 for all). After adjusting for demographic variables, operation duration, and preoperative health status, preoperative CSI was significantly associated with higher postoperative Pain Disability Questionnaire total score (unadjusted P < 0.001, adjusted P = 0.009), higher postoperative Patient Health Questionnaire-9 score (unadjusted P < 0.001, adjusted P = 0.001), and lower postoperative EuroQol-5 Dimensions index (unadjusted P < 0.001, adjusted P = 0.001). For each 10-unit increase in CSI, average length of stay increased by 6.4% (95% confidence interval 0.4%-12.6%, P = 0.035). The odds of being discharged home after adjusting for confounders was not statistically related to preoperative CSI (P = 0.0709).

CONCLUSIONS

Preoperative CSI was associated with worse quality of life outcomes and increased length of stay after spinal fusions. CSI may be an additional measure in evaluating patients preoperatively to better predict successful spinal fusion outcomes.

Process-oriented dynamic group psychotherapy for depression as a teaching modality in a family medicine residency program- A pilot study

Background and Objectives This pilot study provides a description and evaluation of process-oriented dynamic group psychotherapy for depression as a teaching modality for family medicine residents. The main purpose of using this modality was to teach family medicine residents a variety of psychological clinical skills. A secondary benefit of this modality was to provide in-house, primary care treatment to depressed patients, although the efficacy of this was not evaluated in the present study. Methods A 10-item, self-report, Likert-type questionnaire was administered to a convenience sample of family medicine residents who had participated in the program. Results Completed questionnaires were received from 100% of the family medicine resident participants. Responses to the questionnaires indicate that the residents felt they acquired a variety of clinical skills from the training modality, to include developing active listening and interviewing skills; methods to improve the doctor-patient relationship; increased skills in empathy, intuitive processes, and emotional support; a depth understanding of how intra-psychic conflicts and interpersonal problems contribute to depression; how to give effective feedback that promotes behavioral change; and how to place interventions at the appropriate level of change. Eighty-eight percent of residents indicated they would recommend this learning modality to a family medicine physician colleague. Conclusions The family medicine residents' responses to the questionnaires indicate that they perceived process-oriented dynamic group psychotherapy for depression as a constructive and beneficial modality for both patient care and learning a variety of clinical skills.

Health care utilization in outpatients with somatoform disorders: Descriptives, interdiagnostic differences, and potential mediating factors

OBJECTIVE

Somatoform disorders are characterized by increased health care utilization producing high health costs. The aim of this study was to assess facets of and interdiagnostic differences in health care use in somatoform disorders and to examine health anxiety, symptom-related disability, depression, and phobic anxiety as potential mediating factors of the relationship between somatization and health care use.

METHOD

An outpatient sample of N=254 patients with somatoform disorders was investigated by analyzing different facets of their health care use over the last 12months. Multiple mediation analyses were applied.

RESULTS

Participants reported a mean of 28.02 doctor visits over the last year. Patients fulfilling criteria of DSM-IV somatization disorder had a significantly higher number of doctor visits than patients with undifferentiated somatoform, and somatoform pain disorder, all p≤.006. In most health care use variables, patients with comorbid mental disorders did not differ from patients without comorbidities. The mediation model on the effect of all mediator variables on the relationship between somatization and health care use reached significance (b=0.32, 95% CI: 0.0576, 0.6435). Surprisingly, specific mediator effects were found for health anxiety (b=0.06, 95% CI: 0.0004, 0.1505) and disability (b=0.18, 95% CI: 0.0389, 0.3530), but not for depression and phobic anxiety.

CONCLUSIONS

Health anxiety and symptom-related disability should be further considered when investigating potential etiological factors of increased health care use.

The SPADE Symptom Cluster in Primary Care Patients With Chronic Pain

OBJECTIVES

Sleep disturbance, pain, anxiety, depression, and low energy/fatigue, the SPADE pentad, are the most prevalent and co-occurring symptoms in the general population and clinical practice. Co-occurrence of SPADE symptoms may produce additive impairment and negatively affect treatment response, potentially undermining patients' health and functioning. The purpose of this paper is to determine: (1) prevalence and comorbidity (ie, clustering) of SPADE symptoms; (2) internal reliability and construct validity of a composite SPADE symptom score derived from the Patient-Reported Outcomes Measurement Information System (PROMIS) measures; and (3) whether improvement in somatic symptom burden represented by a composite score predicted subsequent measures of functional status at 3 and 12 months follow-up.

METHODS

Secondary analysis of data from the Stepped Care to Optimize Pain care Effectiveness study, a randomized trial of a collaborative care intervention for Veterans with chronic pain.

RESULTS

Most patients had multiple SPADE symptoms; only 9.6% of patients were monosymptomatic. The composite PROMIS symptom score had good internal reliability (Cronbach's alpha=0.86) and construct validity and strongly correlated with multiple measures of functional status; improvement in the composite score significantly correlated with higher scores for 5 of 6 functional status outcomes. The standardized error of measurement (SEM) for the composite T-score was 2.84, suggesting a 3-point difference in an individual's composite score may be clinically meaningful.

DISCUSSION

Brief PROMIS measures may be useful in evaluating SPADE symptoms and overall symptom burden. Because symptom burden may predict functional status outcomes, better identification and management of comorbid symptoms may be warranted.

The overlap of somatic, anxious and depressive syndromes: A population-based analysis

OBJECTIVE

The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care cases. As research on this overlap of syndromes in the general population is scarce, the present study investigated the prevalence of the overlapping syndromes and their association with health care use.

METHOD

A national general population survey was conducted between June and July 2012. Trained interviewers contacted participants face-to-face, during which, individuals reported their health care use in the previous 12months. Somatic, anxious and depressive syndromes were assessed using the Somatic Symptom Scale-8 (SSS-8), Generalized Anxiety Disorder-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2) respectively.

RESULTS

Out of 2510 participants, 236 (9.4%) reported somatic (5.9%), anxious (3.4%) or depressive (4.7%) syndromes, which were comorbid in 86 (3.4%) cases. The increase in the number of syndromes was associated with increase in health care visits (no syndrome: 3.18 visits vs. mono syndrome: 5.82 visits vs. multi syndromes: 14.16 visits, (F_(2,2507)=149.10, p<0.00001)). Compared to each somatic (semi-partial r²=3.4%), anxious (semi-partial r²=0.82%) or depressive (semi-partial r²=0.002%) syndrome, the syndrome overlap (semi-partial r²=6.6%) explained the greatest part of variance of health care use (_{change_in}R²⁼11.2%, _{change_in}F_(3,2499)=112.81, p<0.001.) CONCLUSIONS: The overlap of somatic, anxious and depressive syndromes is frequent in the general population but appears to be less common compared to primary care populations. To estimate health care use in the general population the overlap of somatic, anxious and depressive syndromes should be considered.

The differential diagnosis of tiredness: a systematic review

Background

Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care.

Methods

MEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint.

Results

We found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6–4.8 %); malignancy: 0.6 % (CI 0.3–1.3 %); serious somatic disease: 4.3 % (CI 2.7–6.7 %); depression 18.5 % (CI 16.2–21.0 %). Pooling was not appropriate for CFS.

In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness.

Conclusions

Serious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0545-5) contains supplementary material, which is available to authorized users.

Employee Perceived Stress

Repetitive strain injuries (RSIs), specifically carpal tunnel syndrome, are the fastest growing type of occupational injury. Research about precipitating factors and prevention has been controversial and inconclusive. Preventive measures typically have addressed ergonomic changes. The purpose of this research article is to describe the effects of several variables on the perceived development of RSI symptoms, particularly those of carpal tunnel syndrome. Emphasis was placed on the role of perceived stress. The study design was a descriptive survey using a nonprobability sampling method. The study focused on four variables related to perceptions of symptoms: 1) perceptions of level of knowledge related to the prevention of RSIs; 2) taking a specific action to make one's workstation more ergonomically correct; 3) perceptions of having ergonomically correct workstations; and 4) perceptions of being stressed. Study results indicated that perceived stress was significantly associated with perceived RSI symptoms. Workers who use a computer 4 or more hours per day reported significantly more symptoms than those who did not. At risk computer users who perceive an ergonomically correct workstation reported fewer symptoms. To prevent RSIs, occupational health nurses must address ergonomics, stress levels, and knowledge levels.

A systematic review and meta-analysis of the percentage of revised diagnoses in functional somatic symptoms

BACKGROUND

Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. Doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. The purpose of this study is to review available literature on the percentage of patients diagnosed with FSS reported to have an underlying somatic disease that explains their symptoms previously labeled as FSS.

METHODS

We performed a systematic search of Medline, Embase and PsycINFO databases and reference lists of selected articles. We included studies published between January 1980 and July 2014 without language restrictions. Studies that measured the percentage of underlying somatic diseases after a diagnostic evaluation or naturalistic follow-up period in adult patients initially diagnosed with FSS were included. As primary outcome measure the weighted percentage of revised diagnoses was calculated using meta-analyses.

RESULTS

Six diagnostic evaluation studies (total N=1804 patients) and 16 follow-up studies (total N=2440 patients) were included. The percentage of revised diagnosis in patients initially diagnosed with FSS was 8.8% (95% CI 1.0 to 22.2, p=0.007) in diagnostic evaluation studies and 0.5% (95% CI 0.01 to 1.5, p=0.03) in follow-up studies. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically.

CONCLUSIONS

The percentage of underlying somatic diseases in patients previously diagnosed with FSS is relatively small but unneglectable.

Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter

Background

Consultations involving patients with multiple somatic symptoms may be considered as challenging and time-consuming by general practitioners (GPs). Yet, little is known about the possible links between consultation characteristics and GP-experienced burden of encounter. We aimed to explore consultation content, clinical management strategies, time consumption and GP-experienced burden of encounters with patients suffering from multiple somatic symptoms as defined by the concept of bodily distress syndrome (BDS).

Methods

Cross-sectional study of patient encounters in primary care from December 2008 to December 2009; 387 GPs participated (response rate: 44.4 %). Data were based on a one-page registration form completed by the GP and a patient questionnaire including the 25-item BDS checklist for somatic symptoms. Using logistic regression analyses, we compared patients who met the BDS criteria with patients who did not.

Results

A total of 1505 patients were included (response rate: 55.6 %). Health problems were less frequently reported as ‘new’ in patients with BDS (odds ratio (OR) = 0.73, 95 % confidence interval (CI): 0.54; 0.97). Medical prescriptions and referral rates were comparable in the two patient groups. Consultations focusing on mainly biomedical aspects were less frequent among patients with BDS (OR = 0.31, 95 % CI: 0.22; 0.43), whereas additional biomedical and psychosocial problems were more often discussed. GPs were more likely to ensure continuity of care in BDS patients by watchful waiting strategies (OR = 2.32, 95 % CI: 1.53; 3.52) or scheduled follow-up visits (OR = 1.61, 95 % CI: 1.09; 2.37). Patients with BDS were found to be more time-consuming (OR = 1.77, 95 % CI: 1.26; 2.48) and burdensome (OR = 2.54, 95 % CI: 1.81; 3.55) than patients without BDS. However, after adjustments for biomedical and psychosocial content of the consultation, the identified differences for time consumption and burden were no longer statistically significant.

Conclusions

Patients with BDS represent higher care complexity in terms of biomedical and psychosocial needs. GPs seem to allow space and time for discussing these issues and to aim at ensuring continuity in care through watchful waiting or scheduled follow-up consultations. However, the reported GP-experienced burden call for professional development.

Pharmacological interventions on early functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are chronic or recurrent gastrointestinal symptoms without structural or biochemical abnormalities. FGIDs are multifactorial conditions with different pathophysiologic mechanisms including altered motility, visceral hyperalgesia, brain-gut disturbance, genetic, environmental and psychological factors. Although in most cases gastrointestinal symptoms are transient and with spontaneous resolution in infancy multiple dietary changes and pharmacological therapy are often started despite a lack of evidence-based data. Our aim was to update and critically review the current literature to assess the effects and the clinical appropriateness of drug treatment in early (occurring in infants and toddlers) FGIDs.

METHODS

We systematically searched the Medline and GIMBE (Italian Group on Medicine Based on Evidence) databases, according to the methodology of the Critically Appraised Topics (CATs). We included reviews, clinical studies, and evidence-based guidelines reporting on pharmacological treatments. Systematic reviews and randomized controlled trials (RCTs) concerning pharmacologic therapies in children with early FGIDs were included, and data were extracted on participants, interventions, and outcomes.

RESULTS

We found no evidence-based guidelines or systematic reviews about the utility of pharmacological therapy in functional regurgitation, infant colic and functional diarrhea. In case of regurgitation associated with marked distress, some evidences support a short trial with alginate when other non pharmacological approach failed (stepped-care approach). In constipated infants younger than 6 months of age Lactulose is recommended, whilst in older ages Polyethylene glycol (PEG) represents the first-line therapy both for fecal disimpaction and maintenance therapy of constipation. Conversely, no evidence supports the use of laxatives for dyschezia. Furthermore, we found no RCTs regarding the pharmacological treatment of cyclic vomiting syndrome, but retrospective studies showed a high percentage of clinical response using cyproheptadine, propanolol and pizotifen.

CONCLUSION

There is some evidence that a pharmacological intervention is necessary for rectal disimpaction in childhood constipation and that PEG is the first line therapy. In contrast, for the other early FGIDs there is a lack of well-designed high-quality RCTs and no evidence on the use of pharmacological therapy was found.

Predictors of Self-Reported Physical Symptoms in Low-Income, Inner-City African American Women: The Role of Optimism, Depressive Symptoms, and Chronic Illness

In this study we examined the association of optimism and depressive symptoms with self-reported physical symptoms in 241 low-income, inner-city African American women with or without a chronic illness (HIV). Although optimism was not a unique predictor of self-reported physical symptoms over and above depressive symptoms, optimism interacted with depressive symptoms and health status. In the community sample, but not the chronically ill sample, optimism buffered the association between depressive symptoms and self-reported physical symptoms. Clinical implications and directions for future research are discussed.

Treatment gap and help-seeking for postpartum depression in a rural African setting

BACKGROUND

Postpartum depression (PPD) affects more than one in ten women and is associated with adverse consequences for mother, child and family. Integrating mental health care into maternal health care platforms is proposed as a means of improving access to effective care and reducing the 'treatment gap' in low- and middle-income countries. This study aimed to determine the proportion of women with PPD who sought help form a health facility and the associated factors.

METHODS

A community based, cross-sectional survey was conducted in southern Ethiopia. A total of 3147 women who were between one and 12 months postpartum were screened for depressive symptoms in their home using a culturally validated version of the Patient Health Questionnaire (PHQ-9). Women scoring five or more (indicating potential depressive disorder) (n = 385) were interviewed regarding help-seeking behavior. Multiple logistic regression was used to identify factors associated independently with help-seeking from health services.

RESULTS

Only 4.2 % of women (n = 16) with high PPD symptoms had obtained mental health care and only 12.7 % of women (n = 49) had been in contact with any health service since the onset of their symptoms. In the multivariable analysis, urban residence, adjusted odds ratio (aOR): 4.39 (95 % confidence interval (CI) 1.23, 15.68); strong social support, aOR: 2.44 (95 % CI 1.30, 4.56); perceived physical cause, aOR: 6.61 (95 % CI 1.76, 24.80); perceived higher severity aOR: 2.28 (95 % CI 1.41, 5.47); perceived need for treatment aOR: 1.46 (95 % CI 1.57, 18.99); PHQ score, aOR: 1.14 (95 % CI 1.04, 1.25); and disability, aOR: 1.06 (95 % CI 1.01, 1.15) were associated significantly with help-seeking from health services. More than half of the women with high levels of PPD symptoms (n = 231; 60.0  %) attributed their symptoms to a psychosocial cause and 269 (69.9 %) perceived a need for treatment. Equal proportions endorsed biomedical treatment and traditional or religious healing as the appropriate intervention.

CONCLUSION

In the absence of an accessible maternal mental health service the treatment gap was very high. There is a need to create public awareness about PPD, its causes and consequences, and the need for help seeking. However, symptom attributions and help-seeking preferences indicate potential acceptability of interventions located in maternal health care services within primary care.

Neurobiology of fibromyalgia and chronic widespread pain

Fibromyalgia is the current term for chronic widespread musculoskeletal pain for which no alternative cause can be identified. The underlying mechanisms, in both human and animal studies, for the continued pain in individuals with fibromyalgia will be explored in this review. There is a substantial amount of support for alterations of central nervous system nociceptive processing in people with fibromyalgia, and that psychological factors such as stress can enhance the pain experience. Emerging evidence has begun exploring other potential mechanisms including a peripheral nervous system component to the generation of pain and the role of systemic inflammation. We will explore the data and neurobiology related to the role of the CNS in nociceptive processing, followed by a short review of studies examining potential peripheral nervous system changes and cytokine involvement. We will not only explore the data from human subjects with fibromyalgia but will relate this to findings from animal models of fibromyalgia. We conclude that fibromyalgia and related disorders are heterogenous conditions with a complicated pathobiology with patients falling along a continuum with one end a purely peripherally driven painful condition and the other end of the continuum is when pain is purely centrally driven.

Prevalence of dizziness in the population of Minas Gerais, Brazil, and its association with demographic and socioeconomic characteristics and health status

Introduction

The state of Minas Gerais, Brazil has no data on the prevalence of dizziness in the population and this information can be fundamental as the basis of public health policies, promotion, prevention and rehabilitation campaigns.

Objective

Investigate the prevalence of the symptom of dizziness in the population of Minas Gerais according to Sample Survey of Households, as well as describe the profile of interviewed individuals and the association between dizziness and socioeconomic, demographic features and health status.

Methods

This was a cross-sectional observational study that analyzed individuals with dizziness symptom reported in the previous month. The data entered in the Sample Survey of Households of 2011 were analyzed. An independent statistical association was determined between the selected variables and dizziness through multivariate analysis.

Results

Dizziness was the third major complaint among individuals who mentioned any health problems in the previous month, with an estimated population of 209,025 individuals and reported by 6.7% of symptomatic ones, with higher prevalence values only reported for the symptoms of fever and headache. Among individuals who reported dizziness, 94% were adults or elderly (p ≤ 0.001) and 63% were females (p = 0.003). A statistically significant association (p < 0.001) was observed between the response variable and the variables: self-perceived health, hypertension, heart disease, diabetes, depression, seeking or requiring medical or health care in the previous month and private health care plan or insurance. Among individuals with dizziness, 84.2% sought or required medical or health care and 80.1% did not have a private health plan or insurance in the assessed period.

Conclusion

The dizziness symptom was highly prevalent in the population of Minas Gerais during the assessed month of the investigation. Dizziness was prevalent in adults and the elderly and showed a statistical association with socioeconomic and demographic characteristics, as well as the assessed health status.

Psychiatric Characteristics of the Cardiac Outpatients with Chest Pain

Background and Objectives

A cardiologist's evaluation of psychiatric symptoms in patients with chest pain is rare. This study aimed to determine the psychiatric characteristics of patients with and without coronary artery disease (CAD) and explore their relationship with the intensity of chest pain.

Subjects and Methods

Out of 139 consecutive patients referred to the cardiology outpatient department, 31 with atypical chest pain (heartburn, acid regurgitation, dyspnea, and palpitation) were excluded and 108 were enrolled for the present study. The enrolled patients underwent complete numerical rating scale of chest pain and the symptom checklist for minor psychiatric disorders at the time of first outpatient visit. The non-CAD group consisted of patients with a normal stress test, coronary computed tomography angiogram, or coronary angiogram, and the CAD group included those with an abnormal coronary angiogram.

Results

Nineteen patients (17.6%) were diagnosed with CAD. No differences in the psychiatric characteristics were observed between the groups. "Feeling tense", "self-reproach", and "trouble falling asleep" were more frequently observed in the non-CAD (p=0.007; p=0.046; p=0.044) group. In a multiple linear regression analysis with a stepwise selection, somatization without chest pain in the non-CAD group and hypochondriasis in the CAD group were linearly associated with the intensity of chest pain (β=0.108, R²=0.092, p=0.004; β= -0.525, R²=0.290, p=0.010).

Conclusion

No differences in psychiatric characteristics were observed between the groups. The intensity of chest pain was linearly associated with somatization without chest pain in the non-CAD group and inversely linearly associated with hypochondriasis in the CAD group.

The Meaning of Patient Experiences of Medically Unexplained Physical Symptoms

Current diagnostic models in medical practice do not adequately account for patient symptoms that cannot be classified. At the moment, when all known diagnostic possibilities have been excluded, physicians-and patients-confront uncertainty in diagnosis, which gives rise to the label of Medically Unexplained Physical Symptoms (MUPS). This phenomenological study, conducted by two research teams in two geographic locations, sought to explore patients' experiences of prolonged uncertainty in diagnosis. Participants in this study described their experiences with and consequences of MUPS primarily in relation to levels of acuity and acceptance of uncertainty, the latter loosely correlated to length of time since onset of symptoms (the longer the time, the more forbearance participants expressed). We identified three experiential periods including the active search for a diagnosis, living with MUPS, and, finally, acceptance/resignation of their condition. Findings point to the heightened importance of the therapeutic relationship when dealing with uncertainty.

"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

BACKGROUND

Much of a General Practitioner's (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees' clinical and educational experiences of managing people presenting with MUS.

METHOD

A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.

RESULTS

Eighty questionnaires out of 120 (67%) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.

CONCLUSION

Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.

Illness perceptions, negative emotions, and pain in patients with noncardiac chest pain

Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.

Hospitalist attitudes toward the assessment and management of dyspnea in patients with acute cardiopulmonary diseases

BACKGROUND

Dyspnea is a common symptom in patients hospitalized with acute cardiopulmonary diseases. Routine assessment of dyspnea severity is recommended by clinical guidelines based on the evidence that patients are not treated consistently for dyspnea relief.

OBJECTIVE

To evaluate attitudes and beliefs of hospitalists regarding the assessment and management of dyspnea.

DESIGN

Cross-sectional survey.

SETTINGS

Nine hospitals in the United States.

MEASUREMENTS

Survey questions assessed the following domains regarding dyspnea: importance in clinical care, potential benefits and challenges of implementing a standardized assessment, current approaches to assessment, and how awareness of severity affects management. A 5-point Likert scale was used to assess the respondent's level of agreement; strongly agree and agree were combined into a single category.

RESULTS

Of the 255 hospitalists invited to participate, 69.8% completed the survey; 77.0% agreed that dyspnea relief is an important goal when treating patients with cardiopulmonary conditions. Approximately 90% of respondents stated that awareness of dyspnea severity influences their decision to intensify treatment, to pursue additional diagnostic testing, and the timing of discharge. Of the respondents, 61.0% agreed that standardized assessment of dyspnea should be part of the vital signs, and 64.6% agreed that awareness of dyspnea severity influences their decision to prescribe opioids. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized scale.

CONCLUSIONS

Most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and patient care. Measurement and documentation of dyspnea severity may represent an opportunity to improve dyspnea management.

Prevalence of vestibular dysfunction and associated factors in South Korea

OBJECTIVE

To report the nationwide prevalence of dizziness and vestibular dysfunction in the Korean population and determine the associated factors.

DESIGN

Cross-sectional analysis of a nationwide health survey.

METHODS

We obtained data from the 2009 to 2010 Korea National Health and Nutrition Examination Surveys, which were cross-sectional surveys of the South Korean civilian, non-institutionalised population aged 40 years and older (N=3267). A field survey team performed interviews and physical examinations. Structured questionnaires were handed out and balance function tests using the modified Romberg test of standing balance on firm and compliant support surfaces were performed on participants. Failure on the modified Romberg test was regarded to indicate vestibular dysfunction.

RESULTS

The prevalence of dizziness during the past year was 16.70% (95% CI 14.65% to 18.76%). The presence of vestibular dysfunction was noted in 1.84% (95% CI 1.18% to 2.51%). In addition, the prevalence of experiencing falls and positional dizziness were 1.46% (95% CI 0.87% to 2.06%) and 1.73% (95% CI 1.17% to 2.29%), respectively. Multivariable analysis revealed that dizziness was associated with increased age, female gender, hearing loss and stress. Vestibular dysfunction was associated with increased age, history of dizziness and hearing loss.

CONCLUSIONS

Vertigo and dizziness are the greatest contributors to the burden of disability in the aged population. Screening for dizziness and vestibular dysfunction, and management of associated factors might be important for improving compromised quality of life due to postural imbalance caused by vestibular problems.

Behavior medicine specialist

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities. A behavior medicine specialist is a psychologist who works in the medical home with the primary care physician instead of in the Mental Health Department with a psychiatrist. The key to achieving Total Health will be to transform our current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavior medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home. The behavior medicine specialist will help improve outcomes in synergy with the primary care physician by universal screening of high-risk diseases, stepped care protocols, and efficient use of all resources available to care for patients in the medical home (health education classes, wellness coaches, and online social networking lifestyle management programs). These interventions should increase patient satisfaction, increase access to specialty care (psychiatry), and help us achieve Total Health.

Yoga as a Therapeutic Intervention: A Bibliometric Analysis of Published Research Studies from 1967 to 2013

OBJECTIVE

A comprehensive bibliometric analysis was conducted on publications for yoga therapy research in clinical populations.

METHODS

Major electronic databases were searched for articles in all languages published between 1967 and 2013. Databases included PubMed, PsychInfo, MEDLINE, IndMed, Indian Citation Index, Index Medicus for South-East Asia Region, Web of Knowledge, Embase, EBSCO, and Google Scholar. Nonindexed journals were searched manually. Key search words included yoga, yoga therapy, pranayama, asana. All studies met the definition of a clinical trial. All styles of yoga were included. The authors extracted the data.

RESULTS

A total of 486 articles met the inclusion criteria and were published in 217 different peer-reviewed journals from 29 different countries on 28,080 study participants. The primary result observed is the three-fold increase in number of publications seen in the last 10 years, inclusive of all study designs. Overall, 45% of the studies published were randomized controlled trials, 18% were controlled studies, and 37% were uncontrolled studies. Most publications originated from India (n=258), followed by the United States (n=122) and Canada (n=13). The top three disorders addressed by yoga interventions were mental health, cardiovascular disease, and respiratory disease.

CONCLUSION

A surge in publications on yoga to mitigate disease-related symptoms in clinical populations has occurred despite challenges facing the field of yoga research, which include standardization and limitations in funding, time, and resources. The population at large has observed a parallel surge in the use of yoga outside of clinical practice. The use of yoga as a complementary therapy in clinical practice may lead to health benefits beyond traditional treatment alone; however, to effect changes in health care policy, more high-quality, evidence-based research is needed.

The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper

Behavioral health care includes care for patients around mental health and substance abuse conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. Mental and substance use disorders alone are estimated to surpass all physical diseases as a major cause of worldwide disability by 2020. The literature recognizes the importance of the health care system effectively addressing behavioral health conditions. Recently, there has been a call for the use of the primary care delivery platform and the related patient-centered medical home model to effectively address these conditions. This position paper focuses on the issue of better integration of behavioral health into the primary care setting. It provides an environmental scan of the current state of conditions included in the concept of behavioral health and examines the arguments for and barriers to increased integration into primary care. It also examines various approaches of integrated care delivery and offers a series of policy recommendations that are based on the reviewed information and evidence to inform the actions of the American College of Physicians and its members regarding advocacy, research, and practice.

Limitations of Chest Pain Categorization Models to Predict Coronary Artery Disease

We aimed to evaluate how chest pain categorization, currently used to assess the pretest probability of coronary artery disease (CAD), predicts the actual presence of CAD in a population of patients with stable symptoms. We studied 475 consecutive patients enrolled in the Evaluation of Integrated Cardiac Imaging for the Detection and Characterization of Ischemic Heart Disease study based on possible symptoms of CAD. Chest pain or discomfort was categorized as typical angina, atypical angina, or as nonanginal according to the guidelines. Exertional dyspnea and fatigue suspected to be angina equivalents were classified as atypical angina. Patients with a probability of CAD <20 or >90% based on age, gender, and symptoms were excluded. The end points of this substudy were significant CAD (defined by invasive coronary angiography as >50% reduction in lumen diameter in the left main stem or >70% stenosis in a major coronary vessel or 30% to 70% stenosis with fractional flow reserve ≤0.8), inducible myocardial ischemia at noninvasive stress imaging, and their association. Patients' symptoms had limited ability to predict the presence of significant CAD, global chi-square being 5.0. The inclusion of age increased global chi-square to 18.7 and gender increased it further to 51.1. Using inducible myocardial ischemia or the association of CAD with inducible ischemia as end points, the ability to predict these end points was again better for patient demographics than for patient symptoms. Thus, the ability of current models based on symptoms, age, and gender to predict the presence of CAD is mainly based on patient demographics as opposed to symptoms.

Hepatitis C virus infection and pain sensitivity in patients on methadone or buprenorphine maintenance therapy for opioid use disorders

BACKGROUND

Patients with opioid use disorders on opioid agonist therapy (OAT) have lower pain tolerance compared to controls. While chronic viral infections such as HCV and HIV have been associated with chronic pain in this population, no studies have examined their impact on pain sensitivity.

METHODS

We recruited 106 adults (41 uninfected controls; 40 HCV mono-infected; and 25 HCV/HIV co-infected) on buprenorphine or methadone to assess whether HCV infection (with or without HIV) was associated with increased experimental pain sensitivity and self-reported pain. The primary outcome was cold pain tolerance assessed by cold-pressor test. Secondary outcomes were cold pain thresholds, wind-up ratios to repetitive mechanical stimulation (i.e., temporal summation) and acute and chronic pain. Multivariable regression models evaluated associations between viral infection status and outcomes, adjusting for other factors.

RESULTS

No significant differences were detected across groups for primary or secondary outcomes. Adjusted mean cold pain tolerance was 25.7 (uninfected controls) vs. 26.8 (HCV mono-infection) vs. 25.3 (HCV/HIV co-infection) seconds (global p-value=0.93). Current pain appeared more prevalent among HCV mono-infected (93%) compared to HCV/HIV co-infected participants (76%) and uninfected controls (80%), as did chronic pain (77% vs. 64% vs. 61%, respectively). However, differences were not statistically significant in multivariable models.

CONCLUSION

This study did not detect an association between HCV infection and increased sensitivity to pain among adults with and without HIV who were treated with buprenorphine or methadone for opioid use disorders. Results reinforce that pain and hyperalgesia are common problems in this population.