What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?

BACKGROUND

Cyberchondria may be defined as heightened distress evoked through excessive searches of the internet for medical information. In healthy people, cyberchondria is associated with a greater intolerance of uncertainty and greater health anxiety. These relationships are likely bidirectional. People who have a greater intolerance of uncertainty may be more likely to search the internet for medical information and have greater health anxiety. This greater health anxiety may lead to an increased likelihood of engaging in further internet searches and greater intolerance of uncertainty. These three constructs are important for patients because they impact patient function and health care costs. We were specifically interested in understanding the role of cyberchondria in the association between intolerance of uncertainty and health anxiety among orthopaedic patients because it has not been explored before and because knowledge about these interactions could inform treatment recommendations.

QUESTIONS/PURPOSES

Does cyberchondria mediate (that is, explain) the association between intolerance of uncertainty and health anxiety in orthopaedic patients searching for medical information on the internet, after controlling for potentially confounding variables?

METHODS

This was a cross-sectional study of 104 patients who had searched the internet for any medical information about their current condition. A research assistant approached 155 patients attending two orthopaedic outpatient clinics, one hand and upper extremity service and one sports medicine clinic, during a 3-month period. Ten patients declined to participate and 41 patients were excluded, predominantly because they had never searched for medical information online. The patients completed the Cyberchondria Severity Scale, Intolerance of Uncertainty Scale-short version, Short Health Anxiety Inventory, and a numerical rating scale for pain intensity at baseline, as well as demographic and clinical questionnaires. We performed a series of linear regression analyses to determine whether a greater intolerance of uncertainty predicts greater cyberchondria (mediator) and whether cyberchondria predicts greater health anxiety. Although it is more appropriate to use the language of association (such as "whether cyberchondria is associated with health anxiety") in many observational studies, here, we opted to use the language of causation because this is the conventional language for studies testing statistical mediation.

RESULTS

After controlling for potentially confounding variables including pain intensity, multiple pain conditions, and education, cyberchondria explained 33% of the variance of the effect of intolerance of uncertainty on health anxiety (95% CI, 6.98 to 114.72%; p < 0.001).

CONCLUSIONS

Among orthopaedic patients who search the internet for medical information, a greater intolerance of uncertainty is associated with greater cyberchondria, which is associated with greater anxiety about health. Identifying patients with an intolerance of uncertainty and educating them about the negative role of compulsive searches for medical information may improve the success of orthopaedic treatment. Orthopaedic surgeons should also consider making referrals for cognitive behavioral therapy in these instances to increase the patient's tolerance of uncertainty, decrease internet searching habits, and reduce anxiety about health.

LEVEL OF EVIDENCE

Level III, prognostic study.

Factors Associated with Requesting Magnetic Resonance Imaging during the Management of Glomus Tumors

BACKGROUND

The characteristic clinical presentation of glomus tumors and the low negative predictive value of the magnetic resonance imaging (MRI) raise the question whether MRI improves their management. Therefore, this study aimed to investigate whether MRI improved the management of glomus tumors.

METHODS

In total, 87 patients with a histologically confirmed glomus tumor were treated over a 25-year period and analyzed retrospectively. Multivariable logistic regression analysis was used to evaluate the independent predictors of an MRI request during the management of glomus tumors.

RESULTS

ccording to the results, the patients who were treated by orthopaedic surgeons were more likely to have an MRI during the management of a glomus tumor.

CONCLUSION

The role of an MRI during the management of a glomus tumor is unclear. Orthopaedic surgeons are more likely to request an MRI. Furthermore, visible lesions with characteristic symptoms probably do not benefit from MRI. However, it may help to be sure that the highest-quality MRI is used with the best possible coil for the finger.

Type D personality in patients with upper extremity musculoskeletal illness: Internal consistency, structural validity and relationship to pain interference

OBJECTIVE

Type D personality - the joint tendency toward negative affectivity (NA) and social inhibition (SI) - is associated with greater symptom perception and negative health outcomes among various patient populations. We investigated Type D personality among patients with upper extremity musculoskeletal illness.

METHOD

In cross-sectional design, we estimated the prevalence of Type D personality in this population and explored the associations of two different Type D conceptualizations (i.e., categorical and dimensional as the NA×SI interaction) and the individual NA and SI traits with pain interference as well as structural-internal validity of DS14.

RESULTS

The categorical Type D personality and greater NA and SI were associated with pain interference above and beyond descriptive variables, but the interaction term between NA and SI was not. NA explained a larger proportion of the variance in pain interference than SI. DS14 showed a two-factor structure and high internal consistency in this sample.

CONCLUSIONS

The categorical Type D allows for identifying individuals who struggle with recovery from musculoskeletal injury. Although the dimensional conceptualization didn't prove to be associated with pain interference, NA and SI appear to have individual effects on pain interference, with most variance being accounted for by NA. Implications for clinical care are discussed.

Health literacy assessment in adults with neurofibromatosis: electronic and short-form measurement using FCCHL and Health LiTT

Determining health literacy level is an important prerequisite for effective patient education. We assessed multiple dimensions of health literacy and sociodemographic predictors of health literacy in patients with neurofibromatosis. In 86 individuals with a confirmed diagnosis of neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2), or schwannomatosis, we assessed health literacy status using two HL tools-the adapted functional, communicative, and critical health literacy scale (adapted FCCHL) and health literacy assessment using talking touchscreen technology (Health LiTT). Factor analyses of the adapted FCCHL in NF patients showed factor structure and psychometric properties similar to pilot work in other patient populations. As a group, patients with NF had moderate scores on the Health LiTT and moderate to high scores on the adapted FCCHL, with the highest score on the functional health literacy subscale. Patients with NF1, those with lower education and those with learning disabilities had lower scores on Health LiTT; in multivariate analysis, learning disability and education remained significant predictors of HealthLiTT scores. Only lower education was associated with lower adapted FCCHL scores. Results suggest utilizing health literacy tools in NF patients is feasible and could provide physicians with valuable information to tailor health communication to subpopulations with lower health literacy levels.

First Use of a Brief 60-second Mindfulness Exercise in an Orthopedic Surgical Practice; Results from a Pilot Study

BACKGROUND

Mindfulness based interventions may be useful for patients with musculoskeletal conditions in orthopedic surgical practices as adjuncts to medical procedures or alternatives to pain medications. However, typical mindfulness programs are lengthy and impractical in busy surgical practices. We tested the feasibility, acceptability and preliminary effect of a brief, 60-second mindfulness video in reducing pain and negative emotions in patients presenting to an orthopedics surgical practice.

METHODS

This was an open pilot study. Twenty participants completed the Numerical Rating Scale to assess pain intensity, the State Anxiety subscale of the State Trait Anxiety Scale to assess state anxiety, and emotional thermometers to assess distress, anxiety, anger and depression immediately prior to and following the mindfulness video exercise. At the end of the exercise patients also answered three questions assessing satisfaction with the mindfulness video.

RESULTS

Feasibility of the mindfulness video was high (100%). Usefulness, satisfaction and usability were also high. Participants showed improvements in state anxiety, pain intensity, distress, anxiety, depression and anger after watching the video. These changes were both statistically significant and clinically meaningful, when such information was available.

CONCLUSION

People with musculoskeletal pain seeking orthopedic care seem receptive and interested in brief mindfulness exercises that enhance comfort and calm.

First report of factors associated with satisfaction in patients with neurofibromatosis

Patient satisfaction is an integral part of quality health care. We assessed whether health literacy and psychosocial factors are associated with patient satisfaction among adults with neurofibromatosis. Eighty adults (mean age = 44 years; 55% female, 87% white) with NF (50% NF1, 41% NF2, and 9% schwannomatosis) completed an adapted Functional, Communicative, and Critical Health Literacy Questionnaire (FCCHL), the Health Literacy Assessment, a series of Patient Reported Outcome Measures Information System (PROMIS) psychosocial tests, and demographics before the medical visit. After, participants completed two measures of satisfaction: the Medical Interview Satisfaction Scale (MISS) to assess satisfaction with the medical visit, and an adapted version of the Consumer Assessment of Healthcare Providers and Systems Health Literacy Item Set (CAHPS-HL) to assess satisfaction with communication with the provider. Although higher FCCHL health literacy (r = 0.319, P = 0.002), male gender (t = 2.045, P = 0.044) and better psychosocial functioning (r = -0.257 to 0.409, P < 0.05) were associated with higher satisfaction with the medical visit in bivariate correlations, only male gender and higher health literacy remained as significant predictors in multivariable analyses. Higher FCCHL health literacy, less pain interference, fewer pain behaviors, and higher satisfaction with social roles and social discretionary activities (r = -0.231 to 0.331, P < 0.05) were associated with higher satisfaction with the communication with the provider in bivariate analyses. Results support the use of psychosocial and health literacy measures in clinical practice. Referrals to psychosocial treatments in addition to brief interventions focused on increasing health literacy may also be beneficial. © 2017 Wiley Periodicals, Inc.

Cognitive intrusion of pain and catastrophic thinking independently explain interference of pain in the activities of daily living

Patients with musculoskeletal illness often report that pain interferes with their ability to engage in activities of daily living. Catastrophic thinking is consistently depicted as an important cognitive factor that hinders adjustment to pain. Current research has also shown that pain negatively impacts an individual's ability to maintain attention on the task at hand. While a measure of the experience of cognitive intrusion of pain (ECIP) has been recently developed to quantify the extent of that impact, little research has explored this issue in everyday settings. This study tested the mediating roles of cognitive intrusion of pain and pain catastrophizing scale (PCS) on the association of pain intensity with pain interference in 142 patients with upper-extremity musculoskeletal illness. We found that both cognitive intrusion of pain (b = 0.136, bootstrap SE = 0.048, 95% BCa CI [0.052, 0.245]) and pain catastrophizing (b = 0.114, bootstrap SE = 0.044, 95% BCa CI [0.047, 0.221]) partly and independently mediated the relationship between pain intensity and pain interference. Although comparable, the mediation effect of cognitive intrusion of pain was slightly larger than that of pain catastrophizing (25.7%, bootstrap SE = 0.094 vs. 21.5%, bootstrap SE = 0.080). Results suggest that pain sensations can interfere with activities of daily living through two distinct mechanisms. A combination of traditional cognitive behavioral therapy and mindfulness skills training targeting both pain catastrophizing and cognitive intrusion has the potential to decrease pain interference and help patients return to normal healthy living in spite of acute or persistent pain.

Emotion regulation strategies mediate the associations of positive and negative affect to upper extremity physical function

BACKGROUND

The Gross process model of emotion regulation holds that emotion-eliciting situations (e.g. musculoskeletal illness) can be strategically regulated to determine the final emotional and behavioral response. Also, there is some evidence that innate emotional traits may predispose an individual to a particular regulating coping style.

METHODS

We enrolled 107 patients with upper extremity musculoskeletal illness in this cross-sectional study. They completed self-report measures of positive and negative affect, emotion regulation strategies (cognitive reappraisal and expressive suppression), upper extremity physical function, pain intensity, and demographics. We used Preacher and Hayes' bootstrapping approach to process analysis to infer the direct effect of positive and negative affect on physical function as well as their indirect effects through activation of emotion regulation strategies.

RESULTS

Negative affect was associated with decreased physical function. The association was partly mediated by expressive suppression (b (SE)=-.10 (.05), 95% BCa CI [-.21, -.02]). Positive affect was associated with increased physical function. Cognitive reappraisal partially mediated this association (b (SE)=.11 (.05), 95% BCa CI [.03, .24]). After controlling for pain intensity, the ratio of the mediated effect to total effect grew even larger in controlled model comparing to uncontrolled model (33% vs. 26% for expressive suppression and 32% vs. 30% for cognitive reappraisal).

CONCLUSIONS

The relationships between affect, emotion regulation strategies and physical function appear to be more dependent on the emotional response to an orthopedic condition rather than the intensity of the nociceptive stimulation of the pain. Findings support integration of emotion regulation training in skill-based psychotherapy in this population to mitigate the effect of negative affect and enhance the influence of positive affect on physical function.

The direct and indirect effects of the negative affectivity trait on self reported physical function among patients with upper extremity conditions

Negative affectivity is a personality trait that predisposes people to psychological distress and low life satisfaction. Negative affectivity may also affect pain intensity and physical function in patients with musculoskeletal conditions. We explored the association of negative affectivity to pain intensity and self-reported physical function, and tested whether pain intensity mediates the effect of negative affectivity on physical function. In a cross-sectional study, 102 patients with upper extremity musculoskeletal conditions presenting to an orthopedic surgeon completed self-report measures of negative affectivity, pain intensity, and physical function in addition to demographic and injury information. We used the Preacher and Hayes' bootstrapping approach to quantify the indirect effect of negative affectivity on physical function through pain intensity. Negative affectivity correlated with greater pain intensity and lower self-reported physical function significantly. Also, pain intensity mediated the association of negative affectivity with physical function. The indirect effect accounted for one-third of the total effect. To conclude, negative affectivity is associated with decreased engagement in daily life activities both directly, but also indirectly through increased pain intensity. Treatments targeting negative affectivity may be more economical and efficient for alleviation of pain and limitations associated with musculoskeletal illness than those addressing coping strategies or psychological distress.

Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin

BACKGROUND

This study investigated the factors associated with variation in the rate of surgery for enthesopathy of the extensor carpi radialis brevis (eECRB).

METHODS

We used a large database from 3 academic hospitals including 5964 patients with the diagnosis of eECRB from 2001 to 2007. Of those, 244 patients (4%) had surgery for eECRB. We used the date of the first encounter as the date of diagnosis. We also recorded the date of the first cortisone injection and surgery for eECRB. We used Cox multivariable regression analysis to find factors associated with surgery. We considered the following explanatory factors: age, sex, race, diabetes, a diagnosis of major depression, a diagnosis of an anxiety disorder, hospital, provider (surgeon vs. nonsurgeon), corticosteroid injection, and the time from diagnosis to the first cortisone injection.

RESULTS

The hazard ratio of having surgery was 12-times greater if the initial provider was an orthopedic surgeon rather a nonsurgeon and 1.7-times greater at 1 of the 2 hospitals. The rate of surgery varied substantially, ranging from 0% to 22%. Corticosteroid injection delayed the time to surgery but was ultimately associated with a higher rate of surgery. The majority (86%) of surgeries were done within 1 year of the first documented office visit.

CONCLUSIONS

It seems likely that an emphasis on the preferences and values of the patient rather than the surgeon would decrease the variation in surgery rates for eECRB observed in this study. Methods for optimizing the influence of patient preferences and values on decision making (eg, decision aids) merit additional study.

Neutropenia associated with X-linked Agammaglobulinemia in an Iranian referral center

X-linked Agammaglobulinemia (XLA) is a hereditary immunodeficiency, characterized by an early onset of recurrent bacterial infections, hypogammaglobulinemia and markedly reduced B lymphocytes number. In order to determine the association of neutropenia among Iranian patients with XLA, hospital records of 30 patients with confirmed XLA in Children Medical Center Hospital, were reviewed. Eight out of 30 XLA patients (26.7%) developed neutropenia during the course of the disease. In two patients, episodes of neutropenia were identified before or at the time of diagnosis of XLA. Other six patients whom were not visited regularly and did not receive periodical immunoglobulin replacement therapy experienced neutropenia after diagnosis of XLA. Neutropenia in XLA is mainly associated with infection and is resolved with intravenous immunoglobulin replacement and antibiotics therapy.

Comparison of seropositivity of human T lymphotropic virus type 1 in mycosis fungoides patients and normal volunteers: a case-control study and review of literature

BACKGROUND

There have been controversial reports about the possible association between mycosis fungoides (MF), its leukemic variant Siotazary syndrome (SS) and human T lymphotropic virus type 1 (HTLV-1) in different geographical regions.

AIMS

The purpose of this study was to explore any association between MF and presence of HTLV-1 infection in Iran.

METHODS

In a case-control setting, 150 clinically and histopathologically proven MF patients had been admitted to the tertiary referral skin center during a 10-year period and another 150 normal volunteers had been compared with each other for the presence of HTLV-1 infection. Enzyme-linked immunosorbent assay (ELISA) was used to detect antibodies against HTLV-1, and positive results were confirmed with western blotting.

RESULTS

Only three MF patients had HTLV-1 infection, whereas two cases of normal subjects had the infection (P > 0.05). The only three seropositive MF patients were male and from North-Eastern Iran.

CONCLUSION

This study showed that MF does not correlate with HTLV-1 infection in Iran.

Immunologic evaluation of patients with recurrent ear, nose, and throat infections

PURPOSE

In this study, we aimed to study the frequency of possible underlying immunodeficiency responsible for susceptibility to ear, nose, and throat (ENT) infection.

MATERIALS AND METHODS

One hundred three (72 males and 31 females) consecutive children and adult patients with history of recurrent or chronic ENT infections, referred by otolaryngologists to the Department of Allergy and Clinical Immunology, Children's Medical Center, Tehran University of Medical Sciences (Tehran, Iran), were enrolled to the study from March 2003 to March 2006. For each patient, demographic information and medical histories of any ENT infections were collected by reviewing the patient's records. We measured immunoglobulin isotype concentrations and immunoglobulin (Ig) G subclasses by nephelometry and enzyme-linked immunosorbent assay methods, respectively. Of 103 patients, 75 received unconjugated pneumococcus polyvalent vaccine, and blood samples were taken before and 21 days after vaccination. Specific antibodies against whole pneumococcal antigens were measured using enzyme-linked immunosorbent assay method. Existence of bronchiectasis was confirmed in each patient using high resolution computed tomography scan.

RESULTS

Among 103 patients, 17 (16.5%) patients were diagnosed to have defects in antibody-mediated immunity including 6 patients with immunoglobulin class deficiency (2 common variable deficiency and 4 IgA deficiency), 3 with IgG subclass deficiency (2 IgG2 and 1 IgG3), and 8 with specific antibody deficiency against polysaccharide antigens. In our series, bronchiectasis was detected in 5 cases associated with primary immunodeficiency.

CONCLUSIONS

Long-standing history of ENT infections could be an alarm for ENT infections associated with primary antibody deficiency.

Effect of aerobic exercise training on pulmonary function and tolerance of activity in asthmatic patients

The aim of the present study was to examine the effects of a course of aerobic exercise on pulmonary function and tolerance of activity in asthmatic patients. Among the asthmatic patients, 36 patients (M= 16, F= 20) were chosen after clinical examinations, pulmonary function test, skin prick test (SPT) for aeroallergen and a six minute walk test (6MWT) on their own free will. A patient was said to have Exercise Induced Asthma (EIA) when he/she fulfilled the following criteria; (1) FEV1 less than 80%, (2) 12% increase or more in FEV1 or PEF after short-acting ss2 agonist prescription and (3) 15% decrease in FEV1 or PEF after 6MWT with 70% or 80% of maximum heart rate. The patients were randomly put into two groups of case (M=8, F=10, Mean age=27) and control (M=8, F=10, Mean age=29). Case group participated in eight-week aerobic exercise plan, while control group had no plan of exercise. Pulmonary function tests were done before and after the course of exercise. There were significant changes in FEV1, FVC, PEF, FEF25-75%, MVV, RF and 6MWT between asthmatic patients of the two groups (P less than or equal to 0.05), but FEV1/FVC showed no significant change. Mean of changes in FEV1, FVC, PEF, FEF25-75%, MVV, RF and 6MWT were -25.56, -17.19, 32.09, -27.93, -22.18, 5.63 and -307.5 in case group respectively while they were 6.2, 4.67, 1.96, 6.65, 15.56,-2.87 and 18.78 in the control group. This study shows that aerobic exercises in asthmatic patients lead to an improvement in pulmonary functions. Aerobic exercise rehabilitation can be a complement to medical treatment of asthma.

Embolisation of arteriovenous malformation of the maxilla

We describe a 20-year-old male patient who presented with gingival bleeding. Physical examination showed gingival swelling of the right maxilla and loosening of the molar teeth. The initial diagnosis of gingivitis was made, but further examination revealed a lytic lesion of the maxilla. On suspicion of fibrous dysplasia, biopsy was attempted but was unsuccessful due to severe haemorrhage. Further evaluation showed palpable and audible bruit on the gingiva, which caused the suspicion of vascular malformation. Angiography was performed and demonstrated arteriovenous malformation (AVM). Embolisation therapy with polyvinyl alcohol was performed. Post-embolisation angiogram demonstrated complete obliteration of the lesion.

Effects of Echis carinatus Venom on the Haemodynamy and Contractility of Vascular and Visceral Smooth Muscle of Rats

Abstract Echis carinatus is considered to be one of the most dangerous snakes in the world because of its venom toxicity and high population densities in rural agriculture areas. However, little information is available on the pharmacological effects of venom from this snake on haemodynamy and vasculature smooth muscle contractility. The haemodynamic alterations induced by the intravenous administration of Echis carinatus venom was investigated in anaesthetized rats. Injection of several doses of venom (1, 3, 5, and 7 mu g kg (- 1)) decreased the arterial blood pressure. For instance, injection of 3 mu g kg(-1) of Echis carinatus venom reduced the mean arterial blood pressure from 107 +/- 4 to 71 +/- 4 mmHg (p < 0.05). Exposure of the rat isolated vas deferens preparations to Echis carinatus venom (1 mu g ml(-1)) significantly reduced the contractile responses to epinephrine (10 mu g ml(- 1)) without changing the response to KCl (50 mM). To investigate the effects of venom on peripheral vascular resistance, mesenteric bed was removed and perfused with Krebs solution. Addition of different concentrations of venom (1, 3, and 10 mu g ml(-1)) to the precontracted mesenteric bed (with phenylephrine, 5 x 10(- 4) M) decreased the contraction in a concentration-dependent manner. However, preincubation of mesenteric bed with atropine (0.1 mu M), L-NAME (10 (-5) M) or indomethacin (10(-5) M) prevented this effect of the venom. These results may suggest that the inhibitory effect of the venom on nonvascular smooth muscle (such as vas deferens) contractions is a postsynaptic phenomenon. Furthermore, it could be suggested that the cardiovascular effects of Echis carinatus venom are mediated through multiple mechanisms such as activation of muscarinic receptors as well as production of nitric oxide and prostaglandins.