Adriane I. Budavari

Psychosocial aspects of functional gastrointestinal disorders

Psychosocial factors, such as stress, abuse history, psychiatric disturbance, coping style, and learned illness behaviors, play an important role in functional GI disorders in terms of symptom experience and clinical outcome. These psychosocial factors are influenced by and influence GI symptoms in a bidirectional manner as mediated through the brain-gut axis (CNS and ENS pathways). Entering the patient encounter using a biopsychosocial approach and a care (versus cure) style can help avoid excessive diagnostic testing, and elicit crucial information about potential abuse history or psychiatric symptoms that can help guide therapy. Finally, for patients with severe, refractory symptoms, multicomponent treatment involving psychologic therapy, such as CBT, relaxation, or hypnotherapy, can be beneficial.

Thymic Hyperplasia Presenting as Anterior Mediastinal Mass in 2 Patients With Graves Disease

Graves disease is an autoimmune thyroid condition characterized by the production of autoantibodies against the thyrotropin receptor. The autoantibodies mimic the effect of the hormone on thyroid cells, which stimulates autonomous production of thyroxine and triiodothyronine. It has been hypothesized that cross-reactivity of autoantibodies may result in Graves ophthalmopathy and dermopathy. A seldom-recognized feature of Graves disease is thymic hyperplasia. We report 2 patients with Graves disease and incidentally discovered anterior mediastinal masses presumed to be thymic hyperplasia. In both cases, these masses regressed spontaneously after treatment of hyperthyroidism.

Burnout in inpatient-based versus outpatient-based physicians: a systematic review and meta-analysis.

BACKGROUND Burnout is a syndrome affecting the entirety of work life and characterized by cynicism, detachment, and inefficacy. Despite longstanding concerns about burnout in hospital medicine, few data about burnout in hospitalists have been published. PURPOSE A systematic review of the literature on burnout in inpatient-based and outpatient-based physicians worldwide was undertaken to determine whether inpatient physicians experience more burnout than outpatient physicians. DATA SOURCES Five medical databases were searched for relevant terms with no language restrictions. Authors were contacted for unpublished data and clarification of the practice location of study subjects. STUDY SELECTION Two investigators independently reviewed each article. Included studies provided a measure of burnout in inpatient and/or outpatient nontrainee physicians. DATA EXTRACTION Fifty-four studies met inclusion criteria, 15 of which provided direct comparisons of inpatient and outpatient physicians. Twenty-eight studies used the same burnout measure and therefore were amenable to statistical analysis. DATA SYNTHESIS Outpatient physicians reported more emotional exhaustion than inpatient physicians. No statistically significant differences in depersonalization or personal accomplishment were found. Further comparisons were limited by the heterogeneity of instruments used to measure burnout and the lack of available information about practice location in many studies. CONCLUSIONS The existing literature does not support the widely held belief that burnout is more frequent in hospitalists than outpatient physicians. Better comparative studies of hospitalist burnout are needed.

Managing alcohol withdrawal in hospitalized patients.

&NA; Therapy includes benzodiazepines to reduce withdrawal symptoms and prevent delirium. Symptom‐driven protocols may be more beneficial than scheduled‐dosing plans.

Disseminated varicella-zoster virus after vaccination in an immunocompetent patient

Severe adverse events associated with varicella-zoster virus (VZV) vaccination are rare. The authors describe a 53-year-old woman with no known immunodeficiency who presented with diffuse pruritic rash 17 days after receiving the varicella virus vaccine live. She had a low level of white blood cells and received a diagnosis of thrombocytopenia with elevated aminotransferase levels. Punch biopsy demonstrated positive VZV immunostaining and viral culture positive for VZV. After treatment with acyclovir, her rash improved and her white blood cell and platelet counts returned to normal. Mild reactions to vaccines including localized rash are well recognized. Disseminated infections have been reported in patients with congenital and acquired immunodeficiency, but systemic postvaccination infections are rare in immunocompetent adults. This case highlights the importance of recognizing adverse events associated with vaccination.

Should patients at lower cardiac risk receive beta-blockers before noncardiac surgery?

›SEARCH CRITERIA AND RESULTS This question falls under the general category of therapy . The highest levels of evidence to help answer questions about therapy are high-quality metaanalyses; systematic reviews; or very large, well-conducted, randomized controlled trials (RCTs). We conducted a search of the medical literature using the following terms in MEDLINE 1966-current: adrenergic beta-antagonists AND perioperative care. Adrenergic beta-antagonists yielded 32,576 results, and perioperative care (exploded) yielded 65,018 results. Combining the terms yielded 293 articles. Limiting these to humans and English language reduced it to 238; that result was then limited to metaanalysis or RCT, resulting in 32. The abstracts of the excluded non-English papers were reviewed to ensure we did not miss a relevant study. Further searches of PubMed, evidence-based medicine prefi ltered databases, the Cochrane databases, and online search engines failed to yield any additional articles that were more pertinent or of a higher level of evidence. Ultimately, the recently published Perioperative Ischemic Evaluation Study (POISE) trial 3 was deemed to be the most pertinent trial addressing this clinical question.

Can B vitamin therapy help to prevent future vascular events

A70-year-old man with a history of type 2 diabetes, dyslipidemia, and MI (in 2000) is admitted to the hospital after experiencing difficulty speaking and right hemiparesis upon awakening this morning. The symptoms have resolved by the time he arrives in the emergency department. The initial workup, which includes head CT, laboratory tests, and radiology and ECG evaluations, is unremarkable. The patient is admitted for observation and initiation of an expedited workup for transient ischemic attack. Your hospital has preprinted stroke admission order forms that include suggested testing for homocysteine levels. You ask yourself, “Is there any evidence that reducing homocysteine levels will help prevent further vascular events?”