Mukta Panda

Complementary and Alternative Medicine Use by Primary Care Patients with Chronic Pain

OBJECTIVESnTo describe the characteristics and attitudes toward complementary and alternative medicine (CAM) use among primary care patients with chronic pain disorders and to determine if CAM use is associated with better pain control.nnnDESIGNnCross-sectional survey.nnnSUBJECTSnFour hundred sixty-three patients suffering from chronic, nonmalignant pain receiving primary care at 12 U.S. academic medical centers.nnnOUTCOME MEASUREnSelf-reported current CAM usage by patients with chronic pain disorders.nnnRESULTSnThe survey had an 81% response rate. Fifty-two percent reported current use of CAM for relief of chronic pain. Of the patients that used CAM, 54% agreed that nontraditional remedies helped their pain and 14% indicated that their individual alternative remedy entirely relieved their pain. Vitamin and mineral supplements were the most frequently used CAM modalities. There was no association between reported use of CAM and pain severity, functional status, or perceived self-efficacy. Patients who reported having at least a high school education (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.19, P = 0.016) and high levels of satisfaction with their health care (OR 1.47, 95% CI 1.13-1.91, P = 0.004) were significantly more likely to report using CAM.nnnCONCLUSIONSnComplementary and alternative therapies were popular among patients with chronic pain disorders surveyed in academic primary care settings. When asked to choose between traditional therapies or CAM, most patients still preferred traditional therapies for pain relief. We found no association between reported CAM usage and pain severity, functional status, or self-efficacy.

Physicians' comfort in caring for patients with chronic nonmalignant pain

Background:More than 100 million U.S. adults experience chronic nonmalignant pain. Many physicians are uncomfortable managing such patients. We sought to determine the timing and intensity of training that primary care physicians receive in chronic pain treatment, and the effect of training on their comfort in managing patients. Methods:The 4P Study was a cross-sectional study conducted at 12 academic medical centers in the United States. More than 500 primary care physicians completed a survey regarding their attitudes toward patients with chronic nonmalignant pain and their education in chronic pain management. Results:We received 572 surveys out of 753 distributed. The respondents’ mean age was 35 years; 64% were white, non-Hispanic and 41% were women. Eighty-eight percent were internists, and mean years spent in practice were 7.6. Fifty-seven percent of the physicians felt that they should serve as the principal doctor managing patients with chronic nonmalignant pain. Only 34% of physicians felt comfortable in managing patients with chronic pain. More intensive education after entry into practice was associated with the highest comfort level. Conclusions:Most primary care physicians are not comfortable treating patients with chronic nonmalignant pain. Education increases primary care physicians’ comfort in managing these patients. Increased comfort was associated with the willingness of primary care physicians to take charge of managing chronic pain. In addition, physician comfort is greatest when pain management skills are taught after residency training.

Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review

BACKGROUNDnStudies report high burnout prevalence among resident physicians, with little consensus on methods to effectively reduce it.nnnOBJECTIVEnThis systematic literature review explores the efficacy of interventions in reducing resident burnout.nnnMETHODSnPubMed, Embase, and Web of Science were searched using these key words: burnout and resident, intern, or residency. We excluded review articles, editorials, letters, and non-English-language articles. We abstracted data on study characteristics, population, interventions, and outcomes. When appropriate, data were pooled using random effects meta-analysis to account for between-study heterogeneity. Study quality was assessed using Newcastle-Ottawa Scale (cohort studies) and Jadad scale (randomized control trials [RCTs]).nnnRESULTSnOf 1294 retrieved articles, 19 (6 RCTs, 13 cohort studies) enrolling 2030 residents and examining 12 interventions met criteria, with 9 studying the 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions. Work hour reductions were associated with score decrease (mean difference, -2.73; 95% confidence interval (CI) -4.12 to -1.34; Pu2009<u2009.001) and lower odds ratio (OR) for residents reporting emotional exhaustion (42%; ORu2009=u20090.58; 95% CI 0.43-0.77; Pu2009<u2009.001); a small, significant decrease in depersonalization score (-1.73; 95% CI -3.00 to -0.46; Pu2009=u2009.008); and no effect on mean personal accomplishment score (0.93; 95% CI -0.19-2.06; Pu2009=u2009.10) or for residents with high levels of personal accomplishment (ORu2009=u20091.01; 95% CI 0.67-1.54; Pu2009=u2009.95). Among interventions, self-care workshops showed decreases in depersonalization scores, and a meditation intervention reduced emotional exhaustion.nnnCONCLUSIONSnThe ACGME work hour limits were associated with improvement in emotional exhaustion and burnout.

The influence of discordance in pain assessment on the functional status of patients with chronic nonmalignant pain

Background:Chronic pain is a frequent cause of suffering and disability that seriously affects patients quality of life and imposes a staggering socioeconomic toll on society. Little is known about the impact of patient-physician disagreement (discordance) regarding the assessment of chronic pain on patients quality of life in primary care settings. This study evaluates the role of discordance and other potentially modifiable factors that affect the quality of life and functional status of chronic pain patients. Methods:We evaluated 436 patient-physician encounters at 12 academic medical centers in the United States. We surveyed chronic nonmalignant pain patients to understand their pain perceptions. We concurrently surveyed their physicians about their perceptions of their patients pain in primary care settings. Results:More than 50% of physicians disagreed with their patients pain. Thirty-nine percent of primary care physicians underestimated their patients pain. In the multivariate analysis, this discordance was associated with poor physical functioning and worse bodily pain (P < 0.018 and P < 0.001 respectively). Patients with chronic, nonmalignant pain have reductions in physical function and bodily pain domains of the SF-36 compared to age-matched populations. Depression and obesity represented other associations. Conclusion:Patients with chronic nonmalignant pain have poor physical functioning and worse bodily pain. Discordance, obesity, and depression are other modifiable factors. Prospective studies are needed to design interventions. However, a multifaceted approach appears to represent the best opportunity to reduce the pain and suffering of this challenging population.

Refractory hypoxemia in right ventricular infarction: a case report.

Right ventricular infarction has many clinical features. Although hypoxemia is a common presenting symptom with multiple causes in the setting of myocardial infarction, the authors present a case resulting from an acute right-to-left shunt secondary to a previously dormant patent foramen ovale. A 74-year-old male presented to the hospital after feeling unwell for the previous 2 days. Initial evaluation revealed marked hypoxemia without respiratory distress. Electrocardiographic findings and cardiac seromarkers revealed a completed inferior myocardial infarction. The patients hypoxemia was refractory to 100% oxygen, indicating a right-to-left shunt. A transesophageal echocardiogram confirmed clinical suspicions for a right-to-left shunt through a patent foramen ovale. Despite sporadic reports in the literature, this still is a poorly recognized clinical condition. The authors review a case report that will enable the general internist to consider a right-to-left shunt in the setting of hypoxemia in myocardial infarction.

Primary pulmonary choriocarcinoma in a male

The authors report a case of a 48-year-old male smoker who presented with respiratory distress and constitutional symptoms along with gynaecomastia and multiple pulmonary nodules. Based on normal physical and ultrasound findings of the testes, presence of markedly elevated serum β human chorionic gonadotrophin (HCG) and biopsy findings of the lung a diagnosis of primary pulmonary choriocarcinoma was made.

Beer potomania: a case report.

A syndrome of hyponatraemia associated with excessive beer drinking was first recognised in 1971. This syndrome has been referred to as beer potomania. Dilutional hyponatraemia occurs due to excessive consumption of an exclusive beer diet which is poor in salt and protein. We report a case of beer potomania who improved dramatically with introduction of solute load, with no subsequent neurological sequelae.

Pulmonary Tuberculosis in a Young Pregnant Female: Challenges in Diagnosis and Management

Background. With the world becoming a global village, tuberculosis is no longer limited to endemic areas. Our case emphasizes the impact of immigration on infectious disease epidemiology and challenges associated with diagnosis and treatment in pregnancy. Case. A 21-year-old Hispanic female presented in preterm labor and was found to be hypoxic. Chest X-ray revealed a paratracheal mass which a CT scan confirmed. PPD test was positive. Bronchoalveolar lavage did not reveal acid-fast bacilli and biopsy revealed caseating granulomas. Diagnosis and treatment were challenging due to constraints in radiological investigations, lack of initial evidence of acid-fast bacilli, and toxic profile of medications. Due to her high risk, she was started on antituberculosis regimen. The diagnosis was confirmed on Day 26 when Mycobacterium tuberculosis was isolated by DNA probe. Conclusion. A high index of suspicion is required to recognize the changing face and disease spectrum of tuberculosis and initiate treatment for better outcomes.

Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report

BackgroundRheumatoid arthritis has varied pleuroparenchymal manifestations. Wegeners granulomatosis can develop in an established case of rheumatoid arthritis and this association although previously reported is very rare.Case presentationA 60-year-old lady had been diagnosed with rheumatoid arthritis on the basis of her clinical symptoms and serological tests which were positive RA factor and anti-CCP antibodies. Her rheumatoid arthritis activity had been mild and well controlled with hydroxychloroquine and low dose prednisone. She presented with a productive cough and right-sided pleuritic chest pain. CT scan of the chest showed three lung nodules with increased uptake on PET CT scan, raising concerns for an inflammatory or malignant process. The differential diagnosis included rheumatoid nodules, infections or malignancy. A CT-guided needle biopsy of the largest nodule was undertaken which showed vasculitis typical of Wegeners granulomatosis. Stains and cultures of the biopsy specimen were negative for bacteria, fungi and acid fast bacilli. A panel of serological tests for vasculitis were checked and showed elevated titers of cANCA and anti-proteinase 3 antibodies. Urine analysis and CT scan of paranasal sinuses was normal. Since the upper respiratory tract and the kidneys were spared a diagnosis of limited Wegeners granulomatosis affecting only the lungs was made. Due to the toxicity of cyclophosphamide, her relatively mild disease sparing the kidneys and the underlying rheumatoid arthritis, weekly methotrexate was started and low dose prednisone was continued. She had marked symptomatic improvement and complete resolution of the nodules was documented on subsequent imaging.ConclusionWegeners granulomatosis developing in a patient with rheumatoid arthritis is very rare but should be considered as it warrants a different and possibly more aggressive treatment approach.

Locked lung by looped hernia: a case report

BackgroundLarge pleural effusions are usually symptomatic. We report a patient with asymptomatic massive left sided pleural effusion with left lung collapse secondary to a traumatic diaphragmatic hernia.Case presentationA 44 year old male presented with recurrent pleural effusions over six weeks. His pleural effusion was first diagnosed incidentally on a chest X-ray after a fall. Extensive diagnostic studies were unyielding for the etiology of the effusion. A diagnostic and therapeutic video assisted thoracoscopy revealed a diaphragmatic hernia with inflamed, incarcerated omentum. After hernia repair there was no recurrence.ConclusionThis case underscores the obscure presentation of an incarcerated diaphragmatic hernia presenting as massive recurrent pleural effusions.