Gardner-Diamond syndrome: Difficulties in the management of patients with unexplained medical symptoms

PubMed Central

Meeder, Robert; Bannister, Susan

2006-01-01

The case of an adolescent girl who presented with unexplained bruising is reported. Subsequent investigations failed to elucidate an organic etiology. The diagnosis of Gardner-Diamond syndrome – a syndrome of predictable bruising preceded by pain and warmth at the bruise site, often associated with physical or psychosocial stress – was made. In the present report, the authors use their experience with this rare syndrome to highlight some important ethical and practical considerations with regard to investigation, treatment and communication in illnesses with unexplained medical symptoms. PMID:19030312

Psychological Mechanisms of Medically Unexplained Symptoms: An Integrative Conceptual Model

ERIC Educational Resources Information Center

Brown, Richard J.

2004-01-01

Theories of medically unexplained illness based on the concepts of dissociation, conversion, and somatization are summarized. Evidence cited in support of these theories is described and the conceptual strengths and shortcomings of each approach are considered. It is argued that each of these approaches adds to the understanding of unexplained…

Psychosoma in Crisis: An Autoethnographic Study of Medically Unexplained Symptoms and Their Diverse Contexts

ERIC Educational Resources Information Center

Hills, John; Lees, John; Freshwater, Dawn; Cahill, Jane

2018-01-01

In this study, we examine autoethnographic data from three critical incidents as experienced by the first author demonstrating the importance of context in understanding medically unexplained symptoms, their incidence and underlying patterns. We make the case for ethnographies as a crucial research strand in discerning the finer aspects of the…

"Unexplainable" medical histories and childhood sexual abuse. New doctoral thesis tells you how to investigate the links.

PubMed

Getz, L

1999-06-01

This is a brief summary and a personal reflection on Anne Luise Kirkengen's PhD thesis "Embodiment of sexual boundary violations in childhood". It is written to encourage other clinicians to familiarise themselves with this original and important study. It has high relevance for every clinician who is ever confronted with patients that present medical histories that are "diffuse" or unexplainable according to traditional medical knowledge.

Disturbed EEG sleep, paranoid cognition and somatic symptoms identify veterans with post-traumatic stress disorder

PubMed Central

Rothman, Lorne; Kleinman, Robert; Rhind, Shawn G.; Richardson, J. Donald

2016-01-01

Background Chronic post-traumatic stress disorder (PTSD) behavioural symptoms and medically unexplainable somatic symptoms are reported to occur following the stressful experience of military combatants in war zones. Aims To determine the contribution of disordered EEG sleep physiology in those military combatants who have unexplainable physical symptoms and PTSD behavioural difficulties following war-zone exposure. Method This case-controlled study compared 59 veterans with chronic sleep disturbance with 39 veterans with DSM-IV and clinician-administered PTSD Scale diagnosed PTSD who were unresponsive to pharmacological and psychological treatments. All had standardised EEG polysomnography, computerised sleep EEG cyclical alternating pattern (CAP) as a measure of sleep stability, self-ratings of combat exposure, paranoid cognition and hostility subscales of Symptom Checklist-90, Beck Depression Inventory and the Wahler Physical Symptom Inventory. Statistical group comparisons employed linear models, logistic regression and chi-square automatic interaction detection (CHAID)-like decision trees. Results Veterans with PTSD were more likely than those without PTSD to show disturbances in non-rapid eye movement (REM) and REM sleep including delayed sleep onset, less efficient EEG sleep, less stage 4 (deep) non-REM sleep, reduced REM and delayed onset to REM. There were no group differences in the prevalence of obstructive sleep apnoeas/hypopnoeas and periodic leg movements, but sleep-disturbed, non-PTSD military had more EEG CAP sleep instability. Rank order determinants for the diagnosis of PTSD comprise paranoid thinking, onset to REM sleep, combat history and somatic symptoms. Decision-tree analysis showed that a specific military event (combat), delayed onset to REM sleep, paranoid thinking and medically unexplainable somatic pain and fatigue characterise chronic PTSD. More PTSD veterans reported domestic and social misbehaviour. Conclusions Military combat, disturbed REM/non-REM EEG sleep, paranoid ideation and medically unexplained chronic musculoskeletal pain and fatigue are key factors in determining PTSD disability following war-zone exposure. Declaration of interest None. Copyright and usage © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license. PMID:29018561

[The diagnostic value of medical thoracoscopy for unexplained pleural effusion].

PubMed

Jiang, Shu-juan; Mu, Xiao-yan; Zhang, Song; Su, Li-li; Ma, Wei-xia

2013-05-01

To explore the endoscopic features of patients with unexplained pleural effusion, and to evaluate the diagnostic value of medical thoracoscopy. A retrospective analysis of 2380 patients with unexplained pleural effusion (1320 males and 1060 females; age 15-94 years) in Shandong Provincial Hospital from 1992 to 2011 were performed .The diagnosis was confirmed by medical thoracoscopy. The endoscopic findings of malignant pleural effusion mostly showed nodules of varying sizes. The nodules could be grape-like, cauliflower-like, fused into masses, or diffused small nodules . The appearance of cancerous nodules was more diversified compared to tuberculous nodules. Tuberculous pleurisy was manifested as diffuse pleural congestion and miliary changes, multiple small gray-white nodules, fibrin deposition and adhesion in the pleural cavity, pleural thickening and loculation . The pathological diagnosis was as follows: pleural metastases in 899 (37.8%), primary pleural mesothelioma in 439 (18.4%), tuberculous pleurisy in 514 (21.6%), non-specific inflammation in 226 (9.5%), empyema in 190 (8.0%), hepatic pleural effusion in 36 (1.5%) and pleural effusion of unknown causes in 76 (3.2%) cases. The diagnostic positive rate of medical thoracoscopy was 96.8%. No serious complications were observed. Medical thoracoscopy is a relatively safe procedure and has an important application value in the diagnosis of unexplained pleural effusion.

Unexplained chronic leukopenia treated with oral iron supplements.

PubMed

Abuirmeileh, Ayman; Bahnassi, Anas; Abuirmeileh, Amjad

2014-04-01

A 67-year-old woman known to have iron deficiency anemia and persistent unexplained chronic leukopenia was cared for by our medical center for about 16 years. During this period she was examined thoroughly and diagnosed to have chronic idiopathic neutropenia (also known as chronic benign neutropenia). Her iron deficiency was attributed to nutritional factors and she was non-compliant with her oral iron supplements. The patient fully received her iron supplement medication by nursing staff for two and a half months during an unexpected prolonged hospital stay after her suffering an acute ischemic cerebrovascular accident. An astonishing outcome was that in addition to having her iron deficiency anemia treated, her long-term unexplained neutropenia was also corrected. Some patients diagnosed with chronic idiopathic neutropenia and clinically present as having unexplained chronic neutropenia might actually be suffering from a form of not yet described iron deficiency induced neutropenia.

A Randomized Double-Blind Controlled Trial Comparing Davanloo Intensive Short-Term Dynamic Psychotherapy as Internet-Delivered Vs Treatment as Usual for Medically Unexplained Pain: A 6-Month Pilot Study.

PubMed

Chavooshi, Behzad; Mohammadkhani, Parvaneh; Dolatshahi, Behrouz

2016-01-01

Research has shown that Intensive Short-Term Dynamic Psychotherapy (ISTDP) can effectively decrease pain intensity and improve quality of life in patients with medically unexplained pain. Understanding that not all patients with medically unexplained pain have access to in-person ISTDP, this study aims to investigate the efficacy of an Internet-delivered ISTDP for individuals with medically unexplained pain using Skype in comparison with treatment as usual. In this randomized controlled trial, 100 patients were randomly allocated into Internet-delivered ISTDP (n = 50) and treatment-as- usual (n = 50) groups. Treatment intervention consisted of 16 weekly, hour-long therapy sessions. The primary outcome was perceived pain assessed using the Numeric Pain Rating Scale. The secondary outcome included Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale, and Quality-of-Life Inventory. Blind assessments were conducted at the baseline, posttreatment, and at a 6-month follow-up. In the intention-to-treat analysis, pain symptoms in the intervention group were significantly reduced (p < 0.001), whereas a reduction was not observed in the treatment as usual group (p = 0.651). Moreover, there were significant decreases in depression, anxiety, and stress, as well as a greater increase in emotion regulation functioning, mindfulness, and quality of life observed in the intervention group 6 months after the treatment compared with the treatment as usual condition. The results of this pilot trial demonstrate that 16 weeks of ISTDP delivered by Skype can significantly improve pain intensity and clinical symptoms of medically unexplained pain. Copyright © 2016 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Solving medical mysteries: hidden stresses and unexplained symptoms.

PubMed

Clarke, David D

2016-09-01

Medically unexplained symptoms and chronic functional syndromes are common but few healthcare professionals have had formal training about their connection to psychosocial issues. A systematic approach to diagnosis and treatment based on experience with over 7000 of these patients is described. Outcomes improve with assessment for and treatment of current life stresses, the prolonged impact of adversity in childhood and somatic presentations of depression, post-traumatic stress, and anxiety disorders.

Medical student attitudes about mental illness: does medical-school education reduce stigma?

PubMed

Korszun, Ania; Dinos, Sokratis; Ahmed, Kamran; Bhui, Kamaldeep

2012-05-01

Reducing stigma associated with mental illness is an important aim of medical education, yet evidence indicates that medical students' attitudes toward patients with mental health problems deteriorate as they progress through medical school. Authors examined medical students' attitudes to mental illness, as compared with attitudes toward other medical illness, and the influence of the number of years spent in medical school, as well as of several key socio-demographic, ethnic, and cultural variables. A group of 760 U.K. medical students completed a nationwide on-line survey examining their attitudes toward patients with five conditions (pneumonia, depression, psychotic symptoms, intravenous drug use, long-standing unexplained abdominal complaints), using the Medical Condition Regard Scale (MCRS). Students were also asked whether they had completed the psychiatry rotation or had personal experience of mental disorders themselves or among their friends or family members. They were also asked about their ethnic group (using U.K. national census categories), religious affiliation, and how important religion was in their lives. Independent-samples t-tests and one-way ANOVA were used to compare differences between groups on the MCRS. Students showed the highest regard for patients with pneumonia and lowest regard for patients with long-standing, unexplained abdominal complaints. Although attitudes toward pneumonia were more positive in fifth-year students than in first-year students, attitudes toward unexplained chronic abdominal pain were worse in fifth-year students than in first-year students. Personal experience of mental health treatment, or that among family and friends, were associated with less stigmatizing attitudes. Men showed more stigmatization than women for nearly all conditions; Chinese and South Asian students showed more stigmatizing attitudes toward delusions and hallucinations than their white British counterparts. Medical students in this survey showed the lowest regard for patients with unexplained abdominal pain, and these attitudes were worse in the most experienced medical students. Students' gender, culture and direct or indirect experience of mental illness influenced stigmatizing attitudes.

Blame, shame and hopelessness: medically unexplained symptoms and the 'heartsink' experience.

PubMed

Stone, Louise

2014-04-01

'Heartsink' patients present a moral dilemma. We recognise their suffering, but at the same time struggle with the feelings they trigger in us. Patients also experience negative feelings. Without a diagnosis they lack a narrative or vocabulary to make sense of their own suffering. This article explores some of the challenges faced and strategies utilised when managing patients with medically unexplained symptoms. Doctors and patients often experience frustration and helplessness in consultations around medically unexplained symptoms. Without a diagnosis, patients lack social legitimacy as 'sick' people with 'real' illnesses. They often describe feeling blamed for their own distress. Because of this, they can experience deep feelings of worthlessness and shame. Patients with a history of abuse can be particularly vulnerable. Management includes validating their suffering, helping them construct appropriate explanations for their distress and providing empathic interpersonal care, while minimising the risk of iatrogenic harm.

Medically unexplained dyspnoea and panic.

PubMed

Hauzer, Rose; Verheul, Willeke; Griez, Eric; Wesseling, Geertjan; van Duinen, Marlies

2015-07-01

Medically unexplained dyspnoea in the pulmonary setting is often accompanied by considerable levels of anxiety, suggestive of psychopathology, in particular panic disorder (PD). This pilot study investigates the value of the Multidimensional Dyspnea Profile as a tool to facilitate identification of a specific dyspnoea profile suggestive of comorbid PD. The verbal descriptors, feeling depressed, air hunger and concentrating on breathing, significantly differentiated between the two groups of patients with pulmonary disease with and without PD. © 2015 Asian Pacific Society of Respirology.

Diagnostic value of FDG-PET/(CT) in children with fever of unknown origin and unexplained fever during immune suppression.

PubMed

Blokhuis, Gijsbert J; Bleeker-Rovers, Chantal P; Diender, Marije G; Oyen, Wim J G; Draaisma, Jos M Th; de Geus-Oei, Lioe-Fee

2014-10-01

Fever of unknown origin (FUO) and unexplained fever during immune suppression in children are challenging medical problems. The aim of this study is to investigate the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and FDG-PET combined with computed tomography (FDG-PET/CT) in children with FUO and in children with unexplained fever during immune suppression. All FDG-PET/(CT) scans performed in the Radboud university medical center for the evaluation of FUO or unexplained fever during immune suppression in the last 10 years were reviewed. Results were compared with the final clinical diagnosis. FDG-PET/(CT) scans were performed in 31 children with FUO. A final diagnosis was established in 16 cases (52 %). Of the total number of scans, 32 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in these patients was 80 % and 78 %, respectively. FDG-PET/(CT) scans were performed in 12 children with unexplained fever during immune suppression. A final diagnosis was established in nine patients (75 %). Of the total number of these scans, 58 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in children with unexplained fever during immune suppression was 78 % and 67 %, respectively. FDG-PET/CT appears a valuable imaging technique in the evaluation of children with FUO and in the diagnostic process of children with unexplained fever during immune suppression. Prospective studies of FDG-PET/CT as part of a structured diagnostic protocol are warranted to assess the additional diagnostic value.

Kisspeptin: A Potential Factor for Unexplained Infertility and Impaired Embryo Implantation

PubMed Central

Mumtaz, Aaida; Khalid, Aqsa; Jamil, Zehra; Fatima, Syeda Sadia; Arif, Sara; Rehman, Rehana

2017-01-01

Background Kisspeptin (KP) is a neuropeptide that causes the release of the gonadotropin releasing hormone, which controls hypothalamo pituitary ovarian axis and exerts a number of peripheral effects on reproductive organs. The primary objective of this study was to compare baseline KP levels in females with different types of infertility and identify possible correlations with risk of failure to conceive, preclinical abortion and pregnancy after intracytoplasmic sperm injection (ICSI). Materials and Methods A longitudinal cohort study was carried out from August 2014 until May 2015 by recruiting 124 female patients undergoing ICSI, after obtaining ethical approval from the Australian Concept Infertility Medical Center. Cause of infertility due to male, female and unexplained factors was at a frequency of 32 (24%), 33 (31%) and 59 (45%) among the individuals respectively. KP levels were measured by ELISA assay before the initiation of the ICSI treatment protocol. Outcome of ICSI was categorized into three groups of non-pregnant with beta-human chorionic gonadotropin (β-hCG)<5-25 mIU/ml, preclinical abortion with β-hCG>25 mIU/ml and no cardiac activity, and clinical pregnancy declared upon confirmation of cardiac activity. Results based on cause of infertility and outcome groups were analyzed by one-way ANOVA. Results Females with unexplained infertility had significantly lower levels of KP when compared with those with male factor infertility (176.69 ± 5.03 vs. 397.6 ± 58.2, P=0.001). Clinical pregnancy was observed in 28 (23%) females of which 17 (71%) had a female cause of infertility. In the non-pregnant group of 66 (53%) females, common cause of infertility was unexplained 56(85%). A weak positive correlation of KP levels with fertilized oocytes and endometrial thickness was observed (P=0.04 and 0.01 respectively). Conclusion Deficiency of KP in females with unexplained infertility was associated with reduced chances of implantation after ICSI. PMID:28670427

Potentially harmful side-effects: medically unexplained symptoms, somatization, and the insufficient illness narrative for viewers of mystery diagnosis.

PubMed

Farkas, Carol-Ann

2013-09-01

Illness narrative has often been found to play a positive role in both patients' and providers' efforts to find meaning in the illness experience. However, illness narrative can sometimes become counterproductive, even pathological, particularly in cases of medical mystery--cases wherein biopsychosocial factors blur the distinction between bodily dysfunction and somatizing behavior. In this article, the author draws attention to two examples of medical mystery, the clinical presentation of medically unexplained symptoms, and the popular reality television program Mystery Diagnosis, to demonstrate the potentially harmful effects of illness narrative. The medical mystery's complex narrative structure reflects and tends to reinforce providers' and patients' mistaken assumptions, anxieties, and conflicts in ways which obstruct, rather than facilitate, healing.

An experiential mind-body approach to the management of medically unexplained symptoms.

PubMed

Bakal, D; Steiert, M; Coll, P; Schaefer, J

2006-01-01

This article outlines an experiential mind-body framework for understanding and treating patients with medically unexplained symptoms. The model relies on somatic awareness, a normal part of consciousness, to resolve the mind-body dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which allows for a linear treatment application of the biopsychosocial model. The heuristic acknowledges the validity of the patient's physical symptoms and identifies psychological and social factors needed for the healing process. Somatic awareness is used to direct changes in coping styles, illness beliefs, medication dependence and personal dynamics that are necessary to achieve symptom control. The mind-body concept is consistent with and supported by neurobiological models which draw on central nervous system mechanisms to explain medically unexplained symptoms. The concept is also supported by a recent hypothesis concerning the role peripheral connective tissue may play in influencing illness and well-being. Finally, somatic awareness is described as having potential to enhance understanding and conscious use of inner healing mechanisms at the basis of the placebo effect.

A research coding method to evaluate medical clinicians conduct of behavioral health care in patients with unexplained symptoms.

PubMed

Grayson-Sneed, Katelyn A; Smith, Robert C

2018-04-01

Develop a reliable coding method of a Behavioral Health Treatment Model for patients with Medically Unexplained Symptoms (BHTM-MUS). Two undergraduates trained for 30h coded videotaped interviews from 161 resident-simulated patient (SP) interactions. Trained on 45 videotapes, coders coded 33 (20%) of 161 study set tapes for the BHTM-MUS. Guetzkow's U, Cohen's Kappa, and percent of agreement were used to measure coders' reliability in unitizing and coding residents' skills for eliciting: education and informing (4 yes/no items), motivating (2), treatment statements (5), commitment and goals (2), negotiates plan (8), non-emotion patient-centered skills (4), and patient-centered emotional skills (8). 60 items were dichotomized a priori from analysis of the BHTM-MUS and were reduced to 33 during training. Guetzkow's U ranged from .00 to .082. Kappa ranged from 0.76 to 0.97 for the 7 variables and 33 individual items. The overall kappa was 0.87, and percent of agreement was 95.7%. Percent of agreement by item ranged from 85 to 100%. A highly reliable coding method is recommended to evaluate medical clinicians' behavioral care skills in patients with unexplained symptoms. A way to rate behavioral care in patients with unexplained symptoms. Copyright © 2017 Elsevier B.V. All rights reserved.

Anxiety and depression predicted by medically unexplained symptoms in Pakistani children: a case-control study.

PubMed

Imran, Nazish; Ani, Cornelius; Mahmood, Zahid; Hassan, Khawaja Amjad; Bhatti, Muhammad Riaz

2014-02-01

To explore association between medically unexplained symptoms in children in Pakistan with emotional difficulties and functional impairments. We conducted a matched three-group case-control study of 186 children aged 8-16 years in Lahore, Pakistan. Cases were 62 children with chronic somatic symptoms for which no organic cause was identified after investigations. Two control groups of 62 children with chronic medical paediatric conditions, and 62 healthy children were identified. Cases and controls were matched for gender, age, and school class. Somatisation was measured with the Children's Somatisation Inventory (CSI-24) while anxiety and depression were measured with the Spencer Children's Anxiety Scale and the Short Mood and Feelings Questionnaire respectively. All questionnaires were translated into Urdu. Mean age was 11.7 years (SD=2.1). Cases scored significantly higher on somatisation (CSI-24), anxiety and depression than both control groups. Paediatric controls scored significantly higher than healthy controls on all three measures. Two hierarchical linear regression models were used to explore if somatisation predicted depression and anxiety while controlling for several confounders. Somatisation (higher CSI-24 scores) independently and significantly predicted higher anxiety (β=.37, p=.0001) and depression (β=.41, p=.0001) scores. This is the first study to show an association between medically unexplained symptoms and anxiety and depression in Pakistani children. This highlights the importance of screening for emotional difficulties in children presenting with unexplained somatic symptoms in this region. Copyright © 2013 Elsevier Inc. All rights reserved.

Opinion paper: the role of work in the management of medically unexplained physical symptoms.

PubMed

Tobback, Els; Mariman, An; Clauwaert, Lies; Godderis, Lode; Heytens, Stefan; Ruppol, Patrick; Spooren, Daniel; Tytgat, Rita; De Muynck, Martine; Vogelaers, Dirk

2018-05-04

Patients with medically unexplained physical symptoms suffer from chronic fatigue and/or pain in combination with a variety of other symptoms. A flexible, biopsychosocial approach is needed for diagnostic screening and global management. It is crucial to involve the direct patient environment, including family, friends, colleagues as well as health providers, evaluation, and reintegration sector. The aim of this paper is to review the importance of work in the management of medically unexplained physical symptoms. In this paper, different actors involved explain their views and handling concerning work in the management of MUPS. Symptom severity and lack of understanding from the environment can negatively impact on earning an independent income from labor for years. Work, whether or not paid, is however, an important life domain with positive effects on physical, psychological, and social well-being. Therefore, health actors are pivotal in starting the professional reintegration process as soon as possible and should discuss this item from the early stage onward. Support services can be consulted in mutual interaction as required. A case manager, acting as a central intermediator within this multidisciplinary approach, may promote effective communication and coordination between the patients and their surrounding actors. The professional reintegration process should start as soon as possible within the management of medically unexplained physical symptoms. As such, the care sector, the evaluation sector, and the professional integration sector should collaborate and effectively communicate with each other.

Training Medical Specialists to Communicate Better with Patients with Medically Unexplained Physical Symptoms (MUPS). A Randomized, Controlled Trial

PubMed Central

Weiland, Anne; Blankenstein, Annette H.; Van Saase, Jan L. C. M.; Van der Molen, Henk T.; Jacobs, Mariël E.; Abels, Dineke C.; Köse, Nedim; Van Dulmen, Sandra; Vernhout, René M.; Arends, Lidia R.

2015-01-01

Background Patients with medically unexplained physical symptoms (MUPS) are prevalent 25–50% in general and specialist care. Medical specialists and residents often find patients without underlying pathology difficult to deal with, whereas patients sometimes don’t feel understood. We developed an evidence-based communication training, aimed to improve specialists’ interviewing, information-giving and planning skills in MUPS consultations, and tested its effectiveness. Methods The intervention group in this multi-center randomized controlled trial received a 14-hour training program to which experiential learning and feedback were essential. Using techniques from Cognitive Behavioral Therapy, they were stimulated to seek interrelating factors (symptoms, cognitions, emotions, behavior, and social environment) that reinforced a patient’s symptoms. They were taught to explain MUPS understandably, reassure patients effectively and avoid unnecessary diagnostic testing. Before and after the intervention training, specialists videotaped a total of six consultations with different MUPS patients. These were evaluated to assess doctors’ MUPS-focused communicating skills using an adapted version of the Four Habit Coding Scheme on five-point Likert scales. Participants evaluated the training by self-report on three-point Likert scales. Doctors in the control group received training after completion of the study. Results 123 doctors (40% specialists, 60% residents) and 478 MUPS patients from 11 specialties were included; 98 doctors completed the study (80%) and 449 videotaped consultations were assessed. Trained doctors interviewed patients more effectively than untrained ones (p < 0.001), summarized information in a more patient-centered way (p = 0.001), and better explained MUPS and the role of perpetuating factors (p < 0.05). No effects on planning skills were found. On a 3-point scale the training was evaluated with 2.79. Conclusion MUPS-focused communication training increases the interviewing and information-giving skills of medical specialists. We recommend that the training is incorporated in postgraduate education for medical specialists and residents who frequently encounter patients with MUPS. Trial Registration Dutch Trial Registration NTR2612 PMID:26381400

Psychosocial correlates, psychological distress, and quality of life in patients with medically unexplained symptoms: a primary care study in Karachi, Pakistan.

PubMed

Husain, Muhammad Ishrat; Chaudhry, Nasim; Morris, Julie; Zafar, Shehla Naeem; Jaffery, Farhat; Rahman, Raza; Duddu, Venu; Husain, Nusrat

2015-01-01

To examine the psychosocial correlates and association of psychological distress and quality of life (QOL) in patients with medically unexplained symptoms (MUS) compared to those with medically explained symptoms (MES) in a primary care setting in Karachi, Pakistan. A cross-sectional study of 472 patients attending GP clinics between March and August 2009 in Karachi. Participants completed questionnaires to assess demographic details, somatic symptoms, anxiety, depression, and QOL. The patients' GP recorded whether the presenting complaint was medically unexplained or medically explained. MUS subjects in our study were more educated, had better social support and fewer financial problems, were less depressed and had a better QOL than subjects who had medically explained symptoms (non-MUS). Both groups (MUS and non-MUS) were comparable in terms of anxiety and number of somatic symptoms, but non-MUS subjects were more depressed than the MUS group. In a regression analysis, the number of somatic symptoms and lower levels of anxiety predicted poorer QOL in this sample. Whether these symptoms were medically explained (or not) did not seem to contribute significantly to the QOL. Our findings confirm that even in the developing world, patients with MUS are common among primary care attendees. However, patients with MUS in urban Karachi, Pakistan may differ from Western MUS subjects in the role of stress, support, and anxiety in their presentation, and may be reflective of a conceptually different group of difficulties. © 2015, The Author(s).

Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study.

PubMed

Ring, Adele; Dowrick, Christopher; Humphris, Gerry; Salmon, Peter

2004-05-01

To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions. Qualitative analysis of audiorecorded consultations between patients and general practitioners. 7 general practices in Merseyside, England. 36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained. Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners. Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including: graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations. Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms.

PubMed

Crimlisk, H L; Bhatia, K; Cope, H; David, A; Marsden, C D; Ron, M A

1998-02-21

To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Follow up study. National Hospital for Neurology and Neurosurgery, London--a secondary and tertiary referral hospital for neurological disorders. 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview--the schedule for affective disorders and schizophrenia--conducted by a psychiatrist. Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Unlike Slater's study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients' symptoms or disability was found. However, a high level of psychiatric comorbidity existed.

Laparoscopy In Unexplained Abdominal Pain: Surgeon's Perspective.

PubMed

Abdullah, Muhammad Tariq; Waqar, Shahzad Hussain; Zahid, Muhammad Abdul

2016-01-01

Unexplained abdominal pain is a common but difficult presenting feature faced by the clinicians. Such patients can undergo a number of investigations with failure to reach any diagnosis. The objective of this study was to evaluate the use of laparoscopy in the diagnosis and management of patients with unexplained abdominal pain. This cross-sectional study was conducted at Pakistan Institute of Medical Sciences Islamabad from January 2009 to December 2013. This study included 91 patients of unexplained abdominal pain not diagnosed by routine clinical examination and investigations. These patients were subjected to diagnostic laparoscopy for evaluation of their conditions and to confirm the diagnosis. These patients presented 43% of patients undergoing investigations for abdominal pain. Patients diagnosed with gynaecological problems were excluded to see surgeon's perspective. The findings and the outcomes of the laparoscopy were recorded and data was analyzed. Unexplained abdominal pain is common in females than in males. The most common laparoscopic findings were abdominal tuberculosis followed by appendicitis. Ninety percent patients achieved pain relief after laparoscopic intervention. Laparoscopy is both beneficial and safe in majority of patients with unexplained abdominal pain. General surgeons should acquire training and experience in laparoscopic surgery to provide maximum benefit to these difficult patients.

Sickness absence, marginality, and medically unexplained physical symptoms: a focus-group study of patients' experiences.

PubMed

Aamland, Aase; Werner, Erik L; Malterud, Kirsti

2013-06-01

Medically unexplained physical symptoms (MUPS) form a major cause of sickness absence. The purpose of this study was to explore factors which may influence further marginalization among patients with MUPS on long-term sickness absence. Two focus-group discussions were conducted with a purposive sample of 12 participants, six men and six women, aged 24-59 years. Their average duration of sickness absence was 10.5 months. Participants were invited to share stories about experiences from the process leading to the ongoing sickness absence, with a focus on the causes being medically unexplained. Systematic text condensation was applied for analysis. Inspired by theories of marginalization and coping, the authors searched for knowledge of how patients' positive resources can be mobilized to counteract processes of marginality. Analysis revealed how invisible symptoms and lack of objective findings were perceived as an additional burden to the sickness absence itself. Factors that could counteract further marginalization were a supportive social network, positive coping strategies such as keeping to the daily schedule and physical activity, and positive attention and confidence from professionals. Confidence from both personal and professional contacts is crucial. GPs have an important and appreciated role in this aspect.

Retrospective Validation of a Surveillance System for Unexplained Illness and Death: New Haven County, Connecticut

PubMed Central

Kluger, Michael D.; Sofair, Andre N.; Heye, Constance J.; Meek, James I.; Sodhi, Rajesh K.; Hadler, James L.

2001-01-01

Objectives. This study investigated retrospective validation of a prospective surveillance system for unexplained illness and death due to possibly infectious causes. Methods. A computerized search of hospital discharge data identified patients with potential unexplained illness and death due to possibly infectious causes. Medical records for such patients were reviewed for satisfaction of study criteria. Cases identified retrospectively were combined with prospectively identified cases to form a reference population against which sensitivity could be measured. Results. Retrospective validation was 41% sensitive, whereas prospective surveillance was 73% sensitive. The annual incidence of unexplained illness and death due to possibly infectious causes during 1995 and 1996 in the study county was conservatively estimated to range from 2.7 to 6.2 per 100 000 residents aged 1 to 49 years. Conclusions. Active prospective surveillance for unexplained illness and death due to possibly infectious causes is more sensitive than retrospective surveillance conducted through a published list of indicator codes. However, retrospective surveillance can be a feasible and much less labor-intensive alternative to active prospective surveillance when the latter is not possible or desired. PMID:11499106

Projecting the potential impact of the Cap-Score™ on clinical pregnancy, live births, and medical costs in couples with unexplained infertility.

PubMed

Babigumira, Joseph B; Sharara, Fady I; Garrison, Louis P

2018-01-01

The Cap-Score™ was developed to assess the capacitation status of men, thereby enabling personalized management of unexplained infertility by choosing timed intrauterine insemination (IUI), versus immediate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in individuals with a low Cap-Score™. The objective of this study was to estimate the differences in outcomes and costs comparing the use of the Cap-Score™ with timed IUI (CS-TI) and the standard of care (SOC), which was assumed to be three IUI cycles followed by three IVF-ICSI cycles. We developed and parameterized a decision-analytic model of management of unexplained infertility for women based on data from the published literature. We calculated the clinical pregnancy rates, live birth rates, and medical costs comparing CS-TI and SOC. We used Monte Carlo simulation to quantify uncertainty in projected estimates and performed univariate sensitivity analysis. Compared to SOC, CS-TI was projected to increase the pregnancy rate by 1-26%, marginally reduce live birth rates by 1-3% in couples with women below 40 years, increase live birth rates by 3-7% in couples with women over 40 years, reduce mean medical costs by $4000-$19,200, reduce IUI costs by $600-$1370, and reduce IVF costs by $3400-$17,800, depending on the woman's age. The Cap-Score™ is a potentially valuable clinical tool for management of unexplained infertility because it is projected to improve clinical pregnancy rates, save money, and, depending on the price of the test, increase access to treatment for infertility.

Medically unexplained physical symptoms: toward an alternative paradigm for diagnosis and treatment.

PubMed

Ballas, Christos A; Staab, Jeffrey P

2003-12-01

The treatment of patients with unexplained medical symptoms is difficult because there is neither a clear etiology for the symptoms, nor a useful paradigm with which to understand and treat them. Patients with such symptoms are often referred to psychiatry with vague diagnoses of "somatization" or "hypochondriasis." Rather than considering somatoform diagnoses based on the number or diversity of physical symptoms, evolving research suggests an emphasis on the type of physical symptom as an indicator of Axis I pathology. This article links specific symptomatic complaints, such as chronic pain, chest pain, and dizziness, to the respective Axis I disorders associated with them, such as depression, panic disorder, and anxiety disorders.

Medically unexplained physical symptoms, misunderstood and wrongly treated? A semiotic perspective on chronic pain.

PubMed

Busvold, Kari Irene H; Bondevik, Hilde

2018-06-01

Medically unexplained physical symptoms (MUPS) are a significant and increasing health issue in the western world. Chronic pain constitutes a considerable element of these symptoms, and the lack of a biomedical explanation of their cause challenges the clinical encounter. The limitations of biomedicine become evident in these encounters and expose the need for an expanded understanding of body and symptom. Semiotics, as an anti-dualistic meta-theory, closes the gap between natural science and the humanities and views the human body in an evolutionary and existential perspective. By focusing on interpretation and communication of signs as ongoing processes at all levels of life, biology and experience, the subjective and the measurable will be integrated. A special type of sign, the self-referential, is part of the body's internal communication. These signs may be viewed as the body's warnings to itself, for instance when the individual's consciousness, thought and action run counter to the organism's physiological and psychological needs. In a semiotic perspective, existential conditions may also activate the body's defense systems. In this context, the unexplained pain may be understood as a functional warning sign. The enhanced understanding of body and symptom that a semiotic approach calls for is relevant for the work of physiotherapists and may lead to more constructive clinical encounters with patients with unexplained chronic pain.

The most popular terms for medically unexplained symptoms: the views of CFS patients.

PubMed

Picariello, Federica; Ali, Sheila; Moss-Morris, Rona; Chalder, Trudie

2015-05-01

Medically unexplained symptoms/syndromes are common, highly distressing and are often associated with profound disability. One of the controversies surrounding this area relates to which umbrella term should be used to group such symptoms. The purpose of this research was to establish the preferences of patients with chronic fatigue syndrome (CFS) for an umbrella term for medically unexplained symptoms. A cross-sectional mixed methods survey design was used. Participants were asked to indicate their three most preferred terms out of a list of commonly used terms and to provide any extra comments. Frequency analysis was employed to look at the preferences of terms for each rank. Comments were analysed using principles of inductive thematic analysis. Eighty-seven patients with CFS completed a self-report survey. The term "Persistent Physical Symptoms" was the most popular first choice term chosen by 20.7% of patients. Terms containing the word "physical" were consistently more likely to be chosen. Three main themes emerged from the thematic analysis: 1) Physical nature of the illness, 2) Stigma, and 3) Evaluation of the terms, giving a more in-depth understanding of the findings. According to CFS patients, an umbrella term has to reflect the physical experience of MUS. Copyright © 2015 Elsevier Inc. All rights reserved.

Sickness absence, marginality, and medically unexplained physical symptoms: A focus-group study of patients’ experiences

PubMed Central

2013-01-01

Abstract Purpose Medically unexplained physical symptoms (MUPS) form a major cause of sickness absence. The purpose of this study was to explore factors which may influence further marginalization among patients with MUPS on long-term sickness absence. Methods Two focus-group discussions were conducted with a purposive sample of 12 participants, six men and six women, aged 24–59 years. Their average duration of sickness absence was 10.5 months. Participants were invited to share stories about experiences from the process leading to the ongoing sickness absence, with a focus on the causes being medically unexplained. Systematic text condensation was applied for analysis. Inspired by theories of marginalization and coping, the authors searched for knowledge of how patients’ positive resources can be mobilized to counteract processes of marginality. Results Analysis revealed how invisible symptoms and lack of objective findings were perceived as an additional burden to the sickness absence itself. Factors that could counteract further marginalization were a supportive social network, positive coping strategies such as keeping to the daily schedule and physical activity, and positive attention and confidence from professionals. Conclusions Confidence from both personal and professional contacts is crucial. GPs have an important and appreciated role in this aspect. PMID:23659708

Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial.

PubMed

Koch, Hèlen; van Bokhoven, Marloes A; ter Riet, Gerben; van Alphen-Jager, Jm Tineke; van der Weijden, Trudy; Dinant, Geert-Jan; Bindels, Patrick J E

2009-04-01

Unexplained fatigue is frequently encountered in general practice. Because of the low prior probability of underlying somatic pathology, the positive predictive value of abnormal (blood) test results is limited in such patients. The study objectives were to investigate the relationship between established diagnoses and the occurrence of abnormal blood test results among patients with unexplained fatigue; to survey the effects of the postponement of test ordering on this relationship; and to explore consultation-related determinants of abnormal test results. Cluster randomised trial. General practices of 91 GPs in the Netherlands. GPs were randomised to immediate or postponed blood-test ordering. Patients with new unexplained fatigue were included. Limited and expanded sets of blood tests were ordered either immediately or after 4 weeks. Diagnoses during the 1-year follow-up period were extracted from medical records. Two-by-two tables were generated. To establish independent determinants of abnormal test results, a multivariate logistic regression model was used. Data of 325 patients were analysed (71% women; mean age 41 years). Eight per cent of patients had a somatic illness that was detectable by blood-test ordering. The number of false-positive test results increased in particular in the expanded test set. Patients rarely re-consulted after 4 weeks. Test postponement did not affect the distribution of patients over the two-by-two tables. No independent consultation-related determinants of abnormal test results were found. Results support restricting the number of tests ordered because of the increased risk of false-positive test results from expanded test sets. Although the number of re-consulting patients was small, the data do not refute the advice to postpone blood-test ordering for medical reasons in patients with unexplained fatigue in general practice.

Covert video monitoring in the assessment of medically unexplained symptoms in children.

PubMed

Wallace, Dustin P; Sim, Leslie A; Harrison, Tracy E; Bruce, Barbara K; Harbeck-Weber, Cynthia

2012-04-01

Diagnosis of medically unexplained symptoms (MUS) occurs after thorough evaluations have failed to identify a physiological cause for symptoms. However, families and providers may wonder if something has been missed, leading to reduced confidence in behavioral treatment. Confidence may be improved through the use of technology such as covert video monitoring to better assess functioning across settings. A 12-year-old male presented with progressive neurological decline, precipitated by chronic pain. After thorough evaluation and the failure of standard treatments (medical, rehabilitative, and psychological) covert video monitoring revealed that the patient demonstrated greater abilities when alone in his room. Negative reinforcement was used to initiate recovery, accompanied by positive reinforcement and a rehabilitative approach. Covert video monitoring assisted in three subsequent cases over the following 3 years. In certain complex cases, video monitoring can inform the assessment and treatment of MUS. Discussion includes ethical and practical considerations.

Contributions of societal and geographical environments to "chronic Lyme disease": the psychopathogenesis and aporology of a new "medically unexplained symptoms" syndrome.

PubMed Central

Sigal, Leonard H; Hassett, Afton L

2002-01-01

Lyme disease is a relatively well-described infectious disease with multisystem manifestations. Because of confusion over conflicting reports, anxiety related to vulnerability to disease, and sensationalized and inaccurate lay media coverage, a new syndrome, "chronic Lyme disease," has become established. Chronic Lyme disease is the most recent in a continuing series of "medically unexplained symptoms" syndromes. These syndromes, such as fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity, meet the need for a societally and morally acceptable explanation for ill-defined symptoms in the absence of objective physical and laboratory findings. We describe factors involved in the psychopathogenesis of chronic Lyme disease and focus on the confusion and insecurity these patients feel, which gives rise to an inability to adequately formulate and articulate their health concerns and to deal adequately with their medical needs, a state of disorganization termed aporia. PMID:12194894

Contributions of societal and geographical environments to "chronic Lyme disease": the psychopathogenesis and aporology of a new "medically unexplained symptoms" syndrome.

PubMed

Sigal, Leonard H; Hassett, Afton L

2002-08-01

Lyme disease is a relatively well-described infectious disease with multisystem manifestations. Because of confusion over conflicting reports, anxiety related to vulnerability to disease, and sensationalized and inaccurate lay media coverage, a new syndrome, "chronic Lyme disease," has become established. Chronic Lyme disease is the most recent in a continuing series of "medically unexplained symptoms" syndromes. These syndromes, such as fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity, meet the need for a societally and morally acceptable explanation for ill-defined symptoms in the absence of objective physical and laboratory findings. We describe factors involved in the psychopathogenesis of chronic Lyme disease and focus on the confusion and insecurity these patients feel, which gives rise to an inability to adequately formulate and articulate their health concerns and to deal adequately with their medical needs, a state of disorganization termed aporia.

Natural and Undetermined Sudden Death: Value of Post-Mortem Genetic Investigation

PubMed Central

Fernández-Falgueras, Anna; Sarquella-Brugada, Georgia; Cesar, Sergi; Mademont, Irene; Mates, Jesus; Pérez-Serra, Alexandra; Coll, Monica; Pico, Ferran; Iglesias, Anna; Tirón, Coloma; Allegue, Catarina; Carro, Esther; Gallego, María Ángeles; Ferrer-Costa, Carles; Hospital, Anna; Bardalet, Narcís; Borondo, Juan Carlos; Vingut, Albert; Arbelo, Elena; Brugada, Josep; Castellà, Josep; Medallo, Jordi; Brugada, Ramon

2016-01-01

Background Sudden unexplained death may be the first manifestation of an unknown inherited cardiac disease. Current genetic technologies may enable the unraveling of an etiology and the identification of relatives at risk. The aim of our study was to define the etiology of natural deaths, younger than 50 years of age, and to investigate whether genetic defects associated with cardiac diseases could provide a potential etiology for the unexplained cases. Methods and Findings Our cohort included a total of 789 consecutive cases (77.19% males) <50 years old (average 38.6±12.2 years old) who died suddenly from non-violent causes. A comprehensive autopsy was performed according to current forensic guidelines. During autopsy a cause of death was identified in most cases (81.1%), mainly due to cardiac alterations (56.87%). In unexplained cases, genetic analysis of the main genes associated with sudden cardiac death was performed using Next Generation Sequencing technology. Genetic analysis was performed in suspected inherited diseases (cardiomyopathy) and in unexplained death, with identification of potentially pathogenic variants in nearly 50% and 40% of samples, respectively. Conclusions Cardiac disease is the most important cause of sudden death, especially after the age of 40. Close to 10% of cases may remain unexplained after a complete autopsy investigation. Molecular autopsy may provide an explanation for a significant part of these unexplained cases. Identification of genetic variations enables genetic counseling and undertaking of preventive measures in relatives at risk. PMID:27930701

Severe hypoglycaemia associated with ingesting counterfeit medication.

PubMed

Chaubey, Santosh K; Sangla, Kunwarjit S; Suthaharan, Emershia N; Tan, Yong M

2010-06-21

Cross-border importation of traditional and prescription medications is common, and many of these drugs are not approved by the Australian Therapeutic Goods Administration. Furthermore, counterfeit versions of prescription medications are also available (eg, weight-loss medications, anabolic steroids, and medications to enhance sexual performance). We describe a 54-year-old man with the first Australian case of severe hypoglycaemia induced by imported, laboratory-confirmed counterfeit Cialis. This serves to remind medical practitioners that counterfeit medication may be the cause of severe hypoglycaemia (or other unexplained illness).

"It´s incredible how much I´ve had to fight." Negotiating medical uncertainty in clinical encounters.

PubMed

Lian, Olaug S; Robson, Catherine

2017-01-01

Clinical encounters related to medically unexplained physical symptoms (MUPS) are associated with high levels of conflict between patients and doctors. Collaborative difficulties are fused by the medical uncertainty that dominates these consultations. The main aim of this study is to explore the interactional dynamics of clinical encounters riddled by medical uncertainty, as experienced by people living with long-term medically unexplained fatigue in Norway. A qualitative thematic analysis of written texts from 256 study participants. We found that patients experience being met with disbelief, inappropriate psychological explanations, marginalisation of experiences, disrespectful treatment, lack of physical examination and damaging health advice. The main source of their discontent is not the lack of biomedical knowledge, but doctors who fail to communicate acknowledgement of patients' experiences, knowledge and autonomy. War metaphors are emblematic of how participants describe their medical encounters. The overarching storyline depicts experiences of being caught in a power struggle with doctors and health systems, fused by a lack of common conceptual ground. When physical symptoms cannot be detected, explained and managed by biomedical knowledge and technology, good doctor-patient partnerships are crucial. Without clearly acknowledging patients' perspectives and capabilities in clinical practice, such partnerships cannot be achieved.

Post-graduate education for medical specialists focused on patients with medically unexplained physical symptoms; development of a communication skills training programme.

PubMed

Weiland, Anne; Blankenstein, Annette H; Willems, Mariëtte H A; Van Saase, Jan L C M; Van der Molen, Henk T; Van Dulmen, Alexandra M; Arends, Lidia R

2013-09-01

Stepwise description of the development of a post-graduate communication skills training programme for medical specialists focused on patients with medically unexplained physical symptoms (MUPS) to improve specialist interaction with MUPS patients. Using the 'intervention mapping approach' we accomplished a needs assessment (literature study and pilot) to formulate intervention objectives and identify methods and techniques for a MUPS-focused communication skills training programme for medical specialists. A 14-h training programme which consists of experiential learning, role-play and feedback. Using skills from Cognitive Behavioural Therapy, medical specialists are stimulated to explore interrelating factors that reinforce symptoms, to reassure patients effectively and to provide plausible and understandable explanations for MUPS. Dealing with complex referrals and informing GPs properly are also practiced. By applying the 'intervention mapping approach' we were able to create a feasible and promising intervention to improve specialist interaction with MUPS patients. Intervention effects are currently being assessed in a randomized controlled trial. If the RCT demonstrates sufficient effectiveness and efficiency of the MUPS focused communication skills training programme for medical specialists the intervention could be embedded in post-graduate education of medical specialists and residents. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Assessment of Somatization and Medically Unexplained Symptoms in Later Life

PubMed Central

van Driel, T. J. W.; Hilderink, P. H.; Hanssen, D. J. C.; de Boer, P.; Rosmalen, J. G. M.; Oude Voshaar, R. C.

2017-01-01

The assessment of medically unexplained symptoms and “somatic symptom disorders” in older adults is challenging due to somatic multimorbidity, which threatens the validity of somatization questionnaires. In a systematic review study, the Patient Health Questionnaire–15 (PHQ-15) and the somatization subscale of the Symptom Checklist 90-item version (SCL-90 SOM) are recommended out of 40 questionnaires for usage in large-scale studies. While both scales measure physical symptoms which in younger persons often refer to unexplained symptoms, in older persons, these symptoms may originate from somatic diseases. Using empirical data, we show that PHQ-15 and SCL-90 SOM among older patients correlate with proxies of somatization as with somatic disease burden. Updating the previous systematic review, revealed six additional questionnaires. Cross-validation studies are needed as none of 46 identified scales met the criteria of suitability for an older population. Nonetheless, specific recommendations can be made for studying older persons, namely the SCL-90 SOM and PHQ-15 for population-based studies, the Freiburg Complaint List and somatization subscale of the Brief Symptom Inventory 53-item version for studies in primary care, and finally the Schedule for Evaluating Persistent Symptoms and Somatic Symptom Experiences Questionnaire for monitoring treatment studies. PMID:28745072

Diagnostic value of radiological imaging pre- and post-drainage of pleural effusions.

PubMed

Corcoran, John P; Acton, Louise; Ahmed, Asia; Hallifax, Robert J; Psallidas, Ioannis; Wrightson, John M; Rahman, Najib M; Gleeson, Fergus V

2016-02-01

Patients with an unexplained pleural effusion often require urgent investigation. Clinical practice varies due to uncertainty as to whether an effusion should be drained completely before diagnostic imaging. We performed a retrospective study of patients undergoing medical thoracoscopy for an unexplained effusion. In 110 patients with paired (pre- and post-drainage) chest X-rays and 32 patients with paired computed tomography scans, post-drainage imaging did not provide additional information that would have influenced the clinical decision-making process. © 2015 Asian Pacific Society of Respirology.

[Genetics of sudden unexplained death].

PubMed

Campuzano, Oscar; Allegue, Catarina; Brugada, Ramon

2014-03-20

Sudden unexplained death is defined by death without a conclusive diagnosis after autopsy and it is responsible for a large percentage of sudden deaths. The progressive interaction between genetics and forensics in post-mortem studies has identified inheritable alterations responsible for pathologies associated with arrhythmic sudden death. The genetic diagnosis of the deceased enables the undertaking of preventive measures in family members, many of them asymptomatic but at risk. The implications of this multidisciplinary translational medical approach are complex, requiring the dedication of a specialized team. Copyright © 2013 Elsevier España, S.L. All rights reserved.

Unexplained abdominal pain as a driver for inappropriate therapeutics: an audit on the use of intravenous proton pump inhibitors

PubMed Central

Wong, Yin Yen; Low, Yong Chia; Lau, Hui Ling; Chin, Kin-Fah; Mahadeva, Sanjiv

2014-01-01

Background. Proton pump inhibitors (PPIs) are currently the most effective agents for acid-related disorders. However, studies show that 25–75% of patients receiving intravenous PPIs had no appropriate justification, indicating high rates of inappropriate prescribing. Objective. To examine the appropriate use of intravenous PPIs in accordance with guidelines and the efficacy of a prescribing awareness intervention at an Asian teaching institution. Setting. Prospective audit in a tertiary hospital in Malaysia. Method. Every 4th intravenous PPI prescription received in the pharmacy was screened against hospital guidelines. Interventions for incorrect indication/dose/duration were performed. Patients’ demographic data, medical history and the use of intravenous PPI were collected. Included were all adult inpatients prescribed intravenous PPI. Main Outcome Measure. Proportion of appropriate IV PPI prescriptions. Results. Data for 106 patients were collected. Most patients were male [65(61.3%)], Chinese [50(47.2%)], with mean age ± SD = 60.3 ± 18.0 years. Most intravenous PPI prescriptions were initiated by junior doctors from the surgical [47(44.3%)] and medical [42(39.6%)] departments. Only 50/106(47.2%) patients had upper gastrointestinal endoscopy/surgery performed to verify the source of bleeding. Unexplained abdominal pain [81(76.4%)] was the main driver for prescribing intravenous PPIs empirically, out of which 73(68.9%) were for suspected upper gastrointestinal bleed. Overall, intravenous PPI was found to be inappropriately prescribed in 56(52.8%) patients for indication, dose or duration. Interventions on the use of intravenous PPI were most effective when performed by senior doctors (100%), followed by clinical pharmacists (50%), and inpatient pharmacists (37.5%, p = 0.027). Conclusion. Inappropriate intravenous PPI usage is still prevalent despite the enforcement of hospital guidelines. The promotion of prescribing awareness and evidence-based prescribing through education of medical staff could result in more judicious use of intravenous PPI and dose-optimization. PMID:25024919

Unexplained abdominal pain as a driver for inappropriate therapeutics: an audit on the use of intravenous proton pump inhibitors.

PubMed

Lai, Pauline Siew Mei; Wong, Yin Yen; Low, Yong Chia; Lau, Hui Ling; Chin, Kin-Fah; Mahadeva, Sanjiv

2014-01-01

Background. Proton pump inhibitors (PPIs) are currently the most effective agents for acid-related disorders. However, studies show that 25-75% of patients receiving intravenous PPIs had no appropriate justification, indicating high rates of inappropriate prescribing. Objective. To examine the appropriate use of intravenous PPIs in accordance with guidelines and the efficacy of a prescribing awareness intervention at an Asian teaching institution. Setting. Prospective audit in a tertiary hospital in Malaysia. Method. Every 4th intravenous PPI prescription received in the pharmacy was screened against hospital guidelines. Interventions for incorrect indication/dose/duration were performed. Patients' demographic data, medical history and the use of intravenous PPI were collected. Included were all adult inpatients prescribed intravenous PPI. Main Outcome Measure. Proportion of appropriate IV PPI prescriptions. Results. Data for 106 patients were collected. Most patients were male [65(61.3%)], Chinese [50(47.2%)], with mean age ± SD = 60.3 ± 18.0 years. Most intravenous PPI prescriptions were initiated by junior doctors from the surgical [47(44.3%)] and medical [42(39.6%)] departments. Only 50/106(47.2%) patients had upper gastrointestinal endoscopy/surgery performed to verify the source of bleeding. Unexplained abdominal pain [81(76.4%)] was the main driver for prescribing intravenous PPIs empirically, out of which 73(68.9%) were for suspected upper gastrointestinal bleed. Overall, intravenous PPI was found to be inappropriately prescribed in 56(52.8%) patients for indication, dose or duration. Interventions on the use of intravenous PPI were most effective when performed by senior doctors (100%), followed by clinical pharmacists (50%), and inpatient pharmacists (37.5%, p = 0.027). Conclusion. Inappropriate intravenous PPI usage is still prevalent despite the enforcement of hospital guidelines. The promotion of prescribing awareness and evidence-based prescribing through education of medical staff could result in more judicious use of intravenous PPI and dose-optimization.

Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: a focus group study

PubMed Central

olde Hartman, Tim C; Hassink-Franke, Lieke J; Lucassen, Peter L; van Spaendonck, Karel P; van Weel, Chris

2009-01-01

Background Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice. Methods A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis. Results GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin. Conclusion GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions. PMID:19775481

Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study

PubMed Central

2010-01-01

Background The two primary objectives of this study were to the assess consultation load of occupational health physicians (OHPs), and their difficulties and needs with regard to their sickness certification tasks in sick-listed employees with severe medical unexplained physical symptoms (MUPS). Third objective was to determine which disease-, patient-, doctor- and practice-related factors are associated with the difficulties and needs of the OHPs. Methods In this cross-sectional study, 43 participating OHPs from 5 group practices assessed 489 sick-listed employees with and without severe MUPS. The OHPs filled in a questionnaire about difficulties concerning sickness certification tasks, consultation time, their needs with regard to consultation with or referral to a psychiatrist or psychologist, and communication with GPs. The OHPs also completed a questionnaire about their personal characteristics. Results OHPs only experienced task difficulties in employees with severe MUPS in relation to their communication with the treating physician. This only occured in cases in which the OHP attributed the physical symptoms to somatoform causes. If they attributed the physical symptoms to mental causes, the OHPs reported a need to consultate a psychiatrist about the diagnosis and treatment. Conclusions OHPs experience few difficulties with their sickness certification tasks and consultation load concerning employees with severe MUPS. However, they encounter problems if the diagnostic uncertainties of the treating physician interfere with the return to work process. OHPs have a need for psychiatric expertise whenever they are uncertain about the psychiatric causes of a delayed return to work process. We recommend further training programs for OHPs. They should also have more opportunity for consultation and referral to a psychiatrist, and their communication with treating physicians should be improved. PMID:21059232

Unexplained chest pain in the ED: could it be panic?

PubMed

Foldes-Busque, Guillaume; Marchand, André; Chauny, Jean-Marc; Poitras, Julien; Diodati, Jean; Denis, Isabelle; Lessard, Marie-Josée; Pelland, Marie-Ève; Fleet, Richard

2011-09-01

This study aimed at (1) establishing the prevalence of paniclike anxiety in emergency department (ED) patients with unexplained chest pain (UCP); (2) describing and comparing the sociodemographic, medical, and psychiatric characteristics of UCP patients with and without paniclike anxiety; and (3) measuring the rate of identification of panic in this population. A structured interview, the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was administered to identify paniclike anxiety and evaluate patients' psychiatric status. Anxious and depressive symptoms were evaluated with self-report questionnaires. Medical information was extracted from patients' medical records. The prevalence of paniclike anxiety was 44% (95% CI, 40%-48%) in the sample (n = 771). Psychiatric disorders were more common in panic patients (63.4% vs 20.1%), as were suicidal thoughts (21.3% vs 11.3%). Emergency physician diagnosed only 7.4% of panic cases. Paniclike anxiety is common in ED patients with UCP, and this condition is rarely diagnosed in this population. Copyright © 2011 Elsevier Inc. All rights reserved.

Unexplained cough: it is time to rule out Sjogren's syndrome.

PubMed

Koslow, Matthew; Kivity, Shaye; Vishnevskia-Dai, Vicktoria; Ben-Dov, Issahar

2018-05-01

Sjogren's syndrome is associated with chronic cough, but sicca symptoms are missing from cough evaluation guidelines. We evaluated patients with unexplained cough for undiagnosed Sjogren's syndrome. Patients referred to our pulmonary clinic (Sheba Medical Center, 2009 to 2012) with unexplained cough and concomitant dry eyes were selected for evaluation. Unexplained cough was defined as chronic cough of unknown etiology despite algorithm-based evaluation and treatment. Patients were evaluated in a dedicated clinic by a pulmonologist, rheumatologist, and ophthalmologist specializing in autoimmune disease. Patients completed the Leicester Cough Questionnaire, spirometry, antibody testing for anti Ro/La, ophthalmologic examination with visual acuity, eyelid, ocular surface fluorescein staining, tear break-up time and Schirmer's test, full slit lamp, and fundus examinations. Four-year follow-up was conducted by telephone questionnaire. We identified 24 patients among which 22 (21 females) agreed for evaluation. Eight patients (36%), seven initially, and one during follow-up were diagnosed with Sjogren's syndrome (SS) (six secondary and two primary SS). At 4-year follow-up, cough tended to persist and improve in only 37% with SS. These include 2 (Scl and RA) who received rituximab and 1 (stage 1 sarcoidosis) with spontaneous improvement. In contrast, cough improved in most (64%) patients without SS; the majority (eight/nine) report intensified disease-specific treatment (five allergic and three GERD). We describe patients in whom unexplained chronic cough was associated with dry eyes. Focused workup revealed undiagnosed Sjogren's syndrome in 36%. Dry eyes, with or without SS, is under-recognized and should be added to diagnostic algorithms for unexplained cough.

Why Bioethics Should Be Concerned With Medically Unexplained Symptoms.

PubMed

O'Leary, Diane

2018-05-01

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.

Primary care consultations about medically unexplained symptoms: how do patients indicate what they want?

PubMed

Salmon, Peter; Ring, Adele; Humphris, Gerry M; Davies, John C; Dowrick, Christopher F

2009-04-01

Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs. To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention. Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients' desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said. Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS. Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients' wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them. In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.

Nephrocalcinosis (Enamel Renal Syndrome) Caused by Autosomal Recessive FAM20A Mutations

PubMed Central

Jaureguiberry, Graciana; De la Dure-Molla, Muriel; Parry, David; Quentric, Mickael; Himmerkus, Nina; Koike, Toshiyasu; Poulter, James; Klootwijk, Enriko; Robinette, Steven L.; Howie, Alexander J.; Patel, Vaksha; Figueres, Marie-Lucile; Stanescu, Horia C.; Issler, Naomi; Nicholson, Jeremy K.; Bockenhauer, Detlef; Laing, Christopher; Walsh, Stephen B.; McCredie, David A.; Povey, Sue; Asselin, Audrey; Picard, Arnaud; Coulomb, Aurore; Medlar, Alan J.; Bailleul-Forestier, Isabelle; Verloes, Alain; Le Caignec, Cedric; Roussey, Gwenaelle; Guiol, Julien; Isidor, Bertrand; Logan, Clare; Shore, Roger; Johnson, Colin; Inglehearn, Christopher; Al-Bahlani, Suhaila; Schmittbuhl, Matthieu; Clauss, François; Huckert, Mathilde; Laugel, Virginie; Ginglinger, Emmanuelle; Pajarola, Sandra; Spartà, Giuseppina; Bartholdi, Deborah; Rauch, Anita; Addor, Marie-Claude; Yamaguti, Paulo M.; Safatle, Heloisa P.; Acevedo, Ana Carolina; Martelli-Júnior, Hercílio; dos Santos Netos, Pedro E.; Coletta, Ricardo D.; Gruessel, Sandra; Sandmann, Carolin; Ruehmann, Denise; Langman, Craig B.; Scheinman, Steven J.; Ozdemir-Ozenen, Didem; Hart, Thomas C.; Hart, P. Suzanne; Neugebauer, Ute; Schlatter, Eberhard; Houillier, Pascal; Gahl, William A.; Vikkula, Miikka; Bloch-Zupan, Agnès; Bleich, Markus; Kitagawa, Hiroshi; Unwin, Robert J.; Mighell, Alan; Berdal, Ariane; Kleta, Robert

2013-01-01

Background/Aims Calcium homeostasis requires regulated cellular and interstitial systems interacting to modulate the activity and movement of this ion. Disruption of these systems in the kidney results in nephrocalcinosis and nephrolithiasis, important medical problems whose pathogenesis is incompletely understood. Methods We investigated 25 patients from 16 families with unexplained nephrocalcinosis and characteristic dental defects (amelogenesis imperfecta, gingival hyperplasia, impaired tooth eruption). To identify the causative gene, we performed genome-wide linkage analysis, exome capture, next-generation sequencing, and Sanger sequencing. Results All patients had bi-allelic FAM20A mutations segregating with the disease; 20 different mutations were identified. Conclusions This au-tosomal recessive disorder, also known as enamel renal syndrome, of FAM20A causes nephrocalcinosis and amelogenesis imperfecta. We speculate that all individuals with biallelic FAM20A mutations will eventually show nephrocalcinosis. PMID:23434854

Unexplained metabolic acidosis in critically ill patients: the role of pyroglutamic acid.

PubMed

Mizock, Barry A; Belyaev, Stanislav; Mecher, Carter

2004-03-01

To determine the role of pyroglutamic acid (PGA) in the pathogenesis of unexplained metabolic acidosis in critically ill patients. Case series in the medical ICU of an urban hospital. 23 patients admitted to the medical ICU with acidemia (pH <7.35 or HC0(3) < or = 16 mEq/l) not explained by the presence of ketoacidosis, lactic acidosis, renal failure or ingestion of drugs or toxins and who had an increase in the strong ion gap (SIG) greater than 5. Plasma levels of sodium, potassium, chloride, bicarbonate, calcium (ionized), magnesium, lactate, phosphate, albumin, blood urea nitrogen, and creatinine were measured. Arterial blood gases and urine dipstick for ketones were also analyzed. Plasma was assayed for PGA using gas chromatography. The patient's history and Kardex were reviewed for evidence of acetaminophen administration. The plasma PGA level was found to be very low in all patients studied. The correlation between SIG and PGA (r) was -0.01 (95% CI: -0.42 to 0.40). PGA therefore did not account for the observed increase in the SIG. There appeared to be no obvious influence of acetaminophen intake on levels of PGA in the plasma. We were unable to confirm the importance of PGA as a cause of unexplained metabolic acidosis and increased SIG in our critically ill patients.

Training tomorrow's doctors to explain 'medically unexplained' physical symptoms: An examination of UK medical educators' views of barriers and solutions.

PubMed

Joyce, Emmeline; Cowing, Jennifer; Lazarus, Candice; Smith, Charlotte; Zenzuck, Victoria; Peters, Sarah

2018-05-01

Co-occuring physical symptoms, unexplained by organic pathology (known as Functional Syndromes, FS), are common and disabling presentations. However, FS is absent or inconsistently taught within undergraduate medical training. This study investigates the reasons for this and identifies potential solutions to improved implementation. Twenty-eight medical educators from thirteen different UK medical schools participated in semi-structured interviews. Thematic analysis proceeded iteratively, and in parallel with data production. Barriers to implementing FS training are beliefs about the complexity of FS, tutors' negative attitudes towards FS, and FS being perceived as a low priority for the curriculum. In parallel participants recognised FS as ubiquitous within medical practice and erroneously assumed it must be taught by someone. They recommended that students should learn about FS through managed exposure, but only if tutors' negative attitudes and behaviour are also addressed. Negative attitudes towards FS by educators prevents designing and delivering effective education on this common medical presentation. Whilst there is recognition of the need to implement FS training, recommendations are multifaceted. Increased liaison between students, patients and educators is necessary to develop more informed and effective teaching methods for trainee doctors about FS and in order to minimise the impact of the hidden curriculum. Crown Copyright © 2017. Published by Elsevier B.V. All rights reserved.

Prayer Healing: A Case Study Research Protocol.

PubMed

Kruijthoff, Dirk J; van der Kooi, Cornelis; Glas, Gerrit; Abma, Tineke A

2017-01-01

Context • Prayer healing is a common practice in many religious communities around the world. Even in the highly secularized Dutch society, cases of prayer healing are occasionally reported in the media, often generating public attention. There is an ongoing debate regarding whether such miraculous cures do actually occur and how to interpret them. Objective • The aim of the article was to present a research protocol for the investigation of reported cases of remarkable and/or unexplained healing after prayer. Design • The research team developed a method to perform a retrospective, case-based study of prayer healing. Reported prayer healings can be investigated systematically in accordance with a step-by-step methodology. The focus is on understanding the healing by studying it from multiple perspectives, using both medical judgment and patients' narratives collected by qualitative methods Setting • The study occurred at Vrije Universiteit (VU) and VU Medical Center (Amsterdam, Netherlands) as well as the general medical practice of the first author. Participants • Potential participants could be any individuals in the Netherlands or neighboring countries who claim to have been healed through prayer. The reports of healing came from multiple sources, including the research team's medical practices and their direct vicinities, newspaper articles, prayer healers, and medical colleagues. Outcome Measures • Medical data were obtained before and after prayer. Subsequently, a member of a research team and of a medical assessment committee made a standardized judgment that evaluated whether a cure was clinically remarkable or scientifically unexplained. The participants' experiences and insider perspectives were studied, using in-depth interviews in accordance with a qualitative research methodology, to gain insight into the perceptions and explanations of the cures that were offered by participants and by the members of the medical assessment committee. The medical findings and participants' experiences were weighed and interpreted based on a transdisciplinary framework, including biopsychosocial and theological perspectives, with reference to a conceptual framework derived from Ian Barbour's typology of positions in the science-religion debate. Conclusion • A case-based, research study protocol that compares medical and experiential findings and that interprets and structures those findings with reference to Ian Barbour's conceptual model is an innovative way of gaining deeper insight into the nature of remarkable and/or unexplained cures.

Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy

PubMed Central

Pearson, Michele L.; Selby, Joseph V.; Katz, Kenneth A.; Cantrell, Virginia; Braden, Christopher R.; Parise, Monica E.; Paddock, Christopher D.; Lewin-Smith, Michael R.; Kalasinsky, Victor F.; Goldstein, Felicia C.; Hightower, Allen W.; Papier, Arthur; Lewis, Brian; Motipara, Sarita; Eberhard, Mark L.

2012-01-01

Background Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. Methods A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006–2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. Results We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17–93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. Conclusions This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation. PMID:22295070

Anxiety and depressive symptoms and anxiety sensitivity in youngsters with noncardiac chest pain and benign heart murmurs.

PubMed

Lipsitz, Joshua D; Masia-Warner, Carrie; Apfel, Howard; Marans, Zvi; Hellstern, Beth; Forand, Nicholas; Levenbraun, Yosef; Fyer, Abby J

2004-12-01

Chest pain in children and adolescents is rarely associated with cardiac disease. We sought to examine psychological symptoms in youngsters with medically unexplained chest pain. We hypothesized that children and adolescents with medically unexplained chest pain would have high rates of anxiety and depressive symptoms. We assessed 65 youngsters with noncardiac chest pain (NCCP) and 45 comparison youngsters with benign heart murmurs using self-report measures of anxiety and depressive symptoms and anxiety sensitivity. Compared with the asymptomatic benign-murmur group, youngsters with NCCP had higher levels of some anxiety symptoms and anxiety sensitivity. Differences on depressive symptoms were not significant. Though preliminary, results suggest that youngsters with chest pain may experience increased levels of some psychological symptoms. Future studies of noncardiac chest pain in youngsters should include larger samples and comprehensive diagnostic assessments as well as long-term follow-up evaluations.

Gulf war syndrome: a toxic exposure? A systematic review.

PubMed

Gronseth, Gary S

2005-05-01

Using the strength-of-conclusion scheme enumerated in Box 2, based on two class II studies, there is probably a causal link between deployment to the Persian Gulf theater of operation and the development of the poorly defined multisymptom illness known as GWS (level B). Based on class IV studies, there is insufficient evidence to determine if exposure to toxins encountered during the Persian Gulf war caused GWS (level U). A major limitation of the literature regarding the GWS is the reliance on self-reporting to measure exposure to putative causal toxins. Although objective measures of toxin exposure in GWV generally is unavailable, modeling techniques to estimate exposure levels to low-level nerve agents and smoke from oil well fires have been developed. It would be useful to determine if exposure levels determined by these techniques are associated with GWS. The lack of a clear case definition GWS also hampers research. Some go even further, claiming that the absence of such a definition renders the condition illegitimate. Although an objective marker to GWS would be useful for studies, the absence of such a marker does not make the syndrome any less legitimate. in essence, GWS merely is a convenient descriptive term that describes a phenomenon: GWV reporting suffering from medically unexplained health-related symptoms. In this sense, it shares much with the other medically unexplained syndromes encountered in practice. The real debate surrounding medically unexplained conditions is not whether or not they exist, but defining their cause. In this regard, investigators fall into two camps. One camp insists that the conditions are caused by a yet-to-be-discovered medical problem, rejecting out of hand the possibility of a psychologic origin. The other camp insists the conditions are fundamentally psychogenic rejecting the possibility of an undiscovered medical condition. The evidence shows, however, that the conditions exists, the suffering is real, and the causes are unknown.

Prevalence and clinical significance of antinuclear antibodies in Iranian women with unexplained recurrent miscarriage

PubMed Central

Molazadeh, Morteza; Karimzadeh, Hadi; Azizi, Mohammad R

2014-01-01

Background: Antinuclear antibodies (ANAs) in women with recurrent miscarriage have been reported. The presence of moderate to high titers of these antibodies represents an autoimmune condition that can endanger the health of the fetus in pregnant women. Objective: In this study, we evaluated the prevalence of ANAs in Iranian women with a history of two or more unexplained abortion. Materials and Methods: 560 women with unexplained recurrent miscarriage and 560 healthy controls accounted for this study over a period of 13 months. ANAs were detected by indirect immunofluorescence technique. Results: ANAs were detected in 74 of 560 (13.21%) patient with recurrent miscarriage, and in only 5 of 560 (0.9%) controls (p<0.001). ANA positivity was generally found with low-positive results (1.40-1.80) in about 38% of positive cases, whereas moderate titres (1.160-1.320) and high titres (>1.640) were seen in about 46% and 16% of cases respectively. Finally evaluating of microscopic ANA patterns revealed that about half of positive cases had antibodies against DNA- histone complex, associated with systemic lupus erythematosus disease. Conclusion: Antinuclear antibodies are not uncommon in women with unexplained recurrent miscarriage, suggesting the possible role of an autoimmune disorder on abortion, at least in a subgroup of patients. PMID:24799884

Medically unexplained conditions considered by patients in general practice.

PubMed

Tschudi-Madsen, Hedda; Kjeldsberg, Mona; Natvig, Bård; Ihlebaek, Camilla; Straand, Jørund; Bruusgaard, Dag

2014-04-01

Patients frequently present with multiple and 'unexplained' symptoms, often resulting in complex consultations. To better understand these patients is a challenge to health care professionals, in general, and GPs, in particular. In our research on symptom reporting, we wanted to explore whether patients consider that they may suffer from conditions commonly regarded as unexplained, and we explored associations between these concerns and symptom load, life stressors and socio-demographic factors. Consecutive, unselected patients in general practice completed questionnaires addressing eight conditions commonly regarded as unexplained (amalgam poisoning, Candida syndrome, fibromyalgia, food intolerance, electromagnetic hypersensitivity, burnout syndrome, chronic fatigue syndrome and irritable bowel syndrome). With logistic regression, we analysed associations with symptom load, burden of life stressors with negative impact on present health and socio-demographic variables. Out of the 909 respondents (response rate = 88.8%), 863 had complete data. In total, 39.6% of patients had considered that they may suffer from one or more unexplained conditions (UCs). These concerns were strongly and positively associated with recent symptom load and number of life stressors. If we excluded burnout and food intolerance, corresponding associations were found. Patients frequently considered that they may suffer from UCs. The likelihood of such concerns strongly increased with an increasing symptom load and with the number of life stressors with negative impact on present health. Hence, the number of symptoms may be a strong indicator of whether patients consider their symptoms part of such often controversial multisymptom conditions.

Historical approaches to post-combat disorders.

PubMed

Jones, Edgar

2006-04-29

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.

Clinical perspectives on osteogenesis imperfecta versus non-accidental injury.

PubMed

Pereira, Elaine Maria

2015-12-01

Although non-accidental injuries (NAI) are more common in cases of unexplained fractures than rare disorders such as osteogenesis imperfecta (OI), ruling out OI and other medical causes of fracture is always indicated. The majority of OI patients can be diagnosed with the help of family history, physical examination, and radiographic findings. In particular, there are a few radiological findings which are seen more commonly in NAI than in OI which may help guide clinician considerations regarding the probability of either of these diagnoses. At the same time, molecular testing still merits careful consideration in cases with unexplained fractures without obvious additional signs of abuse. © 2015 Wiley Periodicals, Inc.

Psychiatric disorders and medical care utilization among people in the general population who report fatigue.

PubMed

Walker, E A; Katon, W J; Jemelka, R P

1993-08-01

To study the prevalence of fatigue in the general population and its association with psychiatric disorders, somatization, and medical utilization. The public-use data tape from the 1984 National Institute of Mental Health Epidemiologic Catchment Area Study. Household sample of 18,571 subjects. Structured psychiatric interviews were reviewed to study the prevalence of complaints of current and lifetime fatigue and their relationship to selected psychiatric disorders. Fatigue has high current (6.7%) and lifetime (24.4%) prevalences in the general population. Medically unexplained fatigue also has high current (6.0%) and lifetime (15.5%) prevalences. When compared with those reporting no current fatigue, subjects who reported current (one-month) fatigue were significantly more likely to have experienced current and lifetime episodes of major depression, dysthymic disorder, panic disorder, and somatization disorder. They also had significantly higher mean numbers of lifetime and current DSM-III psychiatric diagnoses, medically unexplained physical symptoms (not just fatigue-related symptoms), and visits to health care providers than did patients without current episodes of fatigue. The high prevalence of fatigue in the general population appears to be significantly associated with increased lifetime and current risk for affective, anxiety, and somatoform disorders, as well as increased utilization of medical services. These data suggest that assessment of both medical and psychological health may be essential for the proper care of patients with fatigue.

Meta-analysis of genome-wide association studies for circulating phylloquinone concentrations

USDA-ARS?s Scientific Manuscript database

Background: Poor vitamin K status is linked to greater risk of several chronic diseases. Age, sex, and diet are determinants of circulating vitamin K; however, there is still large unexplained interindividual variability in vitamin K status. Although a strong genetic component has been hypothesized,...

Diagnostic value of [(18)F]-FDG PET/CT in children with fever of unknown origin or unexplained signs of inflammation.

PubMed

Jasper, Niklas; Däbritz, Jan; Frosch, Michael; Loeffler, Markus; Weckesser, Matthias; Foell, Dirk

2010-01-01

Fever of unknown origin (FUO) and unexplained signs of inflammation are challenging medical problems especially in children and predominantly caused by infections, malignancies or noninfectious inflammatory diseases. The aim of this study was to assess the diagnostic value of (18)F-FDG PET and PET/CT in the diagnostic work-up in paediatric patients. In this retrospective study, 47 FDG PET and 30 PET/CT scans from 69 children (median age 8.1 years, range 0.2-18.1 years, 36 male, 33 female) were analysed. The diagnostic value of PET investigations in paediatric patients presenting with FUO (44 scans) or unexplained signs of inflammation without fever (33 scans) was analysed. A diagnosis in paediatric patients with FUO or unexplained signs of inflammation could be established in 32 patients (54%). Of all scans, 63 (82%) were abnormal, and of the total number of 77 PET and PET/CT scans 35 (45%) were clinically helpful. In patients with a final diagnosis, scans were found to have contributed to the diagnosis in 73%. Laboratory, demographic or clinical parameters of the children did not predict the usefulness of FDG PET scans. This is the first larger study demonstrating that FDG PET and PET/CT may be valuable diagnostic tools for the evaluation of children with FUO and unexplained signs of inflammation. Depicting inflammation in the whole body, while not being traumatic, it is attractive for use especially in children. The combination of PET with CT seems to be superior, since the site of inflammation can be localized more accurately.

Functional genomics analysis of big data identifies novel PPARy target SNPs showing association with cardio metabolic outcomes

USDA-ARS?s Scientific Manuscript database

Background - Cardiovascular disease and type-2-diabetes represent overlapping diseases where a large portion of the variation attributable to genetics remains unexplained. An important player in their etiology is Peroxisome Proliferator-activated Receptor gamma (PPARy) that is involved in lipid and ...

Lead intoxication due to ayurvedic medications as a cause of abdominal pain in adults.

PubMed

Mehta, Varun; Midha, Vandana; Mahajan, Ramit; Narang, Vikram; Wander, Praneet; Sood, Ridhi; Sood, Ajit

2017-02-01

Though a majority of cases of lead intoxication come from occupational exposures, traditional and folk remedies have also been reported to contain toxic amounts of lead. We present a large series of patients with lead poisoning due to intake of Ayurvedic medicines, all of whom presented with unexplained abdominal pain. This was a retrospective, observational case series from a tertiary care center in India. The charts of patients who underwent blood lead level (BLL) testing as a part of workup for unexplained abdominal pain between 2005 and 2013 were reviewed. The patients with lead intoxication (BLLs >25 μg/dl) were identified and demographics, history, possible risk factors, clinical presentation and investigations were reviewed. Treatment details, duration, time to symptomatic recovery, laboratory follow-up and adverse events during therapy were recorded. BLLs were tested in 786 patients with unexplained abdominal pain and high levels were identified in 75 (9.5%) patients, of which a majority (73 patients, 9.3%) had history of Ayurvedic medication intake and only two had occupational exposure. Five randomly chosen Ayurvedic medications were analyzed and lead levels were impermissibly high (14-34,950 ppm) in all of them. Besides pain in abdomen, other presenting complaints were constipation, hypertension, neurological symptoms and acute kidney injury. Anemia and abnormal liver biochemical tests were observed in all the 73 patients. Discontinuing the Ayurvedic medicines and chelation with d-penicillamine led to improvement in symptoms and reduction in BLLs in all patients within 3-4 months. The patients presenting with severe recurrent abdominal pain, anemia and history of use of Ayurvedic medicines should be evaluated for lead toxicity. Early diagnosis in such cases can prevent unnecessary investigations and interventions, and permits early commencement of the treatment.

Review of somatic symptoms in post-traumatic stress disorder.

PubMed

Gupta, Madhulika A

2013-02-01

Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.

The negotiation of the sick role: general practitioners’ classification of patients with medically unexplained symptoms

PubMed Central

Mik-Meyer, Nanna; Obling, Anne Roelsgaard

2012-01-01

In encounters between general practitioners (GPs) and patients with medically unexplained symptoms (MUS), the negotiation of the sick role is a social process. In this process, GPs not only use traditional biomedical diagnostic tools but also rely on their own opinions and evaluations of a patient’s particular circumstances in deciding whether that patient is legitimately sick. The doctor is thus a gatekeeper of legitimacy. This article presents results from a qualitative interview study conducted in Denmark with GPs concerning their approach to patients with MUS. We employ a symbolic interaction approach that pays special attention to the external validation of the sick role, making GPs’ accounts of such patients particularly relevant. One of the article’s main findings is that GPs’ criteria for judging the legitimacy of claims by those patients that present with MUS are influenced by the extent to which GPs are able to constitute these patients as people with social problems and problematic personality traits. PMID:22384857

Unexplained illness among Persian Gulf War veterans in an Air National Guard Unit: preliminary report--August 1990-March 1995.

PubMed

1995-06-16

In November 1994, the U.S. Department of Veterans' Affairs (VA), the Department of Defense (DoD), and the Pennsylvania Department of Health requested that CDC investigate a report of unexplained illnesses among members of an Air National Guard (ANG) unit in south-central Pennsylvania (Unit A) who were veterans of the Persian Gulf War (PGW) (August 1990-June 1991). These veterans had been evaluated at a local VA medical center for symptoms that included recurrent rash, diarrhea, and fatigue. A three-stage investigation was planned to 1) verify and characterize signs and symptoms in PGW veterans attending the VA medical center; 2) determine whether the prevalence of symptoms was higher among members of Unit A than among members of other units deployed to the PGW and, if so, whether the increased prevalence was associated with PGW deployment; and 3) characterize the illness and identify associated risk factors. This report presents preliminary findings from stages 1 and 2 (stage 3 is in progress).

Medically Unexplained and Explained Physical Symptoms in the General Population: Association with Prevalent and Incident Mental Disorders

PubMed Central

van Eck van der Sluijs, Jonna; ten Have, Margreet; Rijnders, Cees; van Marwijk, Harm; de Graaf, Ron; van der Feltz-Cornelis, Christina

2015-01-01

Background Clinical studies have shown that Medically Unexplained Symptoms (MUS) are related to common mental disorders. It is unknown how often common mental disorders occur in subjects who have explained physical symptoms (PHY), MUS or both, in the general population, what the incidence rates are, and whether there is a difference between PHY and MUS in this respect. Aim To study the prevalence and incidence rates of mood, anxiety and substance use disorders in groups with PHY, MUS and combined MUS and PHY compared to a no-symptoms reference group in the general population. Method Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face survey of the general population aged 18-64 years. We selected subjects with explained physical symptoms only (n=1952), with MUS only (n=177), with both MUS and PHY (n=209), and a reference group with no physical symptoms (n=4168). The assessment of common mental disorders was through the Composite International Diagnostic Interview 3.0. Multivariate logistic regression analyses were used to examine the association between group membership and the prevalence and first-incidence rates of comorbid mental disorders, adjusted for socio-demographic characteristics. Results MUS were associated with the highest prevalence rates of mood and anxiety disorders, and combined MUS and PHY with the highest prevalence rates of substance disorder. Combined MUS and PHY were associated with a higher incidence rate of mood disorder only (OR 2.9 (95%CI:1.27,6.74)). Conclusion In the general population, PHY, MUS and the combination of both are related to mood and anxiety disorder, but odds are highest for combined MUS and PHY in relation to substance use disorder. Combined MUS and PHY are related to a greater incidence of mood disorder. These findings warrant further research into possibilities to improve recognition and early intervention in subjects with combined MUS and PHY. PMID:25853676

Historical approaches to post-combat disorders

PubMed Central

Jones, Edgar

2006-01-01

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise. PMID:16687259

Birth characteristics in a clinical sample of women seeking infertility treatment: a case-control study.

PubMed

Vikström, Josefin; Hammar, Mats; Josefsson, Ann; Bladh, Marie; Sydsjö, Gunilla

2014-03-10

To determine the distribution of low birth weight (LBW), preterm birth, small for gestational age (SGA) and large for gestational age (LGA) by main cause of infertility (female, combined, male, unexplained) in women seeking infertility treatment. A case-control study. A Centre for Reproductive Medicine in Sweden. All women (n=1293) born in Sweden in 1973 or later and who were part of heterosexual couples seeking infertility treatment at a Centre of Reproductive Medicine from 2005 to 2010 were asked to participate. Those who had not begun the diagnostic process and who declined participation in the study were excluded. In total, 1206 women (94.5%) participated in the study. Main cause of infertility (female, combined, male, unexplained) collected from the patients' medical charts. LBW (<2500 g), preterm birth (<37 weeks), SGA (<-2SD of the mean weight for the gestational length) and LGA (>+2SD of the mean weight for the gestational length), collected from the Swedish Medical Birth Register. The risk of being born with LBW was increased about 2.4 times (OR=2.40, CI 1.13 to 5.07, p=0.02) in women seeking treatment for infertility due to female causes rather than for male or unexplained causes. Women with a female infertility factor were 2.7 times more likely to be born SGA (OR=2.73, CI 1.02 to 7.34, p=0.047) compared with those in whom the cause of infertility was unexplained. Women born with LBW or SGA seem to suffer an increased risk of infertility due to a female factor. Thus, infants born with birth characteristics that deviate from the norm may be at greater risk of difficulties in childbearing later on in life. Since this study is the first of its kind, more studies are needed to verify the associations found in this study and to determine their nature.

Mental health care use in medically unexplained and explained physical symptoms: findings from a general population study

PubMed Central

van Eck van der Sluijs, Jonna F; ten Have, Margreet; Rijnders, Cees A; van Marwijk, Harm WJ; de Graaf, Ron; van der Feltz-Cornelis, Christina M

2016-01-01

Objective The aim of this study was to explore mental health care utilization patterns in primary and specialized mental health care of people with unexplained or explained physical symptoms. Methods Data were derived from the first wave of the Netherlands Mental Health Survey and Incidence Study-2, a nationally representative face-to-face cohort study among the general population aged 18–64 years. We selected subjects with medically unexplained symptoms (MUS) only (MUSonly; n=177), explained physical symptoms only (PHYonly, n=1,952), combined MUS and explained physical symptoms (MUS + PHY, n=209), and controls without physical symptoms (NONE, n=4,168). We studied entry into mental health care and the number of treatment contacts for mental problems, in both primary care and specialized mental health care. Analyses were adjusted for sociodemographic characteristics and presence of any 12-month mental disorder assessed with the Composite International Diagnostic Interview 3.0. Results At the primary care level, all three groups of subjects with physical symptoms showed entry into care for mental health problems significantly more often than controls. The adjusted odds ratios were 2.29 (1.33, 3.95) for MUSonly, 1.55 (1.13, 2.12) for PHYonly, and 2.25 (1.41, 3.57) for MUS + PHY. At the specialized mental health care level, this was the case only for MUSonly subjects (adjusted odds ratio 1.65 [1.04, 2.61]). In both the primary and specialized mental health care, there were no significant differences between the four groups in the number of treatment contacts once they entered into treatment. Conclusion All sorts of physical symptoms, unexplained as well as explained, were associated with significant higher entry into primary care for mental problems. In specialized mental health care, this was true only for MUSonly. No differences were found in the number of treatment contacts. This warrants further research aimed at the content of the treatment contacts. PMID:27574433

Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review.

PubMed

olde Hartman, Tim C; Borghuis, Machteld S; Lucassen, Peter L B J; van de Laar, Floris A; Speckens, Anne E; van Weel, Chris

2009-05-01

To study the course of medically unexplained symptoms (MUS), somatisation disorder, and hypochondriasis, and related prognostic factors. Knowledge of prognostic factors in patients presenting persistent MUS might improve our understanding of the naturalistic course and the identification of patients with a high risk of a chronic course. A comprehensive search of Medline, PsycInfo, CINAHL, and EMBASE was performed to select studies focusing on patients with MUS, somatisation disorder, and hypochondriasis, and assessing prognostic factors. Studies focusing on patients with single-symptom unexplained disorder or distinctive functional somatic syndromes were excluded. A best-evidence synthesis for the interpretation of results was used. Only six studies on MUS, six studies on hypochondriasis, and one study on abridged somatisation could be included. Approximately 50% to 75% of the patients with MUS improve, whereas 10% to 30% of patients with MUS deteriorate. In patients with hypochondriasis, recovery rates vary between 30% and 50%. In studies on MUS and hypochondriasis, we found some evidence that the number of somatic symptoms at baseline influences the course of these conditions. Furthermore, the seriousness of the condition at baseline seemed to influence the prognosis. Comorbid anxiety and depression do not seem to predict the course of hypochondriasis. Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients presenting persistent MUS. However, it seems that a more serious condition at baseline is associated with a worse outcome.

Two Models of Learning and Achievement: An Explanation for the Achievement Gap?

ERIC Educational Resources Information Center

Yeh, Stuart S.

2015-01-01

Background/Context: Despite decades of research, the persistence of the gap in student achievement between disadvantaged minority students and their middle-class peers remains unexplained. Purpose/Objective: The purpose of the current article is to propose a new model of the achievement gap. Research Design: Data were analyzed from three…

Functional genomics analysis of big data identifies novel peroxisome proliferator–activated receptor gamma target single nucleotide polymorphisms showing association with cardiometabolic outcomes

USDA-ARS?s Scientific Manuscript database

Background Cardiovascular disease and type 2 diabetes mellitus represent overlapping diseases where a large portion of the variation attributable to genetics remains unexplained. An important player in their pathogenesis is peroxisome proliferator–activated receptor gamma (PPARgamma) that is involve...

Variations of the origin of collateral branches emerging from the posterior aspect of the brachial plexus

PubMed Central

2007-01-01

Background The frequency of variation found in the arrangement and distribution of the branches in the brachial plexus, make this anatomical region extremely complicated. The medical concerns involved with these variations include anesthetic blocks, surgical approaches, interpreting tumor or traumatic nervous compressions having unexplained clinical symptoms (sensory loss, pain, wakefulness and paresis), and the possibility of these structures becoming compromised. The clinical importance of these variations is discussed in the light of their differential origins. Methods The anatomy of brachial plexus structures from 46 male and 11 female cadaverous specimens were studied. The 40–80 year-old specimens were obtained from the Universidad Industrial de Santander's Medical Faculty's Anatomy Department (dissection laboratory). Parametric measures were used for calculating results. Results Almost half (47.1%) of the evaluated plexuses had collateral variations. Subscapular nerves were the most varied structure, including the presence of a novel accessory nerve. Long thoracic nerve variations were present, as were the absence of C5 or C7 involvement, and late C7 union with C5–C6. Conclusion Further studies are needed to confirm the existence of these variations in a larger sample of cadaver specimens. PMID:17587464

Is the relationship between your hospital and your medical staff sustainable?

PubMed

Carlson, Greg; Greeley, Hugh

2010-01-01

Issues in the macro-environment are affecting the historic relationships that have existed between hospitals and their medical staffs over the last half century. Rising healthcare costs, deteriorating relationships, unexplained variations in clinical outcomes, transparency in healthcare outcomes, medical tourism, competition between hospitals and physicians, and reluctance by hospitals and physicians to change are among the issues challenging the sustainability of the current business model. This article highlights barriers to maintaining traditional relationships and concludes with strategies to preserve and strengthen relationships between physicians and hospitals.

78 FR 52532 - Agency Forms Undergoing Paperwork Reduction Act Review

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-23

... Determining Causes of Sudden, Unexpected Infant Death: A National Survey of U.S. Medical Examiners and... and coroners interpret and report sudden unexpected and unexplained infant deaths and the extent to... the number of SUID-related deaths that they reported in 2005-2009. Interviewers will telephone...

Case Series: Outbreak of Conversion Disorder among Amish Adolescent Girls.

ERIC Educational Resources Information Center

Cassady, Joslyn D.; Kirschke, David L.; Jones, Timothy F.; Craig, Allen S.; Bermudez, Ovidio B.; Schaffner, William

2005-01-01

Objective: Outbreak investigations are challenging in a cross-cultural context, and outbreaks of psychiatric disease are rare in any community. We investigated a cluster of unexplained debilitating illness among Amish girls. Method: We reviewed the medical records of cases, consulted with health care providers, performed active case finding,…

Extended letrozole regimen versus clomiphene citrate for superovulation in patients with unexplained infertility undergoing intrauterine insemination: A randomized controlled trial

PubMed Central

2011-01-01

Background The aim of this randomized controlled trial was to compare the efficacy of extended letrozole regimen with clomiphene citrate in women with unexplained infertility undergoing superovulation and intrauterine insemination (IUI). Methods Two hundred and fourteen patients with unexplained infertility were randomized into two equal groups using computer generated list and were treated by either letrozole 2.5 mg/day from cycle day 1 to 9 (extended letrozole group, 211 cycles) or clomiphene citrate 100 mg/day from cycle day 3 to 7 (clomiphene citrate group,210 cycles). Intrauterine insemination was performed 36 to 40 hours after HCG administration. Results Both groups were comparable with regard to number of mature follicles (2.24 +/- 0.80 Vs 2.13 +/- 0.76) and the day of HCG administration. Serum estradiol was significantly greater in clomiphene citrate group (356 +/- 151 Vs 822 +/- 302 pg/ml, P = < 0.001) and the endometrial thickness was significantly greater in extended letrozole group (9.10 +/- 1.84 Vs 8.18 +/- 1.93 mm, P = < 0.001).The pregnancy rate per cycle and cumulative pregnancy rate were significantly greater in extended letrozole group (18.96% Vs 11.43% and 37.73% Vs 22.86%, respectively). Conclusion The extended letrozole regimen had a superior efficacy as compared with clomiphene citrate in patients of unexplained infertility undergoing superovulation and IUI. Trial registration ClinicalTrials.gov, NCT01232075 PMID:21693030

Do parents excuse the misbehavior of children with physical or emotional symptoms? An investigation of the pediatric sick role.

PubMed

Walker, L S; Garber, J; Van Slyke, D A

1995-06-01

Assessed attributions and responses to descriptions of the misbehavior of children with symptoms of physical and emotional illnesses. Subjects (160 mothers; 160 fathers) read a vignette about a child in one of four illness conditions (medically explained pain with organic etiology; medically unexplained pain, depression, well) who was described as misbehaving at home and school. Within each illness condition, the child protagonist varied by age (8 vs. 16) and gender. A between-subjects design was used in which subjects made judgments regarding causes and responsibility for the child's misbehavior, affective reactions to the child, and the consequences that should be administered to the child. Results indicated that, in comparison to subjects' perceptions of the misbehavior of children in the other conditions, subjects viewed the misbehavior of children with medically explained pain as less intentional, more excusable, and due to causes that were less internal to the child. Subjects held children with medically explained pain less responsible for their misbehavior and indicated that they would respond to them with less anger, disappointment, blame, and punishment than to children in the other conditions. Subjects did not hold children with symptoms of depression and children with unexplained pain complaints less responsible for their misbehavior, but indicated that they would respond to them with less anger, disappointment, and punishment than to well children.

Incidence of Norovirus-Associated Medical Encounters among Active Duty United States Military Personnel and Their Dependents

PubMed Central

Rha, Brian; Lopman, Benjamin A.; Alcala, Ashley N.; Riddle, Mark S.; Porter, Chad K.

2016-01-01

Background Norovirus is a leading cause of gastroenteritis episodes and outbreaks in US military deployments, but estimates of endemic disease burden among military personnel in garrison are lacking. Methods Diagnostic codes from gastroenteritis-associated medical encounters of active duty military personnel and their beneficiaries from July 1998–June 2011 were obtained from the Armed Forces Health Surveillance Center. Using time-series regression models, cause-unspecified encounters were modeled as a function of encounters for specific enteropathogens. Model residuals (representing unexplained encounters) were used to estimate norovirus-attributable medical encounters. Incidence rates were calculated using population data for both active duty and beneficiary populations. Results The estimated annual mean rate of norovirus-associated medically-attended visits among active duty personnel and their beneficiaries was 292 (95% CI: 258 to 326) and 93 (95% CI: 80 to 105) encounters per 10,000 persons, respectively. Rates were highest among beneficiaries <5 years of age with a median annual rate of 435 (range: 318 to 646) encounters per 10,000 children. Norovirus was estimated to cause 31% and 27% of all-cause gastroenteritis encounters in the active duty and beneficiary populations, respectively, with over 60% occurring between November and April. There was no evidence of any lag effect where norovirus disease occurred in one population before the other, or in one beneficiary age group before the others. Conclusions Norovirus is a major cause of medically-attended gastroenteritis among non-deployed US military active duty members as well as in their beneficiaries. PMID:27115602

When to suspect a genetic syndrome.

PubMed

Solomon, Benjamin D; Muenke, Maximilian

2012-11-01

Family physicians should be able to recognize findings on physical examination and history that suggest the presence of a genetic syndrome to aid in the diagnosis and treatment of potentially affected patients, as well as subspecialty referral. General themes that can alert family physicians to the presence of genetic conditions include dysmorphic features that are evident on physical examination; multiple anomalies in one patient; unexplained neurocognitive impairment; and a family history that is suggestive of a hereditary disease. The presence of one obvious malformation should not limit the full evaluation, because additional, subtler findings will often be important in the differential diagnosis. Taking an accurate three-generation family history is invaluable when considering a genetic syndrome. Important elements include the age and sex of family members; when family members were affected by disease or when they died; the ethnic background; and if there is consanguinity. Genetic subspecialists can assist family physicians in diagnosis, suggest additional testing and referrals if warranted, help direct medical care, and provide counseling for affected patients and their families.

Respiratory complaints in Chinese: cultural and diagnostic specificities.

PubMed

Han, Jiangna; Zhu, Yuanjue; Li, Shunwei; Chen, Xiansheng; Put, Claudia; Van de Woestijne, Karel P; Van den Bergh, Omer

2005-06-01

We investigated the qualitative components of a wide range of Chinese descriptors of dyspnea and associated symptoms, and their relevance for clinical diagnosis. Sixty-one spontaneously reported descriptors were elicited in Chinese patients to make a symptom checklist, which was administered to new groups of patients with different cardiopulmonary diseases, to patients with medically unexplained dyspnea and to healthy subjects. Test-retest reliability was satisfactory for most of the descriptors. A principal component analysis on 61 descriptors yielded the following eight factors: dyspnea-effort of breathing; dyspnea-affective aspect; wheezing; anxiety; tingling; palpitation; coughing and sputum; and dying experience. Although the descriptors of dyspnea-effort of breathing resembled Western wordings and were shared by patients with a variety of diseases, the descriptors of dyspnea-affective aspect appeared to be more culturally specific and were primarily linked to the diagnosis of medically unexplained dyspnea, whereas wheezing was specifically linked to asthma. Three factors of breathlessness were found in Chinese. The descriptors of dyspnea-effort of breathing and wheezing appear to be similar to Western descriptors, whereas the dyspnea-affective aspect seems to bear cultural specificity.

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

PubMed Central

Cooper, Angela; Abbass, Allan; Town, Joel

2017-01-01

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’. PMID:29186054

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

PubMed

Cooper, Angela; Abbass, Allan; Town, Joel

2017-11-29

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'.

Comparative gene expression profiling of placentas from patients with severe pre-eclampsia and unexplained fetal growth restriction

PubMed Central

2011-01-01

Background It has been well documented that pre-eclampsia and unexplained fetal growth restriction (FGR) have a common etiological background, but little is known about their linkage at the molecular level. The aim of this study was to further investigate the mechanisms underlying pre-eclampsia and unexplained FGR. Methods We analyzed differentially expressed genes in placental tissue from severe pre-eclamptic pregnancies (n = 8) and normotensive pregnancies with or (n = 8) without FGR (n = 8) using a microarray method. Results A subset of the FGR samples showed a high correlation coefficient overall in the microarray data from the pre-eclampsia samples. Many genes that are known to be up-regulated in pre-eclampsia are also up-regulated in FGR, including the anti-angiogenic factors, FLT1 and ENG, believed to be associated with the onset of maternal symptoms of pre-eclampsia. A total of 62 genes were found to be differentially expressed in both disorders. However, gene set enrichment analysis for these differentially expressed genes further revealed higher expression of TP53-downstream genes in pre-eclampsia compared with FGR. TP53-downstream apoptosis-related genes, such as BCL6 and BAX, were found to be significantly more up-regulated in pre-eclampsia than in FGR, although the caspases are expressed at equivalent levels. Conclusions Our current data indicate a common pathophysiology for FGR and pre-eclampsia, leading to an up-regulation of placental anti-angiogenic factors. However, our findings also suggest that it may possibly be the excretion of these factors into the maternal circulation through the TP53-mediated early-stage apoptosis of trophoblasts that leads to the maternal symptoms of pre-eclampsia. PMID:21810232

Sudden onset unexplained encephalopathy in infants: think of cannabis intoxication.

PubMed

Lavi, Eran; Rekhtman, David; Berkun, Yackov; Wexler, Isaiah

2016-03-01

The use of cannabis as both a therapeutic agent and recreational drug is common, and its availability is increasing as a result of legalization in many countries. Among older children, the manifestations of cannabis intoxication are numerous and include both neurological and systemic manifestations that are frequently non-specific. There have been only a few reports detailing cannabis intoxication in infants and toddlers. We describe three infants who presented to the emergency department with encephalopathic signs without prominent systemic manifestations. During the initial interview of caregivers, no history of exposure to neurotoxic agents was obtained. All three patients were subsequently diagnosed with cannabis intoxication based on urine toxic screens for delta-9-tetrahydrocannabinol (THC). The infants recovered with supportive care that included fluids and monitoring. The non-specific symptomatology of cannabis intoxication in infants together with the wide differential for unexplained acute onset encephalopathy may delay diagnosis and lead to inappropriate procedures and interventions such as antimicrobial treatments and imaging studies. Healthcare personnel of emergency rooms, urgent care centers, and general clinics should be aware of the potential risk of cannabis ingestion in young infants. A thorough medical history and toxic screen are warranted in all infants with unexplained decreased sensorium.

Overtreatment in couples with unexplained infertility.

PubMed

Kersten, F A M; Hermens, R P G M; Braat, D D M; Hoek, A; Mol, B W J; Goddijn, M; Nelen, W L D M

2015-01-01

What is the percentage of overtreatment, i.e. fertility treatment started too early, in couples with unexplained infertility who were eligible for tailored expectant management? Overtreatment occurred in 36% of couples with unexplained infertility who were eligible for an expectant management of at least 6 months. Prognostic models in reproductive medicine can help to identify infertile couples that would benefit from fertility treatment. In couples with unexplained infertility with a good chance of natural conception within 1 year, based on the Hunault prediction model, an expectant management of 6-12 months, as recommended in international fertility guidelines, prevents unnecessary treatment. A retrospective cohort study in 25 participating clinics, with follow-up of all couples who were seen for infertility in 2011-2012. In all, 9818 couples were seen for infertility in the participating clinics. Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis of natural conception (>30%) within 1 year based on the Hunault prediction model. Data to assess overtreatment were collected from medical records. Multilevel regression analyses were performed to investigate associations of overtreatment with patient and clinic characteristics. Five hundred and forty-four couples eligible for expectant management were included in this study. Among these, overtreatment, i.e. starting medically assisted reproduction within 6 months, occurred in 36%. The underlying quality indicators showed that in 34% no prognosis was calculated and that in 42% expectant management was not recommended. Finally, 16% of the couples for whom a correct recommendation of expectant management for at least 6 months was made, started treatment within 6 months anyway. Overtreatment was associated with childlessness, higher female age and a longer duration of infertility. No associations between overtreatment and clinic characteristics were found. The response rate was low compared with other fertility studies. Evaluation of possible selection bias showed that responders had a higher socio-economic status than non-responders. Our findings show that developing and publishing guideline recommendations on tailored expectant management (TEM) is not enough and that overtreatment still occurs frequently. Future research should focus on tailored efforts to implement guideline recommendations on TEM. Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none. www.trialregister.nl NTR3405. © The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Blended care; development of a day treatment program for medically unexplained physical symptoms (MUPS) in the Dutch Armed Forces.

PubMed

Zeylemaker, M M P; Linn, F H H; Vermetten, E

2015-01-01

A subgroup of servicemen can be identified that seek a disproportionally amount of health care in comparison to diagnostic and therapeutic perspectives. This group can be identified on the basis of an absence of a structural medical explanation for their symptoms. The symptoms manifest predominantly as fatigue and pain, and are often chronic. Patients with medical unexplained medical symptoms (MUPS) often have multiple and complex problems that would be best treated by a multidisciplinary team of medical specialists and paramedics. The military is characterized by high loyalty towards peers and leadership, leading to neglect for personal care. While consensus on the biological basis for these complaints is lacking, awareness on the need for effective treatments for this patient group is high. Based on reviews, expert recommendations and clinical demand, a specialized treatment program for soldiers with MUPS has recently been developed and implemented in the system of health care in the Netherlands Armed Forces. We developed a functional rehabilitation program with blended care elements of cognitive behavioral therapy (CBT), physical therapy, case management, and psychoeducation, embedded in a day treatment setting. The program received high scores on participant as well as team satisfaction. The program is illustrated by two clinical vignettes. The blended care program for MUPS that focused on allostatic load awareness offered a more holistic and preventive approach that contributed to a reduction of unnecessary medical consumption, and increased job participation. We recommend that the development of guidelines for diagnoses and treatment of these complaints in military settings will improve the quality of patient care, reduce disability, facilitate reintegration, and encourage scientific research.

An evaluation of the use of serum 7-alpha-hydroxycholestenone as a diagnostic test of bile acid malabsorption causing watery diarrhea

PubMed Central

Brydon, W Gordon; Culbert, Pearl; Kingstone, Kathleen; Jarvie, Ann; Iacucci, Marietta; Tenhage, Merel; Ghosh, Subrata

2011-01-01

BACKGROUND: Bile acid malabsorption (BAM) is a recognized cause of watery diarrhea, often diagnosed empirically based on clinical response to cholestyramine. The radionuclide selenium-labelled homocholic acid-taurine whole body retention test is expensive, labour intensive and of limited availability. OBJECTIVE: To report on the clinical performance of serum 7-alpha-hydroxy-4-cholesten-3-one (7HCO) as a test of BAM in adult patients with unexplained diarrhea. METHODS: Patients with unexplained diarrhea were investigated over a three-year period. Final diagnosis was determined based on medical history and investigations, serum levels of 7HCO and response to cholestyramine. ROC analysis was used to determine the ideal upper reference range cut-off value to optimize sensitivity/specificity for BAM. Time of blood specimen collection was recorded to investigate possible variation in results throughout the working day. RESULTS: ROC analysis yielded a sensitivity/specificity of 90%/77% for type 1 BAM (ileal disease/resection) and 97%/74% for type 2 BAM (idiopathic) using 30 ng/mL as the upper limit of normal for serum 7HCO when compared with all other patients. Of 813 patients, 196 tested positive. Serum 7HCO levels were significantly higher in blood specimens that were collected between 12:00 and 13:00 (median 24 ng/mL) than in specimens collected between 09:00 and 10:00 (median 17 ng/mL) (P<0.05). CONCLUSION: Serum 7HCO testing is a simple, sensitive, noninvasive, inexpensive alternative to other more commonly used tests for BAM. Time of specimen collection, however, resulted in small but significant result variations and, although unlikely to have much impact on test value, it should ideally be standardized. PMID:21766092

[The cenesthesiopathies].

PubMed

Blom, J D; Neven, A; Aouaj, Y; Jonker, B; Hoek, H W

2010-01-01

Up till a century ago the classic concepts of cenesthesis and cenesthesiopathy played a major role in the conceptualisation of aberrant somatosensory sensations and disturbances in the sensation of physical existence. Although these concepts are considered obsolete by a number of authors, the conceptual work of the German psychiatrist Gert Huber and the results of modern neuroimaging studies point to the need for a re-evaluation of the concepts cenesthesis and cenesthesiopathy. Background information was obtained from PubMed, Embase and the medical historical literature. By way of illustration, two cases are presented: the first is a female patient with a strongly diminished sense of physical existence (hypocenesthesiopathy) and the second is a male patient with such pronounced somatosensory sensations that he believed he was being transformed into a werewolf (hypercenesthesiopathy, clinical lycanthropy). On the basis of the literature and the two case studies, it is shown that the concepts of cenesthesis and cenesthesiopathy may be helpful in the conceptualisation of disorders of the sensation of bodily existence brought about by aberrant somatosensory sensations. In the cases of peculiar and unexplained physical symptoms, the cenesthesiopathies should be part of the differential diagnosis. Particularly if patients have longlasting, medication-resistant forms of cenesthesiopathy, it is strongly recommended that such patients undergo neuroimaging and are given an EEG so that treatable somatic conditions can either be demonstrated or ruled out.

Evidence of small-fiber polyneuropathy in unexplained, juvenile-onset, widespread pain syndromes.

PubMed

Oaklander, Anne Louise; Klein, Max M

2013-04-01

We tested the hypothesis that acquired small-fiber polyneuropathy (SFPN), previously uncharacterized in children, contributes to unexplained pediatric widespread pain syndromes. Forty-one consecutive patients evaluated for unexplained widespread pain beginning before age 21 had medical records comprehensively analyzed regarding objective diagnostic testing for SFPN (neurodiagnostic skin biopsy, nerve biopsy, and autonomic function testing), plus histories, symptoms, signs, other tests, and treatments. Healthy, demographically matched volunteers provided normal controls for SFPN tests. Age at illness onset averaged 12.3 ± 5.7 years; 73% among this poly-ethnic sample were female (P = .001). Sixty-eight percent were chronically disabled, and 68% had hospitalizations. Objective testing diagnosed definite SFPN in 59%, probable SFPN in 17%, and possible SFPN in 22%. Only 1 of 41 had entirely normal SFPN test results. Ninety-eight percent of patients had other somatic complaints consistent with SFPN dysautonomia (90% cardiovascular, 82% gastrointestinal, and 34% urologic), 83% reported chronic fatigue, and 63% had chronic headache. Neurologic examinations identified reduced sensation in 68% and vasomotor abnormalities in 55%, including 23% with erythromelalgia. Exhaustive investigations for SFPN causality identified only history of autoimmune illnesses in 33% and serologic markers of disordered immunity in 89%. Treatment with corticosteroids and/or intravenous immune globulin objectively and subjectively benefited 80% of patients (12/15). More than half among a large series of patients with childhood-onset, unexplained chronic widespread pain met rigorous, multitest, diagnostic criteria for SFPN, which extends the age range of acquired SFPN into early childhood. Some cases appeared immune-mediated and improved with immunomodulatory therapies.

An Evaluation of Factors Associated With Pathogenic PRSS1, SPINK1, CTFR, and/or CTRC Genetic Variants in Patients With Idiopathic Pancreatitis.

PubMed

Jalaly, Niloofar Y; Moran, Robert A; Fargahi, Farshid; Khashab, Mouen A; Kamal, Ayesha; Lennon, Anne Marie; Walsh, Christi; Makary, Martin A; Whitcomb, David C; Yadav, Dhiraj; Cebotaru, Liudmila; Singh, Vikesh K

2017-08-01

We evaluated factors associated with pathogenic genetic variants in patients with idiopathic pancreatitis. Genetic testing (PRSS1, CFTR, SPINK1, and CTRC) was performed in all eligible patients with idiopathic pancreatitis between 2010 to 2015. Patients were classified into the following groups based on a review of medical records: (1) acute recurrent idiopathic pancreatitis (ARIP) with or without underlying chronic pancreatitis; (2) idiopathic chronic pancreatitis (ICP) without a history of ARP; (3) an unexplained first episode of acute pancreatitis (AP)<35 years of age; and (4) family history of pancreatitis. Logistic regression analysis was used to determine the factors associated with pathogenic genetic variants. Among 197 ARIP and/or ICP patients evaluated from 2010 to 2015, 134 underwent genetic testing. A total of 88 pathogenic genetic variants were found in 64 (47.8%) patients. Pathogenic genetic variants were identified in 58, 63, and 27% of patients with ARIP, an unexplained first episode of AP <35 years of age, and ICP without ARP, respectively. ARIP (OR: 18.12; 95% CI: 2.16-151.87; P=0.008) and an unexplained first episode of AP<35 years of age (OR: 2.46; 95% CI: 1.18-5.15; P=0.017), but not ICP, were independently associated with pathogenic genetic variants in the adjusted analysis. Pathogenic genetic variants are most likely to be identified in patients with ARIP and an unexplained first episode of AP<35 years of age. Genetic testing in these patient populations may delineate an etiology and prevent unnecessary diagnostic testing and procedures.

Evidence of Small-Fiber Polyneuropathy in Unexplained, Juvenile-Onset, Widespread Pain Syndromes

PubMed Central

Klein, Max M.

2013-01-01

OBJECTIVE: We tested the hypothesis that acquired small-fiber polyneuropathy (SFPN), previously uncharacterized in children, contributes to unexplained pediatric widespread pain syndromes. METHODS: Forty-one consecutive patients evaluated for unexplained widespread pain beginning before age 21 had medical records comprehensively analyzed regarding objective diagnostic testing for SFPN (neurodiagnostic skin biopsy, nerve biopsy, and autonomic function testing), plus histories, symptoms, signs, other tests, and treatments. Healthy, demographically matched volunteers provided normal controls for SFPN tests. RESULTS: Age at illness onset averaged 12.3 ± 5.7 years; 73% among this poly-ethnic sample were female (P = .001). Sixty-eight percent were chronically disabled, and 68% had hospitalizations. Objective testing diagnosed definite SFPN in 59%, probable SFPN in 17%, and possible SFPN in 22%. Only 1 of 41 had entirely normal SFPN test results. Ninety-eight percent of patients had other somatic complaints consistent with SFPN dysautonomia (90% cardiovascular, 82% gastrointestinal, and 34% urologic), 83% reported chronic fatigue, and 63% had chronic headache. Neurologic examinations identified reduced sensation in 68% and vasomotor abnormalities in 55%, including 23% with erythromelalgia. Exhaustive investigations for SFPN causality identified only history of autoimmune illnesses in 33% and serologic markers of disordered immunity in 89%. Treatment with corticosteroids and/or intravenous immune globulin objectively and subjectively benefited 80% of patients (12/15). CONCLUSIONS: More than half among a large series of patients with childhood-onset, unexplained chronic widespread pain met rigorous, multitest, diagnostic criteria for SFPN, which extends the age range of acquired SFPN into early childhood. Some cases appeared immune-mediated and improved with immunomodulatory therapies. PMID:23478869

Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis.

PubMed

den Boeft, Madelon; Huisman, Daniëlle; Morton, LaKrista; Lucassen, Peter; van der Wouden, Johannes C; Westerman, Marjan J; van der Horst, Henriëtte E; Burton, Christopher D

2017-02-01

Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations. To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes. Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes. We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted. We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Unorthodox Alternative Therapies Marketed to Treat Lyme Disease

PubMed Central

Lantos, Paul M.; Shapiro, Eugene D.; Auwaerter, Paul G.; Baker, Phillip J.; Halperin, John J.; McSweegan, Edward; Wormser, Gary P.

2015-01-01

Background. Some patients with medically unexplained symptoms or alternative medical diagnoses suspect that they chronically suffer from the tick-borne infection Lyme disease. These patients are commonly targeted by providers of alternative therapies. This study was designed to identify and characterize the range of unorthodox alternative therapies advertised to patients with a diagnosis of Lyme disease. Methods. Internet searches using the Google search engine were performed to identify the websites of clinics and services that marketed nonantimicrobial therapies for Lyme disease. We subsequently used the PubMed search engine to identify any scientific studies evaluating such treatments for Lyme disease. Websites were included in our review so long as they advertised a commercial, nonantimicrobial product or service that specifically mentioned utility for Lyme disease. Websites with patient testimonials (such as discussion groups) were excluded unless the testimonial appeared as marketing on a commercial site. Results. More than 30 alternative treatments were identified, which fell into several broad categories: these included oxygen and reactive oxygen therapy; energy and radiation-based therapies; nutritional therapy; chelation and heavy metal therapy; and biological and pharmacological therapies ranging from certain medications without recognized therapeutic effects on Borrelia burgdorgeri to stem cell transplantation. Review of the medical literature did not substantiate efficacy or, in most cases, any rationale for the advertised treatments. Conclusions. Providers of alternative therapies commonly target patients who believe they have Lyme disease. The efficacy of these unconventional treatments for Lyme disease is not supported by scientific evidence, and in many cases they are potentially harmful. PMID:25852124

Medical conditions with neuropsychiatric manifestations.

PubMed

Isaac, Margaret L; Larson, Eric B

2014-09-01

Medical disease sometimes affects patients through neuropsychiatric manifestations. When neuropsychiatric symptoms are predominant, identifying medical disease early in the illness course is imperative because many of these conditions are reversible with appropriate treatment. A high index of suspicion is required on the part of clinicians, particularly when patients also present with physical signs or unexplained symptoms that might suggest a broader, systemic process. The processes that most commonly cause neuropsychiatric symptoms include infectious, autoimmune, endocrinologic, metabolic, and neoplastic diseases. This article focuses on the most common of these conditions, and conditions for which early diagnosis and treatment are particularly important. Copyright © 2014 Elsevier Inc. All rights reserved.

Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility

PubMed Central

Pashayan, Nora; Lyratzopoulos, Georgios; Mathur, Raj

2006-01-01

Background In unexplained and mild male factor subfertility, both intrauterine insemination (IUI) and in-vitro fertilisation (IVF) are indicated as first line treatments. Because the success rate of IUI is low, many couples failing IUI subsequently require IVF treatment. In practice, it is therefore important to examine the comparative outcomes (live birth-producing pregnancy), costs, and cost-effectiveness of primary offer of IVF, compared with primary offer of IUI followed by IVF for couples failing IUI. Methods Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including frozen cycles when applicable) or "IUI + IVF" (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used in calculations were derived from the published peer-reviewed literature as well as activity data of local infertility units. Results Cost-effectiveness ratios for IVF, "unstimulated-IUI (U-IUI) + IVF", and "stimulated IUI (S-IUI) + IVF" were £12,600, £13,100 and £15,100 per live birth-producing pregnancy respectively. For a hypothetical cohort of 100 couples with unexplained or mild male factor subfertility, compared with primary offer of IVF, 6 cycles of "U-IUI + IVF" or of "S-IUI + IVF" would cost an additional £174,200 and £438,000, representing an opportunity cost of 54 and 136 additional IVF cycles and 14 to 35 live birth-producing pregnancies respectively. Conclusion For couples with unexplained and mild male factor subfertility, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF. PMID:16796733

Ambulatory Assessment of Depression in Primary Care

DTIC Science & Technology

2016-06-29

activities (anhedonia) for over 2 weeks, plus at least four of the following symptoms: changes in sleep, changes in appetite or weight, fatigue, change...such as pain are the initial presenting symptoms of patients who are subsequently diagnosed with depression in a family practice clinic. Somatic...authors concluded that general practitioners should carefully evaluate medically unexplained physical symptoms. These symptoms included back pain

Medically unexplained physical symptoms (MUPS) among adults in Canada: Comorbidity, health care use and employment.

PubMed

Park, Jungwee; Gilmour, Heather

2017-03-15

Based on data from the 2014 Canadian Community Health Survey and the 2012 Canadian Community Health Survey-Mental Health, this study provides estimates of the prevalence of medically unexplained physical symptoms (MUPS) in the household population aged 25 or older. MUPS are examined in relation to sociodemographic characteristics, physical and mental comorbidity, health care use and unmet needs, labour force participation and productivity. In 2014, 5.5% of Canadian adults-an estimated 1.3 million - reported having chronic fatigue syndrome (1.6%), fibromyalgia (2.0%) and/or multiple chemical sensitivity (2.7%). Half (51%) of people with MUPS reported other chronic physical conditions, compared with 8% of those without MUPS. Similarly, mental comorbidities were more prevalent among those with MUPS. Higher health care use was observed among people with MUPS, but 25% of them reported unmet health care needs, compared with 11% of those without MUPS. People with MUPS were more likely than those without MUPS to be permanently unable to work or to not have a job; fewer than half (45%) were employed. Among those who were employed, 18% had missed work because of a chronic condition, compared with 5% of workers without MUPS.

Somatoform disorders and rheumatic diseases: from DSM-IV to DSM-V.

PubMed

Alciati, A; Atzeni, F; Sgiarovello, P; Sarzi-Puttini, P

2014-06-06

Medically unexplained symptoms are considered 'somatoform disorders' in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The introduction of this nosographic category has been helpful in drawing attention to a previously neglected area, but has not been successful in promoting an understanding of the disorders' biological basis and treatment implications, probably because of a series of diagnostic shortcomings. The newly proposed DSM-V diagnostic criteria try to overcome the limitations of the DSM-IV definition, which was organised centrally around the concept of medically unexplained symptoms, by emphasising the extent to which a patient's thoughts, feelings and behaviours concerning their somatic symptoms are disproportionate or excessive. This change is supported by a growing body of evidence showing that psychological and behavioural features play a major role in causing patient disability and maintaining high level of health care use. Pain disorders is the sub-category of DSM-IV somatoform disorders that most closely resembles fibromyalgia. Regardless of the diagnostic changes recently brought about by DSM-V, neuroimaging studies have identified important components of the mental processes associated with a DSM- IV diagnosis of pain disorder.

The course of newly presented unexplained complaints in general practice patients: a prospective cohort study.

PubMed

Koch, H; van Bokhoven, M A; Bindels, P J E; van der Weijden, T; Dinant, G J; ter Riet, G

2009-12-01

Newly presented unexplained complaints (UCs) are common in general practice. Factors influencing the transition of newly presented into persistent UCs have been scarcely investigated. We studied the number and the nature of diagnoses made over time, as well as factors associated with UCs becoming persistent. Finally, we longitudinally studied factors associated with quality of life (QoL). Prospective cohort study in general practice of patients presenting with a new UC. Data sources were case record forms, patient questionnaires and electronic medical registries at inclusion, 1, 6 and 12 months. Presence of complaints and diagnoses made over time were documented. Potential risk factors were assessed in mixed-effect logistic and linear regression models. Sixty-three GPs included 444 patients (73% women; median age 42) with unexplained fatigue (70%), abdominal complaints (14%) and musculoskeletal complaints (16%). At 12 months, 43% of the patients suffered from their initial complaints. Fifty-seven percent of the UCs remained unexplained. UCs had (non-life-threatening) somatic origins in 18% of the patients. QoL was often poor at presentation and tended to remain poor. Being a male [odds ratio (OR) 0.6; 95% confidence interval (CI) 0.4-0.8] and GPs' being more certain about the absence of serious disease (OR 0.9; 95% CI 0.8-0.9) were the strongest predictors of a diminished probability that the complaints would still be present and unexplained after 12 months. The strongest determinants of complaint persistence [regardless of (un)explicability] were duration of complaints >4 weeks before presentation (OR 2.6; 95% CI 1.6-4.3), musculoskeletal complaint at baseline (OR 2.3; 1.2-4.5), while the passage of time acted positively (OR 0.8 per month; 95% CI 0.78-0.84). Musculoskeletal complaints, compared to fatigue, decreased QoL on the physical domain (4.6 points; 2.6-6.7), while presence of psychosocial factors decreased mental QoL (5.0; 3.1-6.9). One year after initial presentation, a large proportion of newly presented UCs remained unexplained and unresolved. We identified determinants that GPs might want to consider in the early detection of patients at risk of UC persistence and/or low QoL.

Physical Examination for the Academic Psychiatrist: Primer and Common Clinical Scenarios.

PubMed

Azzam, Pierre N; Gopalan, Priya; Brown, Jennifer R; Aquino, Patrick R

2016-04-01

As clinical psychiatry has evolved to mirror the patient care model followed in other medical specialties, psychiatrists are called upon increasingly to utilize general medical skills in routine practice. Psychiatrists who practice in academic settings are often required to generate broad differential diagnoses that include medical and neurologic conditions and, as a result, benefit from incorporating physical examination into their psychiatric assessments. Physical examination allows psychiatrists to follow and to teach patient-informed clinical practices and comprehensive treatment approaches. In this commentary, the authors encourage routine use of a targeted physical examination and outline common scenarios in which physical examination would be useful for the academic psychiatrist: delirium, toxidromes, and unexplained medical conditions (e.g., somatic symptom disorders).

Big Five personality traits and medically unexplained symptoms in later life.

PubMed

van Dijk, S D M; Hanssen, D; Naarding, P; Lucassen, P; Comijs, H; Oude Voshaar, R

2016-10-01

Personality dysfunction has been postulated as the most clinically salient problem of persons suffering from medically unexplained symptoms (MUS) but empirical studies are scarce. This study aims to compare the personality profile of older patients suffering from MUS with two comparison groups and a control group. Ninety-six older patients with MUS were compared with 153 frequent attenders in primary care suffering from medically explained symptoms (MES), 255 patients with a past-month depressive disorder (DSM-IV-TR), and a control group of 125 older persons. The Big Five personality domains (NEO-Five-Factor Inventory) were compared between groups by multiple ANCOVAs adjusted for age, sex, education, partner status and cognitive functioning. Linear regression analyses were applied to examine the association between health anxiety (Whitley Index) and somatization (Brief Symptom Inventory). The four groups differed with respect to neuroticism (P<0.001), extraversion (P<0.001), and agreeableness (P=0.045). Post hoc analyses, showed that MUS patients compared to controls scored higher on neuroticism and agreeableness, and compared to depressed patients lower on neuroticism and higher on extraversion as well agreeableness. Interestingly, MUS and MES patients had a similar personality profile. Health anxiety and somatization were associated with a higher level of neuroticism and a lower level of extraversion and conscientiousness, irrespective whether the physical symptom was explained or not. Older patients with MUS have a specific personality profile, comparable to MES patients. Health anxiety and somatization may be better indicators of psychopathology than whether a physical symptom is medically explained or not. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials.

PubMed

Heijmans, Mieke; Olde Hartman, Tim C; van Weel-Baumgarten, Evelyn; Dowrick, Christopher; Lucassen, Peter L B J; van Weel, Chris

2011-08-01

The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients. To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research. We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts. We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research. MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Rapid clinical deterioration in an individual with Down syndrome.

PubMed

Jacobs, Julia; Schwartz, Alison; McDougle, Christopher J; Skotko, Brian G

2016-07-01

A small percentage of adolescents and young adults with Down syndrome experience a rapid and unexplained deterioration in cognitive, adaptive, and behavioral functioning. Currently, there is no standardized work-up available to evaluate these patients or treat them. Their decline typically involves intellectual deterioration, a loss of skills of daily living, and prominent behavioral changes. Certain cases follow significant life events such as completion of secondary school with friends who proceed on to college or employment beyond the individual with DS. Others develop this condition seemingly unprovoked. Increased attention in the medical community to clinical deterioration in adolescents and young adults with Down syndrome could provide a framework for improved diagnosis, evaluation, and treatment. This report presents a young adult male with Down syndrome who experienced severe and unexplained clinical deterioration, highlighting specific challenges in the systematic evaluation and treatment of these patients. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Mental Health and Recruits (Briefing Charts)

DTIC Science & Technology

2010-01-01

MENTAL HEALTH AND RECRUITS COL Elspeth Cameron Ritchie, MD, MPH Director, Behavioral Health Proponency Offi f h A S G lce o t e rmy urgeon enera...collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and...Desert Storm/Shield – “Persian Gulf illnesses”, medically unexplained physical symptoms • Operations Other than War (OOTW) – Combat and

Predictors of Treatment with Duloxetine or Venlafaxine XR among Adult Patients Treated for Depression in Primary Care Practices in the United Kingdom

PubMed Central

Shi, Nianwen; Durden, Emily; Torres, Amelito; Cao, Zhun; Happich, Michael

2012-01-01

Background. Knowledge about real-world use of duloxetine and venlafaxine XR to treat depression in the UK is limited. Aims. To identify predictors of duloxetine or venlafaxine XR initiation. Method. Adult depressed patients who initiated duloxetine or venlafaxine XR between January 1, 2006 and September 30, 2007 were identified in the UK's General Practice Research Database. Demographic and clinical predictors of treatment initiation with duloxetine and venlafaxine XR were identified using logistic regression. Results. Patients initiating duloxetine (n = 909) were 4 years older than venlafaxine XR recipients (n = 1286). Older age, preexisting unexplained pain, respiratory disease, and pre-period use of anticonvulsants, opioids, and antihyperlipidemics were associated with increased odds of initiating duloxetine compared to venlafaxine XR. Pre-period anxiety disorder was associated with decreased odds of receiving duloxetine. Conclusion. Initial treatment choice with duloxetine versus venlafaxine XR was primarily driven by patient-specific mental and medical health characteristics. General practitioners in the UK favor duloxetine over venlafaxine XR when pain conditions coexist with depression. PMID:22720149

Alacrima as a Harbinger of Adrenal Insufficiency in a Child with Allgrove (AAA) Syndrome

PubMed Central

Brown, Brande; Agdere, Levon; Muntean, Cornelia; David, Karen

2016-01-01

Patient: Female, 6 Final Diagnosis: Allgrove syndrome Symptoms: Achalasia • adrenal insufficiency • alacrima Medication: — Clinical Procedure: — Specialty: Pediatrics and Neonatology Objective: Rare disease Background: Allgrove syndrome, or triple “A” syndrome (3A syndrome), is a rare autosomal recessive syndrome with variable phenotype, and an estimated prevalence of 1 per 1,000,000 individuals. Patients usually display the triad of achalasia, alacrima, and adrenocorticotropin (ACTH) insensitive adrenal insufficiency, though the presentation is inconsistent. Case Report: Here, the authors report a case of Allgrove syndrome in a pediatric patient with delayed diagnosis in order to raise awareness of this potentially fatal disease as a differential diagnosis of alacrima. Conclusions: The prevalence of Allgrove syndrome may be much higher as a result of underdiagnosis and missed diagnosis due to the variable presentation and sudden unexplained childhood death from adrenal crisis. The authors review the characteristic symptoms of Allgrove syndrome in relation to the case study in order to avoid missed or delayed diagnosis, potentially decreasing morbidity, and mortality in those affected by this disease. PMID:27698338

Helpful strategies for GPs seeing patients with medically unexplained physical symptoms: a focus group study.

PubMed

Aamland, Aase; Fosse, Anette; Ree, Eline; Abildsnes, Eirik; Malterud, Kirsti

2017-08-01

Patients with long-lasting and disabling medically unexplained physical symptoms (MUPS) are common in general practice. GPs have previously described the challenges regarding management and treatment of patients with MUPS. To explore GPs' experiences of the strategies perceived as helpful when seeing patients with MUPS. Three focus group interviews with a purposive sample of 24 experienced GPs were held in southern Norway. Discussions were audiotaped and transcribed. Systematic text condensation was used for analysis. Several strategies were considered helpful during consultations with patients with MUPS. A comprehensive outline of the patient's medical past and present could serve as the foundation of the dialogue. Reviewing the patient's records and sharing relevant information with them or conducting a thorough clinical examination could offer 'golden moments' of trust and common understanding. A very concrete exchange of symptoms and diagnosis interpretation sometimes created a space for explanations and action, and confrontations could even strengthen the alliance between the GP and the patient. Bypassing conventional answers and transcending tensions by negotiating innovative explanations could help patients resolve symptoms and establish innovative understanding. GPs use tangible, down-to-earth strategies in consultations with patients with MUPS. Important strategies were: thorough investigation of the patient's symptoms and story; sharing of interpretations; and negotiation of different explanations. Sharing helpful strategies with colleagues in a field in which frustration and dissatisfaction are not uncommon can encourage GPs to develop sustainable responsibility and innovative solutions. © British Journal of General Practice 2017.

The effect of an educational intervention in family phisicians on self-rated quality of life in patients with medically unexplained symptoms.

PubMed

Ivetić, Vojislav; Pašić, Klemen; Selič, Polona

2017-06-01

Medically unexplained symptoms (MUS) are very common in family medicine, despite being a poorly-defined clinical entity. This study aimed to evaluate the effect of an educational intervention (EI) on self-rated quality of life, treatment satisfaction, and the family physician-patient relationship in patients with MUS. In a multi-centre longitudinal intervention study, which was performed between 2012 and 2014, patients were asked to rate their quality of life, assess their depression, anxiety, stress and somatisation, complete the Hypochondriasis Index, the Medical Interview Satisfaction Scale and the Patient Enablement Instrument for assessing the physician-patient relationship, before and after the EI. The mean values before and after the intervention showed that after the EI, patients with MUS gave a lower (total) mean rating of their health issues and a higher rating of their quality of life, and they also had a more positive opinion of their relationship with the physician (p<0.05). However, there were no differences in the (total) rating of treatment satisfaction before and after the EI (p=0.423). Significant differences in the symptoms in patients with MUS before and after the intervention were confirmed for stress, somatisation and hypochondriasis (p<0.05). It could be beneficial to equip family physicians with the knowledge, skills and tools to reduce hypochondriasis and somatisation in MUS patients, which would improve patients' self-rated health status.

The identification in primary care of patients who have been repeatedly referred to hospital for medically unexplained symptoms: a pilot study.

PubMed

Smith, Benjamin J; McGorm, Kelly J; Weller, David; Burton, Christopher; Sharpe, Michael

2009-09-01

The study aimed (a) to test a method of identifying patients who have been repeatedly referred (RR) from primary care to medical outpatient clinics where they have received multiple diagnoses of medically unexplained symptoms (MUS) and (b) to describe the prevalence and characteristics of these patients. RR patients with MUS (RRMUS) were arbitrarily defined as those with (a) five or more referrals in a 5-year period and (b) a specialist final diagnosis of MUS for at least three of these referrals. A two-stage method of identifying these patients was piloted in one primary care practice: Stage 1 used computerized health service data to identify RR; Stage 2 used manual case note review to identify referrals that ended with specialist diagnoses of MUS. The RRMUS patients identified were asked to complete a questionnaire, a psychiatric diagnostic interview, and their GPs were asked to rate how "difficult to manage" they were. The process was feasible and reasonably accurate. From 6770 registered patients aged 18 to 65 years, 23 (0.3%) were identified as RRMUS. They accounted for 157 referrals over the 5-year period. Sixteen agreed to further assessment, and 8 (50%) had a current anxiety or depressive disorder. GPs rated only 8 (50%) as "difficult to manage." This two-stage procedure offers a practical method of identifying RRMUS patients in primary care as a first step in achieving more cost-effective care. These patients have substantial psychiatric morbidity.

Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation.

PubMed Central

Engel, Charles C; Adkins, Joyce A; Cowan, David N

2002-01-01

Medically unexplained physical symptoms (MUPS) are persistent idiopathic symptoms that drive patients to seek medical care. MUPS syndromes include chronic fatigue syndrome, fibromyalgia syndrome, and multiple chemical sensitivities. When MUPS occur after an environmental exposure or injury, an adversarial social context that we call "contested causation" may ensue. Contested causation may occur publicly and involve media controversy, scientific disagreement, political debate, and legal struggles. This adversarial social context may diminish the effectiveness of the provider-patient relationship. Contested causation also may occur privately, when disagreement over the causes of MUPS takes place in the patient-provider context. These patient-provider disagreements over causation often occur because of the enigmatic nature of MUPS. We suggest that a context of contested causation may have serious negative effects on healthcare for individuals with MUPS. Context plays a larger role in MUPS care than it does for most medical care because of the uncertain nature of MUPS, the reliance of standard MUPS therapies on a potentially tenuous patient-provider partnership, and the clinical need to rely routinely on subjective MUPS assessments that often yield discordant patient and provider conclusions. Contested causation may erode patient-provider trust, test the provider's self-assurance and capacity to share power with the patient, and raise problematic issues of compensation, reparation, and blame. These issues may distract patients and providers from therapeutic goals. In occupational and military settings, the adverse impact of contested causation on the patient-provider partnership may diminish therapeutic effectiveness to a greater degree than it does in other medical settings. Contested causation therefore raises questions regarding generalizability of standard therapies for MUPS and related syndromes to these settings. Future research is needed to learn whether intuitively sensible and evidence-based MUPS therapies benefit occupational and military medical patients who are afforded care in the context of contested causation. PMID:12194900

Medically Unexplained Physical Symptoms in Military Health (Symptomes physiques medicalement inexpliques dans la sante militaire)

DTIC Science & Technology

2017-12-01

Development of Persistent Pain and psychological Morbidity after Motor Vehicle Collision: Integrating the Potential Role of Stress Response Systems... abnormalities of quantitative EEG which suggest a THE LONG-TERM COSTS OF TRAUMATIC STRESS: INTERTWINED PHYSICAL AND PSYCHOLOGICAL CONSEQUENCES STO-TR-HFM...S.A., Clauw, D.J., Abelson, J.L. et al., The development of persistent pain and psychological morbidity after motor vehicle collision: integrating

[Disease at any price: psychological challenge and the financial costs of somatization].

PubMed

Matalon, A

1996-01-01

In clinical medicine we sometimes deal with patients with unexplained somatic complaints. In a 45-year-old woman with multiple somatic complaints, 2 years of medical examinations in search of a disease diagnosis cost almost 250,000 shekels (about +84,000). The differential diagnosis between somatization, hypochondriasis and psychosomatic pain, and the reasons why physicians are tempted to participate in the "investigation dance" are presented.

A taxonomy of explanations in a general practitioner clinic for patients with persistent "medically unexplained" physical symptoms.

PubMed

Morton, LaKrista; Elliott, Alison; Cleland, Jennifer; Deary, Vincent; Burton, Christopher

2017-02-01

To develop a taxonomy of explanations for patients with persistent physical symptoms. We analysed doctors' explanations from two studies of a moderately-intensive consultation intervention for patients with multiple, often "medically-unexplained," physical symptoms. We used a constant comparative method to develop a taxonomy which was then applied to all verbatim explanations. We analysed 138 explanations provided by five general practitioners to 38 patients. The taxonomy comprised explanation types and explanation components. Three explanation types described the overall structure of the explanations: Rational Adaptive, Automatic Adaptive, and Complex. These differed in terms of who or what was given agency within the explanation. Three explanation components described the content of the explanation: Facts - generic statements about normal or dysfunctional processes; Causes - person-specific statements about proximal or distal causes for symptoms; Mechanisms - processes by which symptoms arise or persist in the individual. Most explanations conformed to one type and contained several components. This novel taxonomy for classifying clinical explanations permits detailed classification of explanation types and content. Explanation types appear to carry different implications of agency. The taxonomy is suitable for examining explanations and developing prototype explanatory scripts in both training and research settings. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness.

PubMed

Yunus, Muhammad B

2008-06-01

To discuss the current terminologies used for fibromyalgia syndrome (FMS) and related overlapping conditions, to examine if central sensitivity syndromes (CSS) is the appropriate nosology for these disorders, and to explore the issue of disease versus illness. A literature search was performed through PubMed, Web of Science, and ScienceDirect using a number of keywords, eg, functional somatic syndromes, somatoform disorders, medically unexplained symptoms, organic and nonorganic, and diseases and illness. Relevant articles were then reviewed and representative ones cited. Terminologies currently used for CSS conditions predominantly represent a psychosocial construct and are inappropriate. On the other hand, CSS seems to be the logical nosology based on a biopsychosocial model. Such terms as "medically unexplained symptoms," "somatization," "somatization disorder," and "functional somatic syndromes" in the context of CSS should be abandoned. Given current scientific knowledge, the concept of disease-illness dualism has no rational basis and impedes proper patient-physician communication, resulting in poor patient care. The concept of CSS is likely to promote research, education, and proper patient management. CSS seems to be a useful paradigm and an appropriate terminology for FMS and related conditions. The disease-illness, as well as organic/non-organic dichotomy, should be rejected.

Medically unexplained symptoms as a threat to patients' identity? A conversation analysis of patients' reactions to psychosomatic attributions.

PubMed

Burbaum, Christina; Stresing, Anne-Maria; Fritzsche, Kurt; Auer, Peter; Wirsching, Michael; Lucius-Hoene, Gabriele

2010-05-01

Interactions between patients suffering from medically unexplained symptoms (MUS) and their physicians are usually perceived as difficult and unsatisfactory by both parties. In this qualitative study, patients' reactions to psychosomatic attributions were analyzed on a micro-level. 144 consultations between consultation-and-liaison (CL) psychotherapists and inpatients with MUS, who were treated according to a modified reattribution model, were recorded. Linguists and psychologists evaluated these consultations by applying conversation and positioning analysis. When introducing a psychosomatic attribution, therapists use discursive strategies to exert interactional pressure on the patient; while simultaneously using careful and implicit formulations. Three linguistic patterns could be found in which patients subtly refute, drop or undermine the psychosomatic attribution in their reply. Moreover, in this context patients position themselves as somatically ill or justify their own life situation. The results suggest that patients interpret psychosomatic attributions and even subtle suggestions from the psychotherapists as face-threatening 'other-positionings'. When implementing the reattribution model, it should be taken into account that interactional resistance might be a necessary step in the process of the patient's understanding. Nevertheless therapists should introduce reattribution in a patient-centered rather than persuasive way and they should openly address patients' fears of being stigmatized. Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.

Unexplained somatic symptoms during major depression: prevalence and clinical impact in a national sample of Italian psychiatric outpatients.

PubMed

Perugi, Giulio; Canonico, Pier Luigi; Carbonato, Paolo; Mencacci, Claudio; Muscettola, Giovanni; Pani, Luca; Torta, Riccardo; Vampini, Claudio; Fornaro, Michele; Parazzini, Fabio; Dumitriu, Arina

2011-01-01

The aim of this study was to explore the prevalence and impact of unexplained somatic symptoms during major depression. A total of 560 consecutive outpatients with a major depressive episode according to the DSM-IV (text revision) were evaluated in 30 psychiatric facilities throughout Italy. 'Unexplained' somatic symptoms were evaluated using the 30-item Somatic Symptoms Checklist (SSCL-30). Somatic symptoms were considered explained if they were best accounted for as coming from a concomitant physical illness or side effects. Patients evaluated their own mood symptomatology using the Zung questionnaires for depression and anxiety and the Hypomania Checklist-32. According to the SSCL-30, only 90 subjects (16.1%) had no unexplained somatic symptoms, while 231 (41.3%) had 1-5 unexplained symptoms and 239 (42.7%) had more than 5. Asthenia was the most commonly observed unexplained somatic symptom (53% of patients). Unexplained somatic symptoms were more common in females and among those suffering from major depression and depression not otherwise specified rather than in patients with recurrent major depression and bipolar disorders. No relationship between unexplained somatic symptoms and hypomanic features was observed. The presence of a large number of unexplained somatic symptoms is associated with more severe depression and higher rates of misdiagnosis and inappropriate treatment. Copyright © 2011 S. Karger AG, Basel.

Contributions of late-type dwarf stars to the soft X-ray diffuse background

NASA Technical Reports Server (NTRS)

Schmitt, J. H. M. M.; Snowden, S. L.

1990-01-01

Comprehensive calculations of the contribution of late-type dwarf stars to the soft X-ray diffuse background are presented. The mean X-ray luminosity as derived from optically and X-ray selected samples is examined, using the Bahcall-Soneira Galaxy model to describe the spatial distribution of stars and recent results on the X-ray spectra. The model calculations are compared with the Wisconsin sky maps in the C, M1, M2, I and J bands to assess the uncertainties of the calculations. Contributions of up to 10 percent to the M2 and I band background at high Galactic latitudes are found, while at low Galactic latitudes late-type stars contribute up to 40 percent of the background. However, a Galactic ridge as well as a relatively isotropic component still remains unexplained, even with the added contribution of the extrapolated high-energy power law.

The usefulness of carotid sinus massage in different patient groups.

PubMed

Kumar, Narasimhan Pradeep; Thomas, Alan; Mudd, Paul; Morris, Robert O; Masud, Tahir

2003-11-01

to determine the positive yield of carotid sinus massage in different patient groups: unexplained syncope, falls, dizziness and controls. observational study. teaching hospital. we studied consecutive patients over the age of 60 years referred to the 'falls clinic' with a history of unexplained syncope, unexplained falls and unexplained dizziness. We also studied asymptomatic control subjects recruited from a general practice register aged 60 years and over. All patients and control subjects underwent a full clinical assessment (comprehensive history and detailed clinical examination including supine and erect blood pressure measurements) and 12-lead electrocardiography. We performed carotid sinus massage in the supine position for 5 seconds separately on both sides followed by repeating the procedure in the upright positions using a motorised tilt table. Heart rate and blood pressure were recorded using a cardiac monitor and digital plethysmography respectively. The test was considered positive if carotid sinus massage produced asystole with more than a 3 second pause (cardioinhibitory type of carotid sinus syndrome), or a fall in systolic blood pressure of more than 50 mmHg in the absence of significant cardioinhibition (vasodepressor type of carotid sinus syndrome) or where there was evidence of both vasodepressor and cardio-inhibition as above (mixed type). we studied 44 asymptomatic control subjects and 221 symptomatic patients (130 with unexplained syncope, 41 with unexplained falls and 50 with unexplained dizziness). In the overall symptomatic patient group, the positive yield (any type of carotid sinus syndrome) was 17.6% (95% CI = 12.7-22.5). The positive yield in men (26.3% (95% CI = 16.4-36.2)) was twice that in women (13.1% (95% CI = 7.6-18.6)) (P = 0.014). Overall any type of carotid sinus syndrome was present in 22.3% (n = 29) of the syncope group, 17.1% (n = 7) in the unexplained fallers group and 6% (n = 3) in the dizziness group. We also found that no women with unexplained dizziness had a positive carotid sinus massage test. None of the controls demonstrated a positive response. None of the subjects suffered any complications during or after the test. the positive yield of carotid sinus massage in symptomatic patients was 17.6% with the yield in men being twice that in women. None of the asymptomatic control subjects demonstrated a positive response. The yields in unexplained syncope and unexplained falls patients were around 4-fold and 3-fold higher respectively than in unexplained dizziness patients. The positive yield in women with unexplained dizziness (without a definite history of syncope and falls) is zero. Hence, carotid sinus massage in older adults should particularly be targeted at patients with unexplained syncope and unexplained falls.

Veterans worry that unexplained medical problems a legacy of service during Gulf War.

PubMed Central

Robinson, A

1995-01-01

Some Canadians who served in the military in the Persian Gulf 4 years ago complain of a range of symptoms commonly described as Gulf War syndrome. Although the syndrome is not recognized as a clinical entity, symptoms include fatigue, lack of sleep, depression, cognitive problems, rashes, bone aches, lassitude, lack of motivation, forgetfulness, mood changes irritability and diarrhea. The medical branch of the Department of National Defence has established programs to inform, guide diagnosis and reach out to symptomatic veterans of the Persian Gulf conflict. Civilian physicians who provide similar care to military personnel who participated in the conflict are invited to call the medical branch (613 996-3752) for further information. Images p945-a PMID:7697587

Prevalence and diagnostic distribution of medically unexplained painful somatic symptoms across 571 major depressed outpatients.

PubMed

Fornaro, Michele; Maremmani, Icro; Canonico, Pier Luigi; Carbonatto, Paolo; Mencacci, Claudio; Muscettola, Giovanni; Pani, Luca; Torta, Riccardo; Vampini, Claudio; Parazzini, Fabio; Dumitriu, Arina; Perugi, Giulio

2011-01-01

To assess the prevalence and distribution of medically unexplained painful somatic symptoms (PSSs) versus nonpainful somatic symptoms (NPSSs) in patients diagnosed with major depressive episode (MDE). A total of 571 outpatients diagnosed with MDE according to DSM-IV-TR criteria were consecutively enrolled into a cross-sectional, multicentric, observational study over a period of 7 months. Subjects were evaluated by means of the ad hoc validated 30-item Somatic Symptoms Checklist (SSCL-30) and Zung's questionnaires for depression and anxiety. The 32-item Hypomania Checklist (HCL-32) was also administered in order to explore any eventual association of PSSs or NPSSs with sub-threshold (DSM-IV-TR [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision] not recognized) bipolar disorder (BD). In our sample, just 183 patients (32%) did not report painful somatic symptoms (NPSSs). Of these, 90 patients (15.76%) had no somatic symptoms at all. The remaining 388 (68%) had at least one PSS being subdivided as follows: 248 (43%) had one or two PSSs, while 140 (25%) experienced two or more. Patients with at least one PSS also reported a greater number of nonpainful somatic symptoms than NPSS. Bipolar patients (associated with higher HCL-32 scores) were less represented across PSS cases than NPSS subjects. Conversely, females were more prone to having a higher number of total somatic symptoms (and bipolar features). PSSs are common in patients with MDE, especially among those patients reporting fewer somatic symptoms in general as opposed to those patients who exhibit more somatic symptoms (both PSSs and NPSSs) with lower relative number of PSSs. A major therapeutic implication is that antidepressant monotherapy could be used with more confidence in unexplained PSS patients than in NPSS patients because of the latter group's lower frequency of (sub)-threshold bipolar features.

The relative economic progress of male foreign workers in Kuwait.

PubMed

Al-qudsi, S S; Shah, N M

1991-01-01

"A human capital framework is utilized to examine the economic progress of nine nationality groups of foreign workers [in Kuwait] using data from the 1983 national Labor Survey. The sources of earnings' variations of particular interest to us included different degrees of education and experience transferability, occupational affiliation and ethnic background. In general, the results derived from the analysis suggest that 1) foreign workers achieve a discernible economic progress as their residence lengthens; 2) the rate of economic progress varies depending on worker's education, home and Kuwait-specific experience, occupational status and ethnic background; and 3) about one third of the earnings inequality is due to unexplained factors including discrimination." excerpt

A pilot registry of unexplained fatiguing illnesses and chronic fatigue syndrome

PubMed Central

2013-01-01

Background Chronic fatigue syndrome (CFS) has no diagnostic clinical signs or biomarkers, so diagnosis requires ruling out conditions with similar signs and symptoms. We conducted a pilot registry of unexplained fatiguing illnesses and CFS to determine the feasibility of establishing and operating a registry and implementing an education outreach initiative. The pilot registry was conducted in Bibb County, Georgia. Patient referrals were obtained from healthcare providers who were identified by using various education outreach initiatives. These referrals were later supplemented with self-referrals by members of a local CFS support group. All patients meeting referral criteria were invited to participate in a screening interview to determine eligibility. If patients met registry criteria, they were invited to a one-day clinic for physical and laboratory evaluations. We classified patients based on the 1994 case definition. Results We registered 827 healthcare providers. Forty-two providers referred 88 patients, and 58 patients (66%) completed clinical evaluation. Of the 188 CFS support group members, 53 were self-referred and 46 (87%) completed the clinical evaluation. Of the 104 participants completing evaluation, 36% (n = 37) met the criteria for CFS, 17% (n = 18) had insufficient fatigue or symptoms (ISF), and 47% (n = 49) were found to have exclusionary medical or psychiatric illnesses. Classification varied significantly by type of referral but not by previous history of CFS diagnosis. Healthcare providers referred more patients who were classified as CFS as compared to support group referrals in which more exclusionary conditions were identified. Family practice and internal medicine specialties made the most referrals and had the highest number of CFS cases. We conducted three CME events, held three “Meet and Greet” sessions, visited four large clinical health practices and health departments, mailed five registry newsletters, and conducted in-person office visits as part of education outreach, which contributed to patient referrals. Conclusions Referrals from healthcare providers and self-referrals from the patient support group were important to registry enrollment. The number of potentially treatable conditions that were identified highlights the need for continued medical management in this population, as well as the limitations of registries formed without clinical examination. Education initiatives were successful in part because of partnerships with local organizations. PMID:23915640

Professional support requirements and grief interventions for parents bereaved by an unexplained death at different time periods in the grief process.

PubMed

Rudd, Rebecca A; D'Andrea, Livia M

2013-01-01

The purpose of this qualitative phenomenological study examines the support needs and grief interventions professional and bereaved parents believed were helpful during different time periods in the grief process: the first 72 hours, first three to 14 days, and two weeks and beyond. Ten professionals from the following disciplines were interviewed: emergency communications, emergency medical technician, police, fireman, detective, social worker funeral director chaplain, peer support leader, and bereavement organization. Five parents and one grandparent bereaved by Sudden Infant Death Syndrome (SIDS) or Sudden Unexplained Death in Childhood (SUDC) were interviewed. This study identified 13 support need and grief interventions: contact support people, emotional and cognitive regulation, preliminary information on cause of death, time with deceased child, accommodate and advocate, human compassion and support, describe timeline and process, referrals and resources, affordable and easy access to services, communication and follow-up, community experience, professional mental health support, and memorialize. Recommendations are provided on ways to improve services to newly bereaved parents.

Clinical observation of lymphocyte active immunotherapy in 380 patients with unexplained recurrent spontaneous abortion.

PubMed

Chen, Jian-Ling; Yang, Jian-Ming; Huang, Ya-Zhe; Li, Ying

2016-11-01

This study aims to investigate the clinical curative effect of lymphocyte active immunotherapy (LAI) on unexplained recurrent spontaneous abortion (RSA). A total of 749 RSA patients who received medical service in our hospital from October 2009 to June 2013 were enrolled into this study. These patients were randomly divided into two groups: LAI group (treatment group) and routine progesterone for maintenance tocolysis group (control group). A comparative analysis on the pregnancy outcomes in these two groups was conducted. Abortion rate was significantly lower in the LAI group than in the control group (P<0.05). Furthermore, pregnancy success rates were 89.7% and 32.2% in patients who received LAI and routine progesterone for maintenance tocolysis, respectively, and the difference was statistically significant (P<0.05). Our analysis suggested that LAI can treat RSA effectively and has an excellent clinical effect. Furthermore, the detection of blocking antibodies showed a positive prediction on pregnancy outcome. Copyright © 2016 Elsevier B.V. All rights reserved.

What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms.

PubMed

Maatz, Anke; Wainwright, Megan; Russell, Andrew J; Macnaughton, Jane; Yiannakou, Yan

2016-11-01

The term 'difficult' is pervasively used in relation to medically unexplained symptoms (MUS) and patients with MUS. This article scrutinises the use of the term by analysing interview data from a study of secondary care specialists' experiences with and attitudes towards patients suffering from MUS. Qualitative design employing semi-structured open-ended interviews systematically analysed in three stages: first, data were analysed according to the principles of content analysis. The analysis subsequently focused on the use of the term 'difficult'. Iterations of the term were extracted by summative analysis and thematic coding revealed its different meanings. Finally, alternative expressions were explored. Three NHS trust secondary care hospitals in North-East England. 17 senior clinicians from seven medical and two surgical specialities. Unsolicited use of the term 'difficult' was common. 'Difficult' was rarely used as a patient characteristic or to describe the therapeutic relationship. Participants used 'difficult' to describe their experience of diagnosing, explaining, communicating and managing these conditions and their own emotional reactions. Health care system deficits and the conceptual basis for MUS were other facets of 'difficult'. Participants also reported experiences that were rewarding and positive. This study shows that blanket statements such as 'difficult patients' mask the complexity of doctors' experiences in the context of MUS. Our nuanced analysis of the use of 'difficult' challenges preconceived attitudes. This can help counter the unreflexive perpetuation of negative evaluations that stigmatize patients with MUS, encourage greater acknowledgement of doctors' emotions, and lead to more appropriate conceptualizations and management of MUS. Copyright © 2016 Elsevier Inc. All rights reserved.

The interpretation of low mood and worry by high users of secondary care with medically unexplained symptoms.

PubMed

Burton, Christopher; McGorm, Kelly; Weller, David; Sharpe, Michael

2011-10-02

Around 1% of adults are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS); many of these patients have depression and anxiety disorders which are unrecognized or inadequately treated. We aimed to investigate the ways patients with MUS and their General Practitioners (GPs) interpret low mood and worry, whether they regard them as depressive or anxiety disorders and how they relate them causally to symptoms. We carried out semi-structured interviews with 27 patients who had been repeatedly referred to specialists for MUS and their GPs and analysed transcripts by qualitative comparison. The analysis examined themes relating to low mood and worry, and their influence on symptoms. It drew on the concept of "otherness", whereby mental phenomena can be located either within the self or as separate entities. Both patients and GPs acknowledged the presence of low mood and worry. They viewed low mood as either an individual's personal response to circumstances (including their physical symptoms) or as the illness called "depression"; only the latter was amenable to medical intervention. Worry was seen as a trait rather than as a symptom of an anxiety disorder. While low mood and worry were acknowledged to influence physical symptoms, they were considered insufficient to be the main cause by either the patients or their doctors. Patients with MUS who are high users of secondary care services interpret low mood and worry in ways which allow them to be discussed with professionals, but not as the cause of their physical symptoms.

Altered autonomic nervous system activity in women with unexplained recurrent pregnancy loss.

PubMed

Kataoka, Kumie; Tomiya, Yumi; Sakamoto, Ai; Kamada, Yasuhiko; Hiramatsu, Yuji; Nakatsuka, Mikiya

2015-06-01

Autonomic nervous system activity was studied to evaluate the physical and mental state of women with unexplained recurrent pregnancy loss (RPL). Heart rate variability (HRV) is a measure of beat-to-beat temporal changes in heart rate and provides indirect insight into autonomic nervous system tone and can be used to assess sympathetic and parasympathetic tone. We studied autonomic nervous system activity by measuring HRV in 100 women with unexplained RPL and 61 healthy female volunteers as controls. The degree of mental distress was assessed using the Kessler 6 (K6) scale. The K6 score in women with unexplained RPL was significantly higher than in control women. HRV evaluated on standard deviation of the normal-to-normal interval (SDNN) and total power was significantly lower in women with unexplained RPL compared with control women. These indices were further lower in women with unexplained RPL ≥4. On spectral analysis, high-frequency (HF) power, an index of parasympathetic nervous system activity, was significantly lower in women with unexplained RPL compared with control women, but there was no significant difference in the ratio of low-frequency (LF) power to HF power (LF/HF), an index of sympathetic nervous system activity, between the groups. The physical and mental state of women with unexplained RPL should be evaluated using HRV to offer mental support. Furthermore, study of HRV may elucidate the risk of cardiovascular diseases and the mechanisms underlying unexplained RPL. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.

Development of metaphors to explain cognitive behavioural principles for patients with medically unexplained symptoms in Sri Lanka.

PubMed

Sumathipala, Athula

2014-03-01

Medically unexplained symptoms (MUS) are common in primary care across cultures, accounting for high consultations with multiple providers and unnecessary investigations. Cognitive behavioural therapy (CBT) is efficacious for MUS and reduces physical symptoms, psychological distress and disability. Two intervention trials by the author and his group remain the only reported trials from the developing world. A treatment package was designed by modifying a CBT model. The modifications were innovative use of locally relevant appropriate language and strategies that were simple enough while conforming to the CBT principles. The aim was to convey the principles of CBT to people using simple techniques--using metaphor. These are described in the paper as generic metaphors that could be used to explain the CBT principles and specific ones for patients with MUS. Metaphor is an effective clinical tool. The author's clinical experience and patients' feedback suggest that these metaphors are helpful in conveying the CBT principles to patients. To develop metaphors appealing to the client and effective clinically, carrying out qualitative research among patients' explanatory model is an important prerequisite. The generic and MUS-specific metaphors reported here should be tried in other cultural and clinical settings and evaluated. Further systematic work including qualitative work for consensus evaluation among CBT experts as well as opinion on user-friendliness of these techniques tested among CBT practitioners will be needed.

A developmental, body-oriented intervention for children and adolescents with medically unexplained chronic pain.

PubMed

Kozlowska, Kasia; Khan, Rubina

2011-10-01

The regulation of pain and other emotions is a developmental process that takes place in the context of attachment relationships. Children with chronic, medically unexplained pain struggle to accurately identify, communicate and regulate negative body states, and to connect these body states to their day-to-day experience. This article describes an individual intervention - one component of a multimodal treatment programme - whose aim is to help children find skills to manage their pain. The intervention incorporates ideas and practices from several theoretical models - the dynamic-maturational model of attachment, cognitive-behavioural theories, narrative therapy, art therapy, sensorimotor approaches -pragmatically selected and adapted to help children presenting to our Chronic Pain Service achieve good clinical outcomes. At the outset we assess the child's capacity to identify, regulate and communicate positive and negative body states, and tailor our individual intervention so as to extend each child's proximal level of development. We initially focus on the body in an effort to equip the child with a non-verbal, image-based language for identifying and communicating pain and other negative body states. Once the child has developed a non-verbal way of knowing her body, a range of cognitive-behavioural, narrative and other strategies are introduced. The intervention aims to increase the child's emotional functioning: her skill in identifying, symbolically representing, communicating and managing pain and other negative body states.

[Uterine anomalies in women with recurrent pregnancy loss].

PubMed

Galamb, Ádám; Pethő, Boglárka; Fekete, Dávid; Petrányi, Győző; Pajor, Attila

2015-07-05

One percent of couples trying to have children are affected by recurrent miscarriage. These pregnancy losses have different pathogenetic (genetic, endocrine, anatomic, immunologic, microbiologic, haematologic and andrologic) backgrounds, but recurrent miscarriage remains unexplained in more than half of the affected couples. To explore risk factors for recurrent pregnancy loss the authors studied the incidence of anatomic disorders of the uterine cavity occur in Hungarian women with recurrent miscarriage. Medical records of 152 patients with recurrent miscarriage were analyzed retrospectively. In order to explore disorders of the uterine cavity hysteroscopy or 3-dimensional sonography in 132 women, hysterosalpingography in 16 and hysterosalpingo-sonography in 4 patients were used. Incidence of anomalies in the uterine cavity was found in women with recurrent miscarriage to be 15.8%. A variety of the uterine anomalies was found including uterine septum in 6.5%, endometrial polyp in 2.6%, arcuate and bicornuate uteri both in 2% and 2%, submucosal myoma in 1.3 %, and intrauterine synechiae in 1.3%. These findings suggest that morphologic disorder of the uterine cavity is frequent in Hungarian women with recurrent miscarriage. Therefore, assessment of the uterine anatomy is recommended in such patients.

Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management.

PubMed

Nolte, Kurt B; Hanzlick, Randy L; Payne, Daniel C; Kroger, Andrew T; Oliver, William R; Baker, Andrew M; McGowan, Dennis E; DeJong, Joyce L; Bell, Micahel R; Guarner, Jeannette; Shieh, Wun-Ju; Zaki, Sherif R

2004-06-11

Medical examiners and coroners (ME/Cs) are essential public health partners for terrorism preparedness and response. These medicolegal investigators support both public health and public safety functions and investigate deaths that are sudden, suspicious, violent, unattended, and unexplained. Medicolegal autopsies are essential for making organism-specific diagnoses in deaths caused by biologic terrorism. This report has been created to 1) help public health officials understand the role of ME/Cs in biologic terrorism surveillance and response efforts and 2) provide ME/Cs with the detailed information required to build capacity for biologic terrorism preparedness in a public health context. This report provides background information regarding biologic terrorism, possible biologic agents, and the consequent clinicopathologic diseases, autopsy procedures, and diagnostic tests as well as a description of biosafety risks and standards for autopsy precautions. ME/Cs' vital role in terrorism surveillance requires consistent standards for collecting, analyzing, and disseminating data. Familiarity with the operational, jurisdictional, and evidentiary concerns involving biologic terrorism-related death investigation is critical to both ME/Cs and public health authorities. Managing terrorism-associated fatalities can be expensive and can overwhelm the existing capacity of ME/Cs. This report describes federal resources for funding and reimbursement for ME/C preparedness and response activities and the limited support capacity of the federal Disaster Mortuary Operational Response Team. Standards for communication are critical in responding to any emergency situation. This report, which is a joint collaboration between CDC and the National Association of Medical Examiners (NAME), describes the relationship between ME/Cs and public health departments, emergency management agencies, emergency operations centers, and the Incident Command System.

Ten questions about terminology for children with unexplained language problems

PubMed Central

Bishop, D V M

2014-01-01

Background In domains other than language, there is fairly consistent diagnostic terminology to refer to children's developmental difficulties. For instance, the terms ‘dyslexia’, ‘attention deficit hyperactivity disorder’ and ‘autistic spectrum disorder’ are used for difficulties with reading, attention or social cognition, respectively. There is no agreed label, however, for children with unexplained language problems. Aims To consider whether we need labels for unexplained language problems in children, and if so, what terminology is appropriate. Main Contribution There are both advantages and disadvantages to labels, but they are important to ensure children receive services, and to increase our knowledge of the nature and causes of such problems. A survey of labels in current use found 132 different terms, 33 of which had 600 or more returns on Google Scholar between 1994 and 2013. Many of these labels were too general to be useful. Of the remainder, the term ‘specific language impairment’ was the most commonly used. Conclusions The current mayhem in diagnostic labels is unsustainable; it causes confusion and impedes research progress and access to appropriate services. We need to achieve consensus on diagnostic criteria and terminology. The DSM-5 term ‘language disorder’ is problematic because it identifies too wide a range of conditions on an internet search. One solution is to retain specific language impairment, with the understanding that ‘specific’ means idiopathic (i.e., of unknown origin) rather than implying there are no other problems beyond language. Other options are the terms ‘primary language impairment’, ‘developmental language disorder’ or ‘language learning impairment’. PMID:25142090

Awareness of cancer symptoms and anticipated patient interval for healthcare seeking. A comparative study of Denmark and Sweden.

PubMed

Hvidberg, Line; Lagerlund, Magdalena; Pedersen, Anette F; Hajdarevic, Senada; Tishelman, Carol; Vedsted, Peter

2016-07-01

Background Recent epidemiologic data show that Denmark has considerably poorer survival from common cancers than Sweden. This may be related to a lower awareness of cancer symptoms and longer patient intervals in Denmark than in Sweden. The aims of this study were to: 1) compare population awareness of three possible symptoms of cancer (unexplained lump or swelling, unexplained bleeding and persistent cough or hoarseness); 2) compare anticipated patient interval when noticing any breast changes, rectal bleeding and persistent cough; and 3) examine whether potential differences were noticeable in particular age groups or at particular levels of education in a Danish and Swedish population sample. Method Data were derived from Module 2 of the International Cancer Benchmarking Partnership. Telephone interviews using the Awareness and Beliefs about Cancer measure were conducted in 2011 among 3000 adults in Denmark and 3070 adults in Sweden. Results Danish respondents reported a higher awareness of two of three symptoms (i.e. unexplained lump or swelling and persistent cough or hoarseness) and a shorter anticipated patient interval for two of three symptoms studied (i.e. any breast changes and rectal bleeding) than Swedish respondents. Differences in symptom awareness and anticipated patient interval between these countries were most pronounced in highly educated respondents. Conclusion Somewhat paradoxically, the highest awareness of symptoms of cancer and the shortest anticipated patient intervals were found in Denmark, where cancer survival is lower than in Sweden. Thus, it appears that these differences in symptom awareness and anticipated patient interval do not help explain the cancer survival disparity between Denmark and Sweden.

Analysis of Wind Tunnel Polar Replicates Using the Modern Design of Experiments

NASA Technical Reports Server (NTRS)

Deloach, Richard; Micol, John R.

2010-01-01

The role of variance in a Modern Design of Experiments analysis of wind tunnel data is reviewed, with distinctions made between explained and unexplained variance. The partitioning of unexplained variance into systematic and random components is illustrated, with examples of the elusive systematic component provided for various types of real-world tests. The importance of detecting and defending against systematic unexplained variance in wind tunnel testing is discussed, and the random and systematic components of unexplained variance are examined for a representative wind tunnel data set acquired in a test in which a missile is used as a test article. The adverse impact of correlated (non-independent) experimental errors is described, and recommendations are offered for replication strategies that facilitate the quantification of random and systematic unexplained variance.

Evaluating physical and behavioral changes in older adults.

PubMed

Walton, J C; Miller, J M

1998-04-01

In older adults, subtle and sometime not so subtle physical or behavior changes can act as early warning signs of changing status. Nonspecific signs and symptoms occurring in older adults such as decline in previous functional capacity, urinary incontinence, anorexia, confusion, or unexplained falls may be signs of infection, medication interaction, dehydration, constipation, or sleep deprivation. Nurses, by critically assessing the situation early, may identify a developing problem. Prompt and early diagnosis of the underlying problem may save costly extended hospitalization or even prevent life-threatening complications.

Competing and coexisting logics in the changing field of English general medical practice.

PubMed

McDonald, Ruth; Cheraghi-Sohi, Sudeh; Bayes, Sara; Morriss, Richard; Kai, Joe

2013-09-01

Recent reforms, which change incentive and accountability structures in the English National Health Service, can be conceptualised as trying to shift the dominant institutional logic in the field of primary medical care (general medical practice) away from medical professionalism towards a logic of "population based medicine". This paper draws on interviews with primary care doctors, conducted during 2007-2009 and 2011-2012. It contrasts the approach of active management of populations, in line with recent reforms with responses to patients with medically unexplained symptoms. Our data suggest that rather than one logic becoming dominant, different dimensions of organisational activity reflect different logics. Although some aspects of organisational life are relatively untouched by the reforms, this is not due to 'resistance' on the part of staff within these organisations to attempts to 'control' them. We suggest that a more helpful way of understanding the data is to see these different aspects of work as governed by different institutional logics. Copyright © 2012 Elsevier Ltd. All rights reserved.

Etiology of Syncope and Unexplained Falls in Elderly Adults with Dementia: Syncope and Dementia (SYD) Study.

PubMed

Ungar, Andrea; Mussi, Chiara; Ceccofiglio, Alice; Bellelli, Giuseppe; Nicosia, Franco; Bo, Mario; Riccio, Daniela; Martone, Anna Maria; Guadagno, Livia; Noro, Gabriele; Ghidoni, Giulia; Rafanelli, Martina; Marchionni, Niccolò; Abete, Pasquale

2016-08-01

To investigate the etiology of transient loss of consciousness (T-LOC) suspected to be syncope and unexplained falls in elderly adults with dementia. Prospective, observational, multicenter study. Acute care wards, syncope units or centers for the diagnosis of dementia. Individuals aged 65 and older with a diagnosis of dementia and one or more episodes of T-LOC of a suspected syncopal nature or unexplained falls during the previous 3 months were enrolled. The causes of T-LOC suspected to be syncope and unexplained falls were evaluated using a simplified protocol based on European Society of Cardiology guidelines. Of 357 individuals enrolled, 181 (50.7%) had been referred for T-LOC suspected to be syncope, 166 (46.5%) for unexplained falls, and 10 (2.8%) for both. An initially suspected diagnosis of syncope was confirmed in 158 (87.3%), and syncope was identified as the cause of the event in 75 (45.2%) of those referred for unexplained falls. Orthostatic hypotension was the cause of the event in 117 of 242 (48.3%) participants with a final diagnosis of syncope. The simplified syncope diagnostic protocol can be used in elderly people with dementia referred for suspected syncope or unexplained falls. Unexplained falls may mask a diagnosis of syncope or pseudosyncope in almost 50% of cases. Given the high prevalence of orthostatic syncope in participants (~50%), a systematic reappraisal of drugs potentially responsible for orthostatic hypotension is warranted. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Social characteristics and care needs of older persons with medically unexplained symptoms: a case-control study.

PubMed

Hanssen, Denise J C; Oude Voshaar, Richard C; Naarding, Paul; Rabeling-Keus, Inge M; Olde Hartman, Tim C; Lucassen, Peter L B J

2016-12-01

Research in younger patients with medically unexplained symptoms (MUS) has shown impairments in social functioning, such as loneliness and a reduced quality of the patient-doctor relationship. As far as we know, no studies have been performed on social functioning in older MUS patients; self-reported care needs of older MUS patients remain unknown. To explore social characteristics and care needs of older persons with chronic MUS, when compared to older persons with chronic medically explained symptoms (MES). Patient characteristics of 107 older persons (>60 years) with chronic MUS were compared to 150 older persons with chronic MES in a case-control design. Participants were recruited via advertisements, general practices and a specialized clinic. All participants completed questionnaires on social functioning; the Camberwell Assessment of Need for the Elderly was used to draw up care needs. Linear regression analyses were performed to explore the association between social characteristics and group (MUS/MES), adjusted for demographic and physical determinants. Multiple chi-square tests were performed to detect between-group differences regarding care needs. After adjustments, older MUS patients were slightly but significantly lonelier, reported a somewhat lower quality of their patient-doctor relationship, but reported equal social support levels when compared to MES patients. MUS patients more often reported unmet care needs regarding health and information provision about their health status. Only small differences in social functioning were found between older MUS and MES patients. Possibly, training future doctors in giving acceptable explanations for the patient's complaints could improve the unmet care need of information provision in older MUS patients. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study.

PubMed

den Boeft, Madelon; Twisk, Jos W R; Terluin, Berend; Penninx, Brenda W J H; van Marwijk, Harm W J; Numans, Mattijs E; van der Wouden, Johannes C; van der Horst, Henriette E

2016-03-22

Medically unexplained physical symptoms (MUPS) are highly prevalent and are associated with frequent health care use (HCU). MUPS frequently co-occur with psychiatric disorders. With this study we examined the longitudinal association between MUPS and HCU over 2 years and the influence of depressive and anxiety disorders and personality traits on this association. We analysed follow-up data from 2045 to 2981 participants from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study. The study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms for depressive and/or anxiety disorders and healthy controls. HCU, measured with the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness (TIC-P), was operationalized as the number of used medical services and the number of associated contacts. MUPS were measured with the Four Dimensional Symptoms Questionnaire, depressive and anxiety disorders with the Composite International Diagnostic Interview and personality traits with the NEO Five-Factory Inventory. Measurements were taken at baseline, 1 and 2 years follow-up. We used generalized estimating equations (GEE), using HCU at all three measurements as (multivariate) outcome. GEE also takes into account the dependency of observations within participants. MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017-1.022; contacts: RR 1.037, 95 % CI 1.030-1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008-1.014; contacts: RR 1.023, 95 % CI 1.015-1.032). Our results show that MUPS were positively associated with HCU over 2 years, even after adjusting for depressive and anxiety disorders and personality traits.

[A description of children and adolescents with somatic unexplained physical symptoms in a Dutch mental health care institution].

PubMed

Kouijzer, M E J; Loman, F; van der Feltz-Cornelis, C M

2013-01-01

Medically unexplained symptoms (MUS) occur frequently in children and adolescents. Treatment of MUS in children and adolescents takes place mainly in mental health care (MHC) institutions, as does the treatment of adults with MUS. However, there is hardly any literature about the prevalence of MUS in children and adolescents in MHC. To study the prevalence of MUS in children and adolescents in Dutch MHC. Comparisons were drawn between children and adolescents with MUS and those without MUS who had been referred to a Dutch MHC institution. Children and adolescents with MUS had more anxiety and depression and more introvert personality characteristics than children and adolescents without MUS. However, the quality of life of children and adolescents with MUS was similar to that of children and adolescents without MUS. One in five children and adolescents in Dutch MHC had MUS. These children and adolescents had introverted personality characteristics and showed anxious and depressed behavior, withdrawn-depressed behavior, and thought problems. The quality of life of children and adolescents with MUS and those without MUS was below average.

Increased Anti-HSP60 and Anti-HSP70 Antibodies in Women with Unexplained Recurrent Pregnancy Loss.

PubMed

Matsuda, Miwa; Sasaki, Aiko; Shimizu, Keiko; Kamada, Yasuhiko; Noguchi, Soichi; Hiramatsu, Yuji; Nakatsuka, Mikiya

2017-06-01

　Vascular dysfunction has been reported in women with recurrent pregnancy loss (RPL). We investigated the severity of vascular dysfunction in non-pregnant women with RPL and its correlation with anti-heat shock protein (HSP) antibodies that are known to induce arteriosclerosis. We measured the serum anti-HSP60 antibodies, anti-HSP70 antibodies, and anti-phospholipid antibodies (APA) in 68 women with RPL and 29 healthy controls. Among the women with RPL, 14 had a diagnosis of antiphospholipid syndrome (APS), and in the remaining 54, the causes for RPL were unexplained. Compared to the controls, the brachial-ankle pulse wave velocity (baPWV), carotid augmentation index (cAI), and uterine artery pulsatility index (PI) were all significantly higher in the women with both APS and unexplained RPL. Compared to the controls, the anti-HSP60 antibody levels were significantly higher in the APA-positive group of women with unexplained RPL, and the anti-HSP70 antibody levels were significantly higher in APS and APA-positive group of women with unexplained RPL. However, the anti-HSP60 and anti-HSP70 antibody levels did not correlate with the values of baPWV or cAI. Our results demonstrated anti-HSP60 and anti-HSP70 antibodies are increased in women with unexplained RPL. Further studies are needed to elucidate the roles of anti-HSP antibodies and their pathophysiology in unexplained RPL.

Extension of the Peters–Belson method to estimate health disparities among multiple groups using logistic regression with survey data

PubMed Central

Li, Y.; Graubard, B. I.; Huang, P.; Gastwirth, J. L.

2015-01-01

Determining the extent of a disparity, if any, between groups of people, for example, race or gender, is of interest in many fields, including public health for medical treatment and prevention of disease. An observed difference in the mean outcome between an advantaged group (AG) and disadvantaged group (DG) can be due to differences in the distribution of relevant covariates. The Peters–Belson (PB) method fits a regression model with covariates to the AG to predict, for each DG member, their outcome measure as if they had been from the AG. The difference between the mean predicted and the mean observed outcomes of DG members is the (unexplained) disparity of interest. We focus on applying the PB method to estimate the disparity based on binary/multinomial/proportional odds logistic regression models using data collected from complex surveys with more than one DG. Estimators of the unexplained disparity, an analytic variance–covariance estimator that is based on the Taylor linearization variance–covariance estimation method, as well as a Wald test for testing a joint null hypothesis of zero for unexplained disparities between two or more minority groups and a majority group, are provided. Simulation studies with data selected from simple random sampling and cluster sampling, as well as the analyses of disparity in body mass index in the National Health and Nutrition Examination Survey 1999–2004, are conducted. Empirical results indicate that the Taylor linearization variance–covariance estimation is accurate and that the proposed Wald test maintains the nominal level. PMID:25382235

[Diagnosis of a case with Williams-Beuren syndrome with nephrocalcinosis using chromosome microarray analysis].

PubMed

Jin, S J; Liu, M; Long, W J; Luo, X P

2016-12-02

Objective: To explore the clinical phenotypes and the genetic cause for a boy with unexplained growth retardation, nephrocalcinosis, auditory anomalies and multi-organ/system developmental disorders. Method: Routine G-banding and chromosome microarray analysis were applied to a child with unexplained growth retardation, nephrocalcinosis, auditory anomalies and multi-organ/system developmental disorders treated in the Department of Pediatrics of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in September 2015 and his parents to conduct the chromosomal karyotype analysis and the whole genome scanning. Deleted genes were searched in the Decipher and NCBI databases, and their relationships with the clinical phenotypes were analyzed. Result: A six-month-old boy was refered to us because of unexplained growth retardation and feeding intolerance.The affected child presented with abnormal manifestation such as special face, umbilical hernia, growth retardation, hypothyroidism, congenital heart disease, right ear sensorineural deafness, hypercalcemia and nephrocalcinosis. The child's karyotype was 46, XY, 16qh + , and his parents' karyotypes were normal. Chromosome microarray analysis revealed a 1 436 kb deletion on the 7q11.23(72701098_74136633) region of the child. This region included 23 protein-coding genes, which were reported to be corresponding to Williams-Beuren syndrome and its certain clinical phenotypes. His parents' results of chromosome microarray analysis were normal. Conclusion: A boy with characteristic manifestation of Williams-Beuren syndrome and rare nephrocalcinosis was diagnosed using chromosome microarray analysis. The deletion on the 7q11.23 might be related to the clinical phenotypes of Williams-Beuren syndrome, yet further studies are needed.

Investigating unexplained fatigue in general practice with a particular focus on CFS/ME.

PubMed

Bansal, Amolak S

2016-07-19

Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood.Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.

Clinical Usefulness of SPECT-CT in Patients with an Unexplained Pain in Metal on Metal (MOM) Total Hip Arthroplasty.

PubMed

Berber, Reshid; Henckel, Johann; Khoo, Michael; Wan, Simon; Hua, Jia; Skinner, John; Hart, Alister

2015-04-01

SPECT-CT is increasingly used to assess painful knee arthroplasties. The aim of this study was to evaluate the clinical usefulness of SPECT-CT in unexplained painful MOM hip arthroplasty. We compared the diagnosis and management plan for 19 prosthetic MOM hips in 15 subjects with unexplained pain before and after SPECT-CT. SPECT-CT changed the management decision in 13 (68%) subjects, Chi-Square=5.49, P=0.24. In 6 subjects (32%) pain remained unexplained however the result reassured the surgeon to continue with non-operative management. SPECT-CT should be reserved as a specialist test to help identify possible causes of pain where conventional investigations have failed. It can help reassure surgeons making management decisions for patients with unexplained pain following MOM hip arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.

Randomized trial of reattribution on psychosocial talk between doctors and patients with medically unexplained symptoms.

PubMed

Morriss, R; Gask, L; Dowrick, C; Dunn, G; Peters, S; Ring, A; Davies, J; Salmon, P

2010-02-01

In reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients. A cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor-patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation. After RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention. After RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.

Rift Valley fever outbreak--Kenya, November 2006-January 2007.

PubMed

2007-02-02

In mid-December 2006, several unexplained fatalities associated with fever and generalized bleeding were reported to the Kenya Ministry of Health (KMOH) from Garissa District in North Eastern Province (NEP). By December 20, a total of 11 deaths had been reported. Of serum samples collected from the first 19 patients, Rift Valley fever (RVF) virus RNA or immunoglobulin M (IgM) antibodies against RVF virus were found in samples from 10 patients; all serum specimens were negative for yellow fever, Ebola, Crimean-Congo hemorrhagic fever, and dengue viruses. The outbreak was confirmed by isolation of RVF virus from six of the specimens. Humans can be infected with RVF virus from bites of mosquitoes or other arthropod vectors that have fed on animals infected with RVF virus, or through contact with viremic animals, particularly livestock. Reports of livestock deaths and unexplained animal abortions in NEP provided further evidence of an RVF outbreak. On December 20, an investigation was launched by KMOH, the Kenya Field Epidemiology and Laboratory Training Program (FELTP), the Kenya Medical Research Institute (KEMRI), the Walter Reed Project of the U.S. Army Medical Research Unit, CDC-Kenya's Global Disease Detection Center, and other partners, including the World Health Organization (WHO) and Médecins Sans Frontières (MSF). This report describes the findings from that initial investigation and the control measures taken in response to the RVF outbreak, which spread to multiple additional provinces and districts, resulting in 404 cases with 118 deaths as of January 25, 2007.

Illness explanations among patients with medically unexplained symptoms: different idioms for different contexts.

PubMed

Risør, Mette Bech

2009-09-01

Patients with medically unexplained symptoms (MUS) are often considered to be strictly confined to thinking about their symptoms as having only a physical etiology. However, several studies have shown, that the patients also apply other explanations for their sufferings. The aim of this study is to analyse the social construction of illness explanations among patients with MUS, and to illustrate the use of explanatory idioms as being dependent on space, time and setting, legitimizing each idiom. The study is based on repeated, semi-structured, qualitative interviews with nine informants during a period of 1.5 years. A thematic content analysis was performed on a pragmatic and phenomenological basis. We found, that patients with MUS employ at least four different explanatory idioms defined as: (1) the symptomatic idiom; (2) the personal idiom; (3) the social idiom; and (4) the moral idiom. All idioms play an important role in the process of creating meaning in the patients' everyday life. The symptomatic idiom is mainly used at clinical consultations in primary care, but it is not the only idiom of significance for the patients. Simultaneously other idioms exist and gradually become important for especially patients with MUS due to the lack of valid diagnoses and treatment opportunities. Clinical settings, however, call for the employment of the symptomatic idiom and a discrepancy is found between the general practitioners' notion of the bio-psycho-social model and the patients' everyday life idioms.

The treatment of patients with medically unexplained physical symptoms in China: a study comparing expectations and treatment satisfaction in psychosomatic medicine, biomedicine, and traditional Chinese medicine.

PubMed

Fritzsche, Kurt; Xudong, Zhao; Anselm, Kathrin; Kern, Stephanie; Wirsching, Michael; Schaefert, Rainer

2011-01-01

Little is known about treatment for patients with medically unexplained symptoms (MUS) in China. This study investigates the treatment expectations and treatment satisfaction of patients with MUS in psychosomatic medicine, biomedicine, and Traditional Chinese Medicine (TCM). In a cross-sectional survey, n = 96 (10.3%) out of 931 participating patients were screened positive for multiple somatoform symptoms. These patients answered questionnaires concerning symptom duration, number of doctor visits, functional impairment, emotional distress, treatment expectations, treatment satisfaction, and empathy in the consultation. The physicians filled in a questionnaire about applied or recommended treatment. Most of the patients from psychosomatic medicine wanted psychotherapy. In TCM, 55% of the patients had already received TCM treatment and most of them wanted to continue TCM treatment. Patients in biomedicine did not express clear expectations; most of them had had no previous treatment. A combination of treatment methods was most prevalent in biomedicine in comparison to psychosomatic medicine and TCM. The outcome from the patients' point of view was significantly better in TCM than in psychosomatic medicine and biomedicine. Psychosomatic medicine's strength was the empathetic physician-patient interaction. From a biopsychosocial perspective, these results suggest that various treatment approaches with various emphases can be effective depending on the patient's complaints, his illness beliefs, and what the physician offers. The results will be verified in a larger multicenter longitudinal study.

Inheritance of Febrile Seizures in Sudden Unexplained Death in Toddlers

PubMed Central

Holm, Ingrid A.; Poduri, Annapurna; Crandall, Laura; Haas, Elisabeth; Grafe, Marjorie R.; Kinney, Hannah C.; Krous, Henry F.

2014-01-01

Sudden unexplained death in toddlers has been associated with febrile seizures, family history of febrile seizures, and hippocampal anomalies. We investigated the mode of inheritance for febrile seizures in these families. A three-generation pedigree was obtained from families enrolled in the San Diego Sudden Unexplained Death in Childhood Research Project, involving toddlers with sudden unexplained death, febrile seizures, and family history of febrile seizures. In our six cases, death was unwitnessed and related to sleep. The interval from last witnessed febrile seizure to death ranged from 3 weeks to 6 months. Hippocampal abnormalities were identified in one of three cases with available autopsy sections. Autosomal dominant inheritance of febrile seizures was observed in three families. A fourth demonstrated autosomal dominant inheritance with incomplete penetrance or variable expressivity. In two families, the maternal and paternal sides manifested febrile seizures. In this series, the major pattern of inheritance in toddlers with sudden unexplained death and febrile seizures was autosomal dominant. Future studies should develop markers (including genetic) to identify which patients with febrile seizures are at risk for sudden unexplained death in childhood, and to provide guidance for families and physicians. PMID:22490769

Attributions of Cancer ‘Alarm’ Symptoms in a Community Sample

PubMed Central

Whitaker, Katriina L.; Scott, Suzanne E.; Winstanley, Kelly; Macleod, Una; Wardle, Jane

2014-01-01

Background Attribution of early cancer symptoms to a non-serious cause may lead to longer diagnostic intervals. We investigated attributions of potential cancer ‘alarm’ and non-alarm symptoms experienced in everyday life in a community sample of adults, without mention of a cancer context. Methods A questionnaire was mailed to 4858 adults (≥50 years old, no cancer diagnosis) through primary care, asking about symptom experiences in the past 3 months. The word cancer was not mentioned. Target 'alarm' symptoms, publicised by Cancer Research UK, were embedded in a longer symptom list. For each symptom experienced, respondents were asked for their attribution (‘what do you think caused it'), concern about seriousness (‘not at all’ to ‘extremely’), and help-seeking (‘did you contact a doctor about it’: Yes/No). Results The response rate was 35% (n = 1724). Over half the respondents (915/1724; 53%) had experienced an ‘alarm’ symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for ‘unexplained lump’; 7% (6/87). Cancer attributions were lowest for ‘unexplained weight loss’ (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be ‘serious’, ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking. Conclusions Consistent with retrospective reports from cancer patients, ‘alarm’ symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer. PMID:25461959

Functional illness in primary care: dysfunction versus disease

PubMed Central

Williams, Nefyn; Wilkinson, Clare; Stott, Nigel; Menkes, David B

2008-01-01

Background The Biopsychosocial Model aims to integrate the biological, psychological and social components of illness, but integration is difficult in practice, particularly when patients consult with medically unexplained physical symptoms or functional illness. Discussion This Biopsychosocial Model was developed from General Systems Theory, which describes nature as a dynamic order of interacting parts and processes, from molecular to societal. Despite such conceptual progress, the biological, psychological, social and spiritual components of illness are seldom managed as an integrated whole in conventional medical practice. This is because the biomedical model can be easier to use, clinicians often have difficulty relinquishing a disease-centred approach to diagnosis, and either dismiss illness when pathology has been excluded, or explain all undifferentiated illness in terms of psychosocial factors. By contrast, traditional and complementary treatment systems describe reversible functional disturbances, and appear better at integrating the different components of illness. Conventional medicine retains the advantage of scientific method and an expanding evidence base, but needs to more effectively integrate psychosocial factors into assessment and management, notably of 'functional' illness. As an aid to integration, pathology characterised by structural change in tissues and organs is contrasted with dysfunction arising from disordered physiology or psychology that may occur independent of pathological change. Summary We propose a classification of illness that includes orthogonal dimensions of pathology and dysfunction to support a broadly based clinical approach to patients; adoption of which may lead to fewer inappropriate investigations and secondary care referrals and greater use of cognitive behavioural techniques, particularly when managing functional illness. PMID:18482442

Hypochondria: the worried well.

PubMed

Wick, Jeannette Y; Zanni, Guido R

2008-03-01

Approximately 13% of physician visits are for medically unexplained physical symptoms (MUPS), and up to 25% of patients report MUPS during visits to the doctor. Most of these patients' symptoms abate. But approximately 5% of patients are convinced they have a serious disease, although no problem can be diagnosed; these individuals are considered to be individuals with hypochondria. Estimates indicate they consume at least 10% of health care dollars and frustrate health care professionals. Treatment is possible, but paradoxical in nature. Clinicians must accept that the patient's concerns are real, and respect the patient's psychological defenses.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report.

PubMed

Park, Sang-Hee; Lee, Yoon-Sook; Min, Too Jae; Kim, Woon Young; Kim, Jae Hwan; Park, Young Cheol

2014-10-01

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report

PubMed Central

Park, Sang-hee; Min, Too Jae; Kim, Woon Young; Kim, Jae Hwan; Park, Young Cheol

2014-01-01

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis. PMID:25368787

Discordant transsexualism in male monozygotic twins: neuroanatomical and psychological differences.

PubMed

Andreazza, Tahiana Signorini; Costa, Angelo Brandelli; Massuda, Raffael; Salvador, Jaqueline; Silveira, Esalba Maria; Piccon, Felipe; Carvalho, Renata; Fontanari, Anna Martha Vaitses; Koff, Walter; Belmonte-de-Abreu, Paulo; Lobato, Maria Inês Rodrigues

2014-02-01

One monozygotic male twin pair discordant for transsexualism is described. Both twins were interviewed and tested with the Wechsler Adult Intelligence Scale battery for cognitive functions and they underwent magnetic resonance imaging to measure the volumes of specific cerebral structures. Interviews with the twins and their mother indicated no unusual medical or life history events that could have had a causal role in the emergence of the disorder. Both cognitive function testing and neuroimaging detected differences between the twins that could be related to unexplained epigenetic effects and exogenous hormone usage.

Cross-cultural differences in the epidemiology of unexplained fatigue syndromes in primary care.

PubMed

Skapinakis, Petros; Lewis, Glyn; Mavreas, Venetsanos

2003-03-01

Unexplained fatigue has been extensively studied but most of the samples used were from Western countries. To present international data on the prevalence of unexplained fatigue and fatigue as a presenting complaint in primary care. Method Secondary analysis of the World Health Organization study of psychological problems in general health care. A total of 5438 primary care attenders from 14 countries were assessed with the Composite International Diagnostic Interview. The prevalence of unexplained fatigue of 1-month duration differed across centres, with a range between 2.26 (95% CI 1.17-4.33) and 15.05 (95% CI 10.85-20.49). Subjects from more-developed countries were more likely to report unexplained fatigue but less likely to present with fatigue to physicians compared with subjects from less developed countries. In less-developed countries fatigue might be an indicator of unmet psychiatric need, but in more-developed countries it is probably a symbol of psychosocial distress.

Sperm chromatin structure assay results in Nigerian men with unexplained infertility

PubMed Central

Kolade, Charles Oluwabukunmi

2015-01-01

Objective Several publications have established a relationship between sperm DNA damage and male factor infertility, based on data from America, Europe, and Asia. This study aimed to compare the extent of sperm DNA damage in sperm samples from Nigerian men with unexplained infertility and in sperm samples from a fertile group composed of sperm donors who had successfully impregnated a female partner naturally or through assisted conception. Methods A total of 404 men underwent male fertility evaluation at Androcare Laboratories and Cryobank participated in this study. Semen analysis and a sperm chromatin structure assay (SCSA) were performed on all subjects. Results The men in the unexplained infertility group were slightly older than the men in the fertile sperm group (36±10 years vs. 32±6 years, p=0.051). No significant difference was observed between the two groups in semen analysis parameters (p≥0.05). Men in the unexplained infertility group with normal semen parameters had a significantly higher DNA fragmentation index (DFI) than men in the fertile sperm group (27.5%±7.0% vs. 14.1%±5.3%, p<0.05). In the unexplained infertility group, 63% of the men had a DFI greater than 20%, compared to 4% in the fertile sperm group. In the unexplained infertility group, 15.2% of the subjects had a DFI greater than 30%, compared to 1% in the fertile sperm group. Conclusion Our study showed that the SCSA may be a more reliable predictor of fertility potential than traditional semen analysis in cases of unexplained infertility. PMID:26473109

Prevalence, Types, Risk Factors and Clinical Correlates of Anaemia in Older People in a Rural Ugandan Population

PubMed Central

Mugisha, Joseph O.; Baisley, Kathy; Asiki, Gershim; Seeley, Janet; Kuper, Hannah

2013-01-01

Background Studies conducted in high income countries have shown that anaemia is a common medical condition among older people, but such data are scarce in Africa. The objectives of this study were to estimate the prevalence, types, risk factors and clinical correlates of anaemia in older people. Methods Participants were aged (≥ 50) years recruited from a general population cohort from January 2012 to January 2013. Blood samples were collected for assessing hemoglobin, serum ferritin, serum vitamin B12, serum folate, C-reactive protein, malaria infection and stool samples for assessment of hookworm infection. HIV status was assessed using an algorithm for HIV rapid testing. Questionnaires were used to collect data on sociodemographic characteristics and other risk factors for anaemia. Results In total, 1449 people participated (response rate 72.3%). The overall prevalence of anaemia was 20.3 % (95% CI 18.2-22.3%), and this was higher for males (24.1%, 95% CI=20.7-27.7%) than females (17.5%, 95% CI=15.0-20.1%). In males, the prevalence of anaemia increased rapidly with age almost doubling between 50 and 65 years (p-trend<0.001). Unexplained anaemia was responsible for more than half of all cases (59.7%). Anaemia was independently associated with infections including malaria (OR 3.49, 95% CI 1.78-6.82), HIV (OR 2.17, 1.32-3.57) heavy hookworm infection (OR 3.45, 1.73-6.91), low fruit consumption (OR 1.55, 1.05-2.29) and being unmarried (OR 1.37 , 95% CI 1.01-1.89). However, the odds of anaemia were lower among older people with elevated blood pressure (OR 0.47, 95% CI 0.29-0.77). Conclusion Anaemia control programmes in Uganda should target older people and should include interventions to treat and control hookworms and educational programs on diets that enhance iron absorption. Clinicians should consider screening older people with HIV or malaria for anaemia. Further studies should be done on unexplained anaemia and serum ferritin levels that predict iron deficiency anaemia in older people. PMID:24194926

The symmetry rule: a seven-year study of symptoms and explanatory labels among Gulf War veterans.

PubMed

Brewer, Noel T; Hallman, William K; Kipen, Howard M

2008-12-01

Noticing medical symptoms can cause one to search for explanatory labels such as "ate bad food" or even "exposed to anthrax," and perhaps these labels may cause new symptom reports. The present study examined whether there is empirical support for this symptom-label "symmetry rule." We interviewed veterans (N= 362) from the Gulf War Registry in 1995 and 2002 about their medical symptoms and about their exposure to war-related hazards and stressors. Health symptom reports were strongly correlated between the two time periods and showed relatively stable mean levels, whereas recall of war-related exposures was notably unstable. Veterans starting with fewer medical symptoms recalled fewer war-related exposures seven years later. Initial recollection of chemical and biological warfare exposure (but not other exposures) longitudinally predicted novel medical symptoms. The findings generally support the symmetry rule hypotheses, although the evidence for the label to symptom link was less strong. The findings account for some variability in symptoms and exposure recall over time, but they do not, on their own, account for the Gulf War veterans' elevated number of unexplained medical symptoms.

Modeling Efficacy of Bevacizumab Treatment for Metastatic Colon Cancer

PubMed Central

Islam, Rezwan; Chyou, Po-Huang; Burmester, James K

2013-01-01

Purpose: Bevacizumab, an FDA-approved adjuvant treatment for metastatic colon cancer, has extended survival for many patients. However, factors predicting response to treatment remain undefined. Patients and Methods: Relevant clinical and environmental data were abstracted from medical records of 149 evaluable patients treated with bevacizumab for metastatic colon cancer at a multi-specialty clinic. Tumor response was calculated from radiologic reports using Response Evaluation Criteria in Solid Tumors (RECIST) criteria and verified by oncologist review. Patients with at least one occurrence of complete or partial response or stable disease were classified as responders; those exhibiting progressive disease were classified as non-responders. Results: Univariate analysis demonstrated that blood in stool (P<0.05), unexplained weight loss (P<0.05), primary colon cancer site (P<0.05), chemotherapy treatment of primary tumor site (P<0.05), and adenocarcinoma versus adenoma subtype (P<0.05) was associated with tumor responsiveness. Factors remaining statistically significant following multivariate modeling included adenocarcinoma as tumor cell type versus other adenocarcinoma subtypes (OR=6.35, 95% CI: 1.08-37.18), chemotherapy treatment applied to primary tumor (OR= 0.07, 95% CI: 0.0-0.76,), tumor localization to cecal/ascending colon (OR=0.061, 95% CI: 0.006-0.588,), and unexplained weight loss (OR=0.1, 95% CI: 0.02-0.56,). Chemotherapy treatment of primary tumor, unexplained weight loss, and cecal/ascending localization of the tumor were associated with poorer outcomes. Adenocarcinoma as cell type compared to other adenocarcinoma subtypes was associated with better response to bevacizumab treatment. Conclusion: Results suggest that response to bevacizumab therapy may be predicted by modeling clinical factors including symptomology on presentation, tumor location and type, and initial response to chemotherapy. PMID:23678369

Multiple unexplained fractures in infants and child physical abuse.

PubMed

Cannell, John Jacob; Holick, Michael F

2018-01-01

When an infant presents with X-rays showing multiple unexplained fractures in various stages of healing (MUFVSH), the child is usually diagnosed with child abuse based on criteria of the Academy of Pediatrics' Committee on Child Abuse and Neglect (AAPCCAAN). Almost always, the infant is subsequently removed from the home and civil or criminal proceeding commence. It may be that healing infantile rickets or other poorly understood metabolic bone disorders of infancy are responsible for these x-rays. Activated vitamin D is a seco-steroid hormone, whose mechanism of action is genetic regulation. Lack of it can result in musculoskeletal defects known as rickets. Low calcium can also cause rickets. However, it is clear that experts for the state believe that the x-rays in these cases are so definitive as to be pathognomonic for child abuse. Therefore, if the caregivers deny abusing their infants, experts following American Academy of Pediatric's Committee on Child Abuse and Neglect. guidelines are essentially claiming that x-rays showing multiple unexplained fractures in various stages of healing are lie detector tests. However, it is not widely appreciated that the gold standard for the diagnosis of rickets is a bone biopsy, not x-rays, as radiologists miss biopsy proven rickets 80% of the time; that is, 4 out of 5 infants with rickets will have normal x-rays. In this article we provide reports of two cases and their outcomes. We discuss information about healing infantile rickets and an example of common sense medical conclusions in these cases. This information could lead to a significant reduction in the number of innocent parents having their infant removed or sent to prison. Copyright © 2016 Elsevier Ltd. All rights reserved.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'.

PubMed

Carson, A; Stone, J; Hibberd, C; Murray, G; Duncan, R; Coleman, R; Warlow, C; Roberts, R; Pelosi, A; Cavanagh, J; Matthews, K; Goldbeck, R; Hansen, C; Sharpe, M

2011-07-01

To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease. As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status. 3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)). New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Subfertility in Women With Rheumatoid Arthritis and the Outcome of Fertility Assessments.

PubMed

Brouwer, Jenny; Fleurbaaij, Rosalie; Hazes, Johanna M W; Dolhain, Radboud J E M; Laven, Joop S E

2017-08-01

Subfertility is frequently encountered among female rheumatoid arthritis (RA) patients and has been associated with disease activity and antirheumatic drugs. However, little is known about the results of the fertility assessments in these women. Our aim was to study the outcome of fertility assessments in subfertile women with RA. A cross-sectional study was performed in a nationwide cohort of female RA patients who were pregnant or trying to conceive between 2002 and 2010 (Pregnancy-Induced Amelioration of Rheumatoid Arthritis Study). Patients who had given consent for future contact (n = 260) received a questionnaire on reproductive history, fertility examinations, and fertility treatments. Medical files were obtained from attending gynecologists. A completed questionnaire was returned by 178 women (68%), of whom 96% had ended their efforts to conceive. Eighty-two subjects (46%) had at least 1 subfertile episode, and for 61 women a diagnosis for subfertility was available. Unexplained subfertility (48%) and anovulation (28%) were the most common gynecologic diagnoses, and both occurred more often in RA patients than reported in the general population. Women with unexplained subfertility more often used nonsteroidal antiinflammatory drugs (NSAIDs) during the periconceptional period. Seventeen percent of all pregnancies were conceived after fertility treatments. Fertility treatments had equal or higher pregnancy rates in RA compared to other subfertile populations. Unexplained subfertility is more often diagnosed in subfertile female RA patients than in the general population, and is related to periconceptional NSAID use. Despite the higher incidence of subfertility in women with RA, the outcome of fertility treatments in these women appears favorable. © 2016 The Authors. Arthritis Care & Research published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.

Surgical lung biopsy in patients with hematological malignancy or hematopoietic stem cell transplantation and unexplained pulmonary infiltrates: improved outcome with specific diagnosis.

PubMed

Zihlif, Mamoon; Khanchandani, Geeta; Ahmed, Huma P; Soubani, Ayman O

2005-02-01

Using a retrospective review of medical records, we sought the findings of surgical lung biopsy (SLB) in patients with hematological malignancy or hematopoietic stem cell transplantation (HSCT) and unexplained pulmonary infiltrates and to determine the impact of this procedure on management and outcome of these patients. Sixty-two patients who underwent SLB were evaluated; 31 patients had underlying hematological malignancy and 31 patients were HSCT recipients; 58% of whom underwent allogeneic HSCT. Thirty-three patients (53%) had focal infiltrates on chest CT scan while 29 (47%) had diffuse infiltrates. Thirteen patients were mechanically ventilated prior to SLB, and 27 (43%) were neutropenic. There were 66 diagnoses in the 62 patients, 44 (67%) were specific and 22 (33%) were nonspecific. The most common specific diagnoses were infection (29%), malignancy (27%), and inflammatory conditions (11%). Aspergillosis was the most common diagnosis of all biopsies (21%). SLB led to a change in therapy in 40% of patients and was associated with complications in 7 patients (11%). Specific diagnosis was more likely to lead to a change in therapy (48% vs. 27%, P = 0.06) and was associated with a lower mortality when compared to a nonspecific finding (30% vs. 59%, P = 0.02). Nonspecific diagnosis, on the other hand, was seen more in patients on mechanical ventilation prior to SLB compared to those off mechanical ventilation (69% vs. 27%, P = 0.02). SLB provides a specific diagnosis in the majority of patients with hematologic malignancy or HSCT recipients and unexplained pulmonary infiltrates. Specific diagnosis is more likely to lead to a change in therapy and is associated with a better outcome. Copyright 2005 Wiley-Liss, Inc.

Hydrogen dimer structures in the far-infrared spectra of Jupiter and Saturn

NASA Technical Reports Server (NTRS)

Frommhold, L.; Samuelson, R.; Birnbaum, G.

1984-01-01

On the basis of a spectral line shape computation and radiative transfer calculations, it is shown that the unexplained, diminutive structures seen in the Voyager IRIS Jovian spectra near the hydrogen S0(0) and S0(1) rotational frequencies are due to bound-free transitions involving hydrogen dimers. The absorption intensities of these transitions, as well as of the collision-induced background, are given. These dimer structures may possibly prove to be useful for determining the helium/hydrogen ratio and the para-hydrogen fraction in the atmospheres of the outer planets.

Reversible dementia: two nursing home patients with voltage-gated potassium channel antibody-associated limbic encephalitis.

PubMed

Reintjes, Wesley; Romijn, Marloes D M; Hollander, Daan; Ter Bruggen, Jan P; van Marum, Rob J

2015-09-01

Voltage-gated potassium channel antibody-associated limbic encephalitis (VGKC-LE) is a rare disease that is a diagnostic and therapeutic challenge for medical practitioners. Two patients with VGKC-LE, both developing dementia are presented. Following treatment, both patients showed remarkable cognitive and functional improvement enabling them to leave the psychogeriatric nursing homes they both were admitted to. Patients with VGKC-LE can have a major cognitive and functional improvement even after a diagnostic delay of more than 1 year. Medical practitioners who treat patients with unexplained cognitive decline, epileptic seizures, or psychiatric symptoms should be aware of LE as an underlying rare cause. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Neonatal intrahepatic cholestasis caused by citrin deficiency in two Malaysian siblings: outcome at one year of life.

PubMed

Thong, M K; Boey, C C; Sheng, J S; Ushikai, M; Kobayashi, K

2010-01-01

We report two Malaysian siblings with neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD). The younger sibling, a six-month-old Chinese girl, presented with prolonged neonatal jaundice, and was investigated for biliary atresia. Urine metabolic screen showed the presence of urinary-reducing sugars, and she was treated with a lactose-free formula. NICCD was suspected based on the clinical history, examination and presence of urinary citrulline. Mutation study of the SLC25A13 gene showed the compound heterozygotes, 851del4 and IVS16ins3kb, which confirmed the diagnosis of NICCD in the patient and her three-year-old female sibling, who also had unexplained neonatal cholestasis. Long-term dietary advice, medical surveillance and genetic counselling were provided to the family. The diagnosis of NICCD should be considered in infants with unexplained prolonged jaundice. DNA-based genetic testing of the SLC25A13 gene may be performed to confirm the diagnosis retrospectively. An awareness of this condition may help in early diagnosis using appropriate metabolic and biochemical investigations, thus avoiding invasive investigations in infants with neonatal cholestasis caused by NICCD.

[A child whose parents denied her psychiatric care].

PubMed

de Vries, T W; Doddema, J W

2003-01-11

A 15-year-old girl was admitted because of an abdominal tumour and inability to eat. History revealed that after an accident at 9 years of age she increasingly developed medically unexplained signs and symptoms (e.g. tunnel vision with blindness, paralysis and loss of sensitivity below the umbilicus, periods of diminished consciousness). No somatic explanation could be found; the parents rejected psychiatric examination. Upon physical examination the patient's weight's was far below the third percentile (32 kg) and the tumour appeared to be the lumbar spine, palpable through the abdominal wall. Following tube feeding and behavioural therapy the girl gained weight and the tumour disappeared. No cause for the underweight was found. Conversion disorder was diagnosed. However, the parents strongly refused to accept this diagnosis; they lodged complaints with various bodies and made further treatment and counseling impossible. Children with psychological problems who were treated as having a somatic disorder by their mothers have been described before. The outcome can be lethal. Children showing unexplained signs and symptoms whose parents strongly refuse psychiatric care will be seriously jeopardised in terms of their somatic and psychological development. Physicians should identify this situation at an early stage.

Usefulness of Medical Thoracoscopy in the Management of Pleural Effusion Caused by Chronic Renal Failure.

PubMed

Colella, Sara; Fioretti, Federica; Massaccesi, Chiara; Primomo, Gian L; Panella, Gianluca; D'Emilio, Vittorio; Pela, Riccardo

2017-10-01

Although pleural effusion (PE) can be caused by several pathologies like congestive heart failure, infections, malignancies, and pulmonary embolism, it is also a common finding in chronic kidney disease (CKD). Diagnostic thoracentesis is of limited value in the differential diagnosis, and the role of more invasive investigations like medical thoracoscopy (MT) is still unclear. To evaluate the usefulness of MT in unexplained PE in CKD. In the electronic database of our Institution, we retrospectively searched for patients with CKD who underwent MT for unexplained PE between January 2008 and August 2016. Ten patients were included in the present study. The average age was 72.4 years, the male:female ratio 9:1 and the average blood creatinine value 5.96 mg/dL. The average follow-up was 18 months.A thoracentesis showed an exudate was found in 9 patients and in 1 case pleural fluid characteristics were not recorded for technical reasons; in none of them the cytologic or microbiological analyses were considered diagnostic.The clinical suspicion was a neoplastic (5) or an infectious disease (5). In 4 patients with recurrent PE, MT was performed to obtain talc pleurodesis.No immediate procedure-related complications were recorded; 1 patient developed empyema after 2 months. In 6 cases final diagnosis was chronic uremic pleuritis, hydrothorax in 2, and chronic lymphocytic pleurisy in 2. MT represents a safe and effective diagnostic and therapeutic procedure in patients with CKD, that itself is a common cause of exudative effusion, and those patients may not require MT.

Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice.

PubMed

Aamland, Aase; Malterud, Kirsti; Werner, Erik L

2014-05-29

Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients' characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners' (GPs) management strategy. During a four-week period the participating Norwegian GPs (n=84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age. The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling. A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of "MUPS patients" as a group.

Psychological factors associated with self-reported sensitivity to mobile phones.

PubMed

Rubin, G James; Cleare, Anthony J; Wessely, Simon

2008-01-01

Some people report symptoms associated with mobile phone use. A minority also report "electrosensitivity," experiencing symptoms following exposure to other electrical devices. Research suggests that electromagnetic fields do not trigger these symptoms. In this study, we examined the differences between these two "sensitive" groups and healthy controls. Fifty-two people who reported sensitivity to mobile phones, 19 people who reported sensitivity to mobile phones and "electrosensitivity," and 60 nonsensitive controls completed a questionnaire assessing the following: primary reason for using a mobile phone, psychological health, symptoms of depression, modern health worries (MHW), general health status, symptom severity, and the presence of other medically unexplained syndromes. Perceived sensitivity was associated with an increased likelihood of using a mobile phone predominantly for work (3% of controls, 13% of those sensitive to mobile phones, and 21% of those reporting "electrosensitivity") and greater MHW concerning radiation [mean (S.D.) on a scale of 1-5: 2.0 (1.0), 2.7 (0.9), and 4.0 (0.8), respectively]. Participants who reported "electrosensitivity" also experienced greater depression, greater worries about tainted food and toxic interventions, worse general health on almost every measure, and a greater number of other medically unexplained syndromes compared to participants from the other two groups. No group differences were observed with regards to psychiatric cases. The data illustrate that patients reporting "electrosensitivity" experience substantially worse health than either healthy individuals or people who report sensitivity to mobile phones but who do not adopt the label "electrosensitivity." Clinicians and researchers would be wise to pay greater attention to this subdivision.

[The Chinese expert consensus on clinical practice of "medically unexplained symptoms"].

PubMed

2017-02-01

"Medically unexplained symptoms" (MUS) are commonly seen in all clinical specialties. The preliminary investigations in China show a prevalence of MUS in 4.15%-18.2% of clinical patients. Based on international and national guidelines and the most advanced studies, a Chinese expert consensus on clinical practice of MUS is reached through three rounds of discussion seminars by 25 experts from various specialties including psychiatry, internal medicine, surgery, gynecology-obstetrics, otorhinolar-yngology and traditional Chinese medicine. Clinical doctors should be alert of patients whose discomfort complaints cannot be explained by organic conditions after thorough physical examination and necessary laboratory tests. MUS should be recognized as early as possible so as to avoid complicating iatrogenic factors. A full bio-psycho-social evaluation of the patient is the basic structure of understanding MUS patients. In clinical practice, a trustful doctor-patient relationship is the first step of successful treatment. Then after a reasonable clinical evaluation, explain to the patient that it is a harmless functional symptom, communicate with the patient and reach an acceptable therapeutic goal, help the patient understand the symptoms in a psycho-somatic aspect and rebuild confidence of getting back to normal life. Patients with mild symptoms can be treated by doctors in various specialties, from whom the patient seeks help. Patients with severe symptoms need multi-disciplinary care including specific psychotherapy. Pharmaceutical treatment includes symptom alleviating drugs and antidepressants. In clinical care of patients with "MUS" , a full bio-psycho-social evaluation, a good doctor-patient relationship, a treatment plan according to the severity of symptoms, and a multi-disciplinary cooperation should be noted and practiced.

Characteristics of Patients Referred to a Pediatric Infectious Diseases Clinic With Unexplained Fever.

PubMed

Statler, Victoria A; Marshall, Gary S

2016-09-01

Older case series established diagnostic considerations for children meeting a priori definitions of fever of unknown origin (FUO). No recent study has examined the final diagnoses of children referred for unexplained fever. This study was conducted with a retrospective chart review of patients referred to a pediatric infectious diseases clinic from 2008 to 2012 for unexplained fever. Sixty-nine of 221 patients were referred for "prolonged" unexplained fever. Ten of these were not actually having fever, and 11 had diagnoses that were readily apparent at the initial visit. The remaining 48 were classified as having FUO. The median duration of reported fever for these patients was 30 days; 15 had a diagnosis made, 5 of which were serious. None of the serious FUO diagnoses were infections. Of 152 patients with "recurrent" unexplained fever, 92 had an "intermittent" fever pattern, and most of these had sequential, self-limited viral illnesses or no definitive diagnosis made. Twenty of the 60 patients with a "periodic" fever pattern were diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Overall, 166 patients either were not having fever, had self-limited illnesses, or ultimately had no cause of fever discovered. Only 12 had a serious illness, 2 of which were infections (malaria and typhoid fever). Most children referred with unexplained fever had either self-limited illnesses or no specific diagnosis established. Serious diagnoses were unusual, suggesting that these diagnoses rarely present with unexplained fever alone, or that, when they do, the diagnoses are made by primary care providers or other subspecialists. © The Author 2015. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Lower FOXO3 mRNA expression in granulosa cells is involved in unexplained infertility.

PubMed

Yamamoto, Hikaru; Yamashita, Yoshiki; Saito, Natsuho; Hayashi, Atsushi; Hayashi, Masami; Terai, Yoshito; Ohmichi, Masahide

2017-06-01

The aim of this study was to investigate whether FOXO1 and FOXO3 mRNA expression in granulosa cells is the cause of unexplained infertility. Thirty-one patients aged <40 years (13 with unexplained infertility and 18 with male partner infertility as a control group) whose serum anti-Müllerian hormone level was >0.5 ng/μL were enrolled in the study. All patients underwent oocyte retrieval under a short protocol from June 2012 to October 2013. Real-time PCR was carried out using mRNA extracted from granulosa cells retrieved from mature follicles. We compared FOXO1 and FOXO3 mRNA expression ratios in granulosa cells between the unexplained infertility group and the male infertility group. The relation between FOXO1 and FOXO3 mRNA expression ratios in granulosa cells and assisted reproduction technology clinical outcome was also examined. FOXO3 mRNA expression ratio was significantly lower in the unexplained infertility group than in the male infertility group. Moreover, FOXO3 mRNA expression ratio showed a positive correlation with both the number of retrieved oocytes and serum anti-Müllerian hormone level. A positive correlation was also identified between FOXO1 mRNA expression and total dose of hMG. As well, the number of retrieved oocytes in the unexplained infertility group was statistically lower than that in the male infertility group. A lower FOXO3 mRNA expression in granulosa cells leads to poor oocyte development in patients with unexplained infertility undergoing controlled ovarian stimulation for in vitro fertilization-embryo transfer. © 2017 Japan Society of Obstetrics and Gynecology.

Maternal serum amyloid A level as a novel marker of primary unexplained recurrent early pregnancy loss.

PubMed

Ibrahim, Moustafa I; Ramy, Ahmed R; Abdelhamid, Ahmed S; Ellaithy, Mohamed I; Omar, Amna; Harara, Rany M; Fathy, Hayam; Abolouz, Ashraf S

2017-03-01

To assess maternal serum amyloid A (SAA) levels among women with primary unexplained recurrent early pregnancy loss (REPL). A prospective study was conducted among women with missed spontaneous abortion in the first trimester at Ain Shams University Maternity Hospital, Cairo, Egypt, between January 21 and December 25, 2014. Women with at least two consecutive primary unexplained REPLs and no previous live births were enrolled. A control group was formed of women with no history of REPL who had at least one previous uneventful pregnancy with no adverse outcomes. Serum samples were collected to measure SAA levels. The main outcome was the association between SAA and primary unexplained REPL. Each group contained 96 participants. Median SAA level was significantly higher among women with REPL (50.0 μg/mL, interquartile range 26.0-69.0) than among women in the control group (11.6 μg/mL, interquartile range 6.2-15.5; P<0.001). The SAA level was an independent indicator of primary unexplained REPL, after adjusting for maternal age and gestational age (odds ratio 1.12, 95% confidence interval 1.06-1.19; P<0.001). Elevated SAA levels found among women with primary unexplained REPL could represent a novel biomarker for this complication of pregnancy. © 2016 International Federation of Gynecology and Obstetrics.

Definition and epidemiology of unexplained infertility.

PubMed

Gelbaya, Tarek A; Potdar, Neelam; Jeve, Yadava B; Nardo, Luciano G

2014-02-01

The diagnosis of unexplained infertility can be made only after excluding common causes of infertility using standard fertility investigations,which include semen analysis, assessment of ovulation, and tubal patency test. These tests have been selected as they have definitive correlation with pregnancy. It is estimated that a standard fertility evaluation will fail to identify an abnormality in approximately 15% to 30% of infertile couples. The reported incidence of such unexplained infertility varies according to the age and selection criteria in the study population. We conducted a review of the literature via MEDLINE. Articles were limited to English-language, human studies published between 1950 and 2013. Since first coined more than 50 years ago, the term unexplained infertility has been a subject of debate. Although additional investigations are reported to explain or define other causes of infertility, these have high false-positive results and therefore cannot be recommended for routine clinical practice. Couples with unexplained infertility might be reassured that even after 12 months of unsuccessful attempts, 50% will conceive in the following 12 months and another 12% in the year after.

Association of Testosterone Levels With Anemia in Older Men

PubMed Central

Roy, Cindy N.; Snyder, Peter J.; Stephens-Shields, Alisa J.; Artz, Andrew S.; Bhasin, Shalender; Cohen, Harvey J.; Farrar, John T.; Gill, Thomas M.; Zeldow, Bret; Cella, David; Barrett-Connor, Elizabeth; Cauley, Jane A.; Crandall, Jill P.; Cunningham, Glenn R.; Ensrud, Kristine E.; Lewis, Cora E.; Matsumoto, Alvin M.; Molitch, Mark E.; Pahor, Marco; Swerdloff, Ronald S.; Cifelli, Denise; Hou, Xiaoling; Resnick, Susan M.; Walston, Jeremy D.; Anton, Stephen; Basaria, Shehzad; Diem, Susan J.; Wang, Christina; Schrier, Stanley L.; Ellenberg, Susan S.

2017-01-01

Importance In one-third of older men with anemia, no recognized cause can be found. Objective To determine if testosterone treatment of men 65 years or older with unequivocally low testosterone levels and unexplained anemia would increase their hemoglobin concentration. Design, Setting, and Participants A double-blinded, placebo-controlled trial with treatment allocation by minimization using 788 men 65 years or older who have average testosterone levels of less than 275 ng/dL. Of 788 participants, 126 were anemic (hemoglobin Š12.7 g/dL), 62 of whom had no known cause. The trial was conducted in 12 academic medical centers in the United States from June 2010 to June 2014. Interventions Testosterone gel, the dose adjusted to maintain the testosterone levels normal for young men, or placebo gel for 12 months. Main Outcomes and Measures The percent of men with unexplained anemia whose hemoglobin levels increased by 1.0 g/dL or more in response to testosterone compared with placebo. The statistical analysis was intent-to-treat by a logistic mixed effects model adjusted for balancing factors. Results The men had a mean age of 74.8 years and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) of 30.7; 84.9% were white. Testosterone treatment resulted in a greater percentage of men with unexplained anemia whose month 12 hemoglobin levels had increased by 1.0 g/dL or more over baseline (54%) than did placebo (15%) (adjusted OR, 31.5; 95% CI, 3.7-277.8; P = .002) and a greater percentage of men who at month 12 were no longer anemic (58.3%) compared with placebo (22.2%) (adjusted OR, 17.0; 95% CI, 2.8-104.0; P = .002). Testosterone treatment also resulted in a greater percentage of men with anemia of known cause whose month 12 hemoglobin levels had increased by 1.0 g/dL or more (52%) than did placebo (19%) (adjusted OR, 8.2; 95% CI, 2.1-31.9; P = .003). Testosterone treatment resulted in a hemoglobin concentration of more than 17.5 g/dL in 6 men who had not been anemic at baseline. Conclusions and Relevance Among older men with low testosterone levels, testosterone treatment significantly increased the hemoglobin levels of those with unexplained anemia as well as those with anemia from known causes. These increases may be of clinical value, as suggested by the magnitude of the changes and the correction of anemia in most men, but the overall health benefits remain to be established. Measurement of testosterone levels might be considered in men 65 years or older who have unexplained anemia and symptoms of low testosterone levels. PMID:28241237

Interdisciplinary diagnostics in environmental medicine--findings and follow-up in patients with chronic medically unexplained health complaints.

PubMed

Herr, Caroline E; Kopka, Ines; Mach, Jens; Runkel, Bettina; Schill, Wolf-Bernhard; Gieler, Uwe; Eikmann, Thomas F

2004-01-01

In patients attributing their chronic, medically unexplained complaints to environmental factors the greatest challenge is to overcome their disabling belief in toxicogenic explanations. Patients presenting with health complaints that they attributed to environmental causes in an environmental outpatient department (EOPD) within a university medical center in Germany were studied. An interdisciplinary review of previously diagnosed medical conditions, current clinical consultations, personal risk communication and therapeutic advice is presented. Additionally, patient contentedness, complaint development, and belief in environmental attribution in a follow-up interview are given. The open, prospective study comprises 51 patients reporting more than one complaint. Symptoms had lasted for more than 3 years in 63% of the cases. Seventy percent attributed their complaints to more than one environmental cause. The clinical diagnostic procedure reduced the number of prediagnosed clinical conditions by 50%. Numerous foregoing environmental laboratory analyses had overestimated toxicologically relevant findings. These were not confirmed in 80% (8/10) of the cases. In 8% (n = 4) of the patients a relevant environmental or occupational medical condition was found. A mental or behavioral condition was not considered to have first priority in explaining all complaints in 43% (22/51) of the patients. Among these, mostly respiratory or skin-related diseases were found. All patients contacted participated in a follow-up study after a minimum of 21 months. Sixty-seven percent reported having felt that they were taken seriously, 38% felt better after the beginning of the study, and 45% were no longer certain about the importance of the environmental attribution. Since 83% of the patients with a preceding residential diagnosis of MCS or SBS still believed in environmental causes of their complaints in the follow-up study, we conclude that these prediagnoses appear to be a risk for persisting attribution of the environmental factor. About one third (37%) of these patients with complaints that had not been medically explained by an organic condition during interdisciplinary diagnostics had meanwhile consulted a psychotherapist. Interdisciplinary diagnostics and scientifically based risk assessment in a specialized clinical center were effective and mostly well accepted by the patients and resulted in reduced attribution of complaints to environmental conditions. No indication was found that patients with complaints not medically explained by organic conditions were managed less successfully by this approach. Considering the high costs that these patients have previously caused, it appears valuable to apply an interdisciplinary diagnostic strategy.

Incidence and risk factors of aplastic anemia in Latin American countries: the LATIN case-control study

PubMed Central

Maluf, Eliane; Hamerschlak, Nelson; Cavalcanti, Alexandre Biasi; Júnior, Álvaro Avezum; Eluf-Neto, José; Falcão, Roberto Passetto; Lorand-Metze, Irene G.; Goldenberg, Daniel; Santana, Cézar Leite; de Oliveira Werneck Rodrigues, Daniela; da Motta Passos, Leny Nascimento; Rosenfeld, Luis Gastão Mange; Pitta, Marimilia; Loggetto, Sandra; Feitosa Ribeiro, Andreza A.; Velloso, Elvira Deolinda; Kondo, Andrea Tiemi; de Miranda Coelho, Erika Oliveira; Pintão, Maria Carolina Tostes; de Souza, Hélio Moraes; Borbolla, José Rafael; Pasquini, Ricardo

2009-01-01

Background Associations between aplastic anemia and numerous drugs, pesticides and chemicals have been reported. However, at least 50% of the etiology of aplastic anemia remains unexplained. Design and Methods This was a case-control, multicenter, multinational study, designed to identify risk factors for agranulocytosis and aplastic anemia. The cases were patients with diagnosis of aplastic anemia confirmed through biopsy or bone marrow aspiration, selected through an active search of clinical laboratories, hematology clinics and medical records. The controls did not have either aplastic anemia or chronic diseases. A total of 224 patients with aplastic anemia were included in the study, each case was paired with four controls, according to sex, age group, and hospital where the case was first seen. Information was collected on demographic data, medical history, laboratory tests, medications, and other potential risk factors prior to diagnosis. Results The incidence of aplastic anemia was 1.6 cases per million per year. Higher rates of benzene exposure (≥30 exposures per year) were associated with a greater risk of aplastic anemia (odds ratio, OR: 4.2; 95% confidence interval, CI: 1.82–9.82). Individuals exposed to chloramphenicol in the previous year had an adjusted OR for aplastic anemia of 8.7 (CI: 0.87–87.93) and those exposed to azithromycin had an adjusted OR of 11.02 (CI 1.14–108.02). Conclusions The incidence of aplastic anemia in Latin America countries is low. Although the research study centers had a high coverage of health services, the underreporting of cases of aplastic anemia in selected regions can be discussed. Frequent exposure to benzene-based products increases the risk for aplastic anemia. Few associations with specific drugs were found, and it is likely that some of these were due to chance alone. PMID:19734415

A note on cognitive dissonance and malingering.

PubMed

Merckelbach, Harald; Merten, Thomas

2012-01-01

This paper proposes that malingered symptoms may become internalized due to the self-deceptive power of cognitive dissonance. Studies demonstrating how other-deception may turn into self-deception are briefly discussed, as are clinical notions about the overlap between malingering and medically unexplained symptoms. In our view this literature showcases the relevance of cognitive dissonance for research on malingering. A cognitive dissonance perspective may help to clarify how ambiguous sensations may escalate into subjectively compelling symptoms. This perspective suggests that malingered symptom reports are more than just a complication during psychological evaluation. It may generate new research avenues and may clarify practically relevant issues.

[Hypochondriasis and somatisation in elderly].

PubMed

Thomas, Philippe; Hazif-Thomas, Cyril; Pareaud, Maurice

2008-11-30

Anxiety or masked depression are often associated with somatisation in elderly. Hypochondriasis is an excessive preoccupation or worry about having a serious illness. The DSM-IV defines it as a somatoform disorder. It affects about 3% of the population but has a heavy health care cost. Depression, obsessive-compulsive disorder generalized anxiety and somatization disorder are common in elderly and are the most common accompanying conditions in people with hypochondriasis. Old persons' unexplained medical symptoms in generalized anxiety and their relationship to the somatoform disorders are presented. Supportive care and psychotherapy are as necessary as antidepressant to help patients.

Somatization disorders in dermatology.

PubMed

Gupta, Madhulika A

2006-02-01

This paper reviews a wide range of somatization-related symptoms that are encountered in dermatology. These include the unexplained cutaneous sensory syndromes especially the cutaneous dysesthesias associated with pain, numbness and pruritus; traumatic memories in post-traumatic stress disorder (PTSD) which are experienced on a sensory level as 'body memories' and may present as local or generalized pruritic states, urticaria and angioedema; and unexplained flushing reactions and profuse perspiration, in addition to unexplained exacerbations of stress-reactive dermatoses such as psoriasis and atopic eczema secondary to the autonomic hyperarousal in PTSD; classic 'pseudoneurologic' symptoms associated with dissociation including unexplained loss of touch or pain, in addition to the self-induced dermatoses such as dermatitis artefacta and trichotillomania that are encountered with dissociative states; and body dysmorphic disorder where the patient often presents with a somatic preoccupation involving the skin or hair.

Screening for Chlamydia trachomatis in Egyptian women with unexplained infertility, comparing real-time PCR techniques to standard serology tests: case control study.

PubMed

Abdella, Rana M A; Abdelmoaty, Hatem I; Elsherif, Rasha H; Sayed, Ahmed Mahmoud; Sherif, Nadine Alaa; Gouda, Hisham M; El Lithy, Ahmed; Almohamady, Maged; Abdelbar, Mostafa; Hosni, Ahmed Naguib; Magdy, Ahmed; Ma, Youssef

2015-06-02

To study the prevalence of Chlamydia infection in women with primary and secondary unexplained infertility using ELISA technique for antibody detection and real time, fully automated PCR for antigen detection and to explore its association with circulating antisperm antibodies (ASA). A total of 50 women with unexplained infertility enrolled in this case control study and a control group of 44 infertile women with a known cause of infertility. Endocervical specimens were collected for Chlamydia antigen detection using PCR and serum samples for antibodies detection. Circulating anti-sperm antibodies were detected using sperm antibody Latex Agglutination tests. The overall prevalence of Chlamydial infection in unexplained infertility cases as detected by both ELISA and PCR was 40 % (20/50). The prevalence of current Chlamydial genital infection as detected by real-time PCR was only 6.0 % (3/50); two of which were also IgM positive. Prevalence of ASA was 6.0 % (3/50); all were sero-negative for anti-C.trachomatis IgM and were PCR negative. The incidence of Chlamydial infection in Egyptian patients with unexplained infertility is relatively high. In the setting of fertility investigations; screening for anti. C.trachomatis antibodies using ELISA, and treatment of positive cases should be considered. The presence of circulating ASA does not correlate with the presence of old or current Chlamydia infection in women with unexplained infertility.

Explaining the Muslim employment gap in Western Europe: individual-level effects and ethno-religious penalties.

PubMed

Connor, Phillip; Koenig, Matthias

2015-01-01

It is well-documented that Muslims experience economic disadvantages in Western European labor markets. However, few studies comprehensively test individual-level explanations for the Muslim employment gap. Using data from the European Social Survey, this research note briefly examines the role of individual-level differences between Muslims and non-Muslims in mediating employment differences. Results reveal that human capital, migration background, religiosity, cultural values, and perceptions of discrimination jointly account for about 40% of the employment variance between Muslims and non-Muslims. Model specifications for first- and second-generation Muslim immigrants reveal a similar pattern, with migration background and perceived discrimination being of key relevance in mediating employment difference. While individual-level effects are indeed relevant, unexplained variance suggests that symbolic boundaries against Islam may still translate into tangible ethno-religious penalties. Copyright © 2014 Elsevier Inc. All rights reserved.

Incidence, Etiology, and Comparative Frequency of Sudden Cardiac Death in NCAA Athletes: A Decade in Review

PubMed Central

Harmon, Kimberly G.; Asif, Irfan M.; Maleszewski, Joseph J.; Owens, David S.; Prutkin, Jordan M.; Salerno, Jack C.; Zigman, Monica L.; Ellenbogen, Rachel; Rao, Ashwin; Ackerman, Michael J.; Drezner, Jonathan A.

2015-01-01

Background The incidence and etiology of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy (HCM) often reported as the most common etiology. Methods and Results A database of all NCAA deaths (2003 – 2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4,242,519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16,508 AY) followed by medical causes (147, 29%, 1:28,861 AY). The most common medical cause of death was SCD (79, 15%, 1:53,703 AY). Males were at higher risk than females 1:37,790 AY vs. 1:121,593 AY (IRR 3.2, 95% CI, 1.9-5.5, p < .00001), and black athletes were at higher risk than white athletes 1:21,491 AY vs. 1:68,354 AY (IRR 3.2, 95% CI, 1.9-5.2, p < .00001). The incidence of SCD in Division 1 male basketball athletes was 1:5,200 AY. The most common findings at autopsy were autopsy negative sudden unexplained death (AN-SUD) in 16 (25%) and definitive evidence for HCM was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%) while percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions The rate of SCD in NCAA athletes is high, with males, black athletes and basketball players at substantially higher risk. The most common finding at autopsy is AN-SUD. Media reports are more likely to capture high profile deaths, while insurance claims are not a reliable method for case identification. PMID:25977310

Use of health care services and pharmaceutical agents in coeliac disease: a prospective nationwide study

PubMed Central

2012-01-01

Background Approximately 1% of the population suffer from coeliac disease. However, the disease is heavily underdiagnosed. Unexplained symptoms may lead to incremented medical consultations and productivity losses. The aim here was to estimate the possible concealed burden of untreated coeliac disease and the effects of a gluten-free diet. Methods A nationwide cohort of 700 newly detected adult coeliac patients were prospectively evaluated. Health care service use and sickness absence from work during the year before diagnosis were compared with those in the general population; the data obtained from an earlier study. Additionally, the effect of one year on dietary treatment on the aforementioned parameters and on consumption of pharmaceutical agents was assessed. Results Untreated coeliac patients used primary health care services more frequently than the general population. On a gluten-free diet, visits to primary care decreased significantly from a mean 3.6 to 2.3. The consumption of medicines for dyspepsia (from 3.7 to 2.4 pills/month) and painkillers (6.8-5.5 pills/month) and the number of antibiotic courses (0.6-0.5 prescriptions/year) was reduced. There were no changes in hospitalizations, outpatient visits to secondary and tertiary care, use of other medical services, or sickness absence, but the consumption of nutritional supplements increased on treatment. Conclusions Coeliac disease was associated with excessive health care service use and consumption of drugs before diagnosis. Dietary treatment resulted in a diminished burden to the health care system and lower use of on-demand medicines and antibiotic treatment. The results support an augmented diagnostic approach to reduce underdiagnosis of coeliac disease. Trial registration ClinicalTrials.gov NCT01145287 PMID:23016889

Unexplained Cases of Allergic Reactions Linked to Red Meat

MedlinePlus

... that starts after being bitten by a lone star tick may cause unexplained cases of recurrent anaphylaxis. ... after eating meat. Previous studies have linked lone star tick bites to this unusual food allergy. The ...

Central Sensitization Syndrome and the Initial Evaluation of a Patient with Fibromyalgia: A Review

PubMed Central

Fleming, Kevin C.; Volcheck, Mary M.

2015-01-01

In both primary care and consultative practices, patients presenting with fibromyalgia (FM) often have other medically unexplained somatic symptoms and are ultimately diagnosed as having central sensitization (CS). Central sensitization encompasses many disorders where the central nervous system amplifies sensory input across many organ systems and results in myriad symptoms. A pragmatic approach to evaluate FM and related symptoms, including a focused review of medical records, interviewing techniques, and observations, is offered here, giving valuable tools for identifying and addressing the most relevant symptoms. At the time of the clinical evaluation, early consideration of CS may improve the efficiency of the visit, reduce excessive testing, and help in discerning between typical and atypical cases so as to avoid an inaccurate diagnosis. Discussion of pain and neurophysiology and sensitization often proves helpful. PMID:25973272

Influence of chronic barbiturate administration on sleep apnea after hypersomnia presentation: case study.

PubMed Central

Takhar, J; Bishop, J

2000-01-01

When sleepiness is excessive, undesirable, inappropriate or unexplained, it often indicates a clinical disorder that is generically termed hypersomnia. One of the leading causes of hypersomnia is sleep apnea. We present the case of a 44-year-old woman with a history of bipolar spectrum disorder and epilepsy who initially showed evidence of hypersomnia. The hypersomnia settled with changes to her medication, but the patient was subsequently found to have severe obstructive sleep apnea. The relation between the patient's medication and sleep apnea is discussed, and the possible respiratory-suppressant effects of chronic barbiturate treatment are considered. The role of other evoking factors within the context of this case and the mechanisms by which drug interactions and psychotropic treatment may worsen, obscure or perpetuate sleep apnea are also examined. PMID:11022396

A case of anorexia nervosa in an elderly man.

PubMed

Malik, Fahd; Wijayatunga, Uditha; Bruxner, George M

2014-06-01

To explore aspects of anorexia nervosa occurring in older populations, especially men, by reviewing the literature and presenting a case study of an elderly man with unexplained vomiting and weight loss. The literature is reviewed and an illustrative case study of an elderly man with unexplained vomiting and weight loss is described. Anorexia nervosa is an uncommon cause of unexplained weight loss in the elderly, but may be under-recognized and associated with a high level of mortality. © The Royal Australian and New Zealand College of Psychiatrists 2014.

The Symmetry Rule: A Seven-Year Study of Symptoms and Explanatory Labels Among GulfWar Veterans

PubMed Central

Brewer, Noel T.; Hallman, William K.; Kipen, Howard M.

2014-01-01

Noticing medical symptoms can cause one to search for explanatory labels such as “ate bad food” or even “exposed to anthrax,” and perhaps these labels may cause new symptom reports. The present study examined whether there is empirical support for this symptom-label “symmetry rule.” We interviewed veterans (N = 362) from the Gulf War Registry in 1995 and 2002 about their medical symptoms and about their exposure to war-related hazards and stressors. Health symptom reports were strongly correlated between the two time periods and showed relatively stable mean levels, whereas recall of war-related exposures was notably unstable. Veterans starting with fewer medical symptoms recalled fewer war-related exposures seven years later. Initial recollection of chemical and biological warfare exposure (but not other exposures) longitudinally predicted novel medical symptoms. The findings generally support the symmetry rule hypotheses, although the evidence for the label to symptom link was less strong. The findings account for some variability in symptoms and exposure recall over time, but they do not, on their own, account for the Gulf War veterans’ elevated number of unexplained medical symptoms. PMID:18795995

Gestational age of pregnancy loss in women with unexplained recurrent miscarriage.

PubMed

Ticconi, Carlo; Giuliani, Emma; Sorge, Roberto; Patrizi, Lodovico; Piccione, Emilio; Pietropolli, Adalgisa

2016-03-01

The aim of this study was to investigate the gestational age (GA) of pregnancy loss in women with unexplained recurrent miscarriage (RM) and to determine whether the miscarriages occur at similar GA in RM women. This retrospective study was carried out in a university hospital and included 288 women with unexplained RM. The GA at which each miscarriage occurred was carefully determined. Overall, 739 miscarriages were analyzed. RM women had miscarriages at a median GA of 7 weeks (range: 3-20). In RM women, 47.2% (n = 136) experienced miscarriages within a 1-week range of GA and 53.4% (n = 154) had miscarriages in the same period of fetal development (pre-embryonic, embryonic or fetal). Women with unexplained RM tend to have miscarriages at the same GA, which is characteristic for each patient. © 2015 Japan Society of Obstetrics and Gynecology.

Unexplained overexposures on physical dosimetry reported by biological dosimetry.

PubMed

Montoro, A; Almonacid, M; Villaescusa, J I; Verdu, G

2009-01-01

The Medical Service of the Radiation Protection Service from the University Hospital La Fe (Valencia, Spain), carries out medical examinations of the workers occupationally exposed to ionising radiation. The Biological Dosimetry Laboratory is developing its activity since 2001. Up to now, the activities have been focused in performing biological dosimetry studies of Interventionists workers from La Fe Hospital. Recently, the Laboratory has been authorized by the Health Authority in the Valencian Community. Unexplained overexposures of workers and patients are also studied. Workers suspected of being overexposed to ionising radiation were referred for investigation by cytogenetic analysis. Two of these were from Hospitals of the Valencian Community and one belonged to an uranium mine from Portugal. Hospital workers had a physical dose by thermoluminiscence dosimeters (TLD) that exceeded the established limit. The worker of the uranium mine received a dose from a lost source of Cesium 137 with an activity of 170 mCi. All three cases showed normal values after the hematological analysis. Finally, the aim of this study consist to determine whether the dose showed by the dosimeter is reliable or not. In the case of workers that wore dosimeter, it is concluded that the doses measured by dosimeter are not corresponding to real doses. Hospital worker with a physical dose of 2.6 Sv and 0.269 Sv had an estimated absorbed dose by biological dosimetry of 0.076 Gy (0-0.165 Gy) and 0 Gy (0-0.089 Gy), respectively. In case of the mine worker an estimated absorbed dose of 0.073 Gy (0-0.159 Gy) was obtained by biological dosimetry. In all cases we used the odds ratio to present the results due to a very low frequency of observed aberrations [1].

Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS).

PubMed

van Dessel, Nikki Claassen-; van der Wouden, Johannes C; Dekker, Joost; van der Horst, Henriette E

2016-03-01

This study aimed (1) to describe frequencies of DSM IV somatisation disorder, undifferentiated somatoform disorder and pain disorder versus DSM 5 somatic symptom disorder (SSD) in a multi-setting population of patients with medically unexplained physical symptoms (MUPS), (2) to investigate differences in sociodemographic and (psycho)pathological characteristics between these diagnostic groups and (3) to explore the clinical relevance of the distinction between mild and moderate DSM 5 SSD. We used baseline data of a cohort of 325 MUPS patients. Measurements included questionnaires about symptom severity, physical functioning, anxiety, depression, health anxiety and illness perceptions. These questionnaires were used as proxy measures for operationalization of DSM IV and DSM 5 diagnostic criteria. 92.9% of participants fulfilled criteria of a DSM IV somatoform disorder, while 45.5% fulfilled criteria of DSM 5 SSD. Participants fulfilling criteria of DSM 5 SSD suffered from more severe symptoms than those only fulfilling criteria of a DSM IV somatoform disorder(mean PHQ-15 score of 13.98 (SD 5.17) versus 11.23 (SD 4.71), P-value<0.001). Furthermore their level of physical functioning was significantly lower. Compared to patients with mild SSD, patients with moderate SSD suffered from significantly lower physical functioning and higher levels of depression. Within a population of MUPS patients DSM 5 SSD criteria are more restrictive than DSM IV criteria for somatoform disorders. They are associated with higher symptom severity and lower physical functioning. However, further specification of the positive psychological criteria of DSM 5 SSD may improve utility in research and practice. Copyright © 2016 Elsevier Inc. All rights reserved.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial.

PubMed

Schaefert, R; Kaufmann, C; Wild, B; Schellberg, D; Boelter, R; Faber, R; Szecsenyi, J; Sauer, N; Guthrie, E; Herzog, W

2013-01-01

Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention. We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS). At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group. Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care. Copyright © 2012 S. Karger AG, Basel.

Sustained medically unexplained physical symptoms in euthymic patients with recurrent depression: predictive value for recurrence and associations with omega 3- and 6 fatty acids and 5-HTTLPR?

PubMed

Lok, Anja; Assies, Johanna; Koeter, Maarten W J; Bockting, Claudi L H; Wouters, Luuk F; Mocking, Roel J T; Schene, Aart H

2012-02-01

Identification of potentially modifiable risk factors for recurrence in recurrent depression could provide opportunities to improve preventive interventions. In this study we aimed to examine the predictive value of medically unexplained physical symptoms (MUPS) on time to recurrence in recurrent depression. Additionally, to elucidate pathophysiological mechanisms that could explain the relations between MUPS and depression, we investigate the association between a sustained high level of MUPS, and (I) omega (ω)-3 and -6 fatty acid (FA)-status and (II) functional polymorphisms in the promoter region of the serotonin transporter gene (5-HTTLPR). Based on three Physical Symptom Checklist (PCS) scores over 12 months, we defined two groups of remitted recurrently depressed patients: 41 patients with a sustained high number of MUPS and 34 patients with a sustained low number or no MUPS. Patients were followed-up for 3.5 years while recurrence of their depression was monitored. In addition, we analyzed patients' erythrocyte's FA-profiles and triallelically genotyped their 5-HTTLPR. A sustained high level of MUPS predicted consecutive depression recurrence over 3.5 years (adjusted relative risk 2.8). FA-status and distribution of 5-HTTLPR variant frequencies did not differ between patients with sustained high compared to low/absent MUPS-levels. Our sample was relatively small. Remitted recurrently depressed patients with sustained MUPS have a considerably increased risk of recurrence. Having sustained MUPS is not associated with either erythrocyte ω-3 or -6 FA-levels or 5-HTTLPR polymorphism. Recognition and reducing MUPS in an early state could prevent a (depressive) relapse. Copyright © 2011 Elsevier B.V. All rights reserved.

Medically unexplained physical symptoms and work functioning over 2 years: their association and the influence of depressive and anxiety disorders and job characteristics.

PubMed

den Boeft, Madelon; Twisk, Jos W R; Hoekstra, Trynke; Terluin, Berend; Penninx, Brenda W J H; van der Wouden, Johannes C; Numans, Mattijs E; van der Horst, Henriette E

2016-04-14

Medically unexplained physical symptoms (MUPS) are highly prevalent and may affect work functioning. In this study we aimed to assess the longitudinal association between MUPS and work functioning over 2 years and the influence of job characteristics and depressive and anxiety disorders on this association. We assessed the longitudinal association between MUPS and work functioning, operationalized in terms of absenteeism and disability at work, in 1887 working participants from the Netherlands Study of Depression and Anxiety (NESDA). The NESDA study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms and healthy controls. Absenteeism was assessed with the Health and Labour Questionnaire Short Form and disability with the World Health Organization Disability Assessment Schedule II. MUPS were measured with the Four Dimensional Symptom Questionnaire. Measurements were taken at baseline and at 2 years follow-up. We used mixed model analyses to correct for the dependency of observations within participants. MUPS were positively associated with disability (regression coefficient 0.304; 95% CI 0.281-0.327) and with short and long-term absenteeism over 2 years (OR 1.030, 95% CI 1.016-1.045; OR 1.099, 95% CI 1.085-1.114). After adjusting for depressive disorders, anxiety disorders and job characteristics, associations weakened but remained significant. Our results show that MUPS were positively associated with disability and absenteeism over 2 years, even after adjusting for depressive and anxiety disorders and job characteristics. This suggests that early identification of MUPS and adequate management is important.

Recurrent Renal Colic in a Patient with Munchausen Syndrome

PubMed Central

Miconi, Francesco; Rapaccini, Valentina; Savarese, Emanuela; Cabiati, Gabriele; Pasini, Augusto; Miconi, Giovanni; Principi, Nicola

2018-01-01

Background: In most of the cases regarding children, factitious disorders (FDs) are intentionally produced by parents. Less attention is paid to FDs in which a child or adolescent intentionally induces or falsifies the disease to attain a patient’s role. Case presentation: A 13-year-old immigrated and adopted boy previously underwent an operation for renal joint syndrome and was affected by recurrent episodes of renal colic. The boy was admitted reporting acute left flank pain with scars on the mucous face of his prepuce and had a recent previous hospitalization for the same reason. Laboratory tests and radiological findings did not reveal any morphological or functional alterations. Self-induced FD was suspected, and a psychiatric consultation was performed. After psychiatric consultation and remission of the symptoms with a placebo, a diagnosis of Munchausen syndrome was suspected. The patient’s uncle was not initially convinced of the diagnosis. Some videos clearly showed that the boy was handling his prepuce to excrete stones, explaining the scars. A therapeutic plan with psychiatrist support was later accepted with a positive outcome. No further signs and symptoms of renal colic were reported. Conclusions: It is recommended that paediatricians include FD in the differential diagnosis of a persistent and unexplained medical condition. If suspicion arises, confirmation and long-term therapy by a group of qualified specialists, including psychiatrists, should be planned. PMID:29596350

[Medication use among community-dwelling older Icelanders. Population-based study in urban and rural areas].

PubMed

Sigurdardottir, Arun K; Arnadottir, Solveig Asa; Gunnarsdottir, Elín Díanna

2011-12-01

To describe medication use among older community-dwelling Icelanders by collecting information on number of medicine, polypharmacy (>5 medications), and medications by ATC categories. Moreover, to explore the relationship between medication use and various influential factors emphasizing residency in urban and rural areas. Population-based, cross-sectional study. Participants were randomly selected from the National registry in one urban (n=118) and two rural (n=68) areas. 1) ≥ 65 years old, 2) community-dwelling, 3) able to communicate verbally. Information on medication use was obtained from each person's medication list and interviews. A questionnaire and five standardized instruments were used to assess the potential influencing factors. On average, participants used 3.9 medications and prevalence of polypharmacy was 41%. Men used 3.5 medications on average and women 4.4 (p=0.018). Compared to rural residents, urban residents had fewer medical diagnoses, better mobility, less pain, and fewer depressive symptoms. By controlling for the effects of these variables, more medications were associated with urban living (p<0.001) and more medical diagnoses (p<0.001). Likewise, adjusted odds for polypharmacy increased with urban residency (p=0.023) and more medical diagnoses (p=0.005). Urban residency, more medical diagnoses, higher age, and male gender were related to use of drugs for blood and blood forming organs. The results reveal an unexplained regional difference in medications use by older Icelanders. Further studies are required on why urban residents use at least equal amount of medications as rural residents despite better scores on health assessments.

The Molecular Autopsy: Should the Evaluation Continue After the Funeral?

PubMed Central

Tester, David J.; Ackerman, Michael J.

2012-01-01

Sudden cardiac death (SCD) is one of the most common causes of death in developed countries, with most SCDs involving the elderly, and structural heart disease evident at autopsy. Each year, however, thousands of sudden deaths involving individuals younger than 35 years of age remain unexplained after a comprehensive medicolegal investigation that includes an autopsy. In fact, several epidemiologic studies have estimated that at least 3% and up to 53% of sudden deaths involving previously healthy children, adolescents, and young adults show no morphologic abnormalities identifiable at autopsy. Cardiac channelopathies associated with structurally normal hearts such as long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and Brugada syndrome (BrS) yield no evidence to be found at autopsy, leaving coroners, medical examiners, and forensic pathologists only to speculate that a lethal arrhythmia might lie at the heart of a sudden unexplained death (SUD). In cases of autopsy-negative SUD, continued investigation through either a cardiologic and genetic evaluation of first- or second-degree relatives or a molecular autopsy may elucidate the underlying mechanism contributing to the sudden death and allow for identification of living family members with the pathogenic substrate that renders them vulnerable, with an increased risk for cardiac events including syncope, cardiac arrest, and sudden death. PMID:22307399

Cancer screening behaviors and risk perceptions among family members of colorectal cancer patients with unexplained mismatch repair deficiency.

PubMed

Katz, Lior H; Advani, Shailesh; Burton-Chase, Allison M; Fellman, Bryan; Polivka, Katrina M; Yuan, Ying; Lynch, Patrick M; Peterson, Susan K

2017-04-01

Communication gaps in families with unexplained mismatch repair (MMR) deficiency (UMMRD) could negatively impact the screening behaviors of relatives of individual with UMMRD. We evaluated cancer risk perception, screening behaviors, and family communication among relatives of colorectal cancer (CRC) patients with UMMRD. Fifty-one family members of 17 probands with UMMRD completed a questionnaire about cancer risk perception, adherence to Lynch syndrome (LS) screening recommendations, and communication with relatives. Clinical data about the probands were obtained from medical records. Thirty-eight participants (78%) were worried from having cancer and twenty-one participants (42%) had undergone colonoscopy in the past 2 years, as recommended for LS families. In terms of screening for extracolonic cancers, only two eligible participants (3.9%) were screened for gastric, endometrial (10.0%), and ovarian (9.5%) cancers. Additionally, 5 participants (10%) underwent genetic counseling. Most participants were not told by anyone to be screened for extracolonic cancers (84, 85, and 95% for gastric, ovarian, and endometrial cancers, respectively). A minority of family members of CRC patients with UMMRD follow cancer screening as recommended for LS families. Health care providers should encourage patients with UMMRD to share information on LS-related cancers screening, especially extracolonic cancers, with their relatives.

Cancer screening behaviors and risk perceptions among family members of colorectal cancer patients with unexplained mismatch repair deficiency

PubMed Central

Advani, Shailesh; Burton-Chase, Allison M.; Fellman, Bryan; Polivka, Katrina M.; Yuan, Ying; Lynch, Patrick M.; Peterson, Susan K.

2018-01-01

Communication gaps in families with unexplained mismatch repair (MMR) deficiency (UMMRD) could negatively impact the screening behaviors of relatives of individual with UMMRD. We evaluated cancer risk perception, screening behaviors, and family communication among relatives of colorectal cancer (CRC) patients with UMMRD. Fifty-one family members of 17 probands with UMMRD completed a questionnaire about cancer risk perception, adherence to Lynch syndrome (LS) screening recommendations, and communication with relatives. Clinical data about the probands were obtained from medical records. Thirty-eight participants (78%) were worried from having cancer and twenty-one participants (42%) had undergone colonoscopy in the past 2 years, as recommended for LS families. In terms of screening for extracolonic cancers, only two eligible participants (3.9%) were screened for gastric, endometrial (10.0%), and ovarian (9.5%) cancers. Additionally, 5 participants (10%) underwent genetic counseling. Most participants were not told by anyone to be screened for extracolonic cancers (84, 85, and 95% for gastric, ovarian, and endometrial cancers, respectively). A minority of family members of CRC patients with UMMRD follow cancer screening as recommended for LS families. Health care providers should encourage patients with UMMRD to share information on LS-related cancers screening, especially extracolonic cancers, with their relatives. PMID:27832499

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2010 CFR

2010-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2013 CFR

2013-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2014 CFR

2014-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2011 CFR

2011-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2012 CFR

2012-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

Unexplained Absences and Risk of Death and Injury Among Nursing Home Residents: A Systematic Review.

PubMed

Woolford, Marta H; Weller, Carolina; Ibrahim, Joseph E

2017-04-01

Unexplained absence of nursing home (NH) residents is one of the most challenging issues related to the care of older people. The aim of this review was to examine the death and injury outcomes of unexplained absence of NH residents. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, AgeLine, and Cochrane Library to identify qualitative and quantitative studies published in the English language. Data on death and injury were collated, and aggregate proportions were calculated where possible. Nine studies were identified; most (n = 6) were conducted in the United States. Persons with dementia formed the study population in all studies. There were 1440 individual unexplained absences reported across the 9 studies. We calculated a rate of 82 deaths and 61 injuries per 1000 incidents of unexplained absence. Extreme temperatures were the most common cause of death. Most individuals left by foot, and were found within a 1-mile radius of place last seen in green vegetation and waterways. This review provides valuable insight into death and injury outcomes. Further studies are recommended to improve understanding and prevent adverse outcomes. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

IVF with planned single-embryo transfer versus IUI with ovarian stimulation in couples with unexplained subfertility: an economic analysis.

PubMed

van Rumste, Minouche M E; Custers, Inge M; van Wely, Madelon; Koks, Carolien A; van Weering, Hans G I; Beckers, Nicole G M; Scheffer, Gabrielle J; Broekmans, Frank J M; Hompes, Peter G A; Mochtar, Monique H; van der Veen, Fulco; Mol, Ben W J

2014-03-01

Couples with unexplained subfertility are often treated with intrauterine insemination (IUI) with ovarian stimulation, which carries the risk of multiple pregnancies. An explorative randomized controlled trial was performed comparing one cycle of IVF with elective single-embryo transfer (eSET) versus three cycles of IUI-ovarian stimulation in couples with unexplained subfertility and a poor prognosis for natural conception, to assess the economic burden of the treatment modalities. The main outcome measures were ongoing pregnancy rates and costs. This study randomly assigned 58 couples to IVF-eSET and 58 couples to IUI-ovarian stimulation. The ongoing pregnancy rates were 24% in with IVF-eSET versus 21% with IUI-ovarian stimulation, with two and three multiple pregnancies, respectively. The mean cost per included couple was significantly different: €2781 with IVF-eSET and €1876 with IUI-ovarian stimulation (P<0.01). The additional costs per ongoing pregnancy were €2456 for IVF-eSET. In couples with unexplained subfertility, one cycle of IVF-eSET cost an additional €900 per couple compared with three cycles of IUI-ovarian stimulation, for no increase in ongoing pregnancy rates or decrease in multiple pregnancies. When IVF-eSET results in higher ongoing pregnancy rates, IVF would be the preferred treatment. Couples that have been trying to conceive unsuccessfully are often treated with intrauterine insemination (IUI) and medication to improve egg production (ovarian stimulation). This treatment carries the risk of multiple pregnancies like twins. We performed an explorative study among those couples that had a poor prognosis for natural conception. One cycle of IVF with transfer of one selected embryo (elective single-embryo transfer, eSET) was compared with three cycles of IUI-ovarian stimulation. The aim of this study was to assess the economic burden of both treatments. The Main outcome measures were number of good pregnancies above 12weeks and costs. We randomly assigned 58 couples to IVF-eSET and 58 couples to IUI-ovarian stimulation. The ongoing pregnancy rates were comparable: 24% with IVF-eSET versus 21% with IUI-ovarian stimulation. There were two multiple pregnancies with IVF-eSET and three multiple pregnancies with IUI-ovarian stimulation. The mean cost per included couple was significantly different, €2781 with IVF-eSET and €1876 with IUI-ovarian stimulation. The additional costs per ongoing pregnancy were €2456 for IVF-eSET. In couples with unexplained subfertility, one cycle of IVF-eSET costed an additional €900 per couple compared to three cycles of IUI-ovarian stimulation, for no increase in ongoing pregnancy rates or decrease in multiple pregnancies. We conclude that IUI-ovarian stimulation is the preferred treatment to start with. When IVF-eSET results in a higher ongoing pregnancy rate (>38%), IVF would be the preferred treatment. Copyright © 2013 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy.

PubMed

Pearson, Michele L; Selby, Joseph V; Katz, Kenneth A; Cantrell, Virginia; Braden, Christopher R; Parise, Monica E; Paddock, Christopher D; Lewin-Smith, Michael R; Kalasinsky, Victor F; Goldstein, Felicia C; Hightower, Allen W; Papier, Arthur; Lewis, Brian; Motipara, Sarita; Eberhard, Mark L

2012-01-01

Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.

Comprehensive analysis of immune, extracellular matrices and pathogens profile in lung granulomatosis of unexplained etiology.

PubMed

da Costa Souza, Paola; Dondo, Patrícia Suemi; Souza, Gabriela; Lopes, Deborah; Moscardi, Marcel; de Miranda Martinho, Vinicius; de Mattos Lourenço, Rodolfo Daniel; Prieto, Tabatha; Balancin, Marcelo Luiz; Assato, Aline Kawassaki; Teodoro, Walcy Rosolia; Rodrigues, Silvia; Lima, Mariana; Castellano, Maria Vera; Coletta, Ester; Parra, Edwin Roger; Capelozzi, Vera Luiza

2018-05-01

This study analyzed the type 1 and type 2T helper (Th1/Th2) cytokines (including interleukins), immune cellular, matrix profile, and pathogens in granulomas with unexplained etiology compared to those with infectious and noninfectious etiology. Surgical lung biopsies from 108 patients were retrospectively reviewed. Histochemistry, immunohistochemistry, immunofluorescence, morphometry and polymerase chain reaction were used, respectively, to evaluate total collagen and elastin fibers, collagen I and III, immune cells, cytokines, matrix metalloproteinase-9, myofibroblasts, and multiple usual and unusual pathogens. No relevant polymerase chain reaction expression was found in unexplained granulomas. A significant difference was found between the absolute number of eosinophils, macrophages, and lymphocytes within granulomas compared to uninvolved lung tissue. Granulomas with unexplained etiology (UEG) presented increased number of eosinophils and high expression of interleukins (ILs) IL-4/IL-5 and transforming growth factor-β. In sarcoidosis, CD4/CD8 cell number was significantly higher within and outside granulomas, respectively; the opposite was detected in hypersensitivity pneumonitis. Again, a significant difference was found between the high number of myofibroblasts and matrix metalloproteinase-9 in UEG, hypersensitivity pneumonitis, and sarcoidosis compared to granulomas of tuberculosis. Granulomas of paracoccidioisis exhibited increased type I collagen and elastic fibers. Th1 immune cellular profile was similar among granulomas with unexplained, infectious, and noninfectious etiology. In contrast, modulation of Th2 and matrix remodeling was associated with more fibroelastogenesis and scarring of lung tissue in UEG compared to infectious and noninfectious. We concluded that IL-4/IL-5 and transforming growth factor-β might be used as surrogate markers of early fibrosis, reducing the need for genotyping, and promise therapeutic target in unexplained granulomas. Copyright © 2018 Elsevier Inc. All rights reserved.

Sexual function in infertile women with polycystic ovary syndrome and unexplained infertility.

PubMed

Diamond, Michael P; Legro, Richard S; Coutifaris, Christos; Alvero, Ruben; Robinson, Randal D; Casson, Peter A; Christman, Gregory M; Huang, Hao; Hansen, Karl R; Baker, Valerie; Usadi, Rebecca; Seungdamrong, Aimee; Bates, G Wright; Rosen, R Mitchell; Schlaff, William; Haisenleder, Daniel; Krawetz, Stephen A; Barnhart, Kurt; Trussell, J C; Santoro, Nanette; Eisenberg, Esther; Zhang, Heping

2017-08-01

While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P < .001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function. Copyright © 2017 Elsevier Inc. All rights reserved.

A case with unexplained bleeding from multiple sites: munchausen syndrome by proxy.

PubMed

Tüfekçi, Özlem; Gözmen, Salih; Yılmaz, Şebnem; Hilkay Karapınar, Tuba; Çetin, Benhur; Burak Dursun, Onur; Emiroğlu, Neslihan; Ören, Hale; Irken, Gülersu

2011-08-01

Munchausen syndrome by proxy (MBP) is an extreme form of child abuse where children were unnecessarily treated or investigated for medical conditions that were falsified by their caregivers. Here the authors report a 16-year-old female with the complaints of bleeding from multiple and unusual sites, including hemoptysis, hematuria, bloody tears, and bloody nipple discharge, all of which are only witnessed by her mother. Extensive investigation revealed no organic etiologies for bleeding. The diagnosis of MBP was put by a multidisciplinary team. The diagnosis of MBP must be kept in mind in conditions where there is no underlying organic pathology in a bleeding patient.

Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of perpetuating factors.

PubMed

Van Houdenhove, Boudewijn; Luyten, Patrick

2008-01-01

Syndromes characterized by chronic, medically unexplained fatigue, effort- and stress-intolerance, and widespread pain are highly prevalent in medicine. In chronic fatigue syndrome (CFS) and fibromyalgia (FM), various perpetuating factors may impair patients' quality of life and functioning and impede recovery. Although cognitive-behavioral and graded-exercise therapy are evidence-based treatments, the effectiveness and acceptability of therapeutic interventions in CFS/FM may largely depend on a customized approach taking the heterogeneity of perpetuating factors into account. Further research should clarify the aim and outcome of different treatment strategies in CFS/FM, as well as the underlying mechanisms of change, including those facilitating neurobiological recovery.

Two Cases of Transiently Elevated Serum CEA Levels in Severe Hypothyroidism without Goiter.

PubMed

Sekizaki, Tomonori; Yamamoto, Chiho; Nomoto, Hiroshi

2018-04-27

Carcinoembryonic antigen (CEA), the level of which is known to increase in both patients with gastrointestinal cancers and those with non-neoplastic conditions, is one of the most widely-used tumor markers. Hypothyroidism is a common endocrinological disorder in which CEA levels can rise, and is sometimes overlooked as a diagnosis in the absence of typical symptoms or thyroid enlargement. We report the cases of two patients with non-goiterous severe hypothyroidism with markedly elevated CEA levels that effectively decreased with levothyroxine replacement therapy alone. Hypothyroidism should be considered as an important cause of unexplained high serum CEA levels in order to avoid unnecessary medical examination.

Colonic histoplasmosis in acquired immunodeficiency syndrome. Report of two cases.

PubMed

Graham, B D; McKinsey, D S; Driks, M R; Smith, D L

1991-02-01

Colonic histoplasmosis is a rare entity. There have been four previous reported cases within the population of patients with human immunodeficiency virus (HIV) infection. Because of the increasing incidence of HIV infection within regions where histoplasmosis is endemic, this condition may become more common. Gastrointestinal histoplasmosis has protean clinical manifestations, and symptoms are often nonspecific. Any patient with HIV infection who has unexplained GI symptoms should undergo evaluation for possible histoplasmosis. Aggressive long-term amphotericin B therapy has been effective in HIV patients with histoplasmosis. Resection or diversion of symptomatic colonic strictures caused by histoplasmosis may be necessary in addition to medical therapy.

The relationship between the First World War and neurology: 100 years of "Shell Shock".

PubMed

Pedroso, José Luiz; Linden, Stefanie C; Barsottini, Orlando G; Maranhão, Péricles; Lees, Andrew J

2017-05-01

The First World War was a global war, beginning on 28 July 1914, until 11 November 1918. Soon after the beginning of the war, there was an "epidemic" of neurological conversion symptoms. Soldiers on both sides started to present in large numbers with neurological symptoms, such as dizziness, tremor, paraplegia, tinnitus, amnesia, weakness, headache and mutism of psychosomatic origin. This condition was known as shell shock, or "war neurosis". Because medically unexplained symptoms remain a major challenge, and considering the close relationship of symptoms described in shell shock with clinical neurology, we should study their history in order to improve future care.

"United We Stand": Framing Myalgic Encephalomyelitis in a Virtual Symbolic Community.

PubMed

Lian, Olaug S; Nettleton, Sarah

2015-10-01

In this article, we report on a study that seeks to explore how the contested chronic condition myalgic encephalomyelitis (ME), one of the current medical diagnoses for medically unexplained long-term exhaustion, is negotiated within the context of Norwegian internet sites. From an analysis of discussions on 14 internet forums sustained by and for people living with ME, we seek to understand how their online activity sustains a virtual symbolic community (VSC). After exploring the content on these sites, we identified four discursive domains, or fields of conversation, that are demarcated by a discursive frame, or norms, values, and goals that define and reinforce the boundaries of the community. Interpreting discursive domains and their discursive frame provides insight not only to the culture of the ME VSC but also to its role in an international social health movement, including its potential for becoming politically influential. © The Author(s) 2014.

Cultural differences in the experience of everyday symptoms: a comparative study of South Asian and European American women.

PubMed

Karasz, Alison; Dempsey, Kara; Fallek, Ronit

2007-12-01

This paper describes a study of medically ambiguous symptoms in two contrasting cultural groups. The study combined a qualitative, meaning-centered approach with a structured coding system and comparative design. Thirty-six South Asian immigrants and thirty-seven European Americans participated in a semistructured health history interview designed to elicit conceptual models of medically unexplained illness. The groups reported similar symptoms, but the organization of illness episodes and explanatory models associated with these episodes differed sharply. A variety of cultural variables and processes is proposed to account for observed differences, including somatization, the role of local illness categories, and the divergent core conflicts and values associated with gender roles. It is argued that the comparative design of the study provided insights that could not have been achieved through the study of a single group.

[Vaccinations and malaria prophylaxis for international travelers].

PubMed

Alberer, Martin; Löscher, Thomas

2015-05-01

The prevention of infectious diseases by vaccination and by counselling about malaria prophylaxis is a central aspect of travel medicine. Besides mandatory vaccinations required for entry to certain countries various vaccinations may be indicated depending on destination and type of travel as well as on individual risks of the traveler. In addition, pre-travel counselling should always include a check-up of standard vaccinations. Protection against mosquito bites is the basis of malaria prophylaxis. The addition of chemoprophylaxis is warranted in high risk areas. When regular chemoprophylaxis is not applied it is recommended to carry an appropriate antimalarial drug which can be used for emergency stand-by treatment in case of unexplained fever and when medical attention is not available within 24 hours. Travelers should realize that self-treatment is a first-aid measure and that they should still seek medical advice as soon as possible. © Georg Thieme Verlag KG Stuttgart · New York.

A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield.

PubMed

Wasserman, G M; Martin, B L; Hyams, K C; Merrill, B R; Oaks, H G; McAdoo, H A

1997-06-01

Reports suggest that deployed soldiers during Operations Desert Shield and Desert Storm remained healthy, but primary care data are limited. We reviewed the outpatient visit surveillance data from the 3d Armored Cavalry Regiment to obtain information regarding soldiers' health in the field. Nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits, followed by unintended injuries, gastrointestinal, respiratory, and dermatologic conditions. Visits for heat injuries, sexually transmitted diseases, unexplained fever, and psychiatric problems were low, probably due to preventive measures. These results suggest that increased prevention to decrease orthopedic problems and unintended injuries may substantially reduce outpatient visits during future deployments. Medical surveillance during future deployments can be improved by taking advantage of current advances in technology to facilitate patient data retrieval and provide timely information to first- and second-echelon medical personnel.

[Chlamydia trachomatis infection in mother and child; the importance of a complete history and efficient interdisciplinary communication].

PubMed

Naafs, Jolanda C; Kleinhout, Mirjam Y

2016-01-01

General practitioners and paediatricians are frequently confronted with coughing infants. The age of the infant, the history of both mother and child, as well as the current maternal condition may provide important diagnostic information. A 4-week-old male infant was referred to the paediatrician with a persistent cough. He was admitted to hospital with dyspnoea and need for supplemental oxygen. Meanwhile, his mother was admitted with unexplained abdominal pain and elevated laboratory inflammation markers. Her history revealed an ectopic pregnancy. The infant's condition, for which the initial differential diagnosis was viral bronchiolitis or whooping cough, deteriorated. His medical history revealed a purulent conjunctivitis. Chlamydia trachomatis PCR turned out to be positive in both mother and child. C. trachomatis pneumonia is a common, yet often overlooked cause of cough in infants. This clinical lesson emphasises the importance of a complete history and efficient communication between medical specialists.

White Matter Damage in 4,725 Term-Born Infants Is Determined by Head Circumference at Birth: The Missing Link

PubMed Central

Holmer, Bert

2018-01-01

Background White matter damage (WMD) is a prime risk factor for cerebral palsy, in part occurring unexplained. Though primarily a problem of preterm infants, there is growing evidence that in large newborns cephalopelvic disproportion and prolonged labor are involved. Objective To explore both incidence of and morphometric risk factors for WMD in term-born infants. Study Design We related growth variables and risk factors of term-born infants to WMD (61/4,725) using odds ratios of z-score bands. Results The key result is the novel observation that head circumference is a prime and unique index for WMD in term-born neonates over the whole range of centiles (U-shaped; WMD (%) = 3.1168–0.12797∗HC (centile) + 0.0014741∗HC2; p < 0.0001). This suggests different mechanisms for WMD in the lowest and highest z-score band. In the latter, cephalic pressure gradients and prolonged labor with preserved neonatal vitality prevail, whereas in the previous one, acute and chronic oxygen deprivation with reduced vitality predominate. Conclusions The fact that seemingly healthy term-born neonates are not screened by head imaging, in spite of both large head circumference and prolonged labor, is considered to be the missing link between the insult that escapes diagnosis and the development of unexplained developmental delay and cerebral palsy in childhood. PMID:29681945

Absence of subtelomeric rearrangements in selected patients with mental retardation as assessed by multiprobe T FISH

PubMed Central

2012-01-01

Background Mental retardation (MR) is a heterogeneous condition that affects 2-3% of the general population and is a public health problem in developing countries. Chromosomal abnormalities are an important cause of MR and subtelomeric rearrangements (STR) have been reported in 4-35% of individuals with idiopathic MR or an unexplained developmental delay, depending on the screening tests and patient selection criteria used. Clinical checklists such as that suggested by de Vries et al. have been used to improve the predictive value of subtelomeric screening. Findings Fifteen patients (1–20 years old; five females and ten males) with moderate to severe MR from a genetics outpatient clinic of the Gaffrée and Guinle Teaching Hospital (HUGG) of the Federal University of Rio de Janeiro State (UNIRIO) were screened with Multiprobe T FISH after normal high resolution karyotyping. No subtelomeric rearrangements were detected even though the clinical score of the patients ranged from four to seven. Conclusion In developing countries, FISH-based techniques such as Multiprobe T FISH are still expensive. Although Multiprobe T FISH is a good tool for detecting STR, in this study it did not detect STR in patients with unexplained MR/developmental delay even though these patients had a marked chromosomal imbalance. Our findings also show that clinical scores are not reliable predictors of STR. PMID:23259705

A Bermuda Triangle of Science

ERIC Educational Resources Information Center

Winkelsas, John

2006-01-01

The Bermuda Triangle is famous for the unexplained disappearances of ships and aircraft, and for strange meteorological phenomena that allegedly have occurred within its boundaries. This article presents an activity wherein students are asked to create their own geographical triangles to research, but instead of focusing on the unexplainable,…

Discrepancy between clinical practice and standardized indications for an implantable loop recorder in patients with unexplained syncope†

PubMed Central

Vitale, Elena; Ungar, Andrea; Maggi, Roberto; Francese, Maura; Lunati, Maurizio; Colaceci, Roberto; Del Rosso, Attilio; Castro, Antonio; Santini, Massimo; Giuli, Silvia; Belgini, Lara; Casagranda, Ivo; Brignole, Michele

2010-01-01

Aim An implantable loop recorder (ILR) is indicated in patients with unexplained syncope after complete conventional work-up. Data from the literature imply that, in clinical practice, the ILR is underused. The aim of the study was to verify if there is any discrepancy between the use of ILRs in clinical practice and the potential indications based on the most potentially appropriate guideline indications. Method and results We compared the prevalence of ILRs actually implanted in patients with unexplained syncope in the Syncope Unit Project (SUP) study and the potential one using the standard given by the guidelines. In the SUP study, 28 (18%) out of 159 patients with unexplained syncope received an ILR. Appropriate criteria for implantation of ILRs according to guidelines were present in 110 (69%) patients. Moreover, 7 (25%) of ILRs actually implanted did not satisfy the guideline standards. During the follow-up, 32% of patients who had received an ILR had a diagnosis compared with 5% of those who did not (P= 0.001). Conclusions The estimated indications were four times higher than those observed. Moreover, in about one quarter of the cases, the use of ILRs proved to be potentially inappropriate according to guideline indications. Two-thirds of patients with unexplained syncope had indications potentially appropriate for ILRs. PMID:20876604

Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution.

PubMed

Jones, Edgar; Hodgins-Vermaas, Robert; McCartney, Helen; Everitt, Brian; Beech, Charlotte; Poynter, Denise; Palmer, Ian; Hyams, Kenneth; Wessely, Simon

2002-02-09

To discover whether post-combat syndromes have existed after modern wars and what relation they bear to each other. Review of medical and military records of servicemen and cluster analysis of symptoms. Records for 1856 veterans randomly selected from war pension files awarded from 1872 and from the Medical Assessment Programme for Gulf war veterans. Characteristic patterns of symptom clusters and their relation to dependent variables including war, diagnosis, predisposing physical illness, and exposure to combat; and servicemen's changing attributions for post-combat disorders. Three varieties of post-combat disorder were identified-a debility syndrome (associated with the 19th and early 20th centuries), somatic syndrome (related primarily to the first world war), and a neuropsychiatric syndrome (associated with the second world war and the Gulf conflict). The era in which the war occurred was overwhelmingly the best predictor of cluster membership. All modern wars have been associated with a syndrome characterised by unexplained medical symptoms. The form that these assume, the terms used to describe them, and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare, and underlying cultural forces.

Medicine and public health in a multiethnic world.

PubMed

Bhopal, Raj

2009-09-01

Achievement of medical and public health goals requires mutual understanding between professionals and the public, a challenge in diverse societies. Despite their massive diversity humans belong to one species, with race and ethnicity used to subgroup/classify humans and manage diversity. Classifications are contextual and vary by time, place and classifier. As classifications show major variations in health status, and risk factors, research using race and ethnicity has accelerated. Medical sciences, including epidemiology, are learning fast to extract value from such data. Among the debatable issues is the value of the relative risk versus absolute risk approaches (the latter is gaining ground), and how to assess ethnicity and race (self-assignment is favoured in the UK and North America, country of birth in continental Europe). Racial and ethnic variations in disease and risk factors are often large and usually unexplained. There is a compelling case for ethnic monitoring, despite its difficulties, for tackling inequalities and as a foundation for research. Medical and public health goals require good data collected in a racism-free social environment. Health professionals need to find the benefits of exploring differences while avoiding social division. Advances in health care, public health and medical science will follow.

Diagnostic yield of hair and urine toxicology testing in potential child abuse cases.

PubMed

Stauffer, Stephanie L; Wood, Stephanie M; Krasowski, Matthew D

2015-07-01

Detection of drugs in a child may be the first objective finding that can be reported in cases of suspected child abuse. Hair and urine toxicology testing, when performed as part of the initial clinical evaluation for suspected child abuse or maltreatment, may serve to facilitate the identification of at-risk children. Furthermore, significant environmental exposure to a drug (considered by law to constitute child abuse in some states) may be identified by toxicology testing of unwashed hair specimens. In order to determine the clinical utility of hair and urine toxicology testing in this population we performed a retrospective chart review on all children for whom hair toxicology testing was ordered at our academic medical center between January 2004 and April 2014. The medical records of 616 children aged 0-17.5 years were reviewed for injury history, previous medication and illicit drug use by caregiver(s), urine drug screen result (if performed), hair toxicology result, medication list, and outcome of any child abuse evaluation. Hair toxicology testing was positive for at least one compound in 106 cases (17.2%), with unexplained drugs in 82 cases (13.3%). Of these, there were 48 cases in which multiple compounds (including combination of parent drugs and/or metabolites within the same drug class) were identified in the sample of one patient. The compounds most frequently identified in the hair of our study population included cocaine, benzoylecgonine, native (unmetabolized) tetrahydrocannabinol, and methamphetamine. There were 68 instances in which a parent drug was identified in the hair without any of its potential metabolites, suggesting environmental exposure. Among the 82 cases in which hair toxicology testing was positive for unexplained drugs, a change in clinical outcome was noted in 71 cases (86.5%). Urine drug screens (UDS) were performed in 457 of the 616 reviewed cases. Of these, over 95% of positive UDS results could be explained by iatrogenic drug administration. There were no cases in which a urine drug screen alone altered the outcome of a case. In summary, hair toxicology testing proved clinically useful in the evaluation of a child for suspected abuse; in contrast, urine drug testing showed low clinical yield. Copyright © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

Effects of mobile phone use on specific intensive care unit devices.

PubMed

Hans, Nidhi; Kapadia, Farhad N

2008-10-01

To observe the effects of mobile phone use in the vicinity of medical devices used in a critical care setting. Electromagnetic interference (EMI) was tested by using two types of mobile phones - GSM and CDMA. Mobile phones were placed at a distance of one foot from three medical devices - syringe pump, mechanical ventilator, and the bedside monitor - in switch off, standby, and talking modes of the phone. Medical devices were observed for any interference caused by the electromagnetic radiations (EMR) from the mobile phones. Out of the three medical devices that were tested, EMI occurred while using the mobile phone in the vicinity of the syringe pump, in the 'talk mode.' The mean variation observed in the calculated and delivered volume of the syringe pump was 2.66 ml. Mechanical ventilator did not show any specific adverse effects with mobile phone use in the one-foot vicinity. No other adverse effects or unexplained malfunctions or shutdown of the syringe pump, mechanical ventilator, or the bedside monitor was noted during the study period of 36 hours. EMI from mobile phones have an adverse effect on the medical devices used in critical care setup. They should be used at least one foot away from the diameter of the syringe pump.

A spiritual problem? Primary care physicians' and psychiatrists' interpretations of medically unexplained symptoms.

PubMed

Shin, Jiwon Helen; Yoon, John D; Rasinski, Kenneth A; Koenig, Harold G; Meador, Keith G; Curlin, Farr A

2013-03-01

Patients commonly present to their physicians with medically unexplained symptoms (MUS), and there is no consensus about how physicians should interpret or treat such symptoms. To examine how variations in physicians' interpretations of MUS are associated with physicians' religious characteristics and with physician specialty (primary care vs. psychiatry). A national survey of a stratified random sample of 1,504 primary care physicians and 512 psychiatrists in 2009-2010. The extent to which physicians believe MUS reflect a root problem that is spiritual in nature or result from conditions that scientific research will eventually explain, and whether such patients would benefit from attention to their relationships, attention to their spiritual life, taking medications, and/or treatment by physicians. Response rate was 63 % (1,208/1,909). More religious/spiritual physicians were more likely to believe that MUS reflect a spiritual problem (55 % for high vs. 24 % for low spirituality; OR = 2.8, 1.7-4.5) and that these patients would benefit from paying attention to their spiritual life (79 % for high vs. 55 % for low spirituality; OR = 3.1, 1.8-5.3). Psychiatrists were more likely to believe that scientific research will one day explain MUS (66 % vs. 52 %; OR = 1.9, 1.4-2.5) and that these symptoms will improve with treatment by a physician (54 % vs. 35 %; OR = 2.4, 1.8-3.3). They were less likely to believe that MUS reflect a spiritual problem (23 % vs. 38 %; OR = 0.5, 0.4-0.8). Physicians' interpretations of MUS vary widely, depending in part on physicians' religious characteristics and specialty. One in three physicians believes that patients with MUS have root problems that are spiritual in nature. Physicians who are more religious or spiritual are more likely to think of MUS as stemming from spiritual concerns. Psychiatrists are more optimistic that these patients will get better with treatment by physicians.

Modeling patterns of coral bleaching at a remote Central Pacific atoll.

PubMed

Williams, Gareth J; Knapp, Ingrid S; Maragos, James E; Davy, Simon K

2010-09-01

A mild bleaching event (9.2% prevalence) at Palmyra Atoll occurred in response to the 2009 ENSO, when mean water temperature reached 29.8-30.1 degrees C. Prevalence among both abundant and sparse taxa varied with no clear pattern in susceptibility relating to coral morphology. Seven taxon-specific models showed that turbidity exacerbated while prior exposure to higher background temperatures alleviated bleaching, with these predictors explaining an average 16.3% and 11.5% variation in prevalence patterns, respectively. Positive associations occurred between bleaching prevalence and both immediate temperature during the bleaching event (average 8.4% variation explained) and increased sand cover (average 3.7%). Despite these associations, mean unexplained variation in prevalence equalled 59%. Lower bleaching prevalence in areas experiencing higher background temperatures suggests acclimation to temperature stress among several coral genera, while WWII modifications may still be impacting the reefs via shoreline sediment re-distribution and increased turbidity, exacerbating coral bleaching susceptibility during periods of high temperature stress. Copyright 2010 Elsevier Ltd. All rights reserved.

Sexual, Physical, Verbal/Emotional Abuse and Unexplained Chest Pain

ERIC Educational Resources Information Center

Eslick, Guy D.; Koloski, Natasha A.; Talley, Nicholas J.

2011-01-01

Objectives: Approximately one third of patients with non cardiac chest pain (NCCP) report a history of abuse, however no data exists on the prevalence of abuse among people with unexplained chest pain in the general population. We aimed to determine if there is a relationship between childhood sexual, physical, emotional abuse and unexplained…

Dexamethasone in unexplained infertility.

PubMed

Moradan, Sanam; Ghorbani, Raheb

2009-08-01

To determine if dexamethasone could be a suitable option in the treatment of patients with unexplained infertility. This study was carried out in the Obstetrics Department of Amir University Hospital, Semnan, Iran, from April 2001 to May 2008. One hundred and twenty-four cases of unexplained infertility that underwent ovulation induction and intrauterine insemination (IUI) (only one cycle) were evaluated, and divided into 2 groups. Sixteen cases were excluded, as they were unresponsive to the induction ovulation regimen. Group I (n=42) received clomiphene citrate (CC) + dexamethasone, and the control group (group II, n=66) received CC alone. These groups were the same in age, duration of infertility, and body mass index. The clinical pregnancy rates were evaluated in 2 groups by using statistical tests. The clinical pregnancy rate was 21.4% in group I, and 4.5% in group II. There was a significant statistical difference between the groups (relative risk=4.71, 95% confidence interval=1.35-16.42, p=0.0085). The pregnancy rate in women with unexplained infertility that underwent ovulation induction with CC + dexamethasone + IUI was significantly higher than those who underwent ovulation induction with CC alone + IUI.

Unexplained agglutination of stored red blood cells in Alsever's solution caused by the gram-negative bacterium Serratia liquefaciens.

PubMed

Martincic, I; Mastronardi, C; Chung, A; Ramirez-Arcos, S

2008-01-01

Alsever's solution has been used for decades as a preservative solution for storage of RBCs. From October 2005 to January 2006, unexplained hemagglutination of approximately 10 to 20 percent of RBCs stored for several days in a modified version of Alsever's solution was noticed in quality control testing at the Canadian Blood Services Serology Laboratory. An investigation, including microbial testing, was initiated to determine the cause of the unexplained hemagglutination. The gram-negative bacterium Serratia liquefaciens was isolated from supernatant solutions of agglutinated RBCs. Further characterization of this strain revealed that it has the ability to form biofilms; presents high levels of resistance to chloramphenicol, neomycin, and gentamicin; and causes mannose-sensitive hemagglutination. The source of S. liquefaciens contamination in RBC supernatants was not found. However, this bacterium has not been isolated since January 2006 after enhanced cleaning practices were implemented in the serology laboratory where the RBCs are stored. This biofilm-forming, antibiotic-resistant S. liquefaciens strain could be directly linked to the unexplained hemagglutination observed in stored RBCs.

A Practical Methodology for Quantifying Random and Systematic Components of Unexplained Variance in a Wind Tunnel

NASA Technical Reports Server (NTRS)

Deloach, Richard; Obara, Clifford J.; Goodman, Wesley L.

2012-01-01

This paper documents a check standard wind tunnel test conducted in the Langley 0.3-Meter Transonic Cryogenic Tunnel (0.3M TCT) that was designed and analyzed using the Modern Design of Experiments (MDOE). The test designed to partition the unexplained variance of typical wind tunnel data samples into two constituent components, one attributable to ordinary random error, and one attributable to systematic error induced by covariate effects. Covariate effects in wind tunnel testing are discussed, with examples. The impact of systematic (non-random) unexplained variance on the statistical independence of sequential measurements is reviewed. The corresponding correlation among experimental errors is discussed, as is the impact of such correlation on experimental results generally. The specific experiment documented herein was organized as a formal test for the presence of unexplained variance in representative samples of wind tunnel data, in order to quantify the frequency with which such systematic error was detected, and its magnitude relative to ordinary random error. Levels of systematic and random error reported here are representative of those quantified in other facilities, as cited in the references.

Anemia and mortality in older persons: does the type of anemia affect survival?

PubMed

Shavelle, Robert M; MacKenzie, Ross; Paculdo, David R

2012-03-01

Anemia is a common condition among community-dwelling older adults. The present study investigates the effect of type of anemia on subsequent mortality. We analyzed data from participants of the Third National Health and Nutrition Survey who were aged ≥50 and had valid hemoglobin levels determined by laboratory measurement. Anemia was defined by World Health Organization criteria. 7,171 subjects met our inclusion criterion. Of those with anemia (n = 862, deaths = 491), 24% had nutritional anemia, 11% had anemia of chronic renal disease, 26% had anemia of chronic inflammation, and 39% had unexplained anemia. We found an overall relative risk (RR) for mortality of 1.8 (p < 0.001) comparing those with anemia to those without, after adjusting for age, sex, and race. After we controlled for a number of chronic medical conditions, the overall RR was 1.6. Compared to persons without anemia, we found the following RRs for the type of anemia: nutritional (2.34, p < 0.0001), chronic renal disease (1.70, p < 0.0001), chronic inflammation (1.48, p < 0.0001), and unexplained (1.26, p < 0.01). Anemia is common although not severe in older non-institutionalized adults. When compared with non-anemic older adults, those with nutritional anemia or anemia due to chronic renal disease have the highest mortality risk.

Diagnosis and treatment of tuberculous uveitis in a low endemic setting.

PubMed

Vos, A G; Wassenberg, M W M; de Hoog, J; Oosterheert, J J

2013-11-01

To determine factors associated with the diagnosis of tuberculous uveitis and the response to anti-tuberculous treatment (ATT). A retrospective case study was performed at the University Medical Centre Utrecht between October 2007 and December 2009. Patients with possible tuberculous uveitis (TBU) were selected from all patients with an unexplained uveitis. Demographics, ethnicity, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), tuberculin skin test (TST), QuantiFERON (QFT) test, and ocular findings were evaluated. An interdisciplinary panel discussed if there was a presumed TBU and decided to start treatment. When there was a decrease in intraocular cell count and/or improvement in visual acuity after ATT, the confirmation of presumed TBU was made. Of 585 patients with unexplained uveitis, 66 (11.3%) fulfilled the definition of possible TBU. Ten (15.4%) patients were regarded as having presumed TBU and received ATT. All of them had latent tuberculosis (LTB). The ocular situation improved in seven patients (70%). A history of TB contact, abnormalities on chest radiology, and extraocular manifestations of TB were associated with a good response to ATT in the case of presumed tuberculous uveitis. Tuberculous uveitis remains difficult to diagnose. No clearly correlating factors that predicted the response to ATT, including ocular parameters, could be identified. Copyright © 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

[Relationship between unexplained palpitation in 
children and head-up tilt test].

PubMed

Gan, Tuoyu; Wu, Lijia; Zou, Runmei; Lin, Ping; Li, Fang; Yang, Hong; Liu, Ping; Gong, Xiaohui; Wang, Cheng

2018-03-28

To explore the relationship between unexplained palpitation in children and head-up tilt test (HUTT).
 Methods: A total of 142 children with the main symptom of unexplained palpitation were admitted to the Specialist Out-Patient Clinic of Children's Cardiovascular Disease from Sept. 2008 to Feb. 2017 in the Second Xiangya Hospital, Central South University. Among them, 63 cases were male, 79 cases were female, with the mean age of (10.12±2.88) years old. The detailed history, physical examinations, conventional 12 electrocardiogram, chest X-ray, echocardiography, myocardial enzymes and thyroid function were all examined. The disorders of heart disease, systemic disease and drug effect were ruled out. The HUTT inspection was then given to them.
 Results: Among the 142 palpitation cases, 79 cases were HUTT positive (55.6%) and 63 cases were HUTT negative (44.4%). The age in HUTT positive patients was older than that in HUTT negative patients (P<0.05), with no significant difference in gender (P>0.05). There were three types of hemodynamic changes in HUTT positive patients. Among them, 38 cases were postural orthostatic tachycardia syndrome (48.1%), 36 cases were the vasovagal syncope vasodepressive type (45.6%) and 5 cases were the vasovagal syncope mixed type (6.3%). There were no hemodynamic types for vasovagal syncope cardioinhibitory type, orthostatic hypotension and orthostatic hypertension.
 Conclusion: Among the clinically unexplained palpitations children, more than half are caused by unbalanced autonomic nervous function. HUTT can help clear the cause of unexplained palpitations.

Explained and unexplained tissue loss in corals from the Tropical Eastern Pacific

USGS Publications Warehouse

Rodriguez-Villalobos, Jenny Carolina; Work, Thierry M.; Calderon-Aguilera, Luis Eduardo; Reyes-Bonilla, Hector; Hernández, Luis

2015-01-01

Coral reefs rival rainforest in biodiversity, but are declining in part because of disease. Tissue loss lesions, a manifestation of disease, are present in dominant Pocillopora along the Pacific coast of Mexico. We characterized tissue loss in 7 species of Pocillopora from 9 locations (44 sites) spanning southern to northern Mexico. Corals were identified to species, and tissue loss lesions were photographed and classified as those explainable by predation and those that were unexplained. A focal predation study was done concurrently at 3 locations to confirm origin of explained lesions. Of 1054 cases of tissue loss in 7 species of corals, 84% were associated with predation (fish, snails, or seastar) and the remainder were unexplained. Types of tissue loss were not related to coral density; however there was significant geographic heterogeneity in type of lesion; one site in particular (Cabo Pulmo) had the highest prevalence of predator-induced tissue loss (mainly pufferfish predation). Crown-of-thorns starfish, pufferfish, and snails were the most common predators and preferred P. verrucosa, P. meandrina, and P. capitata, respectively. Of the 9 locations, 4 had unexplained tissue loss with prevalence ranging from 1 to 3% with no species predilection. Unexplained tissue loss was similar to white syndrome (WS) in morphology, indicating additional study is necessary to clarify the cause(s) of the lesions and the potential impacts to dominant corals along the Pacific coast of Mexico.

Preovulatory uterine flushing with saline as a treatment for unexplained infertility: a randomised controlled trial protocol.

PubMed

Maheux-Lacroix, Sarah; Dodin, Sylvie; Moore, Lynne; Bujold, Emmanuel; Lefebvre, Jessica; Bergeron, Marie-Ève

2016-01-06

In vitro fertilisation (IVF) is the treatment of choice for unexplained infertility. Preovulatory uterine flushing could reduce intrauterine debris and inflammatory factors preventing pregnancy and constitute an alternative to IVF. Our objective is to assess the efficacy of preovulatory uterine flushing with physiological saline for the treatment of unexplained infertility. We will perform a randomised controlled trial based on consecutive women aged between 18 and 37 years consulting for unexplained infertility for at least 1 year. On the day of their luteinising hormone surge, 192 participants will be randomised in two equal groups to either receive 20 mL of physiological saline by an intrauterine catheter or 10 mL of saline intravaginally. We will assess relative risk of live birth (primary outcome), as well as pregnancy (secondary outcome) over one cycle of treatment. We will report the side effects, complications and acceptability of the intervention. This project was approved by the Ethics committee of the Centre Hospitatlier Universitaire de Quebec (no 2015-1146). Uterine flushing is usually well tolerated by women and would constitute a simple, affordable and minimally invasive treatment for unexplained infertility. We plan to communicate the results of the review by presenting research abstracts at conferences and by publishing the results in a peer-reviewed journal. NCT02539290; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Chronic fatigue in patients with unexplained self-reported food hypersensitivity and irritable bowel syndrome: validation of a Norwegian translation of the Fatigue Impact Scale.

PubMed

Lind, Ragna; Berstad, Arnold; Hatlebakk, Jan; Valeur, Jørgen

2013-01-01

Patients with unexplained self-reported food hypersensitivity and irritable bowel syndrome (IBS) suffer from several health complaints, including fatigue. The aim of the present study was to validate a Norwegian translation of the Fatigue Impact Scale (FIS), and to assess the impact of fatigue in patients with self-reported food hypersensitivity and IBS, as compared with healthy controls. Thirty-eight patients with unexplained self-reported food hypersensitivity and IBS, who participated in the validation of the FIS completed the following additional questionnaires: the Short Form of Nepean Dyspepsia Index for assessment of quality of life, the Subjective Health Complaint Inventory, and questionnaires for diagnosis and severity of IBS. Impact of fatigue was studied in 43 patients with unexplained self-reported food hypersensitivity, 70% diagnosed with IBS, and 42 healthy controls. Cronbach's α for the FIS was 0.98, indicating excellent agreement between individual items. Scores on the FIS correlated with scores on the Short Form of Nepean Dyspepsia Index (r = 0.50, P = 0.001), indicating good convergent validity, and were higher in patients (median 85.0, interquartile range 36.8-105.3) than in controls (median 14.0, interquartile range 3.0-29.0, P ≤ 0.0001). The Norwegian translation of the FIS performed excellently in patients with unexplained self-reported food hypersensitivity and IBS, with patients reporting significantly more impact of chronic fatigue than healthy controls.

Unravelling associations between unassigned mass spectrometry peaks with frequent itemset mining techniques.

PubMed

Vu, Trung Nghia; Mrzic, Aida; Valkenborg, Dirk; Maes, Evelyne; Lemière, Filip; Goethals, Bart; Laukens, Kris

2014-01-01

Mass spectrometry-based proteomics experiments generate spectra that are rich in information. Often only a fraction of this information is used for peptide/protein identification, whereas a significant proportion of the peaks in a spectrum remain unexplained. In this paper we explore how a specific class of data mining techniques termed "frequent itemset mining" can be employed to discover patterns in the unassigned data, and how such patterns can help us interpret the origin of the unexpected/unexplained peaks. First a model is proposed that describes the origin of the observed peaks in a mass spectrum. For this purpose we use the classical correlative database search algorithm. Peaks that support a positive identification of the spectrum are termed explained peaks. Next, frequent itemset mining techniques are introduced to infer which unexplained peaks are associated in a spectrum. The method is validated on two types of experimental proteomic data. First, peptide mass fingerprint data is analyzed to explain the unassigned peaks in a full scan mass spectrum. Interestingly, a large numbers of experimental spectra reveals several highly frequent unexplained masses, and pattern mining on these frequent masses demonstrates that subsets of these peaks frequently co-occur. Further evaluation shows that several of these co-occurring peaks indeed have a known common origin, and other patterns are promising hypothesis generators for further analysis. Second, the proposed methodology is validated on tandem mass spectrometral data using a public spectral library, where associations within the mass differences of unassigned peaks and peptide modifications are explored. The investigation of the found patterns illustrates that meaningful patterns can be discovered that can be explained by features of the employed technology and found modifications. This simple approach offers opportunities to monitor accumulating unexplained mass spectrometry data for emerging new patterns, with possible applications for the development of mass exclusion lists, for the refinement of quality control strategies and for a further interpretation of unexplained spectral peaks in mass spectrometry and tandem mass spectrometry.

Hypochondriacal Concerns: Management Through Understanding

PubMed Central

Holder-Perkins, Vicenzio; Wise, Thomas N.; Williams, Darren E.

2000-01-01

The medically unexplained complaint is often a symptom of hypochondriacal concerns. Patients with hypochondriasis may be managed with either naive realism or consideration of morbid categorization or via dimensional assessment of illness beliefs and behaviors. Naive realism will foster focus somatization and promote regression as well as lead to needless tests and treatments. Attention to categorical entities such a major depression or anxiety disorders will alert the clinician to comorbid psychiatric disorders that respond to traditional psychiatric treatments. Finally, by assessing the domains of illness behaviors such as disease conviction, beliefs in organic versus psychological causes, and denial, the clinician can document and then confront abnormal cognitive schema that revolve around somatic concerns that are a proxy for psychosocial difficulties. PMID:15014644

Urinary urge seizure semiology localization by intracranial monitoring.

PubMed

Rengarajan, Ronak; Shamim, Sadat

2018-01-01

Seizures may present with many different symptom complexes. Seizure semiologies have localization value when contemplating surgical therapies. Epilepsy presenting as a desire to micturate is exceedingly rare, with only a handful of published cases. We present a patient who had initially unexplained childhood urinary urge that progressed into lapses of memory and confusion that was eventually diagnosed as epilepsy in adulthood. Due to refractoriness to medical management, our patient's epileptic focus was localized through both noninvasive and invasive subdural electrode arrays to the nondominant medial temporal lobe and successfully treated with an amygdalohippocampectomy. Only one other case of ictal urinary urgency seizures has been recorded with intracranial electroencephalogram monitoring in the literature.

Urinary urge seizure semiology localization by intracranial monitoring

PubMed Central

Rengarajan, Ronak; Shamim, Sadat

2018-01-01

ABSTRACT Seizures may present with many different symptom complexes. Seizure semiologies have localization value when contemplating surgical therapies. Epilepsy presenting as a desire to micturate is exceedingly rare, with only a handful of published cases. We present a patient who had initially unexplained childhood urinary urge that progressed into lapses of memory and confusion that was eventually diagnosed as epilepsy in adulthood. Due to refractoriness to medical management, our patient's epileptic focus was localized through both noninvasive and invasive subdural electrode arrays to the nondominant medial temporal lobe and successfully treated with an amygdalohippocampectomy. Only one other case of ictal urinary urgency seizures has been recorded with intracranial electroencephalogram monitoring in the literature. PMID:29686574

Prevalence and pattern of use of indigenous medicines in diabetic patients attending a tertiary care centre.

PubMed

Sethi, Ankur; Srivastava, Saurabh; Madhu, S V

2011-07-01

The aim of the study was to see the pattern of use of indigenous medicines in diabetic patients and to find out its correlation with various demographic variables in patients of type 2 diabetes. A sample of 113 patients with diabetes (type 1 and type 2) was interviewed using a structured questionnaire by trained medical personnel about the intake of indigenous medicines. Correlation of intake of indigenous medicines with various demographic variables was assessed using appropriate statistical tests. Male to female ratio in the present study was 1:3. Mean duration of diabetes was 5.2 +/- 2 years. It was found that majority of patients 101/113 (89.4%) attending diabetic clinic were using indigenous medicines in one form or the other. Most common drugs used were karela (78.8%), jamun (65.5%), methi (38.9%) and neem (28.3%). Majority were taking on advice from fellow diabetics (41.6%) and were not sure (39.8%) about the effect. No significant correlation was found with their intake and demographic variables as age, sex, per capita income, duration of diabtes, occupation, cultural background and antidiabetic medicine used. There is a high percentage of indigenous drug use in patients with diabetes which is often not reported. Treating physicians need to be alert to this possibility while managing diabetic patients in order to correctly interpret glycaemic control, hypoglycaemic episodes and other unexplained comorbidities that might arise in them.

The relaxation exercise and social support trial-resst: study protocol for a randomized community based trial

PubMed Central

2011-01-01

Background Studies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health. Methods/Design This is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used. Discussion The results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress). Trial Registration The trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241 PMID:21864414

New parvovirus in child with unexplained diarrhea, Tunisia.

PubMed

Phan, Tung G; Sdiri-Loulizi, Khira; Aouni, Mahjoub; Ambert-Balay, Katia; Pothier, Pierre; Deng, Xutao; Delwart, Eric

2014-11-01

A divergent parvovirus genome was the only eukaryotic viral sequence detected in feces of a Tunisian child with unexplained diarrhea. Tusavirus 1 shared 44% and 39% identity with the nonstructural protein 1 and viral protein 1, respectively, of the closest genome, Kilham rat parvovirus, indicating presence of a new human viral species in the Protoparvovirus genus.

New Parvovirus in Child with Unexplained Diarrhea, Tunisia

PubMed Central

Phan, Tung G.; Sdiri-Loulizi, Khira; Aouni, Mahjoub; Ambert-Balay, Katia; Pothier, Pierre; Deng, Xutao

2014-01-01

A divergent parvovirus genome was the only eukaryotic viral sequence detected in feces of a Tunisian child with unexplained diarrhea. Tusavirus 1 shared 44% and 39% identity with the nonstructural protein 1 and viral protein 1, respectively, of the closest genome, Kilham rat parvovirus, indicating presence of a new human viral species in the Protoparvovirus genus. PMID:25340816

Unexplained Deaths and Critical Illnesses of Suspected Infectious Cause, Taiwan, 2000–2005

PubMed Central

Wei, Kuo-Chen; Jiang, Donald Dah-Shyong; Chiu, Chan-Hsian; Chang, Shan-Chwen

2008-01-01

We report 5 years’ surveillance data from the Taiwan Centers for Disease Control on unexplained deaths and critical illnesses suspected of being caused by infection. A total of 130 cases were reported; the incidence rate was 0.12 per 100,000 person-years; and infectious causes were identified for 81 cases (62%). PMID:18826839

Using read codes to identify patients with irritable bowel syndrome in general practice: a database study

PubMed Central

2013-01-01

Background Estimates of the prevalence of irritable bowel syndrome (IBS) vary widely, and a large proportion of patients report having consulted their general practitioner (GP). In patients with new onset gastrointestinal symptoms in primary care it might be possible to predict those at risk of persistent symptoms. However, one of the difficulties is identifying patients within primary care. GPs use a variety of Read Codes to describe patients presenting with IBS. Furthermore, in a qualitative study, exploring GPs’ attitudes and approaches to defining patients with IBS, GPs appeared reluctant to add the IBS Read Code to the patient record until more serious conditions were ruled out. Consequently, symptom codes such as 'abdominal pain’, 'diarrhoea’ or 'constipation’ are used. The aim of the current study was to investigate the prevalence of recorded consultations for IBS and to explore the symptom profile of patients with IBS using data from the Salford Integrated Record (SIR). Methods This was a database study using the SIR, a local patient sharing record system integrating primary, community and secondary care information. Records were obtained for a cohort of patients with gastrointestinal disorders from January 2002 to December 2011. Prevalence rates, symptom recording, medication prescribing and referral patterns were compared for three patient groups (IBS, abdominal pain (AP) and Inflammatory Bowel Disease (IBD)). Results The prevalence of IBS (age standardised rate: 616 per year per 100,000 population) was much lower than expected compared with that reported in the literature. The majority of patients (69%) had no gastrointestinal symptoms recorded in the year prior to their IBS. However a proportion of these (22%) were likely to have been prescribed NICE guideline recommended medications for IBS in that year. The findings for AP and IBD were similar. Conclusions Using Read Codes to identify patients with IBS may lead to a large underestimate of the community prevalence. The IBS diagnostic Read Code was rarely applied in practice. There are similarities with many other medically unexplained symptoms which are typically difficult to diagnose in clinical practice. PMID:24295337

Hb Hope [beta136(H14)Gly-->Asp (GGT-->GAT)]: interactions with Hb S [beta6(A3)Glu-->Val (GAG-->GTG)], other variant hemoglobins and thalassemia.

PubMed

Ingle, John; Adewoye, Adeboye; Dewan, Robert; Okoli, Michael; Rollins, Lamarr; Eung, Shawn H; Luo, Hong-Yuan; Chui, David H K; Steinberg, Martin H

2004-01-01

Hb Hope [beta136(H14)Gly-->Asp (GGT-->GAT)] was first described in an African-American family in 1965. Since then, it has been found in combination with several different globin gene mutations in many other families of divergent ethnic backgrounds. The basis for its relatively frequent occurrences remains unexplained. This variant hemoglobin (Hb) is mildly unstable and has reduced oxygen affinity, but is generally innocuous clinically. This variant Hb can present as a confounding factor in arriving at a correct diagnosis by either electrophoresis or high performance liquid chromatography (HPLC), particularly during the neonatal period. DNA-based diagnostics can help solve this potential problem.

A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction.

PubMed

Reddy, Yogesh N V; Carter, Rickey E; Obokata, Masaru; Redfield, Margaret M; Borlaug, Barry A

2018-05-23

Background -Diagnosis of heart failure with preserved ejection fraction (HFpEF) is challenging in euvolemic patients with dyspnea, and no evidence-based criteria are available. We sought to develop and then validate non-invasive diagnostic criteria that could be used to estimate the likelihood that HFpEF is present among patients with unexplained dyspnea in order to guide further testing. Methods -Consecutive patients with unexplained dyspnea referred for invasive hemodynamic exercise testing were retrospectively evaluated. Diagnosis of HFpEF (case) or non-cardiac dyspnea (control) was ascertained by invasive hemodynamic exercise testing. Logistic regression was performed to evaluate the ability of clinical findings to discriminate cases from controls. A scoring system was developed and then validated in a separate test cohort. Results -The derivation cohort included 414 consecutive patients (267 HFpEF and 147 controls, HFpEF prevalence 64%). The test cohort included 100 consecutive patients (61 HFpEF, prevalence 61%). Obesity, atrial fibrillation, age>60 years, treatment with 2 or more antihypertensives, echocardiographic E/e' ratio>9 and echocardiographic pulmonary artery systolic pressure>35 mmHg were selected as the final set of predictive variables. A weighted score based on these six variables was used to create a composite score (H 2 FPEF score) ranging from 0-9. The odds of HFpEF doubled for each 1 unit score increase [OR 1.98 [1.74-2.30], p<0.0001], with an AUC of 0.841 (p<0.0001). The H 2 FPEF score was superior to a currently-used algorithm based upon expert consensus (increase in AUC of +0.169 [+0.120 to +0.217], p<0.0001). Performance in the independent test cohort was maintained [AUC 0.886, p<0.0001]. Conclusions -The H 2 FPEF score, which relies upon simple clinical characteristics and echocardiography, enables discrimination of HFpEF from non-cardiac causes of dyspnea, and can assist in determination of the need for further diagnostic testing in the evaluation of patients with unexplained exertional dyspnea.

High sensitivity 1H-NMR spectroscopy of homeopathic remedies made in water

PubMed Central

Anick, David J

2004-01-01

Background The efficacy of homeopathy is controversial. Homeopathic remedies are made via iterated shaking and dilution, in ethanol or in water, from a starting substance. Remedies of potency 12 C or higher are ultra-dilute (UD), i.e. contain zero molecules of the starting material. Various hypotheses have been advanced to explain how a UD remedy might be different from unprepared solvent. One such hypothesis posits that a remedy contains stable clusters, i.e. localized regions where one or more hydrogen bonds remain fixed on a long time scale. High sensitivity proton nuclear magnetic resonance spectroscopy has not previously been used to look for evidence of differences between UD remedies and controls. Methods Homeopathic remedies made in water were studied via high sensitivity proton nuclear magnetic resonance spectroscopy. A total of 57 remedy samples representing six starting materials and spanning a variety of potencies from 6 C to 10 M were tested along with 46 controls. Results By presaturating on the water peak, signals could be reliably detected that represented H-containing species at concentrations as low as 5 μM. There were 35 positions where a discrete signal was seen in one or more of the 103 spectra, which should theoretically have been absent from the spectrum of pure water. Of these 35, fifteen were identified as machine-generated artifacts, eight were identified as trace levels of organic contaminants, and twelve were unexplained. Of the unexplained signals, six were seen in just one spectrum each. None of the artifacts or unexplained signals occurred more frequently in remedies than in controls, using a p < .05 cutoff. Some commercially prepared samples were found to contain traces of one or more of these small organic molecules: ethanol, acetate, formate, methanol, and acetone. Conclusion No discrete signals suggesting a difference between remedies and controls were seen, via high sensitivity 1H-NMR spectroscopy. The results failed to support a hypothesis that remedies made in water contain long-lived non-dynamic alterations of the H-bonding pattern of the solvent. PMID:15518588

How do women at increased, but unexplained, familial risk of breast cancer perceive and manage their risk? A qualitative interview study

PubMed Central

2011-01-01

Background The perception of breast cancer risk held by women who have not had breast cancer, and who are at increased, but unexplained, familial risk of breast cancer is poorly described. This study aims to describe risk perception and how it is related to screening behaviour for these women. Methods Participants were recruited from a population-based sample (the Australian Breast Cancer Family Study - ABCFS). The ABCFS includes women diagnosed with breast cancer and their relatives. For this study, women without breast cancer with at least one first- or second-degree relative diagnosed with breast cancer before age 50 were eligible unless a BRCA1 or BRCA2 mutation had been identified in their family. Data collection consisted of an audio recorded, semi-structured interview on the topic of breast cancer risk and screening decision-making. Data was analysed thematically. Results A total of 24 interviews were conducted, and saturation of the main themes was achieved. Women were classified into one of five groups: don't worry about cancer risk, but do screening; concerned about cancer risk, so do something; concerned about cancer risk, so why don't I do anything?; cancer inevitable; cancer unlikely. Conclusions The language and framework women use to describe their risk of breast cancer must be the starting point in attempts to enhance women's understanding of risk and their prevention behaviour. PMID:21896163

Unexplained head tilt following surgical treatment of congenital esotropia: a postural manifestation of dissociated vertical divergence

PubMed Central

Brodsky, M C; Jenkins, R; Nucci, P

2004-01-01

Background: Strabismus surgery for congenital esotropia can be complicated by the development of a postoperative head tilt. Purpose: To determine the pathophysiology of acquired head tilting following horizontal realignment of the eyes in children with congenital esotropia. Materials and methods: Retrospective analysis of nine children with congenital esotropia who developed unexplained head tilts following horizontal realignment of the eyes. Results: Shortly after strabismus surgery, each child developed a head tilt in association with asymmetrical dissociated vertical divergence (DVD). Five children maintained a head tilt toward the side of the fixing eye (group 1), which did not serve to control the DVD. Four children maintained a head tilt toward the side of the hyperdeviating eye, which served to control the DVD (group 2). Children in group 2 had earlier horizontal muscle surgery and developed better stereopsis than those in group 1, suggesting that the higher degree of single binocular vision and stereopsis in these children may have led to a compensatory torticollis to control an asymmetrical DVD. Conclusions: The onset of an unexpected head tilt after congenital esotropia surgery is usually a postural manifestation of asymmetrical DVD. In this setting, a head tilt toward the side of the fixing eye corresponds with a postural manifestation of the underlying central vestibular imbalance that produces DVD, while a head tilt toward the side of the hyperdeviating eye serves to counteract the hyperdeviation and stabilise binocular vision. PMID:14736789

May Underdiagnosed Nutrition Imbalances Be Responsible for a Portion of So-Called Unexplained Infertility? From Diagnosis to Potential Treatment Options.

PubMed

Noventa, Marco; Quaranta, Michela; Vitagliano, Amerigo; Cinthya, Vescio; Valentini, Romina; Campagnaro, Tania; Marci, Roberto; Paola, Rossana Di; Alviggi, Carlo; Gangemi, Michele; Saccardi, Carlo; Nardelli, Giovanni Battista; Gizzo, Salvatore

2016-06-01

The aim of the study was to investigate whether women affected by unexplained infertility may have undiagnosed dietary imbalances which negatively affect fertility. Secondarily, we investigated whether varying degrees of nutritional abnormalities may benefit from different periconceptional dietary supplementations, evaluating the most effective intervention in improving pregnancy rate after in vitro fertilization (IVF). We conducted a survey on 2 cohorts of patients (group A: unexplained infertility and group B: healthy first trimester spontaneous pregnancies) with the scope of investigating and comparing their dietary status discriminating women without dietary abnormalities (cohort 1) from those with abnormalities exclusively in micronutrient intake (cohort 2) or combined abnormalities in both micronutrient and macronutrient intake and associated obesity (cohort 3). All women included in group A were offered the opportunity to receive a prescription for one of the 3 designated daily dietary supplementation schemes (subgroups A1, A2, and A3) which were to be implemented in the 3 months immediately prior to beginning IVF treatment. When compared with fertile women, patients having unexplained infertility showed significant abnormalities in dietary habits. These differences ranged from a minimal imbalance in micronutrient intake (potentially avoidable with dietary supplementation) to severe combined macronutrient and micronutrient imbalance frequently associated with obesity (partially amendable by inositol supplementation and frequently requiring long-term dietary reeducation before establishment of fertility). Nutritional investigation and treatment may explain and resolve a portion of cases of unexplained infertility, improving the outcome of IVF treatment and, with minimal imbalances, likely restore spontaneous fertility. © The Author(s) 2015.

Clinical significance of somatic mutation in unexplained blood cytopenia

PubMed Central

Gallì, Anna; Travaglino, Erica; Ambaglio, Ilaria; Rizzo, Ettore; Molteni, Elisabetta; Elena, Chiara; Ferretti, Virginia Valeria; Catricalà, Silvia; Bono, Elisa; Todisco, Gabriele; Bianchessi, Antonio; Rumi, Elisa; Zibellini, Silvia; Pietra, Daniela; Boveri, Emanuela; Camaschella, Clara; Toniolo, Daniela; Papaemmanuil, Elli; Ogawa, Seishi; Cazzola, Mario

2017-01-01

Unexplained blood cytopenias, in particular anemia, are often found in older persons. The relationship between these cytopenias and myeloid neoplasms like myelodysplastic syndromes is currently poorly defined. We studied a prospective cohort of patients with unexplained cytopenia with the aim to estimate the predictive value of somatic mutations for identifying subjects with, or at risk of, developing a myeloid neoplasm. The study included a learning cohort of 683 consecutive patients investigated for unexplained cytopenia, and a validation cohort of 190 patients referred for suspected myeloid neoplasm. Using granulocyte DNA, we looked for somatic mutations in 40 genes that are recurrently mutated in myeloid malignancies. Overall, 435/683 patients carried a somatic mutation in at least 1 of these genes. Carrying a somatic mutation with a variant allele frequency ≥0.10, or carrying 2 or more mutations, had a positive predictive value for diagnosis of myeloid neoplasm equal to 0.86 and 0.88, respectively. Spliceosome gene mutations and comutation patterns involving TET2, DNMT3A, or ASXL1 had positive predictive values for myeloid neoplasm ranging from 0.86 to 1.0. Within subjects with inconclusive diagnostic findings, carrying 1 or more somatic mutations was associated with a high probability of developing a myeloid neoplasm during follow-up (hazard ratio = 13.9, P < .001). The predictive values of mutation analysis were confirmed in the independent validation cohort. The findings of this study indicate that mutation analysis on peripheral blood granulocytes may significantly improve the current diagnostic approach to unexplained cytopenia and more generally the diagnostic accuracy of myeloid neoplasms. PMID:28424163

Antimüllerian hormone levels and antral follicle counts are not reduced compared with community controls in patients with rigorously defined unexplained infertility.

PubMed

Greenwood, Eleni A; Cedars, Marcelle I; Santoro, Nanette; Eisenberg, Esther; Kao, Chia-Ning; Haisenleder, Daniel J; Diamond, Michael P; Huddleston, Heather G

2017-12-01

To test the hypothesis that women with unexplained infertility demonstrate evidence of diminished ovarian reserve when compared with a population of community controls. Cross-sectional study. Multicenter university-based clinical practices. Study participants included 277 healthy, normo-ovulatory female partners with rigorously defined unexplained infertility randomly selected from a multicenter trial (Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation). Controls included 226 healthy, normo-ovulatory women not seeking treatment for fertility from a community-based cohort (Ovarian Aging study). Serum antimüllerian hormone (AMH) assay at a central laboratory, FSH, fasting serum metabolic testing, transvaginal ultrasonography for antral follicle counts (AFCs), anthropometric measurements. Average AMH, AFC, and AMH/AFC were compared between infertile and control women by age. Analyses of covariance compared these outcomes while controlling for confounders, including age, race, body mass index, smoking history, and study site. In our models, AMH, AFC, and AMH/AFC ovarian reserve indices did not differ between infertile women and community-based controls, after controlling for age, race, body mass index, smoking history, and study site. Currently utilized predictors of ovarian reserve do not discriminate women with rigorously defined unexplained infertility from healthy community-based women of similar demographic characteristics. Contrary to our hypothesis, among women with FSH in the normal range (≤12 IU/L), women with unexplained infertility did not show evidence of decreased ovarian reserve as measured by AMH and AFC. Ovarian reserve markers in isolation may not serve as predictors of future fertility. Copyright © 2017 American Society for Reproductive Medicine. All rights reserved.

Unexplained infertility: overall ongoing pregnancy rate and mode of conception.

PubMed

Brandes, M; Hamilton, C J C M; van der Steen, J O M; de Bruin, J P; Bots, R S G M; Nelen, W L D M; Kremer, J A M

2011-02-01

Unexplained infertility is one of the most common diagnoses in fertility care. The aim of this study was to evaluate the outcome of current fertility management in unexplained infertility. In an observational, longitudinal, multicentre cohort study, 437 couples were diagnosed with unexplained infertility and were available for analysis. They were treated according to their prognosis using standing national treatment protocols: (i) expectant management-IUI-IVF (main treatment route), (ii) IUI-IVF and (iii) directly IVF. Primary outcome measures were: ongoing pregnancy rate, patient flow over the strategies, numbers of protocol violation and drop out rates. A secondary outcome measure was the prediction of ongoing pregnancy and mode of conception. Of all couples 81.5% (356/437) achieved an ongoing pregnancy and 73.9% (263/356) of the pregnancies were conceived spontaneously. There were 408 couples (93.4%) in strategy-1, 21 (5.0%) in strategy-2 and 8 (1.8%) in strategy-3. In total, 33 (7.6%) couples entered the wrong strategy. There were 104 couples (23.8%) who discontinued fertility treatment prematurely: 26 on doctor's advice (with 4 still becoming pregnant) and 78 on their own initiative (with 33 still achieving a pregnancy). Predictors for overall pregnancy chance and mode of conception were duration of infertility, female age and obstetrical history. Overall success rate in couples with unexplained infertility is high. Most pregnancies are conceived spontaneously. We recommend that if the pregnancy prognosis is good, expectant management should be suggested. The prognosis criteria for treatment with IUI or IVF needs to be investigated in randomized controlled trials.

Emotion awareness and coping in children with functional abdominal pain: a controlled study.

PubMed

van der Veek, Shelley M C; Derkx, H H F; de Haan, Else; Benninga, Marc A; Boer, Frits

2012-01-01

Literature on somatization suggests that patients suffering from medically unexplained symptoms are less aware of their emotions and use maladaptive coping strategies when coping with everyday problems. In addition, coping is hypothesized to mediate between emotion awareness and medically unexplained symptoms. Scientific evidence for the relevance of this hypothesis for children with functional abdominal pain (FAP) is, however, lacking. Therefore, the purpose of the present study was to investigate this hypothesis in Dutch children with functional abdominal pain (FAP), aged 7-18 years. Between April 2007 and April 2010, a total of 114 referred children with FAP, 235 schoolchildren without abdominal pain and 407 schoolchildren with some abdominal pain (AP) of diverse etiology filled out questionnaires concerning their pain, emotion awareness and coping. MANOVA was used to investigate group differences in emotional awareness and coping. Structural equation modeling was used to investigate the mediational role of coping. The results showed that children with FAP scored significantly lower on most aspects of emotion awareness than children without AP, although these differences were small. Contrary to expectations, children with FAP were more aware of a link between emotions and bodily sensations than children without AP. As for coping, we found that children with FAP used avoidant coping more often than children without AP. Overall, children with FAP mostly did not differ in their emotional awareness and coping compared to children with some AP. Problem focused coping had a small mediating effect for two aspects of emotion awareness. We conclude that children with FAP show only small differences in emotion awareness and coping compared to children without AP, and are practically no different from children with some AP. Contrary to common belief, it can be questioned whether emotion awareness and general coping are useful targets for psychological treatments of FAP to focus on. Copyright © 2011 Elsevier Ltd. All rights reserved.

High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection.

PubMed

Aquina, Christopher T; Probst, Christian P; Becerra, Adan Z; Hensley, Bradley J; Iannuzzi, James C; Noyes, Katia; Monson, John R T; Fleming, Fergal J

2016-04-01

Hospital-acquired Clostridium difficile infection is associated with adverse patient outcomes and high medical costs. The incidence and severity of C. difficile has been rising in both medical and surgical patients. Our aim was to assess risk factors and variation associated with the development of nosocomial C. difficile colitis among patients undergoing colorectal resection. This was a retrospective cohort study. The study included segmental colectomy and proctectomy cases in New York State from 2005 to 2013. The study cohort included 150,878 colorectal resections. Patients with a documented previous history of C. difficile infection or residence outside of New York State were excluded. A diagnosis of C. difficile colitis either during the index hospital stay or on readmission within 30 days was the main measure. C. difficile colitis occurred in 3323 patients (2.2%). Unadjusted C. difficile colitis rates ranged from 0% to 11.3% among surgeons and 0% to 6.8% among hospitals. After controlling for patient, surgeon, and hospital characteristics using mixed-effects multivariable analysis, significant unexplained variation in C. difficile rates remained present across hospitals but not surgeons. Patient factors explained only 24% of the total hospital-level variation, and known surgeon and hospital-level characteristics explained an additional 8% of the total hospital-level variation. Therefore, ≈70% of the hospital variation in C. difficile infection rates remained unexplained by captured patient, surgeon, and hospital factors. Furthermore, there was an ≈5-fold difference in adjusted C. difficile rates across hospitals. A limited set of hospital and surgeon characteristics was available. Colorectal surgery patients appear to be at high risk for C. difficile infection, and alarming variation in nosocomial C. difficile infection rates currently exists among hospitals after colorectal resection. Given the high morbidity and cost associated with C. difficile colitis, adopting institutional quality improvement programs and maintaining strict prevention strategies are of the utmost importance.

Progress for Women in Academe, Yet Inequities Persist: Evidence from NSOPF:99

ERIC Educational Resources Information Center

Toutkoushian, Robert K.; Conley, Valerie Martin

2005-01-01

In this study, we use data from the 1999 National Study of Postsecondary Faculty (NSOPF:99) to measure the unexplained wage gap between men and women in academe. We pay particular attention to how these unexplained wage gaps have changed over time by comparing the results from the 1999 survey to published results from previous national surveys and…

Education, Occupation and Career Expectations: Determinants of the Gender Pay Gap for UK Graduates. CEE DP 69

ERIC Educational Resources Information Center

Chevalier, Arnaud

2006-01-01

A large proportion of the gender wage gap is usually left unexplained. In this paper, we investigate whether the unexplained component is due to misspecification. Using a sample of recent UK graduates, we introduce variables on career expectations and character traits, variables that are typically not observed. The evidence indicates that women…

A unique and unexplained ricochet leak post PCI - successfully treated with intra-coronary glue.

PubMed

Goel, Pravin K; Syal, Sanjeev K

2014-01-01

We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate. Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Interferon Regulatory Factor 5 Gene Polymorphisms in Iranian Women with Unexplained Recurrent Pregnancy Loss.

PubMed

Amiri Jahromi, Rakhshan; Nasiri, Mahboobeh; Jahromi, Athar Rasekh

2017-01-01

This study aimed to examine the association of three functional IRF5 rs10954213, rs3757385, and rs41298401 polymorphisms with susceptibility to unexplained recurrent pregnancy loss (RPL) among Iranian women from south of Iran. 176 women with unexplained RPL and 173 healthy postmenopausal controls were enrolled in this case-control study. Genotyping of the polymorphisms rs10954213 and rs3757385 was carried out using touchdown tetra-primer amplification refractory mutation system-polymerase chain reaction (T-ARMS PCR), and polymorphism rs41298401 was typed using PCR-restriction fragment length polymorphism (PCR-RFLP). Genotype frequencies were significantly different between RPL cases and controls regarding AG heterozygote genotype of rs10954213, GT genotype of rs3757385, and GG genotype of rs41298401. In addition, allele variants (G for rs10954213, T for rs3757385, and G for rs41298401) showed protective role against RPL, while GG haplotype of two first variants was shown to be a susceptibility factor for the disease. These data provide the first evidence, to our knowledge, of the protective role of the studied IRF5 gene polymorphisms against unexplained RPL among Iranian women from south of Iran.

A Comparison of Pattern of Pregnancy Loss in Women with Infertility Undergoing IVF and Women with Unexplained Recurrent Miscarriages Who Conceive Spontaneously

PubMed Central

Tamhankar, Vidya A.; Liu, Beiyu; Yan, Junhao; Li, Tin-Chiu

2015-01-01

Objective. Women with infertility and recurrent miscarriages may have an overlapping etiology. The aim of this study was to compare the pregnancy loss in pregnancies after IVF treatment with spontaneous pregnancies in women with recurrent miscarriages and to assess differences related to cause of infertility. Methods. The outcome from 1220 IVF pregnancies (Group I) was compared with 611 spontaneous pregnancies (Group II) in women with recurrent miscarriages. Subgroup analysis was performed in Group I based on cause of infertility: tubal factor (392 pregnancies); male factor (610 pregnancies); and unexplained infertility (218 pregnancies). Results. The clinical pregnancy loss rate in Group I (14.3%) was significantly lower than that of Group II (25.8%, p < 0.001) and this was independent of the cause of infertility. However the timing of pregnancy loss was similar between Groups I and II. The clinical pregnancy loss rate in Group I was similar in different causes of infertility. Conclusions. The clinical pregnancy loss rate following IVF treatment is lower than that of women with unexplained recurrent miscarriages who conceived spontaneously. This difference persists whether the infertility is secondary to tubal factors, male factors, or unexplained cause. PMID:26576157

Expectant management may reduce overtreatment in women affected by unexplained infertility confirmed by diagnostic laparoscopy.

PubMed

De Cicco, S; Tagliaferri, Valeria; Selvaggi, L; Romualdi, D; Di Florio, C; Immediata, V; Lanzone, A; Guido, M

2017-02-01

To determine whether the mini-invasive surgery still play a role in the diagnostic workup and in the management of the couples affected by unexplained infertility. 170 infertile women (age range 25-38 years) with documented normal ovarian, tubal and uterine function underwent combined hysteroscopic and laparoscopic surgery; 100 women refused surgery or ART treatment (control group) choosing expectant management. A retrospective assessment questionnaire was proposed to enrolled women to collect the rate of spontaneous or ART-induced pregnancies. The combined surgery revealed pelvic pathologies in 49.4% of patients, confirming the diagnosis of unexplained infertility only in 86 of studied patients. In this group of 86 selected women, 28 of them achieved a spontaneous pregnancy and 23 women obtained pregnancy after ART. The Chi-square analysis shows that the pregnancy rate was not influenced by the employment of ART. In the group of 100 control women, only 14 (14%) achieved a spontaneous pregnancy after 18 months of expectant management. Combined laparoscopy and hysteroscopy in women with unexplained infertility may reveal previously undiagnosed pathologies that could require ART, and in those without abnormal surgical finding, ART does not improve pregnancy rate.

The correlation of sperm morphology with unexplained recurrent spontaneous abortion: A systematic review and meta-analysis

PubMed Central

Cao, Xiaodan; Cui, Yun; Zhang, Xiaoxia; Lou, Jiangtao; Zhou, Jun; Wei, Renxiong

2017-01-01

Sperm morphology displays a potential impact on sperm function and may ultimately impact reproductive function. Current studies have investigated the correlation between sperm morphology with unexplained recurrent spontaneous abortion (RSA) but have shown inconsistent results. Hence, we systematically searched MEDLINE, EMBASE, CNKI databases, as well as the Cochrane Library for studies that examined the association between sperm morphology and unexplained RSA. Fifteen studies were identified, including 883 cases and 530 controls. Our meta-analysis results indicated that the percentage of normal sperm morphology from men with RSA partners was significantly lower than those from normal controls(SMD [95% CI]: − 0.60 [−0.81, −0.40]; P<0.00001) and the percentage of sperm morphologic alterations was significantly higher in patients with RSA compared with the control group (SMD [95% CI]: 0.92 [0.42, 1.43]; P=0.0004). The present study suggested that the percentage of normal sperm morphology may indeed decrease in men from RSA group compared with controls. However, there were some limitations in the study such as the differences in stain techniques and classification criteria. Further evidences are needed to better elucidate the relationship between sperm morphology and unexplained RSA. PMID:28903451

Medicine's perception of reality - a split picture: critical reflections on apparent anomalies within the biomedical theory of science.

PubMed

Kirkengen, Anna Luise; Ekeland, Tor-Johan; Getz, Linn; Hetlevik, Irene; Schei, Edvin; Ulvestad, Elling; Vetlesen, Arne Johan

2016-08-01

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised. © 2015 John Wiley & Sons, Ltd.

A retrospective review of newborn screening for congenital hypothyroidism and newborn thyroid disease at a major medical center.

PubMed

Cameo, Tamara; Gumer, Lindsey Barst; Williams, Kristen M; Gomez, Jackie; McMahon, Donald J; Oberfield, Sharon E

2013-11-01

Objective. To study the frequency of congenital hypothyroidism (CH)/thyroid disorders at a major, urban medical center. Methods. We conducted a retrospective review of a preexisting database for 2007 to 2011. Infants were classified as having CH, secondary/tertiary hypothyroidism, thyroid-binding globulin deficiency, and other types of newborn thyroid dysfunctions. Results. A total of 353 (50%) abnormal newborn screens were found to be normal and 42% were abnormal on repeat. Of the latter, 14% had true CH, 1% had thyroid-binding globulin deficiency, and 27% had other causes of thyroid dysfunction. The 5-year incidence of CH at NYP Morgan Stanley Children's Hospital was significantly greater than in New York City, New York State, and Upstate New York. Conclusion. The incidence of CH and other thyroid dysfunctions were greater in our population for 2007 to 2010, after which there was an unexplained decline. The study underlines the importance of continued newborn screening for thyroid dysfunction.

(In)Visibility Online: The Benefits of Online Patient Forums for People with a Hidden Illness: The Case of Multiple Chemical Sensitivity (MCS).

PubMed

Phillips, Tarryn; Rees, Tyson

2018-06-01

Sufferers of medically unexplained conditions that are not observable in the clinic can experience multiple layers of invisibility: a lack of biomedical diagnosis; legal skepticism; political disinterest; and a loss of their prior social identity. For those with environmental sensitivities, this is compounded by literal hiddenness due to often being housebound. Drawing on an online survey of people with multiple chemical sensitivity, this article examines how the everyday experience of invisibility is mitigated by engaging with other patients online. Respondents used online forums to undertake various forms of "visibility work," including attempts to crystallize their suffering into something recognizable medically, legally, and politically, and to reconstruct an identity considered valid and deserving-although the therapeutic potential of online support was contingent on intra-group politics. This study demonstrates that online forums allow biomedicine's "invisible others" to struggle for alternative forms of recognition beyond the clinical gaze. © 2017 by the American Anthropological Association.

Munchausen Syndrome by Proxy: two case reports and an update of the literature.

PubMed

Moldavsky, Maria; Stein, Daniel

2003-01-01

Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis. Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period. The study reviews the required diagnostic criteria for MSP and possible treatment options.

Intermittent hypoxia in patients with unexplained polycythaemia.

PubMed Central

Moore-Gillon, J C; Treacher, D F; Gaminara, E J; Pearson, T C; Cameron, I R

1986-01-01

The aetiology of polycythaemia is unclear in up to 30% of patients. Twenty patients with unexplained polycythaemia were investigated to see whether they had an intermittent hypoxic stimulus to erythropoiesis that was undetected by conventional investigations for hypoxic secondary polycythaemia. Overnight polygraphic sleep studies showed that five patients had prolonged nocturnal hypoxaemia. Their arterial oxygen saturation was below 92%, the level at which appreciable hypoxic stimulation of erythropoiesis occurs, for 26-68% of the time for which they were studied. Considerable evidence is accumulating that intermittent hypoxia is a potent stimulus to erythropoiesis, and clinicians should consider the possibility of nocturnal hypoxia in patients with unexplained polycythaemia. Appropriate investigation will lead to the correct diagnosis of polycythaemia secondary to hypoxia in some cases previously regarded as idiopathic, and treatment may then be planned accordingly. PMID:3092936

The framing effect in medical decision-making: a review of the literature.

PubMed

Gong, Jingjing; Zhang, Yan; Yang, Zheng; Huang, Yonghua; Feng, Jun; Zhang, Weiwei

2013-01-01

The framing effect, identified by Tversky and Kahneman, is one of the most striking cognitive biases, in which people react differently to a particular choice depending whether it is presented as a loss or as a gain. Numerous studies have subsequently demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision-making. Compared to daily decisions, medical decisions are of low frequency but of paramount importance. The framing effect is a well-documented bias in a variety of studies, but research is inconsistent regarding whether and how variables influence framing effects in medical decision-making. To clarify the discrepancy in the previous literature, published literature in the English language concerning the framing effect was retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion and evaluated the articles' methodological quality. The framing effect in medical decision-making was reviewed in these papers. No studies identified an influence of framing information upon compliance with health recommendations, and different studies demonstrate different orientations of the framing effect. Because so many variables influence the presence or absence of the framing effect, the unexplained heterogeneity between studies suggests the possibility of a framing effect under specific conditions. Further research is needed to determine why the framing effect is induced and how it can be precluded.

Complaints of neurotic patients that are of interest for a cardiologist.

PubMed

Sobański, Jerzy A; Klasa, Katarzyna; Popiołek, Lech; Rutkowski, Krzysztof; Dembińska, Edyta; Mielimąka, Michał; Cyranka, Katarzyna; Müldner-Nieckowski, Łukasz; Smiatek-Mazgaj, Bogna; Rodziński, Paweł

2015-01-01

Patients in various areas of medicine report symptoms that are unexplained by other medical reasons than psychological/psychiatric. Some of them urgently seek treatment due to cardiovascular complaints, mostly rapid heart rate, palpitations and chest pain. Typical cardiac investigations, usually showing no organic reasons for these conditions, bring little information about stressful life events and psychological predispositions of these patients. Identification of coexistence of "cardiac" symptoms with other symptoms typical for neurotic disorders and difficult life circumstances may facilitate not only psychiatric diagnosis but also evaluation by cardiologists, primary care physicians, and other specialists. To determine the psychosocial context of psychogenic "pseudocardiac" symptoms and their coexistence with other symptoms in patients with neurotic disorders. Medical records of patients from the years 1980-2002 that included self-administered questionnaires transformed into an anonymised database were examined. An analysis of the relationship between symptoms reported in the Symptom Checklist and biographical circumstances described in the Life Inventory before admission to a psychotherapy day clinic for patients with neurotic disorders was performed using simple logistic regression with estimation of odds ratios and their 95% confidence intervals. The symptoms of tachycardia/palpitations and chest pain were very common, present in most subjects, and were significantly associated with such circumstances as suboptimal conflict solving by passive aggression or quarrels, uncertainty in the relationship, a sense of being inferior to the partner, and poor financial situation. In addition, these "pseudocardiac" symptoms were also associated with such childhood reminiscences as origin from a large low income family, feeling that the family of origin was inferior to others, and experience of parental hostility or lack of support. Physicians of all specialties who deal with patients experiencing pseudocardiac symptoms should expect their psychological background and perform a simple interview to identify the presence of adverse biographical circumstances described above. Identification and discussing these difficult experiences with the patients may help to convince them to seek psychological support or psychotherapy.

Bacterial vaginosis and infertility: cause or association?

PubMed

Salah, Rasheed M; Allam, Abdelmonem M; Magdy, Amin M; Mohamed, Abeer Sh

2013-03-01

To estimate the prevalence of bacterial vaginosis (BV) in infertile women and evaluate the effect of treatment of BV on the pregnancy rate in patients with polycystic ovarian disease (PCOD) and unexplained infertility. Cohort study conducted at the Department of Obstetrics and Gynecology in collaboration with the Microbiology Department of Sohag University Hospital, Egypt. All eligible women with female factor infertility (n=874) were enrolled and all asymptomatic fertile women (n=382) attending the family planning clinic of the study hospital were recruited as a control group. The study was in two phases: the first included screening all participants for BV after Gram-staining of the vaginal discharge. The second phase was concerned with evaluating the effect of treatment of BV on the cumulative pregnancy rate (CPP) in patients with PCOD (group I; n=278) and unexplained infertility (group II; n=170). Each group was divided into three sub-groups: groups Ia (n=129) and IIa (n=73) were BV positive and treated for BV; groups Ib (n=61) and IIb (n=49) were BV positive and did not receive treatment for BV, and groups Ic (n=88) and IIc (n=48) were BV negative. The prevalence of BV was compared using the Chi-square. The long rank test of Kaplan-Meier life table analysis was used to compare the CPR. A multivariate regression model was designed to define the most significant variable which affected the pregnancy rate in patients with PCOD. The prevalence of BV was significantly higher in infertile than fertile women (45.5% vs 15.4%). The highest prevalence was found in patients with PCOD (60.1%) and unexplained infertility (37.4%). The CPR in both patients with PCOD and unexplained infertility were significantly higher in the patients who were treated for BV. Regression model showed that BV was one of the significant factors interfering with pregnancy. BV is strongly implicated in female infertility and is probably an underestimated cause of unexplained infertility. Screening and treatment of BV in patients with PCOD and unexplained infertility improved the pregnancy rate considerably. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Medical evacuation for unrecognized abdominal wall pain: a case series.

PubMed

Msonda, Hapu T; Laczek, Jeffrey T

2015-05-01

Chronic abdominal pain is a frequently encountered complaint in the primary care setting. The abdominal wall is the etiology of this pain in 10 to 30% of all cases of chronic abdominal pain. Abdominal cutaneous nerve entrapment at the lateral border of the rectus abdominis muscle has been attributed as a cause of this pain. In the military health care system, patients with unexplained abdominal pain are often transferred to military treatment facilities via the Military Medical Evacuation (MEDEVAC) system. We present two cases of patients who transferred via MEDEVAC to our facility for evaluation and treatment of chronic abdominal pain. Both patients had previously undergone extensive laboratory evaluation, imaging, and invasive procedures, such as esophagogastroduodenoscopy before transfer. Upon arrival, history and physical examinations suggested an abdominal wall source to their pain, and both patients experienced alleviation of their abdominal wall pain with lidocaine and corticosteroid injection. This case series highlights the need for military physicians to be aware of abdominal wall pain. Early diagnosis of abdominal cutaneous nerve entrapment syndrome by eliciting Carnett's sign will limit symptom chronicity, avoid unnecessary testing, and even prevent medical evacuation. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Numb chin syndrome as a manifestation of possible breast cancer metastasis around dental implants.

PubMed

Orhan, Kaan; Bayndr, Hakan; Aksoy, Seçil; Seker, Basak Kusakci; Berberoğlu, Atilla; Ozan, Oğuz

2011-05-01

Numb chin syndrome, sometimes called numb lip syndrome, is an uncommon but well-recognized symptom in medical oncology. It may be a metastatic neurologic manifestation of malignancy, often with no clinically visible pathologic finding. The authors report a numb chin syndrome as a manifestation possible breast cancer metastasis around dental implants in a 69-year-old woman. The patient was presented with complaint of numbness in the lower jaw. Medical anamnesis revealed a metastatic breast carcinoma (CA). Radiographic imaging with conventional panoramic radiography and cone beam computed tomographic examination, revealed a moth-eaten shape, radiolucent, and radiopaque mixed appearance around the dental implants that was related with possible metastasis of the breast cancer. Numb chin syndrome is almost unknown within the dental and oral and maxillofacial community, despite being well reported in the medical literature. General dentists, oral medicine specialists, and oral and maxillofacial surgeons must be aware of this condition to consider metastatic cancer in patients with unexplained facial hypoesthesia. Moreover, although the development of metastatic lesions around implants is an uncommon pathologic finding, the examination of peri-implant lesion should be performed carefully considering the entire pathologic situations.

Metabolic acidosis in an infant associated with permethrin toxicity.

PubMed

Goksugur, Sevil B; Karatas, Zehra; Goksugur, Nadir; Bekdas, Mervan; Demircioglu, Fatih

2015-01-01

Pyrethroids are broad-spectrum insecticides. Permethrin intoxication due to topical application has not been documented in humans. We report a 20-month-old infant who had used 5% permethrin lotion topically for scabies treatment. Approximately 60 mL (20 mL/day) was used and after the third application he developed agitation, nausea, vomiting, respiratory distress, tachycardia, and metabolic acidosis. His clinical symptoms and metabolic acidosis normalized within 20 hours. His follow-up was unremarkable. Toxicity of permethrin is rare, and although permethrin is a widely and safely used topical agent in the treatment of scabies and lice, inappropriate use may rarely cause toxicity. Moreover, in cases of unexplained metabolic acidosis, topically applied medications should be carefully investigated. © 2014 Wiley Periodicals, Inc.

Ovulation induction and controlled ovarian stimulation using letrozole gonadotropin combination: A single center retrospective cohort study.

PubMed

Arya, Sushila; Kupesic-Plavsic, Sanja; Mulla, Zuber D; Dwivedi, Alok K; Crisp, Zeni; Jose, Jisha; Noble, Luis S

2017-11-01

To assess the effect of letrozole in combination with low dose gonadotropins for ovulation induction in anovulatory infertility from polycystic ovary syndrome (PCOS) and controlled ovarian stimulation for endometriosis, and unexplained infertility patients. Retrospective cohort study in a setting of private Reproductive Endocrinology and Infertility Clinic affiliated with the University. Three hundred couples (650 cycles) requiring OI/COS for PCOS (92 patients, 195 cycles), endometriosis (89 patients, 217 cycles), and unexplained infertility (119 patients, 238 cycles). Patients received 2.5mg or 5mg letrozole for 5days (D3-D7) and recombinant follicle-stimulating hormone on alternating D3-D7 and human menopausal gonadotropin-highly purified alternating D5-D10 until growth of ideally 2 mature follicles. Ovulation was triggered with 10,000 IU of HCG. Maximum number of cycles per patient was four. Main outcome measures were clinical pregnancy rates, multiple order pregnancy rates, miscarriage rates, number of follicles and endometrial thickness on the day of HCG administration. The cumulative incidence of pregnancy was estimated as 35% (95%CI: 29%-41%) overall and was highest in patients with PCOS (36.6%), followed by unexplained infertility (34.6%) and endometriosis (32.5%). The pregnancy rates per cycle in PCOS, endometriosis and unexplained infertility patients were 17%, 13.2% and 17.2% respectively, no statistically significant difference between the groups. There were three twin pregnancies in PCOS, and one in unexplained infertility group. Monofolliculogenesis was noted in 48% of patients. Letrozole-low dose gonadotropins combination appears to be effective across different causes of infertility for superovulation. The letrozole-low dose gonadotropin combination resulted in high rate of monofolliculogenesis, low occurrence of multiple gestations and no case of OHSS or cycle cancellation. Published by Elsevier B.V.

Characteristics and clinical assessment of unexplained sudden cardiac arrest in the real-world setting: focus on idiopathic ventricular fibrillation

PubMed Central

Waldmann, Victor; Bougouin, Wulfran; Karam, Nicole; Dumas, Florence; Sharifzadehgan, Ardalan; Gandjbakhch, Estelle; Algalarrondo, Vincent; Narayanan, Kumar; Zhao, Alexandre; Amet, Denis; Jost, Daniel; Geri, Guillaume; Lamhaut, Lionel; Beganton, Frankie; Ludes, Bertrand; Bruneval, Patrick; Plu, Isabelle; Hidden-Lucet, Françoise; Albuisson, Juliette; Lavergne, Thomas; Piot, Olivier; Alonso, Christine; Leenhardt, Antoine; Lellouche, Nicolas; Extramiana, Fabrice; Cariou, Alain; Jouven, Xavier; Marijon, Eloi

2018-01-01

Abstract Aims Recent studies have shown that in more than half of apparently unexplained sudden cardiac arrests (SCA), a specific aetiology can be unmasked by a careful evaluation. The characteristics and the extent to which such cases undergo a systematic thorough investigation in real-life practice are unknown. Methods and results Data were analysed from an ongoing study, collecting all cases of out-of-hospital cardiac arrest in Paris area. Investigations performed during the index hospitalization or planned after discharge were gathered to evaluate the completeness of assessment of unexplained SCA. Between 2011 and 2016, among the 18 622 out-of-hospital cardiac arrests, 717 survivors (at hospital discharge) fulfilled the definition of cardiac SCA. Of those, 88 (12.3%) remained unexplained after electrocardiogram, echocardiography, and coronary angiography. Cardiac magnetic resonance imaging yielded the diagnosis in 25 (3.5%) cases, other investigations accounted for 14 (2.4%) additional diagnoses, and 49 (6.8%) patients were labelled as idiopathic ventricular fibrillation (IVF) (48.7 ± 15 years, 69.4% male). Among those labelled IVF, only 8 (16.3%) cases benefited from a complete workup (including pharmacological testing). Younger patients [odds ratio (OR) 6.00, 95% confidence interval (CI) 1.80–22.26] and those admitted to university centres (OR 3.60, 95% CI 1.12–12.45) were more thoroughly investigated. Genetic testing and family screening were initiated in only 9 (18.4%) and 12 (24.5%) cases, respectively. Conclusion Our findings suggest that complete investigations are carried out in a very low proportion of unexplained SCA. Standardized, systematic approaches need to be implemented to ensure that opportunities for specific therapies and preventive strategies (including relatives) are not missed. PMID:29566157

Characteristics and clinical assessment of unexplained sudden cardiac arrest in the real-world setting: focus on idiopathic ventricular fibrillation.

PubMed

Waldmann, Victor; Bougouin, Wulfran; Karam, Nicole; Dumas, Florence; Sharifzadehgan, Ardalan; Gandjbakhch, Estelle; Algalarrondo, Vincent; Narayanan, Kumar; Zhao, Alexandre; Amet, Denis; Jost, Daniel; Geri, Guillaume; Lamhaut, Lionel; Beganton, Frankie; Ludes, Bertrand; Bruneval, Patrick; Plu, Isabelle; Hidden-Lucet, Françoise; Albuisson, Juliette; Lavergne, Thomas; Piot, Olivier; Alonso, Christine; Leenhardt, Antoine; Lellouche, Nicolas; Extramiana, Fabrice; Cariou, Alain; Jouven, Xavier; Marijon, Eloi

2018-06-01

Recent studies have shown that in more than half of apparently unexplained sudden cardiac arrests (SCA), a specific aetiology can be unmasked by a careful evaluation. The characteristics and the extent to which such cases undergo a systematic thorough investigation in real-life practice are unknown. Data were analysed from an ongoing study, collecting all cases of out-of-hospital cardiac arrest in Paris area. Investigations performed during the index hospitalization or planned after discharge were gathered to evaluate the completeness of assessment of unexplained SCA. Between 2011 and 2016, among the 18 622 out-of-hospital cardiac arrests, 717 survivors (at hospital discharge) fulfilled the definition of cardiac SCA. Of those, 88 (12.3%) remained unexplained after electrocardiogram, echocardiography, and coronary angiography. Cardiac magnetic resonance imaging yielded the diagnosis in 25 (3.5%) cases, other investigations accounted for 14 (2.4%) additional diagnoses, and 49 (6.8%) patients were labelled as idiopathic ventricular fibrillation (IVF) (48.7 ± 15 years, 69.4% male). Among those labelled IVF, only 8 (16.3%) cases benefited from a complete workup (including pharmacological testing). Younger patients [odds ratio (OR) 6.00, 95% confidence interval (CI) 1.80-22.26] and those admitted to university centres (OR 3.60, 95% CI 1.12-12.45) were more thoroughly investigated. Genetic testing and family screening were initiated in only 9 (18.4%) and 12 (24.5%) cases, respectively. Our findings suggest that complete investigations are carried out in a very low proportion of unexplained SCA. Standardized, systematic approaches need to be implemented to ensure that opportunities for specific therapies and preventive strategies (including relatives) are not missed.

Catatonia in Down syndrome; a treatable cause of regression

PubMed Central

Ghaziuddin, Neera; Nassiri, Armin; Miles, Judith H

2015-01-01

Objective: The main aim of this case series report is to alert physicians to the occurrence of catatonia in Down syndrome (DS). A second aim is to stimulate the study of regression in DS and of catatonia. A subset of individuals with DS is noted to experience unexplained regression in behavior, mood, activities of daily living, motor activities, and intellectual functioning during adolescence or young adulthood. Depression, early onset Alzheimer’s, or just “the Down syndrome” are often blamed after general medical causes have been ruled out. Clinicians are generally unaware that catatonia, which can cause these symptoms, may occur in DS. Study design: Four DS adolescents who experienced regression are reported. Laboratory tests intended to rule out causes of motor and cognitive regression were within normal limits. Based on the presence of multiple motor disturbances (slowing and/or increased motor activity, grimacing, posturing), the individuals were diagnosed with unspecified catatonia and treated with anti-catatonic treatments (benzodiazepines and electroconvulsive therapy [ECT]). Results: All four cases were treated with a benzodiazepine combined with ECT and recovered their baseline functioning. Conclusion: We suspect catatonia is a common cause of unexplained deterioration in adolescents and young adults with DS. Moreover, pediatricians and others who care for individuals with DS are generally unfamiliar with the catatonia diagnosis outside schizophrenia, resulting in misdiagnosis and years of morbidity. Alerting physicians to catatonia in DS is essential to prompt diagnosis, appropriate treatment, and identification of the frequency and course of this disorder. PMID:25897230

Fatal coma in a young adult due to late-onset urea cycle deficiency presenting with a prolonged seizure: a case report.

PubMed

Alameri, Majid; Shakra, Mustafa; Alsaadi, Taoufik

2015-11-23

Unexplained hyperammonemic coma in adults can be a medical dilemma in the absence of triggering factors and known comorbidities. Ornithine transcarbamylase deficiency presents most commonly with hyperammonemic coma. Although a rare disorder, ornithine transcarbamylase deficiency is the most common of the urea cycle disorders, which can occur both in children, and less commonly, in adults. The urea cycle disorder is usually acquired as an X-linked trait, and very rarely, similar to our reported case, may be acquired as a "new" mutation. Mutations that lead to later-onset presentations may lead to life-threatening disease and may be unrecognized, particularly when the first clinical symptoms occur in adulthood. We report the case of a previously healthy 17-year-old white man who developed a prolonged seizure and a rapid decline in mental status leading to coma over a 3-day period. Analysis of the OTC gene showed a 119G variant, which was identified in exon 2 of the OTC gene by sequencing. A diagnosis of ornithine transcarbamylase deficiency should be considered in adult patients who present with unexplained hyperammonemic coma and for all adult patients presenting with cryptogenic new-onset seizure and laboratory finding of elevated blood ammonia levels. This reported case highlights the importance of early recognition of this potentially reversible cause of life-threatening encephalopathy, as timely recognition and appropriate treatment can be lifesaving.

Unexplained lower abdominal pain associated with sacroiliac joint dysfunction: report of 2 cases.

PubMed

Morimoto, Daijiro; Isu, Toyohiko; Kim, Kyongsong; Matsumoto, Ryoji; Isobe, Masanori

2011-01-01

A 25-year-old woman and a 31-year-old man presented with chronic lower back pain and unexplained lower abdominal pain. Both patients had groin tenderness at the medial border of the anterior superior iliac spine. The results of radiographical and physical examinations suggested sacroiliac joint dysfunction. Sacroiliac joint injection relieved their symptoms, including groin tenderness. In our experience, groin tenderness is highly specific for sacroiliac joint dysfunction. We speculate that spasm of the iliac muscle can cause groin pain and tenderness. Groin pain and a history of unexplained abdominal pain, with lower back pain, are symptoms that suggest sacroiliac joint dysfunction. Additionally, compression of the iliac muscle is a simple and useful maneuver; therefore, it can be used as a screening test for sacroiliac joint dysfunction, alongside other provocation tests.

Introversion and medical student education: challenges for both students and educators.

PubMed

Davidson, Bernard; Gillies, Ralph A; Pelletier, Allen L

2015-01-01

Introversion is one of the personality factors that has been shown to be associated with performance in medical school. Prior cross-sectional studies highlight performance evaluation differences between introverted and extraverted medical students, though the mechanisms and implications of these differences remain relatively unexplained and understudied. This gap in the literature has become more salient as medical schools are employing more interactive learning strategies into their curricula which may disproportionately challenge introverted learners. In this article, we provide an overview and working definition of introversion as a valid construct occurring on a continuum. We apply a goodness of fit model to explore how various medical training contexts may be more or less challenging for introverted students and the potential consequences of a poor fit. As preliminary support for these hypothesized challenges, we share observations from students self-identified as introverts. Examples include introverted students feeling at times like misfits, questioning a need to change their identity to succeed in medical school, and being judged as underperformers. We offer pragmatic suggestions for improving the fit between introverted students and their training contexts, such as teachers and students pausing between a question being asked and the initial response being offered and teachers differentiating between anxious and introverted behaviors. We conclude with suggested areas for future qualitative and quantitative research to examine how medical school curricula and the teaching environment may be differentially impacting the learning and health of introverted and extraverted students. Extraverted behaviors will continue to be an important part of medical training and practice, but the merits of introverted behaviors warrant further consideration as both medical training and practice evolve. Educators who make manageable adjustments to current teaching practices can improve the learning for both introverted and extraverted styles of academic engagement.

What is the financial state of medical students from rural backgrounds during tuition fee deregulation?

PubMed

Woloschuk, Wayne; Lemay, Jean-François; Wright, Bruce

2010-01-01

We sought to examine the financial state of medical students from rural backgrounds during a time of tuition fee deregulation. We surveyed incoming classes from 2007 to 2011 at the University of Calgary. Community background, expected educational debt at graduation, educational debt at entry to medical school and parental income were collected for analysis. Data were analyzed using the Χ² test, analysis of variance and the Newman-Keuls multiple comparison test. The overall response rate was 95.3%. Of the 571 (93.5%) respondents who supplied data on their background and debt, 94.4% expected to have educational debt at graduation. The mean projected educational debt at graduation by medical students from both rural ($107 226 [95% confidence interval (CI) $98 030-$116 423]) and regional ($99 456 [95% CI $91 905-$107 006]) backgrounds was significantly greater than the debt projected by students from metropolitan ($88 565 [95% CI $83 607-$93 524]) backgrounds. Medical students who came from rural backgrounds had the highest mean debt at entry to medical school ($33 053 [95% CI $25 715-$40 391]) compared with their peers from regional ($23 253 [95% CI $16 621-$29 885]) and metropolitan ($22 053 [95% CI $17 344-$26 762]) backgrounds. Students of rural origin also had parents whose mean income ($104 024 [95% CI $75 976-$132 173]) was significantly lower than the mean parental income of their peers who originated from regional ($143 167 [95% CI $119 898-$166 435]) and metropolitan ($150 339 [95% CI $135 241-165 438]) centres. Rising tuition and subsequent debt may be affecting the diversity of medical students' backgrounds. Financial programs dedicated to rural-background students and their interest in medicine may become necessary.

Trends in the earnings gender gap among dentists, physicians, and lawyers.

PubMed

Nguyen Le, Thanh An; Lo Sasso, Anthony T; Vujicic, Marko

2017-04-01

The authors examined the factors associated with sex differences in earnings for 3 professional occupations. The authors used a multivariate Blinder-Oaxaca method to decompose the differences in mean earnings across sex. Although mean differences in earnings between men and women narrowed over time, there remained large, unaccountable earnings differences between men and women among all professions after multivariate adjustments. For dentists, the unexplained difference in earnings for women was approximately constant at 62% to 66%. For physicians, the unexplained difference in earnings for women ranged from 52% to 57%. For lawyers, the unexplained difference in earnings for women was the smallest of the 3 professions but also exhibited the most growth, increasing from 34% in 1990 to 45% in 2010. The reduction in the earnings gap is driven largely by a general convergence between men and women in some, but not all, observable characteristics over time. Nevertheless, large unexplained gender gaps in earnings remain for all 3 professions. Policy makers must use care in efforts to alleviate earnings differences for men and women because measures could make matters worse without a clear understanding of the nature of the factors driving the differences. Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.

Investigation of fatigue by Australian general practice registrars: a cross-sectional study.

PubMed

Morgan, Simon; Henderson, Kim M; Tapley, Amanda; Thomson, Allison; Wilson, Jessica; Scott, John; Spike, Neil A; McArthur, Lawrie; van Driel, Mieke L; Magin, Parker J

2015-06-01

Fatigue is the most common undifferentiated problem presenting in general practice. Previous studies have shown that this presentation leads to multiple investigations. There is no published literature describing the management of patients with fatigue by general practice (GP) registrars. To document the investigation-ordering behaviour of GP registrars in managing patients with a new diagnosis of unexplained fatigue. This was a cross-sectional analysis of data from Registrar Clinical Encounters in Training (ReCEnT), an ongoing cohort study of GP registrars' consultations. We established the prevalence of new diagnoses of unexplained fatigue and associations with that diagnosis, the rate of test ordering and the number and types of investigations ordered. 644 registrars contributed data from 68 986 encounters. In 0.78% of patient encounters, a new diagnosis of unexplained fatigue was made. Pathology was ordered in 78.4% of these problems (versus 18.1% in non-fatigue problems), at a rate of 488 tests per 100 new fatigue problems. Our study suggests that unexplained fatigue elicits a non-rational approach to test ordering by registrars. These findings contribute to the understanding of GP registrar management of fatigue, and undifferentiated presentations more broadly, and suggest educational approaches to improve practice, including dealing with uncertainty.

High prevalence of antibodies against hepatitis E virus in HIV-infected patients with unexplained liver disease.

PubMed

Merchante, Nicolás; Parra-Sánchez, Manuel; Rivero-Juárez, Antonio; Cifuentes, Celia; Camacho, Ángela; Macías, Juan; Martínez-Dueñas, Loreto; Pérez-Navarro, Elisabet; Rivero, Antonio; Pineda, Juan A

2015-10-01

To look for evidence of hepatitis E virus (HEV) exposure in HIV-infected patients with unexplained elevations of liver stiffness (LS). Case-control study conducted in 31 HIV-infected patients with unexplained elevations of LS and in 31 HIV-controls with normal LS, matched by age, sex and CD4 cell-counts. Serum HEV antibodies were tested by two ELISA procedures and by Immunoblot. We defined exposure to HEV as the detection of serum HEV antibodies by at least one of the two ELISA assays, provided that it was confirmed by Immunoblot. A real-time PCR RNA assay was conducted in all plasma samples to identify subjects with active HEV infection. Exposure to HEV was demonstrated, according to the criteria used in this study, in 9 (29%) of the cases, whereas it was shown in 5 (16%) of the controls (p=.3). Serum HEV RNA was detected in none of the controls and in only in one case. This patient had a documented chronic hepatitis E with progression to cirrhosis. HEV antibodies are frequently found in HIV-infected patients with unexplained liver disease. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Celiac disease and dysfunctional uterine bleeding; the efficiency of gluten free diet.

PubMed

Ehsani-Ardakani, M J; Fallahian, M; Rostami, K; Rostami-Nejad, M; Lotfi, S; Mohaghegh-Shalmani, H; Dabiri, R; Norouzinia, M; Azizpour-Shoobi, F; Zali, M R

2014-01-01

The aim of this study was to investigate the relation between Celiac disease (CD) and unexplained dysfunctional uterine bleeding (DUB) in celiac women. The celiac patients were selected from women who were referred to celiac department. Controls were selected from those women without any signs of celiac disease and matched with age. Meanwhile, a trained physician was ready to explain the study, and then in case of their allowance, a questionnaire was completed by the physician. 24 % of celiac women reported a past history of at least one menstrual cycle disorder vs 10 % of controls reported these problems (p=0.038) and higher percentage of unexplained DUB has been observed in celiac women. All celiac patients were undertaking gluten free diet for at least 3 months and the celiac patients who reported the history of DUB were again interviewed for any signs of unexplained DUB. From 12 celiac women with DUB, 10 patients reported no more unexplained DUB after getting gluten-free diet (83.3 %). The occurrence of a significant correlation between CD and DUB suggests the possibility of considering CD as one of the potential causes of abnormal uterine bleeding. Therefore, celiac disease must be seriously considered in the screening of patients with reproductive disorders (Tab. 2,Ref. 23).

Low molecular weight heparin use in unexplained recurrent miscarriage

PubMed Central

Yuksel, Halide; Kayatas, Semra; Boza, Aysen Telce; Api, Murat; Ertekin, A. Aktug; Cam, Cetin

2014-01-01

Objective: The aim of the study was to investigate whether the use of low molecular weight heparin (LMWH) improve live birth rates when compared with control group in patients with unexplained recurrent miscarriages (URM). Methods: In this prospective observational study 150 women with a history of two or more previous unexplained first trimester pregnancy loss who received LMWH; either enoxaparin (n=50), tinzaparin (n=50) or nothing (n=50) were followed for the pregnancy outcome measures. Only the patients who have used standardized dosage of LMWH (4000 IU/day enoxaparin or 3500 IU/day tinzaparin ) were included to the study. The primary end point was the live birth rate and secondary end points were the side effects, late pregnancy complications and neonatal outcome in the study cohorts. Results: Live birth was achieved 85% of the LMWH group and 66% of the control group (p=0.007). According to the subgroup analysis; live birth rates did not differ significantly between the enoxaparin and tinzaparin group (84% and 86%, respectively). Maternal and neonatal side effects were not statistically significant among the study participants. Conclusion: Thromboprophylaxis with LMWH resulted in a improved live-birth rate in patient with 2 or more consecutive unexplained recurrent pregnancy loss. Nevertheless these findings need to be confirmed in larger randomized trials. PMID:25674114

Paraoxonase-2 and paraoxonase-3: comparison of mRNA expressions in the placentae of unexplained intrauterine growth restricted and noncomplicated pregnancies.

PubMed

Dikbas, Levent; Yapca, Omer Erkan; Dikbas, Neslihan; Gundogdu, Cemal

2017-05-01

Recent evidence suggests that oxidative stress is involved in the pathophysiology of many human diseases. It has been demonstrated that oxidative stress is associated with intrauterine growth restriction (IUGR), and the depletion of placental antioxidant systems has been suggested as a key factor in this disease. Our aims were to explore the possible role of antioxidant paraoxonase-2 (PON2) and paraoxonase-3 (PON3) in the pathophysiology of unexplained IUGR. We have studied the expression of mRNA for PON2, PON3 in placental tissues by using RT-qPCR. Two groups, consisting of normal (n = 18) and unexplained IUGR pregnancies (n = 20) were compared. Our results demonstrated that there were no significant differences in the mRNA expressions of PON2, PON3 between the two groups (p = 0.28, p = 0.90, respectively). PON2 and PON3 were down-regulated in IUGR. Antenatal steroid therapy had no effect on the expression mRNA in placentae of unexplained IUGR pregnancies compared to non-treated group. These results suggest that PON2, PON3 mRNA levels were not changed significantly in placentae of IUGR when compared to normal pregnant women.

Level, Causes and Risk Factors of Neonatal Mortality, in Jordan: Results of a National Prospective Study.

PubMed

Batieha, Anwar M; Khader, Yousef S; Berdzuli, Nino; Chua-Oon, Chuanpit; Badran, Eman F; Al-Sheyab, Nihaya A; Basha, Asma S; Obaidat, Ahmad; Al-Qutob, Ra'eda J

2016-05-01

The present study aimed at assessment of the magnitude of neonatal mortality in Jordan, and its causes and associated factors. Through a multistage sampling technique, a total of 21,928 deliveries with a gestational period ≥20 weeks from 18 hospitals were included in the study. The status of their babies 28 days after birth, whether dead or alive, was ascertained. Extensive data were collected about mothers and their newborns at admission and after 28 days of birth. Causes of death were classified according to the neonatal and intrauterine death classification according to etiology. Preventability of death was classified according to Herman's classification into preventable, partially preventable, and not preventable. Neonatal mortality rate, overall and for subgroups of the study was obtained. Risk factors for neonatal mortality were first examined in bivariate analyses and finally by multivariate logistic regression models to account for potential confounders. A total of 327 babies ≥20 weeks of gestation died in the neonatal period (14.9/1000 LB). Excluding babies <1000 g and <28 weeks of gestation to be consistent with the WHO and UNICEF's annual neonatal mortality reports, the NNMR decreased to 10.5/1000 LB. About 79 % of all neonatal deaths occurred in the first week after birth with over 42 % occurring in the first day after birth. According to NICE hierarchical classification, most neonatal deaths were due to congenital anomalies (27.2 %), multiple births (26.0 %), or unexplained immaturity (21.7 %). Other important causes included maternal disease (6.7 %), specific infant conditions (6.4 %), and unexplained asphyxia (4.9 %). According to Herman's classification, 37 % of neonatal deaths were preventable and 59 % possibly preventable. An experts' panel determined that 37.3 % of neonatal deaths received optimal medical care while the medical care provided to the rest was less than optimal. After adjusting for socio-demographic characteristics, type of the hospital, and clinical and medical history of women, the following variables were significantly associated with neonatal mortality: male gender, congenital defects, inadequate antenatal visits, multiple pregnancy, presentation at delivery, and gestational age. The present study showed the level, causes, and risk factors of NNM in Jordan. It showed also that a large proportion of NNDs are preventable or possibly preventable. Providing optimal intrapartum, and immediate postpartum care is likely to result in avoidance of a large proportion of NNDs.

“Could this Be Something Serious?”

PubMed Central

Hadee, Taj; Carroll, Jennifer; Meldrum, Sean C.; Lardner, Judi; Shields, Cleveland G.

2007-01-01

BACKGROUND Previous work suggests that exploration and validation of patients’ concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care. OBJECTIVE To describe physicians’ responses to patients’ worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients’ ratings of interpersonal aspects of care. DESIGN Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about “something serious” in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS. PARTICIPANTS One hundred primary care physicians and 4,746 patients. MEASUREMENTS Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses. RESULTS Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence. CONCLUSIONS Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry. PMID:17972141

Educational Gradients and Pathways of Disability Onset Among Older Mexicans.

PubMed

Saenz, Joseph L; Wong, Rebeca

2016-04-01

Educational disparities research is less common in developing countries. We evaluate whether educational gradients of disability onset exist in Mexico across groups (birth cohort and sex) and whether the association is unexplained or indirect via health (health behaviors, chronic conditions, and self-rated health) or economic (income, wealth, and health insurance) pathways. Data come from the Mexican Health & Aging study. Activities of daily living are reported in 2001, 2003, and 2012 by respondents and spouses aged 50+ (N = 9,560). Groups are analyzed using logistic regression to test education-disability onset associations. Significant education-ADL onset associations were observed across groups, and much of these associations were direct (unexplained by pathways). Indirect effects operated primarily through the health pathway. Those with less education were disadvantaged in terms of disability across birth cohorts and sex. Unexplained effects of education may suggest unobserved mediators or differential returns to resources by educational level. © The Author(s) 2016.

Increased Prevalence of Celiac Disease in Patients with Unexplained Infertility in the United States: A Prospective Study

PubMed Central

Lebwohl, Benjamin; Wang, Jeffrey; Lee, Susie K.; Murray, Joseph A.; Sauer, Mark V.; Green, Peter H. R.

2011-01-01

Celiac disease is an autoimmune disorder which can present with a variety of non-gastrointestinal manifestations. In women, it may manifest with an assortment of gynecologic or obstetric disorders. Some reports have linked female infertility with undiagnosed celiac disease. Though there are a number of studies from Europe and the Middle East, only two prior American studies have examined the prevalence of “silent” celiac disease in a female infertility population. We prospectively performed serologic screening for celiac disease in 188 infertile women (ages 25–39). While we did not demonstrate an increased prevalence of celiac disease in our overall infertile female population, we were able to detect a significantly increased prevalence (5.9%) of undiagnosed celiac disease among women presenting with unexplained infertility (n=51). Our findings suggest the importance of screening infertile female patients, particularly those with unexplained infertility, for celiac disease. PMID:21682114

Educational Gradients and Pathways of Disability Onset Among Older Mexicans

PubMed Central

Saenz, Joseph L.; Wong, Rebeca

2016-01-01

Introduction Educational disparities research is less common in developing countries. We evaluate whether educational gradients of disability onset exist in Mexico across groups (birth cohort and sex) and whether the association is unexplained or indirect via health (health behaviors, chronic conditions, and self-rated health) or economic (income, wealth, and health insurance) pathways. Method Data come from the Mexican Health & Aging study. Activities of daily living are reported in 2001, 2003, and 2012 by respondents and spouses aged 50+ (N = 9,560). Groups are analyzed using logistic regression to test education–disability onset associations. Results Significant education–ADL onset associations were observed across groups, and much of these associations were direct (unexplained by pathways). Indirect effects operated primarily through the health pathway. Discussion Those with less education were disadvantaged in terms of disability across birth cohorts and sex. Unexplained effects of education may suggest unobserved mediators or differential returns to resources by educational level. PMID:26966253

Mass psychogenic illness: psychological predisposition and iatrogenic pseudo-vocal cord dysfunction and pseudo-reactive airways disease syndrome.

PubMed

Staudenmayer, Herman; Christopher, Kent L; Repsher, Lawrence; Hill, Ronald H

2011-06-01

A multidisciplinary team assessed five patients who alleged chronic medically unexplained multiorgan system symptoms described by idiopathic environmental intolerance allegedly triggered by exposure to solvents used in membrane roofing repair work on an office building. The event precipitated an incident of mass psychogenic illness (MPI). Treating physicians diagnosed irritant-associated vocal cord dysfunction (IVCD) and reactive airways disease syndrome (RADS) resulting from exposure. The authors conducted medical, psychological, and industrial hygiene evaluations. Air monitoring data for total volatile organic compounds obtained during the 2-day exposure period, measurements of emissions during membrane roofing repair at a similar site, mathematical modeling of air contaminant concentrations, and injection of tracer gas into the incident building revealed exposure levels well below those doses anticipated to cause clinical symptoms. There was no objective medical evidence validating symptoms. Review of the medical records indicated that the video laryngoscopy data, pulmonary function tests, and medical examinations relied upon by the treating physicians were inconsistent with published criteria for IVCD and RADS. Psychological evaluation identified defensiveness and self-serving misrepresentations of exaggerated health concerns associated with somatization and malingering. Each case had personality traits associated with at least one personality disorder. Social histories identified premorbid life events and stressors associated with distress. This is the first study to assess psychological predisposition, social interaction among the plaintiffs, and iatrogenic reinforcement of beliefs by diagnoses of pseudo-disorders associated with patient misrepresentation of exaggerated health concerns in an incident of MPI.

Incidence of Norovirus-Associated Medical Encounters among Active Duty United States Military Personnel and Their Dependents.

PubMed

Rha, Brian; Lopman, Benjamin A; Alcala, Ashley N; Riddle, Mark S; Porter, Chad K

2016-01-01

Norovirus is a leading cause of gastroenteritis episodes and outbreaks in US military deployments, but estimates of endemic disease burden among military personnel in garrison are lacking. Diagnostic codes from gastroenteritis-associated medical encounters of active duty military personnel and their beneficiaries from July 1998-June 2011 were obtained from the Armed Forces Health Surveillance Center. Using time-series regression models, cause-unspecified encounters were modeled as a function of encounters for specific enteropathogens. Model residuals (representing unexplained encounters) were used to estimate norovirus-attributable medical encounters. Incidence rates were calculated using population data for both active duty and beneficiary populations. The estimated annual mean rate of norovirus-associated medically-attended visits among active duty personnel and their beneficiaries was 292 (95% CI: 258 to 326) and 93 (95% CI: 80 to 105) encounters per 10,000 persons, respectively. Rates were highest among beneficiaries <5 years of age with a median annual rate of 435 (range: 318 to 646) encounters per 10,000 children. Norovirus was estimated to cause 31% and 27% of all-cause gastroenteritis encounters in the active duty and beneficiary populations, respectively, with over 60% occurring between November and April. There was no evidence of any lag effect where norovirus disease occurred in one population before the other, or in one beneficiary age group before the others. Norovirus is a major cause of medically-attended gastroenteritis among non-deployed US military active duty members as well as in their beneficiaries.

Assessment of Prevalence, Beliefs, and Habits of Hookah Smoking Among People with a Medical Background Compared to People with a Non-medical Background: A Cross-sectional Self-administered Questionnaire-based Study

PubMed Central

Jain, Ashna

2016-01-01

Introduction: Hookah smoking has seen a reemergence in popularity in the last 30 years, particularly in the young urban population. This study aimed to compare the prevalence of and the attitude and beliefs about hookah smoking of people with a medical background and compare it with people from a non-medical background. Materials and methods: An anonymous questionnaire with ten questions about various aspects of hookah smoking was formulated using Google forms®, which was then circulated via Facebook®, Whatsapp® and emails to the intended participants and all responses were recorded and analyzed. Results: The total number of respondents were 470. The number of respondents with a medical background was 45.31%. The percentage of the respondents with a medical background who smoked a hookah was 28.63%, while the same percentage of the respondents with a non-medical background was 63.42. The perception of hookah being less harmful than a cigarette was not found to be statistically different between the two groups. Respondents with a medical background were more ignorant of the presence or absence of tobacco in the hookah they smoked. The average duration of the hookah smoking habit, the frequency of its use per month, and the average lengths of the hookah smoking session were 3.52 years (95% CI of 3.21 to 3.82), 1.946 (95% CI 1.799 to 2.093), and 58.90 minutes (95% CI of 54.42 to 63.37), respectively. Conclusion: The knowledge about the ill effects of smokeless tobacco should be integrated into the structured teaching curriculum of undergraduate medical and dental courses as they prepare future physicians and dental surgeons for an anti-tobacco campaign. PMID:27660734

'Sink or swim': an evaluation of the clinical characteristics of individuals with high bone mass.

PubMed

Gregson, C L; Steel, S A; O'Rourke, K P; Allan, K; Ayuk, J; Bhalla, A; Clunie, G; Crabtree, N; Fogelman, I; Goodby, A; Langman, C M; Linton, S; Marriott, E; McCloskey, E; Moss, K E; Palferman, T; Panthakalam, S; Poole, K E S; Stone, M D; Turton, J; Wallis, D; Warburton, S; Wass, J; Duncan, E L; Brown, M A; Davey-Smith, G; Tobias, J H

2012-02-01

High bone mineral density on routine dual energy X-ray absorptiometry (DXA) may indicate an underlying skeletal dysplasia. Two hundred fifty-eight individuals with unexplained high bone mass (HBM), 236 relatives (41% with HBM) and 58 spouses were studied. Cases could not float, had mandible enlargement, extra bone, broad frames, larger shoe sizes and increased body mass index (BMI). HBM cases may harbour an underlying genetic disorder. High bone mineral density is a sporadic incidental finding on routine DXA scanning of apparently asymptomatic individuals. Such individuals may have an underlying skeletal dysplasia, as seen in LRP5 mutations. We aimed to characterize unexplained HBM and determine the potential for an underlying skeletal dysplasia. Two hundred fifty-eight individuals with unexplained HBM (defined as L1 Z-score ≥ +3.2 plus total hip Z-score ≥ +1.2, or total hip Z-score ≥ +3.2) were recruited from 15 UK centres, by screening 335,115 DXA scans. Unexplained HBM affected 0.181% of DXA scans. Next 236 relatives were recruited of whom 94 (41%) had HBM (defined as L1 Z-score + total hip Z-score ≥ +3.2). Fifty-eight spouses were also recruited together with the unaffected relatives as controls. Phenotypes of cases and controls, obtained from clinical assessment, were compared using random-effects linear and logistic regression models, clustered by family, adjusted for confounders, including age and sex. Individuals with unexplained HBM had an excess of sinking when swimming (7.11 [3.65, 13.84], p < 0.001; adjusted odds ratio with 95% confidence interval shown), mandible enlargement (4.16 [2.34, 7.39], p < 0.001), extra bone at tendon/ligament insertions (2.07 [1.13, 3.78], p = 0.018) and broad frame (3.55 [2.12, 5.95], p < 0.001). HBM cases also had a larger shoe size (mean difference 0.4 [0.1, 0.7] UK sizes, p = 0.009) and increased BMI (mean difference 2.2 [1.3, 3.1] kg/m(2), p < 0.001). Individuals with unexplained HBM have an excess of clinical characteristics associated with skeletal dysplasia and their relatives are commonly affected, suggesting many may harbour an underlying genetic disorder affecting bone mass.

An evaluation of classification systems for stillbirth

PubMed Central

Flenady, Vicki; Frøen, J Frederik; Pinar, Halit; Torabi, Rozbeh; Saastad, Eli; Guyon, Grace; Russell, Laurie; Charles, Adrian; Harrison, Catherine; Chauke, Lawrence; Pattinson, Robert; Koshy, Rachel; Bahrin, Safiah; Gardener, Glenn; Day, Katie; Petersson, Karin; Gordon, Adrienne; Gilshenan, Kristen

2009-01-01

Background Audit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach. Methods We evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement. Results InfoKeep scores were significantly different across the classifications (p ≤ 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different (p ≤ 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement. Conclusion The Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system. PMID:19538759

Ongoing pregnancies in patients with unexplained recurrent pregnancy loss: adverse obstetric outcomes.

PubMed

Cozzolino, Mauro; Rizzello, Francesca; Riviello, Chiara; Romanelli, Chiara; Coccia Elisabetta, Maria

2018-05-25

To investigate the incidence of adverse pregnancy outcomes in couples with an unexplained Recurrent Pregnancy Loss (RPL) history, a retrospective cohort study was conducted between 2014 and 2015. The study group (A) included couples with an unexplained RPL, and the control group (B) was composed of couples who attended the Low-Risk Antenatal Unit during the same period. On the other hand, 53 couples were included in the study group (A) and on the other hand, 65 in the control group (B). Women with previous unexplained recurrent pregnancies loss had a significantly increased risk of gestational diabetes with 12 cases (22.6%) in the study group and 3 cases (4.6%) in the control (OR: 6.048; 95% CI: 1.607-22.762; p = 0.007). A slight increase in the risk of preterm delivery and hepatic cholestasis was observed in the study group (6 cases, 11.3%, in study group and 1 case, 1.5% in the controls (OR: 8.170; 95% CI: 0.951-70.158; p = 0.0555). Women with a history of RPL delivered more frequently by caesarean section (OR: 3.252; 95% CI: 1.460-7.241; p = 0.0039). Women with a history of RPL were at an increased risk for adverse pregnancy outcomes, mainly gestational diabetes. Therefore, a closer surveillance during the antenatal period is recommended in this group of patients.

Treatment of central sensitization in patients with 'unexplained' chronic pain: what options do we have?

PubMed

Nijs, Jo; Meeus, Mira; Van Oosterwijck, Jessica; Roussel, Nathalie; De Kooning, Margot; Ickmans, Kelly; Matic, Milica

2011-05-01

Central sensitization accounts for chronic 'unexplained' pain in a wide variety of disorders, including chronic whiplash-associated disorders, temporomandibular disorders, chronic low back pain, osteoarthritis, fibromyalgia, chronic fatigue syndrome and chronic tension-type headache among others. Given the increasing evidence supporting the clinical significance of central sensitization in those with unexplained chronic pain, the awareness is growing that central sensitization should be a treatment target in these patients. This article provides an overview of the treatment options available for desensitizing the CNS in patients with chronic pain due to central sensitization. It focuses on those strategies that specifically target pathophysiological mechanisms known to be involved in central sensitization. In addition, pharmacological options, rehabilitation and neurotechnology options are discussed. Acetaminophen, serotonin-reuptake inhibitor drugs, selective and balanced serototin and norepinephrine-reuptake inhibitor drugs, the serotonin precursor tryptophan, opioids, N-methyl-d-aspartate (NMDA)-receptor antagonists, calcium-channel alpha(2)delta (a2δ) ligands, transcranial magnetic stimulation, transcutaneous electric nerve stimulation (TENS), manual therapy and stress management each target central pain processing mechanisms in animals that - theoretically - desensitize the CNS in humans. To provide a comprehensive treatment for 'unexplained' chronic pain disorders characterized by central sensitization, it is advocated to combine the best evidence available with treatment modalities known to target central sensitization. © 2011 Informa UK, Ltd

Temporal association of cannabis use with symptoms in individuals at clinical high risk for psychosis.

PubMed

Corcoran, Cheryl M; Kimhy, David; Stanford, Arielle; Khan, Shamir; Walsh, Julie; Thompson, Judy; Schobel, Scott; Harkavy-Friedman, Jill; Goetz, Ray; Colibazzi, Tiziano; Cressman, Victoria; Malaspina, Dolores

2008-12-01

Cannabis use is reported to increase the risk for psychosis, but no prospective study has longitudinally examined drug use and symptoms concurrently in clinical high risk cases. We prospectively followed for up to 2 years 32 cases who met research criteria for prodromal psychosis to examine the relationship between substance use and clinical measures. Cases with a baseline history of cannabis use (41%) were older, but did not differ in clinical measures. Longitudinal assessments showed these cases had significantly more perceptual disturbances and worse functioning during epochs of increased cannabis use that were unexplained by concurrent use of other drugs or medications. These data demonstrate that cannabis use may be a risk factor for the exacerbation of subthreshold psychotic symptoms, specifically perceptual disturbances, in high risk cases.

Post-mortem genetic testing in a family with long-QT syndrome and hypertrophic cardiomyopathy.

PubMed

Kane, David A; Triedman, John

2014-01-01

Pediatric sudden unexplained deaths are rare and tragic events that should be evaluated with all the tools available to the medical community. The current state of genetic testing is an excellent resource that improves our ability to diagnose cardiovascular disorders that can lead to sudden cardiac arrest. Post-mortem genetic testing is not typically a covered benefit of health insurance and may not be offered to families in the setting of a negative autopsy. This unusual case includes two separate cardiovascular disorders that highlight the use of genetic testing and its role in diagnosis, screening, and risk stratification. The insurance company's decision to cover post-mortem testing demonstrated both compassion as well as an understanding of the long-term cost effectiveness. Copyright © 2014 Elsevier Inc. All rights reserved.

Thyroid eye disease.

PubMed

Cockerham, Kimberly P; Chan, Stephanie S

2010-08-01

Thyroid eye disease (TED) is the most common cause of proptosis in adults, and should always be a consideration in patients with unexplained diplopia, pain, or optic nerve dysfunction. At least 80% of TED is associated with Graves disease (GD), and at least 50% of patients with GD develop clinically evident symptomatic TED. The most confusing patients for doctors of all subspecialties are the patients with eye symptoms and signs that precede serum evidence of a thyroid imbalance. Management of TED may include immunosuppressive medications, radiation, or surgery. Although the prognosis for optic nerve function is excellent, the restrictive dysmotility can result in permanent disability. Orbit and eyelid reconstruction are reserved for stable, inactive patients and are the final steps in minimizing facial alterations and enhancing the patient's daily functioning. Copyright 2010 Elsevier Inc. All rights reserved.

Medication discrepancies across multiple care transitions: A retrospective longitudinal cohort study in Italy.

PubMed

Bonaudo, Marco; Martorana, Maria; Dimonte, Valerio; D'Alfonso, Alessandra; Fornero, Giulio; Politano, Gianfranco; Gianino, Maria Michela

2018-01-01

Medication discrepancies are defined as unexplained differences among regimens across different sites of care. The problem of medication discrepancies that occur during the entire care pathway from hospital admission to a local care setting discharge (namely all types of settings dedicated to formal care other than hospitals) has received little attention in the medical literature. The present study aims to (1) determine the prevalence of medication discrepancies that occur during the entire care pathway from hospital admission to local care setting discharge, (2) describe the discrepancy and medication type, and (3) identify potential risk factors for experiencing medication discrepancies in patient care transitions. Evidence from an integrated health care system, such as the Italian one, may explain results from other studies in different healthcare systems. A retrospective longitudinal cohort study of patients admitted from July 2015 to July 2016 to the Giovanni Bosco Hospital serving Turin, Italy and its surrounding territory was performed. Discrepancies were recorded at the following four care transitions: T1: Hospital admission; T2: Hospital discharge; T3: Admission into local care settings; T4: Discharge from local care settings. All evaluations were based on documented regimens and were performed by a team (doctor, nurse and pharmacists). Of 366 included patients, 25.68% had at least one discrepancy. The most frequent type of discrepancy was from medication omission (N = 74; 71.15%). Only discharge from a long-stay care setting (T4) was significantly associated with the onset of discrepancies (p = 0.045). When considering a lack of adequate documentation, not as missing data but as a discrepancy, 43.72% of patients had at least one discrepancy. This study suggests that an integrated health care system, such as Italian system, may influence the prevalence of discrepancies, thus highlighting the need for structured multidisciplinary and, if possible, computerized medication reconciliation to prevent medication discrepancies and improve the quality of medical documentation.

[A Case of Lead Poisoning with Drug-induced Liver Injury after Ingestion of Herbal Medicine].

PubMed

Jeon, Gi Jung; Park, Jong Ha; Kim, Min Sung; Yu, Jong Won; Park, Jae Hyun; Kim, Min Sik

2015-06-01

A 61-year-old male patient was admitted because of unexplained abdominal pain and anemia. His past medical history was unremarkable except for having taken herbal medicine to treat facial palsy two months ago. The result of health examination performed about a month ago showed increased serum aspartate and alanine aminotransferase level, and he was diagnosed with toxic hepatitis by herbal medicine. When the patient presented to the outpatient department three weeks ago, follow-up liver function test results showed improvement but he complained of abdominal pain. Despite extensive blood chemistry tests and computed tomography, the cause of pain could not be found. After much deliberation, serum lead level and herbal medicines analysis was performed based on the fact that he took herbal medicine two months ago, and he could finally be diagnosed with lead poisoning. Since the serum lead level was high enough to be indicated for lead chelating therapy, conservative management was given. When a patient with toxic hepatitis due to herbal medication presents with abdominal pain, the possibility of lead poisoning should always be taken into consideration.

The effectiveness, safety, and economic evaluation of Korean medicine for unexplained infertile women: A multi-center, prospective, observational study protocol.

PubMed

Kim, Su-Hyun; Jo, Junyoung; Kim, Dong-Il

2017-12-01

Infertility is a condition in which a woman has not been pregnant despite having had normal intercourse for 1 year. The number of unexplained infertile females is increasing because of late marriage customs, as well as environmental and lifestyle habits. In Korea, infertile females have been treated with Korean medicine (KM). However, these effects have not been objectively confirmed through clinical trials. Therefore, this study was conducted to demonstrate the effectiveness of herbal medicine treatment in infertile patients and to demonstrate the economic feasibility through economical evaluation with assisted reproductive technology.This study is designed as a multicenter, single-arm clinical trial. All participants included will be from 3 Korean Medicine hospitals in Korea and will voluntarily sign an informed consent agreement. All recruited patients will conduct related surveys and tests, and be provided with treatment according to their menstrual cycle. Patients will take herbal medicines for 4 menstruation cycles and receive acupuncture and moxibustion treatment at 3 times (menstrual cycle day 3, 8, 14) during 4 menstruation cycles. They will also undergo an approximately 4 menstrual cycle treatment period, and 3 menstrual cycle observation period. If pregnant during the study, participants will take the herbal medicine for implantation for about 15 days. In this study, the primary outcome will be the clinical pregnancy rate, whereas the secondary outcome will include the implantation rate, ongoing pregnancy rate, and live birth rate.Ultimately, this study will provide clinical data regarding the effectiveness and safety of KM treatment for females with unexplained infertility and important evidence for establishing standard KM treatments for unexplained infertility. Moreover, we will identify the most cost-effective way to treat unexplained infertility. Korean Clinical Trial Registry (CRIS), Republic of Korea: KCT0002235. Date: February 21, 2017 (retrospectively registered). Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases.

PubMed

Shokeir, Tarek; Abdelshaheed, Mahmoud; El-Shafie, Mohamed; Sherif, Lotfy; Badawy, Ahmed

2011-03-01

To evaluate prospectively the effect of hysteroscopic septoplasty as therapy for unexplained primary infertility in women with uterine septum as a sole cause for reproductive failure and to define the factors influencing reproductive success. In a prospective comparative study, we enrolled 103 infertile women with uterine septum as a sole cause for reproductive failure. They had had unexplained primary infertility >2 years and a follow-up >12 months. Uterine anomalies were diagnosed by means of hysterosalpingography (HSG) and 2D-transvaginal sonography (TVS) with intrauterine saline infusion. Hysteroscopic septoplasty was performed in the early follicular phase. Pregnancy rates (PR) according to patient and septum characteristics (septum size) were the main outcome measures. Follow-up was complete for 88 patients. The mean (±SD) age of the patients was 36.1±2.1 years. Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5±2.6 months. Nearly 80% of the pregnant women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. The PR was significantly higher in women <35 years of age or with <3 years of unexplained primary infertility. Moreover, in women with a septum size larger than one-half of their uterine length the PR was significantly higher than those with septum size <1/2 of their uterus (P=.12). Fertility and pregnancy after hysteroscopic septoplasty in women with unexplained primary infertility and uterine septum as a sole cause for reproductive failure seems to depend on patient age, duration of infertility before septoplasty, and septum size. Women with a septum size larger than one-half of their uterine length have a higher chance of successful pregnancy after hysteroscopic septoplasty. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

The barriers and facilitators people with diabetes from a nonEnglish speaking background experience when managing their medications: a qualitative study.

PubMed

Claydon-Platt, Kate; Manias, Elizabeth; Dunning, Trisha

2014-08-01

To explore the barriers to and facilitators of effective medication management from the perspectives of people with diabetes from a nonEnglish speaking background, carers and health professionals. The barriers that people with diabetes experience managing their medications can adversely impact on health outcomes. People from nonEnglish speaking backgrounds are at risk of medication-related problems, although there is a paucity of research in this area. A qualitative research design using a purposive sampling approach. People with type 1 or type 2 diabetes from a nonEnglish speaking background, their carers, and health professionals who assisted these people and their carers to manage their medications were recruited from the diabetes outpatient clinic at an adult teaching public hospital in Melbourne, Australia. Participants were interviewed using a semi-structured interview guide. All interviews were audio-recorded, transcribed verbatim and analysed using a thematic framework method. Eleven people with diabetes, 10 carers and 10 health professionals were interviewed, and four key issues were identified: diabetes knowledge, diabetes impact, medication knowledge and medication management. The cost of medications, language barriers that hinder communication, forgetfulness, and poor knowledge and understanding emerged as barriers to effective medication management. Facilitators included the use of dose administration aids to manage medications, but current medication lists were not used. Findings revealed people with diabetes experienced a multitude of barriers when managing their medications, and, despite the problems people experienced, there appeared to be poor use of support aids to assist people to effectively manage their medications. The findings can be used to develop strategies aiming at improving how people from nonEnglish speaking backgrounds manage their medicines. © 2013 John Wiley & Sons Ltd.

Lourdes: A uniquely Catholic approach to medicine.

PubMed

Dichoso, Travis Jon

2015-02-01

As an American medical student, I spent the summer break between my first and second year in Lourdes, France, the site where the Immaculate Conception appeared eighteen times to St. Bernadette in 1858 as proclaimed approved by the Catholic Church and whose water is associated with over seven thousand unexplained cures. During this time I volunteered with St. Joseph's Service and Poste Secour, followed several medical teams taking care of large pilgrim groups, and shadowed Dr. Alessandro de Franciscis the president of Le Bureau des Constations Médicales, the office in Lourdes charged with investigating claims of miracles. Through my experiences, I found the mission of medicine in Lourdes to be twofold: to provide the critical care needed to give sick persons the chance to transform their experience of disease through their faith; and secondly, through the efforts of the Medical Bureau, to be an instrument by which we can comprehend the wonders of the work of God. I conclude that this twofold mission should inform the work of every Catholic in health care or research, and Lourdes provides the venue par excellence to cultivate this mission. Lay Summary: Lourdes is a pilgrimage site in southern France that has been associated with medical miracles for the past 150 years. The site is unique in that throughout its history, physicians, of any or no faith, have been invited to participate in the proceedings of the investigations of each claimed cure. The investigations have formalized into a process handled by the Lourdes Medical Bureau and the Lourdes International Medical Association. Travis Dichoso, an American medical student, writes about his experiences as part of this process.

HSV-1/HSV-2 Infection-Related Cancers in Bantu Populations Driving HIV-1 Prevalence in Africa: Tracking the Origin of AIDS at the Onset of the 20th Century.

PubMed

Le Goaster, Jacqueline; Bouree, Patrice; El Sissy, Franck N; Phuong Bui, Florence; Pokossy Epee, Johanna; Rollin, Paul; Tangy, Frédéric; Haenni, Anne-Lise

2016-01-01

At the onset of the 20th century, ancient clinical observations of cancer epidemics in Bantu populations of Sub-Saharan Africa were discovered. They were reported from 1914 to 1960, but remained unexplained. In 1983, in San Francisco, Calif., USA, cancer epidemics were related to infections by the human immunodeficiency virus type 1 (HIV-1) known as AIDS disease. Yet since 1996, it is known that HIV-1 strains are not the only ones involved. In Sub-Saharan Africa, recurrent orobuccal herpes simplex virus type 1 (HSV-1) and genital recurrent herpes simplex virus type 2 (HSV-2) appeared many times prior to infection by HIV-1. Data on these ancient medical observations regarding African cancer epidemics can today be referred to as the relationship between the unfortunate immune deficiency of herpes in Bantu populations and HIV-1 viral strains. For centuries, the Bantu populations dispersed in forests were living in close proximity to chimpanzees infected by simian immunodeficiency virus (SIV) and were exposed to SIV contamination which became HIV-1 in human beings. Presently, these unexplained Bantu cancer epidemics can be linked to the viral partnership of HSV-1/HSV-2 to HIV-1 strains. The key issue is now to prevent HSV-1/HSV-2 diseases related to HIV-1. An anti-herpes treatment administered early during childhood to Bantu populations will offer a mean of preventing herpes diseases related to HIV-1 infection and hence avoid cancer epidemics.

HSV-1/HSV-2 Infection-Related Cancers in Bantu Populations Driving HIV-1 Prevalence in Africa: Tracking the Origin of AIDS at the Onset of the 20th Century

PubMed Central

Le Goaster, Jacqueline; Bouree, Patrice; El Sissy, Franck N.; Phuong Bui, Florence; Pokossy Epee, Johanna; Rollin, Paul; Tangy, Frédéric; Haenni, Anne-Lise

2016-01-01

Introduction At the onset of the 20th century, ancient clinical observations of cancer epidemics in Bantu populations of Sub-Saharan Africa were discovered. They were reported from 1914 to 1960, but remained unexplained. In 1983, in San Francisco, Calif., USA, cancer epidemics were related to infections by the human immunodeficiency virus type 1 (HIV-1) known as AIDS disease. Yet since 1996, it is known that HIV-1 strains are not the only ones involved. In Sub-Saharan Africa, recurrent orobuccal herpes simplex virus type 1 (HSV-1) and genital recurrent herpes simplex virus type 2 (HSV-2) appeared many times prior to infection by HIV-1. Case Reports Data on these ancient medical observations regarding African cancer epidemics can today be referred to as the relationship between the unfortunate immune deficiency of herpes in Bantu populations and HIV-1 viral strains. For centuries, the Bantu populations dispersed in forests were living in close proximity to chimpanzees infected by simian immunodeficiency virus (SIV) and were exposed to SIV contamination which became HIV-1 in human beings. Presently, these unexplained Bantu cancer epidemics can be linked to the viral partnership of HSV-1/HSV-2 to HIV-1 strains. Conclusion The key issue is now to prevent HSV-1/HSV-2 diseases related to HIV-1. An anti-herpes treatment administered early during childhood to Bantu populations will offer a mean of preventing herpes diseases related to HIV-1 infection and hence avoid cancer epidemics. PMID:28413399

A Systematic Review of the Probability of Asphyxia in Children Aged <2 Years with Unexplained Epistaxis.

PubMed

Rees, Philippa; Kemp, Alison; Carter, Ben; Maguire, Sabine

2016-01-01

To determine the proportion of children aged <2 years who have been asphyxiated presenting with epistaxis in the absence of trauma or medical explanation and to identify the characteristics of the clinical presentation indicative of asphyxiation. An all-language systematic review was conducted by searching 10 databases from 1900 to 2015 and gray literature to identify high-quality studies that included children with epistaxis aged <2 years (alive or dead) with explicit confirmation of intentional or unintentional asphyxiation (upper airway obstruction). Studies of traumatic or pathological epistaxis were excluded. For each comparative study, the proportion of children presenting with epistaxis that were asphyxiated is reported with 95% CI. Of 2706 studies identified, 100 underwent full review, resulting in 6 included studies representing 30 children with asphyxiation-related epistaxis and 74 children with non-asphyxiation-related epistaxis. The proportion of children presenting with epistaxis that had been asphyxiated, reported by 3 studies, was between 7% and 24%. Features associated with asphyxiation in live children included malaise, altered skin color, respiratory difficulty, and chest radiograph abnormalities. There were no explicit associated features described among those children who were dead on arrival. There is an association between epistaxis and asphyxiation in young children; however, epistaxis does not constitute a diagnosis of asphyxia in itself. In any infant presenting with unexplained epistaxis, a thorough investigation of etiology is always warranted, which must include active exploration of asphyxia as a possible explanation. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Potential asphyxia and brainstem abnormalities in sudden and unexpected death in infants.

PubMed

Randall, Bradley B; Paterson, David S; Haas, Elisabeth A; Broadbelt, Kevin G; Duncan, Jhodie R; Mena, Othon J; Krous, Henry F; Trachtenberg, Felicia L; Kinney, Hannah C

2013-12-01

Sudden and unexplained death is a leading cause of infant mortality. Certain characteristics of the sleep environment increase the risk for sleep-related sudden and unexplained infant death. These characteristics have the potential to generate asphyxial conditions. We tested the hypothesis that infants may be exposed to differing degrees of asphyxia in sleep environments, such that vulnerable infants with a severe underlying brainstem deficiency in serotonergic, γ-aminobutyric acid-ergic, or 14-3-3 transduction proteins succumb even without asphyxial triggers (e.g., supine), whereas infants with intermediate or borderline brainstem deficiencies require asphyxial stressors to precipitate death. We classified cases of sudden infant death into categories relative to a "potential asphyxia" schema in a cohort autopsied at the San Diego County Medical Examiner's Office. Controls were infants who died with known causes of death established at autopsy. Analysis of covariance tested for differences between groups. Medullary neurochemical abnormalities were present in both infants dying suddenly in circumstances consistent with asphyxia and infants dying suddenly without obvious asphyxia-generating circumstances. There were no differences in the mean neurochemical measures between these 2 groups, although mean measures were both significantly lower (P < .05) than those of controls dying of known causes. We found no direct relationship between the presence of potentially asphyxia conditions in the sleep environment and brainstem abnormalities in infants dying suddenly and unexpectedly. Brainstem abnormalities were associated with both asphyxia-generating and non-asphyxia generating conditions. Heeding safe sleep messages is essential for all infants, especially given our current inability to detect underlying vulnerabilities.

Potential Asphyxia and Brainstem Abnormalities in Sudden and Unexpected Death in Infants

PubMed Central

Randall, Bradley B.; Paterson, David S.; Haas, Elisabeth A.; Broadbelt, Kevin G.; Duncan, Jhodie R.; Mena, Othon J.; Krous, Henry F.; Trachtenberg, Felicia L.

2013-01-01

OBJECTIVE: Sudden and unexplained death is a leading cause of infant mortality. Certain characteristics of the sleep environment increase the risk for sleep-related sudden and unexplained infant death. These characteristics have the potential to generate asphyxial conditions. We tested the hypothesis that infants may be exposed to differing degrees of asphyxia in sleep environments, such that vulnerable infants with a severe underlying brainstem deficiency in serotonergic, γ-aminobutyric acid-ergic, or 14-3-3 transduction proteins succumb even without asphyxial triggers (eg, supine), whereas infants with intermediate or borderline brainstem deficiencies require asphyxial stressors to precipitate death. METHODS: We classified cases of sudden infant death into categories relative to a “potential asphyxia” schema in a cohort autopsied at the San Diego County Medical Examiner’s Office. Controls were infants who died with known causes of death established at autopsy. Analysis of covariance tested for differences between groups. RESULTS: Medullary neurochemical abnormalities were present in both infants dying suddenly in circumstances consistent with asphyxia and infants dying suddenly without obvious asphyxia-generating circumstances. There were no differences in the mean neurochemical measures between these 2 groups, although mean measures were both significantly lower (P < .05) than those of controls dying of known causes. CONCLUSIONS: We found no direct relationship between the presence of potentially asphyxia conditions in the sleep environment and brainstem abnormalities in infants dying suddenly and unexpectedly. Brainstem abnormalities were associated with both asphyxia-generating and non–asphyxia generating conditions. Heeding safe sleep messages is essential for all infants, especially given our current inability to detect underlying vulnerabilities. PMID:24218471

Nonulcer dyspepsia.

PubMed Central

Thompson, W. G.

1984-01-01

One third to one half of cases of dyspepsia remain unexplained. The cause of nonulcer dyspepsia is unknown, but aerophagia, esophageal dysfunction, pyloroduodenal dysmotility and the irritable bowel syndrome may be important factors in some patients. The symptoms are often affected by diet and emotion. History-taking and endoscopy are the most discriminating diagnostic tests. Unexplained dyspepsia tends to be a lifelong disease with few, if any, sequelae. Nevertheless, reassurance and treatment with a placebo, such as an antacid or simethicone, provide effective and safe relief for many patients. PMID:6365298

Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study.

PubMed

Yon, Katherine; Nettleton, Sarah; Walters, Kate; Lamahewa, Kethakie; Buszewicz, Marta

2015-12-01

To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. Qualitative study using in-depth interviews analysed using the framework method. Participants were recruited from three North Thames London hospitals within the UK. Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Racialized identity and health in Canada: results from a nationally representative survey.

PubMed

Veenstra, Gerry

2009-08-01

This article uses survey data to investigate health effects of racialization in Canada. The operative sample was comprised of 91,123 Canadians aged 25 and older who completed the 2003 Canadian Community Health Survey. A "racial and cultural background" survey question contributed a variable that differentiated respondents who identified with Aboriginal, Black, Chinese, Filipino, Latin American, South Asian, White, or jointly Aboriginal and White racial/cultural backgrounds. Indicators of diabetes, hypertension and self-rated health were used to assess health. The healthy immigrant effect suppressed some disparity in risk for diabetes by racial/cultural identification. In logistic regression models also containing gender, age, and immigrant status, no racial/cultural identifications corresponded with significantly better health outcomes than those reported by survey respondents identifying as White. Subsequent models indicated that residential locale did little to explain the associations between racial/cultural background and health and that socioeconomic status was only implicated in relatively poor health outcomes for respondents identifying as Aboriginal or Aboriginal/White. Sizable and statistically significant relative risks for poor health for respondents identifying as Aboriginal, Aboriginal/White, Black, Chinese, or South Asian remained unexplained by the models, suggesting that other explanations for health disparities by racialized identity in Canada - perhaps pertaining to experiences with institutional racism and/or the wear and tear of experiences of racism and discrimination in everyday life - also deserve empirical investigation in this context.

Effects of Age, Gender and Educational Background on Strength of Motivation for Medical School

ERIC Educational Resources Information Center

Kusurkar, Rashmi; Kruitwagen, Cas; ten Cate, Olle; Croiset, Gerda

2010-01-01

The aim of this study was to determine the effects of selection, educational background, age and gender on strength of motivation to attend and pursue medical school. Graduate entry (GE) medical students (having Bachelor's degree in Life Sciences or related field) and Non-Graduate Entry (NGE) medical students (having only completed high school),…

Letrozole versus clomiphene citrate for unexplained infertility: a systematic review and meta-analysis.

PubMed

Liu, Aihai; Zheng, Chao; Lang, Junzhe; Chen, Wenbing

2014-05-01

The objective of this study is to investigate and compare the effectiveness of letrozole and clomiphene citrate for improving fertility outcomes, including pregnancy rate, miscarriage rate, multiple pregnancy rate, and incidence rate of adverse events, number of dominant follicles, endometrial thickness at hCG day and serum E2 on hCG day. MEDLINE, EMBASE, CENTRAL, CNKI and CBMdisc databases were searched up to March 2013. Randomized controlled trials comparing letrozole with clomiphene in women with unexplained infertility were included. Pooled relative risk, mean difference and 95% confidence intervals were calculated. We found that there are no differences in pregnancy, miscarriage and multiple pregnancy rates, incidence rate of adverse events, number of dominant follicles (>18 mm) and endometrial thickness at hCG day in women with unexplained infertility between letrozole and clomiphene regimens. The mean (±standard deviation) concentration of serum E2 on hCG day was lower in those treated with letrozole than those with clomiphene. The subgroup of 2.5 mg letrozole displayed a statistically significant higher rate of clinical pregnancy as compared with 100 mg of clomiphene. The results of this study conclude that letrozole is as effective as clomiphene in women with unexplained infertility. Letrozole at a dose of 2.5 mg seems more effective. Further high-quality studies assessing the possible effectiveness of letrozole in selected groups of patients are warranted. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.

[The usefullness of implantable loop recorders for evaluation of unexplained syncope and palpitations].

PubMed

Kristjánsdóttir, Ingibjörg; Reimarsdóttir, Guđrun; Arnar, Davíđ O

2012-09-01

Syncope is a common complaint and determining the underlying cause can be difficult despite extensive evaluation. The purpose of this study was to evaluate the usefulness of an implantable loop recorder for patients with unexplained syncope and palpitations. This was a retrospective analysis of 18 patients, five of whom still have the device implanted. All patients had undergone extensive evaluation for their symptoms before getting the loop recorder implanted and this was therefore a highly select group. Of the thirteen patients where use of the device was completed, the mean age was 65±20 years. The loop recorder was in use for a mean time of 20±13 months. Unexplained syncope, eleven of thirteen, was the most common indication. The other two received the loop recorder for unexplained palpitations. Four patients had sick sinus syndrome during monitoring, three had supraventricular tachycardia and one had ventricular tachycardia. Further three had typical symptoms but no arrhythmia was recorded and excluding that as a cause. Two patients had no symptoms the entire time they had the loop recorder. Of the five patients still with the device three had syncope as the indication for monitoring and two have the device as a means of evaluating the results of treatment for arrhythmia. This study on our initial experience with implantable loop recorders shows that these devices can be useful in the investigation of the causes of syncope and palpitations.

Massive immunoglobulin treatment in women with four or more recurrent spontaneous primary abortions of unexplained aetiology.

PubMed

Yamada, H; Kishida, T; Kobayashi, N; Kato, E H; Hoshi, N; Fujimoto, S

1998-09-01

The aim of this trial was to investigate the efficacy of massive i.v. immunoglobulin (MIVIg) treatment for women with a history of recurrent spontaneous abortion (RSA) due to unexplained aetiology. The study included nine women (11 pregnancies) with a history of four or more consecutive RSA with unexplained aetiology and no live births. The mean number of fetal losses was 4.5 (range 4-6 abortions). Over the course of 5 days, immunoglobulin (20 g/day) was infused i.v. at gestational weeks 4-7. No additional infusions were carried out. Two pregnancies out of the 11 conceptions resulted in missed abortions at gestational weeks 6 and 7 respectively. Mosaicism (46XX/ 48XX, +16, +20), and tetraploidy (92XXXX) were found by chromosome analyses of the two aborti. Eight out of the other nine pregnancies resulted in full term deliveries of healthy neonates. One pregnancy developed intrauterine growth retardation and fetal distress, resulting in a premature delivery (30 gestational weeks) by Caesarean section. Thus, excluding the two abortions with chromosome aberrations, the MIVIg treatment was effective in all nine pregnancies of RSA women with unexplained aetiology. This MIVIg treatment (100 g administered in early gestation) may be a beneficial alternative to previous IVIg infusion methods, and should be further evaluated in a multicentric, placebo-controlled study, employing a larger number of homogeneous patients who fall into a high risk category of first trimester abortions.

Hydrotubation in the management of female infertility: outcome in low resource settings.

PubMed

Adesiyun, A G; Cole, B; Ogwuche, P

2009-01-01

To determine the outcome of therapeutic hydrotubation (tubal flushing) in patients with tubal infertility and unexplained infertility. Prospective non-randomised observational study. Alba hospital, a five bed multidisciplinary private hospital in Kaduna city, Nigeria. Infertile women with tubal and unexplained infertility. Two hundred and fifty seven patients that had therapeutic hydrotubation over 7.5 years were analysed. The age range was 21 to 44 years with mean of 34.5 years. Secondary infertility was found in 209 (81.3%) patients and primary infertility in 166 (64.6%) patients. Of the 257 patients, 134 (52.1%) had had induced abortion. Indications for hydrotubation were bilateral perifimbrial adhesion (incomplete tubal occlusion) 47.9%, bilateral fimbrial end occlusion 24.9%, bilateral cornual blockage 16% and unexplained infertility in 11.3% of cases. One hundred and nine conceptions were recorded in this study and the overall conception rate was 42.4%. Likewise, percentage ratio of conception in these 154 patients with evidence of post-hydrotubation tubal patency was 70.8%. Pregnancy outcome of the 109 conceptions are term pregnancy 84.4%, preterm pregnancy 9.2%, miscarriage 4.6% and ectopic pregnancy in 1.8% of the conceptions. Recorded complications were pelvic pain in 177 (68.9%) patients and vaginal bleeding in 63 (24.5%) patients. With good case selection, therapeutic hydrotubation may be beneficial in resource poor countries, especially in patients with incomplete tubal occlusion (bilateral perifimbrial adhesions) and as part of treatment for unexplained infertility.

The Effects of Total Motile Sperm Count on Spontaneous Pregnancy Rate and Pregnancy After IUI Treatment in Couples with Male Factor and Unexplained Infertility.

PubMed

Hajder, Mithad; Hajder, Elmira; Husic, Amela

2016-02-01

Male infertility factor is defined if the total number of motile spermatozoa (TMSC) < 20 × 10(6)/ejaculated, and unexplained infertility if spermiogram is normal with normal female factor. of this study was to determine the predictive value of TMSC for spontaneous pregnancy (ST) and pregnancy after treatment with intrauterine insemination (IUI) in couples with male factor and unexplained infertility. According to the WHO qualification system abnormal spermiogram can be diagnosed as oligozoospermia (O), asthenozoospermia (A), teratozoospermia (T) or combination (O+A+T) and azoospermia (A). Although this classification indicates the accuracy of findings its relevance for prognosis in infertile couple and the choice of treatment is questionable. The study included 98 couples with male infertility factor (bad spermiogram) and couples with normospermia and normal female factor (unexplained infertility). Testing group is randomized at: group (A) with TMSC> 3,10(6) / ejaculate and a spontaneous pregnancy, group (B) with TMSCl <3 x 10(6) / ejaculate and pregnancy after IUI, plus couples who have not achieved SP with TMSC> 3 x 10(6) / ejaculate and couples who have not achieved pregnancy. From a total of 98 pairs of men's and unexplained infertility, 42 of them (42.8%) achieved spontaneous pregnancy, while 56 (57.2%) pairs did not achieve spontaneous pregnancy. TMSC was significantly higher (42.4 ± 28.4 vs. 26.2 ± 24, p <0.05) in the group A compared to group B. Couples with TMSC 1-5 × 10(6) ejaculate had significantly lower (9.8% vs. 22.2%, p <0.0001) rate of spontaneous pregnancy in comparison to couples after IUI treatment. Couples with unexplained infertility had significantly higher (56.8% vs. 29.9%, p <0.01) spontaneous pregnancy rate compared to couples after IUI treatment. Infertile couples had significant pregnancy rate with TMSC 5-10 x 10(6) / ejaculate (OR = 1.45, 95% CI:1.26-1.78, <0.01); with TMSC 10-20 x 10(6) / ejaculate (OR = 1.36, 95% CI: 1:12 to 1:46, <0.0001) with TMSC> 20 x 10(6) / ejaculate (RR = 1.7, 95% CI: 1.56-1.82, <0.001) after treatment with IUI compared to spontaneous pregnancy. Based on these results we can conclude that couples with the TMSC> 5 x 10(6) / ejaculate are indicated for treatment with IUI. TMSC can be used as the method of choice for diagnosis and treatment of male infertility.

Mesoscale spatiotemporal variability in a complex host-parasite system influenced by intermediate host body size

PubMed Central

2017-01-01

Background Parasites are essential components of natural communities, but the factors that generate skewed distributions of parasite occurrences and abundances across host populations are not well understood. Methods Here, we analyse at a seascape scale the spatiotemporal relationships of parasite exposure and host body-size with the proportion of infected hosts (i.e., prevalence) and aggregation of parasite burden across ca. 150 km of the coast and over 22 months. We predicted that the effects of parasite exposure on prevalence and aggregation are dependent on host body-sizes. We used an indirect host-parasite interaction in which migratory seagulls, sandy-shore molecrabs, and an acanthocephalan worm constitute the definitive hosts, intermediate hosts, and endoparasite, respectively. In such complex systems, increments in the abundance of definitive hosts imply increments in intermediate hosts’ exposure to the parasite’s dispersive stages. Results Linear mixed-effects models showed a significant, albeit highly variable, positive relationship between seagull density and prevalence. This relationship was stronger for small (cephalothorax length >15 mm) than large molecrabs (<15 mm). Independently of seagull density, large molecrabs carried significantly more parasites than small molecrabs. The analysis of the variance-to-mean ratio of per capita parasite burden showed no relationship between seagull density and mean parasite aggregation across host populations. However, the amount of unexplained variability in aggregation was strikingly higher in larger than smaller intermediate hosts. This unexplained variability was driven by a decrease in the mean-variance scaling in heavily infected large molecrabs. Conclusions These results show complex interdependencies between extrinsic and intrinsic population attributes on the structure of host-parasite interactions. We suggest that parasite accumulation—a characteristic of indirect host-parasite interactions—and subsequent increasing mortality rates over ontogeny underpin size-dependent host-parasite dynamics. PMID:28828270

High Prevalence of Tuberculosis and Serious Bloodstream Infections in Ambulatory Individuals Presenting for Antiretroviral Therapy in Malawi

PubMed Central

Bedell, Richard A.; Anderson, Suzanne T. B.; van Lettow, Monique; Åkesson, Ann; Corbett, Elizabeth L.; Kumwenda, Moses; Chan, Adrienne K.; Heyderman, Robert S.; Zachariah, Rony; Harries, Anthony D.; Ramsay, Andrew R.

2012-01-01

Background Tuberculosis (TB) and serious bloodstream infections (BSI) may contribute to the high early mortality observed among patients qualifying for antiretroviral therapy (ART) with unexplained weight loss, chronic fever or chronic diarrhea. Methods and Findings A prospective cohort study determined the prevalence of undiagnosed TB or BSI among ambulatory HIV-infected adults with unexplained weight loss and/or chronic fever, or diarrhea in two routine program settings in Malawi. Subjects with positive expectorated sputum smears for AFB were excluded. Investigations Bacterial and mycobacterial blood cultures, cryptococcal antigen test (CrAg), induced sputum (IS) for TB microscopy and solid culture, full blood count and CD4 lymphocyte count. Among 469 subjects, 52 (11%) had microbiological evidence of TB; 50 (11%) had a positive (non-TB) blood culture and/or positive CrAg. Sixty-five additional TB cases were diagnosed on clinical and radiological grounds. Nontyphoidal Salmonellae (NTS) were the most common blood culture pathogens (29 cases; 6% of participants and 52% of bloodstream isolates). Multivariate analysis of baseline clinical and hematological characteristics found significant independent associations between oral candidiasis or lymphadenopathy and TB, marked CD4 lymphopenia and NTS infection, and severe anemia and either infection, but low positive likelihood ratios (<2 for all combinations). Conclusions We observed a high prevalence of TB and serious BSI, particularly NTS, in a program cohort of chronically ill HIV-infected outpatients. Baseline clinical and hematological characteristics were inadequate predictors of infection. HIV clinics need better rapid screening tools for TB and BSI. Clinical trials to evaluate empiric TB or NTS treatment are required in similar populations. PMID:22761767

Exome Sequencing and the Management of Neurometabolic Disorders

PubMed Central

Tarailo-Graovac, M.; Shyr, C.; Ross, C.J.; Horvath, G.A.; Salvarinova, R.; Ye, X.C.; Zhang, L.-H.; Bhavsar, A.P.; Lee, J.J.Y.; Drögemöller, B.I.; Abdelsayed, M.; Alfadhel, M.; Armstrong, L.; Baumgartner, M.R.; Burda, P.; Connolly, M.B.; Cameron, J.; Demos, M.; Dewan, T.; Dionne, J.; Evans, A.M.; Friedman, J.M.; Garber, I.; Lewis, S.; Ling, J.; Mandal, R.; Mattman, A.; McKinnon, M.; Michoulas, A.; Metzger, D.; Ogunbayo, O.A.; Rakic, B.; Rozmus, J.; Ruben, P.; Sayson, B.; Santra, S.; Schultz, K.R.; Selby, K.; Shekel, P.; Sirrs, S.; Skrypnyk, C.; Superti-Furga, A.; Turvey, S.E.; Van Allen, M.I.; Wishart, D.; Wu, J.; Wu, J.; Zafeiriou, D.; Kluijtmans, L.; Wevers, R.A.; Eydoux, P.; Lehman, A.M.; Vallance, H.; Stockler-Ipsiroglu, S.; Sinclair, G.; Wasserman, W.W.; van Karnebeek, C.D.

2016-01-01

BACKGROUND Whole-exome sequencing has transformed gene discovery and diagnosis in rare diseases. Translation into disease-modifying treatments is challenging, particularly for intellectual developmental disorder. However, the exception is inborn errors of metabolism, since many of these disorders are responsive to therapy that targets pathophysiological features at the molecular or cellular level. METHODS To uncover the genetic basis of potentially treatable inborn errors of metabolism, we combined deep clinical phenotyping (the comprehensive characterization of the discrete components of a patient’s clinical and biochemical phenotype) with whole-exome sequencing analysis through a semiautomated bioinformatics pipeline in consecutively enrolled patients with intellectual developmental disorder and unexplained metabolic phenotypes. RESULTS We performed whole-exome sequencing on samples obtained from 47 probands. Of these patients, 6 were excluded, including 1 who withdrew from the study. The remaining 41 probands had been born to predominantly nonconsanguineous parents of European descent. In 37 probands, we identified variants in 2 genes newly implicated in disease, 9 candidate genes, 22 known genes with newly identified phenotypes, and 9 genes with expected phenotypes; in most of the genes, the variants were classified as either pathogenic or probably pathogenic. Complex phenotypes of patients in five families were explained by coexisting monogenic conditions. We obtained a diagnosis in 28 of 41 probands (68%) who were evaluated. A test of a targeted intervention was performed in 18 patients (44%). CONCLUSIONS Deep phenotyping and whole-exome sequencing in 41 probands with intellectual developmental disorder and unexplained metabolic abnormalities led to a diagnosis in 68%, the identification of 11 candidate genes newly implicated in neurometabolic disease, and a change in treatment beyond genetic counseling in 44%. (Funded by BC Children’s Hospital Foundation and others.) PMID:27276562

The Role of Infertility Etiology in Success Rate of Intrauterine Insemination Cycles: An Evaluation of Predictive Factors for Pregnancy Rate

PubMed Central

Ashrafi, Mahnaz; Rashidi, Mandana; Ghasemi, Afsaneh; Arabipoor, Arezoo; Daghighi, Sara; Pourasghari, Parisa; Zolfaghari, Zahra

2013-01-01

Background: The objective of this study was to identify the prognostic factors that influence the outcome of ovarian stimulation with intrauterine insemination (IUI) cycles in couples with different infertility etiology. Materials and Methods: This retrospective study was performed in data of 1348 IUI cycles with ovarian stimulation by clomiphene citrate (CC) and/or gonadotropins in 632 women with five different infertility etiology subgroups at Akbarabbadi Hospital, Tehran, Iran. Results: The pregnancy rate (PR)/ cycle was highest (19.9%) among couples with unexplained infertility and lowest (10.6%) in couples with multiple factors infertility. In cases of unexplained infertility, the best PRs were seen after CC plus gonadotropins stimulation (26.3%) and with inseminated motile sperm count>30×106 (21.9%), but the tendency didn’t reach statistical significant. In the ovarian factor group, the best PRs were observed in women aged between 30 and 34 years (20.8%), with 2-3 preovulatory follicles (37.8%) and infertility duration between 1and 3 years (20.8%), while only infertility duration (p=0.03) and number of preovulatory follicles (p=0.01) were statistically significant. Multiple logistic regression analysis determined that number of preovulatory follicles (p=0.02), duration of infertility (p=0.015), age (p=0.019), infertility etiology (p=0.05) and stimulation regimen (p=0.01) were significant independent factors in order to predict overall clinical PR. Conclusion: The etiology of infertility is important to achieve remarkable IUI success. It is worth mentioning that within different etiologies of infertility, the demographic and cycles characteristics of couples did not show the same effect. Favorable variables for treatment success are as follows: age <40, duration of infertility ≤5 years and a cause of infertility except of multiple factors. PMID:24520471

Apnea in the term infant.

PubMed

Patrinos, Mary Elaine; Martin, Richard J

2017-08-01

Whereas apnea of prematurity has been well defined and its pathophysiology extensively studied, apnea in the term infant remains a greater challenge. Unfortunately, clear diagnostic criteria are lacking and pathogenesis and management vary widely. In this review we have arbitrarily organized the discussion chronologically into earlier and later postnatal periods. In the first days of life, presumed apnea may reflect physiologic events such as positional or feeding etiologies, or may be a manifestation of serious pathophysiology, such as a seizure disorder. Beyond the neonatal period, presumed apnea may be characterized as a BRUE event (brief resolved unexplained event; formerly referred to as ALTE: apparent life-threatening event) and most frequently a precipitating event cannot be identified. Medical providers are left with somewhat of a dilemma regarding the need to hospitalize and/or work up such patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Case report of unexplained hypocalcaemia in a slightly haemolysed sample.

PubMed

Cornes, Michael

2017-06-15

The case presented highlights a common pre-analytical problem identified in the laboratory that was initially missed. It concerns a young, generally healthy adult patient with no significant medical history and no significant family history. They presented with common flu like symptoms to their primary care clinician who considered this was most likely a viral problem that would pass with time. The clinician, however, did some routine bloods to reassure the patient despite a lack of clinical indication. When the sample was analysed the sample was haemolysed with strikingly low calcium. This led to the patient being called into hospital for urgent repeat investigations, all of which turned out to be within normal ranges. On further investigation the original sample was found to be contaminated. This result would normally have been flagged but was missed due to the complication of haemolysis.

Experimental human pain models in gastro-esophageal reflux disease and unexplained chest pain

PubMed Central

Drewes, Asbjørn Mohr; Arendt-Nielsen, Lars; Funch-Jensen, Peter; Gregersen, Hans

2006-01-01

Methods related to experimental human pain research aim at activating different nociceptors, evoke pain from different organs and activate specific pathways and mechanisms. The different possibilities for using mechanical, electrical, thermal and chemical methods in visceral pain research are discussed with emphasis of combinations (e.g., the multimodal approach). The methods have been used widely in assessment of pain mechanisms in the esophagus and have contributed to our understanding of the symptoms reported in these patients. Hence abnormal activation and plastic changes of central pain pathways seem to play a major role in the symptoms in some patients with gastro-esophageal reflux disease and in patients with functional chest pain of esophageal origin. These findings may lead to an alternative approach for treatment in patients that does not respond to conventional medical or surgical therapy. PMID:16718803

Overview of somatization: diagnosis, epidemiology, and management.

PubMed

Escobar, J I

1996-01-01

This article outlines critical issues in the psychiatric assessment of patients presenting with medically unexplained physical symptoms that form the core of the somatoform disorders in current nosologies. The prevalence of these disorders in communities and clinical settings emphasizes that a majority of these patients are primary care service users rather than mental health clients. A brief review of previous studies on the pharmacological management of these syndromes with antidepressants highlights unique features of these disorders that are relevant to the design of double-blind studies. The promising results emerging from some of these studies bring new excitement to the field that may help counter the prevailing therapeutic nihilism, thus attracting new investigators to this area. Finally, several caveats are provided on issues of research design and interpretation for the benefit of those entering this field of research.

DSM-IV hypochondriasis in primary care.

PubMed

Escobar, J I; Gara, M; Waitzkin, H; Silver, R C; Holman, A; Compton, W

1998-05-01

The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

Space-time acupuncture for intractable cough after lupus nephropathy: A case report and literature review.

PubMed

Guo, Taipin; Chen, Zukun; Tai, Xiantao; Liu, Zili; Zhu, Miansheng

2017-12-01

Some intractable chronic cough remains a common complaint for seeking medical care. Unexplained cough in lupus nephropathy patient is rare and therapeutic options are limited. A 57 year-old woman with a 7-year history of lupus nephropathy. She has suffered from chronic cough for 3 years accompanied with chronic low back pain and fatigue, as the conventional therapy cannot relieve the symptoms. The woman is diagnosed as intractable cough after lupus nephropathy. 9 times space-time acupuncture (STA) treatment was performed. The cough, as well as other uncomfortable symptoms like chronic low-back pain and fatigue have resolved, and no relapse for one year follow-up. STA may be an effective therapy to treat intractable chronic cough. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Acute abdominal pain and constipation due to lead poisoning.

PubMed

Mongolu, S; Sharp, P

2013-01-01

Although uncommon, lead poisoning should be considered as a differential diagnosis in cases of unexplained acute abdominal pain in both adults and children. We present the case of a 35-year-old Asian male who presented with abdominal pain and constipation secondary to lead poisoning. Initially, the source of lead exposure was not apparent; this was later found to be due to ingestion of an Ayurvedic herbal medicine for the treatment of infertility. Lead poisoning due to the ingestion of Ayurvedic remedies is well described. We discuss the diagnosis, pathophysiology and treatment of lead poisoning. This case illustrates one of the rarer medical causes of acute abdominal pain and emphasizes the need to take a thorough history (including specific questioning regarding the use of over-the-counter and traditional/ herbal remedies) in cases of suspected poisoning or drug toxicity.

An outbreak of Candida albicans folliculitis masquerading as Malassezia folliculitis in a prison population.

PubMed

Jalalat, Sheila; Hunter, Lindsey; Yamazaki, Mika; Head, Elizabeth; Kelly, Brent

2014-04-01

Several inmates from a non-air-conditioned prison were sent to the University of Texas Medical Branch dermatology clinic for unexplained eruptions not responding to various treatments. They were initially diagnosed with Malassezia folliculitis based on clinical examination and histological findings. The patients' cultures from skin scrapings, however, revealed Candida albicans confirmed by growth on Mycosel agar and further by the germ tube production method. Five cases were brought to the clinic, but at least 30 other inmates were reported to have similar cutaneous eruptions. Given that these patients were generally immunocompetent, this is a rare finding. Factors favoring pseudohyphal growth for these patients included use of topical steroids and/or systemic antibiotics and hot and humid climate. All patients' folliculitis resolved with fluconazole and/or antifungal cream with no further complications.

Bullying Borrelia: When the Culture of Science is Under Attack

PubMed Central

Auwaerter, Paul G.; Melia, Michael T.

2012-01-01

Although Lyme disease responds to short courses of antibiotics, tick-borne Borrelia burgdorferi has been advanced by some as a frequent explanation for medically unexplained symptoms such as continual fatigue, musculoskeletal pains, and subjective neurocognitive dysfunction. Often called “chronic Lyme disease” by adherents of this philosophy, it is loosely defined, and practitioners liberally prescribe nostrums, including prolonged antimicrobial therapies, in a belief that this eradicates suspected infection. Perhaps due to the lack of supportive data, proponents of this theory have developed their own meetings, literature, activist groups, and substantial internet activities to advance their views. Forces motivating this movement are explored, as are tactics used to advance non-scientific ideas that have included legal action and garnering legislative endorsement. While neither logical nor evidence-based, “chronic Lyme disease” harnesses corrosive energies that taint modern medicine and society. PMID:23303970

[Stress and fertility].

PubMed

Ősapay, György; Ősapay, Klára

2015-08-30

In Western countries, sperm quality and fertility of men significantly worsened. Female infertility does not show a better trend either. Subtle defects in the reproductive functions can not be explained by the current methods, and "unexplained infertility" is becoming a more common diagnosis. Every year 1 million couples seek expensive and time consuming fertility treatment in the world. Deeper understanding of an unhealthy lifestyle and the environmental damages may lead to personalized treatments to increase the chance of conception.The effects of various stressors on the male and female reproductive performance were scientifically substantiated by Selye and coworkers in 1976. Cognitive therapy methods can be applied against emotional stressors, supplementation by antioxidants against reactive oxygen compounds, and administration of vitamins and trace elements, especially when deficiency is found, may help before medical intervention on a rational and economical way in the fight against infertility.

Famous people and genetic disorders: from monarchs to geniuses--a portrait of their genetic illnesses.

PubMed

Ho, Nicola C; Park, Susan S; Maragh, Kevin D; Gutter, Emily M

2003-04-15

Famous people with genetic disorders have always been a subject of interest because such news feeds the curiosity the public has for celebrities. It gives further insight into their lives and provides a medical basis for any unexplained or idiosyncratic feature or behavior they exhibit. It draws admiration from society of those who excel in their specialized fields despite the impositions of their genetic illnesses and also elicits sympathy even in the most casual observer. Such news certainly catapults a rare genetic disorder into the realm of public awareness. We hereby present six famous figures: King George III, Toulouse-Lautrec, Queen Victoria, Nicolo Paganini, Abraham Lincoln, and Vincent van Gogh, all of whom made a huge indelible mark in either the history of politics or that of the arts. Copyright 2003 Wiley-Liss, Inc.

Differential auditory-oculomotor interactions in patients with right vs. left sided subjective tinnitus: a saccade study

PubMed Central

Lang, Alexandre; Vernet, Marine; Yang, Qing; Orssaud, Christophe; Londero, Alain; Kapoula, Zoï

2013-01-01

Subjective tinnitus (ST) is a frequent but poorly understood medical condition. Recent studies demonstrated abnormalities in several types of eye movements (smooth pursuit, optokinetic nystagmus, fixation, and vergence) in ST patients. The present study investigates horizontal and vertical saccades in patients with tinnitus lateralized predominantly to the left or to the right side. Compared to left sided ST, tinnitus perceived on the right side impaired almost all the parameters of saccades (latency, amplitude, velocity, etc.) and noticeably the upward saccades. Relative to controls, saccades from both groups were more dysmetric and were characterized by increased saccade disconjugacy (i.e., poor binocular coordination). Although the precise mechanisms linking ST and saccadic control remain unexplained, these data suggest that ST can lead to detrimental auditory, visuomotor, and perhaps vestibular interactions. PMID:23550269

Lead poisoning due to bullets lodged in the human body.

PubMed

Gerstner Garcés, Juan Bernardo; Manotas Artuz, Rafael Ignacio

2012-07-01

With the increased violence and use of firearms in Colombia, we may see more cases of lead poisoning in our environment, and must be prepared to diagnose and treat them. Subtle signs and symptoms as unexplained anemia, gastro-intestinal discomfort and abdominal cramps, as well as severe signs such as changes in behavior and neurological status, nephropathy, and unexplained death, may be associated with a history of gunshot wounds and bullets in the human body. We must offer the patient knowledge and management strategies of pathology.

Lead poisoning due to bullets lodged in the human body

PubMed Central

Manotas Artuz, Rafael Ignacio

2012-01-01

With the increased violence and use of firearms in Colombia, we may see more cases of lead poisoning in our environment, and must be prepared to diagnose and treat them. Subtle signs and symptoms as unexplained anemia, gastro-intestinal discomfort and abdominal cramps, as well as severe signs such as changes in behavior and neurological status, nephropathy, and unexplained death, may be associated with a history of gunshot wounds and bullets in the human body. We must offer the patient knowledge and management strategies of pathology. PMID:24893198

Case-control study of medical comorbidities in women with interstitial cystitis.

PubMed

Clemens, J Quentin; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Kimes, Teresa A; Calhoun, Elizabeth A

2008-06-01

We used physician assigned diagnoses in an electronic medical record to assess comorbidities associated with interstitial cystitis. A computer search of the administrative database at Kaiser Permanente Northwest, Portland, Oregon was performed for May 1, 1998 to April 30, 2003. All women with a medical record diagnosis of interstitial cystitis (ICD-9 code 595.1) were identified. These cases were then matched with 3 controls each based on age and duration in the health plan. The medical diagnoses (using ICD-9 codes restricted to 3 digits) assigned to these 2 groups were compared using the OR. A total of 239 cases and 717 matched controls were analyzed. There were 23 diagnoses that were significantly more common in cases than in controls (p < or = 0.005). Seven of these 23 diagnoses were other urological or gynecological codes used to describe pelvic symptoms. Additional specific conditions associated with interstitial cystitis were gastritis (OR 12.2), child abuse (OR 9.3), fibromyalgia (OR 3.0), anxiety disorder (OR 2.8), headache (OR 2.5), esophageal reflux (OR 2.2), unspecified back disorder (OR 2.2) and depression (OR 2.0). A diagnosis of interstitial cystitis was associated with multiple other unexplained physical symptoms and certain psychiatric conditions. Studies to explore the possible biological explanations for these associations are needed. Interstitial cystitis was also associated with a history of child abuse, although 96% of patients with IC did not have this diagnosis.

EMOTIONAL CONSEQUENCES OF NUCLEAR POWER PLANT DISASTERS

PubMed Central

Bromet, Evelyn J.

2014-01-01

The emotional consequences of nuclear power plant disasters include depression, anxiety, post-traumatic stress disorder, and medically unexplained somatic symptoms. These effects are often long term and associated with fears about developing cancer. Research on disasters involving radiation, particularly evidence from Chernobyl, indicates that mothers of young children and cleanup workers are the highest risk groups. The emotional consequences occur independently of the actual exposure received. In contrast, studies of children raised in the shadows of the Three Mile Island (TMI) and Chernobyl accidents suggest that although their self-rated health is less satisfactory than that of their peers, their emotional, academic, and psychosocial development is comparable. The importance of the psychological impact is underscored by its chronicity and by several studies showing that poor mental health is associated with physical health conditions, early mortality, disability, and over-utilization of medical services. Given the established increase in mental health problems following TMI and Chernobyl, it is likely that the same pattern will occur in residents and evacuees affected by the Fukushima meltdowns. Preliminary data from Fukushima indeed suggest that workers and mothers of young children are at risk of depression, anxiety, psychosomatic, and post-traumatic symptoms both as a direct result of their fears about radiation exposure and an indirect result of societal stigma. Thus, it is important that nonmental health providers learn to recognize and manage psychological symptoms and that medical programs be designed to reduce stigma and alleviate psychological suffering by integrating psychiatric and medical treatment within the walls of their clinics. PMID:24378494

Inclusion Body Myositis: A Case Presenting with Respiratory Failure and Autopsy Findings Leading to the Hypothesis of a Paraneoplastic Cause

PubMed Central

Dardis, Christopher; Antezana, Ariel; Tanji, Kurenai; Maccabee, Paul

2017-01-01

Patient: Female, 48 Final Diagnosis: Inclusion body myositis Symptoms: Shortness of breath • weakness Medication: — Clinical Procedure: Biopsy Specialty: Neurology Objective: Rare disease Background: Sporadic inclusion body myositis (IBM) is the most common acquired myopathy seen in adults aged over 50 years, with a prevalence estimated at between 1 and 70 per million. Weakness of the diaphragm with loss of vital capacity is almost universal in IBM. This is almost always asymptomatic. When respiratory complications occur, they are most often due to aspiration. Respiratory failure due to diaphragmatic weakness is exceptionally rare, particularly as the presenting symptom of the disease. It is not currently considered to be a paraneoplastic syndrome. Case Report: Our patient presented with hypercarbic respiratory failure. This is the first such reported case without signs of weakness elsewhere of which we are aware. We suspected IBM based on her history of progressive weakness and findings on electromyography. There was a delay of 5 years in obtaining biopsy for confirmation, during which she presented with recurrent episodes of respiratory failure despite using non-invasive ventilation. An autopsy revealed the presence of papillary thyroid carcinoma with spread to local lymph nodes. On the basis that these co-morbidities are unlikely to have occurred by chance (we estimate 1×10−17), we hypothesize that IBM may be a paraneoplastic condition. We acknowledge that proof would require demonstrating a pathogenic antibody. Conclusions: IBM should be considered in older patients (age >45) presenting with otherwise unexplained respiratory failure. A workup for possible malignancy in this setting appears reasonable. PMID:28642454

Multiple physical symptoms in a military population: a cross-sectional study

PubMed Central

2013-01-01

Background Medically unexplained symptoms have been reported among both civilians and military personnel exposed to combat. A large number of military personnel deployed to the Gulf War in 1991 reported non-specific symptoms. These symptoms did not constitute a clearly defined syndrome. Post-traumatic stress disorder (PTSD) and to a lesser degree exposure to combat are associated with physical symptoms. Methods This is a cross-sectional study of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a 1-year period. Multiple physical symptoms were elicited using a checklist of 53 symptoms. Cases were defined as individuals with ten or more symptoms. Symptoms of common mental disorder were identified using the General Health Questionnaire 12 (GHQ-12). PTSD was diagnosed using the 17-item National Centre for PTSD checklist civilian version. Results Prevalence of multiple physical symptoms was 10.4% (95% CI 8.11–12.75). Prevalence was significantly less in the Special Forces (5.79%) than in the regular forces (13.35%). The mean number of symptoms reported by those who met the criteria for PTSD was 12.19 (SD 10.58), GHQ caseness 7.87 (SD 7.57) and those without these conditions 2.84 (SD 3.63). After adjusting for socio-demographic and service variables, ‘thought I might be killed’ , ‘coming under small arms fire’ , and ‘coming under mortar, missile and artillery fire’ remained significant. Multiple physical symptoms were associated with functional impairment and poor perceived general health. Conclusions Prevalence of multiple physical symptoms was significantly lower in the Special Forces despite high exposure to potentially traumatic events. More multiple physical symptoms were reported by personnel with PTSD and common mental disorders. Multiple physical symptoms were associated with functional impairment. PMID:23866109

Rehabilitation of torture survivors in five countries: common themes and challenges

PubMed Central

2010-01-01

Background Torture continues to be a global problem and there is a need for prevention and rehabilitation efforts. There is little available data on torture survivors from studies designed and conducted by health professionals in low income countries. This study is a collaboration between five centres from Gaza, Egypt, Mexico, Honduras and South Africa who provide health, social and legal services to torture survivors, advocate for the prevention of torture and are part of the network of the International Rehabilitation Council for Torture Victims (IRCT). Methods Socio-demographic, clinical and torture exposure data was collected on the torture survivors attending the five centres at presentation and then at three and six month follow-up periods. This sample of torture survivors is presented using a range of descriptive statistics. Change over time is demonstrated with repeated measures analysis of variance. Results Of the 306 torture survivors, 23% were asylum seekers or refugees, 24% were socially isolated, 11% in prison. A high level of traumatic events was experienced. 64% had suffered head injury whilst tortured and 24% had ongoing torture injury problems. There was high prevalence of symptoms of anxiety, depression, post traumatic stress as well as medically unexplained somatic symptoms. The analysis demonstrates a modest drop in symptoms over the six months of the study. Conclusions Data showed that the torture survivors seen in these five centres had high levels of exposure to torture events and high rates of clinical symptoms. In order to provide effective services to torture survivors, health professionals at torture rehabilitation centres in low income countries need to be supported to collect relevant data to document the needs of torture survivors and to evaluate the centres' interventions. PMID:20565852

Protocol investigating the clinical outcomes and cost-effectiveness of cognitive–behavioural therapy delivered remotely for unscheduled care users with health anxiety: randomised controlled trial

PubMed Central

Patel, Shireen; Malins, Sam; Guo, Boliang; James, Marilyn; Kai, Joe; Kaylor-Hughes, Catherine; Rowley, Emma; Simpson, Jayne; Smart, David; Stubley, Michelle; Tyrer, Helen

2016-01-01

Background Health anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable. Aims To investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive–behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036). Method A multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6–12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome. Results This trial will be the first to test the clinical outcomes and cost-effectiveness of remotely delivered CBT for the treatment of high health anxiety. Conclusions The findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care. Declaration of interest None. Copyright and usage © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-commercial, No Derivatives (CC BY-NC-ND) licence. PMID:27703758

Toll-like Receptor 4 and Comorbid Pain in Interstitial Cystitis/Bladder Pain Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study

PubMed Central

Schrepf, Andrew; Bradley, Catherine S.; O'Donnell, Michael; Luo, Yi; Harte, Steven E.; Kreder, Karl; Lutgendorf, Susan

2015-01-01

Background Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a condition characterized by pelvic pain and urinary symptoms. Some IC/BPS patients have pain confined to the pelvic region, while others suffer widespread pain. Inflammatory processes have previously been linked to pelvic pain in IC/BPS, but their association with widespread pain in IC/BPS has not been characterized. Methods Sixty-six women meeting criteria for IC/BPS completed self-report measures of pain as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP), collected 3 days of saliva for cortisol assays, and provided blood samples. Peripheral blood mononuclear cells (PBMCs) were stimulated with Toll-Like Receptor (TLR) 2 and 4 agonists and cytokines were measured in supernatant; IL-6 was also measured in plasma. Associations between inflammatory variables and the likelihood of endorsing extra-pelvic pain, or the presence of a comorbid syndrome, were tested by logistic regression and General Linear Models, respectively. A subset of patients (n=32) completed Quantitative Sensory Testing. Results A one standard deviation increase in TLR-4 inflammatory response was associated with a 1.59 greater likelihood of endorsing extra-pelvic pain (p = .019). Participants with comorbid syndromes also had higher inflammatory responses to TLR-4 stimulation in PBMCs (p = .016). Lower pressure pain thresholds were marginally associated with higher TLR-4 inflammatory responses (p = .062), and significantly associated with higher IL-6 in plasma (p = .031). Conclusions TLR-4 inflammatory responses in PBMCs are a marker of widespread pain in IC/BPS, and should be explored in other conditions characterized by medically unexplained pain. PMID:25771510

Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands.

PubMed

van den Ban, Els F; Souverein, Patrick C; van Engeland, Herman; Swaab, Hanna; Egberts, Toine C G; Heerdink, Eibert R

2015-07-01

Differences in incidence and prevalence of ADHD medication use between ethnic groups have been reported. Goal of this study was to determine whether there are also differences in usage patterns of ADHD medication among native Dutch children and adolescents and those with a Moroccan, Turkish and Surinam cultural background in the Netherlands between 1999 and 2010. In a cohort of ADHD patients <19 years (N = 817) incident use and discontinuation of ADHD medication were measured for ethnicity and adjusted for age, gender and socio-economic status. A significant higher proportion of ADHD-diagnosed patients from Moroccan (32 %) and Turkish (42 %) cultural background never used ADHD medication compared to Dutch natives (21 %). One-fifth of native Dutch and Turkish patients already used ADHD medication before the ADHD diagnosis date. Discontinuation of ADHD medication within 5 years was significantly higher in Moroccan [HR 2.4 (95 % CI 1.8-3.1)] and Turkish [HR 1.7 (95 % CI 1.1-2.6)] patients. A sensitivity analysis with a zip code-matched comparison between Dutch natives and non-natives showed similar results, suggesting this effect is probably not explained by socio-economic status (SES). Differences are found in prescribing and use of ADHD medication between patients with a different cultural background. Native Dutch and Turkish patients start more frequently with ADHD medication before the ADHD diagnose date, which can be an indication of differences in either referral patterns and/or access to care. A higher percentage of patients with a Moroccan and Turkish cultural background never start using ADHD medication at all and discontinuation rate is higher compared to Dutch natives and Surinamese.

Association between rural clinical clerkship and medical students’ intentions to choose rural medical work after graduation: A cross-sectional study in western China

PubMed Central

Zhu, Bin; Mao, Ying

2018-01-01

Background A large number of programs have been implemented in many countries to increase the healthcare workforce recruitment in rural and remote areas. Rural early exposure programs for medical students have been shown to be effective strategies. However, no related studies have been reported before in China. This study was carried out to determine the association between medical students’ participation in rural clinical clerkships and their intentions to choose rural medical work after graduation from western medical schools in China. Methods Based on a two-stage random sampling method, the cross-sectional survey was carried out in ten western provinces in China. A brief questionnaire filled in by medical students was used for data collection. A total of 4278 medical students participated in the study. The response rate was approximately 90.34%. Pearson’s chi-squared tests and binary logistic regression analyses were performed for data analyses. Results Approximately 52.0% of medical students disclosed intentions to work in rural medical institutions after graduation. Only one in five participants had experience with a rural clinical clerkship. Rural clinical clerkships were significantly associated with medical students’ intentions to work in rural medical institutions (OR: 1.24, 95%CI: 1.05–1.46); further analyses indicated that such clerkships only had a significant impact among the medical students with an urban background (OR: 2.10, 95%CI: 1.48–2.97). In terms of the sociodemographic characteristics, younger age, low level of parental education, majoring in general practice, and studying in low-level medical schools increased the odds of having intentions to engage in rural medical work among medical students; however, rural origins was the only positive univariate predictor. In addition, the predictors of intentions to choose rural medical work were different between medical students with a rural background and those with an urban background. Conclusions Rural clinical clerkship is likely to increase the odds of having intentions to work in rural medical institutions after graduation among medical students in western China, especially for those with an urban background. Related policy makers could consider developing compulsory rural clerkship programs and implement them among medical students to increase early rural exposure. PMID:29608624

Predictive factors for somatization in a trauma sample

PubMed Central

2009-01-01

Background Unexplained somatic symptoms are common among trauma survivors. The relationship between trauma and somatization appears to be mediated by posttraumatic stress disorder (PTSD). However, only few studies have focused on what other psychological risk factors may predispose a trauma victim towards developing somatoform symptoms. Methods The present paper examines the predictive value of PTSD severity, dissociation, negative affectivity, depression, anxiety, and feeling incompetent on somatization in a Danish sample of 169 adult men and women who were affected by a series of explosions in a firework factory settled in a residential area. Results Negative affectivity and feelings of incompetence significantly predicted somatization, explaining 42% of the variance. PTSD was significant until negative affectivity was controlled for. Conclusion Negative affectivity and feelings of incompetence significantly predicted somatization in the trauma sample whereas dissociation, depression, and anxiety were not associated with degree of somatization. PTSD as a risk factor was mediated by negative affectivity. PMID:19126224

Cardiovascular Assessment of Falls in Older People

PubMed Central

Tan, Maw Pin; Kenny, Rose Anne

2006-01-01

Falls in older people can be caused by underlying cardiovascular disorders, either because of balance instability in persons with background gait and balance disorders, or because of amnesia for loss of consciousness during unwitnessed syncope. Pertinent investigations include a detailed history, 12-lead electrocardiography, lying and standing blood pressure, carotid sinus massage (CSM), head-up tilt, cardiac electrophysiological tests, and ambulatory blood pressure and heart rate monitoring, which includes external and internal cardiac monitoring. The presence of structural heart disease predicts an underlying cardiac cause. Conversely, the absence of either indicates that neurally mediated etiology is likely. CSM and tilt-table testing should be considered in patients with unexplained and recurrent falls. Holter monitoring over 24 hours has a low diagnostic yield. Early use of an implantable loop recorder may be more cost-effective. A dedicated investigation unit increases the likelihood of achieving positive diagnoses and significantly reduces hospital stay and health expenditure. PMID:18047258

Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: A systematic review and meta-analysis.

PubMed

Burkowitz, Jörg; Merzenich, Carina; Grassme, Kathrin; Brüggenjürgen, Bernd

2016-08-01

Insertable or implantable cardiac monitors (ICMs) continuously monitor the heart rhythm and record irregularities over 3 years, enabling the diagnosis of infrequent rhythm abnormalities associated with syncope and stroke. The enhanced recognition capabilities of recent ICM models are able to accurately detect atrial fibrillation (AF) and have led to new applications of ICMs for the detection and monitoring of AF. Based on a systematic literature search, two indications were identified for ICMs for which considerable evidence, including randomized studies, exists: diagnosing the underlying cardiac cause of unexplained recurrent syncope and detecting AF in patients after cryptogenic stroke (CS). Three randomized controlled trials (RCTs) were identified that compared the effectiveness of ICMs in diagnosing patients with unexplained syncope (n = 556) to standard of care. A meta-analysis was conducted in order to generate an overall effect size and confidence interval of the diagnostic yield of ICMs versus conventional monitoring. In the indication CS, one RCT and five observational studies were included in order to assess the performance of ICMs in diagnosing patients with AF (n = 1129). Based on these studies, there is strong evidence that ICMs provide a higher diagnostic yield for detecting arrhythmias in patients with unexplained syncope and for detection of AF in patients after CS compared to conventional monitoring. Prolonged monitoring with ICMs is an effective tool for diagnosing the underlying cardiac cause of unexplained syncope and for detecting AF in patients with CS. In all RCTs, ICMs have a superior diagnostic yield compared to conventional monitoring. © The European Society of Cardiology 2016.

Frequency of and reasons for paroxysmal nocturnal haemoglobinuria screening in patients with unexplained anaemia.

PubMed

England, James T; Dalal, Bakul; Leitch, Heather A

2018-04-01

Referral to hematology for anemia is common. In paroxysmal nocturnal hemoglobinuria (PNH), cells deficient in the glycosylphosphatidyl inositol (GPI) anchor are lysed by complement. Eculizumab improves overall survival and quality of life while reducing hemolysis, transfusion requirements, and thrombosis. We evaluated the frequency of screening for PNH in patients with unexplained anemia. Key clinical features, laboratory data, and investigations were recorded for patients referred for anemia since 2010, without a specific cause found. PNH testing was done by flow cytometry. 540 patients had: anemia not yet diagnosed (NYD, n=318 (including unexplained iron deficiency, n=92; DAT-negative hemolysis, n=9)); anemia of chronic disease, n=173; and pancytopenia NYD, n=49. 82.4% had LDH testing done; 85.0% total bilirubin; 78.7% reticulocyte counts; and 40.6% haptoglobin level; 131 (24.2%) had possible hemolysis. PNH testing was done in 56 (10.4%). Those screened for PNH were more likely to have: younger age (P=0.04); a history of thrombosis (P<0.001); undergone a BMBx (P<0.001); received RBC transfusions (P=0.0018); or evidence of DAT-negative hemolysis (P<0.001). In summary, PNH was tested for in a minority of patients with unexplained anemia (10.4%) despite potential indicators of hemolysis in 24.2%. Increased screening could identify patients who would benefit from treatment and should be considered. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Un-explained visual loss following silicone oil removal: results of the Pan American Collaborative Retina Study (PACORES) Group.

PubMed

Roca, Jose A; Wu, Lihteh; Berrocal, Maria; Rodriguez, Francisco; Alezzandrini, Arturo; Alvira, Gustavo; Velez-Montoya, Raul; Quiroz-Mercado, Hugo; Fernando Arevalo, J; Serrano, Martín; Lima, Luiz H; Figueroa, Marta; Farah, Michel; Chico, Giovanna

2017-01-01

To report the incidence and clinical features of patients that experienced un-explained visual loss following silicone oil (SO) removal. Multicenter retrospective study of patients that underwent SO removal during 2000-2012. Visual loss of ≥2 lines was considered significant. A total of 324 eyes of 324 patients underwent SO removal during the study period. Forty two (13%) eyes suffered a significant visual loss following SO removal. Twenty three (7.1%) of these eyes lost vision secondary to known causes. In the remaining 19 (5.9%) eyes, the loss of vision was not explained by any other pathology. Eleven of these 19 patients (57.9%) were male. The mean age of this group was 49.2 ± 16.4 years. Eyes that had an un-explained visual loss had a mean IOP while the eye was filled with SO of 19.6 ± 6.9 mm Hg. The length of time that the eye was filled with SO was 14.8 ± 4.4 months. In comparison, eyes that did not experience visual loss had a mean IOP of 14 ± 7.3 mm Hg ( p  < 0.0002) and a mean tamponade duration of 9.3 ± 10.9 months ( p  < 0.0001). An un-explained visual loss after SO removal was observed in 5.9% of eyes. Factors associated with this phenomenon included a higher IOP and longer SO tamponade duration.

Do alterations in follicular fluid proteases contribute to human infertility?

PubMed

Cookingham, Lisa Marii; Van Voorhis, Bradley J; Ascoli, Mario

2015-05-01

Cathepsin L and ADAMTS-1 are known to play critical roles in follicular rupture, ovulation, and fertility in mice. Similar studies in humans are limited; however, both are known to increase during the periovulatory period. No studies have examined either protease in the follicular fluid of women with unexplained infertility or infertility related to advanced maternal age (AMA). We sought to determine if alterations in cathepsin L and/or ADAMTS-1 existed in these infertile populations. Patients undergoing in vitro fertilization (IVF) for unexplained infertility or AMA-related infertility were prospectively recruited for the study; patients with tubal or male factor infertility were recruited as controls. Follicular fluid was collected to determine gene expression (via quantitative polymerase chain reaction), enzyme concentrations (via enzyme-linked immunosorbent assays), and enzymatic activities (via fluorogenic enzyme cleavage assay or Western blot analysis) of cathepsin L and ADAMTS-1. The analysis included a total of 42 patients (14 per group). We found no statistically significant difference in gene expression, enzyme concentration, or enzymatic activity of cathepsin L or ADAMTS-1 in unexplained infertility or AMA-related infertility as compared to controls. We also found no statistically significant difference in expression or concentration with advancing age. Cathepsin L and ADAMTS-1 are not altered in women with unexplained infertility or AMA-related infertility undergoing IVF, and they do not decline with advancing age. It is possible that differences exist in natural cycles, contributing to infertility; however, our findings do not support a role for protease alterations as a common cause of infertility.

Predictors of Pregnancy and Live Birth in Couples with Unexplained or Male-factor Infertility after Insemination

PubMed Central

Huang, Hao; Hansen, Karl R.; Factor-Litvak, Pamela; Carson, Sandra A.; Guzick, David S.; Santoro, Nanette; Diamond, Michael P.; Eisenberg, Esther; Zhang, Heping

2012-01-01

Objective To identify risk factors for pregnancy outcomes in couples treated with intracervical or intrauterine insemination, with or without superovulation for unexplained or male-factor infertility. The treatment continued for four cycles unless pregnancy was achieved. Design Secondary analysis of data from a randomized superovulation and intrauterine insemination trial. Setting Academic medical centers. Intervention(s) None. Patients Out of 932 couples randomized to four treatment groups, 664 couples who had completed the lifestyle questionnaires were assessed for occurrence of pregnancy and live birth. Main outcome measure(s) pregnancy and live birth. Results The pregnancy and live birth rates were significantly higher in couples in which the female partners reported that they had consumed coffee or tea in the past or drank alcoholic beverages in the past (past users) when compared to those who had never consumed coffee or tea (4.0, 1.6–10.2 for pregnancy; 3.1, 1.2–8.1 for live birth) or alcoholic beverages (1.9, 1.1–3.3 for pregnancy; 2.1, 1.2–3.7 for live birth) (data are adjusted odds ratio and 95% confidence interval). Past users also had significantly higher pregnancy and live birth rates than those who were currently consuming coffee or tea or alcoholic beverages. Demographic, occupational exposures and other lifestyle factors were not significant. Conclusion(s) Couples in which the female partners drank coffee, tea, or alcoholic beverages in the past had higher pregnancy and live birth rates when compared to never or current users. When discontinuing these habits, they might have made other lifestyle changes to improve the pregnancy outcome. PMID:22270557

Long QT molecular autopsy in sudden unexplained death in the young (1-40 years old): Lessons learnt from an eight year experience in New Zealand.

PubMed

Marcondes, Luciana; Crawford, Jackie; Earle, Nikki; Smith, Warren; Hayes, Ian; Morrow, Paul; Donoghue, Tom; Graham, Amanda; Love, Donald; Skinner, Jonathan R

2018-01-01

To review long QT syndrome molecular autopsy results in sudden unexplained death in young (SUDY) between 2006 and 2013 in New Zealand. Audit of the LQTS molecular autopsy results, cardiac investigations and family screening data from gene-positive families. During the study period, 365 SUDY cases were referred for molecular autopsy. 128 cases (35%) underwent LQTS genetic testing. 31 likely pathogenic variants were identified in 27 cases (21%); SCN5A (14/31, 45%), KCNH2 (7/31, 22%), KCNQ1 (4/31, 13%), KCNE2 (3/31, 10%), KCNE1 (2/31, 7%), KCNJ2 (1/31, 3%). Thirteen variants (13/128, 10%) were ultimately classified as pathogenic. Most deaths (63%) occurred during sleep. Gene variant carriage was more likely with a positive medical history (mostly seizures, 63% vs 36%, p = 0.01), amongst females (36% vs 12%, p = 0.001) and whites more than Maori (31% vs 0, p = 0.0009). Children 1-12 years were more likely to be gene-positive (33% vs 14%, p = 0.02). Family screening identified 42 gene-positive relatives, 18 with definitive phenotypic expression of LQTS/Brugada. 76% of the variants were maternally inherited (p = 0.007). Further family investigations and research now support pathogenicity of the variant in 13/27 (48%) of gene-positive cases. In New Zealand, variants in SCN5A and KCNH2, with maternal inheritance, predominate. A rare variant in LQTS genes is more likely in whites rather than Maori, females, children 1-12 years and those with a positive personal and family history of seizures, syncope or SUDY. Family screening supported the diagnosis in a third of the cases. The changing classification of variants creates a significant challenge.

Cardiac events in football and strategies for first-responder treatment on the field.

PubMed

Schmied, Christian; Drezner, Jonathan; Kramer, Efraim; Dvorak, Jiri

2013-12-01

The incidence and outcomes of sudden cardiac arrest (SCA) and global strategies for prevention of sudden cardiac death (SCD) in football are not known. The aim of this study was to estimate the occurrence of cardiac events in football and to investigate the preventive measures taken among the Fédération International de Football Association (FIFA) member associations internationally. A questionnaire was sent to the member associations of FIFA. The first section addressed the previous events of SCA, SCD or unexplained sports-related sudden death within the last 10 years. Further questions focused on football player medical screening strategies and SCA resuscitation response protocols on the field. 126 of 170 questionnaires were returned (response rate 74.1%), and 103 questionnaires (60.6%) were completed sufficiently to include in further analysis. Overall, 107 cases of SCA/SCD and 5 unexplained football-associated sudden deaths were reported. These events occurred in 52 of 103 responding associations (50.5%). 23 of 112 (20.5%) footballers survived. 12 of 22 (54.5%) players treated with an available automated external defibrillators (AED) on the pitch survived. A national registry to monitor cardiac events was established in only 18.4% of the associations. Most associations (85.4%) provide regular cardiac screening for their national teams while 75% screen teams of the national leagues. An AED is available at all official matches in 68% of associations. National registries to accurately measure SCA/SCD in football are rare and greatly needed. Deficiencies in emergency preparations, undersupply of AEDs on the field during matches, and variability in resuscitation response protocols and training of team-staff members should be addressed to effectively prevent SCD in football.

A Randomized Clinical Trial to Determine Optimal Infertility Treatment in Older Couples: The Forty and Over Treatment Trial (FORT-T)

PubMed Central

Goldman, Marlene B.; Thornton, Kim L.; Ryley, David; Alper, Michael M.; Fung, June L.; Hornstein, Mark D.; Reindollar, Richard H.

2014-01-01

Objective To determine optimal infertility therapy in women at the end of their reproductive potential. Design Randomized clinical trial. Setting Academic medical centers and private infertility center in a state with mandated insurance coverage. Patients Couples with ≥ 6 months of unexplained infertility; female partner aged 38–42. Interventions Randomized to treatment with 2 cycles of clomiphene citrate (CC) and intrauterine insemination (IUI), follicle stimulating hormone (FSH)/IUI, or immediate IVF, followed by IVF if not pregnant. Main Outcome Measures Proportion with a clinically recognized pregnancy, number of treatment cycles, and time to conception after 2 treatment cycles and at the end of treatment. Results 154 couples were randomized to receive CC/IUI (N=51), FSH/IUI (N=52), or immediate IVF (N=51); 140 (90.9%) couples initiated treatment. Cumulative clinical pregnancy rates per couple after the first 2 cycles of CC/IUI, FSH/IUI, or immediate IVF were 21.6%, 17.3%, and 49.0%, respectively. After all treatment, 71.4% (110/154) of couples conceived a clinically recognized pregnancy and 46.1% delivered at least one live-born baby. 84.2% of all live born infants resulting from treatment were achieved from IVF. There were 36% fewer treatment cycles in the IVF arm compared to either COH/IUI arm and couples conceived a pregnancy leading to a live birth after fewer treatment cycles. Conclusions An RCT to compare treatment initiated with 2 cycles of COH/IUI to immediate IVF in older women with unexplained infertility demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group. PMID:24796764

The use of medical care and the prevalence of serious illness in an adult Prader-Willi syndrome cohort.

PubMed

Sinnema, Margje; Maaskant, Marian A; van Schrojenstein Lantman-de Valk, Henny M J; Boer, Harm; Curfs, Leopold M G; Schrander-Stumpel, Constance T R M

2013-08-01

Adults with Prader-Willi syndrome (PWS) have an increased occurrence of several medical conditions. We report on the consequences of high morbidity rates such as prevalence rate of hospital admissions, medication use and surgery in a Dutch cohort of adults with PWS. Special attention is paid to causes and symptoms of serious illness. Participants were contacted via the Dutch Prader-Willi Parent Association and through physicians specializing in persons with ID. The persons with PWS and their main caregivers were visited at home. Information was collected through semi-structured interviews on 102 adults with PWS. The need for medical care in the neonatal period is associated with hypotonia and feeding problems. Hospital admissions for respiratory tract infections are frequent. During childhood most hospital admissions were due to PWS syndrome specific surgery. During adolescence hospital admissions occurred for scoliosis surgery and endocrine evaluations. At adult age, hospitalization was associated with inguinal hernia surgery, diabetes mellitus, psychosis, erysipelas, water and drug intoxications. In the older group, respiratory infections were again the main reason for hospital admissions. Frequently used medications at adult age included psychotropics, laxatives, anti-diabetics and dermatologic preparations. Abnormal drinking patterns, problems with anesthesia, decreased ability to vomit, abnormal pain awareness and unpredictable fever responses were frequent and often lead to delayed diagnoses of serious conditions. People with PWS are frequent users of medical-care. Reasons for hospitalization and medication use are age specific. Knowledge on the different presentation of symptoms in people with PWS is needed. In case of unexplained illness, disturbances of consciousness and behavioral changes in people with PWS, an infection should be ruled out in the first place. Information from this study may help in preventing conditions and recognizing conditions in an early stage. Adequate preventive management and treatment of PWS related morbidity, could reduce medical care use in the long term and could improve quality adjusted life years. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss.

PubMed

Murugappan, Gayathree; Ohno, Mika S; Lathi, Ruth B

2015-05-01

To determine whether in vitro fertilization with preimplantation genetic screening (IVF/PGS) is cost effective compared with expectant management in achieving live birth for patients with unexplained recurrent pregnancy loss (RPL). Decision analytic model comparing costs and clinical outcomes. Academic recurrent pregnancy loss programs. Women with unexplained RPL. IVF/PGS with 24-chromosome screening and expectant management. Cost per live birth. The IVF/PGS strategy had a live-birth rate of 53% and a clinical miscarriage rate of 7%. Expectant management had a live-birth rate of 67% and clinical miscarriage rate of 24%. The IVF/PGS strategy was 100-fold more expensive, costing $45,300 per live birth compared with $418 per live birth with expectant management. In this model, IVF/PGS was not a cost-effective strategy for increasing live birth. Furthermore, the live-birth rate with IVF/PGS needs to be 91% to be cost effective compared with expectant management. Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Severe oligohydramnios with intact membranes: an indication for diagnostic amnioinfusion.

PubMed

Pryde, P G; Hallak, M; Lauria, M R; Littman, L; Bottoms, S F; Johnson, M P; Evans, M I

2000-01-01

To quantify the improvement in ultrasonographic fetal imaging following diagnostic amnioinfusion for the indication of unexplained midtrimester oligohydramnios. Patients referred for unexplained midtrimester oligohydramnios were retrospectively reviewed. Videotapes of those undergoing diagnostic antenatal amnioinfusion were analyzed for quality of visualization of routinely imaged structures before and after the infusion procedure. The overall rate of adequate visualization of fetal structures improved from 50.98 to 76.79% (p < 0.0001). In fetuses having preinfusion-identified obstructive uropathy, there was improvement in identification of associated anomalies from 11.8 to 31.3%. Several authors have suggested that diagnostic amnioinfusion can facilitate fetal imaging and increase diagnostic precision in the setting of unexplained severe oligohydramnios. We have quantified the improvement in the rate of optimal visualization of fetal structures which likely translates, in experienced hands, into this observed improved diagnostic precision. Of particular importance is the improvement in appreciation of associated anomalies in cases of obstructive uropathy in which such findings may determine whether or not invasive fetal therapy is indicated. Copyright 2000 S. Karger AG, Basel.

Medical school admission test: advantages for students whose parents are medical doctors?

PubMed

Simmenroth-Nayda, Anne; Görlich, Yvonne

2015-04-23

Admission candidates especially in medicine do not represent the socio-demographic proportions of the average population: children of parents with an academic background are highly overrepresented, and those with parents who are medical doctors represent quite a large and special group. At Göttingen University Medicine, a new admission procedure was established with the intention to broaden the base of applicants towards including candidates with previous medical training or lower final school grades. With a view to family background, we wished to know whether candidates differ in the test scores in our admission procedure. In February 2014 we asked all admission candidates of Göttingen University Medicine by questionnaire (nine closed, four open questions) about the academic background in their families, specifically, the medical background, school exam grades, and previous medical training as well as about how they prepared for the admission test. We also analysed data from admission scores of this group (semi-structured interview and four multiple mini-interviews). In addition to descriptive statistics, we used a Pearson correlation, means comparisons (t-test, analysis of variance), ANOVA, and a Scheffé test. In February 2014 nearly half of the applicants (44%) at Göttingen University Medicine had a medical background, most frequently, their parents were physicians. This rate is much higher than reported in the literature. Other socio-demographic baseline data did not differ from the percentages given in the literature. Of all applicants, 20% had previous medical training. The group of applicants with parents who were medical doctors did not show any advantage in either test-scoring (MMI and interview), their individual preparation for the admission test, or in receiving or accepting a place at medical school. Candidates with parents who were medical doctors had scored slightly lower in school exam grades. Our results suggest that there is a self-selection bias as well as a pre-selection for this particular group of applicants. This effect has to be observed during future admission procedures.

Tolerance of ambiguity, perfectionism and resilience are associated with personality profiles of medical students oriented to rural practice.

PubMed

Eley, Diann S; Leung, Janni K; Campbell, Narelle; Cloninger, C Robert

2017-05-01

Resilience, coping with uncertainty and learning from mistakes are vital characteristics for all medical disciplines - particularly rural practice. Levels of coping constructs were examined in medical students with and without a rural background or an interest in rural practice. Cross-sectional surveys identified two personality profiles, and their association with levels of Tolerance of Ambiguity, Resilience, Perfectionism-High Standards and Concern over mistakes as constructs indicative of coping. Medical students (N = 797) were stratified by rural background and degree of rural interest. Mediation analysis tested the effect of personality profile on levels of the coping constructs. More (72%) rural background students had Profile 1 which was associated with higher levels of Tolerance of Ambiguity, High standards, and Resilience, but lower Concern over mistakes. Non-rural background students reporting a strong rural interest also had Profile 1 (64%) and similar levels of coping constructs. Personality profile mediated the association between rural interest and levels of coping constructs regardless of background. Having a rural background or strong rural interest are associated with a personality profile that indicates a better capacity for coping. Personality may play a part in an individual's interest in rural practice. Rural workforce initiatives through education should encourage and nurture students with a genuine interest in rural practice - regardless of background.

[A rare case of Graves' disease in a patient on regular haemodialysis].

PubMed

Boubaker, Karima; Ounissi, Mondher; Khiari, Karima; Harzallah, Amel; Abbes, Monia; El Younsi, Fethi; Ben Abdellah, Taieb; Ben Maïz, Hedi; Kaaroud, Hayet; Kheder, Adel

2010-07-01

Abnormal thyroid hormone production and metabolism are relatively common in chronic renal failure and in regular haemodialysis. Graves' disease is a very unusual condition and is difficult to identify. We report a case of Graves' disease in a patient on regular hemodialysis. A 26-year-old man undergoing regular hemodialysis from unknown chronic nephropathy since four years. The patient suffered from unexplained slimming and aggressiveness. On admission, he had an irritability, tremor of the extremities, arterial hypertension not controlled by the medical treatment, discrete asynergy oculo-palpebral, glare of the glance and protrusion of the ocular spheres. The thyroid was non palpable. Biological tests demonstrated hyperthyroidism. Thyroid-stimulating hormone receptor antibodies were positive. Thyroid echography and scintiscanning showed vascular and hyperfonctionnel character of the thyroid. The patient was treated radically by radioactive iodine 131 therapy after medical preparation by antithyroid agent. He developed hypothyroidism treated by substitutive treatment. The diagnosis of Graves' disease must be evoked even in the absence of specific symptoms in haemodialysis patients. In front of clinical symptoms, since the conventional treatment is effective and inoffensive. Copyright 2010 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

Nephrotoxicity and Chinese Herbal Medicine.

PubMed

Yang, Bo; Xie, Yun; Guo, Maojuan; Rosner, Mitchell H; Yang, Hongtao; Ronco, Claudio

2018-04-03

Chinese herbal medicine has been practiced for the prevention, treatment, and cure of diseases for thousands of years. Herbal medicine involves the use of natural compounds, which have relatively complex active ingredients with varying degrees of side effects. Some of these herbal medicines are known to cause nephrotoxicity, which can be overlooked by physicians and patients due to the belief that herbal medications are innocuous. Some of the nephrotoxic components from herbs are aristolochic acids and other plant alkaloids. In addition, anthraquinones, flavonoids, and glycosides from herbs also are known to cause kidney toxicity. The kidney manifestations of nephrotoxicity associated with herbal medicine include acute kidney injury, CKD, nephrolithiasis, rhabdomyolysis, Fanconi syndrome, and urothelial carcinoma. Several factors contribute to the nephrotoxicity of herbal medicines, including the intrinsic toxicity of herbs, incorrect processing or storage, adulteration, contamination by heavy metals, incorrect dosing, and interactions between herbal medicines and medications. The exact incidence of kidney injury due to nephrotoxic herbal medicine is not known. However, clinicians should consider herbal medicine use in patients with unexplained AKI or progressive CKD. In addition, exposure to herbal medicine containing aristolochic acid may increase risk for future uroepithelial cancers, and patients require appropriate postexposure screening. Copyright © 2018 by the American Society of Nephrology.

Toxicological assessments of Gulf War veterans.

PubMed

Brown, Mark

2006-04-29

Concerns about unexplained illnesses among veterans of the 1991 Gulf War appeared soon after that conflict ended. Many environmental causes have been suggested, including possible exposure to depleted uranium munitions, vaccines and other drugs used to protect troops, deliberate or accidental exposure to chemical warfare agents and pesticides and smoke from oil-well fires. To help resolve these issues, US and UK governments have sought independent expert scientific advice from prestigious, independent scientific and public health experts, including the US National Academies of Science and the UK Royal Society and Medical Research Council. Their authoritative and independent scientific and medical reviews shed light on a wide range of Gulf War environmental hazards. However, they have added little to our understanding of Gulf War veterans' illnesses, because identified health effects have been previously well characterized, primarily in the occupational health literature. This effort has not identified any new health effects or unique syndromes associated with the evaluated environmental hazards. Nor do their findings provide an explanation for significant amounts of illnesses among veterans of the 1991 Gulf War. Nevertheless, these independent and highly credible scientific reviews have proven to be an effective means for evaluating potential health effects from deployment-related environmental hazards.

Toxicological assessments of Gulf War veterans

PubMed Central

Brown, Mark

2006-01-01

Concerns about unexplained illnesses among veterans of the 1991 Gulf War appeared soon after that conflict ended. Many environmental causes have been suggested, including possible exposure to depleted uranium munitions, vaccines and other drugs used to protect troops, deliberate or accidental exposure to chemical warfare agents and pesticides and smoke from oil-well fires. To help resolve these issues, US and UK governments have sought independent expert scientific advice from prestigious, independent scientific and public health experts, including the US National Academies of Science and the UK Royal Society and Medical Research Council. Their authoritative and independent scientific and medical reviews shed light on a wide range of Gulf War environmental hazards. However, they have added little to our understanding of Gulf War veterans' illnesses, because identified health effects have been previously well characterized, primarily in the occupational health literature. This effort has not identified any new health effects or unique syndromes associated with the evaluated environmental hazards. Nor do their findings provide an explanation for significant amounts of illnesses among veterans of the 1991 Gulf War. Nevertheless, these independent and highly credible scientific reviews have proven to be an effective means for evaluating potential health effects from deployment-related environmental hazards. PMID:16687269

A description of 'Australian Lyme disease' epidemiology and impact: an analysis of submissions to an Australian senate inquiry.

PubMed

Brown, Jeremy D

2018-04-01

Many Australian patients are diagnosed and treated for the scientifically and politically controversial diagnosis of an endemic form of 'Australian Lyme Disease'. Patient advocacy led Senator John Madigan to propose an Australian Senate Inquiry into this illness. To describe the symptomology and outcomes of patients diagnosed and treated with Lyme disease in Australia. All public, first-person submissions (n = 698) to the inquiry were reviewed and responses analysed for epidemiology, symptoms and impact against structured criteria. The most common symptoms described were fatigue (62.6%), disordered thinking (51.9%) and sensory disturbance (46.1%). Respondents reported experiencing symptoms for a median of 10 years and spent a median of $30 000 on diagnosis and treatment. Almost 10% of respondents self-diagnosed after being exposed to a media report of Australian Lyme disease. Patients diagnosed with Lyme disease in Australia display a symptomology similar to 'medically unexplained physical symptoms' syndromes, experience social and financial harms, and are at risk of nosocomial harms. Negative medical interactions and the media may contribute to patients seeking alternative and potentially non-evidence-based diagnoses and treatments. © 2018 Royal Australasian College of Physicians.

Dielectric Spectroscopic Detection of Early Failures in 3-D Integrated Circuits.

PubMed

Obeng, Yaw; Okoro, C A; Ahn, Jung-Joon; You, Lin; Kopanski, Joseph J

The commercial introduction of three dimensional integrated circuits (3D-ICs) has been hindered by reliability challenges, such as stress related failures, resistivity changes, and unexplained early failures. In this paper, we discuss a new RF-based metrology, based on dielectric spectroscopy, for detecting and characterizing electrically active defects in fully integrated 3D devices. These defects are traceable to the chemistry of the insolation dielectrics used in the through silicon via (TSV) construction. We show that these defects may be responsible for some of the unexplained early reliability failures observed in TSV enabled 3D devices.

Demographic attributes and knowledge acquisition among graduate-entry medical students.

PubMed

Finucane, Paul; Flannery, Denise; McGrath, Deirdre; Saunders, Jean

2013-01-01

Recent changes to undergraduate (basic) medical education in Ireland have linked an expansion of student numbers with wide-ranging reforms. Medical schools have broadened access by admitting more mature students from diverse backgrounds and have increased their international student numbers. This has resulted in major changes to the demographic profile of students at Irish medical schools. To determine whether the demographic characteristics of students impact on their academic performance and specifically on their rate of knowledge acquisition. As a formative assessment exercise, we administered a progress test to all students twice each year during a 4 year graduate-entry medical programme. We compared scores over time between students from different age cohorts, of different gender, of different nationalities and from different academic backgrounds. In the 1143 tests taken by 285 students to date, there were no significant differences in the rate of knowledge acquisition between the various groups. Early in the course, students from a non-biological science background performed less well than others but outperformed their peers by the time of graduation. Neither age, gender, nationality nor academic background impacts on the rate of knowledge acquisition among graduate-entry medical students.

Stress response in female veterans: an allostatic perspective.

PubMed

Groër, Maureen Wimberly; Burns, Candace

2009-01-01

Women serving in the military face many sources of stress, such as separation from home and family, sexual harassment and assault, and deployment to traumatic war zones. Some women are vulnerable to the effects of these stressors, resulting in deleterious mental and physical health outcomes. Understanding these risks through the theoretical model of allostasis can help identify those who will be most vulnerable and help healthcare providers prevent some negative outcomes and improve rehabilitation for some women when they return stateside. Women may be more likely than men to present with mental health problems such as posttraumatic stress disorder and depression after military service. They also may be at increased risk, based on their war-zone stress response, for disparate illness such as medically unexplained illness, cancer, and heart disease. The need for care for these women is expected to increase as more women are deployed to conflicts.

[Inveterate squamous cell carcinoma of the upper eyelid: a case report].

PubMed

Rinaldi, S; Marcasciano, M; Pacitti, F; Toscani, M; Tarallo, M; Fino, P; Scuderi, G L

2013-01-01

Squamous cell carcinoma (SCC) is a malignant tumor of epithelium that shows squamous cell differentiation. It is the second most common cancer of the skin and usually occurs in areas exposed to the sun but it can rarely arise within the conjunctival epithelium with a deep component. We describe a woman with a history of chronic blepharoconjunctivitis unresponsive to topical medications. Examination disclosed a hyperaemic translucent patch with blurred margins of the upper palpebral conjunctiva. Tarsoconjunctival biopsy revealed intraepithelial squamous cell carcinoma. Management consisted of complete tumor excision with removal of the entire posterior lamella of the left upper eyelid and reconstruction. Histopathologic analysis confirmed primary squamous cell carcinoma arising from conjunctival epithelium, involving the underlying tarsus. Patients with unexplained chronic unilateral blepharoconjunctivitis or papillary hypertrophy of the palpebral conjunctiva should be considered for biopsy to rule out neoplasia, even when there is no sign of an evident mass.

[Doctor shopping: the difficult-to-manage patient].

PubMed

de Zwaan, Martina; Müller, Astrid

2006-08-01

Medically unexplained symptoms and bodily dysfunctions are the single most prevalent class of symptoms in primary care. Differences in opinion as to the cause of the illness between the patients and the health care professionals make somatoform disorders a challenge for the patient-doctor relationship, and frequently produce negative feelings in health care professionals. The patients are usually reluctant to consider psychosocial aspects of their illness to be a factor. Early recognition of patients with somatization tendencies would be beneficial so that more effective treatment could begin sooner and unnecessary treatment be avoided. In order not to reinforce the patient's symptomatology, physicians should schedule appointments in a time contingent rather than a symptom contingent manner. Repetition of different tests should be avoided despite patients' demands in order not to further exacerbate the disorder. In many patients, psychotherapy should be recommended, although motivational work should already be initiated at the primary care stage.

Psychogenic dyspnea and therapeutic chest radiograph.

PubMed

Kaufman, Kenneth R; Endres, Jennifer K; Kaufman, Nathaniel D

2007-04-01

Conversion disorders, the physical expression of unresolved psychological pain, can be associated with mourning. This case report is third in a series of articles by the authors on childhood mourning reflecting the effects of multiple losses (K. R. Kaufman & N. D. Kaufman, 2005; K. R. Kaufman & N. D. Kaufman, 2006). In this case report, perception of potential death (self or parent) after a motor vehicle accident precipitated psychogenic dyspnea. A "therapeutic" chest radiograph was an effective initial treatment. Rapid intervention with explanation of the functional nature of the conversion symptom, why this symptom developed, and how to address the underlying stresses in the future led to an excellent outcome. Psychosocial intervention should be included in the multidisciplinary approach toward the child with conversion disorder, be it in an ambulatory, ER, or inpatient setting. The clinician must remember that medically unexplained symptoms in childhood may represent a child's expression of mourning.

Internet-purchased ibogaine toxicity confirmed with serum, urine, and product content levels.

PubMed

O'Connell, Charles W; Gerona, Roy R; Friesen, Matthew W; Ly, Binh T

2015-07-01

Ibogaine, a psychotropic indole alkaloid, is gaining popularity among medical subcultures for its purported anti addictive properties. Its use has been associated with altered mental status, ataxia, gastrointestinal distress, ventricular arrhythmias, and sudden and unexplained deaths.Its pharmacokinetics in toxic states is not well understood. Case report:A 33-year-old man overdosed on ibogaine in an attempt to quit his use of heroin. He developed altered state of consciousness, tremor, ataxia,nausea, vomiting, and transient QT interval prolongation, which all remitted as he cleared the substance. Ibogaine was confirmed in his urine and serum with a peak serum concentration of 377 ng/mL. Nonlinear elimination kinetics and a formula match to its active metabolite noriobgaine were observed as well. This case presents the unique description of serial serum concentrations as well as urine and product-confirmed ibogaine toxicity with transient toxin-related QT interval prolongation.

[Development, factor-analytical control and psychometric evaluation of a questionnaire on specialty choices among medical students].

PubMed

Hermann, K; Buchholz, A; Loh, A; Kiolbassa, K; Miksch, A; Joos, S; Götz, K

2012-07-01

A questionnaire was developed and validated which assesses factors influencing career choices of medical students and their perception of possibilities in general practice. The first questionnaire version, which was developed based on a systematic literature review, was checked for comprehensibility and redundancy using concurrent think aloud. The revised version was filled out by a pilot sample of medical students and the factor structure was assessed using principal component analysis (PCA). The final version was filled out in an online survey by medical students of all 5 Medical Faculties in the federal state of Baden-Wuerttemberg. The factor structure was validated with a confirmatory factor analysis (CFA). Reliability was assessed as internal consistency using Cronbach's α. The questionnaire comprises 2 parts: ratings of (A) the individual importance and of (B) the possibilities in general practice on 5-point scales. The first version comprising 118 items was shortened to 63 items after conducting interviews using concurrent think aloud. A further 3 items giving no information were removed after piloting the questionnaire on 179 students. The 27 items of part A were structured in 7 factors (PCA): image, personal ambition, patient orientation, work-life balance, future perspectives, job-related ambition, and variety in job. This structure had a critical fit in the CFA applied to the final version filled out by 1 299 students. Internal consistency of the factors was satisfactory to very good (Cronbach's α=0.55-0.81). The questionnaire showed good psychometric properties. Further, not assessed factors influence career choice resulting in unexplained variance in our dataset and the critical fit of the model. © Georg Thieme Verlag KG Stuttgart · New York.

Is social sciences and humanities (SSH) premedical education marginalized in the medical school admission process? A review and contextualization of the literature.

PubMed

Hall, Justin N; Woods, Nicole; Hanson, Mark D

2014-07-01

To investigate the performance outcomes of medical students with social sciences and humanities (SSH) premedical education during and beyond medical school by reviewing the literature, and to contextualize this review within today's admission milieu. From May to July 2012, the lead author searched the PubMed, MEDLINE, and PsycINFO databases, and reference lists of relevant articles, for research that compared premedical SSH education with premedical sciences education and its influence on performance during and/or after medical school. The authors extracted representative themes and relevant empirical findings. They contextualized their findings within today's admission milieu. A total of 1,548 citations were identified with 20 papers included in the review. SSH premedical education is predominately an American experience. For medical students with SSH background, equivalent academic, clinical, and research performance compared with medical students with a premedical science background is reported, yet different patterns of competencies exist. Post-medical-school equivalent or improved clinical performance is associated with an SSH background. Medical students with SSH backgrounds were more likely to select primary care or psychiatry careers. SSH major/course concentration, not SSH course counts, is important for admission decision making. The impact of today's admission milieu decreases the value of an SSH premedical education. Medical students with SSH premedical education perform on par with peers yet may possess different patterns of competencies, research, and career interests. However, SSH premedical education likely will not attain a significant role in medical school admission processes.

Characterizing sudden death and dead-in-bed syndrome in Type 1 diabetes: analysis from two childhood-onset Type 1 diabetes registries.

PubMed

Secrest, A M; Becker, D J; Kelsey, S F; Laporte, R E; Orchard, T J

2011-03-01

Type 1 diabetes mellitus increases the risk for sudden unexplained death, generating concern that diabetes processes and/or treatments underlie these deaths. Young (< 50 years) and otherwise healthy patients who are found dead in bed have been classified as experiencing 'dead-in-bed' syndrome. We thus identified all unwitnessed deaths in two related registries (the Children's Hospital of Pittsburgh and Allegheny County) yielding 1319 persons with childhood-onset (age < 18 years) Type 1 diabetes diagnosed between 1965 and 1979. Cause of death was determined by a Mortality Classification Committee (MCC) of at least two physician epidemiologists, based on the death certificate and additional records surrounding the death. Of the 329 participants who had died, the Mortality Classification Committee has so far reviewed and assigned a final cause of death to 255 (78%). Nineteen (8%) of these were sudden unexplained deaths (13 male) and seven met dead-in-bed criteria. The Mortality Classification Committee adjudicated cause of death in the seven dead-in-bed persons as: diabetic coma (n =4), unknown (n=2) and cardiomyopathy (n=1, found on autopsy). The three dead-in-bed individuals who participated in a clinical study had higher HbA(1c) , lower BMI and higher daily insulin dose compared with both those dying from other causes and those surviving. Sudden unexplained death in Type 1 diabetes seems to be increased 10-fold and associated with male sex, while dead-in-bed individuals have a high HbA(1c) and insulin dose and low BMI. Although sample size is too small for definitive conclusions, these results suggest specific sex and metabolic factors predispose to sudden unexplained death and dead-in-bed death. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

PubMed Central

Foldes-Busque, Guillaume; Denis, Isabelle; Poitras, Julien; Fleet, Richard P; Archambault, Patrick; Dionne, Clermont E

2013-01-01

Introduction Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain. Methods and analysis The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument. Ethics and dissemination This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned. PMID:24163208

Antenatal testing to predict outcome in pregnancies with unexplained antepartum haemorrhage.

PubMed

Ajayi, R A; Soothill, P W; Campbell, S; Nicolaides, K H

1992-02-01

To investigate whether Doppler studies of placental perfusion and antenatal tests for fetal hypoxia can identify reduced placental functional reserve in women with unexplained antepartum haemorrhage (APH). A prospective, longitudinal study. Fetal Surveillance Unit, King's College Hospital, London. 48 women with bleeding from the genital tract after 26 weeks gestation without a clinical diagnosis of abruption or ultrasound evidence of placenta praevia. Fetal surveillance by Doppler measurements of the umbilical and uterine arteries, biophysical profile scoring and computerized measurement of the mean minute range of FHR variation. A poor outcome was defined by one or more of the following: (i) birthweight greater than 2SD below the normal mean for gestational age and sex, (ii) abnormal FHR pattern in labour resulting in operative delivery, (iii) umbilical vein blood pH at delivery less than 7.15, (iv) a 5-min Apgar score less than 7. Fifteen of the 48 pregnancies had a poor outcome; seven occurred in the 10 women delivered preterm (less than 37 weeks) and eight in the 36 women delivered between 37 and 42 weeks. Two women were delivered after 42 weeks and both infants had a good outcome. The results of Doppler studies of uterine and umbilical arteries, fetal biophysical profile or FHR variation were not significantly different between the two outcome groups. The 36 pregnancies delivered between 37 and 42 weeks were matched retrospectively for maternal age, parity and race with 36 pregnancies without APH; there was no significant difference in outcome between the women with unexplained APH and the matched comparison group. Morbidity related to unexplained APH is associated with preterm delivery rather than with damage to utero-placental function.

Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility.

PubMed

Pashayan, Nora; Lyratzopoulos, Georgios; Mathur, Raj

2006-06-23

In unexplained and mild male factor subfertility, both intrauterine insemination (IUI) and in-vitro fertilisation (IVF) are indicated as first line treatments. Because the success rate of IUI is low, many couples failing IUI subsequently require IVF treatment. In practice, it is therefore important to examine the comparative outcomes (live birth-producing pregnancy), costs, and cost-effectiveness of primary offer of IVF, compared with primary offer of IUI followed by IVF for couples failing IUI. Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including frozen cycles when applicable) or "IUI + IVF" (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used in calculations were derived from the published peer-reviewed literature as well as activity data of local infertility units. Cost-effectiveness ratios for IVF, "unstimulated-IUI (U-IUI) + IVF", and "stimulated IUI (S-IUI) + IVF" were 12,600 pounds sterling, 13,100 pound sterling and 15,100 pound sterling per live birth-producing pregnancy respectively. For a hypothetical cohort of 100 couples with unexplained or mild male factor subfertility, compared with primary offer of IVF, 6 cycles of "U-IUI + IVF" or of "S-IUI + IVF" would cost an additional 174,200 pounds sterling and 438,000 pounds sterling, representing an opportunity cost of 54 and 136 additional IVF cycles and 14 to 35 live birth-producing pregnancies respectively. For couples with unexplained and mild male factor subfertility, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF.

Occult thyroid eye disease in patients with unexplained ocular misalignment identified by standardized orbital echography.

PubMed

Volpe, Nicholas J; Sbarbaro, James A; Gendron Livingston, Kym; Galetta, Steven L; Liu, Grant T; Balcer, Laura J

2006-07-01

To describe the clinical presentation, orbital echography (OE) findings, and neuroimaging results of patients with chronic unexplained ocular misalignment, which includes patients with clinically occult thyroid eye disease (TED) that is identifiable through a characteristic OE appearance. Retrospective observational case series. Seventy-eight patients with chronic ocular misalignment suspected of TED because of a history of systemic thyroid disease, proptosis, dysmotility, positive forced ductions, or eyelid retraction or lag were categorized as TED positive, negative, and indeterminate with the use of standardized OE. Demographic, clinical, OE, computed tomography, and magnetic resonance imaging information was collected. Analyses determined the prevalence of TED and differences between TED positive, negative, and indeterminate groups. Fifty-five percent of the findings were suspicious for and most consistent with TED (TED positive); 26% of the findings were TED negative, and 19% of the findings were TED indeterminate. Of 30 patients with newly diagnosed TED by OE, 70% had no lid retraction, and 20% had no other findings of TED. The inferior rectus followed by the superior rectus/levator complex, medial rectus, and lateral rectus muscles were the most frequently involved muscles. Neuroimaging that was performed in only 26 of 78 patients (33%) did not appear to yield additional diagnostic information. TED is a potential cause of chronic unexplained ocular misalignment in a substantial proportion of patients. These patients frequently present in an occult fashion without other clinical findings that are typical of TED. In these patients, a diagnosis of TED by OE can reduce further costly evaluation. OE appears to have significant clinical usefulness in the diagnosis of TED in patients with unexplained ocular misalignment.

Association of uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination for unexplained infertility.

PubMed

Styer, Aaron K; Jin, Susan; Liu, Dan; Wang, Baisong; Polotsky, Alex J; Christianson, Mindy S; Vitek, Wendy; Engmann, Lawrence; Hansen, Karl; Wild, Robert; Legro, Richard S; Coutifaris, Christos; Alvero, Ruben; Robinson, Randal D; Casson, Peter; Christman, Gregory M; Christy, Alicia; Diamond, Michael P; Eisenberg, Esther; Zhang, Heping; Santoro, Nanette

2017-03-01

To investigate the association of non-cavity-distorting uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination (OS-IUI) in couples with unexplained infertility. Secondary analysis from a prospective, randomized, multicenter clinical trial investigating fertility outcomes after OS-IUI. Reproductive Medicine Network clinical sites. Nine hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. Participants were randomized to one of three arms (clomiphene citrate, letrozole, or gonadotropins), and treatment was continued for up to four cycles or until pregnancy was achieved. Conception (serum hCG increase), clinical pregnancy (fetal cardiac activity), and live birth rates. A total of 102/900 participants (11.3%) had at least one documented fibroid and a normal uterine cavity. Women with fibroids were older, more likely to be African American, had a greater uterine volume, lower serum antimüllerian hormone levels, and fewer antral follicles than women without fibroids. In conception cycles, clinical pregnancy rates were significantly lower in participants with fibroids than in those without uterine fibroids. Pregnancy loss before 12 weeks was more likely in African American women with fibroids compared with non-African American women with fibroids. There was no difference in conception and live birth rates in subjects with and without fibroids. No differences were observed in conception and live birth rates in women with non-cavity-distorting fibroids and those without fibroids. These findings provide reassurance that pregnancy success is not impacted in couples with non-cavity-distorting fibroids undergoing OS-IUI for unexplained infertility. NCT01044862. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

A NOVEL MUTATION IN THE HCN4 GENE CAUSES SYMPTOMATIC SINUS BRADYCARDIA IN MOROCCAN JEWS

PubMed Central

Laish-Farkash, Avishag; Brass, Dovrat; Marek-Yagel, Dina; Pras, Elon; Dascal, Nathan; Antzelevitch, Charles; Nof, Eyal; Reznik, Haya; Eldar, Michael; Glikson, Michael; Luria, David

2010-01-01

Objectives To conduct a clinical, genetic and functional analysis of three unrelated families with familial sinus bradycardia (FSB). Background Mutations in the hyperpolarization-activated nucleotide-gated channel (HCN4) are known to be associated with FSB. Methods and Results Three males of Moroccan Jewish descent were hospitalized: one survived an out-of-hospital cardiac arrest and 2 presented with weakness and presyncopal events. All 3 had significant sinus bradycardia, also found in other first-degree relatives, with a segregation suggesting autosomal-dominant inheritance. All had normal response to exercise and normal heart structure. Sequencing of the HCN4 gene in all patients revealed a C to T transition at nucleotide position 1454, which resulted in an alanine to valine change (A485V) in the ion channel pore found in most of their bradycardiac relatives, but not in 150 controls. Functional expression of the mutated ion channel in Xenopus oocytes and in human embryonic kidney 293 cells revealed profoundly reduced function and synthesis of the mutant channel compared to wild-type. Conclusions We describe a new mutation in the HCN4 gene causing symptomatic FSB in 3 unrelated individuals of similar ethnic background that may indicate unexplained FSB in this ethnic group. This profound functional defect is consistent with the symptomatic phenotype. PMID:20662977

Background and design of the profiling biobehavioral responses to mechanical support in advanced heart failure study.

PubMed

Lee, Christopher S; Mudd, James O; Gelow, Jill M; Nguyen, Thuan; Hiatt, Shirin O; Green, Jennifer K; Denfeld, Quin E; Bidwell, Julie T; Grady, Kathleen L

2014-01-01

Unexplained heterogeneity in response to ventricular assist device (VAD) implantation for the management of advanced heart failure impedes our ability to predict favorable outcomes, provide adequate patient and family education, and personalize monitoring and symptom management strategies. The purpose of this article was to describe the background and the design of a study entitled "Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure" (PREMISE). PREMISE is a prospective cohort study designed to (1) identify common and distinct trajectories of change in physical and psychological symptom burden; (2) characterize common trajectories of change in serum biomarkers of myocardial stress, systemic inflammation, and endothelial dysfunction; and (3) quantify associations between symptoms and biomarkers of pathogenesis in adults undergoing VAD implantation. Latent growth mixture modeling, including parallel process and cross-classification modeling, will be used to address the study aims and will entail identifying trajectories, quantifying associations between trajectories and both clinical and quality-of-life outcomes, and identifying predictors of favorable symptom and biomarker responses to VAD implantation. Research findings from the PREMISE study will be used to enhance shared patient and provider decision making and to shape a much-needed new breed of interventions and clinical management strategies that are tailored to differential symptom and pathogenic responses to VAD implantation.

Toxicovigilance: a new approach for the hazard identification and risk assessment of toxicants in human beings.

PubMed

Descotes, Jacques; Testud, François

2005-09-01

The concept of toxicovigilance encompasses the active detection, validation and follow-up of clinical adverse events related to toxic exposures in human beings. Poison centers are key players in this function as poisoning statistics are essential to define the cause, incidence and severity of poisonings occurring in the general population. In addition, the systematic search for unexpected shifts in the recorded causes of poisonings, e.g., following the introduction of a new product, or change in the formulation or recommended use of an old product, allows for a rapid detection of potential adverse health consequences and the implementation of preventive or corrective measures. However, toxicovigilance is genuinely a medical and not only a statistical approach of human toxicity issues. In contrast to epidemiology, toxicovigilance is based on the in-depth medical assessment of acute or chronic intoxications on an individual basis, which requires detailed information that poison centers can rarely obtain via emergency telephone calls and that epidemiologists cannot collect or process. Validation of this medical information must primarily be based on toxicological expertise to help identify causal links between otherwise unexplained pathological conditions and documented toxic exposures. Thus, toxicovigilance can contribute to hazard identification and risk assessment by providing medically validated data which are often overlooked in the process of risk assessment. So far, very few structured toxicovigilance systems have been set up and hopefully national and international initiatives will bridge this gap in our knowledge of the toxicity of many chemicals and commercial products in human beings.

Toxicovigilance: A new approach for the hazard identification and risk assessment of toxicants in human beings

DOE Office of Scientific and Technical Information (OSTI.GOV)

Descotes, Jacques; Testud, Francois

2005-09-01

The concept of toxicovigilance encompasses the active detection, validation and follow-up of clinical adverse events related to toxic exposures in human beings. Poison centers are key players in this function as poisoning statistics are essential to define the cause, incidence and severity of poisonings occurring in the general population. In addition, the systematic search for unexpected shifts in the recorded causes of poisonings, e.g., following the introduction of a new product, or change in the formulation or recommended use of an old product, allows for a rapid detection of potential adverse health consequences and the implementation of preventive or correctivemore » measures. However, toxicovigilance is genuinely a medical and not only a statistical approach of human toxicity issues. In contrast to epidemiology, toxicovigilance is based on the in-depth medical assessment of acute or chronic intoxications on an individual basis, which requires detailed information that poison centers can rarely obtain via emergency telephone calls and that epidemiologists cannot collect or process. Validation of this medical information must primarily be based on toxicological expertise to help identify causal links between otherwise unexplained pathological conditions and documented toxic exposures. Thus, toxicovigilance can contribute to hazard identification and risk assessment by providing medically validated data which are often overlooked in the process of risk assessment. So far, very few structured toxicovigilance systems have been set up and hopefully national and international initiatives will bridge this gap in our knowledge of the toxicity of many chemicals and commercial products in human beings.« less

Understanding of diagnosis and medications among non-English-speaking older patients.

PubMed

Teo, Ken Gw; Tacey, Mark; Holbeach, Edwina

2018-01-28

To determine whether non-English-speaking background (NESB) patients had a poorer understanding of diagnosis and medications compared to English-speaking background (ESB) patients. English-speaking background and NESB patients admitted to inpatient geriatric evaluation and management (GEM) unit were asked standardised questions about their admission diagnosis, reason for GEM admission and medications. Accuracy of answers, as compared to medical notes, ranked as 'full credit', 'partial credit' or 'no credit'. Of the 66 patients recruited (30 NESB), understanding of diagnosis and purpose of GEM admission was good. There was no difference between ESB and NESB patients. Understanding of medications taken prior to admission was poor, with 67% of overall patients scoring 'no credit'. NESB patients were more likely to score 'no credit' compared to ESB (80% vs 56%, P = 0.036). Reassuringly, patients had a reasonable understanding of diagnosis and purpose of GEM admission. Lack of understanding of medications, especially among NESB patients, should be improved. © 2018 AJA Inc.

Effects of age, gender and educational background on strength of motivation for medical school.

PubMed

Kusurkar, Rashmi; Kruitwagen, Cas; ten Cate, Olle; Croiset, Gerda

2010-08-01

The aim of this study was to determine the effects of selection, educational background, age and gender on strength of motivation to attend and pursue medical school. Graduate entry (GE) medical students (having Bachelor's degree in Life Sciences or related field) and Non-Graduate Entry (NGE) medical students (having only completed high school), were asked to fill out the Strength of Motivation for Medical School (SMMS) questionnaire at the start of medical school. The questionnaire measures the willingness of the medical students to pursue medical education even in the face of difficulty and sacrifice. GE students (59.64 ± 7.30) had higher strength of motivation as compared to NGE students (55.26 ± 8.33), so did females (57.05 ± 8.28) as compared to males (54.30 ± 8.08). 7.9% of the variance in the SMMS scores could be explained with the help of a linear regression model with age, gender and educational background/selection as predictor variables. Age was the single largest predictor. Maturity, taking developmental differences between sexes into account, was used as a predictor to correct for differences in the maturation of males and females. Still, the gender differences prevailed, though they were reduced. Pre-entrance educational background and selection also predicted the strength of motivation, but the effect of the two was confounded. Strength of motivation appears to be a dynamic entity, changing primarily with age and maturity and to a small extent with gender and experience.

Within-Tunnel Variations in Pressure Data for Three Transonic Wind Tunnels

NASA Technical Reports Server (NTRS)

DeLoach, Richard

2014-01-01

This paper compares the results of pressure measurements made on the same test article with the same test matrix in three transonic wind tunnels. A comparison is presented of the unexplained variance associated with polar replicates acquired in each tunnel. The impact of a significance component of systematic (not random) unexplained variance is reviewed, and the results of analyses of variance are presented to assess the degree of significant systematic error in these representative wind tunnel tests. Total uncertainty estimates are reported for 140 samples of pressure data, quantifying the effects of within-polar random errors and between-polar systematic bias errors.

Check-Standard Testing Across Multiple Transonic Wind Tunnels with the Modern Design of Experiments

NASA Technical Reports Server (NTRS)

Deloach, Richard

2012-01-01

This paper reports the result of an analysis of wind tunnel data acquired in support of the Facility Analysis Verification & Operational Reliability (FAVOR) project. The analysis uses methods referred to collectively at Langley Research Center as the Modern Design of Experiments (MDOE). These methods quantify the total variance in a sample of wind tunnel data and partition it into explained and unexplained components. The unexplained component is further partitioned in random and systematic components. This analysis was performed on data acquired in similar wind tunnel tests executed in four different U.S. transonic facilities. The measurement environment of each facility was quantified and compared.

Efficacy of cognitive-behavioural therapy by general practitioners for unexplained fatigue among employees: Randomised controlled trial.

PubMed

Huibers, Marcus J H; Beurskens, Anna J H M; Van Schayck, Constant P; Bazelmans, Ellen; Metsemakers, Job F M; Knottnerus, J Andre; Bleijenberg, Gijs

2004-03-01

Fatigue is a common complaint that may lead to long-term sick leave and work disability. To assess the efficacy of cognitive-behavioural therapy by general practitioners for unexplained, persistent fatigue among employees. A randomised controlled trial, using a pre-randomisation design in primary care, investigated 151 employees on sick leave with fatigue. Participants in the experimental group were offered five to seven 30 min sessions of cognitive-behavioural therapy by a general practitioner; those in the control group were offered no treatment. Main outcome measures (fatigue severity, self-reported absenteeism, registered absenteeism and clinical recovery) were assessed at 4 months, 8 months and 12 months. At baseline, 44% of the patients already met research criteria for chronic fatigue syndrome. There was no significant difference between the experimental group and the control group on primary or secondary outcomes at any point. Cognitive-behavioural therapy by general practitioners for unexplained, persistent fatigue did not prove to be an effective intervention. Since these doctors were unable to deliver this therapy effectively under ideal circumstances, it is unlikely that doctors in routine practice would be more successful in doing so.

Clinical application of hysteroscopic hydrotubation for unexplained infertility in the mare.

PubMed

Inoue, Y; Sekiguchi, M

2017-11-07

Therapeutic techniques for oviductal obstruction in the mare are limited. Nonsurgical and retrograde flushing may be an attractive alternative to current treatment methods for oviductal blockage. To evaluate hysteroscopic selective hydrotubation as a treatment option for presumptive equine oviductal blockage. Retrospective case series. A quantity of 10 mL of saline was flushed through the oviducts in 28 standing sedated mares, which had reproductive histories of unexplained subfertility, by inserting a catheter into the uterotubal junction under endoscopic guidance. All mares in the study had been mated through several cycles (2-20 oestrous cycles) by known fertile stallions prior to treatment, with no evidence of conception. The average number of cycles for each mare prior to treatment was 6.5 ± 4.5. Saline was successfully infused into a total of 50 oviducts. Of 28 mares, 26 conceived after the treatment. The average number of cycles for each mare to become pregnant after treatment was 1.8 ± 0.8. Diagnosis of blocked oviducts was presumptive, and pretreatment infertility was used as the control. This study revealed that hysteroscopic hydrotubation using saline improved pregnancy rates in mares in which oviductal blockage was suspected as a cause of unexplained subfertility. © 2017 EVJ Ltd.

[Similarities and differences in the social background of female medical, nursing and public health visiting students].

PubMed

Feith, Helga Judit; Soósné Kiss, Zsuzsanna; Kovácsné Tóth, Agnes; Balázs, Péter

2008-06-15

According to our knowledge, there has never been a comprehensive research in Hungary dealing with healthcare university or college students' social background. The main objectives of our cross-section research were to analyze differences in the social background of female students who decided to become doctors, professional nurses and health visitors. This research was conducted among female medical and nursing college students at the Semmelweis University. There were 295 students invited to participate, the response rate was 68,08% (N = 201). Data analysis was performed by SPSS software by using descriptive methods of statistics. We found a decisive difference among medical, nursing and health visitor students while analyzing a number of socio-demographic characteristics. Most medical students came from families where the parents had college or university degrees, but we can state that there is a minimal likelihood in the case of college students that they are descendants of parents with higher educational degrees. We did not find statistical differences in the three student sample groups regarding their marital status, but fewer nursing college students lived in marriage or household partnership. We found a significant difference in the social background of nursing college and medical students. The social disadvantages of nursing and health visitor students are more considerable than those of medical students.

Combining Task Execution and Background Knowledge for the Verification of Medical Guidelines

NASA Astrophysics Data System (ADS)

Hommersom, Arjen; Groot, Perry; Lucas, Peter; Balser, Michael; Schmitt, Jonathan

The use of a medical guideline can be seen as the execution of computational tasks, sequentially or in parallel, in the face of patient data. It has been shown that many of such guidelines can be represented as a 'network of tasks', i.e., as a number of steps that have a specific function or goal. To investigate the quality of such guidelines we propose a formalization of criteria for good practice medicine a guideline should comply to. We use this theory in conjunction with medical background knowledge to verify the quality of a guideline dealing with diabetes mellitus type 2 using the interactive theorem prover KIV. Verification using task execution and background knowledge is a novel approach to quality checking of medical guidelines.

11. Hospital Point, view to southwest from southeast bulkhead; background ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

11. Hospital Point, view to southwest from southeast bulkhead; background left to right: 1960 high-rise hospital, Medical Officer's Quarters B, and Medical Officer's Quarters C - Portsmouth Naval Hospital, Bounded by Elizabeth River, Crawford Street, Portsmouth General Hospital, Parkview Avenue, & Scotts Creek, Portsmouth, Portsmouth, VA

Commentary: criminal background checks for entering medical students: history, current issues, and future considerations.

PubMed

Kleshinski, James; Case, Steven T; Davis, Dwight; Heinrich, George F; Witzburg, Robert A

2011-07-01

In this commentary, the authors aim to contextualize the history and rationale for what has become the Association of American Medical Colleges-facilitated criminal background check process for entering medical students. As the process was being considered, many issues with a standardized process were identified. There were concerns that demographic or socioeconomic factors might unfairly burden certain applicants or discourage them from applying to medical school. On the other hand, a unified, national program would minimize cost and enhance quality assurance. The authors discuss these issues. Lessons learned in the first three years of the program are also addressed, including some unexpected and favorable consequences such as the identification of accepted applicants with at-risk behaviors (e.g., substance abuse), who would have otherwise gone undetected. Several challenges remain, including the fact that the criminal background check process creates an enhanced role for prehealth advisors and encourages undergraduate institutions to establish standards and processes relating to professionalism. While this is, no doubt, an evolving program which needs continued oversight and ongoing reevaluation, the authors support the continued advancement of the criminal background check process for entering medical students.

Association between rural clinical clerkship and medical students' intentions to choose rural medical work after graduation: A cross-sectional study in western China.

PubMed

Liu, Jinlin; Zhu, Bin; Mao, Ying

2018-01-01

A large number of programs have been implemented in many countries to increase the healthcare workforce recruitment in rural and remote areas. Rural early exposure programs for medical students have been shown to be effective strategies. However, no related studies have been reported before in China. This study was carried out to determine the association between medical students' participation in rural clinical clerkships and their intentions to choose rural medical work after graduation from western medical schools in China. Based on a two-stage random sampling method, the cross-sectional survey was carried out in ten western provinces in China. A brief questionnaire filled in by medical students was used for data collection. A total of 4278 medical students participated in the study. The response rate was approximately 90.34%. Pearson's chi-squared tests and binary logistic regression analyses were performed for data analyses. Approximately 52.0% of medical students disclosed intentions to work in rural medical institutions after graduation. Only one in five participants had experience with a rural clinical clerkship. Rural clinical clerkships were significantly associated with medical students' intentions to work in rural medical institutions (OR: 1.24, 95%CI: 1.05-1.46); further analyses indicated that such clerkships only had a significant impact among the medical students with an urban background (OR: 2.10, 95%CI: 1.48-2.97). In terms of the sociodemographic characteristics, younger age, low level of parental education, majoring in general practice, and studying in low-level medical schools increased the odds of having intentions to engage in rural medical work among medical students; however, rural origins was the only positive univariate predictor. In addition, the predictors of intentions to choose rural medical work were different between medical students with a rural background and those with an urban background. Rural clinical clerkship is likely to increase the odds of having intentions to work in rural medical institutions after graduation among medical students in western China, especially for those with an urban background. Related policy makers could consider developing compulsory rural clerkship programs and implement them among medical students to increase early rural exposure.

"Not a university type": focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school.

PubMed

Greenhalgh, Trisha; Seyan, Kieran; Boynton, Petra

2004-06-26

To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school. Focus group study. Six London secondary schools. 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds. Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support. There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfillment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices. Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.

Is IVF-served two different ways-more cost-effective than IUI with controlled ovarian hyperstimulation?

PubMed

Tjon-Kon-Fat, R I; Bensdorp, A J; Bossuyt, P M M; Koks, C; Oosterhuis, G J E; Hoek, A; Hompes, P; Broekmans, F J; Verhoeve, H R; de Bruin, J P; van Golde, R; Repping, S; Cohlen, B J; Lambers, M D A; van Bommel, P F; Slappendel, E; Perquin, D; Smeenk, J; Pelinck, M J; Gianotten, J; Hoozemans, D A; Maas, J W M; Groen, H; Eijkemans, M J C; van der Veen, F; Mol, B W J; van Wely, M

2015-10-01

What is the cost-effectiveness of in vitro fertilization (IVF) with conventional ovarian stimulation, single embryo transfer (SET) and subsequent cryocycles or IVF in a modified natural cycle (MNC) compared with intrauterine insemination with controlled ovarian hyperstimulation (IUI-COH) as a first-line treatment in couples with unexplained subfertility and an unfavourable prognosis on natural conception?. Both IVF strategies are significantly more expensive when compared with IUI-COH, without being significantly more effective. In the comparison between IVF-MNC and IUI-COH, the latter is the dominant strategy. Whether IVF-SET is cost-effective depends on society's willingness to pay for an additional healthy child. IUI-COH and IVF, either after conventional ovarian stimulation or in a MNC, are used as first-line treatments for couples with unexplained or mild male subfertility. As IUI-COH is less invasive, this treatment is usually offered before proceeding to IVF. Yet, as conventional IVF with SET may lead to higher pregnancy rates in fewer cycles for a lower multiple pregnancy rate, some have argued to start with IVF instead of IUI-COH. In addition, IVF in the MNC is considered to be a more patient friendly and less costly form of IVF. We performed a cost-effectiveness analysis alongside a randomized noninferiority trial. Between January 2009 and February 2012, 602 couples with unexplained infertility and a poor prognosis on natural conception were allocated to three cycles of IVF-SET including frozen embryo transfers, six cycles of IVF-MNC or six cycles of IUI-COH. These couples were followed until 12 months after randomization. We collected data on resource use related to treatment, medication and pregnancy from the case report forms. We calculated unit costs from various sources. For each of the three strategies, we calculated the mean costs and effectiveness. Incremental cost-effectiveness ratios (ICER) were calculated for IVF-SET compared with IUI-COH and for IVF-MNC compared with IUI-COH. Nonparametric bootstrap resampling was used to investigate the effect of uncertainty in our estimates. There were 104 healthy children (52%) born in the IVF-SET group, 83 (43%) the IVF-MNC group and 97 (47%) in the IUI-COH group. The mean costs per couple were €7187 for IVF-SET, €8206 for IVF-MNC and €5070 for IUI-COH. Compared with IUI-COH, the costs for IVF-SET and IVF-MNC were significantly higher (mean differences €2117; 95% CI: €1544-€2657 and €3136, 95% CI: €2519-€3754, respectively).The ICER for IVF-SET compared with IUI-COH was €43 375 for the birth of an additional healthy child. In the comparison of IVF-MNC to IUI-COH, the latter was the dominant strategy, i.e. more effective at lower costs. We only report on direct health care costs. The present analysis is limited to 12 months. Since we found no evidence in support of offering IVF as a first-line strategy in couples with unexplained and mild subfertility, IUI-COH should remain the treatment of first choice. The study was supported by a grant from ZonMw, the Netherlands Organization for Health Research and Development, (120620027) and a grant from Zorgverzekeraars Nederland, the Netherlands' association of health care insurers (09-003). Current Controlled Trials ISRCTN52843371; Nederlands Trial Register NTR939. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Tailored expectant management in couples with unexplained infertility does not influence their experiences with the quality of fertility care.

PubMed

Kersten, F A M; Hermens, R P G M; Braat, D D M; Tepe, E; Sluijmer, A; Kuchenbecker, W K; Van den Boogaard, N; Mol, B W J; Goddijn, M; Nelen, W L D M

2016-01-01

Do couples who were eligible for tailored expectant management (TEM) and did not start treatment within 6 months after the fertility work-up, have different experiences with the quality of care than couples that were also eligible for TEM but started treatment right after the fertility work-up? Tailored expectant management of at least 6 months in couples with unexplained infertility is not associated with the experiences with quality of care or trust in their physician. In couples with unexplained infertility and a good prognosis of natural conception within 1 year, expectant management for 6-12 months does not compromise ongoing birth rates and is equally as effective as starting medically assisted reproduction immediately. Therefore, TEM is recommended by various international clinical guidelines. Implementation of TEM is still not optimal because of existing barriers on both patient and professional level. An important barrier is the hesitance of professionals to counsel their patients for TEM because they fear that patients will be dissatisfied with care. However, if and how adherence to TEM actually affects the couples' experience with care is unknown. Experiences with the quality care can be measured by evaluating the patient-centredness of care and the patients' trust in their physician. This is a retrospective cross-sectional study. A survey with written questionnaires was performed among all couples who participated in the retrospective audit of guideline adherence on TEM in 25 Dutch clinics. Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis (>30%) of natural conception within 1 year based on the Hunault prediction model. We used patient's questionnaires to collect data on the couples' experience with the quality of care and possible confounders for their experiences other than having undergone TEM or not. Multilevel regression analyses were performed to investigate case-mix adjusted association of TEM with the patient-centredness of care (PCQ-Infertility) and the patients' trust in their physician (Wake Forest Trust Scale). Couples who adhered to TEM experienced the quality of care on the same level as couples who were exposed to early treatment, i.e. started fertility treatment within 6 months after fertility work-up. There were no associations between adherence to TEM and the patient-centredness of care or the patients' trust in their physician. Because this study is retrospective, recall bias might occur. Furthermore, we were unable to measure the difference in experience with care over time. Therefore, our results have to be interpreted carefully. Prospective research on couples undergoing TEM have to be performed to provide more detailed insight in the patients' experiences with the decision making process and subsequently the expectant period. Tackling the barriers surrounding TEM, i.e. better counselling and more patient information material, could further improve patient experiences with the quality of care for couples who are advised TEM. Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none. www.trialregister.nl NTR3405. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effects of age, gender and educational background on strength of motivation for medical school

PubMed Central

Kruitwagen, Cas; ten Cate, Olle; Croiset, Gerda

2009-01-01

The aim of this study was to determine the effects of selection, educational background, age and gender on strength of motivation to attend and pursue medical school. Graduate entry (GE) medical students (having Bachelor’s degree in Life Sciences or related field) and Non-Graduate Entry (NGE) medical students (having only completed high school), were asked to fill out the Strength of Motivation for Medical School (SMMS) questionnaire at the start of medical school. The questionnaire measures the willingness of the medical students to pursue medical education even in the face of difficulty and sacrifice. GE students (59.64 ± 7.30) had higher strength of motivation as compared to NGE students (55.26 ± 8.33), so did females (57.05 ± 8.28) as compared to males (54.30 ± 8.08). 7.9% of the variance in the SMMS scores could be explained with the help of a linear regression model with age, gender and educational background/selection as predictor variables. Age was the single largest predictor. Maturity, taking developmental differences between sexes into account, was used as a predictor to correct for differences in the maturation of males and females. Still, the gender differences prevailed, though they were reduced. Pre-entrance educational background and selection also predicted the strength of motivation, but the effect of the two was confounded. Strength of motivation appears to be a dynamic entity, changing primarily with age and maturity and to a small extent with gender and experience. PMID:19774476

Chronic Fatigue and Personality: A Twin Study of Causal Pathways and Shared Liabilities

PubMed Central

Poeschla, Brian; Strachan, Eric; Dansie, Elizabeth; Buchwald, Dedra S.; Afari, Niloofar

2013-01-01

Background The etiology of chronic fatigue syndrome (CFS) remains unknown. Personality traits influence well-being and may play a role in CFS and unexplained chronic fatigue. Purpose To examine the association of emotional instability and extraversion with chronic fatigue and CFS in a genetically informative sample. Methods We evaluated 245 twin pairs for two definitions of chronic fatigue. They completed the Neuroticism and Extraversion subscales of the NEO-FFI. Using a co-twin control design, we examined the association between personality and chronic fatigue. Results Higher emotional instability was associated with both definitions of chronic fatigue and was confounded by shared genetics. Lower extraversion was also associated with both definitions of fatigue, but was not confounded by familial factors. Conclusions Both emotional instability and extraversion are related to chronic fatigue and CFS. Whereas emotional instability and chronic fatigue are linked by shared genetic mechanisms, the relationship with extraversion may be causal and bi-directional. PMID:23361410

Chromosomal Microarray Testing in 42 Korean Patients with Unexplained Developmental Delay, Intellectual Disability, Autism Spectrum Disorders, and Multiple Congenital Anomalies.

PubMed

Lee, Sun Ho; Song, Wung Joo

2017-09-01

Chromosomal microarray (CMA) is a high-resolution, high-throughput method of identifying submicroscopic genomic copy number variations (CNVs). CMA has been established as the first-line diagnostic test for individuals with developmental delay (DD), intellectual disability (ID), autism spectrum disorders (ASDs), and multiple congenital anomalies (MCAs). CMA analysis was performed in 42 Korean patients who had been diagnosed with unexplained DD, ID, ASDs, and MCAs. Clinically relevant CNVs were discovered in 28 patients. Variants of unknown significance were detected in 13 patients. The diagnostic yield was high (66.7%). CMA is a superior diagnostic tool compared with conventional karyotyping and fluorescent in situ hybridization.

Pioneer Venus 12.5 km Anomaly Workshop Report, volume 1

NASA Technical Reports Server (NTRS)

Seiff, A.; Sromovsky, L.; Borucki, W.; Craig, R.; Juergens, D.; Young, R. E.; Ragent, B.

1995-01-01

A workshop was convened at Ames Research Center on September 28 and 29, 1993, to address the unexplained electrical anomalies experienced in December 1978 by the four Pioneer Venus probes below a Venus altitude of 12.5 km. These anomalies caused the loss of valuable data in the deep atmosphere, and, if their cause were to remain unexplained, could reoccur on future Venus missions. The workshop participants reviewed the evidence and studied all identified mechanisms that could consistently account for all observed anomalies. Both hardware problems and atmospheric interactions were considered. Based on a workshop recommendation, subsequent testing identified the cause as being an insulation failure of the external harness. All anomalous events are now explained.

ASSET (Age/Sex Standardised Estimates of Treatment): A Research Model to Improve the Governance of Prescribing Funds in Italy

PubMed Central

Favato, Giampiero; Mariani, Paolo; Mills, Roger W.; Capone, Alessandro; Pelagatti, Matteo; Pieri, Vasco; Marcobelli, Alberico; Trotta, Maria G.; Zucchi, Alberto; Catapano, Alberico L.

2007-01-01

Background The primary objective of this study was to make the first step in the modelling of pharmaceutical demand in Italy, by deriving a weighted capitation model to account for demographic differences among general practices. The experimental model was called ASSET (Age/Sex Standardised Estimates of Treatment). Methods and Major Findings Individual prescription costs and demographic data referred to 3,175,691 Italian subjects and were collected directly from three Regional Health Authorities over the 12-month period between October 2004 and September 2005. The mean annual prescription cost per individual was similar for males (196.13 euro) and females (195.12 euro). After 65 years of age, the mean prescribing costs for males were significantly higher than females. On average, costs for a 75-year-old subject would be 12 times the costs for a 25–34 year-old subject if male, 8 times if female. Subjects over 65 years of age (22% of total population) accounted for 56% of total prescribing costs. The weightings explained approximately 90% of the evolution of total prescribing costs, in spite of the pricing and reimbursement turbulences affecting Italy in the 2000–2005 period. The ASSET weightings were able to explain only about 25% of the variation in prescribing costs among individuals. Conclusions If mainly idiosyncratic prescribing by general practitioners causes the unexplained variations, the introduction of capitation-based budgets would gradually move practices with high prescribing costs towards the national average. It is also possible, though, that the unexplained individual variation in prescribing costs is the result of differences in the clinical characteristics or socio-economic conditions of practice populations. If this is the case, capitation-based budgets may lead to unfair distribution of resources. The ASSET age/sex weightings should be used as a guide, not as the ultimate determinant, for an equitable allocation of prescribing resources to regional authorities and general practices. PMID:17611624

Identifying Niemann-Pick type C in early-onset ataxia: two quick clinical screening tools.

PubMed

Synofzik, Matthis; Fleszar, Zofia; Schöls, Ludger; Just, Jennifer; Bauer, Peter; Torres Martin, Juan V; Kolb, Stefan

2016-10-01

Niemann-Pick disease type C (NP-C) is a rare multisystemic lysosomal disorder which, albeit treatable, is still starkly underdiagnosed. As NP-C features early onset ataxia (EOA) in 85-90 % of cases, EOA presents a promising target group for undiagnosed NP-C patients. Here, we assessed the ability of the previously established NP-C suspicion index (SI) and a novel abbreviated '2/3 SI' tool for rapid appraisal of suspected NP-C in unexplained EOA. This was a retrospective observational study comparing 'NP-C EOA' cases (EOA patients with confirmed NP-C) with non-NP-C EOA controls (EOA patients negative for NP-C gene mutations). NP-C risk prediction scores (RPS) from both the original and 2/3 SIs were calculated and their discriminatory performance evaluated. Among 133 patients (47 NP-C EOA cases; 86 non-NP-C EOA controls), moderate (40-69 points) and high (≥70 points) RPS were common based on original SI assessments in non-NP-C EOA controls [16 (19 %) and 8 (9 %), respectively], but scores ≥70 points were far more frequent [46 (98 %)] among NP-C EOA cases. RPS cut-off values provided 98 % sensitivity and 91 % specificity for NP-C at 70-point cut-off, and ROC analysis revealed an AUC of 0.982. Using the 2/3 SI, 90 % of NP-C EOA cases had scores of 2 or 3, and RPS analysis showed an AUC of 0.961. In conclusion, the NP-C SI and the new, quick-to-apply 2/3 SI distinguished well between NP-C and non-NP-C patients, even in EOA populations with high background levels of broadly NPC-compatible multisystemic disease features. While the original SI showed the greatest sensitivity, both tools reliably aided identification of patients with unexplained EOA who warranted further investigation for NP-C.

Unraveling the Enigma of Bangungut: Is Sudden Unexplained Nocturnal Death Syndrome (SUNDS) in the Philippines a Disease Allelic to the Brugada Syndrome?

PubMed Central

Gaw, Albert C.; Lee, Byron; Gervacio-Domingo, Giselle; Antzelevitch, Charles; Divinagracia, Romeo; Jocano, Felipe

2012-01-01

Background Sudden unexplained nocturnal death syndrome (SUNDS) has been reported worldwide. SUNDS is endemic in Southeast Asia and is colloquially known as Bangungut in the Philippines, Lai Tai in Thailand, and Pokkuri in Japan. Although SUNDS in Thailand and Japan have been determined to be phenotypically, genetically and functionally identical to the Brugada syndrome, the relationship between Bangungut/SUNDS in the Philippines and the Brugada syndrome has not been clarified. This paper explores the concordance between Bangungut/SUNDS and the Brugada syndrome. Methods We summarized autopsy studies on Bangungut retrieved from PubMed since 1917 and current epidemiological data on Philippine SUNDS to clarify its diagnostic features. We also reviewed current hypotheses of the pathophysiological mechanism of the Brugada syndrome to explore its applicability to Bangungut/SUNDS. Results The use of the term Bangungut is confusing as it includes many diseases that may cause SUNDS. However, our review reveals a notable subset of Bangungut, identified as Bangungut/SUNDS with no gross cardiac pathology that conforms to the clinical picture of the folk-belief of Bangungut and of the Brugada syndrome, namely: predominance among male in the 20-40 age range; sudden death during sleep or at rest, usually following ingestion of a large meal at night; and victims were in apparent good health prior to their demise. Current pathophysiological mechanisms of Brugada syndrome seemed plausible explanations for a majority of this subset of Bangungut/SUNDS. Conclusion Bangungut/SUNDS and the Brugada syndrome appear closely related. Pathophysiological mechanisms of the Brugada syndrome may explain the enigma of Bangungut/SUND. Whether Bangungut/SUNDS is phenotypically, genetically and functionally an allele of the Brugada syndrome remains inconclusive due to lack of research data. We therefore proposed a research agenda including genetic testing and pharmacological challenge of probands and their family members suspected of SUNDS to conclusively establish the relationship between these two syndromes. PMID:22844180

What is different about medical students interested in non-clinical careers?

PubMed Central

2013-01-01

Background The proportion of medical school graduates who pursue careers other than full-time clinical practice has increased in some countries as the physician’s role has evolved and diversified with the changing landscape of clinical practice and the advancement of biomedicine. Still, past studies of medical students’ career choices have focused on clinical specialties and little is known about their choice of non-clinical careers. The present study examined backgrounds, motivation and perceptions of medical students who intended non-clinical careers. Methods A questionnaire was administered to students at six Korean medical schools distributed across all provinces in the nation. The questionnaire comprised 40 items on respondents’ backgrounds, their motivation for and interest in the study of medicine, their perceptions of medical professions, and their career intentions. Data was analyzed using various descriptive and inferential statistics. Results In total, 1,388 students returned the questionnaire (60% response rate), 12.3% of whom intended non-clinical careers (i.e., basic sciences, non-clinical medical fields, and non-medical fields). Those who planned non-clinical careers were comparable with their peers in their motivation for studying medicine and in their views of medical professions, but they were less interested in the study of medicine (P < 0.01). The two groups also differed significantly on their perceptions of what was uninteresting about the study of medicine (P < 0.01). The two groups were comparable in gender and entry-level ratios but their distributions across ages and years of study differed significantly (P < 0.01). A majority of respondents agreed with the statements that “it is necessary for medical school graduates to pursue non-clinical careers” and that “medical schools need to offer programs that provide information on such careers.” Still, our finding indicates that medical school curricula do not address such needs sufficiently. Conclusions Our study found some differences in backgrounds and perceptions of the study of medicine in medical students interested in non-clinical careers from their peers. Future studies are suggested to enhance our understanding of medical students” choice of non-clinical careers. PMID:23731551

Regional variation in health care utilization in Sweden - the importance of demand-side factors.

PubMed

Johansson, Naimi; Jakobsson, Niklas; Svensson, Mikael

2018-06-04

Differences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources. In this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors. The results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits. 50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.

What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies.

PubMed

Johansen, May-Lill; Risor, Mette Bech

2017-04-01

To gain a deeper understanding of challenges faced by GPs when managing patients with MUS. We used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS. The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem. For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education. Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Ebstein's anomaly in pregnancy: maternal and neonatal outcomes.

PubMed

Chopra, Seema; Suri, Vanita; Aggarwal, Neelam; Rohilla, Meenakshi; Vijayvergiya, Rajesh; Keepanasseril, Anish

2010-04-01

Ebstein's anomaly is a rare congenital cardiac abnormality, associated with cyanosis and arrhythmia. Patients often reach childbearing age and pregnant women pose a challenge to the treating physician. We describe the course and outcome of pregnancy in women with Ebstein's anomaly and discuss the related management issues. Analysis of pregnancies in four women with Ebstein's anomaly was carried out in a referral institute in northern India. Data of two women were analyzed retrospectively and the other two women were prospectively followed in their pregnancies during the study period. The course of the pregnancy, disease and perinatal outcome in each woman were analyzed. Four women had eight pregnancies all resulting in vaginal deliveries. There were two premature deliveries. The mean birth weight was 2.54 + or - 0.88 kg. Of the eight babies, six did not have any cardiac anomalies; one was an unexplained neonatal death and for another, no data was available. Pregnancy was well tolerated in two patients, while one had right heart failure during early pregnancy, and one had arrhythmia during labor, which was managed medically; one patient had arrhythmia in the postpartum period, which was managed medically. When a woman with Ebstein's anomaly reaches childbearing age, fertility is not affected, even in cyanotic women. Under close supervision by the woman's obstetrician and cardiologist, the pregnancy outcome is usually favorable.

Medical Students' Impressions and Satisfactions from Medical Professional Skill Education Lessons

ERIC Educational Resources Information Center

Ongel, Kurtulus; Mergen, Haluk; Kayacan, Hacer; Yildizhan, Alpaslan

2008-01-01

(Background) To help us understand the medical students' reflections about professional skill educations we conducted a study on medical students' conceptions of selected medical phenomena, cardiopulmonary resuscitation, CPR. (Methods) The study was conducted in January 2008, using a sample consisting of medical students from one of the…

Medical Student Attitudes about Mental Illness: Does Medical-School Education Reduce Stigma?

ERIC Educational Resources Information Center

Korszun, Ania; Dinos, Sokratis; Ahmed, Kamran; Bhui, Kamaldeep

2012-01-01

Background: Reducing stigma associated with mental illness is an important aim of medical education, yet evidence indicates that medical students' attitudes toward patients with mental health problems deteriorate as they progress through medical school. Objectives: Authors examined medical students' attitudes to mental illness, as compared with…

Genetic investigation of 100 heart genes in sudden unexplained death victims in a forensic setting

PubMed Central

Christiansen, Sofie Lindgren; Hertz, Christin Løth; Ferrero-Miliani, Laura; Dahl, Morten; Weeke, Peter Ejvin; LuCamp; Ottesen, Gyda Lolk; Frank-Hansen, Rune; Bundgaard, Henning; Morling, Niels

2016-01-01

In forensic medicine, one-third of the sudden deaths remain unexplained after medico-legal autopsy. A major proportion of these sudden unexplained deaths (SUD) are considered to be caused by inherited cardiac diseases. Sudden cardiac death (SCD) may be the first manifestation of these diseases. The purpose of this study was to explore the yield of next-generation sequencing of genes associated with SCD in a cohort of SUD victims. We investigated 100 genes associated with cardiac diseases in 61 young (1–50 years) SUD cases. DNA was captured with the Haloplex target enrichment system and sequenced using an Illumina MiSeq. The identified genetic variants were evaluated and classified as likely, unknown or unlikely to have a functional effect. The criteria for this classification were based on the literature, databases, conservation and prediction of the effect of the variant. We found that 21 (34%) individuals carried variants with a likely functional effect. Ten (40%) of these variants were located in genes associated with cardiomyopathies and 15 (60%) of the variants in genes associated with cardiac channelopathies. Nineteen individuals carried variants with unknown functional effect. Our findings indicate that broad genetic investigation of SUD victims increases the diagnostic outcome, and the investigation should comprise genes involved in both cardiomyopathies and cardiac channelopathies. PMID:27650965

Prediction of thrombophilia in patients with unexplained recurrent pregnancy loss using a statistical model.

PubMed

Wang, Tongfei; Kang, Xiaomin; He, Liying; Liu, Zhilan; Xu, Haijing; Zhao, Aimin

2017-09-01

To establish a statistical model to predict thrombophilia in patients with unexplained recurrent pregnancy loss (URPL). A retrospective case-control study was conducted at Ren Ji Hospital, Shanghai, China, from March 2014 to October 2016. The levels of D-dimer (DD), fibrinogen degradation products (FDP), activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen (Fg), and platelet aggregation in response to arachidonic acid (AA) and adenosine diphosphate (ADP) were collected. Receiver operating characteristic curve analysis was used to analyze data from 158 UPRL patients (≥3 previous first trimester pregnancy losses with unexplained etiology) and 131 non-RPL patients (no history of recurrent pregnancy loss). A logistic regression model (LRM) was built and the model was externally validated in another group of patients. The LRM included AA, DD, FDP, TT, APTT, and PT. The overall accuracy of the LRM was 80.9%, with sensitivity and specificity of 78.5% and 78.3%, respectively. The diagnostic threshold of the possibility of the LRM was 0.6492, with a sensitivity of 78.5% and a specificity of 78.3%. Subsequently, the LRM was validated with an overall accuracy of 83.6%. The LRM is a valuable model for prediction of thrombophilia in URPL patients. © 2017 International Federation of Gynecology and Obstetrics.

Celiac disease presenting as rickets in Saudi children.

PubMed

Assiri, Asaad; Saeed, Anjum; AlSarkhy, Ahmed; El Mouzan, Mohammed Issa; El Matary, Wael

2013-01-01

Rickets is commonly seen as a sign of malabsorption like celiac disease if it is not treated appropriately with vitamin D and calcium supplements. The aim of this study was to examine the frequency of diagnosis of celiac disease among children with unexplained rickets in Saudi children at a tertiary hospital setting. Retrospective review of records of patients referred over 10 years to a pediatric gastroenterology and hepatology unit. The study included all patients referred for evaluation of unexplained rickets and osteomalacia and screened for celiac disease. The diagnosis of rickets was made on the basis of history, physical examination, biochemical and radiological investigations. The diagnosis of celiac disease was made based on the ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) criteria. Twenty-six children with a mean (SD) age of 9.5 (4.6) years (5 males, range 1-15 years) were referred for evaluation of unexplained rickets and were screened for celiac disease. The diagnosis of celiac disease based on small bowel biopsy findings was confirmed in 10 (38.4%) patients with rickets. Serological markers for celiac disease including antiendomyseal antibodies and antitissue transglutaminase antibodies were positive in all ten children. Rickets is not an uncommon presentation of celiac disease in Saudi children and pediatricians should consider celiac disease as an underlying cause for rickets.

Phenotypic Analysis of Korean Patients with Abnormal Chromosomal Microarray in Patients with Unexplained Developmental Delay/Intellectual Disability.

PubMed

Kim, Hyo Jeong; Park, Chang Il; Lim, Jae Woo; Lee, Gyung Min; Cho, Eunhae; Kim, Hyon J

2018-05-01

The present study aimed to investigate chromosomal microarray (CMA) and clinical data in patients with unexplained developmental delay/intellectual disability (DD/ID) accompanying dysmorphism, congenital anomalies, or epilepsy. We also aimed to evaluate phenotypic clues in patients with pathogenic copy number variants (CNVs). We collected clinical and CMA data from patients at Konyang University Hospital between September 2013 and October 2014. We included patients who had taken the CMA test to evaluate the etiology of unexplained DD/ID. All of the 50 patients identified had DD/ID. Thirty-nine patients had dysmorphism, 19 patients suffered from epilepsy, and 12 patients had congenital anomalies. Twenty-nine of the 50 patients (58%) showed abnormal results. Eighteen (36%) were considered to have pathogenic CNVs. Dysmorphism (p=0.028) was significantly higher in patients with pathogenic CNVs than in those with normal CMA. Two or more clinical features were presented by 61.9% (13/21) of the patients with normal CMA and by 83.3% (15/18) of the patients with pathogenic CMA. Dysmorphism can be a phenotypic clue to pathogenic CNVs. Furthermore, pathogenic CNV might be more frequently found if patients have two or more clinical features in addition to DD/ID. © Copyright: Yonsei University College of Medicine 2018.

Genetic investigation of 100 heart genes in sudden unexplained death victims in a forensic setting.

PubMed

Christiansen, Sofie Lindgren; Hertz, Christin Løth; Ferrero-Miliani, Laura; Dahl, Morten; Weeke, Peter Ejvin; LuCamp; Ottesen, Gyda Lolk; Frank-Hansen, Rune; Bundgaard, Henning; Morling, Niels

2016-12-01

In forensic medicine, one-third of the sudden deaths remain unexplained after medico-legal autopsy. A major proportion of these sudden unexplained deaths (SUD) are considered to be caused by inherited cardiac diseases. Sudden cardiac death (SCD) may be the first manifestation of these diseases. The purpose of this study was to explore the yield of next-generation sequencing of genes associated with SCD in a cohort of SUD victims. We investigated 100 genes associated with cardiac diseases in 61 young (1-50 years) SUD cases. DNA was captured with the Haloplex target enrichment system and sequenced using an Illumina MiSeq. The identified genetic variants were evaluated and classified as likely, unknown or unlikely to have a functional effect. The criteria for this classification were based on the literature, databases, conservation and prediction of the effect of the variant. We found that 21 (34%) individuals carried variants with a likely functional effect. Ten (40%) of these variants were located in genes associated with cardiomyopathies and 15 (60%) of the variants in genes associated with cardiac channelopathies. Nineteen individuals carried variants with unknown functional effect. Our findings indicate that broad genetic investigation of SUD victims increases the diagnostic outcome, and the investigation should comprise genes involved in both cardiomyopathies and cardiac channelopathies.

The effect of luteal-phase support with vaginal progesterone on pregnancy rates in gonadotropin and clomiphene citrate/intra-uterine insemination cycles in unexplained infertility: A prospective randomised study.

PubMed

Karadag, Burak; Dilbaz, Berna; Karcaaltincaba, Deniz; Sahin, Elif Gulsah; Ercan, Fedi; Karasu, Yetkin; Tonyalı, Nazan Vanlı

2016-08-01

The purpose of this study is to analyse the effect of luteal-phase support on pregnancy rates in gonadotropin + intra-uterine insemination (Gn/IUI) and clomiphene citrate (CC) +IUI (CC/IUI) cycles in patients with unexplained infertility. Equal numbers of patients were recruited in two treatment arms (CC/IUI and Gn/IUI) (n = 100, n = 100, respectively). In each group, 50 patients received vaginal progesterone for 14 days (Crinone 8% vaginal gel, 90 mg per day) for luteal-phase support from the day after IUI and continued until menstruation or the 10th week of gestation if pregnant. There were 29 clinical pregnancies among 200 patients. Pregnancy rates were 12% in CC/IUI cycles, 10% in luteal-phase-supported CC/IUI cycles 16% in Gn/IUI cycles and 20% in luteal-phase-supported Gn/IUI cycles. Although pregnancy rates were higher in Gn/IUI cycles compared to CC/IUI cycles, luteal-phase support did not significantly affect the pregnancy rates in both groups. This study implies that luteal-phase support with progesterone has no pronounced beneficial effect on pregnancy rates in either CC/IUI or Gn/IUI cycles in patients with unexplained infertility.

Basic psychological need experiences, fatigue, and sleep in individuals with unexplained chronic fatigue.

PubMed

Campbell, Rachel; Tobback, Els; Delesie, Liesbeth; Vogelaers, Dirk; Mariman, An; Vansteenkiste, Maarten

2017-12-01

Grounded in self-determination theory, this study tested the hypothesis that the satisfaction and frustration of the psychological needs for autonomy, competence, and relatedness would relate to fatigue and subjective and objective sleep parameters, with stress and negative sleep cognitions playing an explanatory role in these associations. During a stay at a sleep laboratory in Belgium, individuals with unexplained chronic fatigue (N = 160; 78% female) underwent polysomnography and completed a questionnaire at 3 different points in time (i.e., after arrival in the sleep lab, before bedtime, and the following morning) that assessed their need-based experiences and stress during the previous week, fatigue during the preceding day, and sleep-related cognitions and sleep during the previous night. Results indicated that need frustration related to higher stress, which in turn, related to higher evening fatigue. Need frustration also related to poorer subjective sleep quality and shorter sleep duration, as indicated by both subjective and objective shorter total sleep time and subjective (but not objective) longer sleep latency. These associations were accounted for by stress and negative sleep cognitions. These findings suggest that health care professionals working with individuals with unexplained chronic fatigue may consider focusing on basic psychological needs within their therapeutic approach. Copyright © 2017 John Wiley & Sons, Ltd.

Unorthodox alternative therapies marketed to treat Lyme disease.

PubMed

Lantos, Paul M; Shapiro, Eugene D; Auwaerter, Paul G; Baker, Phillip J; Halperin, John J; McSweegan, Edward; Wormser, Gary P

2015-06-15

Some patients with medically unexplained symptoms or alternative medical diagnoses suspect that they chronically suffer from the tick-borne infection Lyme disease. These patients are commonly targeted by providers of alternative therapies. This study was designed to identify and characterize the range of unorthodox alternative therapies advertised to patients with a diagnosis of Lyme disease. Internet searches using the Google search engine were performed to identify the websites of clinics and services that marketed nonantimicrobial therapies for Lyme disease. We subsequently used the PubMed search engine to identify any scientific studies evaluating such treatments for Lyme disease. Websites were included in our review so long as they advertised a commercial, nonantimicrobial product or service that specifically mentioned utility for Lyme disease. Websites with patient testimonials (such as discussion groups) were excluded unless the testimonial appeared as marketing on a commercial site. More than 30 alternative treatments were identified, which fell into several broad categories: these included oxygen and reactive oxygen therapy; energy and radiation-based therapies; nutritional therapy; chelation and heavy metal therapy; and biological and pharmacological therapies ranging from certain medications without recognized therapeutic effects on Borrelia burgdorgeri to stem cell transplantation. Review of the medical literature did not substantiate efficacy or, in most cases, any rationale for the advertised treatments. Providers of alternative therapies commonly target patients who believe they have Lyme disease. The efficacy of these unconventional treatments for Lyme disease is not supported by scientific evidence, and in many cases they are potentially harmful. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

[Pathway to diagnosis and real-life experience of patients believing they are affected by "chronic Lyme disease"].

PubMed

Forestier, E; Gonnet, F; Revil-Signorat, A; Zipper, A C

2018-04-26

Chronic Lyme disease is a subject of scientific and social controversy in both Europe and the United States. The aim of our study was to analyze the pathway to diagnosis of patients believing they were affected by the disease, and to describe their real-life experience. A qualitative study was performed with 13 patients declaring themselves to be affected by chronic Lyme disease. Interviews were analyzed by 2 general medical practice interns, supervised by a general practitioner with a diploma in socio-anthropology and an infectious diseases specialist. Internet and other media played a major role in informing the patients or their doctor about the existence and the characteristics of chronic Lyme disease. The diagnosis was confirmed by features considered objective (chronic infection by Borrelia, tick bite, positive serology, beneficial or worsening effects of antibiotics). The long medical diagnosis and treatment process of those interviewed was marked by a conflicted relationship with the medical profession, caused by a feeling of non-recognition and abandonment. They reported their experience as being very painful, both because of the physical pain and also the psychological consequences of their condition. Improving the diagnosis and therapeutic management of patients believing themselves to be affected by chronic Lyme disease appears highly necessary both to limit their search for diagnosis and their experience of pain. It could be based on existing guidelines concerning medically unexplained symptoms to which the chronic Lyme disease issue appears quite similar on several points. Copyright © 2018 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.

Emotional consequences of nuclear power plant disasters.

PubMed

Bromet, Evelyn J

2014-02-01

The emotional consequences of nuclear power plant disasters include depression, anxiety, post-traumatic stress disorder, and medically unexplained somatic symptoms. These effects are often long term and associated with fears about developing cancer. Research on disasters involving radiation, particularly evidence from Chernobyl, indicates that mothers of young children and cleanup workers are the highest risk groups. The emotional consequences occur independently of the actual exposure received. In contrast, studies of children raised in the shadows of the Three Mile Island (TMI) and Chernobyl accidents suggest that although their self-rated health is less satisfactory than that of their peers, their emotional, academic, and psychosocial development is comparable. The importance of the psychological impact is underscored by its chronicity and by several studies showing that poor mental health is associated with physical health conditions, early mortality, disability, and overuse of medical services. Given the established increase in mental health problems following TMI and Chernobyl, it is likely that the same pattern will occur in residents and evacuees affected by the Fukushima meltdowns. Preliminary data from Fukushima indeed suggest that workers and mothers of young children are at risk of depression, anxiety, psychosomatic, and post-traumatic symptoms both as a direct result of their fears about radiation exposure and an indirect result of societal stigma. Thus, it is important that non-mental health providers learn to recognize and manage psychological symptoms and that medical programs be designed to reduce stigma and alleviate psychological suffering by integrating psychiatric and medical treatment within the walls of their clinics.Introduction of Emotional Consequences of Nuclear Power Plant Disasters (Video 2:15, http://links.lww.com/HP/A34).

“Not a university type”: focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school

PubMed Central

Greenhalgh, Trisha; Seyan, Kieran; Boynton, Petra

2004-01-01

Objective To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school. Design Focus group study. Setting Six London secondary schools. Participants 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds. Main outcome measures Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support. Results There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards “posh” students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfilment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices. Conclusions Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded. PMID:15217871

Yield and Pitfalls of Ajmaline Testing in the Evaluation of Unexplained Cardiac Arrest and Sudden Unexplained Death: Single-Center Experience With 482 Families.

PubMed

Tadros, Rafik; Nannenberg, Eline A; Lieve, Krystien V; Škorić-Milosavljević, Doris; Lahrouchi, Najim; Lekanne Deprez, Ronald H; Vendrik, Jeroen; Reckman, Yolan J; Postema, Pieter G; Amin, Ahmad S; Bezzina, Connie R; Wilde, Arthur A M; Tan, Hanno L

2017-12-11

This study evaluated the yield of ajmaline testing and assessed the occurrence of confounding responses in a large cohort of families with unexplained cardiac arrest (UCA) or sudden unexplained death (SUD). Ajmaline testing to diagnose Brugada syndrome (BrS) is routinely used in the evaluation of SUD and UCA, but its yield, limitations, and appropriate dosing have not been studied in a large cohort. We assessed ajmaline test response and genetic testing results in 637 individuals from 482 families who underwent ajmaline testing for SUD or UCA. Overall, 89 individuals (14%) from 88 families (18%) had a positive ajmaline test result. SCN5A mutations were identified in 9 of 86 ajmaline-positive cases (10%). SCN5A mutation carriers had positive test results at significantly lower ajmaline doses than noncarriers (0.75 [range: 0.64 to 0.98] mg/kg vs. 1.03 [range: 0.95 to 1.14] mg/kg, respectively; p < 0.01). In 7 of 88 families (8%), it was concluded that the positive ajmaline response was a confounder, either in the presence of an alternative genetic diagnosis accounting for UCA/SUD (5 cases) or noncosegregation of positive ajmaline response and arrhythmia (2 cases). The rate of confounding responses was significantly higher in positive ajmaline responses obtained at >1 mg/kg than in those obtained at ≤1 mg/kg (7 of 48 vs. 0 of 41 individuals; Fisher's exact test: p = 0.014). In line with previous, smaller studies, a positive ajmaline response was observed in a large proportion of UCA/SUD families. Importantly, our data emphasize the potential for confounding possibly false-positive ajmaline responses in this population, particularly at high doses, which could possibly lead to a misdiagnosis. Clinicians should consider all alternative causes in UCA/SUD and avoid ajmaline doses >1 mg/kg. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Expression of retinoid-related orphan receptor (ROR)γt on NK22 cells in the peripheral blood and uterine endometrium of women with unexplained recurrent pregnancy loss and unexplained infertility.

PubMed

Fuchinoue, Kohei; Fukui, Atsushi; Chiba, Hitomi; Kamoi, Mai; Funamizu, Ayano; Taima, Ayako; Fukuhara, Rie; Mizunuma, Hideki

2016-11-01

Recently, NK22 cells, a subset of interleukin (IL)-22-producing natural killer (NK) cells, were identified. We have previously reported the higher percentage of NK22 cells in women suffering recurrent pregnancy loss (RPL). Moreover, we have also reported lower expression of NKp46, a kind of natural cytotoxicity receptor (NCR), on NK cells and the changes of NK cell producing cytokines in women who experience RPL. NK22 cells express NCRs, such as NKp44 or NKp46. Retinoid-related orphan receptor γt (RORγt) is known as a regulator of NK22 cells; however, in NK22 cells of peripheral blood (PB) and the uterine endometrium (UE), the relationship between NCRs and RORγt is unclear. We investigate RORγt expression NK22 cells in the PB and UE of women with unexplained infertility (uI) or unexplained RPL (uRPL). Lymphocytes were extracted from PB and UE, derived from women with uI or uRPL. Expression of RORγt and NCRs in NK cells and NK cell-produced cytokines were analyzed by flow cytometry. CD56 + /NKp46 + /RORγt + cells were positively correlated with CD56 + /IL-22 + cells in both PB and UE. CD56 bright /NKp46 bright /RORγt + cells were significantly higher in uRPL than in uI, and endometrial CD56 bright /NKp46 bright /RORγt + cells were positively correlated with PB. In UE, CD56 bright /RORγt + cells were negatively correlated with CD56 bright /interferon-γ + and CD56 bright /tumor necrosis factor-α + cells of uRPL. RORγt may be associated with NK22 cells in reproduction. Particularly, higher expression of RORγt may be associated with elevated NK22 cells in uRPL. © 2016 Japan Society of Obstetrics and Gynecology.

Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility.

PubMed

Diamond, Michael P; Legro, Richard S; Coutifaris, Christos; Alvero, Ruben; Robinson, Randal D; Casson, Peter; Christman, Gregory M; Ager, Joel; Huang, Hao; Hansen, Karl R; Baker, Valerie; Usadi, Rebecca; Seungdamrong, Aimee; Bates, G Wright; Rosen, R Mitchell; Haisenleder, Daniel; Krawetz, Stephen A; Barnhart, Kurt; Trussell, J C; Ohl, Dana; Jin, Yufeng; Santoro, Nanette; Eisenberg, Esther; Zhang, Heping

2015-09-24

The standard therapy for women with unexplained infertility is gonadotropin or clomiphene citrate. Ovarian stimulation with letrozole has been proposed to reduce multiple gestations while maintaining live birth rates. We enrolled couples with unexplained infertility in a multicenter, randomized trial. Ovulatory women 18 to 40 years of age with at least one patent fallopian tube were randomly assigned to ovarian stimulation (up to four cycles) with gonadotropin (301 women), clomiphene (300), or letrozole (299). The primary outcome was the rate of multiple gestations among women with clinical pregnancies. After treatment with gonadotropin, clomiphene, or letrozole, clinical pregnancies occurred in 35.5%, 28.3%, and 22.4% of cycles, and live birth in 32.2%, 23.3%, and 18.7%, respectively; pregnancy rates with letrozole were significantly lower than the rates with standard therapy (gonadotropin or clomiphene) (P=0.003) or gonadotropin alone (P<0.001) but not with clomiphene alone (P=0.10). Among ongoing pregnancies with fetal heart activity, the multiple gestation rate with letrozole (9 of 67 pregnancies, 13%) did not differ significantly from the rate with gonadotropin or clomiphene (42 of 192, 22%; P=0.15) or clomiphene alone (8 of 85, 9%; P=0.44) but was lower than the rate with gonadotropin alone (34 of 107, 32%; P=0.006). All multiple gestations in the clomiphene and letrozole groups were twins, whereas gonadotropin treatment resulted in 24 twin and 10 triplet gestations. There were no significant differences among groups in the frequencies of congenital anomalies or major fetal and neonatal complications. In women with unexplained infertility, ovarian stimulation with letrozole resulted in a significantly lower frequency of multiple gestation but also a lower frequency of live birth, as compared with gonadotropin but not as compared with clomiphene. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01044862.).

Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease.

PubMed

Kahrilas, Peter J; Hughes, Nesta; Howden, Colin W

2011-11-01

Unexplained chest pain is potentially attributable to gastro-oesophageal reflux disease (GORD) or oesophageal motility disorders. Reflux chest pain may occur without heartburn. We explored the response of unexplained chest pain to proton pump inhibitor (PPI) therapy in randomised clinical trials (RCTs), differentiating patients with and without objective evidence of GORD. PubMed and Embase were systematically searched for RCTs that reported chest pain response to PPIs in patients who had had pH-monitoring and/or endoscopy to differentiate GORD-positive from GORD-negative subpopulations. Heterogeneity among studies was assessed using the Cochran Q and I(2) statistics, and a fixed effect model was applied. Possible publication bias was assessed by Egger's test. Six RCTs met the inclusion criteria. All used 24 h pH monitoring and/or endoscopy to define GORD-positive patients and improvement in chest pain to define response (five used ≥50%; one used ≥ 20%). The therapeutic gain of >50% improvement with PPIs relative to placebo was 56-85% in GORD-positive and 0-17% in GORD-negative patients. The RR of >50% improvement in chest pain with PPI versus placebo was 4.3 (95% CI 2.8 to 6.7; p<0.0001) for GORD-positive and 0.4 (95% CI 0.3 to 0.7; p=0.0004) for GORD-negative patients. Concomitant heartburn varied among trials from being an exclusion criterion to being essentially concordant with GORD-positive status. Unexplained chest pain in patients with endoscopic or pH-monitoring evidence of GORD tends to improve, but not resolve, with PPI therapy, whereas GORD-negative patients have little or no response. Heartburn was a poor predictor of whether patients with chest pain were GORD-positive or GORD-negative by objective testing.

Premature coronary heart disease and autosomal dominant hypercholesterolemia: Increased risk in women with LDLR mutations.

PubMed

Ahmad, Zahid; Li, Xilong; Wosik, Jedrek; Mani, Preethi; Petr, Joye; McLeod, George; Murad, Shatha; Song, Li; Adams-Huet, Beverley; Garg, Abhimanyu

2016-01-01

For patients with autosomal dominant hypercholesterolemia (ADH), it remains unclear whether differences exist in the risk of premature coronary heart disease (CHD) between patients with confirmed mutations in low-density lipoprotein receptor (LDLR) vs those without detectable mutations. This study sought to assess the risk of premature CHD in ADH patients with mutations in LDLR (referred to as familial hypercholesterolemia [FH]) vs those without detectable mutations (unexplained ADH), stratified by sex. Comparative study of premature CHD in a multiethnic cohort of 111 men and 165 women meeting adult Simon-Broome criteria for ADH. Women with FH (n = 51) had an increased risk of premature CHD compared with unexplained ADH women (n = 111; hazard ratio [HR], 2.74; 95% confidence interval, 1.40-5.34; P = .003) even after adjustment for lipid levels and traditional CHD risk factors (HR, 2.53 [1.10-5.83]; P = .005). Men with FH (n = 42), in contrast, had a similar risk of premature CHD when compared with unexplained ADH men (n = 66; unadjusted: HR, 1.48 [0.84-2.63]; P = .18; adjusted: HR, 1.04 [0.46-2.37]; P = .72). To address whether mutation status provides additional information beyond LDL-cholesterol level, we analyzed premature CHD risk for FH vs unexplained ADH at various percentiles of LDL-cholesterol: the risk ratios were significant for women at 25th percentile (HR, 4.90 [1.69-14.19]) and 50th percentile (HR, 3.44 [1.42-8.32]) but not at 75th percentile (HR, 1.99 [0.95-4.17]), and were not significant for men at any percentile. Our findings suggest that genetic confirmation of ADH may be important to identify patient's risk of CHD, especially for female LDLR mutation carriers. Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain.

PubMed

Talley, Nicholas J; Holtmann, Gerald; Nguyen, Quoc Nam; Gibson, Peter; Bampton, Peter; Veysey, Martin; Wong, James; Philcox, Stephen; Koloski, Natasha; Bunby, Lisa; Jones, Michael

2017-11-01

A previous UK study showed that 6.1% of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had evidence of severe pancreatic exocrine insufficiency (PEI), but these findings need replication. We aimed to identify the prevalence of PEI based on fecal elastase stool testing in consecutive outpatients presenting with chronic unexplained abdominal pain and/or diarrhea and/or IBS-D. Patients aged over 40 years presenting to hospital outpatient clinics from six sites within Australia with unexplained abdominal pain and/or diarrhea for at least 3 months and/or IBS-D were studied. Patients completed validated questionnaires and donated a stool sample in which elastase concentration was measured by ELISA. A concentration of < 100 mcg/g stool represented severe and < 200 mcg/g mild to moderate PEI. Patients whose fecal elastase was < 200 mcg/g underwent testing for pancreatic pathology with an endoscopic ultrasound or abdominal CT. Two hundred eighteen patients (mean age of 60 years, 29.4% male) were studied. PEI was found in 4.6% (95% CI 2.2-8.3%) (n = 10), with five patients (2.3% (95% CI 0.8-5.3%) having severe PEI. Only male sex and heavy alcohol use were significantly associated with abnormal versus normal pancreatic functioning. Of seven patients who underwent endoscopic ultrasound or CT, two had features indicative of chronic pancreatitis. One in 50 patients with IBS-D or otherwise unexplained abdominal pain or diarrhea have an abnormal fecal elastase, but unexpected pancreatic insufficiency was detected in only a minority of these. This study failed to confirm the high prevalence of PEI among patients with unexplained GI symptoms previously reported. © 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Financial background and student debt impact on postgraduate residency choices of medical students in Singapore.

PubMed

Fong, Jie Ming Nigel; Tan, Yeong Tze Wilnard; Sayampanathan, Andrew Arjun; Mohan, Niraj; Koh, Yun Qing; Jang, Jin Hao Justin; Low, Jin Rong Ivan; Vasudevan, Anupama; Ng, Chew Lip; Tambyah, Paul Ananth

2018-06-07

Medical school fees are rising globally. Student debt and financial background may affect residency choices, but few studies have been conducted in Asia. This study aimed to explore the relationship between financial background, student debt and postgraduate residency choices among medical students in Singapore. An anonymised survey of all medical students in Singapore was conducted, with a response rate of 67.9%. 40.5% of our study population were graduates with debt. Medical students with monthly per capita household income < SGD 1,000 were more likely to graduate with debt (unadjusted odds ratio [OR] [95% confidence interval {CI}] 2.0 [1.6-2.7]; p < 0.001) and feel burdened by the cost of medical education (unadjusted OR [95% CI] 2.8 [2.0-3.9]; p < 0.001). Students with per capita monthly household income < SGD 1,000 (unadjusted OR [95% CI] 1.818 [1.338-2.470], p < 0.001; adjusted OR [95% CI] 1.692 [1.202-2.381], p = 0.003) and those with debt (unadjusted OR [95% CI] 1.623 [1.261-2.090], p < 0.001; adjusted OR [95% CI] 1.393 [1.048-1.851], p = 0.022) were more likely to rank at least one economic factor as 'very significant' in influencing their postgraduate training choices. It is concerning that despite financial aid schemes, the cost of medical education remained a burden to students from lower income households in Singapore. Student debt and financial background may distort postgraduate career choices, creating an undue push toward high-paying specialties.

Predicting Rural Practice Using Different Definitions to Classify Medical School Applicants as Having a Rural Upbringing

ERIC Educational Resources Information Center

Owen, John A.; Conaway, Mark R.; Bailey, Beth A.; Hayden, Gregory F.

2007-01-01

Purpose: This study determines the relationship between a medical school applicant's rural background and the likelihood of rural practice using different definitions of rural background. Methods: Cohort study of 599 physicians who entered the University of Virginia School of Medicine in 1990-1995 and graduated in 1994-1999. The…

IVF or IUI as first-line treatment in unexplained subfertility: the conundrum of treatment selection markers.

PubMed

Tjon-Kon-Fat, R I; Tajik, P; Zafarmand, M H; Bensdorp, A J; Bossuyt, P M M; Oosterhuis, G J E; van Golde, R; Repping, S; Lambers, M D A; Slappendel, E; Perquin, D; Pelinck, M J; Gianotten, J; Maas, J W M; Eijkemans, M J C; van der Veen, F; Mol, B W; van Wely, M

2017-05-01

Are there treatment selection markers that could aid in identifying couples, with unexplained or mild male subfertility, who would have better chances of a healthy child with IVF with single embryo transfer (IVF-SET) than with IUI with ovarian stimulation (IUI-OS)? We did not find any treatment selection markers that were associated with better chances of a healthy child with IVF-SET instead of IUI-OS in couples with unexplained or mild male subfertility. A recent trial, comparing IVF-SET to IUI-OS, found no evidence of a difference between live birth rates and multiple pregnancy rates. It was suggested that IUI-OS should remain the first-line treatment instead of IVF-SET in couples with unexplained or mild male subfertility and female age between 18 and 38 years. The question remains whether there are some couples that may have higher pregnancy chances if treated with IVF-SET instead of IUI. We performed our analyses on data from the INeS trial, where couples with unexplained or mild male subfertility and an unfavourable prognosis for natural conception were randomly allocated to IVF-SET, IVF in a modified natural cycle or IUI-OS. In view of the aim of this study, we only used data of the comparison between IVF-SET (201 couples) and IUI-OS (207 couples). We pre-defined the following baseline characteristics as potential treatment selection markers: female age, ethnicity, smoking status, type of subfertility (primary/secondary), duration of subfertility, BMI, pre-wash total motile count and Hunault prediction score. For each potential treatment selection marker, we explored the association with the chances of a healthy child after IVF-SET and IUI-OS and tested if there was an interaction with treatment. Given the exploratory nature of our analysis, we used a P-value of 0.1. None of the markers were associated with higher chances of a healthy child from IVF-SET compared to IUI-OS (P-value for interaction >0.10). Since this is the first large study that looked at potential treatment selection markers for IVF-SET compared to IUI-OS, we had no data on which to base a power calculation. The sample size was limited, making it difficult to detect any smaller associations. We could not identify couples with unexplained or mild male subfertility who would have had higher chances of a healthy child from immediate IVF-SET than from IUI-OS. As in the original trial IUI-OS had similar effectiveness and was less costly compared to IVF-SET, IUI-OS should remain the preferred first-line treatment in these couples. The study was supported by a grant from the Netherlands Organization for Health Research and Development, and a grant from the Netherlands' association of health care insurers. There are no conflicts of interest. The trial was registered at the Dutch trial registry (NTR939). © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

General Medical Surveillance Program

NASA Technical Reports Server (NTRS)

1993-01-01

Background on the General Medical Surveillance Program at LeRC is presented. The purpose of the General Medical Surveillance Program at LeRC is outlined, and the specifics of the program are discussed.

D-xylose absorption

MedlinePlus

Xylose tolerance test; Diarrhea - xylose; Malnutrition - xylose; Sprue - xylose; Celiac - xylose ... test if you have: Persistent diarrhea Signs of malnutrition Unexplained weight loss This test is primarily used ...

Profile of graduates of Israeli medical schools in 1981--2000: educational background, demography and evaluation of medical education programs.

PubMed

Bitterman, Noemi; Shalev, Ilana

2005-05-01

In light of changes in the medical profession, the different requirements placed on physicians and the evolving needs of the healthcare system, the need arose to examine the medical education curriculum in Israel. This survey, conducted by the Samuel Neaman Institute for Science and Technology, summarizes 20 years of medical education in Israel's four medical schools, as the first stage in mapping the existing state of medical education in Israel and providing a basis for decision-making on future medical education programs. To characterize the academic background of graduates, evaluate their attitudes towards current and alternative medical education programs, and examine subgroups among graduates according to gender, medical school, high school education, etc. The survey included graduates from all four Israeli medical schools who graduated between the years 1981 and 2000 in a sample of 1:3. A questionnaire and stamped return envelope were sent to every third graduate; the questionnaire included open and quantitative questions graded on a scale of 1 to 5. The data were processed for the entire graduate population and further analyzed according to subgroups such as medical schools, gender, high school education, etc. The response rate was 41.3%. The survey provided a demographic profile of graduates over a 20 year period, their previous educational and academic background, additional academic degrees achieved, satisfaction, and suggestions for future medical education programs. The profile of the medical graduates in Israel is mostly homogenous in terms of demographics, with small differences among the four medical schools. In line with recommendations of the graduates, and as an expression of the changing requirements in the healthcare system and the medical profession, the medical schools should consider alternative medical education programs such as a bachelor's degree in life sciences followed by MD studies, or education programs that combine medicine with disciplines such as law, engineering, computer science, among others.

Does sudden unexplained nocturnal death syndrome remain the autopsy negative disorder: a gross, microscopic, and molecular autopsy investigation in Southern China

PubMed Central

Zhang, Liyong; Tester, David J.; Lang, Di; Chen, Yili; Zheng, Jinxiang; Gao, Rui; Corliss, Robert F.; Tang, Shuangbo; Kyle, John W.; Liu, Chao; Ackerman, Michael J.; Makielski, Jonathan C.; Cheng, Jianding

2016-01-01

Objective To look for previously unrecognized cardiac structural abnormalities and address the genetic cause for sudden unexplained nocturnal death syndrome (SUNDS). Methods and Results 148 SUNDS victims and 444 controls (matched 1:3 on gender, race, and age of death within 1 year) were collected from Sun Yat-sen University from January 1, 1998 to December 31, 2014 to search morphological changes. Additional 17 Brugada syndrome (BrS) patients collected from January 1, 2006 to December 31, 2014 served as a comparative disease cohort. The Target Captured Next Generation sequencing for 80 genes associated with arrhythmia/cardiomyopathy were performed in 44 SUNDS victims and 17 BrS patients to characterize the molecular spectrum. SUNDS had slight but statistically significantly increased heart weight and valve circumference compared to controls. 12/44 SUNDS victims (SCN5A, SCN1B, CACNB2, CACNA1C, AKAP9, KCNQ1, KCNH2, KCNJ5, GATA4, NUP155, ABCC9) and 6/17 BrS patients (SCN5A, CACNA1C, P>.05) carried rare variants in primary arrhythmia-susceptibility genes. Only 2/44 SUNDS cases compared to 5/17 BrS patients hosted a rare variant in the most common BrS causing gene, SCN5A (P=.01). Using the strict American College of Medical Genetics guideline-based definition, only 2/44 (KCNQ1) SUNDS and 3/17 (SCN5A) BrS patients hosted a “(likely) pathogenic” variant. The 14/44 SUNDS cases with cardiomyopathy-related variants had a subtle but significantly decreased circumference of cardiac valves, and tended to die on average 5–6 years younger compared to the remaining 30 cases (P=.02). Conclusions We present the first comprehensive autopsy evidence that SUNDS victims may have concealed cardiac morphological changes. SUNDS and BrS may result from different molecular pathological underpinnings. The distinct association between cardiomyopathy-related rare variants and SUNDS warrants further investigation. PMID:27707468

Cardiac Channel Molecular Autopsy: Insights From 173 Consecutive Cases of Autopsy-Negative Sudden Unexplained Death Referred for Postmortem Genetic Testing

PubMed Central

Tester, David J.; Medeiros-Domingo, Argelia; Will, Melissa L.; Haglund, Carla M.; Ackerman, Michael J.

2012-01-01

Objective To perform long QT syndrome and catecholaminergic polymorphic ventricular tachycardia cardiac channel postmortem genetic testing (molecular autopsy) for a large cohort of cases of autopsy-negative sudden unexplained death (SUD). Methods From September 1, 1998, through October 31, 2010, 173 cases of SUD (106 males; mean ± SD age, 18.4±12.9 years; age range, 1-69 years; 89% white) were referred by medical examiners or coroners for a cardiac channel molecular autopsy. Using polymerase chain reaction, denaturing high-performance liquid chromatography, and DNA sequencing, a comprehensive mutational analysis of the long QT syndrome susceptibility genes (KCNQ1, KCNH2, SCN5A, KCNE1, and KCNE2) and a targeted analysis of the catecholaminergic polymorphic ventricular tachycardia type 1–associated gene (RYR2) were conducted. Results Overall, 45 putative pathogenic mutations absent in 400 to 700 controls were identified in 45 autopsy-negative SUD cases (26.0%). Females had a higher yield (26/67 [38.8%]) than males (19/106 [17.9%]; P<.005). Among SUD cases with exercise-induced death, the yield trended higher among the 1- to 10-year-olds (8/12 [66.7%]) compared with the 11- to 20-year-olds (4/27 [14.8%]; P=.002). In contrast, for those who died during a period of sleep, the 11- to 20-year-olds had a higher yield (9/25 [36.0%]) than the 1- to 10-year-olds (1/24 [4.2%]; P=.01). Conclusion Cardiac channel molecular autopsy should be considered in the evaluation of autopsy-negative SUD. Several interesting genotype-phenotype observations may provide insight into the expected yields of postmortem genetic testing for SUD and assist in selecting cases with the greatest potential for mutation discovery and directing genetic testing efforts. PMID:22677073

Incidence and Etiology of Sudden Cardiac Death: New Updates for Athletic Departments.

PubMed

Asif, Irfan M; Harmon, Kimberly G

Sudden cardiac death (SCD) in a young athlete is a tragic event and is the leading medical cause of death in this population. The precise incidence of SCD in young athletes has been subject of debate, with studies reporting drastically different rates (1:917,000 athlete-years (AYs) to 1:3000 AYs) depending on the methodological design of the investigation or the targeted population. A literature search was performed in PubMed using the terms: incidence, sudden cardiac death, sudden death, sudden cardiac arrest, etiology, pathology, registry, athlete, young, children, and adolescents. Articles were reviewed for relevance and included if they contained information on the incidence of SCD in athletes or young persons up to the age of 35 years. Clinical review. Level 5. Studies of high quality and rigor consistently yield an incidence of 1:50,000 AYs in college athletes and between 1:50,000 and 1:80,000 AYs for high school athletes, with certain subgroups that appear to be at particularly high risk, including the following: men, basketball players, and African Americans. Initial reports suggest that the most common cause of SCD is hypertrophic cardiomyopathy (HCM). However, more comprehensive investigations in the United States and international populations-athletes, nonathletes, and military-support that the most common finding on autopsy in young individuals with SCD is actually a structurally normal heart (autopsy-negative sudden unexplained death). SCD is the leading cause of death in athletes during exercise and usually results from intrinsic cardiac conditions that are triggered by the physiologic demands of vigorous exercise. Current rates of SCD appear to be at least 4 to 5 times higher than previously estimated, with men, African Americans, and male basketball players being at greatest risk. Emerging data suggest that the leading finding associated with SCD in athletes is actually a structurally normal heart (autopsy-negative sudden unexplained death).

A guideline to medical photography: a perspective on digital photography in an orthopaedic setting.

PubMed

de Meijer, P P G; Karlsson, J; LaPrade, R F; Verhaar, J A N; Wijdicks, C A

2012-12-01

Quality photographs are essential for clinical documentation, research, and publication in scientific journals and teaching. Oftentimes, non-ideal lighting and a sterile environment restrict the medical photographer, resulting in lower-quality photographs. This article aims to provide a clear and comprehensible guideline for medical photography in an orthopaedic setting. This article is based on extensive photographic involvement in operating and laboratory settings, in close collaboration with medical professionals from the Steadman Clinic (Vail, Colorado, USA), Gothenburg University (Göteborg, Sweden) and Erasmus MC (Rotterdam, the Netherlands). Background literature was searched through Google Scholar and PubMed. Three relevant journal articles, and one book on medical photography, were used to write this paper. Seventeen Internet articles were used for background information. A relevant, up-to-date and comprehensive guideline to medical photography for medical professionals, with or without photographic experience, is provided. Expert opinion, Level V.

Unusual Presentation of Unilateral Isolated Probable Lyme Optic Neuritis.

PubMed

Burakgazi, Ahmet Z; Henderson, Carl S

2016-01-01

Optic neuritis (ON) is one of the most common manifestations of central nervous system involvement caused by various etiologies. Lyme ON is an exceedingly rare ocular manifestation of Lyme disease (LD) and only a few cases have been published in the literature. Lyme ON is very rare but should be included in the differential diagnosis in unexplained cases, particularly in Lyme endemic areas. Careful and detailed examination and investigation are warranted to make the diagnosis. We report this case to increase awareness of clinicians to include Lyme disease in differential diagnosis of ON for unexplained cases of ON. Herein we present a unique case with a unilateral ON caused by LD along with pre- and posttreatment findings and literature review.

The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women.

PubMed

Lo Sasso, Anthony T; Richards, Michael R; Chou, Chiu-Fang; Gerber, Susan E

2011-02-01

Prior research has suggested that gender differences in physicians' salaries can be accounted for by the tendency of women to enter primary care fields and work fewer hours. However, in examining starting salaries by gender of physicians leaving residency programs in New York State during 1999-2008, we found a significant gender gap that cannot be explained by specialty choice, practice setting, work hours, or other characteristics. The unexplained trend toward diverging salaries appears to be a recent development that is growing over time. In 2008, male physicians newly trained in New York State made on average $16,819 more than newly trained female physicians, compared to a $3,600 difference in 1999.

Hyperactivity, unexplained speech delay, and coarse facies--is it Sanfilippo syndrome?

PubMed

Saini, Arushi Gahlot; Singhi, Pratibha; Sahu, Jitendra Kumar; Ganesan, Saptharishi L; Vyas, Sameer; Rao, Sandeep; Sachdeva, Man Updesh Singh

2014-08-01

Mucopolysaccharidosis-IIIB or Sanfilippo-B syndrome is caused by deficiency of lysosomal α-N-acetylglucosaminidase that leads to accumulation of heparan-sulphate and degeneration of central nervous system with progressive dementia, hyperactivity, and aggressive behavior. Mucopolysaccharidosis-III remains underdiagnosed as a cause of developmental delay and hyperactivity both in adults and children because in contrast to other mucopolysaccharidoses, they have little somatic disease, coarse facial features, hepatosplenomegaly or skeletal changes, and a high incidence of false-negative results on the urinary screening tests. We describe here a girl with the classic phenotype of mucopolysaccharidosis-IIIB to alert pediatricians to the possibility of this disorder in children with unexplained speech delay and hyperactivity and prevent unnecessary investigations. © The Author(s) 2013.

Unexplained sudden death, focussing on genetics and family phenotyping.

PubMed

Raju, Hariharan; Behr, Elijah R

2013-01-01

Unexplained sudden death and the sudden arrhythmic death syndrome (SADS) affect a small but significant proportion of young and apparently healthy individuals. This review revisits the causes underlying such deaths and the investigational strategies that identify surviving family who may be at risk. Recent epidemiological data is available from case series or government records. The yield from familial cardiological evaluation for inherited conditions has been supported by additional small series. The greatest advance has come with molecular autopsy studies, which have utilized various methodologies and candidate genes to investigate SADS cases and their families. The latest research replicates and extends the existing knowledge regarding epidemiology and familial evaluation of SADS, whilst genetic studies support a role for the molecular autopsy.

Left dominant arrhythmogenic cardiomyopathy: a morbid association of ventricular arrhythmias and unexplained infero-lateral T-wave inversion.

PubMed

Protonotarios, Alexandros; Patrianakos, Alexandros; Spanoudaki, Elpida; Kochiadakis, Georgios; Michalodimitrakis, Emmanouel; Vardas, Panagiotis

2013-01-01

Left-dominant arrhythmogenic cardiomyopathy is a subtype of arrhythmogenic right ventricular cardiomyopathy characterized by early predominant left ventricular involvement. Α 34-year-old man presented with palpitations and a history of frequent ventricular extrasystoles of both LBBB and RBBB configuration. Cardiac workup revealed repolarization abnormalities at infero-lateral leads in the absence of diagnostic structural/functional alterations or obstructive coronary artery disease. Six months later he died suddenly. Histopathology was diagnostic for arrhythmogenic right ventricular cardiomyopathy affecting predominantly the left ventricle at subepicardial/midwall myocardial layers. Thus, ventricular arrhythmias accompanied by unexplained infero-lateral T-wave inversion should warn of a possible morbid association underlying left-dominant arrhythmogenic cardiomyopathy. Copyright © 2013 Elsevier Inc. All rights reserved.

Deep seafloor arrivals: an unexplained set of arrivals in long-range ocean acoustic propagation.

PubMed

Stephen, Ralph A; Bolmer, S Thompson; Dzieciuch, Matthew A; Worcester, Peter F; Andrew, Rex K; Buck, Linda J; Mercer, James A; Colosi, John A; Howe, Bruce M

2009-08-01

Receptions, from a ship-suspended source (in the band 50-100 Hz) to an ocean bottom seismometer (about 5000 m depth) and the deepest element on a vertical hydrophone array (about 750 m above the seafloor) that were acquired on the 2004 Long-Range Ocean Acoustic Propagation Experiment in the North Pacific Ocean, are described. The ranges varied from 50 to 3200 km. In addition to predicted ocean acoustic arrivals and deep shadow zone arrivals (leaking below turning points), "deep seafloor arrivals," that are dominant on the seafloor geophone but are absent or very weak on the hydrophone array, are observed. These deep seafloor arrivals are an unexplained set of arrivals in ocean acoustics possibly associated with seafloor interface waves.

Anovulatory and ovulatory infertility: results with simplified management.

PubMed Central

Hull, M G; Savage, P E; Bromham, D R

1982-01-01

A simplified scheme for the management of anovulatory and of ovulatory (usually called unexplained) infertility was evaluated in 244 women. Eighteen patients were excluded because of primary ovarian failure, 164 were treated for ovulatory failure, and 62 with ovulatory infertility remained untreated. Twenty-five patients had a properly validated negative postcoital test. In the remaining 201 patients the two-year conception rates were 96% in patients with amenorrhoea, 83% in those with oligomenorrhoea, 74% in those with luteal deficiency, and 88% in those with ovulatory infertility. Comparison with normal rates implied that amenorrhoea represents a pure form of ovulatory failure that is completely correctable whereas in other conditions unexplained factors also contribute to infertility though to a much smaller extent than was previously thought. PMID:6805656

Foreign bodies in the ear, nose, and throat.

PubMed

Heim, Steven W; Maughan, Karen L

2007-10-15

Foreign bodies in the ear, nose, and throat are occasionally seen in family medicine, usually in children. The most common foreign bodies are food, plastic toys, and small household items. Diagnosis is often delayed because the causative event is usually unobserved, the symptoms are nonspecific, and patients often are misdiagnosed initially. Most ear and nose foreign bodies can be removed by a skilled physician in the office with minimal risk of complications. Common removal methods include use of forceps, water irrigation, and suction catheter. Pharyngeal or tracheal foreign bodies are medical emergencies requiring surgical consultation. Radiography results are often normal. Flexible or rigid endoscopy usually is required to confirm the diagnosis and to remove the foreign body. Physicians need to have a high index of suspicion for foreign bodies in children with unexplained upper airway symptoms. It is important to understand the anatomy and the indications for subspecialist referral. The evidence is inadequate to make strong recommendations for specific removal techniques.

Cervical adenopathy secondary to toxoplasmosis.

PubMed

Rafaty, F M

1977-09-01

Toxoplasmosis is not a rare disease. Infestation occurs in 75% of the general world population and in 35% of the US population. Lymphadenopathy, primarily of the cervical type, is one of the most common signs of acquired toxoplasmosis. During the past 15 years a great number of reports have appeared in the medical literature regarding toxoplasmosis. However, it seems that most clinicians do not consider this disease as a possibility when they encounter patients with unexplained cervical adenopathy in whom the usual tests for infectious mononucleosis are negative. In fact, the majority of such patients come to the operating room with a suspected diagnosis of malignant neoplasm, particularly of malignant lymphoma. Thus, a great deal of unnecessary anxiety is generated and, at times, unnecessary surgery is performed. These may be avoidable. A total of 38 cases of acquired toxoplasmosis manifested by lymphadenopathy (82% in the cervical region) are analyzed with respect to symptomatology, differential diagnosis, clinical and laboratory diagnosis, and treatment. Toxoplasmosis should be included in the differential diagnosis of patients with cervical tumors.

Children of people with somatization disorder.

PubMed

Livingston, R

1993-05-01

The author investigated psychopathology, suicidal behavior, child abuse, somatization, and health care utilization in 34 children with a parent who has somatization disorder (SD-P) and two comparison groups: 41 children with a somatizing parent (SOM) (fewer symptoms than required for diagnosis of SD-P), and 30 pediatrically ill controls (CON). Child and parent versions of the Diagnostic Interview for Children and Adolescents were scored for diagnosis and symptom counts in specified categories. Medical records were obtained and abstracted. Children of SD-P had significantly more psychiatric disorders and suicide attempts than did children of SOM or the CON. SD-P and CON had significantly more unexplained physical symptoms than SOM. SD-P showed a trend toward more hospitalizations and experienced significantly more maltreatment. Children of SD-P are at significant risk in several respects. Clinical implications of these findings include a need for awareness and cooperation among general psychiatrists, primary care physicians, and child and adolescent psychiatrists to facilitate detection and treatment of these children's problems.

[Self-directed learning and academic background of 2010 to 2014 cohorts of medical students].

PubMed

Pérez-Villalobos, Cristhian E; Fasce-Henry, Eduardo A; Ortega-Bastidas, Javiera A; Ortiz-Moreira, Liliana E; Bastías-Vega, Nancy; Bustamante-Durán, Carolina E; Ibáñez-Gracia, Pilar; Márquez-Urrizola, Carolina G; Delgado-Rivera, Macarena; Glaría-López, Rocío

2017-07-01

The widespread growth of higher education is increasing the heterogeneity of university students in terms of socioeconomic characteristics, academic story and cultural background. Medical schools are not an exception of this phenomenon. To compare the academic background and self-directed learning behavior of students who entered to a public medial school between 2010 and 2014. A non-probabilistic sample of 527 medical students aged between 17 and 29 years (60% men), was studied. Their academic information was collected from the University data base; they answered the Self-directed learning readiness scale of Fisher. Students from the 2014 cohort had higher high school grades than their counterparts. The scores in mathematics of the Scholarship Aptitude Test (SAT) were higher in the cohorts of 2010 and 2011. Those of the sciences test were superior in the 2013 cohort. The 2014 cohort had the lower general score of self-directed learning behaviors. The lower SAT and self-directed learning scores of the students entering medical school in 2014, indicate the progressive increase in the heterogeneity of Medical students.

Package Design Affects Accuracy Recognition for Medications

PubMed Central

Endestad, Tor; Wortinger, Laura A.; Madsen, Steinar; Hortemo, Sigurd

2016-01-01

Objective: Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. Background: An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. Method: In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. Results: The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Conclusion: Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. Application: A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. PMID:27591209

ESR

MedlinePlus

Erythrocyte sedimentation rate; Sed rate; Sedimentation rate ... Reasons why a "sed rate" may be done include: Unexplained fevers Certain types of arthritis Muscle symptoms Other vague symptoms that cannot be explained This ...

Rescue karyotyping: a case series of array-based comparative genomic hybridization evaluation of archival conceptual tissue

PubMed Central

2014-01-01

Background Determination of fetal aneuploidy is central to evaluation of recurrent pregnancy loss (RPL). However, obtaining this information at the time of a miscarriage is not always possible or may not have been ordered. Here we report on “rescue karyotyping”, wherein DNA extracted from archived paraffin-embedded pregnancy loss tissue from a prior dilation and curettage (D&C) is evaluated by array-based comparative genomic hybridization (aCGH). Methods A retrospective case series was conducted at an academic medical center. Patients included had unexplained RPL and a prior pregnancy loss for which karyotype information would be clinically informative but was unavailable. After extracting DNA from slides of archived tissue, aCGH with a reduced stringency approach was performed, allowing for analysis of partially degraded DNA. Statistics were computed using STATA v12.1 (College Station, TX). Results Rescue karyotyping was attempted on 20 specimens from 17 women. DNA was successfully extracted in 16 samples (80.0%), enabling analysis at either high or low resolution. The longest interval from tissue collection to DNA extraction was 4.2 years. There was no significant difference in specimen sufficiency for analysis in the collection-to-extraction interval (p = 0.14) or gestational age at pregnancy loss (p = 0.32). Eight specimens showed copy number variants: 3 trisomies, 2 partial chromosomal deletions, 1 mosaic abnormality and 2 unclassified variants. Conclusions Rescue karyotyping using aCGH on DNA extracted from paraffin-embedded tissue provides the opportunity to obtain critical fetal cytogenetic information from a prior loss, even if it occurred years earlier. Given the ubiquitous archiving of paraffin embedded tissue obtained during a D&C and the ease of obtaining results despite long loss-to-testing intervals or early gestational age at time of fetal demise, this may provide a useful technique in the evaluation of couples with recurrent pregnancy loss. PMID:24589081

Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial

PubMed Central

2013-01-01

Background Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, we tested the hypothesis that text-message reminders would be as effective as telephone reminders in an academic primary care clinic. Methods A randomized controlled non-inferiority trial was conducted in the academic primary care division of the Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for whom a cell phone number was available, were randomly selected to receive a text-message or a telephone call reminder 24 hours before the planned appointment. Patients were included each time they had an appointment. The main outcome was the rate of unexplained missed appointments. Appointments were not missed if they were cancelled or re-scheduled before or independently from the intervention. We defined non-inferiority as a difference below 2% in the rate of missed appointments and powered the study accordingly. A satisfaction survey was conducted among a random sample of 900 patients (response rate 41%). Results 6450 patients were included, 3285 in the text-message group and 3165 in the telephone group. The rate of missed appointments was similar in the text-message group (11.7%, 95% CI: 10.6-12.8) and in the telephone group (10.2%, 95% CI: 9.2-11.3 p = 0.07). However, only text message reminders were cost-effective. No patient reported any disturbance by any type of reminder in the satisfaction survey. Three quarters of surveyed patients recommended its regular implementation in the clinic. Conclusions Text-message reminders are equivalent to telephone reminders in reducing the proportion of missed appointments in an academic primary care clinic and are more cost-effective. Both types of reminders are well accepted by patients. PMID:23557331

Elder Abuse

MedlinePlus

... homes. The mistreatment may be Physical, sexual, or emotional abuse Neglect or abandonment Financial abuse - stealing of money or belongings Possible signs of elder abuse include unexplained bruises, burns, and injuries. There ...

Like Father, like Son? Familial Aggregation of Physicians among Medical and Psychology Students

ERIC Educational Resources Information Center

Voracek, Martin; Tran, Ulrich S.; Fischer-Kern, Melitta; Formann, Anton K.; Springer-Kremser, Marianne

2010-01-01

Various research findings, mostly from Anglo-American countries, evidence the medical profession to be strongly familial and further suggest that a medical family background may be associated with study success in medical undergraduates. This study explored the familial aggregation of the medical profession among 1-year cohort samples of medical…

ENTRANCE TO CEMETERY FROM VA MEDICAL CENTER CAMPUS, WITH ADMINISTRATION ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

ENTRANCE TO CEMETERY FROM VA MEDICAL CENTER CAMPUS, WITH ADMINISTRATION BUILDING IN BACKGROUND. VIEW TO NORTH. - Bath National Cemetery, Department of Veterans Affairs Medical Center, San Juan Avenue, Bath, Steuben County, NY

[Immigrated Physicians: Chances and Challenges].

PubMed

Hohmann, Isabel; Glaesmer, Heide; Nesterko, Yuriy

2018-01-19

In the health care infrastructure of Germany a demand for physicians with immigrant background exists. The situation of immigrated physicians is largely unexplored so far. In the framework of a pilot study stressors and resources of physicians with immigrant background have been explored concerning their migration-related experiences at German hospitals, and within the medical team. As part of a qualitative analysis 8 physicians with immigrant background have been interviewed (problem-centered interview) from July to September 2014. The respondents stemmed from countries of the European Union and of non-EU countries. They have worked for 1-4,5 years in different German hospitals. Stressors and challenges derived from a lack in German language skills, different medical skills, cooperation in the team, and from dealing with a new health care system. Perceived discrimination by colleagues and patients represented a particular burden. In the meantime physicians with immigrant background disposed resources on different levels as on communicational, medical, social and organizational levels. The results highlight the particular demands that physicians with immigrant background face. Future research should explore potentials of stressors and resources for physicians with immigrant background by using quantitative methods; in terms of a multi-perspective approach German colleagues and patients should be included. © Georg Thieme Verlag KG Stuttgart · New York.

Fetal karyotyping for chromosome abnormalities after an unexplained elevated maternal serum alpha-fetoprotein screening.

PubMed

Feuchtbaum, L B; Cunningham, G; Waller, D K; Lustig, L S; Tompkinson, D G; Hook, E B

1995-08-01

To study the chromosome abnormality rate among women with elevated levels of maternal serum alpha-fetoprotein (MSAFP) and the types of chromosome abnormalities in this population, and to compare this rate with reports in the literature and the rate observed in the general population. We studied 8097 women who chose to undergo amniocentesis and fetal karyotyping after having an elevated MSAFP test of 2.5 multiples of the median (MOM) or higher. All abnormal karyotypes were reviewed and grouped according to whether the elevated MSAFP value could be explained by a ventral wall or neural tube defect. The overall chromosome abnormality rate was 13.83 per 1000 amniocenteses. The rate in the "unexplained" group was 10.92 per 1000 amniocenteses. Just over half (53%) of the abnormal karyotypes were autosomal anomalies, and 47% were sex chromosome abnormalities. The autosomal aneuploidies observed most frequently were triploidy and trisomy 13. The sex chromosome abnormalities observed most frequently were the XXY and XYY karyotypes. Women who have unexplained elevated MSAFP values of 2.5 MOM or greater have a twofold increase in the rate of chromosome abnormalities in their fetuses compared with the general population (P < or = .001). This rate is consistent with other studies that used a 2.5 MOM cutoff. Studies that used a 2.0 MOM cutoff have reported chromosome abnormality rates that do not vary from general population estimates.

Inherited and acquired thrombophilia in Indian women experiencing unexplained recurrent pregnancy loss.

PubMed

Patil, Rucha; Ghosh, Kanjaksha; Vora, Sonal; Shetty, Shrimati

2015-10-01

The most frequently hypothesized cause of unexplained recurrent pregnancy loss (RPL) refers to a defective maternal haemostatic response leading to uteroplacental thrombosis. Approximately 20% women suffering from pregnancy loss (PL) are associated with autoimmune disorders and more than 50% remain idiopathic after common traditional investigations. The present study aims to investigate the prevalence of different genetic and acquired thrombophilia markers in a large series of Indian women with RPL. Such studies will help analyze the markers which pose maximum risk and help in the appropriate treatment in subsequent pregnancies. The study comprised of 587 women with no apparent etiological causes of RPL and 115 healthy women controls. p values were calculated with two tailed Fisher's exact test; statistical significance was assumed at p<0.05, 95% confidence interval. Relative risks were also calculated. Among genetic thrombophilia, the risk of PL was highest with protein S deficiency (16%, p=0.006) followed by plasminogen activator inhibitor-1 4G/4G (23%, p=0.007) polymorphism. Among acquired markers, the risk of PL was the highest in women with anti-cardiolipin antibodies (24%, p=0.0001), followed by anti-annexin V antibodies (23%, p=0.0009) and lupus anticoagulants (8%, p=0.02). Thrombophilia, inherited and acquired, is an important contributing factor in unexplained RPL and should be screened in the order of its prevalence. Copyright © 2015 Elsevier Inc. All rights reserved.

Classification of stillbirths is an ongoing dilemma.

PubMed

Nappi, Luigi; Trezza, Federica; Bufo, Pantaleo; Riezzo, Irene; Turillazzi, Emanuela; Borghi, Chiara; Bonaccorsi, Gloria; Scutiero, Gennaro; Fineschi, Vittorio; Greco, Pantaleo

2016-10-01

To compare different classification systems in a cohort of stillbirths undergoing a comprehensive workup; to establish whether a particular classification system is most suitable and useful in determining cause of death, purporting the lowest percentage of unexplained death. Cases of stillbirth at gestational age 22-41 weeks occurring at the Department of Gynecology and Obstetrics of Foggia University during a 4 year period were collected. The World Health Organization (WHO) diagnosis of stillbirth was used. All the data collection was based on the recommendations of an Italian diagnostic workup for stillbirth. Two expert obstetricians reviewed all cases and classified causes according to five classification systems. Relevant Condition at Death (ReCoDe) and Causes Of Death and Associated Conditions (CODAC) classification systems performed best in retaining information. The ReCoDe system provided the lowest rate of unexplained stillbirth (14%) compared to de Galan-Roosen (16%), CODAC (16%), Tulip (18%), Wigglesworth (62%). Classification of stillbirth is influenced by the multiplicity of possible causes and factors related to fetal death. Fetal autopsy, placental histology and cytogenetic analysis are strongly recommended to have a complete diagnostic evaluation. Commonly employed classification systems performed differently in our experience, the most satisfactory being the ReCoDe. Given the rate of "unexplained" cases, none can be considered optimal and further efforts are necessary to work out a clinically useful system.

Detection of cardiovascular shunts by transesophageal echocardiography in patients with pulmonary hypertension of unexplained cause.

PubMed

Chen, W J; Chen, J J; Lin, S C; Hwang, J J; Lien, W P

1995-01-01

The purpose of this study was to validate the usefulness of transesophageal echocardiography (TEE) in the assessment of cardiovascular shunts in patients with pulmonary hypertension (PH) of unexplained cause. Twenty-four adult patients, 16 women, 8 men; 15 to 70 years of age, with PH of unexplained cause were studied. All were examined by transthoracic echocardiography (TTE) and TEE. TTE showed the ventricular septal defect in two patients, muscular type in one and perimembranous type in the other. TEE showed the atrial septal defect in eight patients (secundum type in six and primum type in the remaining) and the patient ductus arteriosus in six patients, which were not seen by TTE. The ventricular septal defect shown by TTE was also found by TEE. Patients with a ventricular septal defect were also associated with a patient ductus arteriosus. Among 14 patients with cardiovascular lesions, nine patients displayed a pattern of bidirectional shunt, four a pure left-to-right shunt, and the remaining one a pure right-to-left shunt. All of the cardiovascular defects could be confirmed by passage of the catheter across the defect at cardiac catheterization. In light of PH, transthoracic identification of cardiovascular shunts is difficult because of the low velocity across the defect. In this study, we found that TEE was superior to TTE in detecting and localizing cardiovascular malformations in patient with PH.

Polymorphisms in the methylene tetrahydrofolate reductase and methionine synthase reductase genes and their correlation with unexplained recurrent spontaneous abortion susceptibility.

PubMed

Zhu, L

2015-07-28

We aimed to explore the correlation between unexplained recurrent spontaneous abortion and polymorphisms in the methylene tetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) genes. A case control study was conducted in 118 patients with unexplained recurrent spontaneous abortion (abortion group) and 174 healthy women (control group). The genetic material was extracted from the oral mucosal epithelial cells obtained from all subjects. The samples were subjected to fluorescence quantitative PCR to detect the single nucleotide polymorphisms (SNPs) in the MTHFR (C677T and A1298C) and MTRR (A66G) gene loci. The distribution frequency (18/118, 15.3%) of the MTHFR 677TT genotype was significantly higher in the abortion group (χ2 = 11.006, P = 0.004) than in the control group (2/174, 1.1%); on the other hand, the distribution frequency of the MTHFR A1298C genotype did not significantly differ between the abortion and control groups (χ(2) = 0.441, P = 0.507). The distribution frequency of the MTRR A66G genotype was also significantly higher in the abortion group (14/118, 11.9%; χ(2) = 10.503, P = 0.005) than in the control group (8/174, 4.6%). The MTHFR C677T and MTRR A66G polymorphisms are significantly correlated with the occurrence of spontaneous abortion.