This study evaluated 156 patients diagnosed with fibromyalgia syndrome (FMS) according to research criteria to determine how many met criteria for somatic symptom disorder (SSD) according to DSM-5 research criteria. The study aimed to test the construct validity and clinical utility of the SSD diagnosis in patients with FMS. Twenty-five percent of patients met criteria for SSD. Patients with SSD had significantly higher scores on a self-report measure of disability, but there were no significant differences in measures of health care utilization. The majority of patients with SSD also met criteria for a current anxiety or depressive disorder. Around 80% of patients with SSD received a recommendation for psychotherapy from blinded clinicians.
This document discusses the principles of diagnosis in dentistry and oral medicine. It covers taking a thorough patient history, performing extraoral and intraoral examinations, considering relevant medical and dental histories, and ordering appropriate diagnostic tests and investigations. The key steps in diagnosis include obtaining a detailed history, conducting a physical examination of the head and neck both extraorally and intraorally, and ordering diagnostic tests such as radiographs, biopsies, or blood tests when indicated based on the history and examination findings. Special attention is paid to examining lymph nodes, salivary glands, teeth, and soft tissues during the intraoral examination.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
Referral For Invasive Procedures For Cancer Pain Dr Alison Mitchellepicyclops
Lecture given to the North British Pain Association on 16th May 2008 by Dr Alison Mitchell. In this talk, Dr Mitchell discusses the indications for referral of patients with cancer pain for invasive procedures. She describes the new interventional cancer pain service being set up in Glasgow. www.nbpa.org.uk
The American College of Physicians (ACP) developed guidelines for managing chronic insomnia disorder in adults based on a systematic review of randomized controlled trials. The ACP recommends cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder based on moderate-quality evidence showing its effectiveness. The ACP also recommends a shared decision-making approach when considering adding short-term pharmacological therapy for those where CBT-I is unsuccessful, due to low-quality evidence on medication risks and benefits. Moderate evidence shows CBT-I improves sleep outcomes for both the general adult population and older adults. Evidence is insufficient to determine comparative effectiveness or safety of other therapies.
This document provides guidelines for the evaluation and management of status epilepticus (SE) developed by the Neurocritical Care Society Status Epilepticus Guideline Writing Committee. It defines SE as 5 or more minutes of continuous seizure activity or recurrent seizures without recovery in between. The committee conducted a literature review to develop evidence-based recommendations for diagnosing and treating SE. They determined definitions and classifications of SE, evaluated treatment evidence levels, and developed consensus recommendations, recognizing many decisions lack high-quality evidence from randomized controlled trials. The guidelines are intended to help standardize and improve care for critically ill patients experiencing SE.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
This document discusses pain assessment and management for people with advanced dementia. It notes that pain is underreported and undertreated in cognitively impaired older adults due to challenges in assessment. It recommends using behavioral observation scales to assess pain in people with dementia, and provides examples of assessment tools like the Doloplus-2 scale and Abbey Pain Scale. It also provides guidance on managing chronic pain in older adults with dementia, including starting low-dose regular analgesics and considering transdermal patches to provide steady doses.
This document discusses the principles of diagnosis in dentistry and oral medicine. It covers taking a thorough patient history, performing extraoral and intraoral examinations, considering relevant medical and dental histories, and ordering appropriate diagnostic tests and investigations. The key steps in diagnosis include obtaining a detailed history, conducting a physical examination of the head and neck both extraorally and intraorally, and ordering diagnostic tests such as radiographs, biopsies, or blood tests when indicated based on the history and examination findings. Special attention is paid to examining lymph nodes, salivary glands, teeth, and soft tissues during the intraoral examination.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
Referral For Invasive Procedures For Cancer Pain Dr Alison Mitchellepicyclops
Lecture given to the North British Pain Association on 16th May 2008 by Dr Alison Mitchell. In this talk, Dr Mitchell discusses the indications for referral of patients with cancer pain for invasive procedures. She describes the new interventional cancer pain service being set up in Glasgow. www.nbpa.org.uk
The American College of Physicians (ACP) developed guidelines for managing chronic insomnia disorder in adults based on a systematic review of randomized controlled trials. The ACP recommends cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder based on moderate-quality evidence showing its effectiveness. The ACP also recommends a shared decision-making approach when considering adding short-term pharmacological therapy for those where CBT-I is unsuccessful, due to low-quality evidence on medication risks and benefits. Moderate evidence shows CBT-I improves sleep outcomes for both the general adult population and older adults. Evidence is insufficient to determine comparative effectiveness or safety of other therapies.
This document provides guidelines for the evaluation and management of status epilepticus (SE) developed by the Neurocritical Care Society Status Epilepticus Guideline Writing Committee. It defines SE as 5 or more minutes of continuous seizure activity or recurrent seizures without recovery in between. The committee conducted a literature review to develop evidence-based recommendations for diagnosing and treating SE. They determined definitions and classifications of SE, evaluated treatment evidence levels, and developed consensus recommendations, recognizing many decisions lack high-quality evidence from randomized controlled trials. The guidelines are intended to help standardize and improve care for critically ill patients experiencing SE.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
This document discusses pain assessment and management for people with advanced dementia. It notes that pain is underreported and undertreated in cognitively impaired older adults due to challenges in assessment. It recommends using behavioral observation scales to assess pain in people with dementia, and provides examples of assessment tools like the Doloplus-2 scale and Abbey Pain Scale. It also provides guidance on managing chronic pain in older adults with dementia, including starting low-dose regular analgesics and considering transdermal patches to provide steady doses.
This study examined patient-determined criteria for treatment success across four domains (pain, fatigue, emotional distress, and interference with daily activities) for fibromyalgia and back pain patients. The study found that both patient groups had high standards for considering treatment successful, requiring large reductions across domains. Specifically, fibromyalgia patients required at least a 54% reduction in pain, 60% reductions in fatigue and distress, and a 63% reduction in interference. Back pain patients required 58% pain reduction, 57% reductions in fatigue and distress, and 68% reductions in interference and distress. Both patient groups did not expect existing treatments would meet their stringent criteria for success. The study highlights the importance of assessing patient perspectives on treatment outcomes.
Evidence-based medicine (EBM) involves using the best available evidence from systematic research to inform clinical decision-making. It has its origins in the mid-19th century with emphasis on collecting data from patient experiences. Key milestones included the development of randomized controlled trials in the 1940s-50s and emphasis on using evidence from such trials to guide clinical practice. EBM is now the standard for evaluating treatments and making recommendations, though traditional experience and expertise remain important.
- 49% of chronic pain patients taking opioids reported severe pain (≥7/10).
- Patients reporting higher pain were more likely to have characteristics associated with centralized pain processing, including higher fibromyalgia survey scores, more neuropathic pain symptoms, and higher depression levels.
- While only 3.2% were diagnosed with fibromyalgia by their doctor, 40.8% met criteria for fibromyalgia based on a validated survey questionnaire. This suggests centralized pain characteristics are underrecognized.
The STAR*D trial aimed to identify effective next-step treatments for patients who did not respond to initial antidepressants. However, the study misrepresented data to claim higher remission rates. The actual remission rate was only around 3%, rather than the reported 40%. Investigators inappropriately changed outcome measures and excluded dropouts to inflate results. They also underreported treatment-emergent suicidal ideation. The study investigators had conflicts of interest that may have biased their analysis and presentation of the data. In reality, the study showed antidepressants have only marginal efficacy compared to placebo.
The STAR*D trial was a large, multi-center study that examined the effectiveness of different treatment options for patients with unipolar depression who did not achieve remission with an initial antidepressant. Over 4,000 outpatients were treated across four levels of sequentially increasing treatment intensity. The study found that after two treatment steps, around 67% of patients achieved remission, but relapse rates were high. Patients with more severe and chronic illness required more treatment steps to achieve remission. While the study provided important real-world data on treating depression, it had some limitations like lack of placebo groups and small sample sizes in later levels.
Journal Club route to Evidence Based MedicineCSN Vittal
The document discusses evidence-based medicine and journal clubs. It begins by outlining how doctors historically practiced medicine with little reading, then introduces evidence-based medicine as a better approach. Evidence-based medicine involves forming questions based on patients, current evidence, and clinical expertise. The document then discusses how journal clubs can be used to critically appraise recent studies and apply the evidence to patient care, improving quality. Journal clubs follow the steps of evidence-based medicine by posing questions, searching literature, and critically evaluating evidence to inform clinical decisions.
Diagnostic and therapeutic errors in cluster headache a hospital-based study.rotaryminerva
1) The study found that misdiagnoses were common in cluster headache patients, with 77% receiving an incorrect initial diagnosis. Common misdiagnoses included trigeminal neuralgia, migraine, and sinusitis.
2) There was on average a 5.3 year diagnostic delay between symptom onset and receiving a cluster headache diagnosis. Some patients waited over 10 years for a correct diagnosis.
3) Many patients underwent unnecessary medical tests and some did not receive the appropriate abortive or preventive treatments due to the misdiagnoses. The study emphasizes the need for improved physician education about cluster headache diagnosis and management.
This cross-sectional study analyzed data from nursing homes in Austria and the Czech Republic to compare the prevalence of dementia, behavioral symptoms, mobility, pain, and other health factors. Over 800 residents were assessed between 2016-2017. The main findings showed higher rates of cognitive impairment in Austria (85.2%) than the Czech Republic (53.0%), but higher rates of behavioral problems, pain, and malnutrition in the Czech Republic. While some results were similar, differences indicate a need for improved diagnostic services, dementia-specific care, and support. Overall, the high prevalence of issues found calls for further research and practice development to better address residents' needs.
Case Study Nursing Management in Pathophysiologyemilyparker01
Thank you for the feedback. You're right that including more in-text citations would have strengthened the responses. In the future, I will aim to better support my answers with references as appropriate. The comments provide helpful guidance on how I can continue improving my summarization and analysis skills.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
This document discusses resistant depression and treatment strategies. It begins with an introduction to major depression and outlines its global health burden. It then defines treatment-resistant depression as generally failing to respond to at least two antidepressant trials of adequate dose and duration. The document reviews factors associated with treatment resistance and strategies for managing it, including switching or augmenting antidepressants, adding lithium, psychotherapy, or atypical antipsychotics. It emphasizes the importance of achieving full remission to prevent relapse and improve outcomes.
1) This study investigated whether using 64-slice MDCT as part of the initial diagnostic strategy for patients presenting with acute chest pain could reduce emergency department and hospital length of stay, admissions, and 30-day major adverse cardiac events.
2) 267 patients were randomized to either a conventional diagnostic strategy or a MDCT-based strategy. The MDCT-based strategy reduced unnecessary admissions in patients at intermediate risk and decreased hospital length of stay overall and in high-risk patients specifically.
3) Emergency department length of stay was not different between the strategies. No patients in the MDCT group experienced events at the one-month follow-up.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
This case study describes the end-of-life care of Lorna, a 77-year old woman with metastatic renal cell carcinoma. Lorna originally presented with flank and abdominal pain and was diagnosed with advanced renal cell carcinoma in 2011. In 2014, the cancer recurred and metastasized to her spine, causing cauda equina syndrome with lower limb weakness and urinary/fecal incontinence. She was admitted to palliative care for pain and symptom management, where she received psychological support, medication via syringe pump, and focus on comfort. The document discusses renal cell carcinoma, cauda equina syndrome, medications, nursing interventions and compassionate end-of-life care.
This document provides information about clinical trials and options for breast cancer patients. It discusses how clinical trials work, including the different phases of trials and protections for participants. Key points covered include how trials are regulated to protect participants, the voluntary nature of participation, and factors to consider when deciding whether to enroll in a trial such as potential benefits and drawbacks. Resources for finding current breast cancer trials are also mentioned.
This document summarizes a journal club presentation on a study assessing the knowledge and practices of intensive care nurses regarding the prevention of ventilator-associated pneumonia. The study found that the nurses had average knowledge but unsatisfactory practices in preventing VAP. It concluded that additional in-service education and training programs are needed to improve nurses' knowledge and practices and reduce infections among patients. The presentation reviewed the objectives, methods, findings and conclusions of the descriptive study conducted with 50 nurses in India. It also discussed relevant literature supporting the average knowledge levels found and the need for preventative protocols and guidelines.
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
The values of clinical practice - Jordi VarelaJordi Varela
Three key principles will guide clinical practice: adding value to patient health, organizing doctors according to clinical processes, and measuring outcomes adjusted for risk and cost. Right care considers benefits and harms, is patient-centered, and evidence-based. Half of surgeries and clinical trials lack evidence to support them. Overdiagnosis leads to unnecessary treatment complications. Fragmented care for chronic patients results in clinical instability, unnecessary tests and costs. Clinical value practices aim to reduce wasteful spending through protocols, teamwork and learning from errors.
Este documento resume los conceptos clave de la potestad tributaria. Explica que la potestad tributaria es la facultad del estado para crear impuestos, ya sea de forma originaria o derivada. También describe las limitaciones a la potestad tributaria, como los principios de legalidad, capacidad contributiva, igualdad y no confiscatoriedad. Finalmente, resume las competencias tributarias del poder público nacional y los ingresos estatales derivados de la potestad tributaria.
La contabilidad proporciona información útil para la toma de decisiones económicas mediante el estudio del patrimonio y la presentación de estados financieros. Tiene como objetivos participar en la toma de decisiones estratégicas, determinar las utilidades o pérdidas, prever las probabilidades futuras del negocio y proporcionar una imagen clara de la situación financiera. Existen diferentes tipos de contabilidad como la fiscal, pública, de servicio y por actividades. La contabilidad es muy importante porque permite conocer la realidad económica
This study examined patient-determined criteria for treatment success across four domains (pain, fatigue, emotional distress, and interference with daily activities) for fibromyalgia and back pain patients. The study found that both patient groups had high standards for considering treatment successful, requiring large reductions across domains. Specifically, fibromyalgia patients required at least a 54% reduction in pain, 60% reductions in fatigue and distress, and a 63% reduction in interference. Back pain patients required 58% pain reduction, 57% reductions in fatigue and distress, and 68% reductions in interference and distress. Both patient groups did not expect existing treatments would meet their stringent criteria for success. The study highlights the importance of assessing patient perspectives on treatment outcomes.
Evidence-based medicine (EBM) involves using the best available evidence from systematic research to inform clinical decision-making. It has its origins in the mid-19th century with emphasis on collecting data from patient experiences. Key milestones included the development of randomized controlled trials in the 1940s-50s and emphasis on using evidence from such trials to guide clinical practice. EBM is now the standard for evaluating treatments and making recommendations, though traditional experience and expertise remain important.
- 49% of chronic pain patients taking opioids reported severe pain (≥7/10).
- Patients reporting higher pain were more likely to have characteristics associated with centralized pain processing, including higher fibromyalgia survey scores, more neuropathic pain symptoms, and higher depression levels.
- While only 3.2% were diagnosed with fibromyalgia by their doctor, 40.8% met criteria for fibromyalgia based on a validated survey questionnaire. This suggests centralized pain characteristics are underrecognized.
The STAR*D trial aimed to identify effective next-step treatments for patients who did not respond to initial antidepressants. However, the study misrepresented data to claim higher remission rates. The actual remission rate was only around 3%, rather than the reported 40%. Investigators inappropriately changed outcome measures and excluded dropouts to inflate results. They also underreported treatment-emergent suicidal ideation. The study investigators had conflicts of interest that may have biased their analysis and presentation of the data. In reality, the study showed antidepressants have only marginal efficacy compared to placebo.
The STAR*D trial was a large, multi-center study that examined the effectiveness of different treatment options for patients with unipolar depression who did not achieve remission with an initial antidepressant. Over 4,000 outpatients were treated across four levels of sequentially increasing treatment intensity. The study found that after two treatment steps, around 67% of patients achieved remission, but relapse rates were high. Patients with more severe and chronic illness required more treatment steps to achieve remission. While the study provided important real-world data on treating depression, it had some limitations like lack of placebo groups and small sample sizes in later levels.
Journal Club route to Evidence Based MedicineCSN Vittal
The document discusses evidence-based medicine and journal clubs. It begins by outlining how doctors historically practiced medicine with little reading, then introduces evidence-based medicine as a better approach. Evidence-based medicine involves forming questions based on patients, current evidence, and clinical expertise. The document then discusses how journal clubs can be used to critically appraise recent studies and apply the evidence to patient care, improving quality. Journal clubs follow the steps of evidence-based medicine by posing questions, searching literature, and critically evaluating evidence to inform clinical decisions.
Diagnostic and therapeutic errors in cluster headache a hospital-based study.rotaryminerva
1) The study found that misdiagnoses were common in cluster headache patients, with 77% receiving an incorrect initial diagnosis. Common misdiagnoses included trigeminal neuralgia, migraine, and sinusitis.
2) There was on average a 5.3 year diagnostic delay between symptom onset and receiving a cluster headache diagnosis. Some patients waited over 10 years for a correct diagnosis.
3) Many patients underwent unnecessary medical tests and some did not receive the appropriate abortive or preventive treatments due to the misdiagnoses. The study emphasizes the need for improved physician education about cluster headache diagnosis and management.
This cross-sectional study analyzed data from nursing homes in Austria and the Czech Republic to compare the prevalence of dementia, behavioral symptoms, mobility, pain, and other health factors. Over 800 residents were assessed between 2016-2017. The main findings showed higher rates of cognitive impairment in Austria (85.2%) than the Czech Republic (53.0%), but higher rates of behavioral problems, pain, and malnutrition in the Czech Republic. While some results were similar, differences indicate a need for improved diagnostic services, dementia-specific care, and support. Overall, the high prevalence of issues found calls for further research and practice development to better address residents' needs.
Case Study Nursing Management in Pathophysiologyemilyparker01
Thank you for the feedback. You're right that including more in-text citations would have strengthened the responses. In the future, I will aim to better support my answers with references as appropriate. The comments provide helpful guidance on how I can continue improving my summarization and analysis skills.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
This document discusses resistant depression and treatment strategies. It begins with an introduction to major depression and outlines its global health burden. It then defines treatment-resistant depression as generally failing to respond to at least two antidepressant trials of adequate dose and duration. The document reviews factors associated with treatment resistance and strategies for managing it, including switching or augmenting antidepressants, adding lithium, psychotherapy, or atypical antipsychotics. It emphasizes the importance of achieving full remission to prevent relapse and improve outcomes.
1) This study investigated whether using 64-slice MDCT as part of the initial diagnostic strategy for patients presenting with acute chest pain could reduce emergency department and hospital length of stay, admissions, and 30-day major adverse cardiac events.
2) 267 patients were randomized to either a conventional diagnostic strategy or a MDCT-based strategy. The MDCT-based strategy reduced unnecessary admissions in patients at intermediate risk and decreased hospital length of stay overall and in high-risk patients specifically.
3) Emergency department length of stay was not different between the strategies. No patients in the MDCT group experienced events at the one-month follow-up.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
This case study describes the end-of-life care of Lorna, a 77-year old woman with metastatic renal cell carcinoma. Lorna originally presented with flank and abdominal pain and was diagnosed with advanced renal cell carcinoma in 2011. In 2014, the cancer recurred and metastasized to her spine, causing cauda equina syndrome with lower limb weakness and urinary/fecal incontinence. She was admitted to palliative care for pain and symptom management, where she received psychological support, medication via syringe pump, and focus on comfort. The document discusses renal cell carcinoma, cauda equina syndrome, medications, nursing interventions and compassionate end-of-life care.
This document provides information about clinical trials and options for breast cancer patients. It discusses how clinical trials work, including the different phases of trials and protections for participants. Key points covered include how trials are regulated to protect participants, the voluntary nature of participation, and factors to consider when deciding whether to enroll in a trial such as potential benefits and drawbacks. Resources for finding current breast cancer trials are also mentioned.
This document summarizes a journal club presentation on a study assessing the knowledge and practices of intensive care nurses regarding the prevention of ventilator-associated pneumonia. The study found that the nurses had average knowledge but unsatisfactory practices in preventing VAP. It concluded that additional in-service education and training programs are needed to improve nurses' knowledge and practices and reduce infections among patients. The presentation reviewed the objectives, methods, findings and conclusions of the descriptive study conducted with 50 nurses in India. It also discussed relevant literature supporting the average knowledge levels found and the need for preventative protocols and guidelines.
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
The values of clinical practice - Jordi VarelaJordi Varela
Three key principles will guide clinical practice: adding value to patient health, organizing doctors according to clinical processes, and measuring outcomes adjusted for risk and cost. Right care considers benefits and harms, is patient-centered, and evidence-based. Half of surgeries and clinical trials lack evidence to support them. Overdiagnosis leads to unnecessary treatment complications. Fragmented care for chronic patients results in clinical instability, unnecessary tests and costs. Clinical value practices aim to reduce wasteful spending through protocols, teamwork and learning from errors.
Este documento resume los conceptos clave de la potestad tributaria. Explica que la potestad tributaria es la facultad del estado para crear impuestos, ya sea de forma originaria o derivada. También describe las limitaciones a la potestad tributaria, como los principios de legalidad, capacidad contributiva, igualdad y no confiscatoriedad. Finalmente, resume las competencias tributarias del poder público nacional y los ingresos estatales derivados de la potestad tributaria.
La contabilidad proporciona información útil para la toma de decisiones económicas mediante el estudio del patrimonio y la presentación de estados financieros. Tiene como objetivos participar en la toma de decisiones estratégicas, determinar las utilidades o pérdidas, prever las probabilidades futuras del negocio y proporcionar una imagen clara de la situación financiera. Existen diferentes tipos de contabilidad como la fiscal, pública, de servicio y por actividades. La contabilidad es muy importante porque permite conocer la realidad económica
O documento descreve a árvore Patricia, uma representação compacta de uma trie utilizada para armazenar chaves de tamanho variável de forma eficiente. A árvore Patricia escolhe elementos chave para determinar sub-árvores e armazena as chaves nas folhas, enquanto os nós contêm índices para decidir qual sub-árvore seguir, eliminando problemas de caminhos de uma só direção.
Este documento describe diferentes fármacos utilizados en el tratamiento de úlceras gástricas e intestinales, náuseas y vómitos. Describe antagonistas H2 como la cimetidina, ranitidina y famotidina, los cuales disminuyen la secreción gástrica. También describe inhibidores de la bomba de protones como el omeprazol, los cuales inhiben fuertemente la producción de ácido gástrico. Explica antieméticos como el ondansetrón y la metoclopramida, los cuales
This document discusses customer-based brand equity (CBBE) of Amazon.com. It outlines Keller's CBBE model, which assesses brand equity based on customer mindset. The model examines brand salience, performance, imagery, judgment, feeling, and resonance. Developing CBBE for Amazon requires building positive customer experiences and associations with the brand. Benefits of strong CBBE include greater loyalty, price premiums, communication efficiency, and licensing opportunities.
The document provides strategies for sounding out or decoding tricky words when reading:
1) Re-read the word, think about what looks and sounds right, use picture clues or word parts like prefixes and suffixes, skip the word and come back to it.
2) Make connections to known words, check the middle or end of the word, look through the whole word by sounding it out.
3) The overall message is that there are multiple techniques to figure out tricky words when reading.
ELETROMANETISMO PARA ESTUDAR-PROVAS MILITARESAirton Coelho
O documento classifica materiais em diamagnéticas, paramagnéticas e ferromagnéticas de acordo com como são repelidos ou atraídos por ímãs. Explica também conceitos como campo magnético em condutores, força magnética em cargas elétricas e indução eletromagnética.
Este documento presenta las instrucciones para una actividad de blog que los estudiantes deben completar como parte de un curso de lógica y comunicación. Los estudiantes deben crear un blog usando la plataforma SimpleSite para publicar una historia de la tradición oral con imágenes. Se proporciona una rúbrica para evaluar la calidad del diseño del blog en términos de objetivos, estética, redacción, elementos integrados y puntualidad de entrega.
Los campesinos de varias comunidades en Casacancha crían cuyes de forma organizada, pero ahora producen más de lo que pueden vender localmente. Los intermediarios les compran los cuyes a bajos precios. Los campesinos no saben que hay organismos que pueden comprar su producción a mejores precios si se contactan con ellos.
1) Homens que eram dependentes químicos se casaram em uma comunidade terapêutica, com a presença de bispo e convidados, após se recuperarem do vício.
2) Araranguenses fizeram fila em agência da Caixa Econômica Federal desde cedo para sacar recursos do FGTS de contas inativas.
3) Trabalhadores têm direito ao saque do FGTS se pediram demissão ou foram demitidos por justa causa até dezembro de 2015 e tiverem saldo em conta
Este documento resume los principales tipos de tumores malignos del hígado, incluyendo el carcinoma hepatocelular (el más común), el colangiocarcinoma y el hepatoblastoma. Describe sus causas, síntomas, grupos de riesgo y métodos de diagnóstico. Indica que la cirugía, ya sea la resección quirúrgica o el trasplante hepático, es la primera opción terapéutica para estos tumores cuando es posible realizarla.
This document provides information about purchasing a 3Com E151382 2 product from Launch 3 Telecom. It describes Launch 3 Telecom as a supplier of telecom hardware and genuine 3Com replacement parts. It outlines the payment and shipping options for purchasing the 3Com E151382 2 and details the warranty and customer service provided by Launch 3 Telecom. It also lists additional services offered by Launch 3 Telecom such as equipment repair, maintenance contracts, de-installation, and telecom equipment recycling.
Este documento trata sobre la nutrición en pediatría. Explica los objetivos de una nutrición adecuada como mantener los tejidos corporales y proveer energía. También cubre los requisitos de una alimentación ideal, los diferentes nutrientes, los requerimientos calóricos según el método de Holliday-Segar, y las consideraciones para la alimentación de lactantes, niños preescolares y escolares.
Warner Bros would be the best distributor for the film. While 20th Century Fox and Paramount Pictures have distributed successful films, they have not recently had many major horror film hits. Warner Bros, however, has been very successful with horror franchises like The Conjuring and The Exorcist. They also had great success distributing The Conjuring 2 in 2016. The film Gravity is cited as an example of a similar film that was funded by the British Film Institute and distributed by Warner Bros due to its British creative elements.
El documento describe los pasos para realizar una búsqueda en la base de datos PubMed sobre la prevención de la obesidad y el sobrepeso en niños y adolescentes. Incluye identificar los conceptos clave, traducirlos a términos documentales usando el tesauro DeCS, construir una estrategia de búsqueda usando operadores lógicos, y añadir filtros como tipo de artículo, idioma y fecha.
Analysis of the short-story "Eleven" by Sandra Cisneros. Featuring; plot, character description, vocabulary, brief biography of the author, examples of tenses found in the story and book's message.
Clin exp rheumatol 2013 patient satisfaction fms Paul Coelho, MD
This document summarizes a study examining patient-related predictors of treatment satisfaction in patients with fibromyalgia syndrome (FMS). The study surveyed 1,651 FMS patients recruited through self-help organizations and clinical institutions. It found considerable variety in treatment satisfaction, with 14.8% reporting no satisfaction, 31.7% low satisfaction, 40.8% moderate satisfaction, and 12.7% high satisfaction. Higher treatment satisfaction was predicted by longer time since FMS diagnosis, improved health status since diagnosis, lower depression scores, and receiving a higher amount of active therapies. Other sociodemographic and disease-related factors did not influence satisfaction levels. The results illustrate the impact of factors like depression and enabling active coping on treatment satisfaction in
Somatic symptom disorder, previously known as somatoform disorders, is characterized by physical symptoms that cannot be fully explained by a medical condition. It is a common disorder seen in primary care, affecting 5-7% of the general population. The main feature is the patient's strong concerns and beliefs about their physical symptoms. Effective treatments include cognitive behavioral therapy, mindfulness therapy, antidepressants, and referral to a mental health professional when needed. Primary care physicians play an important role in properly diagnosing and managing these patients.
The document summarizes guidelines from Canada, Germany, Israel, and Europe for the diagnosis and management of fibromyalgia (FM). Key points include:
- FM is a prevalent condition affecting approximately 2% of the population. It is characterized by chronic widespread pain, fatigue, sleep disturbances, and other symptoms.
- Diagnosis is based on a history and exam showing widespread tenderness. Basic tests can rule out other conditions.
- Optimal management begins with education and a graduated approach focusing first on lifestyle changes like exercise. Cognitive behavioral therapy and medications may also be considered.
- Guidelines agree the diagnosis is clinical. Exams and tests aim to rule out other conditions causing pain. History should include symptoms of pain, fatigue,
This document summarizes a study examining differences between individuals granted versus denied insurance coverage for chronic pain treatment after being recommended for an interdisciplinary pain management program. The study found no clinically meaningful differences between the groups on various pain-related measures, suggesting insurance denials were not based on patient need. This implies insurance funding decisions are made on non-clinical criteria rather than patient need. The document provides background on chronic pain, the effectiveness of interdisciplinary treatment, and barriers to treatment access when insurance coverage is denied.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
This document summarizes changes to diagnoses of somatic disorders in the DSM-5 and provides guidance on assessing and treating patients with somatic symptoms. It discusses how the DSM-5 consolidated somatoform disorders into the new category of somatic symptom and related disorders. Specifically, it replaced somatization disorder, undifferentiated somatoform disorder, and pain disorder with the new diagnosis of somatic symptom disorder. It also analyzes challenges with applying the new DSM-5 criteria in clinical practice based on a case example of a patient named Andrew experiencing chronic pain.
The DSM-5 replaces somatoform disorders with somatic symptom and related disorders, making significant changes to criteria. Somatic symptom disorder (SSD) is characterized by distressing or disruptive somatic symptoms accompanied by excessive thoughts, feelings, or behaviors about the symptoms. Unlike DSM-IV, an SSD diagnosis does not require symptoms be medically unexplained. The new SSD criteria remove overlap and confusion from previous editions and encourage comprehensive assessment to provide holistic care.
Homeopathic treatment of elderly patients - a prospective observational study...home
The severity of disease showed marked and sustained improvements under homeopathic treatment,
but this did not lead to an improvement of quality of life. Our findings might indicate that homeopathic medical
therapy may play a beneficial role in the long-term care of older adults with chronic diseases and studies on
comparative effectiveness are needed to evaluate this hypothesis.
Background: Behavioral health conditions are prevalent among patients in inpatient medical settings and when not adequately treated contribute to diminished treatment outcomes and quality of life. Substantial evidence has demonstrated the effectiveness of psychological interventions in addressing behavioral health conditions in a range of settings but, to a lesser extent with psychologically-based interventions delivered in inpatient medical settings. Purpose: The purpose of this paper is to increase attention on psychological interventions being delivered to patients across a broad spectrum of medical specialties in inpatient medical settings to support the implementation of interventions to address increasing patient needs. Methods: This selected, brief review of the literature sought to describe published psychologically-based interventions delivered in inpatient medical settings. A search for studies catalogued on PubMed from 2007 to 2016 was examined and studies were included in the review if they were delivered within inpatient medical settings. Two reviewers independently assessed relevant studies for criteria. Results: A total of ten articles met the inclusion criteria with interventions targeting outcomes across four primary domains: 1) pain and fatigue; 2) cognition; 3) affective/emotional and; 4) self-harm. Several articles support interventions grounded in Cognitive-Behavioral Therapy and brief psychological interventions. Most studies reported favorable outcomes for the interventions relative to controls. Conclusions: Psychologically-based interventions, especially those that integrate components of cognitive-behavioral therapy and a multidisciplinary approach, can be implemented in inpatient medical settings and may promote improved patient outcomes. However, the quality of this evidence requires formal assessment, requiring more comprehensive reviews are needed to replicate findings and clarify effectiveness of interventions.
1. The document describes a study that examined the effects of a 6-month exercise intervention on inflammatory markers in sedentary middle-aged men. 152 men were screened and eligible sedentary men were randomly assigned to an exercise group or control group.
2. Blood samples were taken at regular intervals to measure inflammatory markers like IL-6 and CRP. The results showed that regular exercise over 6 months can positively impact systemic markers of chronic inflammation.
3. The study provides causal evidence that exercise interventions can reduce inflammation, filling gaps in previous research that had inconsistent or limited findings. It establishes a dose-response relationship and controls for compliance through activity monitors.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
Diagnosis and Treatment of Psychosomatic Disorder (Educational Slides)Andri Andri
This is a standard presentation for teaching medical students and colleagues about psychosomatic disorder, its diagnosis and therapy. We hope by reading this slides, you will understand the nature of psychosomatic disorder and its current approach in therapy
The Impact of Ethnicity on Antidepressant Therapy.docxwrite5
This document discusses a case study of a 63-year-old male patient with recurrent depression. It poses additional questions that could provide more context about the patient's psychiatric and family history. It also suggests questions for the patient's wife and children, as well as physical exams and lab tests that may help diagnose the patient. Finally, it discusses potential differential diagnoses and pharmacologic treatment options.
Experience of a comprehensive pain care (cpc) clinic from a provincial gener...Rohitha Jayamaha
1) The document describes the experience of establishing a Comprehensive Pain Care (CPC) Clinic at a Provincial General Hospital in Sri Lanka. A survey found that chronic pain was a major complaint for many outpatients.
2) In response, the hospital set up a CPC Clinic using a multidisciplinary approach to assess, treat, and manage chronic pain through both invasive and non-invasive methods.
3) Over 25 months, the CPC Clinic treated over 2,000 patients, with around 22% receiving interventional pain procedures. The holistic CPC model focused on patient-centered care and lifestyle changes rather than individual treatment approaches.
Measure CritiqueCritiqued byDateName of measure FAD- .docxARIV4
Measure Critique
Critiqued by:
Date:
Name of measure: FAD- Family Assessment Devise
Developer(s):
Source reference (provide the complete citation, using correct APA format, of the article, book or website that contains the key information on the measure you are critiquing here):
Construct(s) assessed (e.g., depression, relationship satisfaction, stress):
Method of administration:
Summary of reliability evidence (this includes internal consistency reliability, usually Cronbach’s alpha and often test-retest reliability as well):
Summary of validity evidence (this may include discussions of content, criterion-related [concurrent and/or predictive], and construct [convergent and/or divergent] validity):
Describe the number of participants used to develop the measure and their demographic characteristics (e.g., age, gender, race/ethnicity):
Provide a brief summary of how clinicians have used this measure in therapy:
Recommendations for effective clinical use:
With what populations has this measure been used with (either clinically or in research) (e.g., age, gender, race/ethnicity, setting)
Find and briefly mention the purpose of 2-3 few research studies that have used the measure:
Provide a summary of the findings from one study that used this measure using this template:
Objective:
Method/Design:
Results:
What future research is needed on this measure?
Overall impression of measure:
References
Sample Measure Critique
Critiqued by: KL
Date: January 25, 2016
Name of measure: PHQ9
Developer(s): Kurt Kroenke, Robert L. Spitzer, & Janet B.W. Williams
Source reference:https://www.communitycarenc.org/media/related-downloads/depression-toolkit.pdf
Construct(s) assessed: Criteria-based diagnosis of depression in individuals seen in primary care and other medical and mental health facilities
Method of administration: Nine symptom checklist that can be professionally or self-administered (paper and pencil, electronically, or over the phone).
Summary of reliability evidence:
· Internal reliability was excellent, with a Cronbach’s alpha of 0.89 in a Primary Care Study and 0.86 in an OB-Gyn Study (Kroenke, Spitzer, & Williams, 2001).
· Test-retest reliability was very high at a 0.96 in a longitudinal study (Draper et al., 2008).
Summary of validity evidence:
In a study done by Kroenke et al. (2001), both criterion and construct validity were established as well as external validity. Construct validity was demonstrated in a sample of 580 primary care patients who underwent an independent re-interview. Criterion validity was shown by the strong association between PHQ-9 scores and functional status disability days and symptoms related difficulty. External validity was achieved by replicating the findings from 3,000 primary care patients in a second sample of 3,000 Ob-gyn patients.
· The PHQ-9 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 sores of 5, 10, 15, 20 fully represented mild, moderate, moderatel ...
This study evaluated depression, anxiety, and stress in 111 patients with oral cancer using the DASS-21 questionnaire. Scores were highest for stress at diagnosis, depression one month after treatment and three months after discharge, but lowest for anxiety at all timepoints. Depression and stress scores significantly increased between diagnosis and three months after surgery, while anxiety scores were stable. The DASS-21 effectively evaluated stress. A positive correlation was found between DASS-21 and HADS questionnaire results. Psychological intervention is recommended to improve patient outcomes.
This study aimed to develop abbreviated versions of the Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) for use in busy orthopedic settings. The researchers analyzed data from 164 patients and identified questions from the original scales that highly correlated with each other and the full scales. For the PCS, questions 3, 6, 8 and 11 were selected, creating the PCS-4. For the SHAI, questions 2, 3, 12, 15 and 17 were chosen, forming the SHAI-5. Both the PCS-4 and SHAI-5 showed good internal consistency and correlated highly with the original full scales. The abbreviated scales also correlated equally well with measures of disability,
This document provides instructions and questions for an assignment on clinical epidemiology and chronic disease epidemiology. It includes 7 questions assessing understanding of key epidemiological concepts like determinants of disease, epidemiological study designs, and interpreting results. Students are asked to apply their knowledge to analyze specific chronic diseases and epidemiological studies, as well as propose public health interventions.
TO REPLY 1 COMMENT TO EACH POST WITH CITATION AND TWO REFERENCE EACH.docxrowthechang
TO REPLY 1 COMMENT TO EACH POST WITH CITATION AND TWO REFERENCE EACH COMMENT APA ABOVE 2013.
POST 1
Three Questions for the Patient
After reviewing the material presented in this case study, there are some concerning questions regarding this patient’s psychiatric history. Additional questions would include:
After each discontinuation of medication after an episode of depression, was this decision the choice of a physician or self -initiated? This question would provide knowledge of the patient’s medication compliance. For example, does the patient stop taking prescribed medication on symptoms are alleviated?
What were the circumstances prior to each depressive episode? his question would enlighten the practitioner on triggers and factors that personally affect the patient before a depressive episode occurs.
There appears to be history of alcohol abuse and depression in your family, has anyone in your family received treatment? This question would provide a view into the patient’s understanding of psychiatric treatment. Since the patient does not believe in psychotherapy due to religious reason, the patient may not know what treatments were, are or will be available to him.
Feedback from People in Patient’s Life
The patient has been married for 33 years. Assuming his spouse is around before, during and after an episode, she may provide information the patient failed to share or may not have been honest about. The first person to be questioned would be the patient’s wife. Some of the questions for the patient’s wife would include onset of symptoms. What occurs before each episode of depression? Is there conflict between you and your spouse? Are there any stressors, such as financial plaguing your spouse and you?
The patient also has three children. All three of his children suffer from some form of depression. Questioning the patient’s children may provide a historical history of the patient. For example, the children may have noticed symptoms leading to the patient’s depression years ago. Questions for the children may include did your parent’s argue often while you were growing up? Did your father ever lose interest in your childhood years? Did you feel love or rejection while growing up from your father? What were your father’s behaviors? Did you ever notice any alcohol or drug abuse while growing up?
Physical and Diagnostic Exams for Patient
Unfortunately, there is not a certain test for depression. The primary goal of physical exam and diagnostic testing would to rule out other conditions causing similar symptoms. A physical exam should be preformed assessing respiratory and cardiovascular system. Vital signs should be taken as well.
Certain labs should be assessed in the patient. The practitioner should check the patient’s thyroid levels. Thyroid hormones have been linked to depression (Stahl, 2008). Depression can be caused by an underactive or overactive thyroid.
Another lab test to consider would be dexamethasone ...
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Labeling Woefulness: The Social Construction of FibromyalgiaPaul Coelho, MD
This document discusses the social construction of fibromyalgia and how it has been established as a legitimate disease label despite a lack of clear biological or clinical evidence. It argues that fibromyalgia serves social and economic purposes for various groups, including patients, doctors, pharmaceutical companies, and the media, but poses risks by medicalizing psychosocial problems. The document proposes that widespread pain is a normal human experience for some that is best addressed by exploring psychosocial factors rather than believing the solution lies in neurobiology. Examining fibromyalgia as a social construct may be more helpful for patients than continuing to medicalize their experiences.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document appears to be a questionnaire assessing symptoms of widespread pain and calculating a WPI (Widespread Pain Index) score and SS (Symptom Severity) score. It asks the respondent to indicate areas of pain on a diagram and rate the severity of symptoms like fatigue, thinking difficulties, and unrefreshed sleep. It also inquires about additional symptoms like abdominal pain, depression, and headaches. The final section rates pain-related worry and fear on a scale. Additional questions determine if the respondent has a workers compensation or disability claim related to their pain complaint.
Fibromyalgia is a condition that causes chronic aches and pains all over the body, fatigue, and often a sleep disorder. The doctor diagnosed the patient with fibromyalgia based on a score of 13 or more on the fibromyalgia questionnaire from the American College of Rheumatology, which is consistent with the syndrome. By focusing on and managing the diagnosis of fibromyalgia, the patient's other pain symptoms can decrease.
This document contains two studies related to psychological treatments for chronic conditions:
1) A study of chronic fatigue syndrome patients found that poorer outcomes were predicted by membership in a self-help group, receiving sickness benefits, and symptoms of dysphoria. Severity and duration of symptoms did not predict response.
2) A randomized controlled trial of 125 fibromyalgia patients compared operant behavioral therapy, cognitive behavioral therapy, and attention placebo. Both behavioral therapies significantly reduced pain intensity while cognitive therapy improved cognitive and affective variables and operant therapy improved physical functioning and behaviors. The attention placebo resulted in no improvement or deterioration.
This document summarizes three studies on the risks and efficacy of opioids for chronic non-cancer pain (CNP). The first study finds that while opioids were associated with small improvements in pain and physical functioning compared to placebo, they also increased the risk of vomiting. Comparisons to other medications found similar benefits to pain and functioning. The second study finds no difference in pain-related function between opioid and non-opioid groups over 12 months, and higher rates of adverse effects and pain intensity in the opioid group. The third study finds limited effectiveness of opioids for CNP, as opioid users did not report improvements in outcomes after 2 years. Regarding risks, higher opioid doses are associated with increased overdose risk across several patient groups in
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Mortality quadrupled among opioid-driven hospitalizations notably within lowe...Paul Coelho, MD
This study analyzed national hospitalization data from 1993-2014 to examine trends in mortality and characteristics of hospitalizations related to opioids compared to other drug and non-drug hospitalizations. The key findings were:
1) Mortality among opioid-related hospitalizations quadrupled from 0.43% before 2000 to 2.02% in 2014, increasing 0.12 percentage points per year relative to other drug hospitalizations.
2) While total opioid-related hospitalizations remained stable, diagnoses shifted from opioid dependence/abuse to opioid/heroin poisoning, which have higher mortality rates. Hospitalizations for poisoning grew by 0.01 per 1,000 people annually after 2000.
3) Patients hospitalized for opioid/
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
This study examined the risk of psychiatric hospitalization in the offspring (second generation) of Finns who were evacuated to Sweden without parents during World War II (first generation), compared to offspring of Finns who were not evacuated. The study found that daughters of mothers who were evacuated during childhood had an elevated risk of psychiatric hospitalization, especially for mood disorders. However, there was no increased risk found for offspring of evacuated fathers or for male offspring of evacuated mothers. This suggests that early childhood adversity experienced by the first generation, such as war-related trauma, may be associated with mental health problems that persist into the second generation.
Correlation of opioid mortality with prescriptions and social determinants -a...Paul Coelho, MD
This study analyzed Medicare Part D data from 2013-2014 to examine the relationship between opioid prescription rates, socioeconomic factors, and opioid-related mortality rates at the county level in the United States. The results showed that higher county-level opioid prescription rates, especially those from emergency medicine, family medicine, internal medicine, and physician assistants, were associated with higher opioid-related mortality rates. Higher poverty levels and proportions of white populations in counties also correlated with increased mortality. Additionally, prescribers in the highest quartile of opioid prescription rates had a disproportionate impact on mortality compared to the remaining 75% of prescribers.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
This study analyzed opioid prescription trends among medical specialties in the U.S. from 2007-2012 using a national prescription database. The key findings were:
- Primary care specialties (family practice, internal medicine, general practice) accounted for nearly half of all dispensed opioid prescriptions in 2012.
- Specialties treating pain conditions like pain medicine, surgery, and physical medicine had the highest rates of opioid prescribing.
- Overall opioid prescribing rates increased from 2007-2010 but stabilized from 2010-2012 as most specialties reduced rates.
- The greatest increase in opioid prescribing was among physical medicine specialists, while the largest decreases were in emergency medicine and dentistry.
The place-of-antipsychotics-in-the-therapy-of-anxiety-disorders-and-obsessive...Paul Coelho, MD
This document summarizes a research article about the use of antipsychotic drugs in the treatment of anxiety disorders and obsessive-compulsive disorders. The review finds evidence that certain second-generation antipsychotics (SGAPs), like quetiapine, risperidone, and aripiprazole, can be effective for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD). Quetiapine in particular receives a recommendation as a first-line treatment for GAD. However, the review finds insufficient evidence for SGAPs in the treatment of social anxiety disorder and panic disorder. First-generation antipsychotics are not recommended for any anxiety disorders based on their side effect profiles
Structured opioid refill clinic epic smartphrases Paul Coelho, MD
#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, an...Paul Coelho, MD
This document summarizes the key issues regarding the use of opioids for chronic pain treatment:
1) An overreliance on opioids to treat chronic pain has contributed to the prescription opioid abuse epidemic in the US, as outpatient use allows for abuse and diversion of these addictive drugs.
2) While clinical trials show opioids effectively treat acute pain and are initially effective for chronic pain, real-world use reveals increased risks of abuse, addiction, and poor functional outcomes over the long-term.
3) The evidence supporting chronic opioid therapy was limited and observational in nature, yet convinced the medical community until larger population studies showed increased abuse rates contrary to initial assumptions.
The potential adverse influence of physicians’ words.Paul Coelho, MD
The physician's words can inadvertently amplify patients' symptoms and increase somatic distress if not carefully considered. Learning about potential side effects from medications, procedures, or test results can lead patients to experience and report those effects more frequently through psychological mechanisms like misattribution and increased attention to bodily sensations. Discussing concepts like nocebo and viscerosomatic amplification with patients can help provide reassuring explanations for symptoms and make them feel less intrusive. Physicians should thoughtfully consider their word choices and focus on benefits as well as side effects to minimize undue distress.
This document is an evidence report published by the Institute for Clinical and Economic Review (ICER) that evaluates the comparative clinical effectiveness and value of cognitive and mind-body therapies for chronic low back and neck pain. It was authored by Jeffrey Tice and others from ICER. The report assesses the clinical evidence on therapies such as cognitive behavioral therapy and mindfulness-based stress reduction and presents economic analyses of the long-term cost-effectiveness and potential budget impact of these therapies. It also incorporates input from clinical experts and stakeholders.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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2. by the direct effects of a substance, or by another mental disorder, are
usually considered by non-psychiatrists to be functional disorders and
functional somatic syndromes (FSSs) respectively [9]. Whether FSS
such as irritable bowel syndrome or fibromyalgia syndrome (FMS)
should be diagnosed as a somatoform disorder, in accordance with
DSM 4, has been a matter of debate [10,11]. Not surprisingly, a discus-
sion started on the application of the SSD diagnostic category to
FSS [12]. .
Given the uncertainties on the prevalence of SSD in FSS and the va-
lidity and usefulness of SSD diagnosis in patients with FSS, we assessed
how many patients diagnosed with FMS in a pain medicine setting met
the current research criteria of a SSD. Furthermore we tested the con-
struct validity and clinical utility of current research criteria of SSD in
these patients.
Methods
Setting
All examinations and interviews with the patients were conducted
by the first author (WH) in an outpatient ambulatory health care center
(secondary care level) for pain medicine. Patients were referred by
rheumatologists or general practitioners or made an appointment by
their own.
Patients
All consecutive patients who presented to the first author from
January 2, 2013 to December 31, 2014, for the evaluation and/or
management of chronic widespread pain/FMS were screened for eligi-
bility for the study. The inclusion criteria were as follows: 1. Medical
testing according to the German guideline on FMS [13] to exclude
somatic diseases fully explaining the symptoms was performed.
Patients with somatic diseases which could explain a part of pain sites
(e.g., osteoarthritis) were included. 2. Patients were designated as
having criteria positive fibromyalgia if they satisfied research criteria
for fibromyalgia [14,15]. 3. Patients were informed either by physicians
and/or by information seeking by their own that FMS is a) a disease
with a normal life expectancy and b) not a progressive illness
that leads to inability to function (e.g., to need a wheel chair). The
exclusion criteria were as follows: 1. Patients with a duration of
FMS-diagnosis b6 months, 2. Patients with concomitant FMS in
inflammatory rheumatic diseases under immunosuppressive treatment
(e.g., biologicals, corticosteroids, methotrexate). To our clinical experi-
ence, FMS-related fears of these patients cannot be disentangled from
fears regarding the course of the inflammatory rheumatic disease and/
or side effects of immunosuppressive therapies, 3. Patients in which
FMS was diagnosed for the first time by the author or which had not
been informed on the normal life expectancy and lack of progress to in-
ability to function in FMS. The German guideline on the management of
FMS recommends as a first of therapy after establishing the diagnosis of
FMS for the first time, that patients should be educated on these issues
to reduce potential symptom-related anxieties [13], and 4. Patients who
were unable to properly complete the questionnaires due to language
or intellectual barriers.
A battery of questionnaires was used by the first author for routine
clinical assessment. The questionnaires were sent to the patient before
the first appointment for completion at home. During the first appoint-
ment the results of the questionnaires were discussed with the patients
and additional questions, e.g., on longer symptom duration than indi-
cated in the self-report questionnaires were asked. The completed ques-
tionnaires were kept apart from medical charts in a separate room only
accessible to the first author. In addition, at the first appointment
patients were required to present records of medical diagnostic and
treatment relating to their symptoms.
Measures
Polysymptomatic distress scale (PSD)
The Widespread Pain Index (WPI) is a 0–19 count of painful body re-
gions. The Symptom Severity Score (SSS) is the sum of the severity
(0–3) of the three symptoms (fatigue, waking unrefreshed, cognitive
symptoms) plus the sum of the number of the following symptoms oc-
curring during the previous six months: headaches, abdominal pain,
and depression (0 = no, 1 = yes). The final score is between 0 and
12. For fatigue, waking unrefreshed, and cognitive problems, scoring is
0 No problem; 1 Slight or mild problems, generally mild or intermittent;
2 Moderate, considerable problems, often present and/or at a moderate
level; and 3 Severe: continuous, life-disturbing problems. The 0–19
widespread pain index and the 0–12 symptom severity score can be
combined by addition into a 0–31 PSD index. The PSD scale is a measure
of the intensity of FMS symptoms and correlates with all general mea-
sures of distress [14].
Patient Health Questionnaire-15
We used the Patient Health Questionnaire (PHQ) as a measure of so-
matic symptom burden [16] and as a generic measure of FMS severity
[17] with scores of 5, 10, and 15 representing cutoff points for low,
medium, and high somatic symptom (FMS) severity, respectively. We
used the validated German version of the PHQ 15 [18].
Patient Health Questionnaire-4
The 4-item Patient Health Questionnaire-4 (PHQ-4) comprises two
DSM-IV criteria of major depression as “0” (not at all) to “3” (nearly
every day) and two DSM-IV criteria of general anxiety disorder [19].
The total score of the PHQ- 4 (Minimum 0, Maximum 12) is a validated
measure of psychological distress [20]. We used the validated German
version of the PHQ-4 [20].
Whiteley Index
The Whiteley Index (WI) is a widely used instrument for measuring
hypochondriacal worries and beliefs. Fourteen questions can be an-
swered in a dichotomic format (yes/no) [21]. We used the validated
German version of the WI [22].
Pain Catastrophizing Scale
The Pain Catastrophizing Scale (PCS) includes 13 items. Participants
are asked to indicate on a 5-point Likert scale the degree to which they
experience various thoughts and feelings on a painful experience. The
total score, indicating the degree of pain catastrophizing, ranges from
0–42. There are no validated cut-off scores of the PCS available neither
for chronic pain patients as a whole nor for fibromyalgia patients as a
subgroup. The authors of the PCS suggest that a total PCS score of 30 rep-
resents clinically relevant level of catastrophizing. In addition we de-
fined an additional cut-off score by the 75th percentile of the study
sample. The reliability and validity of the PCS have been demonstrated
in samples of clinical institutions and of the general population [23,
24]. We used the validated German version of the PCS [25].
Pain Disability Index
The Pain Disability Index (PDI) measures impairment by pain in
seven areas of daily living (family/home responsibilities, recreation, so-
cial activities, occupation sexual behavior, self-care, life-support activi-
ty) on an 11 point Likert scale. The total score of the PDI ranges from
0–70. Psychometric evaluations of the PDI in outpatients and inpatients
with chronic pain found high internal consistency, test–retest reliability
and good convergent validity in reference to pain characteristics
and pain behavior [26]. The validated German version of the PDI was
used [27].
2 W. Häuser et al. / Journal of Psychosomatic Research xxx (2015) xxx–xxx
Please cite this article as: Häuser W, et al, Construct validity and clinical utility of current research criteria of DSM-5 somatic symptom disorder
diagnosis in patients with ..., J Psychosom Res (2015), http://dx.doi.org/10.1016/j.jpsychores.2015.03.151
3. Demographic measures and health care use
The German Pain Questionnaire assesses data on demographics,
employment and disability (e.g., applying for disability pension),
pain, chronic somatic diseases, previous and current treatment of pain
and other diseases and health care seeking (number of doctor visits
within the last 6 months, number of physiotherapies during the last
6 months, number of doctors consulted because of chronic pain prob-
lems and number of hospital stays because of chronic pain problems)
[28]. The answers of the patients in the questionnaire were verified by
the interview and by the medical reports presented by the patient
and – if necessary – modified.
Structured psychiatric interview
Patients underwent a structured psychiatric interview for current
anxiety (including posttraumatic stress disorder [PTSD]) (ICD 10 F 40,
F 41, F 43.1) and depressive (ICD-10 F 32, F33, F 34) disorder using
the International Classification of the World Health Organization check-
list [29]. In addition, patients were asked to report any lifetime in- and
out-patient psychiatric and psychotherapeutic treatments. At least
three appointments with a psychiatrist with at least one prescription
of a psychotropic drug were required to define a psychiatric treatment
within the assessment of health care use. At least five sessions with a li-
censed psychotherapist were required to define a psychotherapeutic
treatment within the assessment of health care use.
Diagnoses of FMS and SSD
For patients to be diagnosed with FMS they had to have either a WPI
score ≥7 and SSS ≥5, or a WPI between 3–6 and SSS ≥9 (research
criteria of FMS) [15,16].
We referred to diagnostic criteria for DSM-5 diagnosis of SSD of
previous studies [5,7]:
a. For criterion A (distressing somatic symptom), patients had to re-
port to be bothered a lot by at least one symptom of the PHQ-15.
For each symptom reported in the PHQ-15, patients were addition-
ally asked if this symptom had been present during the last six
months, on at least half of the days, to assess criterion
b. We employed the WI [21,22] to measure criterion B2 (persistently
high level of anxiety about health or symptoms) by choosing a cut-
off score of 8. We did not use the cut-off score of 6 as previous
studies did [5,7] because two items of the WI, namely to be bothered
“by many different pains and aches” and “by many different symp-
toms” are diagnostic features of FMS [15]. To provide comparability
with previous studies, we report the prevalence rates of SSD using a
WI cut-off score of 6 too.
Recommendation for psychotherapy
Two specialists in pain medicine (one anesthesiologist [PB] and one
psychologist [KW]) experienced in the management of FMS-patients
were blinded to the purpose of the study. They checked independently
the anonymous medical reports wrote by the first author (WH) after the
first appointment. The medical report included the ICD10-diagnoses of
the patient, the medical and psychiatric history of the patients, the cur-
rent somatic and psychological symptoms, the ways of coping with the
symptoms by the patient, the impact of symptoms on daily life and the
results of previous medical and psychological treatments. The recom-
mendations for further management by the first author were removed
from the medical report. The two raters were blinded if the patients
met the criteria of a SSD. Based on the data of the medical report, the
raters assessed if they would recommend to start a psychotherapeutic
treatment to the patient or to continue an ongoing psychotherapeutic
treatment. The recommendations for psychotherapy were based on
the German guideline on the management of FMS which recommends
psychotherapy in the following clinical constellations: a) maladaptive
disease management (e.g., catastrophizing, inappropriate physical
avoidance behavior or dysfunctional perseverance) b) and/or relevant
modulation of the symptoms due to stress of daily life and/or interper-
sonal problems and/or c) comorbid mental disorders with negative im-
pact on FMS-symptoms and coping [30]. Discrepancies in the ratings
were resolved by consensus between the two raters, and if necessary
by the first author.
Hypotheses
Discriminative concurrent criterion validity
The DSM 5 working group on SSD postulated that the combination of
distressing somatic symptoms (A-criterion) and B-type criteria are as-
sociated with functional impairment and increased healthcare use [2].
Therefore we tested if FMS-patients meeting the SSD research criterion
reported higher levels of disability, sick leave and applying for disability
pension (if not housemaker or pensioner) and exhibited more health
care seeking than FMS-patients not meeting current SSD research
criteria.
Clinical utility
The DSM 5 working group on SSD postulated that the diagnosis of
SSD promotes the recommendations of psychological therapies [2].
Therefore we tested if FMS-patients meeting current SSD research
criteria received more recommendations for psychotherapeutic treat-
ment than FMS-patients not meeting the SSD research criteria by the
two blinded assessors.
Statistical analysis
All questionnaires were discussed with the patients and missing
items completed during the first appointment.
Statistical analyses were conducted with the SPSS 20.0 statistical
package. Absolute values and percentages were used for descriptive
statistics of categorical data and means with standard deviations for de-
scriptive statistics of continuous data. Group comparisons of categorical
data were performed by Chi2
-tests and of continuous data by the t-test.
Cohen's Kappa was used as a measure of interrater reliability. P-values
are reported unadjusted for multiple testing in the tables, permitting
the application of preferred methods of adjustment by the readers.
Twenty-five % of 375 patients of a German FMS multicentre study
applied for disability pension [31]. For our study, 54 patients per
group would be necessary to detect a difference of 25% in applying for
disability pension with 80% power and a 1-sided alpha level of 0.05.
Ethics
All participants were informed about the study procedures and gave
their informed consent. The study was reviewed and approved by the
institutional ethics review board of the Medical Faculty of the Ludwig-
Maximilian-University Munich (Project-Number 010-12). There was
no external funding for the study.
Results
Study sample
Of the 198 patients screened for eligibility, 42 were excluded due to exclusion criteria
(see Fig. 1). One hundred and fifty six patients were included into analyses. All patients
were Caucasians.
Prevalence of diagnoses of SSD
176 (99.4%) of patients reported to be bothered a lot by at least one of fifteen somatic
symptoms in the PHQ 15 (A-criterion). 46.8%, 33.3%, 25.6%, 13.5% and 6.4% respectively of
patients reached the WI cut-off scores of 6, 7, 8, 9 and ≥10.
3W. Häuser et al. / Journal of Psychosomatic Research xxx (2015) xxx–xxx
Please cite this article as: Häuser W, et al, Construct validity and clinical utility of current research criteria of DSM-5 somatic symptom disorder
diagnosis in patients with ..., J Psychosom Res (2015), http://dx.doi.org/10.1016/j.jpsychores.2015.03.151
4. 40 (25.6%) patients of the study sample met the predefined criteria of SSD (at least
one distressing symptom in the PHQ 15 and WI score ≥8).
Comparisons of patients with and without meeting SSD criteria
There were no significant differences between the two groups in demographic vari-
ables (age, gender, family status, highest educational level, current professional status)
(see Table 1).
The percentage of patients without job or sick leave (pensioners and homemakers
excluded) did not significantly differ between both groups (Chi2
= 0.1, P = .72). The
percentage of patients applying for disability pension (pensioners and homemakers
excluded) did not significantly differ between both groups (see Table 1).
There were no significant differences between the two groups in the duration of wide-
spread pain and time since FMS-diagnosis. Patients meeting SSD-criteria reported signifi-
cantly more symptoms in the PSD and PHQ 15, more psychological distress in the PHQ 4
and more pain catastrophizing in the PCS than patients not meeting SSD-criteria. Patients
meeting SSD-criteria reported significantly higher levels of disability in the PDI
(see Table 2).
Patients meeting SSD-criteria met significantly more frequently the criteria of a prob-
able current depressive or anxiety disorder by the PHQ 4. Patients meeting SSD-criteria
met significantly more frequently the criteria of current depressive disorder but not of a
current anxiety disorder in the psychiatric interview (see Table 3)
Patients meeting SSD-criteria did not report more doctor visits and physiotherapy
treatments in the previous six months. There were no significant differences between
the two groups in the frequency of previous in- and outpatient pain therapy, of previous
inpatient rehabilitation because of chronic pain and of previous in- and out-patient psy-
chotherapy due to any reason during lifetime. Patients meeting SSD-criteria reported
less current outpatient psychiatric treatment due to any reason than patients not meeting
SSD-criteria (see Table 4).
Cohen's kappa of the ratings for recommendation of psychotherapy was 0.64. 32/40
(80.0%) of patients with SSD and 64/116 (66.7%) of patients without SSD received a con-
sensus recommendation for psychotherapy (Chi2
= 7.8; P = .005).
Discussion
Summary of main results
25% of 156 German patients diagnosed with FMS met current re-
search criteria of a SSD (at least one very distressing somatic symptom
and persistently high level of anxiety about health symptoms). Patients
meeting SSD criteria scored significantly higher in a self-report measure
of disability. There were no significant differences in the number of pa-
tients on sick leave or applying for disability pension and in self-
reported doctor visits and physiotherapies in the previous six months.
Patients with SSD received more frequently a recommendation for
psychotherapy.
Characteristics of the study sample
The demographic data of the study sample with a preponderance of
middle aged women, the high percentage of patients with sick leave
and/or applying for disability pension are in line with the ones reported
by previous German FMS multicenter studies [31,32] as well as of re-
views of international studies [33]. The prevalence rates of (probable)
mental disorders of the study sample is similar to the ones we found
Assessed for eligibility
(n = 198)
Excluded (n=42)
Not meeting inclusion criteria
(n =42)
- First diagnosis of FMS (n=26)
- FMS diagnosis < 6 months
(n=9)
- No adequate education (n=2)
- Inflammatory rheumatic
disease with immuno-
suppressive medication (n=4)
- Language barrier (n=1)
Refused to participate
(n =0)
Other reasons (n =0)
EnrollmentAnalysis
Analyzed (n =156)
Excluded from analysis
(n =0)
Fig. 1. Study flow chart.
Table 1
Comparison of demographic and clinical variables of fibromyalgia syndrome patients with
and without meeting DSM 5 current research criteria of somatic symptom disorder.
Somatic
symptom
disorder
N = 40
No somatic
symptom
disorder
N = 116
Comparison;
P-value
Mean age (mean, SD) 51.6 (8.9) 49.8 (9.6) t = 0.94; .34
Female gender; N (%) 34 (85.0) 105 (90.5) Chi2
= 0.9; .33
Living with family/partner; N (%) 33 (82.5) 82 (71.3) Chi2
= 1.9; .16
Highest educational level Chi2
= 4.2; .38
None N (%) 0 (0) 4 (3.4)
Primary school N (%) 20 (50.0) 51 (44.0)
Secondary school N (%) 12 (30.0) 41 (35.3)
High school N (%) 2 (5.0) 11 (9.5)
University N (%) 6 (15.0) 9 (7.8)
Current professional status Chi2
= 7.0; .22
Working N (%) 12 (30.0) 45 (38.8)
Without job N (%) 10 (25.0) 15 (12.9)
Sick leave N (%) 6 (15.0) 19 (16.4)
Pension N (%) 8 (20.0) 22 (19.0)
Homemaker N (%) 4 (10.0) 15 (12.9)
Applying for disability pension
[pension and homemaker excluded]
N (%)
10 (35.7) 19 (24.0) Chi2
= 1.4; .23
4 W. Häuser et al. / Journal of Psychosomatic Research xxx (2015) xxx–xxx
Please cite this article as: Häuser W, et al, Construct validity and clinical utility of current research criteria of DSM-5 somatic symptom disorder
diagnosis in patients with ..., J Psychosom Res (2015), http://dx.doi.org/10.1016/j.jpsychores.2015.03.151
5. in previous German FMS multicenter studies [34] as well as of system-
atic reviews on FMS and mental disorders [35].
Prevalence of SSD
The percentage of patients meeting the current SSD research criteria
[5–7] would have been 47% in our study and similar to the rate of 52% in
German psychosomatic inpatients diagnosed with somatoform disor-
ders [5] if the same criteria for persistently high level of anxiety about
symptoms by a threshold of 6 on the WI would have been used. By in-
creasing the cut-off score of the WI to 8, the prevalence rate of SSD de-
creased to 25% in our sample. 5.7% of participants of a UK population
based sample reported both high somatic symptom burden (PHQ
15 ≥ 10) and high health anxiety (WI total score ≥ 5) [36]. To sum up,
the prevalence rates of SSD depend on the research criteria used, the
setting of the study and the underlying severity of the patients in the
study sample.
Validity of current SSD research criteria in patients with FMS in clinical
institutions
a. 97% of patients of our study sample reported more than one very
distressing symptom in the PHQ 15. Our data support the assump-
tion that the A-criterion of SSD might be overinclusive because it
requires only one very distressing symptom [37].
b. We question if some items in the WI are appropriate measures for
high levels of disease-related anxieties in FMS-patients. The research
criteria of FMS [15] require the self-reports of two WI items, namely
“to be bothered by many different pains and aches” and “by many
different symptoms”. After the publication on findings on small
fiber pathology in FMS [38], some patients of our study reported in
the interview that they often worried “about the possibility (to)
have a serious illness” or that “there is something seriously wrong
with (their) body”. Other patients worried “a lot about (their)
health” because they were afraid to lose their job because of sick
leave due to their FMS-problems.
The B1 (disproportionate and persistent thoughts about the serious-
ness of one's symptoms) – and B2 (persistently high level of anxiety
about health or symptoms) – diagnostic categories of SSD run the
risk to transform the uncertainties and controversies on FMS of the
scientific community [39] into a mental disorder of the patient.
Disease related thoughts and feelings are the result of the interaction
of the patient with significant others and the medical system [9].
Some FMS authors claim that “fibromyalgia is a persistent and debil-
itating disorder that can have a devastating effect on people's
lives”[40]. Patients searching for information in the internet with
the search term “fibromyalgia” will get 20 million hits in Google
with most prominent information on the seriousness (B1 criterion
of SSD of FMS-symptoms).
Concerns about the over-inclusive criteria of SSD[37], which risks to
mislabeling people as mentally ill, has been raised patients with
major medical diseases [41,42]. These concerns might also be valid
for patients diagnosed with FMS. The DSM 5 authors of SSD replied
to these concerns that “every. diagnosis relies on clinical experience
and judgment, as has always been the case”[43]. There was insuffi-
cient interrater reliability when somatic symptoms were not attrib-
utable to biomedical conditions for the diagnosis of a somatoform
disorder [2]. We speculate that the clinical judgment about
which thoughts, feelings and behaviors associated with FMS are
“excessive” or “disproportionate” for the diagnosis of a SSD will be
as arbitrary and less reliable than the clinical judgment if somatic
symptoms are not attributable to a biomedical condition for the
diagnosis of a somatoform disorder.
c. No research criteria have been defined for criterion B3 (excessive
time and energy devoted to these symptoms or health concerns)
until now. Health care use has been assessed in population-based
studies to support the concept of SSD [12,44]. We used this criterion
for the validation of SSD in our study too. However, national differ-
ences of health care systems and its use must be kept in mind. In ad-
dition, patients might understand “excessive” health care use to be
self-caring behavior. Based on this comment of a patient representa-
tive on the protocol of our Cochrane review on cognitive behavioral
Table 2
Comparison of somatic and psychological symptoms of fibromyalgia syndrome patients with and without meeting DSM 5 current research criteria of somatic symptom disorder.
Somatic symptom disorder
N = 40
No somatic symptom disorder
N = 116
Comparison; P-value
Mean years since chronic widespread pain (SD) 8.6 (6.4) 8.2 (7.1) t = 0.3; .80
Mean years since fibromyalgia diagnosis (SD) 3.6 (4.3) 3.3 (3.5) t = 0.5; .66
Mean number of pain sites polysymptomatic distress scale (SD) (0–19) 13.3 (3.9) 12.7 (3.5) t = 0.8; .40
Mean total score polysymptomatic distress scale (SD) (0–31) 23.3 (4.7) 21.1 (5.0) t = 2.4; .01
Mean somatic symptom burden PHQ 15 (SD) (0–30) 20.0 (4.3) 16.9 (5.6) t = 3.1; .002
Fibromyalgia severity PHQ 15 N (%) Chi2
= 6.5; .09
Slight (5–9) 0 8 (7.2)
Moderate (10–14) 5 (13.9) 31 (27.9)
Severe (15–30) 31 (86.1) 72 (64.9)
PHQ 15 total score ≥ 10 N (%) 40 (100) 106 (91.4) Chi2
= 3.6; .06
Mean psychological distress Patient Health Questionnaire 4 total score (SD) (0–12) 8.9 (2.6) 6.3 (3.6) t = 4.6; b.0001
Mean total score pain catastrophizing (SD) (0–42) 36.5 (7.8) 22.8 (11.6) t = 6.9; b.0001
N (%) ≥30 35 (87.5) 37 (31.9) Chi2
= 37.0; b.0001
N (%) ≥35 23 (57.5) 16 (16.0) Chi2
= 30.3;b.0001
Pain Disability Index total score (SD) (0–70) 45.9 (10.2) 36.6 (13.0) t = 4.1; b.0001
Significant differences are marked as bold.
Table 3
Comparison of (probable) mental disorder diagnoses of fibromyalgia syndrome patients with and without meeting DSM 5 current research criteria of somatic symptom disorder.
Somatic symptom disorder
N = 40
No somatic symptom disorder
N = 116
Comparison; P-value
Probable depressive disorder PHQ 4 N (%) 34 (91.3) 68 (61.3) Chi2
= 12.2; b.0001
Probable anxiety disorder PHQ 4 N (%) 36 (90.0) 64 (64.0) Chi2
= 15.7; b.0001
Current depressive disorder (F 32, F 33, F 34) by psychiatric interview N (%) 25 (62.3) 45 (38.8) Chi2
= 6.8; .009
Current anxiety disorder (F 40, F 41, F 43.1) by psychiatric interview N (%) 13 (32.5) 28 (24.1) Chi2
= 1.1; .30
No current depressive and anxiety disorder by psychiatric interview N (%) 2 (5.0) 33 (28.4) Chi2
= 9.4; .002
Significant differences are marked as bold.
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Please cite this article as: Häuser W, et al, Construct validity and clinical utility of current research criteria of DSM-5 somatic symptom disorder
diagnosis in patients with ..., J Psychosom Res (2015), http://dx.doi.org/10.1016/j.jpsychores.2015.03.151
6. therapies [45], the outcome “health care use” was not included into
the review (personal communication).
d. Our findings support the discriminative concurrent criterion validity
of SSD only for self-report measures of disability (PDI), but not for
objective measures of disability (sick leave, applying for disability
pension) and of health care use (number of doctor and physiothera-
pist visits in the previous six months). Of note, FMS-patients with
SSD reported also more (intensive) somatic and psychological
symptoms and pain catastrophizing that FMS patients without
SSD. Previous US and German studies demonstrated a tendency of
FMS patients to report (high intensities of) any type of somatic and
psychological symptoms [46,47]. Even if FMS can be conceptualized
to be the end of a continuum of biopsychosocial distress [48], people
diagnosed with FMS can be at the end or at the very end of the
continuum, that is to say, may report many or very many somatic
and psychological symptoms. The significant differences between
the two study subgroups in all self-report measures could therefore
be explained by differences in symptom reporting. In addition, the
differences in all self-report measures that we did find, though sig-
nificant, were not clinically important. Only 5% of FMS/SSD-
patients did not meet the criteria of an anxiety or depressive disor-
der. The strong association of FSS with anxiety and depression has
been demonstrated by systematic reviews [49]. Disproportionate
and persistent thoughts about the seriousness of one's symptoms
and persistently high level of anxiety about symptoms can also be
accounted for by a depressive or generalized anxiety disorder.
This view challenges the necessity of the diagnostic category of
a SSD in addition to the existing categories of anxiety (including
hypochondria) and depressive disorders.
Clinical utility of SSD research criteria in patients with FMS in clinical
institutions
In line with the hypothesis, FMS patients with SSD received more
frequently recommendations for psychotherapy by raters blinded for
the purpose of the study. The recommendation was based on the Ger-
man guideline on FMS [31]. However, the different rates of recommen-
dations for psychotherapy can be explained by the differences in the
frequency of current anxiety and depressive disorders which were one
criterion for the recommendation of psychotherapy. In addition, the dif-
ference was not clinically meaningful because two third of the patients
without SSD received a recommendation for psychotherapy by the
blinded assessors.
Limitations
a. We report results of a single center study of secondary care
level that limit the generalizability of the findings. However, the demo-
graphic and psychosocial characteristics of the study center did not
substantially differ from the ones of other German centers of different
settings in previous studies [32,33]. In addition, the psychosocial
characteristics of FMS patients of the study center did not significantly
differ from the ones of FMS-patients of private rheumatology practices
in Washington, D.C. [50]. b. Study findings on health care use in
Germany cannot be generalized to other health care systems. In contrast
to US and UK countries, inpatient and outpatient pain therapy and psy-
chiatric and psychotherapeutic treatmentsare easily available for
German patients. Therefore the study findings on health care use of
FMS-patients with and without SSD might be different in other coun-
tries. c. Our study was underpowered to detect smaller differences be-
tween the two groups in objective measures of disability and health
care use. However, our data question the clinical relevance of these
potential differences.
Conclusions
Current German guidelines categorized FMS as a FSS [14]. The guide-
lines stressed the importance of psychosocial factors in the etiology of
FMS, and the need of psychological therapies in case of mental disorders
or inappropriate coping with the symptoms [31]. Therefore the existing
diagnostic code of FMS (M79.7), located in the ICD classification system
in somatic diseases, and – if present – of comorbid ICD-10 mental
disorders, except somatoform disorder, may be sufficient for the classi-
fication of symptoms and for the management of FMS-patients.
The following five criteria have been suggested for possible inclusion
of a new category into DSM: Adequate literature, specified diagnostic
criteria, acceptable interclinician reliability, evidence that the criteria
form a syndrome, and differentiation from other categories [51]. More
studies with patients with somatic diseases and functional somatic syn-
dromes are necessary to test if current or modified research criteria of
SSD will meet these criteria or not [12,42,52] and if the diagnostic cate-
gory is useful in clinical practice or not.
Conflicts of interest
Winfried Häuser is a member of the medical board of the German
Fibromyalgia Association. The other authors of this article report no
conflict of interest.
Funding source
The study was conducted without external funding.
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Comparison of self-reported health care use of fibromyalgia syndrome patients with and without meeting DSM 5 current research criteria of somatic symptom disorder.
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