Chronic pelvic pain

Chronic pelvic pain is one of the most challenging gynecologic problems seen in primary care practice. Important causes of this problem include endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, and the syndrome of chronic pelvic pain without obvious pathology. The diagnostic approach to chronic pelvic pain begins with a careful medical history and physical examination in conjunction with a comprehensive psychosocial assessment. Laboratory evaluation may include pelvic ultrasonography, psychometric testing, and diagnostic laparoscopy. Optimal management of these patients may require a multidisciplinary approach, integrating chronic pain management techniques with specific therapy.     

Helicobacter pylori associated with chronic urticaria

Chronic urticaria is one of the most frequent skin diseases in medical practice. Urticaria is defined as acute if the whealing persists for less than six weeks and as chronic if it persists for longer. Chronic urticaria that lasts for several years to decades significantly impairs the quality of life. There is evidence that Helicobacter pylori has a critical role in different extragastric diseases such as chronic urticaria. We present a case of chronic urticaria in an adult patient with H. pylori infection and disease regression after triple anti-H. pylori therapy. In contrast to the autoimmune mechanisms involved in chronic urticaria against which no specific treatment strategy has been developed, infections with H. pylori could be treated with triple therapy. It is suggested that laboratory tests for the detection of this pathogen should be performed in patients with chronic urticaria.     

Psychosocial Differences in High Risk Versus Low Risk Acute Low-Back Pain Patients

The current study built upon previous research that predicted with 90.7% accuracy which patients presenting with acute low-back pain go on to develop chronic disability problems. Fifty-seven patients were classified as high risk (HR) or low risk (LR) according to a predictive algorithm, and were evaluated with a variety of psychosocial measures. Overall, HR patients had more Axis I pathology than LR patients, and used poorer coping styles. Logistic regression analyses identified variables that differentiated, with 80% accuracy, between the HR and LR patients. The results highlight the importance of identifying patients who are at risk for developing chronic pain following acute injury so that prophylactic intervention can be offered before chronic pain disability status becomes entrenched.     

The impact of primary care patients' pain and emotional problems on their confidence with self-management

There is a paucity of information about confidence with self-management in primary care practice. This study examines changes over time in patient-reported confidence with self-management on the basis of 1047 patients aged 50-69 who had common chronic diseases, bothersome pain, or emotional problems. We examined the relationship between patients' self-reported confidence, their experiences of medical care, and health outcomes after adjustment for baseline characteristics. We observed that, over a 2-year period, about a third of the patients remained confident and a third remained not confident. Change in pain or emotional problems was strongly associated with whether a patient was confident or not at the end of the follow-up period (P < .001). Persistently good confidence or improved confidence was strongly associated with measures of high-quality medical care. For patients with diabetes, persistent confidence was more often associated with control of blood glucose (P = .004) compared with the control in patients who were not as confident. Confident patients were likely to be fully engaged in everyday work and activities (P < .001). The results suggest that for the majority of patients in primary care practices, the status of their self-reported confidence with self-management persists over time. Their confidence is impacted by their pain or emotional state and strongly associated with their medical care experiences and some outcomes of care.     

Multidisciplinary outpatient care program for patients with chronic low back pain: design of a randomized controlled trial and cost-effectiveness study [ISRCTN28478651]

Background  

Chronic low back pain (LBP) is a major public and occupational health problem, which is associated with very high costs. Although medical costs for chronic LBP are high, most costs are related to productivity losses due to sick leave. In general, the prognosis for return to work (RTW) is good but a minority of patients will be absent long-term from work. Research shows that work related problems are associated with an increase in seeking medical care and sick leave. Usual medical care of patients is however, not specifically aimed at RTW.     

Reason for Visit: Is Migrant Health Care That Different?

PURPOSE: The purpose of this pilot study was to determine the reasons for which migrant agricultural workers in Pennsylvania seek health care. METHODS: Participants were individuals 14 years of age and over, actively involved in agricultural labor and presenting for medical care at 6 migrant health care centers. Bilingual health care providers randomly selected and interviewed the participants. FINDINGS: The most commonly reported reason for visiting the health care provider was for physical examination. The most frequent acute problems were related to the musculoskeletal and integumentary systems. Frequently cited problems in the medical history were hypertension, musculoskeletal/back pain, and gastrointestinal conditions. Most medications being taken were for cardiovascular or pain-related problems. CONCLUSIONS: These results suggest that migrant workers present with medical problems that are similar to those of the general primary care population. Many problems were recurrent and represented common chronic medical conditions.     

Chronic disease and mental disorder

The aim of this study was to achieve a better understanding of the relationship between chronic medical illness and mental distress. Therefore, the association between chronic medical illness and mental distress was analysed, taking into account the modifying effects of generic disease characteristics (concerning course, control and possible stressful consequences), physical quality of life indicators and social and relationship problems. Panel data from the Dutch national Panel of Patients with a Chronic Disease (PPCZ) were used. Data from 1788 chronically medical ill patients (nine disease categories) concerning their mental and physical health have been used in a cross-sectional, multivariate analysis. Somatic disease, generic disease characteristics and physical quality of life were assessed by medical doctors. Mental distress and social/ relationship problems were assessed by questionnaire (respectively, GHQ-12 and Biopro). Members of the panel had more mental distress than a random community sample. However, there were no differences between specific somatic diseases. Relationship, job-related and financial problems increased the probability of mental disorder considerably. Relationship problems may be considered a generic characteristic of chronically ill patients, causing an increased risk of mental disorder. Poor physical health condition contributed to a higher probability of mental disorder as well. General practitioners, home care providers and medical specialists should be aware that people with chronic diseases are in general more at risk of mental disorder. For many chronically ill people, this risk is further exacerbated by social/relationship problems, and a poor level of perceived health.     

Maritime health emergencies

BACKGROUND: Commercial ships flying the US flag must conform to Coast Guard standards and have medical care available onboard. Consultation with a physician is required if medication is to be prescribed. AIM: To evaluate the epidemiology of medical contacts for US ships at sea. METHOD: Retrospective analysis of cases where shipboard caregivers made contact with US emergency medicine physicians for advice. RESULTS: There were 866 cases and 1720 contacts in 48 consecutive months of study. Eighty-eight per cent of cases were men with a mean age of 43.7 years (SD 13.7). Eighty-four per cent of cases were medical, 14% were injuries and 2% were purely psychiatric. Fifty-eight per cent of medical cases, 50% of psychiatric cases and 42% of injury cases were handled with a single contact. Injuries and psychiatric cases required a higher number of contacts per case compared with medical cases (P < 0.01). Five categories of illness accounted for 43% of medical cases (respiratory infections, abdominal problems, genitourinary complaints, rashes and dental issues). Psychiatric cases required the most medication, with 12% requiring four medications. The most common categories of medication given were pain relievers (non-steroidal anti-inflammatory drugs, opiates, heartburn relief) and antibiotics. CONCLUSIONS: Even with pre-screening of seafarers and the potential dangers of life at sea, the majority of cases requiring physician advice are not related to trauma. However, cases of injury or acute psychiatric problems required more physician interaction and medication than medical cases.     

'Women get this': gendered meanings of chronic pelvic pain

Chronic pelvic pain in women is a key site through which explorations of the meanings of female gender and pain might further insights into the broader question of the embodied experience of women in relation to pain. A biocultural approach is used to present an analysis of interviews with 40 New Zealand women in which they reflect on 'how come' they have chronic pelvic pain. Women consistently employ a mechanistic rendition of medical discourse and understandings in their constructions of 'how come' they have pain, accompanied by a reiteration of 'not knowing' and a normalizing of their pelvic pain. We explore how this normalizing works within the narratives to establish women's pelvic pain as intrinsically gendered. Etiological meanings that are constructed in medical terms and yet are unable to be interpreted within a dualist frame of normality and pathology, we argue, permeate and shape gendered experience of chronic pain conditions.     

Oscillating between hope and despair--a qualitative study

OBJECTIVE: The aim of this qualitative study was to elucidate the life situation and psychosocial processes of living with chronic pain in children suffering from juvenile chronic arthritis (JCA). METHODS: Taped open qualitative interviews with 22 children (aged 6-17 years) were transcribed verbatim and analysed using the comparative method for grounded theory. RESULTS: A core category, labelled oscillating between hope and despair, was identified and related to four additional categories labelled disturbed order, dependency, ambivalence and uncertainty about the future. There were relationships between the children's subjective experience of pain and their experiences of disturbed order in daily life, dependency on treatment, health care and significant others, ambivalence related to environmental reactions and uncertainty about the future. Chronic pain and disease control the children's lives and lead to restricted participation in social life. CONCLUSIONS: Chronic pain is a substantial problem for children with JCA, which must be considered in health care. The pain affected and disturbed the children's ordinary way of life. It blocked a number of goals. Psychological and physiological processes interact in the phenomenological experience of pain, and the response of the environment elicits, maintains or decreases the experience of pain. Hopefully,the findings contribute to a deeper understanding of the life situation of children suffering from JCA and can be of importance in developing rehabilitation programmes for these children.     

Chronic pain in primary care.

Chronic pain is a very common cause of suffering, disability and economic adversity in the community. It is a complex problem that needs to be understood in a multi-dimensional way for effective management. Most research to date has been based in specialist clinics rather than in primary care, with consequently limited findings. Chronic pain differs from acute pain in that management follows a rehabilitative rather than a treatment model, though these are not mutually exclusive. Full assessment of the patient, preferably multi-disciplinary, will improve his or her outlook. Management should be holistic, rigorous in the application of conventional therapies (including analgesics and physical therapy) and ready to admit an improved understanding of psychological and social techniques. There may be a role for complementary therapies. As a large proportion of chronic pain presents only in the community, there may be a role for greater primary care input to management.     

Ends of the line: diversity among chronic pain centers.

Chronic pain may cause an endless search for care for its sufferers, while presenting a persistently intractable problem for physicians and disability administrators faced with an illness that defies both conventional medical thinking and established disability compensation mechanisms. In the past 15 years pain centers have mushroomed. Some pain specialists, who are typically based on these centers, have claimed to provide comprehensive treatment for chronic pain and definitive solutions to problems of disability policy. However, pain control is not yet a unified field. Approaches to treatment vary and the definitions of the objects of treatment, i.e. chronic pain syndromes, differ. This paper describes the lines of diversity which characterize this emerging field of health care through an explanatory, cross-sectional survey of 25 pain treatment facilities operating in a single urban community. Pain centers were found to vary with respect to the following dimensions: institutional affiliation, professional background of the staff, treatment modalities offered, populations served, patient selection criteria, types of pain condition treated, and diagnostic and etiologic frames of reference. Pain centers may present a diverse array of options in a pain sufferer's search for care. In addition, the reliance on pain specialists for a resolution of complex problems of disability policy may be premature.     

Self-Management Services

For people with chronic illness, day-to-day responsibilities for care fall most heavily on patients and their families. Organising healthcare to strengthen and support self-management in chronic illness while assuring that effective medical, preventative and health maintenance interventions take place is key to effective disease management.This paper discusses the behavioural principles and empirical evidence about healthcare designed to maximise positive patient participation in chronic disease care. Four main essential elements are key: (i) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; (ii) targeting, goal-setting and planning, where patients and providers together agree on realistic objectives and set an action plan for attaining them; (iii) availability of a continuum of self-management training and support options that teach patients the skills needed to carry out medical regimens, guide health behaviour change and provide emotional support; (iv) active and sustained follow-up during which patients are contacted at specified intervals to monitor health status and reinforce progress in meeting care plan objectives. These elements constitute a common core of services and approaches that do not need to be replicated for each chronic condition.     

Provider-sponsored virtual communities for chronic patients: improving health outcomes through organizational patient-centred knowledge management

Patients with long‐term chronic disease experience numerous illness patterns and disease trends over time, resulting in different sets of knowledge needs than patients who intermittently seek medical care for acute or short‐term problems. Health‐care organizations can promote knowledge creation and utilization by chronic patients through the introduction of a virtual, private, disease‐specific patient community. This virtual socialization alters the role of chronic disease patients from external consumers of health‐care services to a ‘community of practice’ of internal customers so that, with the tacit support of their health‐care organization, they have a forum supporting the integration of knowledge gained from the experiences of living with chronic disease in their self‐management. Patient‐centred health‐care organizations can employ the virtual community to direct and support the empowerment of chronic patients in their care.     

Psychological aspects and details of care of patients on hemodialysis]

Chronic renal failure and periodic hemodialysis, by the physical reach and the therapeutic imperatives that they mislead disrupt by several ways the universe of the patient. This one is confronted to changes, or even to aggressions that undergo his body, his domestic and socio-professional life, which is accepted in general with difficulty. Indeed, our survey that concerned 109 patients on chronic hemodialysis shows that the minor psychiatric pathology is frequent and can represent a source of problems as well for the patients that for the medical and nursing staff. Besides the analysis of minor psychiatric specificities revealed by a known measure instrument (the GHQ), this work insists on the importance to take account of this aspects with the aim to enhance management and holistic care of these patients.     

Psychological assessment and treatment of somatization: adolescents with medically unexplained neurologic symptoms

Adolescent patients who report physical symptoms that are unexplained by physical disease or pathophysiologic processes are prevalent in health care settings. Physical symptoms with no notable physical pathology are often referred to as medically unexplained symptoms (MUS). Common MUS found in adolescent populations include headaches, abdominal pain, back pain, fatigue, dizziness, numbness and tingling sensations in the limbs, and gastrointestinal symptoms. The most important diagnostic concern is the exclusion of neurologic and other general medical conditions. Failure to diagnose real physical pathology appropriately can have serious, deleterious consequences. However, it is also important for physicians to address psychological and other psychosocial factors that may play a role in the etiology or maintenance of MUS. The onus often falls on the primary care physician to screen for such problems and to make cost-effective and appropriate referrals. This article reviews some alternative treatment guidelines for physicians to assist in the assessment, intervention, and referral process for adolescent patients with MUS. The advantages of integrating psychological screening practices into the evaluation process and present recommendations regarding the management of such patients are discussed.