Quantitative assessment of the “inexplicability” of fibromyalgia patients: a pilot study of the fibromyalgia narrative of “medically unexplained” pain

The purpose of this study was to quantify the degree to which fibromyalgia patients perceive the cause of their pain to be inexplicable or difficult to understand. The author developed two simple Likert scales, Understand Pain Scale and Explain Pain Scale, which ask the subject to indicate the degree to which they are able to, respectively, understand the cause of their pain and to explain the cause of their pain to others. A total of 104 subjects who met the 1990 American College of Rheumatology Diagnostic Criteria for fibromyalgia (FM group), and 272 subjects with widespread pain who did not meet these criteria (non-FM group) completed these two instruments. On the Understand Pain Scale, 67.3?% of FM subjects endorsed either the item “understand very little about the cause of my pain (the reason I have pain)” or “cannot understand at all the cause of my pain (the reason I have pain)”. By comparison, 16.2?% of the non-FM group with widespread pain endorsed either of these Understand Pain Scale items. On the Explain Scale, 84.6?% of fibromyalgia subjects endorsed either the item “can very little or not very often explain the cause of my pain (the reason I have pain) to others” or “cannot at all explain the cause of my pain (the reason I have pain) to others”. In contrast, 21.7?% of non-FM group subjects with widespread pain endorsed either of the aforementioned items. Compared to other patients with chronic, widespread pain, fibromyalgia patients report a much greater degree of difficulty in understanding the cause of their pain and explaining the cause of their pain to others. This phenomenon may reflect the narrative of “inexplicability” in fibromyalgia patients that distinguishes them from other widespread pain populations.     

Sex under the Influence of Drugs or Alcohol: Common for Men in Substance Abuse Treatment and Associated with High‐Risk Sexual Behavior

Sex under the influence of drugs or alcohol is associated with high‐risk sexual behavior. Heterosexual men (n = 505) in substance abuse treatment completed a computer‐administered interview assessing sexual risk behaviors. Most men (73.3%) endorsed sex under the influence in the prior 90 days, and 39.1% endorsed sex under the influence during their most recent sexual event. Sex under the influence at the most recent event was more likely to involve anal intercourse, sex with a casual partner, and less condom use. Patients might benefit from interventions targeting sexual behavior and substance use as mutual triggers. (Am J Addict 2010;00:1–9)     

Screening for depression among youth with HIV in an integrated care setting

Youth living with HIV (YLWH) are at risk for depression. Depressive symptoms can impact treatment engagement, health outcomes, and quality of life. Early identification of symptoms can guide treatment planning. This study aimed to identify trends in depressive symptoms for YLWH in a specialty-care clinic and follow-up clinical treatment procedures. An archival review of a clinical database provided depression screening information for a sample of 130 YLWH between 11 and 25 years old in the southeastern United States. Findings indicated that approximately 24% of the sample screened positive for depression-risk. Most commonly endorsed symptoms included fatigue (54.3%) and sleep difficulties (48.5%). Depressive symptoms did not differ significantly by age, gender, race, ethnicity, or sexual orientation. Youth who acquired HIV behaviorally were more likely to endorse the critical item (i.e., self-harm and/or suicidal ideation) than youth who acquired HIV perinatally. Forty-percent of the sample (i.e., 51 youth) had a follow-up treatment plan. YLWH who endorsed the critical item were more likely to receive follow-up action when compared to those who did not endorse the item. Despite limitations of the study, findings have important implications for clinical care and future research.     

HIV-related conspiracy beliefs and its relationships with HIV testing and unprotected sex among men who have sex with men in Tshwane (Pretoria), South Africa

The objective of this study was to determine extent of HIV conspiracy belief endorsement among men who have sex with men (MSM) in Pretoria, and assess whether endorsement of HIV conspiracy beliefs are associated with inconsistent condom use and never testing for HIV. A cross-sectional survey using respondent-driven sampling was conducted between February and August 2009. A high proportion of respondents endorsed HIV conspiracy beliefs. MSM commonly endorsed beliefs related to AIDS information being held back from the general public (51.0%), HIV being a man-made virus (25.5%), and people being used as guinea pigs in HIV research and with HIV treatments (approximately 20%). Bisexually- or heterosexually-identified MSM were significantly more likely to endorse conspiracy beliefs compared to homosexually-identified MSM (38.5% vs. 14.7%). Endorsing conspiracy beliefs was not associated with unprotected anal intercourse; however, it was significantly associated with not having been HIV tested (AOR: 2.4; 95% CI: 1.1-5.7). Endorsing beliefs in HIV conspiracies reflects a mistrust in government institutions and systems which could be an impediment to seeking HIV-related services, including HIV counseling and testing.     

How "soft" are soft neurological signs? The relationship of subjective neuropsychiatric complaints to cognitive function in systemic lupus erythematosus

OBJECTIVE: As part of a longitudinal study of cognitive function in systemic lupus erythematosus (SLE), we documented the range and frequency of subjective neurologic and/or psychiatric (NP) complaints in Never-NP-SLE patients, and related these to cognitive function, using the latter as a primary indicator of nervous system involvement. METHODS: Thirty patients with SLE who did not have major neurologic and psychiatric involvement underwent baseline and followup neuropsychological testing roughly 5 years apart. Within 0-13 months prior to retesting, each patient completed a 42 item questionnaire recording NP symptoms. RESULTS: The group as a whole endorsed 26% of symptoms. Fourteen patients labelled high endorsers (> 35% of items) endorsed, on average, 42% of symptoms. There was a significant association between higher item endorsement and lower cognitive function (r = -0.46, p < 0.02) and significantly poorer cognitive performance in the high compared to low endorser groups (t = -3.07, p < 0.005). In addition, a subset of 8 items was endorsed at least twice as often by SLE patients as by patients with rheumatoid arthritis (n = 12) or healthy controls (n = 10). CONCLUSION: These results suggest that "minor" NP symptoms and, in particular, a small subset of subjective complaints may be sufficient to raise suspicion of subclinical nervous system involvement in the absence of clinically evident NP-SLE.     

Barriers and facilitators to end-of-life care communication for patients with COPD

OBJECTIVE: Patients with COPD frequently do not discuss end-of-life care with physicians; therefore, we sought to identify the barriers and facilitators to this communication as a first step to overcoming barriers and capitalizing on facilitators. DESIGN: Fifteen barriers and 11 facilitators to patient-physician communication about end-of-life care were generated from focus groups of patients with COPD. We subsequently conducted a cross-sectional study of 115 patients with oxygen-dependent COPD and their physicians to identify the common barriers and facilitators and examine the association of these barriers and facilitators with communication about end-of-life care. PARTICIPANTS AND SETTING: Patients with oxygen-dependent COPD were recruited from clinics at a university, county, and Veterans Affairs teaching hospital, and an oxygen delivery company. We also recruited the physician identified by each patient as the doctor primarily responsible for their lung disease. MEASUREMENTS AND RESULTS: Patients were interviewed by trained research interviewers. Physician data collection was completed by mail survey. Participation rates were 40% for patients and 86% for physicians. Only 32% of patients reported having a discussion about end-of-life care with their physician. Two of 15 barriers and 8 of 11 facilitators were endorsed by > 50% of patients. The most commonly endorsed barriers were "I'd rather concentrate on staying alive," and "I'm not sure which doctor will be taking care of me." Two barriers were significantly associated with lack of communication, as follows: "I don't know what kind of care I want," and "I'm not sure which doctor will be taking care of me." The greater the number of barriers endorsed by patients, the less likely they were to have discussed end-of-life care with physicians (p < 0.01), suggesting the validity of these barriers. Conversely, the more facilitators, the more likely patients were to report having had end-of-life discussions with their physicians (p < 0.001). CONCLUSION: Although patients endorsed many barriers and facilitators, few barriers were endorsed by most patients. Barriers and facilitators associated with communication are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.     

Health professionals' views on standards for decision-making capacity regarding refusal of medical treatment in mild Alzheimer's disease

This study was designed to determine which elements professionals consider important for evaluation of decision-making capacity. Survey with a vignette case report of an individual with mild dementia was mailed to four groups of individuals: 1. members of the Academy of Psychosomatic Medicine, 2. chairs of Veterans Affairs (VA) Ethics Advisory Committees (EACs), 3. randomly selected geriatricians who were members of the Gerontological Society of America (GSA), and 4. randomly selected psychologists who were members of the GSA. Two hundred thirty-seven psychiatrists, 95 VA EAC chairs, 103 geriatricians, and 46 psychologists responded to this survey. The majority of the respondents endorsed all five basic elements as necessary for determination of decision-making capacity in the presented vignette, but only a minority of respondents endorsed all five basic elements, and a small proportion of respondents endorsed only one or two elements. The results indicate that physicians do not use uniform standards for assessment of decision-making capacity.     

Conspiracy beliefs about HIV infection are common but not associated with delayed diagnosis or adherence to care

We sought to determine the prevalence of HIV conspiracy beliefs in patients with HIV and how those beliefs correlate with access and adherence to HIV care and health outcomes. From March to December 2005, 113 patients at four public facilities in Houston, Texas, diagnosed with HIV for 3 years or less, participated in a cross-sectional survey. Conspiracy beliefs were assessed with five items that dealt with HIV origin, cure, and vaccine. Medical records were reviewed for CD4 cell counts, HAART use, and appointment dates. Statistical analyses (including analysis of variance [ANOVA], chi(2) testing, and regression) determined the predictors of conspiracy beliefs and correlated them with outcomes. Sixty-three percent of the participants endorsed 1 or more conspiracy beliefs. African American patients more often held HIV conspiracy beliefs than white and other/mixed race patients (73%, 52%, 47%; p = 0.045). Persons holding 1 or more conspiracy beliefs had higher CD4 cell counts at diagnosis (254 cells/mm(3) versus 92, p = 0.03); and similar rates of highly active antiretroviral therapy (HAART) use (73% versus 71%), 100% adherence to HAART by self-report (53% versus 45%,), mean adherence by pharmacy refill (83% versus 87%), and gaps in care greater than 120 days (49% versus 53%), compared to subjects who did not hold any conspiracy beliefs (all p > 0.40). Since recruitment focused on patients in care, patients with extreme conspiracy beliefs may be underrepresented. Despite this, more than 50% of the study population endorsed 1 or more conspiracy belief. However, these beliefs did not negatively impact access or adherence to HIV care. Efforts to improve adherence to HIV care may not need to focus on eliminating conspiracy beliefs.     

Australian prescribers' perspectives on ART initiation in the era of “treatment as prevention”

This study explores Australian prescribers' attitudes towards Treatment as Prevention (TasP) and their practices around initiating combination antiretroviral treatment (cART) for HIV. A brief online survey was conducted nationally amongst antiretroviral treatment (ART) prescribers in Australia. The sample broadly represented ART prescribers in Australia (N = 108), with 40.7% general practitioners (GPs), 25.9% sexual health clinic-based physicians and 21.3% hospital-based infectious diseases physicians. About 60% of respondents had been treating HIV-positive patients for more than 10 years. Respondents estimated that about 70–80% of all their HIV-positive patients were receiving ART. Over half of the prescribers agreed very strongly that their primary concern in recommending cART initiation was clinical benefit to individual patients rather than any population benefit. A majority of the prescribers (68.5%) strongly endorsed cART initiation before CD4+ T-cell count drops below 350 cells/mm³, and a further 22.2% strongly endorsed cART initiation before CD4+ T-cell count drops below 500 cells/mm³. Regarding the optimal timing of cART initiation, this study shows that prescribers in Australia in 2012 focus primarily on the benefits for their individual patients. Prescribers may need more convincing evidence of individual health benefits or increased knowledge about the population health benefits for a TasP approach to be effective in Australia.     

Do physicians tailor their recommendations for breast cancer risk reduction based on patient’s risk?

OBJECTIVE: To investigate how physicians tailor their recommendations for breast cancer prevention and risk reduction. DESIGN: Cross-sectional, mail survey. PARTICIPANTS: Random sample of primary care physicians in California (N = 822). MEASUREMENTS AND MAIN RESULTS: Six standardized patient scenarios were used to assess how women's breast cancer risk factors influence physicians' recommendations for screening mammography, counseling about lifestyle behaviors, genetic testing, the use of tamoxifen, prophylactic surgery, and referral to a breast specialist. Over 90% of physicians endorsed mammography for all of the scenarios. Similarly, approximately 80% of physicians endorsed counseling about lifestyle factors for all of the scenarios. Five-year risk of developing breast cancer and family history were both strongly associated with each of the 6 recommendations. Importantly, however, physicians were more likely to endorse the discussion of genetic testing, the use of tamoxifen, and prophylactic surgery for women with a family history of breast cancer compared with women at a higher risk of developing breast cancer but without a family history. Obstetrician-gynecologists were more likely to endorse most of these practices compared with internists. CONCLUSIONS: Mammography and counseling about lifestyle behaviors are widely endorsed by physicians for breast cancer prevention and risk reduction. Whereas physicians are generally able to tailor their recommendations for prevention and risk reduction based on risk, they may perhaps underutilize genetic evaluation and newer therapeutic options for primary prevention for women who are at high risk of developing breast cancer but do not have a family history.     

Outcome reporting in randomized trials in gout: A systematic scoping review from the OMERACT gout working group assessing the uptake of the core outcome set

ObjectiveThe selection and reporting of core outcome measures in clinical trials is essential for patients, researchers, and healthcare providers for clinical research to have an impact on healthcare. In this systematic scoping review, we aimed to quantify the extent to which gout clinical trials are collecting and reporting data in accordance with the core outcome domains from Outcome Measures in Rheumatology (OMERACT) published in 2009 applicable for both acute and chronic trials and evaluate the reporting according to the core domains before and after the 2009 OMERACT endorsement.MethodsWe searched multiple databases PubMed, EMBASE, the Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) and www.clinicaltrials.gov for randomized controlled trials (RCTs) allocating people with gout versus an active pharmacological gout treatment or a control comparator (no date limitation). We extracted the data in accordance with the core outcome sets, focusing individually on core outcome domains and the core outcome measurements for acute and chronic trials, respectively. In this study ‘Acute trials’ reflect studies that describe interventions for short term management of gout flares, and ‘chronic trials’ describe interventions for long-term urate lowering therapy in the management of gout.ResultsFrom 8,522 records identified in the database search, 134 full text papers were reviewed, and 71 trials were included, of which 36 were acute and 35 were chronic. Only 3 of 36 (8%) acute trials reported all five core domains and none of the 35 included chronic trials reported all 7 core domains. In the acute trials, twenty-seven unique measurement instruments across the 5 core domains were identified. For chronic trials there were 31 unique measurement instruments used across the 7 core domains. Serum urate was reported in 100% of the chronic trials and gout flares in 80%. However, other core domains were reported in <30% of chronic trials. In particular the patient-important domains such as HR-QOL, patient global assessment and activity limitations were rarely reported. A broad variety of different measurement instruments were used to assess each endorsed core domain, a minority of trials used the OMERACT endorsed instruments. For acute trials, the number reporting on all core domains was consistently low and no change was detected before and after the endorsement of the core domains in 2009. None of the included chronic trials reported on all 7 endorsed core domains at any time.ConclusionIn this study we found a low adherence with the intended endorsed (i.e., core) outcome domains for acute and chronic gout studies which represents a poor uptake of the global OMERACT efforts for the minimum of what should be measured in clinical trials. In addition, there is a significant variation in how the OMERACT endorsed outcome domains have been measured. This systematic review demonstrates the need for continuous encouragement among gout researchers to adhere to OMERACT core domains as well as further guidance on outcome measurements reporting.RegistrationProspero: CRD42019151316     

Perceived risks and benefits of quitting smoking in a sample of adults living with HIV/AIDS

Persons living with HIV/AIDS (PLWH) smoke at high prevalences and experience significant smoking-related consequences. In community samples, perceived risks and benefits of quitting smoking are related to quit motivation and outcomes and are more strongly endorsed by women. This study examined perceived risks and benefits of quitting smoking and the relationship between risks and benefits and quit motivation and confidence in male and female PLWH. One hundred seven PLWH who reported current cigarette smoking completed measures of demographics, smoking, perceived risks and benefits of quitting smoking, motivation to quit smoking, and confidence in ability to quit smoking. The highest endorsed risks of quitting smoking were cravings and weight gain and higher endorsement of craving risks was associated with lower confidence in the ability to quit smoking. Women endorsed overall risks and risks related to negative affect more highly than men. Women and men did not differ in their endorsement of the other risks, the benefits of quitting, or the relationship between risks and benefits and quit motivation or confidence. It may be useful for health care professionals to incorporate information about perceived risks and benefits of quitting smoking into treatment when working with PLWH who want to stop smoking.     

Esophageal cancer screening in achalasia: is there a consensus?

Achalasia is an important but relatively uncommon disorder. While highly effective therapeutic options exist, esophageal cancer remains a long‐term potential complication. The risk of esophageal cancer in achalasia remains unclear, with current guidelines recommending against routine endoscopic screening. However, given limited data and conflicting opinion, it is unknown whether consensus regarding screening practices in achalasia among experts exists. A 10‐question survey to assess screening practices in achalasia was created and distributed to 28 experts in the area of achalasia. Experts were identified based on publications and meeting presentations in the field. Survey responses were received from 17 of 28 (61%) experts. Wide geographic distribution was seen among respondents, with eight (47%) from Europe or Australia, seven (41%) from the United States, and two (12%) from Asia. Screening for esophageal cancer was inconsistent, with nine (53%) experts endorsing the practice and eight (47%) not. Screening practices did not differ among geographic regions. No consensus regarding the risk for esophageal cancer in achalasia was seen, with three experts reporting no increased risk compared with the general population, eight experts a lifetime risk of 0.1–0.5%, three experts a 0.5–1% risk, two experts a 1–2% risk, and one expert a 3–5% risk. However, these differences in perception of risk did not influence screening practices. Upper endoscopy was utilized among all experts who endorsed screening. However, practices still varied with screening commencing at or within 1 year of diagnosis in two practices compared with 5 and 10 years in three respective practices each. Surveillance intervals also varied, performed every 2 years in four practices, every 3 years in four practices, and every 5 years in one practice. Practice variation in the management of achalasia itself was also seen, with initial treatment with Heller myotomy endorsed by eight experts, pneumatic dilation by five experts, and two each endorsing peroral endoscopic myotomy or no specific preference. In addition, while 82% (14/17) of experts endorsed long‐term follow up of patients, no consensus regarding long‐term follow up existed, with annual follow up in eight practices, every 3–6 months in three practices, and every 2 years in three practices. Large practice variation in the long‐term management of achalasia exists among experts in the field. Only a slight majority of experts endorse screening for esophageal cancer in achalasia, and no consensus exists regarding how surveillance should be structured even among this group. Interestingly, the lack of consensus on cancer screening parallels a lack of agreement on initial treatment of achalasia. These findings suggest a need for greater homogeneity in the management of longstanding achalasia and cancer screening. Further, this study highlights the need for more data on this topic to foster greater agreement.     

Current insights into the pathogenesis,diagnosis and therapy of inflammatory cardiomyopathy

Persistence of cardiotropic viruses (enterovirus, adenovirus) and anticardiac autoimmunity constitute the predominant etiopathogenic pathways of dilated cardiomyopathy (DCM). The diagnosis of inflammatory cardiomyopathy (InfCM) imposes sensitivity and specificity requirements, which are not fulfilled by the histological Dallas Criteria. The immunohistological quantification and characterization of immunocompetent infiltrates and cell adhesion molecule (CAM) expression has endorsed a new entity of secondary cardiomyopathies acknowledged by the World Health Organization (WHO), InfCM, in approximately 50% of DCM patients. In the absence of viral persistence, InfCM patients benefit from immunosuppressive treatment. Enteroviral and adenoviral genomes have been detected in a significant proportion of DCM patients. Enteroviral persistence is associated with an adverse prognosis. The induction of the coxsackie-adenovirus receptor (CAR) exclusively in 63% of DCM patients, but not in other cardiomyopathies, might constitute a key molecular determinant for cardiotropic viral infections in DCM. In InfCM patients with enterovirus or adenoviral persistence, interferon-beta administration leads to viral elimination and cessation of the intramyocardial inflammation, paralleled by a significant improvement of left ventricular systolic function and heart failure symptoms. The biopsy-guided etiopathogenic differentiation of DCM has endorsed specific treatment strategies: immunosuppressive regimens are favorable in autoimmune InfCM, whereas patients with viral persistence benefit from antiviral immunomodulation.     

Barriers and Treatment Preferences Reported by Worried Drinkers of Various Sexual Orientations

This web-based study evaluated treatment preferences and perceived barriers to seeking treatment reported by heterosexual and lesbian/gay/bisexual worried drinkers. The sample (N = 218: 71% female, 72% heterosexual) was ethnically diverse. Potential barriers to treatment seeking that were endorsed included problem minimization, lack of motivation, stigma, and having negative thoughts about treatment. Treatment preferences included professional outpatient treatment, self-help group, computer-assisted treatment, and self-help book. The majority did not have a preference for therapist by gender or sexual orientation. Clinical implications of findings are discussed in terms minimizing the impact of barriers to improve service utilization.     

Audio-CASI vs interview method of administration of an HIV/STD risk of exposure screening instrument for teenagers

Previous research conducted to examine the implications of using audio-computerized (A-CASI) procedures to gather sensitive sexual behaviour data has provided mixed results. The purpose of this study was to assess differences in the disclosure of HIV risk behaviours between subjects interviewed face to face and subjects interviewed using A-CASI procedures. An HIV/STD risk of exposure screening instrument was administered to 265 male and female adolescents in the juvenile justice system. T-test analyses revealed that adolescents assessed using A-CASI procedures endorsed fewer items on the HIV/STD screen than those interviewed by an assessor. In addition, those in the A-CASI group endorsed fewer items with explicit sexual or drug content and fewer subtle items. Results of this study suggest that A-CASI may not be suitable for use among adolescents in the juvenile justice system when assessing undesirable and/or illegal behaviours.     

The Cutaneous Assessment Tool: development and reliability in juvenile idiopathic inflammatory myopathy

OBJECTIVES: Clinical care and therapeutic trials in idiopathic inflammatory myopathies (IIM) require accurate and consistent assessment of cutaneous involvement. The Cutaneous Assessment Tool (CAT) was designed to measure skin activity and damage in IIM. We describe the development and inter-rater reliability of the CAT, and the frequency of lesions endorsed in a large population of juvenile IIM patients. METHODS: The CAT includes 10 activity, 4 damage and 7 combined lesions. Thirty-two photographic slides depicting IIM skin lesions were assessed by 11 raters. One hundred and twenty-three children were assessed by 11 paediatric rheumatologists at 10 centres. Inter-rater reliability was assessed using simple agreements and intra-class correlation coefficients (ICC). RESULTS: Simple agreements in recognizing lesions as present or absent were generally high (0.5-1.0). ICCs for CAT lesions were moderate (0.4-0.75) in both slides and real patients. ICCs for the CAT activity and damage scores were 0.71 and 0.81, respectively. CAT activity scores ranged from 0 to 44 (median 7, potential range 0-96) and CAT damage scores ranged from 0 to 13 (median 1, potential range 0-22). The most common cutaneous lesions endorsed were periungual capillary loop changes (63%), Gottron's papules/sign (53%), heliotrope rash (49%) and malar/facial erythema (49%). CONCLUSIONS: Total CAT activity and damage scores have moderate to good reliability. Assessors generally agree on the presence of a variety of cutaneous lesions. The CAT is a promising, semi-quantitative tool to comprehensively assess skin disease activity and damage in IIM.     

Adolescents’ Emotions Prior to Sexual Activity and Associations with Sexual Risk Factors

The present study examined the link between the emotional context of sexual situations and sexual risk, specifically by examining the relationship of teens’ recall of their affective states prior to sex with their sexual risk behaviors and attitudes. Adolescents (ages 13–19) attending therapeutic schools due to emotional and behavioral difficulties (n = 247) completed audio computer-assisted self-interviews regarding sexual behavior, including ratings of their emotions prior to last sexual activity. Positive emotions were most commonly endorsed (43–57 % of participants), however, significant proportions (8–23 %) also endorsed negative emotions prior to last sex. Both positive and negative emotions were significantly related to risk attitudes and behavior in regression analyses. The affective contexts of sexual experiences may be important predictors of risk in adolescence.