Clinical Characteristics and Outcomes of Patients With Primary Plasma Cell Leukemia in the Era of Novel Agent Therapy

ObjectiveTo evaluate the clinical outcomes of patients with primary plasma cell leukemia (pPCL) defined by 5% or greater clonal circulating plasma cells on peripheral blood smear and treated with novel agent induction therapies.Patients and MethodsA cohort of 68 patients with pPCL diagnosed at the Mayo Clinic in Rochester, Minnesota, from January 1, 2000, to December 31, 2019, and treated with novel agent induction therapies was evaluated.ResultsThe median follow-up was 46 (95% CI, 41 to 90) months. The median bone marrow plasma cell content was 85% (range, 10% to 100%) and median clonal circulaitng plasma cell percentage on the peripheral blood smear was 26% (range, 5% to 93%). There was a preponderance of t(11;14) primary cytogenetic abnormality in this cohort. The median time to next therapy (TTNT) and overall survival (OS) for all patients with pPCL patients in this cohort was 13 (95% CI, 9 to 17) and 23 (95% CI, 19 to 38) months, respectively. However, when stratified by cytogenetic risk, the median TTNT and OS were 16 and 51 months for standard risk vs 9 and 19 months for high risk (P=.01 for OS).ConclusionPrimary plasma cell leukemia remains an aggressive disease with poor prognosis despite novel agent–based therapies. Some patients have better than expected survival and this phenomenon may be influenced by the absence of high-risk cytogenetics. Newer treatment regimens are needed to improve the prognosis of this devastating disease.     

Brain Activation of Unpleasant Emotions Increases Catastrophizing in Patients with Chronic Pain

BackgroundCatastrophic thinking among patients with chronic pain impairs their quality of life and increases anxiety levels. Further, severe pain causes high emotional brain sensitivity and unpleasant feelings. However, the effects of emotional changes on catastrophic thinking in patients with chronic pain remain unclear.AimsWe hypothesised that emotional brain activity during mild pain stimuli would affect catastrophic thinking in these patients. We aimed to examine the relationship between unpleasant emotional brain activation and catastrophic thinking due to pain stimuli in patients with chronic pain.DesignThis was a prospective observational study.ParticipantsWe included patients with chronic pain and healthy individuals.MethodsThe impact of emotional brain activity on catastrophic thinking was evaluated, specifically, the skin conductance response and oxygenated haemoglobin levels using near-infrared spectroscopy. After receiving three different pain stimuli, the participants were evaluated using the Numeric Rating Scale, Pain Catastrophising Scale, and McGill Pain Questionnaire.ResultsThere were 28 patients in the chronic pain group and 33 patients in the healthy group. There was no between-group difference in oxygenated haemoglobin levels during pain stimulation. The chronic pain group showed a higher Pain Catastrophising Scale score and skin conductance response than the healthy group (p < .05). In the chronic pain group, oxygenated haemoglobin levels after pain stimuli were significantly associated with the Pain Catastrophising Scale score and skin conductance response (p < .05).ConclusionsBrain activity of unpleasant emotions may influence catastrophic thinking in patients with chronic pain.     

Alcohol,Tobacco and Psychotropic Drugs Use Among a Population with Chronic Pain in Southern Spain. A Cross-Sectional Study

BackgroundSubstance use seems to be higher among populations with chronic pain.AimThe aim of this study is to examine the relationship between the quantity of alcohol, tobacco, and psychotropic drugs consumed and chronic pain among women and men.MethodLinear and logistic regression analyses were carried out using data from the 2015-2016 adults’ version of the Andalusian Health Survey which is a representative cross-sectional population-based study (n = 6,569 adults aged >16 years; 50.8% women; 49.2% men).ResultsDisabling chronic pain was statistically associated with higher tobacco consumption among men (β = –30.0, 95% confidenct interval [CI] –59.5 to –0.60; t = –2.0; p < .05). Regarding alcohol, non-disabling chronic pain and a higher quantity of alcohol consumed are statistically associated for both sexes (women: β = 30.4, 95% CI 2.3-58.6; t = 2.12; p < .05 vs. men: β = 164.2, 95% CI 24.3-340.1); t = 2.30; p < .05). For women and men, both disabling chronic pain (women: odds ratio [OR] = 8.7, 95% CI 6.0-12.7); p < .05 vs. men: OR = 3.5, 95% CI 1.5-8.2); p < .05) and non-disabling chronic pain (women: OR = 3.7, 95% CI 2.0-7.0); p <.05 vs. men: OR = 4.7, 95% CI 95% CI 1.5-14.9); p < .05) were statistically significantly associated with a higher consumption of psychotropic drugs.ConclusionsChronic pain may be related to the quantity of alcohol, tobacco, and psychotropic drugs consumed, and disability appears to be one of the factors that modulates this relationship.     

The Evolving Clinical Practice of Chronic Cough

Chronic cough, defined as a cough lasting for greater than 8 weeks, accounts for a substantial number of primary care and specialist consultations in the United States. Although cough can arise from a myriad number of serious respiratory diseases, attention has traditionally focused on diagnosing and treating gastroesophageal reflux, upper airway cough syndrome, and eosinophilic airway inflammation (asthma and nonasthmatic eosinophilic bronchitis) in patients with normal chest imaging. The newly described paradigm and entity of cough hypersensitivity syndrome (CHS) becomes useful when the etiology of cough remains elusive or when the cough remains refractory despite appropriate therapy for underlying causes. We present an update on the evolving understanding of refractory chronic cough and/or unexplained chronic cough as manifestations of laryngeal hypersensitivity and CHS. This includes a focus on understanding the pathophysiology underlying current and novel therapeutics for CHS, while also ensuring that common causes of chronic cough continue to be evaluated and treated in a systematic multidisciplinary manner.     

Chronic Constipation

Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.     

Pain,Anxiety, and Quality of Life of COVID-19 Survivors with Myofascial Pain Syndrome: A cross sectional study

BackgroundPeople who have survived COVID-19 may develop chronic pain.AimsTo investigate the difference in pain level, anxiety, functional status, and quality of life in COVID-19 survivors with myofascial pain syndrome (MPS) in the trapezius muscle compared with MPS patients without COVID-19.DesignCross-sectional observational study.SettingsPhysical medicine and rehabilitation outpatient clinics of a single tertiary-care hospital.Participants/SubjectsEighty patients (40 patients with MPS and 40 patients with MPS + COVID) who were diagnosed with chronic MPS in the trapezius muscle were evaluated.MethodsPain level of the patients was evaluated using the visual analogue scale (VAS), the functional status with the Neck Pain and Disability scale, the psychosocial effects of the pain with the Beck Anxiety Inventory, and the quality of life with the Nottingham Health Profile tests, and the two groups (MPS and MPS + COVID) were compared.ResultsA significant difference was observed between the groups in terms of pain, anxiety, and disability (p < .001). MPS + COVID group showed significantly greater pain intensity on VAS and higher mean total scores on Nottingham Health Profile, Beck Anxiety Inventory, all Nottingham Health Profile subdomains (pain, emotional reactions, sleep, social isolation, physical mobility, energy) compared with the MPS group (p < .001).ConclusionsAfter recovering from COVID-19, patients with MPS showed increased pain, anxiety, disability, and decreased quality of life.     

Whole Body Vibration Exercise for Chronic Musculoskeletal Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

ObjectiveThis study systematically reviews previous work on the effects of whole body vibration exercise (WBVE) on pain associated with chronic musculoskeletal disorders.Data SourcesSeven electronic databases (PubMed, Embase, CINAHL, Web of Science, Cochrane, Physiotherapy Evidence Database [PEDro], and the China National Knowledge Infrastructure) were searched for articles published between January 1980 and September 2018.Study SelectionRandomized controlled trials involving adults with chronic low back pain (CLBP), osteoarthritis (OA), or fibromyalgia were included. Participants in the WBVE intervention group were compared with those in the nontreatment and non-WBVE control groups.Data ExtractionData were independently extracted using a standardized form. Methodological quality was assessed using PEDro.Data SynthesisSuitable data from 16 studies were pooled for meta-analysis. A random effects model was used to calculate between-groups mean differences at 95% confidence interval (CI). The data were analyzed depending on the duration of the follow-up, common disorders, and different control interventions.ResultsAlleviation of pain was observed at medium term (standardized mean difference [SMD], -0.67; 95% CI, -1.14 to -0.21; I², 80%) and long term (SMD, -0.31; 95% CI, -0.59 to -0.02; I², 0%). Pain was alleviated in osteoarthritis (OA) (SMD, -0.37; 95% CI, -0.64 to -0.10; P<.05; I², 22%) and CLBP (SMD, -0.44; 95% CI, -0.75 to -0.13; P<.05; I², 12%). Long-term WBVE could relieve chronic musculoskeletal pain conditions of OA (SMD, -0.46; 95% CI, -0.80 to -0.13; P<.05; I², 0%). WBVE improved chronic musculoskeletal pain compared with the treatment “X” control (SMD, -0.37; 95% CI, -0.61 to -0.12; P<.05; I², 26%), traditional treatment control (SMD, -1.02; 95% CI, -2.44 to 0.4; P>.05; I², 94%) and no treatment control (SMD, -1; 95% CI, -1.76 to -0.24; P<.05; I², 75%).ConclusionsEvidence suggests positive effects of WBVE on chronic musculoskeletal pain, and long durations of WBVE could be especially beneficial. However, WBVE does not significantly relieve chronic musculoskeletal pain compared with the traditional treatment. Further work is required to identify which parameters of WBVE are ideal for patients with chronic musculoskeletal pain.     

Cannabis education needs assessment among Canadian physicians-in-training

BackgroundSince 1999, the Canadian courts have recognized the rights of patients to access cannabis for therapeutic purposes (CTP). Due to the increasing interest in the use of CTP, competency with the topic among health care providers is essential. As concerns mount around the role of industry involvement in cannabis education, it has become increasingly important for medical schools to provide physicians-in-training balanced evidence regarding the harms and benefits of CTP. In the present study, we surveyed Canadian physicians-in-training regarding their knowledge, experience, attitudes, and barriers surrounding CTP.MethodsSurvey questions were adapted from extant physician and nurse practitioner education needs assessments. We invited representatives from all 17 Canadian universities with a Faculty of Medicine to electronically distribute the survey to physicians-in-training.ResultsThe survey was accessed by 93 physicians-in-training of whom 76 provided responses (46 % female; M_age = 28, SD = 3.03). Physicians-in-training reported receiving significantly less instruction on CTP than they desired. Responses demonstrated differences between current and desired knowledge across all domains queried. More education was the factor identified as most likely to increase comfort authorizing and discussing CTP with patients.ConclusionsFindings from this study demonstrate an expressed desire for more education surrounding CTP among a self-selected sample of Canadian physicians-in-training. There was a substantial divergence between current and desired levels of knowledge, and the largest gaps related to creating effective treatment plans and understanding the risks and benefits of CTP. Improving the educational opportunities of students will improve standard-of-care for patients.     

Construction and Application of Chain Management Information System for Cancer Pain

BackgroundWith the rapid development of information technology, hospital information systems (HISs) have been deeply applied in the medical field and have shown broad application prospects. There are still some noninteroperable clinical information systems that pose an obstacle to the effective coordination of care, such as cancer pain management.AimTo construct a chain management information system for cancer pain and explore its clinical application effect.MethodsA quasiexperimental study was conducted in the inpatient department of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine. A total of 259 patients were nonrandomly divided into two groups: the experimental group (after the system was applied, n = 123) and the control group (before the system was applied, n = 136). The cancer pain management evaluation form score, patient satisfaction with pain control, pain score at admission and discharge, and the worst pain score during hospitalization were compared between the two groups.ResultsCompared with the control group, the score of the cancer pain management evaluation form was significantly higher (p < .05). There were no statistically significant differences in worst pain intensity, pain score at admission and discharge, and patients’ satisfaction with pain control between the two groups.ConclusionsThe cancer pain chain management information system can enable nurses to evaluate and record pain in a more standardized way, but it has no significant effect on the pain intensity of cancer patients.     

When Environment Meets Genetics: A Clinical Review of the Epigenetics of Pain,Psychological Factors,and Physical Activity

Epigenetic mechanisms represent a link between the environment and gene function. Recent research shows how early life stress, inflammation, and physical activity can influence gene expression through epigenetic mechanisms. Epigenetic changes—such as DNA methylation and microRNA interference—can be measured in humans and might soon become important biological markers. Epigenetic marks can accompany clinical assessment to measure the effectiveness of various interventions, such as exercise therapy. In addition, epigenetics is improving the understanding of important underlying mechanisms related to the central nervous system, the opioidergic system, and stress responses. Epigenetics is closing a gap in our explanatory abilities and should be implemented to broaden the field of rehabilitation sciences, promote a mechanism-based clinical reasoning, and develop new treatments. In the present review, we focused on epigenetic mechanisms related to pain, psychological factors (such as fear and anxiety), and physical activity, translating relevant findings from these 3 different, yet related, areas of cardinal importance for clinicians.     

Kidney Microstructural Features at the Time of Donation Predict Long-term Risk of Chronic Kidney Disease in Living Kidney Donors

ObjectiveTo determine whether microstructural features on a kidney biopsy specimen obtained during kidney transplant surgery predict long-term risk of chronic kidney disease in the donor.Patients and MethodsWe studied kidney donors from May 1, 1999, through December 31, 2018, with a follow-up survey for the results of recent blood pressure and kidney function tests (estimated glomerular filtration rate [eGFR] and proteinuria). If not recently available, blood pressure and eGFRs were requested from a local clinic. Microstructural features on kidney biopsy at the time of donation were assessed as predictors of hypertension and kidney function after adjusting for years of follow-up, baseline age, sex, and clinical predictors.ResultsThere were 807 donors surveyed a mean 10.5 years after donation. An eGFR less than 45 mL/min/1.73 m² in 6.4% (43/673) of donors was predicted by larger glomerular volume per standard deviation (odds ratio [OR], 1.48; 95% CI, 1.08 to 2.04) and nephron number below the age-specific 5th percentile (OR, 3.38; 95% CI, 1.31 to 8.72). An eGFR less than 60 mL/min/1.73 m² in 42.5% (286/673) of donors was not predicted by any microstructural feature. Residual eGFR (postdonation/predonation eGFR) was predicted by nephron number below the age-specific 5th percentile (difference, ?6.07%; 95% CI, ?10.24% to ?1.89%). Self-reported proteinuria in 5.1% (40/786) of donors was predicted by larger glomerular volume (OR, 1.42; 95% CI, 1.08 to 1.86). Incident hypertension in 18.8% (119/633) of donors was not predicted by any microstructural features.ConclusionLow nephron number for age and larger glomeruli are important microstructural predictors for long-term risk of chronic kidney disease after living kidney donation.     

Evaluating Auricular Point Acupressure for Chronic Low Back Pain Self-Management Using Technology: A Feasibility Study

BackgroundChronic low back pain, one of the most common reasons for seeking healthcare services, causes significant negative impacts on individuals and society. Nonpharmacologic therapies and self-management are included in practice guidelines, but their implementation is challenging.AimTo assess the feasibility of using an auricular point acupressure (APA) mobile app as a self-guided tool to learn and self-administer APA to manage chronic low back pain (cLBP) and to compare cLBP outcomes between 2 groups (app vs app + telehealth).DesignA 2-phase study design was used. In phase 1, participants (app group, n = 18) had in-person study visits and installed the app to learn and self-administer APA to manage cLBP. In phase 2, all research activities occurred remotely due to the COVID-19 pandemic, so a second group was recruited (app + telehealth, n = 19). The app + telehealth group underwent a virtual session, installed the app, and were provided the opportunity for questions and verification on the accuracy of the self-administered APA.SettingThe participants were recruited by distributing study flyers at outpatient clinics and referrals.ParticipantsParticipants with chronic low back pain were eliglbe for the study.MethodsUsing a quasi-experimental design with a mixed methods approach, all participants were instructed to download the APA app, provided an APA kit (includes seeds embedded within pre-cut squares of adhesive tape), and advised to self-administer APA with guidance from the app for 4 weeks to manage their cLBP. Study outcomes were collected at the preintervention time point as well as postintervention and 1-month follow-up. Interviews were also conducted at the postintervention time point.ResultsOf the 37 participants enrolled, six dropped out, and the attrition rate was 16%. Adherence to APA practice was high (85%-94%). After 4 weeks of APA treatment, participants in the app + telehealth group experienced a 29% decrease in pain intensity during the postintervention time point and a 35% reduction during the 1-month follow-up. Similar improvements were noted in pain interference (28%) and physical function (39%) for participants in the app + telehealth group at the 1-month follow-up. These changes are slightly higher compared with those in the app group (21% pain intensity reduction, 23% improved pain interferences, and 26% improved physical function) during the 1-month follow-up. Overall, APA was found to be feasible using the app and the qualitative findings showed acceptability of the intervention in both groups.ConclusionsIt is feasible to learn and self-administer APA with an app, supplemented with either in-person or telehealth sessions, presenting a promising intervention toward cLBP self-management. Telehealth was found to boost this intervention effectively.     

Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap

ObjectiveTo examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR).Patients and MethodsWe retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed.ResultsAt baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m² was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11).ConclusionIn contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m² or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.     

Preoperative Evaluation and Management of Patients With Select Chronic Gastrointestinal,Liver, and Renal Diseases

Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.