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Grass is green, sky is blue, and people in primary care clinic have lower back pain. From insurers to patients to primary care physicians, everyone wants to find inexpensive help. And now a new trial has found that mindfulness-based-stress-reduction (MBSR) and cognitive-behavioral therapy (CBT) were superior to usual care in managing back pain symptoms.
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MBSR and CBT are "acceptance-based interventions" that, beyond appealing to your friend who drinks Kombucha and spurns deodorant, focus on learning to accept and live with pain. MBSR is more physical than CBT. It focuses on acceptance of physical discomfort and difficult emotions, and training includes meditation and yoga. CBT is an educational intervention that focuses on awareness of chronic pain, relaxation techniques, and pain-coping strategies. Patient access to both interventions is limited, since insurance coverage can be hit or miss and the therapies are not universally available.
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About 350 patients were randomized to receive 8 group classes in MBSR or CBT, or continue usual care. The MBSR and CBT groups showed similarly significant improvements in a disability assessment and self-reported back pain at 26 weeks. Since only about half of patients went to at least 6 out of the 8 sessions in both interventions, the treatment benefit could be greater if providers can encourage increased compliance.
JAMA
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Your patients aren't going take their diabetes and hypertension meds if you can't play ball with them on back pain. So consider acceptance-based interventions as another option in your toolkit, and work with your clinic staff to get people enrolled in a center in your area.
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WHEN YOU'RE HOOKED ON CHECKING YOUR PHONE
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Could be worse. Crack/cocaine addicts have always lacked their own version of methadone – a long acting drug that breaks abuse patterns. Small trials of the stimulant dexamfetamine have to date not shown benefit in treating cocaine addiction. But when given in heroin-assisted treatment clinics for patients with mixed heroin and cocaine addictions, sustained-release dexamfetamine prompted significantly fewer days of cocaine use in participants. The authors suggest that the treatment-clinic setting of the trial increased dexamfetamine compliance relative to previous studies.
Lancet
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WHEN YOUR RESIDENCY DIET OF PIZZA AND BAGELS ISN'T DOING YOU ANY FAVORS
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Venture East. The Japanese have famously long life spans, thanks in part to diets high in fish and soybean products. Those with the highest self-reported adherence to the Japanese dietary guidelines, seen in this spinning top diagram, had 15% lower total mortality than their less strict counterparts in an 80,000 member prospective cohort. They also had fewer cardiovascular and cerebrovascular events, and a trend towards lower cancer mortality.
BMJ
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WHEN YOUR SIGNATURE GETS LESS AND LESS INTELLIGBLE
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You're moving in the opposite direction of technology. A 16 gene signature of risk can predict 12 month progression to active tuberculosis infection in patients with latent TB. Sensitivity was about 60% and specificity roughly 80% in a cohort study of African teenagers. The test can help clinicians determine which latent TB patients are at risk for progression and would most benefit from treatment.
Lancet
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WHEN YOU TOSS AND TURN IN YOUR CALL ROOM BED
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Save it for the endoscopy suite. In a multicenter trial, adenoma detection rate was higher in patients undergoing position change during colonoscopy. Position changes included left lateral decubitus position for the right colon, supine position for the transverse colon, and right lateral decubitus position for the left colon and rectum. The increase in detected adenomas was mainly seen in the transverse colon and left colon.
Am J Gastroenterol
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Three or more unformed stools in 24 hours or ileus or toxic megacolon on imaging is highly suspicious for C. diff infection. Diagnosis is made with a positive stool test or with psuedomembranous colitis on colonoscopy. Metronidazole or oral vancomycin are first-line treatments. Use vancomycin for severe (WBC > 15k, Cr > 1.5x baseline), complicated (hypotension, ileus, or megacolon) or recurrent infection. Multiple recurrences prompt treatment with fidaxomicin or fecal microbiota transplant.
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This study from the dark ages of 2006 (when, like, the world economy was about to fall apart) found male surgeons to be better looking than their male physician colleagues, but less good looking than movie stars that played doctors on screen. How times have changed.
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