Discharged and dismissed:A qualitative study with back pain patients discharged without treatment from orthopaedic consultations

BackgroundConsultation-based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment.MethodsSemi-structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed.ResultsMost patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self-management. These behaviours group into four domains: “Knowing my whole story” (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), “Seeing the right person” (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), “Nothing to worry about” (reducing generic reassuring statements but increasing validating statements recognizing suffering) and “Getting to grips with my problem” (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self-manage, reported distress, anger and intention to re-consult.ConclusionEffective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered.SignificanceThis study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self-management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation-based reassurance in orthopaedic spinal care settings.<br/

Reassurance and health care seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners:A prospective cohort study

BackgroundGuidelines recommend self-management for most people living with persistent musculoskeletal low back pain (PMLBP) when surgery is ruled out. Conveying this message to patients can be challenging. This study examined patients' perceptions of reassuring communications from surgical spine team practitioners attempting to deliver this message in a single consultation.MethodsPre-consultation baseline measures included levels of pain, disability and previous consultation history. Patients' perceptions of reassuring communications were measured within 1-week post-consultation. The outcome variables, measured at 3-month follow-up, included patients’ report of subsequent GP visits for back pain, the number of other healthcare providers consulted for back pain and distress.ResultsData from 296 patients (9.8% loss to follow-up) were analysed using hierarchical regression models, controlling for demographic, clinical and study-related factors. In each model, perceived reassurance accounted for a small but significant variance, above and beyond other predictors. Further GP visits were predicted by disability at baseline and perceived reassurance (adjusted R2 of 14.6%). Subsequent consultations with any healthcare professionals were predicted by a shorter duration of back pain, disability at baseline and perceived reassurance (adj. R2 = 10.6%). Distress was predicted by older age, disability and reassurance (adj. R2 = 59.5%).ConclusionFindings suggest that better communication in consultations with orthopaedic spine clinicians might help reduce unnecessary subsequent healthcare utilization and distress.SignificanceLow back pain patients' perceptions of their communication with orthopaedic spine practitioners are associated with subsequent healthcare seeking and distress at follow-up. This study examines the intersection of two important but fairly neglected areas in the pain research: provider communication and patient healthcare utilization

International health and Hispanic culture

This research project focuses on the interrelations between health and culture in the Hispanic countries and their impact on individuals and communities. The research explores medical diseases and conditions, people\u27s traditions, beliefs, and perceptions related to concerns related to health issues, home remedies, behavior change, family and community, doctor-patient relationship, and social aspects of public health (ethnicity, gender, poverty). Students will have the opportunity to travel to the Dominican Republic with the researchers and participate in service learning activities to help Hispanic communities and collect data for this research project. CI students will lead the following research topics in the Dominican Republic: 1) self-medication, low-income population accessibility to medicines, and the governmental pharmacy system (Boticas Populares) (Caleb Addis); 2) domestic violence as a public health concern (Aliyah Anjarwalla); 3) how chronic diseases are promoted, prevented and controlled (Deepti Athavale); 4) hepatitis A as a public health concern (Thomas Cotton); 5) challenges/barriers of people with disabilities to access physical therapy services (Breci Davis) ; 6) cultural and socio-economic determinants of childhood obesity (Michelle Fuentes); 7)medical equipment maintenance at public health care settings: advantages and disadvantages of donated equipment (Hannah Haire); 8) challenges and opportunities for the implementation of the HIV Vertical Transmission Prevention Program (Ashley Jamison); and 9) a behavioral theory analysis of drug abuse (Katherine Orellana)

A Case Study of Eukaryogenesis: The Evolution of Photoreception by Photolyase/Cryptochrome Proteins

Eukaryogenesis, the origin of the eukaryotes, is still poorly understood. Herein, we show how a detailed all-kingdom phylogenetic analysis overlaid with a map of key biochemical features can provide valuable clues. The photolyase/cryptochrome family of proteins are well known to repair DNA in response to potentially harmful effects of sunlight and to entrain circadian rhythms. Phylogenetic analysis of photolyase/cryptochrome protein sequences from a wide range of prokaryotes and eukaryotes points to a number of horizontal gene transfer events between ancestral bacteria and ancestral eukaryotes. Previous experimental research has characterised patterns of tryptophan residues in these proteins that are important for photoreception, specifically a tryptophan dyad, a canonical tryptophan triad, an alternative tryptophan triad, a tryptophan tetrad and an alternative tetrad. Our results suggest that the spread of the different triad and tetrad motifs across the kingdoms of life accompanied the putative horizontal gene transfers and is consistent with multiple bacterial contributions to eukaryogenesis

Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom

Abstract Background Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification. Methods To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers. Results A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years’ experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery. Conclusion This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist. </jats:sec

Supplementary stabilization with anterior lumbar intervertebral fusion - A radiologic review

Study designA radiologic assessment of the success of anterior lumbar interbody fusion (ALIF) using thin-section computerized tomography (CT) was performed.ObjectiveTo assess the effect of different types of posterior stabilization on the fusion rate of ALIF.Summary of background dataThin-section CT has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiologic methods. Cadaveric studies have shown that posterior stabilization would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. To our knowledge, the results of thin-section CT of ALIF, with and without posterior stabilization, has not been reported previously.MethodsPatients with discogenic back pain confirmed by diskography underwent ALIF surgery, either as a stand-alone procedure or with posterior stabilization, using translaminar, unilateral pedicle, or bilateral pedicle screws. The 4 cohorts were followed up prospectively, and thin-section CT was used to assess interbody fusion.ResultsThe fusion rate for stand-alone ALIF was 51%, for patients with supplementary stabilization with translaminar screws 58%, with unilateral pedicle screws 89%, and with bilateral pedicle screws 88%. A significant difference in the fusion rate was found when ALIF was combined with pedicle screw stabilization (P ConclusionThe addition of pedicle screw fixation at ALIF produces a significant increase in the rate of interbody fusion.Anjarwalla, Naffis K; Morcom, Russel K; Fraser, Robert

Perihilar clear cell cholangiocarcinoma: an often-diagnostic challenge

Cholangiocarcinomas are rare and often diagnosed late. Clear cell histology is a rare variant of such cancers. We report one such case of a man in his late 60s, with a history of excess alcohol intake, who was found to have deranged liver biochemical tests incidentally during an admission for an allergic reaction. Subsequent imaging to investigate this suggested a diagnosis of perihilar cholangiocarcinoma (ultrasound, CT, MRI, cholangiogram). Biopsy confirmed this to be of clear cell type on histology and immunohistochemistry. Diagnosis and further management of this rare entity was conducted in multidisciplinary meetings with the regional hepatobiliary centre. The patient was deemed unsuitable for surgical resection, underwent chemotherapy but died 1 year later.</jats:p