Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co‐morbidity include recent stress, lower self‐rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive‐behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms

Scalar and vector games in the evaluation of social and environmental disclosure and their relationship with market value

This study evaluated the association of social, environmental and socio-environmental disclosure with the market value of Brazilian companies with high environmental impact based on the Game Theory. To perform the analysis, rankings were developed by using scalar and vector gaming techniques. After the construction of the rankings, the association between them was verified through Kendall’s correlation analysis. The findings indicate a positive association of social, environmental and socio-environmental disclosure with the market value of Brazilian companies with high environmental impact. In addition, there was an increase in the degree of association during the investigated periods. This result suggests that the market is increasingly demanding regarding the disclosure of this information, which indicates that the disclosure of these information can bring competitive advantages in relation to the market value

Tailoring a cognitive behavioural model for unexplained physical symptoms to patient's perspective: a bottem-up approach.

The prevalence of unexplained physical symptoms (UPS) in primary care is at least 33%. Cognitive behavioural therapy has shown to be effective. Within cognitive behavioural therapy, three models can be distinguished: reattribution model, coping model and consequences model. The consequences model, labelling psychosocial stress in terms of consequences rather than as causes of UPS, has high acceptance among patients and is effective in academic medical care. This acceptance is lost when applied in primary care. To increase acceptance of the consequences model among patients in primary care, we tailor this model to patient's perspective by approaching the model from bottom-up instead of top-down. Subsequently, we use this tailored model in an easily accessible group training. We illu

Capsule Commentary on Meredith et al., Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: A Randomized Controlled Trial

Comment on Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial. [J Gen Intern Med. 2016

Somatic Symptoms Deserve Our Attention

This commentary focuses on two articles in this issue which provide important insights regarding the diagnosis and management of medically unexplained symptoms (MUS). Up to half of all outpatient visits are prompted by a physical/somatic complaint of which at least a third are MUS. Analyzing data from the National Ambulatory Care Medical Survey, Gates, Petterson, Wingrove, Miller, and Klink (2016) confirmed the common finding that depression and anxiety in patients presenting with somatic symptoms are underrecognized. Only 1–4% of such patients received a diagnosis of depression or anxiety, a rate that should have been at least four- to sixfold greater. optimize the care of chronic somatic symptoms. In the second article, Clarke draws upon clinical experience spanning several decades and thousands of patients to delineates a pragmatic approach to managing MUS. His six-step strategy augmented by illustrative cases makes more tangible the process of caring for patients with chronic symptoms

Telemedicine Screening for Eye Disease

Importance Telemedicine is a useful clinical method to extend health care to patients with limited access. Minimal information exists on the subsequent effect of telemedicine activities on eye care resources. Objective To evaluate the effect of a community-based diabetic teleretinal screening program on eye care use and resources. Design, Setting, and Participants The current study was a retrospective medical record review of patients who underwent diabetic teleretinal screening in the community-based clinics of the Atlanta Veterans Affairs Medical Center from October 1, 2008, through March 31, 2009, and who were referred for an ophthalmic examination in the eye clinic. Exposures Clinical medical records were reviewed for a 2-year period after patients were referred from teleretinal screening. The following information was collected for analysis: patient demographics, referral and confirmatory diagnoses, ophthalmology clinic visits, diagnostic procedures, surgical procedures, medications, and spectacle prescriptions. Main Outcomes and Measures The accuracy between referring and final diagnoses and the eye care resources that were used in the care of referred patients. Results The most common referral diagnoses were nonmacular diabetic retinopathy (43.2%), nerve-related disease (30.8%), lens or media opacity (19.1%), age-related macular degeneration (12.9%), and diabetic macular edema (5.6%). The percentage of agreement among these 5 visually significant diagnoses was 90.4%, with a total sensitivity of 73.6%. Diabetic macular edema required the greatest number of ophthalmology clinic visits, diagnostic tests, and surgical procedures. Using Medicare cost data estimates, the mean cost incurred during a 2-year period per patient seen in the eye clinic was approximately $1000. Conclusions and Relevance Although a teleretinal screening program can be accurate and sensitive for multiple visually significant diagnoses, measurable resource burdens should be anticipated to adequately prepare for the associated increase in clinical care

Comparison of Conversation and Narrative Language Abilities in Children with Autism: Diagnostic and Therapeutic Considerations

Many children with autism experience significant difficulty with comprehension and expression of spoken language. Speech-language pathologists (SLPs) require sensitive assessments to describe the unique profiles of individual clients with autism so that appropriate treatments can be prescribed. Language sample analysis is a current best-practice for describing language profiles in children with language difficulties, though there is a limited literature describing clinical best-practices for children with autism. The purpose of this study was to analyze the difference in conversation and narrative language abilities in children with autism. Language ability was also analyzed in comparison to age-matched typically developing peers. This goal of this analysis was to assist in determining the context that reveals language deficits in children with autism to be utilized for diagnostic considerations and planning for intervention. Three children with autism, aged 6, participated in this study. Children were observed having a conversation with their parent or SLP and retelling a story from a wordless picture book originally told by their parent or SLP. Both samples were analyzed for grammatical and semantic errors. The conversation sample was analyzed for contingent responses, while narrative samples were analyzed for story grammar elements and organization. The analysis was completed using the Systematic Analysis of Language Transcripts (SALT) database. The microstructural analysis revealed that the participants’ relative weaknesses surrounded the complexity and accuracy of their utterances. The participants had difficulty producing syntactically accurate conversation samples demonstrated by a high number of word and utterance level errors. Within the narrative samples, the children produced utterances with relatively simple grammar and syntax demonstrated by very low MLU values compared to their peers. The macrostructural analysis of conversation samples revealed that 2 of the 3 participants produced half contingent and half non-contingent responses. Of those contingent responses, the majority were responses to wh-questions, despite one participant whose utterances were primarily self-expansions. The macrostructural analysis of narrative samples using the Narrative Scoring Scheme (NSS) revealed that the participants were at floor. Two participants achieved minimal scores for an introduction while the other participant received a minimum score for a conclusion. All narratives lacked cohesion and story grammar elements. Overall, the participants in this study did relatively worse in the narrative sample possibly due to the fact that it requires a higher level of language. Further research is needed to generalize these findings

Ontong Java Plateau, Leg 130: Synopsis of major drilling results

Sixteen holes were drilled at five sites on the northeastern flank of Ontong Java Plateau during Leg 130 (Sites 803 through 807). All of these sites are near the equator, but are at different depths (803: 02°26.0\u27N, 3410 m; 804: 01°00.3\u27N, 3861 m; 805: 01°13.7\u27N, 3188 m; 806: 00°19.1\u27N, 2520 m; and 807: 03°36.4\u27N, 2805 m). One of our goals was to obtain a depth transect of Neogene carbonate deposition for reconstructing the history of ocean climate, chemistry, and productivity, and for understanding the origin of acoustic reflectors. Another goal was to achieve considerable penetration into basement for elucidating the origin of the plateau. All sites yielded multiple Neogene sequences, which were cored using the advanced hydraulic piston corer (APC) to the ooze-chalk transition (10-14 Ma) and with the extended core barrel (XCB) below that. Sites 803 and 807 were drilled to basement and yielded incomplete Paleogene and Cretaceous sections. Penetration into basement was 25 m at Site 803 and 149 m at Site 807; 98 m of basalt was recovered. In all, we cored 5889 m, taking 639 cores. Of the record 4822 m recovered, 55% was taken with the APC, 39% with the XCB, and 6% with the rotary core barrel (RCB). All sites except Site 804 were logged. Neogene sedimentation rates were found to vary by more than a factor of 2, with a striking maximum in the latest Miocene to early Pliocene and a strong minimum in the Pleistocene. Fluctuations in carbonate content on the millionyear scale are highly coherent among depths over the last 12 m.y., perhaps less so before that. Many acoustic reflectors appear synchronous with carbonate reduction events (CREs) and other paleoceanographic events. Other reflectors are tied to diagenesis (e.g., the ooze-chalk transformation, which is diachronous). Recovery of the Cretaceous/Tertiary (K/T) boundary at Sites 803 and 807 demonstrates the presence of a deep carbonate-compensation depth (CCD) across the transition: one sequence is calcareous, the other is not. Because the K/T sections occur below and above major hiatuses, we postulate that special conditions for preservation existed during the transition. In addition, there is evidence of volcanic activity at that time. The basalts cored at Sites 803 and 807 are predominantly olivine-bearing and were erupted during the mid-Cretaceous. At Site 807, pillow lavas buried sediments. One thick flow (at about 28 m) was penetrated here, apparently a flood basalt. Magnetic paleolatitudes suggest that the Ontong Java Plateau has moved coherently with the Pacific Plate since the Early Cretaceous

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care