A personalized systems medicine approach to refractory rumination.

RATIONALE, AIMS AND OBJECTIVES: As with many functional disorders, rumination syndrome poses a great dilemma when approached via standard of care. This case report illustrates how rumination syndrome may be effectively approached using the systems medicine. METHOD: The patient's treatment involved two distinctively different treatment cycles. Initially she was treated in an academic tertiary inpatient and outpatient multidisciplinary program with a primary symptom-based focus with little improvement. She subsequently sought care at a systems-based integrative medicine clinic within an academic family medicine centre, which identified the inciting events, diagnosed the current pathology and developed a stepwise treatment plan. RESULTS: The patient is now rumination free. CONCLUSION: Chronic or refractory diseases, especially when regarded as 'functional' may be approached by a systems medicine methodology, which allows physicians to fine-tune the vast amount of specific pieces of knowledge to achieve an integrated approach to managing the whole person.

Perceived benefit of Complementary and Alternative Medicine (CAM) for back pain: a national survey.

BACKGROUND: Complementary and alternative medicine (CAM) is commonly used to treat back pain, but little is known about factors associated with improvement. METHODS: We used data from the 2002 National Health Interview Survey to examine the associations between the perceived helpfulness of various CAM therapies for back pain. RESULTS: Approximately 6% of the US population used CAM to treat their back pain in 2002. Sixty percent of respondents who used CAM for back pain perceived a "great deal" of benefit. Using multivariable logistic regression, the factor associated with perceived benefit from CAM modalities was reporting that a reason for using CAM was that "conventional medical treatment would not help" (odds ratio [OR], 1.46; 95% CI, 1.14-1.86). The 2 factors associated with less perceived benefit from CAM modalities were fair to poor self-reported health status (OR, 0.58; 95% CI, 0.41-0.82) and referral by a conventional medical practitioner for CAM (OR, 0.7; 95% CI, 0.54-0.92). Using chiropractic as a reference, massage (OR, 0.62; 95% CI, 0.46-0.83), relaxation techniques (OR, 0.25; 95% CI, 0.14-0.45), and herbal therapy (OR, 0.3; 95% CI, 0.19-0.46) were all associated with less perceived benefit whereas those with similar perceived benefit included yoga/tai chi/qi gong (OR, 0.71; 95% CI, 0.41-1.22) and acupuncture (OR, 0.71; 95% CI, 0.37-1.38). CONCLUSIONS: The majority of respondents who used CAM for back pain perceived benefit. Specific factors and therapies associated with perceived benefit warrant further investigation.

Urinary tract infection in women over the age of 65: is age alone a marker of complication?

BACKGROUND: We were interested to know if our older female patients with urinary tract infections (UTIs) might have differing pathogens or rates of Escherichia coli antibiotic sensitivity and if our physicians managed them in a manner similar or dissimilar to the care provided to younger patients with no complications. METHODS: This was a secondary analysis from patients excluded from a previous retrospective study regarding uncomplicated UTIs. RESULTS: Twenty-six percent of total patients with UTIs were older than 65 and otherwise medically uncomplicated whereas 21% were older patients who did have complicating factors. E. coli was a pathogen in 81% of uncomplicated elders' and 54% of complicated elders' cultures. E. coli sensitivity rate to sulfamethoxazole-trimethoprim (SMX/TMP) in both groups was 86%. Physicians were significantly less likely to prescribe SMX/TMP for complicated older patients with complications than for young patients with an uncomplicated UTI (P = .017); there was a significant trend of physicians to be less likely to prescribe SMX/TMP with advancing age in a patient and complications across all 3 groups (P = .011). Antibiotics rarely needed to be changed after cultures. CONCLUSIONS: The presence of E. coli on culture in patients with a UTI changes based on medical complications, not age. Being medically complex did not result in reduced sensitivity of E. coli to SMX/TMP but was associated with increased rates of the presence of other pathogens. In our setting, treatment employed with SMX/TMP and without the use of culture and sensitivity may be effective for appropriately selected older women. Prospective studies are needed to determine the optimal approach to management.

Assessing adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection.

OBJECTIVE: To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting. PATIENTS AND METHODS: We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined. RESULTS: Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coil was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients. CONCLUSION: Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.