Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial.

Objective: Achilles tendinopathy is a common musculoskeletal condition associated with decreased functionality. The insertional variant (<2cm from the calcaneus) is less responsive to eccentric-exercise therapy. This study looked at the effect of electroacupuncture (EA) + eccentric exercise for treating insertional Achilles tendinopathy. Materials and Methods: Fifty-two active duty and Department of Defense beneficiaries older than 18 years of age with insertional Achilles tendinopathy were randomized to treatment with either eccentric exercise or eccentric exercise with EA. They were evaluated at 0, 2, 4, 6, and 12 weeks. The treatment group received EA treatment in the first 4 visits. The Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A; scored 0-100; higher score = increased function) was used to assess the patients and patient-reported pain (0-10, increasing pain with score) pre- and post-demonstration of the exercises during each visit. Results: Both the treatment group (53.6% reduction; confidence interval [CI]: 2.1, 3.9; P < 0.001) and the control group (37.5% reduction; CI: 0.4, 2.9; P = 0.023) reported decreased pain between the first and last visit. The treatment group had reduced pain (mean difference [MD] = 1.0; P < 0.01) between pre- and post-eccentric-exercise performance at each visit, while the control group did not (MD = -0.3; P = 0.065). VISA-A scores did not show a difference in functional improvement between the groups (P = 0.296). Conclusions: EA as an adjunct to eccentric therapy significantly improves short-term pain control for insertional Achilles tendinopathy.

Clinical Reasoning Curricula in Preclinical Undergraduate Medical Education: A Scoping Review.

PURPOSE: Clinical reasoning is the process of observing, collecting, analyzing, and interpreting patient information to arrive at a diagnosis and management plan. Although clinical reasoning is foundational in undergraduate medical education (UME), the current literature lacks a clear picture of the clinical reasoning curriculum in preclinical phase of UME. This scoping review explores the mechanisms of clinical reasoning education in preclinical UME. METHOD: A scoping review was performed in accordance with the Arksey and O'Malley framework methodology for scoping reviews and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. RESULTS: The initial database search identified 3,062 articles. Of these, 241 articles were selected for a full-text review. Twenty-one articles, each reporting a single clinical reasoning curriculum, were selected for inclusion. Six of the reports included a definition of clinical reasoning, and 7 explicitly reported the theory underlying the curriculum. Reports varied in the identification of clinical reasoning content domains and teaching strategies. Only 4 curricula reported assessment validity evidence. CONCLUSIONS: Based on this scoping review, we recommend 5 key principles for educators to consider when reporting clinical reasoning curricula in preclinical UME: (1) explicitly define clinical reasoning within the report, (2) report clinical reasoning theory(ies) used in the development of the curriculum, (3) clearly identify which clinical reasoning domains are addressed in the curriculum, (4) report validity evidence for assessments when available, and (5) describe how the reported curriculum fits into the larger clinical reasoning education at the institution.

Cluster Headache: Rapid Evidence Review.

Cluster headache, the most common form of trigeminal autonomic cephalgia, is a rare primary headache disorder that affects less than 1% of the population. The mean age of onset is 30 years, and it is two to three times more common in males. Cluster headache consists of attacks of severe unilateral pain located in the orbital, supraorbital, and/or temporal region that occur from every other day up to eight times per day and last from 15 to 180 minutes. The pain is associated with ipsilateral autonomic symptoms (most commonly lacrimation, conjunctival injection, nasal congestion or rhinorrhea, ptosis, edema of the eyelid, sweating of the forehead or face, and miosis) and a sense of agitation or restlessness. Attacks occur in clusters, called bouts, and are episodic or chronic. Common triggers include alcohol, nitroglycerin, food containing nitrates, and strong odors. Abortive treatments include triptans and oxygen; transitional treatments include steroids and suboccipital steroid injections; and prophylactic treatments include verapamil, lithium, melatonin, and topiramate. Newer treatments for cluster headache include galcanezumab, neurostimulation, and somatostatin receptor agonists.

Sinus Node Dysfunction.

Sinus node dysfunction, previously known as sick sinus syndrome, describes disorders related to abnormal conduction and propagation of electrical impulses at the sinoatrial node. An abnormal atrial rate may result in the inability to meet physiologic demands, especially during periods of stress or physical activity. Sinus node dysfunction may occur at any age, but is usually more common in older persons. The causes of sinus node dysfunction are intrinsic (e.g., degenerative idiopathic fibrosis, cardiac remodeling) or extrinsic (e.g., medications, metabolic abnormalities) to the sinoatrial node. Many extrinsic causes are reversible. Electrocardiography findings include sinus bradycardia, sinus pauses or arrest, sinoatrial exit block, chronotropic incompetence, or alternating bradycardia and tachycardia (i.e., bradycardia-tachycardia syndrome). Clinical symptoms result from the hypoperfusion of end organs. About 50% of patients present with cerebral hypoperfusion (e.g., syncope, presyncope, lightheadedness, cerebrovascular accident). Other symptoms include palpitations, decreased physical activity tolerance, angina, muscular fatigue, or oliguria. A diagnosis is made by directly correlating symptoms with a bradyarrhythmia and eliminating potentially reversible extrinsic causes. Heart rate monitoring using electrocardiography or ambulatory cardiac event monitoring is performed based on the frequency of symptoms. An exercise stress test should be performed when symptoms are associated with exertion. The patient's inability to reach a heart rate of at least 80% of their predicted maximum (220 beats per minute - age) may indicate chronotropic incompetence, which is present in 50% of patients with sinus node dysfunction. First-line treatment for patients with confirmed sinus node dysfunction is permanent pacemaker placement with atrial-based pacing and limited ventricular pacing when necessary.

Integrative Medicine: Manual Therapy.

Manual therapy, or manipulative therapy, is performed primarily by osteopathic physicians, chiropractors, and physical therapists to relieve pain and improve function. As safe prescribing of opioids has become a concern and nondrug therapies for pain management are used more widely, manual therapy has become an attractive treatment option for many patients. A variety of techniques are used, including myofascial release, strain-counterstrain, muscle energy, high velocity/low amplitude, Still, and others. The most common conditions for which patients seek manual therapies are back pain, neck pain, and extremity problems. These therapies also are used to manage many other conditions. Studies show that, in general, manual therapies may improve pain and function in the short and moderate term in patients with acute and chronic back pain, neck pain, rotator cuff conditions, and temporomandibular joint disorders. These therapies also are used in patients with sciatica, migraine, carpal tunnel syndrome, pregnancy-related pelvic girdle pain, and infantile colic. Manual therapies may result in improvements in these conditions, but there is no high-quality research to confirm their benefits. Many studies show benefits that are similar to those of other commonly used therapies, or that are not superior to the benefits shown with sham manipulation.

Integrative Medicine: Acupuncture.

Acupuncture is used to manage pain and a variety of medical and psychological conditions. It modulates nociceptive areas of the brain, affects neuropeptide and purinergic signaling, and stimulates production of opioid neuropeptides. There are many types of acupuncture, including traditional, dry needling, laser, auricular, scalp, Japanese, and Korean. There is evidence that traditional acupuncture is effective in the management of many conditions, with strong evidence of benefit for chronic back pain and osteoarthritis-related knee pain. In the United States, the conditions most commonly managed with acupuncture are low back pain, depression, anxiety, headache, and arthritis. There are no absolute contraindications. Relative contraindications include frailty and febrile illness. Acupuncture should not be used in areas of skin infection or breakdown. Acupuncture typically is avoided during the first trimester of pregnancy. Reports of serious adverse effects are rare but include pneumothorax, infection, organ or tissue injuries, and seizures. Serious adverse effects of electroacupuncture (eg, skin burns, pacemaker or implantable cardioverter-defibrillator dysfunction) are limited to case reports. Thirty-three states in the United States consider acupuncture to be within the scope of practice of physicians. Other states require specific acupuncture training. Medicare provides coverage for acupuncture for management of chronic low back pain.

Integrative Medicine: Herbal Supplements.

Various herbal medicines have been used around the world for more than 5,000 years. Herbal medicines, or herbal supplements, are defined as any products originating from plants and used to preserve or recover health. In the United States, the popularity of herbal supplements has increased in the last several decades. Many physicians do not ask patients about herbal supplement use, and one-third of patients do not inform their physician about supplement use. However, physicians should ask, because although many supplements are considered low risk and safe, some have significant risks of adverse effects. For example, St John's wort (Hypericum perforatum) can have significant drug interactions with prescription or over-the-counter drugs. The effectiveness of herbal supplements in the management of specific conditions varies. For some conditions, there is robust clinical data supporting the use of specific herbal supplements, but for other conditions there is poor or insufficient data. The content and safety of herbal supplements are the purview of the Food and Drug Administration (FDA). However, the FDA primarily responds to after-the-fact reports of postmarketing safety concerns. When an herbal supplement-related adverse effect is suspected, patients or physicians should report it to the FDA via the MedWatch reporting system.

Integrative Medicine: Cannabis and Cannabis-Related Drugs.

Cannabis is a genus of flowering herbs in the Cannabaceae family. Federal law defines dried plant material preparations of the subspecies Cannabis sativa as marijuana. The term cannabis refers to all products derived from Cannabis plants. The active compounds in cannabis are cannabinoids, which include delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the psychoactive component, whereas CBD has no psychoactive effects. There are three Food and Drug Administration (FDA)-approved cannabis-related drugs. Dronabinol and nabilone (Cesamet) are approved for chemotherapy-induced nausea and vomiting; cannabidiol (Epidiolex) is approved for two pediatric epilepsy syndromes. FDA-approved cannabis-related drugs, marijuana, and cannabis formulations have been studied for the management of other conditions and symptoms (eg, cachexia, chemotherapy-induced nausea and vomiting, chronic pain, muscle spasticity) and have shown varying effectiveness. CBD formulations have been shown to be effective for certain forms of epilepsy. However, marijuana, cannabis-containing products, and cannabis-derived products in general are not approved by the FDA for any indication. Adverse effects include impaired executive function, cognition, and driving. Physicians can recommend use of marijuana under medical marijuana laws but cannot prescribe it, as it is classified as a Schedule I controlled substance. Laws regulating use of marijuana and cannabis products vary among states.

Acute Lower Gastrointestinal Bleeding: Evaluation and Management.

Evaluation and management of acute lower gastrointestinal bleeding focus on etiologies originating distally to the ligament of Treitz. Diverticular disease is the most common source, accounting for 40% of cases. Hemorrhoids, angiodysplasia, infectious colitis, and inflammatory bowel disease are other common sources. Initial evaluation should focus on obtaining the patient's history and performing a physical examination, including evaluation of hemodynamic status. Subsequent evaluation should be based on the suspected etiology. Most patients should undergo colonoscopy for diagnostic and therapeutic purposes once they are hemodynamically stable and have completed adequate bowel preparation. Early colonoscopy has not demonstrated improved patient-oriented outcomes. Hemodynamic stabilization using normal saline or balanced crystalloids improves mortality in critically ill patients. For persistently unstable patients or those who cannot tolerate bowel preparation, abdominal computed tomographic angiography should be considered for localization of a bleeding source. Technetium Tc 99m-labeled red blood cell scintigraphy should not be routinely used in the evaluation of lower gastrointestinal bleeding. Surgical intervention should be considered only for patients with uncontrolled severe bleeding or multiple ineffective nonsurgical treatment attempts. Percutaneous catheter embolization should be considered for patients who are poor surgical candidates. Treatment is based on the identified source of bleeding.

PURL: Treating migraines: It's different for kids.

Certain medications used for migraine prevention in adults do not perform the same way in children and adolescents and can actually cause harm.

Successful Treatment of Achilles Tendinopathy with Electroacupuncture: Two Cases.

Background: Achilles tendinopathy is a common injury for active patient populations and is challenging to treat. Acupuncture tendon-based therapy was first described in the Yellow Emperor's Classic of Internal Medicine. In modern times, specific techniques have been described poorly in the literature. The aim of this case report is to describe a new technique of acupuncture for the treatment of Achilles tendinopathy and provide 2 illustrative cases. Cases: Treatments for the 2 patients were performed in a deployed military treatment facility. SERIN® 0.25 mm × 40 mm needles placed at BL 60, BL 61, KI 3, and KI 4, with needles directed into the Achilles tendon of each patient. Needles were inserted until a firm catch of the needle entering the tendon was discerned. Energy was placed from KI 3(-) → KI 4(+) and BL61 (-) → BL 60(+) at 30 Hz for 15 minutes. Results: Both patients reported symptomatic reduction in Achilles tendinopathy pain and functional improvement following the described treatments. Conclusions: This case series describes two cases of successful Achilles tendinopathy therapy using direct tendon needle insertion with electrostimulation. This novel technique may provide an effective adjunct to traditional therapies in the treatment of Achilles tendinopathy.