Peripheral Nerve Entrapment and Injury in the Upper Extremity.

Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. The extent of the injury can range from mild neurapraxia, in which the nerve experiences mild ischemia caused by compression, to severe neurotmesis, in which the nerve has full-thickness damage and full recovery may not occur. Most nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. Patients with nerve injury typically present with pain, weakness, and paresthesia. A detailed history and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies can help confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormality.

Cardiovascular considerations in middle-aged athletes at risk for coronary artery disease.

Cardiovascular disease remains the leading cause of death in the United States despite a 50% decrease in deaths from myocardial infarction and stroke in the past 30 years associated with improvements in blood pressure and lipid control. The National Health and Nutrition Evaluation Survey found that the least prevalent metrics of cardiovascular health in adults were healthy diets, normal weights, and optimal levels of exercise. A further reduction in rates of cardiovascular disease will require an increase in exercise. Clinicians who encourage exercise in middle-aged patients face several dilemmas. This article reviews exercise-related risks for sudden death and the performance of a global cardiovascular risk assessment. The need for additional preexercise risk stratification with electrocardiogram, graded exercise testing, or echocardiography is outlined. In addition, the optimum choice of medications for hypertension or dyslipidemia treatment and the effects of these medications and aspirin on endurance exercise are reviewed.

Patient outcomes of a clinician curriculum on how to deliver a diabetes diagnosis.

AIMS: To investigate the effects of a curriculum that teaches medical decision making and interpersonal communication in the context of prediabetes (preDM) and type 2 diabetes (T2DM). METHODS: This evaluation was an active-controlled trial of 56 patients, including patients who received their diagnosis from intervention-trained clinicians or a control group. Patients attended a research appointment for informed consent and collection of baseline measures. Over the following six months, both groups were mailed surveys and informational handouts monthly. Upon conclusion, we recorded the most recent A1c from the patient's record. RESULTS: An analysis of covariance test revealed patients who received a T2DM diagnosis from an intervention-trained clinician reported higher reassurance from the diagnosing clinician and had a higher perception of threat. Although not statistically significant, patients with T2DM in the intervention group had a lower A1c at follow up and patients in the intervention group reported less poor eating and a higher degree of diet decision making. CONCLUSIONS: The curriculum itself does not influence glycemic control, but our results demonstrate the positive impact on patients of the curriculum to teach critical skills to clinicians delivering a diabetes diagnosis.

Diabetes ROADMAP: Teaching Guideline Use, Communication, and Documentation When Delivering the Diagnosis of Diabetes.

Introduction: Most interventions to date regarding breaking bad news focus on late-stage disease or disclosing a cancer diagnosis. Little attention has been given to delivery of chronic metabolic disease diagnoses such as prediabetes/type 2 diabetes. Methods: Informed by the American Diabetes Association standards of care and formative research conducted by our research team, we developed this curriculum through the six-step approach to curriculum development. The curriculum consists of a 2- or 3-hour intervention that teaches medical decision-making, interpersonal communication, and clinical documentation in the context of prediabetes and type 2 diabetes followed by role-play and clinical practice. Results: Across three cohorts, 53 clinicians completed the curriculum. Across the three iterations, learners rated the curricular intervention as worthwhile and delivered at an appropriate level. In a community hospital setting, learners scored significantly higher on a knowledge check than did a control group of six clinicians (p < .001). Learners in the community hospital also indicated high response efficacy and self-efficacy. At the academic medical center, simulated patients indicated high measures on the Diabetes Health Threat Communication Questionnaire. Discussion: The moment of diagnosis presents a key opportunity to affect patients' perceptions of the disease. This curriculum guides clinicians in making the most of diagnosis delivery. Pairing of qualitative, patient-centered research alongside the iterative curriculum design process allows the curriculum to be adaptable and scalable to multiple settings and learner types.

The role of the dorsomedial prefrontal cortex, basolateral amygdala, and dorsal hippocampus in contextual reinstatement of cocaine seeking in rats.

The present study tested the hypothesis that separate neural substrates mediate cocaine relapse elicited by drug-associated contextual stimuli vs explicit conditioned stimuli (CSs) and cocaine. Specifically, we investigated the involvement of the dorsal hippocampus (DH), basolateral amygdala (BLA), and dorsomedial prefrontal cortex (dmPFC) in contextual reinstatement of cocaine-seeking behavior and the involvement of the DH in explicit CS- and cocaine-induced reinstatement. Rats were trained to self-administer cocaine in a distinct context or in the presence of CSs paired explicitly with cocaine infusions. Responding of context-trained rats was then extinguished in the previously cocaine-paired or an alternate context, whereas responding of explicit CS-trained rats was extinguished in the absence of the CSs. Subsequently, the target brain regions or anatomical control regions were functionally inactivated using tetrodotoxin (0 or 5 ng/side), and cocaine-seeking behavior (ie, nonreinforced responses) was assessed in the cocaine-paired context, in the alternate context, in the presence of the explicit CSs, or following cocaine priming (10 mg/kg, i.p.). DH inactivation abolished contextual, but failed to alter explicit CS- or cocaine-induced, reinstatement of cocaine-seeking behavior. BLA or dmPFC inactivation also abolished contextual reinstatement. Conversely, inactivation of the control brain regions failed to alter contextual reinstatement. In conclusion, the DH, BLA, and dmPFC play critical roles in contextual reinstatement. Previous findings suggest that the BLA is critical for explicit CS-induced, but not cocaine-primed, reinstatement and the dmPFC is critical for both explicit CS-induced and cocaine-primed reinstatement. Thus, distinct but partially overlapping neural substrates mediate context-induced, explicit CS-induced, and cocaine-primed reinstatement of extinguished cocaine-seeking behavior.

Potentiated reinstatement of cocaine-seeking behavior following D-amphetamine infusion into the basolateral amygdala.

Reinstatement of extinguished drug-seeking behavior following chronic drug self-administration has been demonstrated in rats in the presence of conditioned cues. This experimental model of cue-induced relapse can be used to assess the neural circuitry involved in relapse. We have previously shown that blockade of dopamine D1 receptors in the basolateral amygdala (BLA) abolishes conditioned cue-induced reinstatement of cocaine-seeking behavior. The present study tested the hypothesis that D-amphetamine-induced facilitation of monoamine neurotransmission in the BLA would potentiate conditioned cue-induced reinstatement of extinguished drug-seeking behavior. During daily self-administration sessions over 10 consecutive days, rats pressed a lever to receive cocaine infusions (0.2 mg/0.05 ml) paired with a light+tone compound stimulus. Following self-administration, rats underwent daily extinction sessions, during which no stimuli were presented. On the test days, rats received intra-BLA D-amphetamine (10 or 30 micro g/side) or vehicle infusions followed by extinction or conditioned cue-induced reinstatement testing. D-amphetamine infusions did not alter extinction responding relative to vehicle infusions. During reinstatement testing, conditioned cue presentation significantly increased responding over extinction levels, and intra-BLA D-amphetamine produced a dose-dependent increase in lever responding relative to vehicle infusions. These findings suggest that enhanced monoamine tone in the BLA potentiates the motivational effect and/or salience of cocaine-paired cues during reinstatement.

Drug addiction, relapse, and the amygdala.

Evidence has extensively implicated the amygdala in the associative learning process for appetitive reinforcers. Recent interest has focused on the role of the amygdala in the learned associations that occur during the process of drug addiction and relapse. Using an animal model of relapse after chronic cocaine self-administration, we found that rats reinstate extinguished lever responding for conditioned stimuli (tone + light) previously paired with cocaine or heroin ("conditioned-cued reinstatement"). The basolateral amygdala (BLA) complex plays a critical role in this behavior, because permanent lesions or reversible pharmacologic inactivation of the BLA attenuates conditioned-cued reinstatement without affecting cocaine self-administration or cocaine-primed reinstatement. Conditioned-cued reinstatement appears to be mediated in part by dopamine inputs to the BLA, as intra-BLA infusion of a dopamine D1 receptor antagonist blocks reinstatement, whereas intra-BLA infusion of amphetamine potentiates reinstatement. Furthermore, the BLA is also necessary for acquisition of associative learning with cocaine-paired stimuli. Disruption of neural activity within the BLA by sodium channel blockade or muscarinic receptor blockade just before acquisition of stimulus-cocaine associations blocks the ability of conditioned stimuli to elicit conditioned-cued reinstatement after extinction. Together, these results reveal the importance of the amygdala as part of a corticolimbic circuit mediating both the acquisition and the expression of conditioning that plays a critical role in relapse to drug-seeking behavior.

The practice of prescribing: discovering differences in what we tell patients about prescription medications.

OBJECTIVE: This study explored patient recall of clinician presentation of information about prescription medication, looking specifically for communication patterns and differences by patient individual characteristics and by medication availability type. METHODS: A cross sectional survey collected information about 216 patients' perceptions of clinician presentations of medication information. RESULTS: Demographically, males recalled receiving more information about reasons, risks, and regimen in medication discussions. By medication type, patients reported receiving more medication information when the clinician presented a prescription-only medication as opposed to a medication that was also available over the counter. CONCLUSION: Given the broad and unmonitored use of over-the-counter products, coupled with the increasing awareness of risks associated with many of these medications, it is concerning that patients report receiving less information about these products. PRACTICE IMPLICATIONS: The emphasis on appropriate medication counseling should not be limited to medications available only by prescription. Prescribers should be mindful of these potential tendencies when discussing medications.

Refining the Practice of Prescribing: Teaching Physician Learners How to Talk to Patients About a New Prescription.

BACKGROUND: Clinician counseling about medication can improve patient understanding and adherence. This study developed a teaching session for physician learners about medication prescribing and communication, with evaluation at the physician and patient levels. OBJECTIVE: We analyzed whether patients would perceive and report more comprehensive clinician presentation of medication information when receiving prescriptions from their physician in the intervention clinic. METHODS: We conducted a single site, prospective intervention study that included lectures, role play, an objective standardized clinical examination (OSCE), and reminders displayed in patient care areas. For physician-level assessment, pretests and posttests included a written case presentation and a OSCE. For patient-level assessment, we used a cross-sectional observational design that included study of patient recall information, and assessment of patient satisfaction before and after intervention. RESULTS: Twenty-seven family medicine residents and sports medicine fellows participated in the teaching session, focused on presenting patients the reasons, risks, and regimen of prescribed medication. In written testing, learners presented significantly more comprehensive information in posttests. In the OSCE (n  =  14), all learners presented risks and regimen information. However, patient-level assessment showed no significant difference between before and after intervention. Notably, the covariates patient activation and satisfaction with communication both had a significant association with patient recall information. CONCLUSIONS: Our intervention improved learner presentation of medication information. However, patient recall of the information conveyed did not change. Although physician training did not have a positive effect on patient recall, patient activation emerged as a critical influence of patients' perceptions of medication discussions.

Persistent back pain in the absence of clear red flags.

A 62-year-old woman with low back pain was eventually diagnosed with vertebral osteomyelitis after multiple visits to emergency, primary and specialty care. The absence of traditional 'red flags' from her history and examination serves as an important reminder that their absence does not necessarily reflect benign pathology.

Exploring patient activation in the clinic: measurement from three perspectives.

OBJECTIVE: To further conceptualize and operationalize patient activation (PA), using measures from patient, physician, and researcher perspectives. DATA SOURCE/STUDY SETTING: Multimethod observation in 2010 within a family medicine clinic. STUDY DESIGN: Part of an intervention with 130 patients with type 2 diabetes, this observational study further looked at PA in 19 physician-patient dyads. Data Collection. Observations occurred in a teaching hospital, which served as recruiting and study site. PRINCIPAL FINDINGS: PA correlated with knowledge, self-efficacy, promotion orientation, and exercise intent. Patient-reported PA did not correlate with researcher-observed or physician-reported PA behavior. Researcher-observed PA correlated with physician-observation items. CONCLUSIONS: Results provide evidence for measuring different perspectives in studies of PA. When patients report they are activated in self-management, behavior does not indicate they are active in clinical communication, a critical component of collaborative decision making.

Extending Physician ReACH: influencing patient activation and behavior through multichannel physician communication.

OBJECTIVE: Despite evidence-based recommendations, physical activity as a self-management technique is underutilized. Many physical activity interventions require significant resources, ranging from repeated phone follow-up with nursing staff to intensive sessions with cooperating physical therapists. This intervention, Extending Physician ReACH (Relationship And Communication in Healthcare), examined physician to patient communication tactics for promoting walking exercise to patients with type 2 diabetes, using limited clinic time and financial resources. METHODS: This was a single-site, six-month prospective intervention, which implemented theoretically driven, evidenced-based information factor strategies. Of the 128 volunteers who participated in the initial clinic visit, 67 patients with type 2 diabetes completed the six-month intervention. RESULTS: Significant intervention effects were detected risk perception, social norms, and patient activation. CONCLUSIONS: This study was designed to identify information factors that could affect physician success in motivating patients with type 2 diabetes to enact the ADA physical activity recommendations. PRACTICE IMPLICATIONS: The success of this intervention models a strategy through which clinicians can reach beyond "one-shot" persuasion without placing onerous time and resource demands on physicians.