Case Report: Initial Successful Treatment of Migraine and Irritable Bowel Syndrome With a Low-FODMAP Diet.

OBJECTIVE: Migraine and irritable bowel syndrome (IBS) can be difficult-to-treat comorbidities that may be driven by underlying gut-brain axis dysfunction. This report describes utilization of a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet (LFD) in a patient with refractory migraine and co-occurring IBS. METHODS: After unremarkable physical and neurological examinations, a 57-year-old woman with IBS and chronic migraine was started on a LFD under the guidance of a registered dietician. Psychometrically validated surveys administered at baseline and initial follow-up assessed patient-reported outcomes related to migraine and IBS symptoms. RESULTS: At baseline, the patient reported 80/90 migraine days with average pain of 8/10, a Migraine Disability Assessment (MIDAS) score of 33, and Headache Impact Test-6 (HIT-6) score of 64, the latter 2 scores indicating severe disability. Baseline IBS symptom severity was noted at 9/10. Within 1 week on a LFD, the patient's IBS symptoms and migraines improved in both frequency and intensity of episodes. After 5 weeks on a LFD elimination, the patient's clinical improvement continued and she reported significant reduction in migraines, with average pain of 1/10 and IBS severity of 3/10. The patient also improved from severe to minimal levels of disability on validated measures (MIDAS, HIT-6, and IBS Patient Global Impression of Change). CONCLUSION: This is the first case report detailing successful initial treatment of migraine and co-occurring IBS utilizing a dietician-guided LFD. There are a number of important reasons for potential improvement in these gut-brain axis disorders which are reviewed as well as an implication for long-term management and food reintroduction. Larger, randomized trials evaluating a LFD in diverse individuals with migraine and co-occurring IBS are warranted to help confirm these results.

COVID-19 Vaccination Might Induce Postural Orthostatic Tachycardia Syndrome: A Case Report.

We report a case of new-onset postural orthostatic tachycardia syndrome in a healthy 46-year-old female after a single dose of the BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine. There have been three prior reports of new-onset postural orthostatic tachycardia syndrome after COVID-19 vaccination. Predominant symptoms noted included fatigue, brain fog, headache, sinus tachycardia, and dizziness. Management includes noninvasive therapies, behavioral approaches, and pharmacologic regimens. Here, the patient presented with fatigue, palpitations, dizziness, and presyncope, with symptoms beginning 7 days after vaccination. Presenting vitals included temperature within normal limits, inappropriate tachycardia, up to 120 beats per minute, blood pressure of 128/87 mm of mercury, and 100% saturation in room air. Her management included lifestyle changes, dietary supplements, and ivabradine. Further studies are needed to evaluate prevalence, etiology, and optimal management.

Natural Supplements for COVID19-Background, Rationale, and Clinical Trials.

Worldwide, the turmoil of the SARS-CoV-2 (COVID-19) pandemic has generated a burst of research efforts in search of effective prevention and treatment modalities. Current recommendations on natural supplements arise from mostly anecdotal evidence in other viral infections and expert opinion, and many clinical trials are ongoing. Here the authors review the evidence and rationale for the use of natural supplements for prevention and treatment of COVID-19, including those with potential benefit and those with potential harms. Specifically, the authors review probiotics, dietary patterns, micronutrients, antioxidants, polyphenols, melatonin, and cannabinoids. Authors critically evaluated and summarized the biomedical literature published in peer-reviewed journals, preprint servers, and current guidelines recommended by expert scientific governing bodies. Ongoing and future trials registered on clinicaltrials.gov were also recorded, appraised, and considered in conjunction with the literature findings. In light of the controversial issues surrounding the manufacturing and marketing of natural supplements and limited scientific evidence available, the authors assessed the available data and present this review to equip clinicians with the necessary information regarding the evidence for and potential harms of usage to promote open discussions with patients who are considering dietary supplements to prevent and treat COVID-19.

Anti-Opioid Antibodies in Individuals Using Chronic Opioid Therapy for Lower Back Pain.

In addition to the risk of developing opioid use disorder (OUD), known side-effects of long-term opioid use include chronic inflammation and hyperalgesia, which may arise from immune responses induced following chronic opioid use. To investigate this hypothesis, blood samples were obtained from individuals with chronic back pain who were either chronically taking prescription opioids or had minimal recent opioid exposure. Patient samples were analyzed using an enzyme-linked immunosorbent assay (ELISA) against hydrocodone- or oxycodone-hapten conjugates to assess the levels of antibodies present in the samples. While no specific response was seen in opioid-naïve subjects, we observed varying levels of anti-opioid IgM antibodies in the exposed subjects. In these subjects, antibody formation was found to be weakly correlated with current reported daily opioid dose. Other drugs of abuse found to elicit an immune response have been shown to generate advanced glycation end-products (AGEs) through reaction with glucose and subsequent modification of self-proteins. Investigations into this potential mechanism of anti-opioid antibody production identified reduced the formation of reactive intermediate species upon norhydrocodone reaction with glucose in comparison with nornicotine, thus identifying potentially important differences in hapten processing to yield the observed adaptive immune response.

Detoxification Enhanced Lifestyle Intervention Targeting Endotoxemia (DELITE) in the Setting of Obesity and Pain: Results of a Pilot Group Intervention.

BACKGROUND: Obesity is a complex multifactorial disorder affecting a growing proportion of the population. While therapeutic lifestyle change (TLC) is foundational, results of interventional programs are often inconsistent. Factors related to systemic inflammation, toxin load and endotoxemia have been postulated to play a contributory role. This pilot study sought to evaluate the role of TLC with enhanced laboratory evaluation and interventions to address these emerging therapeutic targets. METHODS: Twelve participants with a body mass index (BMI) greater than 30 (or 27 with metabolic co-morbidities) were recruited from an outpatient clinic for participation with a primary outcome of pre/post changes in body composition. Participants completed a 12-week program involving weekly group and individualized dietary, exercise, and behavioral support, supplemented with a commercial, 30-day dietary detoxification intervention and ongoing nutritional counseling. All participants completed baseline and post-intervention evaluation including metabolic, toxin load, endotoxin, body composition and functional fitness profiles. RESULTS: After 12-weeks, participants as a group significantly improved body composition parameters including BMI, body fat, fat mass, and waist and hip circumference (P < .01). Significant improvement in several secondary outcomes including levels of lipopolysaccharide, zonulin and leptin were noted. Additionally, results demonstrate substantial improvements in pain, pain interference and functional fitness. Upon completion, all participants rated the program favorably with a high likelihood of continuing or recommending participation to others. CONCLUSIONS: Obesity remains a challenging and often refractory clinical scenario with emerging evidence indicating the potential role of systemic inflammation, toxin load and endotoxemia. A group therapeutic lifestyle change program enhanced with a detoxification component is feasible and may provide a promising intervention for achieving weight loss while also addressing functional and pain related co-morbidities. Future randomized trials evaluating the components of such a program are needed to better delineate the role of specific interventions in the complex setting of obesity.

Analysis of State Insurance Coverage for Nonpharmacologic Treatment of Low Back Pain as Recommended by the American College of Physicians Guidelines.

BACKGROUND: In 2017, the American College of Physicians (ACP) released guidelines encouraging nonpharmacologic treatment of chronic low back pain (LBP). These guidelines recommended utilization of treatments including multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (MBSR), tai chi, yoga, progressive relaxation, biofeedback, cognitive behavioral therapy (CBT), and spinal manipulation. OBJECTIVE: We aimed to determine status of insurance coverage status for multiple nonpharmacological pain therapies based on the 2017 Essential Health Benefits (EHB) benchmark plans across all states. METHODS: The 2017 EHB benchmark plans represent the minimum benefits required in all new policies in the individual and small group health insurance markets and were reviewed for coverage of treatments for LBP recommended by the ACP guidelines. Additionally, plans were reviewed for limitations and exclusionary criteria. RESULTS: In nearly all state-based coverage policies, chronic pain management and multidisciplinary rehabilitation were not addressed. Coverage was most extensive (supported by 46 states) for spinal manipulation. Acupuncture, massage, and biofeedback were each covered by fewer than 10 states, while MBSR, tai chi, and yoga were not covered by any states. Behavioral health treatment (CBT and biofeedback) coverage was often covered solely for mental health diagnoses, although excluded for treating LBP. CONCLUSION: Other than spinal manipulation, evidence-based, nonpharmacological therapies recommended by the 2017 ACP guidelines were routinely excluded from EHB benchmark plans. Insurance coverage discourages multidisciplinary rehabilitation for chronic pain management by providing ambiguous guidelines, restricting ongoing treatments, and excluding behavioral or complementary therapy despite a cohesive evidence base. Better EHB plan coverage of nondrug therapies may be a strategy to mitigate the opioid crisis. Recommendations that reflect current research-based findings are provided to update chronic pain policy statements.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper.

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Integrative Pain Management.

Chronic pain is one of the most common conditions seen in the clinic, and it is often one of the most frustrating for both clinicians and patients. This condition stems from common comorbidities, including depression, insomnia, fatigue, and physical deconditioning, which often create barriers to recovery. In addition, chronic pain has had divergent approaches for treatment, including an overemphasis on analgesia and curative treatments while underemphasizing the biopsychosocial needs of those in pain. This article attempts to provide an initial framework for approaching those in pain and initiating patient-centered options to support improvements in pain, function, and self-care.

The incorporation of stress management programming into family medicine residencies-results of a national survey of residency directors: a CERA study.

BACKGROUND AND OBJECTIVES: Residents' stress and burnout is a concern among family medicine residency programs. Our objective is to assess stress management options available to family medicine residents. METHODS: In 2012, the Council of Academic Family Medicine Educational Research Alliance (CERA) e-mailed a survey to US residency directors. Questions were asked on four types of stress management programming (SMP): (1) access to counselors, social workers, or mental health providers, (2) residency support or Balint groups, (3) stress management lectures or workshops, and (4) residency retreats. We assessed how many programs contained all four types of SMP and their relationship to the following topics: stress management techniques for patients, spirituality, mind/body techniques, and self-care for residents. RESULTS: Of the 212 responses, 29% reported having all four types of SMP. Eighty-three percent reported stress management lectures or workshops, and 79% reported residency retreats. Smaller and mid-size residencies (36%) and residencies in the West (36%) were more likely to have all four types of SMP. There was a correlation between having didactics, clinical rotations, and electives on stress management techniques for patient care and having stress management lectures or workshops for residents. There was statistical significance between having resident self-care curriculum and (1) having retreats and (2) stress management lectures or workshops. CONCLUSIONS: It is necessary to evaluate whether residency programs are providing appropriate stress management skills for residents that will improve physician wellness and patient outcomes.

Targeting systemic inflammation in patients with obesity-related pain: Obesity- related pain: time for a new approach that targets systemic inflammation.

We may be able to reduce pain, disability, and related comorbidities in obese patients by implementing modest weight loss and fitness interventions to address systemic inflammation.

Family medicine residency program directors attitudes and knowledge of family medicine CAM competencies.

CONTEXT: Little is known about the incorporation of integrative medicine (IM) and complementary and alternative medicine (CAM) into family medicine residency programs. OBJECTIVE: The Society for Teachers of Family Medicine (STFM) approved a set of CAM/IM competencies for family medicine residencies. We hope to evaluate whether residency programs are implementing such competencies into their curriculum using an online survey tool. We also hope to assess the knowledge and attitudes of Residency Directors (RDs) on the CAM/IM competencies. DESIGN: A survey was distributed by the Council of Academic Family Medicine (CAFM) Educational Research Alliance to RDs via e-mail. The survey was distributed to 431 RDs. Of those who received it, 212 responded, giving a response rate of 49.1%. Questions assessed the knowledge and attitudes of CAM/IM competencies and incorporation of CAM/IM into the residency curriculum. RESULTS: Forty-five percent of RDs were aware of the competencies. In terms of RD attitudes, 58% reported that CAM/IM is an important component of residents' curriculum; yet, 60% report not having specific learning objectives for CAM/IM in their residency curriculum. Among all programs, barriers to CAM/IM implementation included time in residents' schedules (77%); faculty training (75%); access to CAM experts (43%); lack of reimbursement (43%); and financial resources (29%). CONCLUSIONS: While many RDs are aware of the STFM CAM/IM competencies and acknowledge their role in residence education, there are many barriers that prevent residencies from implementing the STFM CAM/IM competencies.

Coenzyme Q10.

Coenzyme Q10 is a vitamin-like substance used in the treatment of a variety of disorders primarily related to suboptimal cellular energy metabolism and oxidative injury. Studies supporting the efficacy of coenzyme Q10 appear most promising for neurodegenerative disorders such as Parkinson's disease and certain encephalomyopathies for which coenzyme Q10 has gained orphan drug status. Results in other areas of research, induding treatment of congestive heart failure and diabetes, appear to be contradictory or need further clarification before proceeding with recommendations. Coenzyme Q10 appears to be a safe supplement with minimal side effects and low drug interaction potential.

Herbal cancer cures on the Web: noncompliance with The Dietary Supplement Health and Education Act.

BACKGROUND AND OBJECTIVES: A significant portion of the US population uses the Internet to obtain health information; nearly half of Internet users admit that this information influences decisions about their health care and medical treatments. Concurrently, approximately one third of the population uses herbal supplements; a higher percentage is noted for subgroups of cancer patients. The Dietary Supplement Health and Education Act (DSHEA) of 1994 contained regulatory standards for herbal supplements, including restricting any claims for disease prevention, treatment, or cure. This study determined the degree of compliance with the DSHEA, as applied to Internet sites focusing on the subject of herbal supplements and cancer. METHODS: Internet searches were conducted using six popular search engines and three master search engines in October-December 2000 using the linked terms herb and cancer. The Internet sites identified through this search process were examined for categories of information including claims regarding prevention, treatment, or cure; commercial nature; DSHEA and physician consultation warnings; country of origin; and use of research and testimonials. Additionally, commercial sites were reviewed to identify tactics used to promote products or services. RESULTS: Each of the six primary search engines provided between 11,730 and 58,605 matches for herb and cancer. Further cross matching with the three master search engines identified 70 non-repeating sites that appeared on all three master search engines. Of these 70 sites, nine were irrelevant matches or no longer functioning. Of the remaining 61, 34 (54%) were commercial sites (CS) and 27 (42.8%) were noncommercial sites (NCS). Of the CS surveyed, prevention, treatment, and cure were discussed 92%, 89%, and 58%, respectively. CS provided testimonials, physician consultation recommendations, and DSHEA warnings 89%, 38.8%, and 36.1% of the time, respectively. CS provided research with references 30.6% of the time versus 92.6% of the time in NCS. All international commercial sites surveyed claimed herbal cancer cures. CONCLUSIONS: Although the DSHEA was enacted and amended to decrease unlawful claims of disease prevention, treatment, and cure, the results of this study indicate that such claims are prevalent on commercial Internet sites. A majority of sites claim cancer cures through herbal supplementation with little regardfor current regulations, and such claims were more common on sites operated from outside the United States.