Severe unexplained loin pain (loin pain haematuria syndrome): management and long-term outcome.

BACKGROUND: The intractable and unexplained loin pain of severe 'loin pain haematuria syndrome' (LPHS) causes great psychosocial distress and disability. AIM: To examine the psychological factors in LPHS patients who had failed to respond to non-opiate analgesia, and explore the feasibility of conservative management. DESIGN: Retrospective review of case notes, medical and GP records, with follow up. METHODS: We studied 21 consecutive patients referred from specialist renal centres to a regional pain clinic. All records were reviewed, and patients received a comprehensive psychiatric and social assessment. Medication with pain-coping strategies was emphasized, and surgical solutions were discouraged. RESULTS: Patients' median age was 43 years (range 21-64) and duration of symptoms 11 (1-34) years. Sixteen were receiving opiates, and none had enduring benefit from surgery. Patients were divisible into three groups: twelve (57%) gave a history of recurrent, unexplained symptoms involving other parts of the body (somatoform disorder); seven had chronic loin pain; dissimulation was suspected in two. At follow-up (median 42 months), eight (38%) rated their pain absent or improved. Of the 11 whose pain was the same or worse, all were on opiates and seven had a somatoform disorder. A further two patients had developed 'other' medical problems. Despite our advice, three patients underwent major surgery for pain. DISCUSSION: We recommend that patients be managed in a regional pain clinic, where a multidisciplinary approach promotes self-management of pain. Patients who were able to accept conservative treatment, and taper or withdraw opiate analgesia, had a better prognosis.

Ill-health retirement: national rates and updated guidance for occupational physicians.

BACKGROUND: Advising on ill-health retirement is an important role of most practising occupational physicians. In recent years, the eligibility criteria and process for gaining early retirement benefits have changed in many pension schemes in the UK. AIM: To investigate the variation in rates of retirement due to ill-health in National Health Service (NHS) Trusts and Local Authorities and to update previously published guidance on ill-health retirement with specific reference to pension schemes with eligibility criteria that include permanence of incapacity due to ill-health. METHODS: Rates of retirement were calculated for 222 NHS Trusts and 132 Local Authorities with more than 1500 employees. Literature searches and consensus statements by the authors. RESULTS: Rates of retirement were widely distributed in the NHS Trusts and Local Authorities. The median rates of retirement were 2.11 (IQR 1.37-2.91)/1000 active members and 4.10 (IQR 3.01-6.10)/1000 employees, respectively (P<0.001). Difficulties in the doctor-patient relationship and in ascertaining the true functional ability of some patients were identified. CONCLUSION: There continues to be marked variation in rates of early retirement due to ill-health within and between organizations that warrants further investigation. The general and specific guidance that appears as an appendix in Supplementary data to this paper should help occupational physicians to make equitable recommendations when assessing applications for early retirement benefits and fitness to work.

Management of non-cardiac chest pain: from research to clinical practice.

BACKGROUND: Non-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may not be feasible in routine clinical settings. OBJECTIVES: To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutively reassured by cardiologists that there was not a cardiac cause for their presenting symptom of chest pain. DESIGN: Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psychological treatment, which has been separately reported) and followed up at six months. SETTING: A cardiac clinic in a teaching hospital providing a district service to patients referred from primary care. PATIENTS: 133 patients from the Oxfordshire district presenting with chest pain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography. INTERVENTION: A subgroup (n = 56) with persistent disabling chest pain at six weeks were invited to take part in a randomised controlled trial of cognitive behavioural treatment. MAIN OUTCOME MEASURES: Standardised interview and self report measures of chest pain, other physical symptoms, mood and anxiety, everyday activities, and beliefs about the cause of symptoms at six week assessment; repeat of self report measures at six months. RESULTS: Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week assessment and discussion useful. The psychological treatment was helpful to most of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative management. Patients reassured following angiography were compared with those reassured without invasive investigation. They had longer histories of chest pain, more often reported breathlessness on exertion, and were more likely to have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies. CONCLUSION: These findings suggest a need for "stepped" aftercare, with management tailored according to clinical need. This may range from simple reassurance and explanation in the cardiac clinic to more intensive individual psychological treatment of associated underlying and often enduring psychological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for access to specialist psychological treatment discussed.

Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study.

Forty-six patients with chest pain but normal or near-normal coronary arteries were assessed using standardized interviews and rating scales at the time of angiography, after 1 year, and again 11.4 years later. Psychological morbidity was substantial and enduring: 61% of patients were designated as psychiatric cases at angiography and 49% at 11.4 years. Both at the time of angiography, and 1 year later, levels of morbidity were significantly greater than in a control group of 53 patients with coronary artery disease. Anxiety disorders were common at all three interviews, with panic disorder (15% of patients) the most common current diagnosis at final follow-up. Current somatoform disorders were diagnosed in 9 patients (22%), and 11 (27%) reported previous episodes of major depression. Psychological morbidity was associated with continuing chest pain, which was reported in 74% of patients, and with ongoing functional incapacity. These findings suggest that, in a sub-group of these patients, psychological factors contribute in part to the development of chest pain and other physical symptoms, and are also important in maintaining the disorder over long periods. Further research is now required to identify more fully the nature of these psychological factors, and how they interact with cardiac and non-cardiac physical pathology. There is also an urgent need to examine the clinical and economic benefits of specific psychological interventions.

Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study.

Forty-six patients who were investigated in 1979-80 for chest pain, and found to have normal or insignificantly narrowed coronary arteries on coronary angiography, were followed up after a mean interval of 11.4 years. Patients were interviewed and given standardized questionnaires covering chest pain and other physical symptoms, psychiatric morbidity, and functional capacity. Medical records for the follow-up period were reviewed, as were death certificates and post-mortem reports, where appropriate. All patients (100%) were traced to death or their current address. Four had died (11.4 year survival rate 91%), one from ischaemic heart disease. Continuing chest pain was reported by 74%, and in 16 patients (38%), chest pain was either frequent, severe or both. A poor outcome for chest pain was associated with other physical symptoms and increased psychiatric morbidity, which for the entire cohort was higher than at 1 year after angiography. Twenty-six patients (58%) had received further hospital treatment for chest pain, including, in six patients, further coronary angiography. Twenty-nine survivors (71%) were taking cardiac medication, 12 (29%) were unable to work for medical reasons, and levels of functional disability were similar to those found in patients with myocardial infarction or angina. This study confirms the findings of previous studies with shorter follow-up intervals. Mortality was low, but high levels of chest pain, psychological distress, and functional incapacity persisted long after angiography. Patients reported many physical symptoms other than chest pain, and had made heavy use of medical resources. For many patients, reassurance after angiography had been ineffective, and the prognosis was poor. Early identification and effective management of such patients could offer the NHS substantial savings.