Pursuing Scholarship: Creating Effective Conference Submissions

Medical educators are expected to disseminate peer-reviewed scholarly work for academic promotion and tenure. However, developing submissions for presentations at national meetings can be confusing and sometimes overwhelming. Awareness and use of some best practices can demystify the process and maximize opportunities for acceptance for a variety of potential submission categories. This article outlines logistical steps and best practices for each stage of the conference submission process that faculty should consider when preparing submissions. These include topic choice, team composition, consideration of different submission types, and strategies for effectively engaging participants.

Adverse Childhood Experiences and Diabetes: Testing Violence and Distress Mediational Pathways in Family Medicine Patients

Type 2 diabetes mellitus (diabetes) is increasing in frequency and creating a significant burden on the United States healthcare system. Adverse childhood experiences (ACE) and interpersonal violence (IV) have been shown to have detrimental effects on mental and physical health. How ACE can influence IV as an adult and how this can influence the management of diabetes is not known. The purpose of the current study is to understand the relationship between violence and social determinants of health (SDoH), and its effect on patients with type 2 diabetes mellitus. A practiced-based research network (PBRN) of family medicine residency programs was utilized to collect cross-sectional data from seven family medicine residency program primary care clinics. In total, 581 participants with type 2 diabetes were recruited. A serial/parallel mediation model were analyzed. The majority of participants (58.3%) had a Hemoglobin A1c (HbA1c) that was not controlled. ACE was associated with an increase in Hurt-Insult-Threaten-Scream (HITS) scores, which in turn was positively associated with an increase in emotional burden, and finally, emotional burden decreased the likelihood that one's HbA1c was controlled (Effect = -.054, SE = .026 CI [-.115, -.013]). This indirect pathway remained significant even after controlling for several SDoH and gender. The impact of ACE persists into adulthood by altering behaviors that make adults more prone to experiencing family/partner violence. This in turn makes one more emotionally distressed about their diabetes, which influences how people manage their chronic condition. Family physicians should consider screening for both ACE and family/partner violence in those patients with poorly controlled diabetes.

Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination

OBJECTIVES

The purpose of this study was to examine the perspectives of primary care physicians in Texas around vaccine acceptance and potential patient barriers to vaccination. National surveys have shown fluctuating levels of acceptance for COVID-19 vaccination, and primary care physicians could play a crucial role in increasing vaccine uptake.

DESIGN

This study employed a cross-sectional anonymous survey design to collect data using an online questionnaire. Participants were asked about vaccination practices and policies at their practice site, perceptions of patient and community acceptance and confidence in responding to patient vaccine concerns.

SETTING

From November 2020 to January 2021, family medicine physicians and paediatricians completed an online questionnaire on COVID-19 vaccination that was distributed by professional associations.

PARTICIPANTS

The survey was completed by 573 practising physicians, the majority of whom identified as family medicine physicians (71.0%) or paediatricians (25.7%), who are currently active in professional associations in Texas.

RESULTS

About three-fourths (74.0%) of participants reported that they would get the vaccine as soon as it became available. They estimated that slightly more than half (59.2%) of their patients would accept the vaccine, and 67.0% expected that the COVID-19 vaccine would be accepted in their local community. The majority of participants (87.8%) reported always, almost always or usually endorsing vaccines, including high levels of intention to recommend COVID-19 vaccination (81.5%). Participants felt most confident responding to patient concerns related to education about vaccine types, safety and necessity and reported least confidence in responding to personal or religious objections to COVID-19 vaccination.

CONCLUSIONS

The majority of the physicians surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were confident in their ability to respond to patient concerns. With additional education, support and shifting COVID-19 vaccinations into primary care settings, primary care physicians can use the trust they have built with their patients to address vaccine hesitancy and potentially increase acceptance and uptake.

Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion

PURPOSE

Faculty promotion is important for retention and has implications for diversity. This study provides an update on recent trends in faculty promotion in U.S. medical schools.

METHOD

Using data from the Association of American Medical Colleges Faculty Roster, the authors examined trends in faculty promotion over 10 years. Promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 inclusive was followed from January 1, 2010 to January 1, 2019. The authors used bivariate analyses to assess associations and promotion rates by sex, race/ethnicity, department, tenure status, and degree type.

RESULTS

The promotion rate for assistant professors was 44.3% (2,330/5,263) in basic science departments, 37.1% (17,232/46,473) in clinical science departments, and 33.6% (131/390) in other departments. Among clinical departments, family medicine had the lowest rate of promoting assistant professors (24.4%; 484/1,982) and otolaryngology the highest rate (51.2%; 282/551). Faculty members who were male (38.9%; 11,687/30,017), White (40.0%; 12,635/31,596), tenured (58.7%; 98/167) or tenure-eligible (55.6%; 6,653/11,976), and holding MDs/PhDs (48.7%; 1,968/4,038) had higher promotion rates than, respectively, faculty who were female (36.3%; 7,975/21,998), minorities underrepresented in medicine (URM; 31.0%; 1,716/5,539), nontenured (32.5%; 12,174/37,433), and holding other/unknown degrees (20.6%; 195/948; all P < .001). These differences were less pronounced among associate professors; however, URM and nontenured faculty continued to have lower promotion rates compared with White, Asian, or tenured faculty at the associate professor level.

CONCLUSIONS

Promotion rates varied not only by faculty rank but also by faculty sex, race/ethnicity, department, tenure status, and degree type. The differences were more pronounced for assistant professors than associate professors. URM faculty members, particularly assistant professors, were promoted at lower rates than their White and Asian peers. More research to understand the drivers of disparities in faculty promotion seems warranted.

Increased Smoking Cessation among Veterans with Large Decreases in Posttraumatic Stress Disorder Severity

BACKGROUND

Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD.

METHODS

Veterans Health Affairs (VHA) medical record data (2008 to 2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement, was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥ 50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2-years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding.

RESULTS

On average, patients were 39.4 (SD=12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with vs. without clinically meaningful PTSD improvement stopped smoking (n=36, cumulative incidence=40.5% vs. 111, cumulative incidence=30.8%; respectively). After controlling for confounding, patients with vs. without clinically meaningful PTSD improvement were more likely to stop smoking within 2-years (HR=1.57; 95%CI:1.04-2.36).

CONCLUSIONS

Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation.

IMPLICATIONS

Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking related disease.

Identifying and overcoming barriers to trauma screening in the primary care setting

Introduction: Underrecognition of trauma exposure and PTSD has a significant impact on psychiatric health, physical health, and health behaviors. The purpose of this study is to explore barriers and opportunities for trauma screening in primary care. Methods: Primary care physicians (PCPs) and their patients were interviewed about the acceptability of trauma screening and brief treatment in primary care. Interview transcripts were coded and analyzed for themes using Atlas v. 7.0. Results: Data showed PCPs informally screen for trauma but were hampered by organizational constraints including time, availability of behavioral health providers, and knowledge of trauma-informed-care practices. Most patients with trauma history met with behavioral health providers during their lifetimes, but still did not believe it was the PCPs' role to address trauma exposure, had fears of "appearing crazy," or were ambivalent about seeking treatment. Discussion: Findings suggest an enormous complexity involved in screening for trauma in primary care service delivery. Trauma screening appears to work best within the course of relationship building where patients can begin to see that their physician is capable of playing an important role in managing trauma, depression, and PTSD symptoms. We address how trauma discussion can take place within existing trauma informed care guidelines. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Emergency department presentation of opioid use disorder and alcohol use disorder

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data

BACKGROUND

Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization.

METHODS

We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits.

RESULTS

The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits.

CONCLUSIONS

Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.

The association of opioid use duration and new depression episode among patients with and without insomnia

OBJECTIVE

Insomnia commonly co-occurs with depression, chronic pain, and opioid use. Both insomnia and chronic opioid analgesic use (OAU) are independent risk factors for a new depression episode (NDE). This study determined if the association between longer OAU duration and NDE was stronger in those with versus without insomnia.

DESIGN

Retrospective cohort.

SETTING

Veterans Health Administration electronic medical records (2000-2012).

PARTICIPANTS

New opioid users in follow-up (2002-2012), free of depression for two years prior to follow-up, and aged 18-80 (n = 70,997).

METHODS

NDE was ≥ 2 ICD-9 codes in a 12-month period. Insomnia before OAU initiation was ≥1 ICD-9 code. Cox proportional hazard models stratified on insomnia assessed the relationship between initiating a 1-30, 31-90, or > 90 day period of OAU and NDE while controlling for confounders using inverse probability of treatment-weighted propensity scores (PS).

RESULTS

Compared to 1-30 day OAU, 31-90 day was associated with NDE in those without (HR = 1.20; 95 percent CI: 1.12-1.28) but not with insomnia (HR = 1.06; 95 percent CI: 0.86-1.32). Results showed a stronger effect of chronic (>90) OAU in those with insomnia (HR = 1.59; 95 percent CI: 1.27-1.98) compared to those without (HR = 1.31; 95 percent CI: 1.21-1.42). However, all stratum-specific effects were not significantly different (p = 0.136).

CONCLUSIONS

Although stratum-specific risks were statistically similar, there was evidence for a trend that chronic OAU is a stronger risk factor for NDE in those with versus without insomnia. Providers are encouraged to monitor sleep impairment among patients on opioid therapy, as sleep may be associated with greater risk for NDE in patients with chronic OAU.

Prescription opioid use duration and beliefs about pain and pain medication in primary care patients

BACKGROUND

Patient beliefs about pain and opioids have been reported from qualitative data. To overcome limitations of unstructured assessments and small sample sizes, we determined if pain and pain medication beliefs varied by chronic pain status and opioid analgesic use (OAU) duration in primary care patients.

METHODS

Cross-sectional survey data obtained in 2017 and 2018 from 735 patients ≥ 18 years of age. The eight-item Barriers Questionnaire (BQ) measured beliefs about pain and pain medication. Patients reported OAU and use of other pain treatments. Multiple linear regression models estimated the association between never OAU, 1-90 day OAU and >90 day OAU and each BQ item.

RESULTS

Overall, respondents were 49.1 (±15.4) years old, 38.7 percent white, 28.4 percent African-American, 23.5 percent Hispanic, and 68.6 percent female. About one-third never used opioids, 41.8 percent had 1-90 day OAU, and 21.6 percent had > 90 day OAU. Multiple linear regression analyses showed that compared to never OAU, > 90 day OAU had lower average agreement that analgesics are addictive (β = -0.50; 95 percent CI: -0.96, -0.03), and 1-90 day OAU (β = -0.53; 95 percent CI: -0.96, -0.10) and > 90 OAU (β = -0.55; 95 percent CI: -1.04, -0.06) had lower average agreement that analgesics make people do or say embarrassing things.

CONCLUSIONS

Patients with chronic OAU reported less concern about addiction and opioid-related behavior change. Never users were most likely to agree that opioids are addictive. There continues to be a need to educate patients about opioid risks. Assessing patients' beliefs may identify patients at risk for chronic OAU.

The association between depression and type of treatments received for chronic low back pain

BACKGROUND

Depression is associated with receipt of opioids in non-cancer pain.

OBJECTIVES

To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments.

METHODS

Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments.

RESULTS

Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609).

CONCLUSION

There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

PTSD improvement and incident cardiovascular disease in more than 1000 veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown.

METHODS

Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting.

RESULTS

Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD.

CONCLUSIONS

Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.

Clinically meaningful posttraumatic stress disorder (PTSD) improvement and incident hypertension, hyperlipidemia, and weight loss

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss).

METHOD

Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease <10), small (10-19 point PCL decrease), and large (≥20 point PCL decrease) PTSD improvement. To estimate the association between degree of PTSD improvement and incident hypertension (n = 979), incident hyperlipidemia (n = 1,139) and incident ≥5% weight loss (1,330), we computed Cox proportional hazard models, controlling for confounding using inverse probability of exposure weighting (IPEW).

RESULTS

Overall, patients were about 40 years of age, 80% male and 65% White. Worsening or no PCL change occurred in about 60%, small improvement in 20%, and large improvement in 20%. After weighting data, compared with worsening or no change, both small and large PTSD improvements were associated, albeit not significantly, with lower risks for hypertension (HR = 0.68; 95% confidence interval, CI [0.46, 1.01] and HR = 0.79; 95% CI [0.53, 1.18], respectively). In weighted data, PTSD improvement was not associated with incident hyperlipidemia or ≥5% weight loss.

CONCLUSIONS

We observed limited evidence for an association between PTSD improvement and decreased hypertension risk. PCL decreases were not associated with hyperlipidemia or ≥5% weight loss. Further studies that measure potential physical health benefits of change in specific PTSD symptoms are needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comorbid Conditions Explain the Association Between Posttraumatic Stress Disorder and Incident Cardiovascular Disease

Background Posttraumatic stress disorder ( PTSD ) is associated with risk of cardiovascular disease ( CVD ). Biopsychosocial factors associated with PTSD likely account for some or all of this association. We determined whether 1, or a combination of comorbid conditions explained the association between PTSD and incident CVD . Methods and Results Eligible patients used 1 of 5 Veterans Health Affairs medical centers distributed across the United States. Data were obtained from electronic health records. At index date, 2519 Veterans Health Affairs ( VA ) patients, 30 to 70 years of age, had PTSD diagnoses and 1659 did not. Patients had no CVD diagnoses for 12 months before index date. Patients could enter the cohort between 2008 and 2012 with follow-up until 2015. Age-adjusted Cox proportional hazard models were computed before and after adjusting for comorbidities. Patients were middle aged (mean=50.1 years, SD ±11.0), mostly male (87.0%), and 60% were white. The age-adjusted association between PTSD and incident CVD was significant (hazard ratio=1.41; 95% CI : 1.21-1.63). After adjustment for metabolic conditions, the association between PTSD and incident CVD was attenuated but remained significant (hazard ratio=1.23; 95% CI : 1.06-1.44). After additional adjustment for smoking, sleep disorder, substance use disorder, anxiety disorders, and depression, PTSD was not associated with incident CVD (hazard ratio=0.96; 95% CI : 0.81-1.15). Conclusions PTSD is not an independent risk factor for CVD . Physical and psychiatric conditions and smoking that co-occur with PTSD explain why this patient population has an increased risk of CVD . Careful monitoring may limit exposure to CVD risk factors and subsequent incident CVD .

Childhood Trauma, Social Networks, and the Mental Health of Adult Survivors

The purpose of this study was to investigate the relationship of childhood trauma to the quality of social networks and health outcomes later in adulthood. Data were obtained from a convenience sample of 254 adults seen in one of 10 primary care clinics in the state of Texas. Standardized measures of adverse childhood experiences (ACEs), stressful and supportive social relationships, medical conditions, anxiety, depression, and health-related quality of life were administered. Using latent class analysis, subjects were assigned to one of four ACE classes: (a) minimal childhood abuse (56%), (b) physical/verbal abuse of both child and mother with household alcohol abuse (13%), (c) verbal and physical abuse of child with household mental illness (12%), and (d) verbal abuse only (19%). Statistically significant differences across the four ACE classes were found for mental health outcomes in adulthood. Although respondents who were physically and verbally abused as children reported compromised mental health, this was particularly true for those who witnessed physical abuse of their mother. A similar relationship between ACE class and physical health was not found. The quality of adult social networks partly accounted for the relationship between ACE classes and mental health outcomes. Respondents exposed to ACEs with more supportive social networks as adults had diminished odds of reporting poor mental health. Conversely, increasing numbers of stressful social relationships contributed to adverse mental health outcomes. Although efforts to prevent childhood trauma remain a critical priority, the treatment of adult survivors needs to expand its focus on both strengthening social networks and decreasing the negative effects of stressful ones.

Trends in Tenure Status in Academic Family Medicine, 1977-2017: Implications for Recruitment, Retention, and the Academic Mission

PURPOSE

Tenure status has important implications for medical school faculty recruitment and retention and may affect educational quality, academic freedom, and collegiality. However, tenure trends in academic family medicine are unknown. This study aimed to describe trends in tenure status of family medicine faculty overall and by gender and status of minorities underrepresented in medicine (URM) in Liaison Committee on Medical Education-accredited medical schools.

METHOD

Association of American Medical Colleges Faculty Roster data were used to describe trends in tenure status of full-time family medicine faculty, 1977 to 2017. Bivariate and trend analyses were conducted to assess associations and describe patterns between tenure status and gender, race, and ethnicity. Interdepartmental variations in tenure trends over the years were also examined.

RESULTS

Among family medicine faculty, the proportions of faculty tenured or on a tenure track dropped more than threefold from 1977 (46.6%; n = 507/1,089) to 2017 (12.7%; n = 729/5,752). Lower proportions of women and URM faculty were tenured or on a tenure track than male and non-URM faculty, respectively. But the gaps among them were converging. Compared with other clinical departments, family medicine had the highest proportion of faculty (74.6%; n = 4,291/5,752) not on a tenure track in 2017.

CONCLUSIONS

Proportion of tenure positions significantly decreased among family medicine faculty in U.S. medical schools. While gaps between male and female faculty and among certain racial/ethnic groups remained for family medicine tenure status, they have decreased over time, mainly because of a substantial increase in nontenured positions.

Large posttraumatic stress disorder improvement and antidepressant medication adherence

BACKGROUND

Patients with vs. without posttraumatic stress disorder (PTSD) are more likely to have poor antidepressant medication (ADM) adherence but it is unclear if improved PTSD is associated with ADM adherence. We determined if clinically meaningful PTSD symptom reduction was associated with ADM adherence.

METHODS

Electronic health record data (2008-2015) was obtained from 742 Veterans Health Affairs (VHA) patients using PTSD specialty clinics with a PTSD diagnosis and PTSD checklist (PCL) score ≥50. The last PCL in the exposure year after the first PCL≥50 was used to identify patients with a clinically meaningful PCL decrease (≥20 point) versus those without (< 20 point). Patients had a depression diagnosis in the 12-months before the exposure year and received an ADM in the exposure year. Proportion of days covered ≥80% in exposure year defined adherence. Confounding was controlled using propensity scores and inverse probability of treatment weighting.

RESULTS

Patients were 42.2 ± 13.1 years of age, 63.9% white and 18.9% had a clinically meaningful PCL decrease. After controlling for confounding variables, patients with vs. without a clinically meaningful PCL decrease were significantly more likely to be adherent (OR = 1.78; 95% CI:1.16-2.73). However, adherence remained low in both patients with and without meaningful PCL decrease (53.5% vs. 39.3%).

LIMITATIONS

The sample was limited to VHA patients. Patients may not have taken medication as prescribed.

CONCLUSIONS

Large reductions in PTSD symptoms are associated with ADM adherence. Prior literature suggests ADM adherence improves depression symptoms. Thus, PTSD symptom reduction may lead to better depression outcomes.

Adverse childhood experiences, depression, and cardiometabolic disease in a nationally representative sample

OBJECTIVE

Adverse childhood experiences (ACEs) and depression are both independently associated with increased risk of diabetes and cardiovascular disease (CVD). The objective was to determine if the association of ACEs, examined with Latent Class Analysis (LCA), with CVD and diabetes was stronger in patients with versus without depression.

METHODS

Participants were 78,435 non-institutionalized adults in the United States completing the ACEs module in the 2011-2012 Behavioral Risk Factor Surveillance System. LCA grouped participants into ACE classes. Respondents self-reported ACEs and lifetime depression, diabetes and CVD. Complex survey weighted logistic regression models assessed the relationships between ACEs, diabetes, and CVD overall and in those with and without depression.

RESULTS

Half of participants were female (48.6%) and 82.3% White, non-Hispanic. LCA identified a four-class solution characterized as 'low adversity', 'verbal/physical abuse', 'sexual abuse', and 'high adversity'. The odds ratios for each ACE class and diabetes were similar in those with and without depression. An overall adjusted model showed that 'sexual abuse' versus 'low adversity' was significantly associated with diabetes (OR = 1.30; 95% CI: 1.05-1.61). Effect modification was present for CVD such that among those with depression, but not among those without, 'high adversity' had over two times the odds of CVD than 'low adversity' (OR = 2.17; 95% CI: 1.06-2.93).

CONCLUSIONS

'High adversity' in those with but not without depression is positively associated with CVD. 'Sexual abuse' is positively associated with diabetes independent of depression. The study is relevant to trauma-informed care and highlights the contribution of ACEs and depression to poor health outcomes.

PTSD symptom decrease and use of weight loss programs

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with poor health behaviors, including low utilization of Veteran Health Affairs (VHA) weight loss programs. It is not known if clinically meaningful PTSD improvement is associated with increased use of weight loss programs.

METHODS

Medical record data was obtained from VHA patients who received PTSD specialty care between Fiscal Year (FY) 2008 to FY2012. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease between the first PCL ≥ 50 and a second PCL at least 8 weeks later and within 12 months of the first PCL. Eligible patients, n = 993, were followed through FY2015. Propensity scores and inverse probability of exposure weighting controlled confounding. Cox proportional hazard models estimated the association between clinically meaningful PCL decrease and weight loss clinic utilization. Supplemental analysis compared both PTSD groups vs. no PTSD.

RESULTS

Patients were 44.8 (SD ±14) years of age, 88.9% male and 66.8% white. Patients with vs. without a clinically meaningful PCL decrease were more likely to use a weight loss clinic (HR = 1.37; 95%CI:1.02-1.85). Among those with a weight loss encounter, PCL decrease was not associated with the number of encounters (RR = 1.13; 95%CI:0.70-1.81). Compared to no PTSD, patients with PTSD improvement had more weight loss encounters.

CONCLUSIONS

Large improvements in PTSD are associated with increased utilization of weight loss programs, and PTSD is not a barrier to seeking weight loss counseling. Research to understand why improvement in PTSD is not related to better weight loss outcomes is needed.

Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes

IMPORTANCE

Posttraumatic stress disorder (PTSD) is associated with increased risk of type 2 diabetes (T2D). Improvement in PTSD has been associated with improved self-reported physical health and hypertension; however, there is no literature, to our knowledge, on whether PTSD improvement is associated with T2D risk.

OBJECTIVE

To examine whether clinically meaningful PTSD symptom reduction is associated with lower risk of T2D.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study examined Veterans Health Affairs medical record data from 5916 patients who received PTSD specialty care between fiscal years 2008 and 2012 and were followed up through fiscal year 2015. Eligible patients had 1 or more PTSD Checklist (PCL) scores of 50 or higher between fiscal years 2008 and 2012 and a second PCL score within the following 12 months and at least 8 weeks after the first PCL score of 50 or higher. The index date was 12 months after the first PCL score. Patients were free of T2D diagnosis or an antidiabetic medication use for 12 months before the index date and had at least 1 visit after the index date. Data analyses were completed during January 2019.

EXPOSURES

Reduction in PCL scores during a 12-month period was used to define patients as those with a clinically meaningful improvement (≥20-point PCL score decrease) and patients with less or no improvement (<20-point PCL score decrease).

MAIN OUTCOMES AND MEASURES

Incident T2D diagnosed during a 2- to 6-year follow-up.

RESULTS

Medical records from a total of 1598 patients (mean [SD] age, 42.1 [13.4] years; 1347 [84.3%] male; 1060 [66.3%] white) were studied. The age-adjusted cumulative incidence of T2D was 2.6% among patients with a clinically meaningful PCL score decrease and 5.9% among patients without a clinically meaningful PCL score decrease (P = .003). After control for confounding, patients with a clinically meaningful PCL score decrease were significantly less likely to develop T2DM compared with those without a clinically meaningful decrease (hazard ratio, 0.51; 95% CI, 0.26-0.98).

CONCLUSIONS AND RELEVANCE

The findings suggest that clinically meaningful reductions in PTSD symptoms are associated with a lower risk of T2D. A decrease in PCL score, whether through treatment or spontaneous improvement, may help mitigate the greater risk of T2D in patients with PTSD.

Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD

OBJECTIVE

The aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD).

METHODS

PubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed.

RESULTS

The average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers.

CONCLUSIONS

TC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.

Combined effect of posttraumatic stress disorder and prescription opioid use on risk of cardiovascular disease

AIM

Prescription opioid analgesic use (OAU) is associated with increased risk of cardiovascular disease (CVD). OAU is more common in patients with than without posttraumatic stress disorder (PTSD), and PTSD is associated with higher CVD risk. We determined whether PTSD and OAU have an additive or multiplicative association with incident CVD.

METHODS AND RESULTS

Veterans Health Affairs patient medical record data from 2008 to 2015 was used to identify 2861 patients 30-70 years of age, free of cancer, CVD and OAU for 12 months before index date. We defined a four-level exposure variable: 1) no PTSD/no OAU, 2) OAU alone, 3) PTSD alone and 4) PTSD+OAU. Cox proportional hazard models estimated the association between the exposure variable and incident CVD. The mean age was 49.0 (±11.0), 85.7% were male and 58.3% were White, 34.4% had no PTSD/no OAU, 32.9% had PTSD alone, 10.6% had OAU alone, and 22.1% had PTSD+OAU. Compared with patients with no PTSD/no OAU, those with PTSD alone were not at increased risk of incident CVD (hazard ratio = 0.82; 95% confidence interval (CI): 0.63-1.17); however, OAU alone and PTSD+OAU were both significantly associated with incident CVD (hazard ratio = 1.99; 95% CI:1.36-2.92 and hazard ratio = 2.20; 95% CI: 1.61-3.02). There was no significant additive or multiplicative PTSD and OAU association with incident CVD.

CONCLUSION

OAU is associated with nearly a two-fold increased risk of CVD in patients with and without PTSD. Despite no additive or multiplicative interaction effects, the high prevalence of OAU in PTSD may represent a novel contributor to the elevated CVD burden among patients with PTSD.

Disability Benefits and Change in Prescription Opioid Dose

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.

The Role of Obesity in the Association Between Posttraumatic Stress Disorder and Incident Diabetes

IMPORTANCE

Posttraumatic stress disorder (PTSD) is associated with an increased risk of type 2 diabetes mellitus (T2DM). Existing literature has adjusted for obesity in combination with other confounders, which does not allow estimating the contribution of obesity alone on the association of PTSD with incident T2DM.

OBJECTIVE

The current study was designed to determine if obesity accounted for the association between PTSD and incident T2DM.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from Veterans Health Administration medical records collected from patients with PTSD and without PTSD from 2008 to 2015. Patients were eligible for study inclusion if they were free of prevalent PTSD and T2DM for 12 months prior to index date. To estimate whether the association of PTSD and incident T2DM remained independent of obesity, Cox proportional hazard models were computed before and after adding obesity to the model and then further expanded by adding psychiatric disorders, psychotropic medications, physical conditions, smoking status, and demographics. Additional Cox models were computed to compare the risk of incident T2DM in patients with PTSD with and without obesity. Data analysis was completed from February 2018 to May 2018.

EXPOSURES

Two International Classification of Diseases, Ninth Revision (ICD-9) codes for PTSD in the same 12 months and obesity, defined by a body mass index of 30 or more or an ICD-9 code for obesity.

MAIN OUTCOMES AND MEASURES

Incident T2DM, as defined by ICD-9 codes.

RESULTS

Among 2204 patients without PTSD, the mean (SD) age was 47.7 (14.3) years; 1860 (84.4%) were men, 1426 (64.7%) were white, and 956 (43.4%) were married. Among 3450 patients with PTSD, the mean (SD) age was 42.8 (14.2) years; 2983 (86.5%) were men, 2238 (64.9%) were white, and 1525 (44.2%) were married. The age-adjusted association between PTSD and incident T2DM was significant (hazard ratio [HR], 1.33 [95% CI, 1.08-1.64]; P = .01), and after adding obesity to the model, this association was reduced and no longer significant (HR, 1.16 [95% CI, 0.94-1.43]; P = .18). Results of the full model, which included additional covariate adjustment, revealed no association between PTSD and incident T2DM (HR, 0.84 [95% CI, 0.64-1.10]; P = .19). Among patients with PTSD with obesity, the age-adjusted incidence of T2DM was 21.0 per 1000 person-years vs 5.8 per 1000 person-years in patients without obesity. In patients without PTSD, it was 21.2 per 1000 person-years for patients with obesity vs 6.4 per 1000 person-years in those without obesity.

CONCLUSIONS AND RELEVANCE

In this study of patients who use the Veterans Health Administration for health care, obesity moderated the association between PTSD and incident T2DM. The incidence of T2DM in patients with PTSD who are not obese is similar to the national incidence rate in the United States. These results suggest PTSD is not likely to have a causal association with incident T2DM. Future research is needed to determine if PTSD remission can lead to weight loss and reduced T2DM incidence.

Remote sensing of plant-water relations: An overview and future perspectives

Vegetation is a highly dynamic component of the Earth surface and substantially alters the water cycle. Particularly the process of oxygenic plant photosynthesis determines vegetation connecting the water and carbon cycle and causing various interactions and feedbacks across Earth spheres. While vegetation impacts the water cycle, it reacts to changing water availability via functional, biochemical and structural responses. Unravelling the resulting complex feedbacks and interactions between the plant-water system and environmental change is essential for any modelling approaches and predictions, but still insufficiently understood due to currently missing observations. We hypothesize that an appropriate cross-scale monitoring of plant-water relations can be achieved by combined observational and modelling approaches. This paper reviews suitable remote sensing approaches to assess plant-water relations ranging from pure observational to combined observational-modelling approaches. We use a combined energy balance and radiative transfer model to assess the explanatory power of pure observational approaches focussing on plant parameters to estimate plant-water relations, followed by an outline for a more effective use of remote sensing by their integration into soil-plant-atmosphere continuum (SPAC) models. We apply a mechanistic model simulating water movement in the SPAC to reveal insight into the complexity of relations between soil, plant and atmospheric parameters, and thus plant-water relations. We conclude that future research should focus on strategies combining observations and mechanistic modelling to advance our knowledge on the interplay between the plant-water system and environmental change, e.g. through plant transpiration.

Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occuring smoking: A systematic review and meta-analysis

OBJECTIVES

Research has shown that posttraumatic stress disorder (PTSD) increases the risk of development of cardiometabolic disease (CMD) including cardiovascular disease and diabetes. Whether PTSD is also associated with behavioral risk factors (e.g., diet, exercise, smoking and obesity) for CMD, is less clear.

METHODS

PubMed, Web of Science, and Scopus databases were searched to obtain papers published between 1980-2016. Studies were reviewed for quality using the Quality of Cohort screen. Significance values, odds ratios (OR), 95% confidence intervals (CI), and tests of homogeneity of variance were calculated.

PRINCIPAL FINDINGS

A total of 1,349 studies were identified from our search and 29 studies met all eligibility criteria. Individuals with PTSD were 5% less likely to have healthy diets (pooled adjusted OR = 0.95; 95% CI: 0.92, 0.98), 9% less likely to engage in physical activity (pooled adjusted OR = 0.91; 95% CI: 0.88, 0.93), 31% more likely to be obese (pooled adjusted OR = 1.31; 95% CI:1.25, 1.38), and about 22% more likely to be current smokers (pooled adjusted OR = 1.22; 95% CI: 1.19, 1.26), than individuals without PTSD.

CONCLUSIONS

Evidence shows PTSD is associated with reduced healthy eating and physical activity, and increased obesity and smoking. The well-established association between PTSD and metabolic and cardiovascular disease may be partly due to poor diet, sedentary lifestyle, high prevalence of obesity, and co-occurring smoking in this population. The well-established association of PTSD with CMD is likely due in part to poor health behaviors in this patient population. (PsycINFO Database Record

Close-range laser scanning in forests: towards physically based semantics across scales

Laser scanning with its unique measurement concept holds the potential to revolutionize the way we assess and quantify three-dimensional vegetation structure. Modern laser systems used at close range, be it on terrestrial, mobile or unmanned aerial platforms, provide dense and accurate three-dimensional data whose information just waits to be harvested. However, the transformation of such data to information is not as straightforward as for airborne and space-borne approaches, where typically empirical models are built using ground truth of target variables. Simpler variables, such as diameter at breast height, can be readily derived and validated. More complex variables, e.g. leaf area index, need a thorough understanding and consideration of the physical particularities of the measurement process and semantic labelling of the point cloud. Quantified structural models provide a framework for such labelling by deriving stem and branch architecture, a basis for many of the more complex structural variables. The physical information of the laser scanning process is still underused and we show how it could play a vital role in conjunction with three-dimensional radiative transfer models to shape the information retrieval methods of the future. Using such a combined forward and physically based approach will make methods robust and transferable. In addition, it avoids replacing observer bias from field inventories with instrument bias from different laser instruments. Still, an intensive dialogue with the users of the derived information is mandatory to potentially re-design structural concepts and variables so that they profit most of the rich data that close-range laser scanning provides.

Impact of adherence to antidepressants on long-term prescription opioid use cessation

BACKGROUND

Depression contributes to persistent opioid analgesic use (OAU). Treating depression may increase opioid cessation. Aims To determine if adherence to antidepressant medications (ADMs) v. non-adherence was associated with opioid cessation in patients with a new depression episode after >90 days of OAU.

METHOD

Patients with non-cancer, non-HIV pain (n = 2821), with a new episode of depression following >90 days of OAU, were eligible if they received ≥1 ADM prescription from 2002 to 2012. ADM adherence was defined as >80% of days covered. Opioid cessation was defined as ≥182 days without a prescription refill. Confounding was controlled by inverse probability of treatment weighting.

RESULTS

In weighted data, the incidence rate of opioid cessation was significantly (P = 0.007) greater in patients who adhered v. did not adhered to taking antidepressants (57.2/1000 v. 45.0/1000 person-years). ADM adherence was significantly associated with opioid cessation (odds ratio (OR) = 1.24, 95% CI 1.05-1.46).

CONCLUSIONS

ADM adherence, compared with non-adherence, is associated with opioid cessation in non-cancer pain. Opioid taper and cessation may be more successful when depression is treated to remission. Declaration of interest None.

Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low-Income Patients? A Systematic Review and Meta-Analysis

OBJECTIVES

To examine: (1) what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups.

DATA SOURCES/STUDY SETTING

Existing literature on PCMH utilization among health care organizations serving low-income populations.

STUDY DESIGN

Systematic review and meta-analysis.

DATA COLLECTION/EXTRACTION METHODS

We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low-income populations. A total of 434 studies were reviewed. Thirty-three articles met eligibility criteria.

PRINCIPAL FINDINGS

Patient-centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range -0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = -0.248), but there were apparent limitations in study quality.

CONCLUSIONS

Evidence shows that the PCMH model can increase health outcomes among low-income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed.

Racial differences in the association between nonmedical prescription opioid use, abuse/dependence, and major depression

BACKGROUND

African Americans (AAs) have lower rates of depressive disorders and are less likely to receive opioid analgesics for chronic pain than whites. Given the evidence that prescription opioid use is associated with depression, we hypothesized that the opioid abuse/dependence and depression comorbidity would be less common among AAs compared with whites.

METHODS

A cross-sectional secondary analysis of the public use files for the 2012 (n = 55,268) and 2013 (n = 55,160) National Survey on Drug Use and Health (NSDUH) was used to obtain past-year, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria diagnoses of nonmedical prescription opioid use (NMPOU), abuse/dependence, and major depressive episode (MDE). Covariates included anxiety disorder, alcohol and illicit drug abuse/dependence, smoking, age, gender, education, marital status, health insurance, county urbanicity, and income. Logistic regression models estimating the association between opioid use and MDE were computed before and after adjusting for covariates and separately for AAs and whites.

RESULTS

AAs and whites had similar past-year prevalence of NMPOU (3.5% vs. 3.7%) and abuse/dependence (0.7% vs. 0.9%). MDE was significantly more prevalent among whites (7.4% vs. 5.5%; P < .0001). Among whites, NMPOU and abuse/dependence were associated with MDE (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.12-1.64 and OR = 2.22, 95% CI = 1.67-2.94, respectively). Among AAs, there were no significant associations between NMPOU, abuse/dependence, and MDE (OR range: 0.80-0.95).

CONCLUSIONS

In a nationally representative sample, co-occurrence of past-year depression, NMPOU, and abuse/dependence was determined in whites but not AAs. Additional research is needed to establish the contribution of pain and temporal relationships.

The influence of prescription opioid use duration and dose on development of treatment resistant depression

Long-term prescription opioid use is associated both with new-onset and recurrence of depression. Whether chronic opioid use interferes with depression management has not been reported, therefore we determined whether patients' longer duration of opioid use and higher opioid dose are associated with new-onset treatment resistant depression (TRD) after controlling for confounding from pain and other variables. Data was obtained from Veteran Health Administration (VHA) de-identified patient medical records. We used a retrospective cohort design from 2000-2012. Eligible subjects (n=6169) were 18-80years of age, free of cancer and HIV, diagnosed with depression and opioid-free for the 24-month interval prior to the observation period. Duration of a new prescription for opioid analgesic was categorized as 1-30days, 31-90days and >90days. Morphine-equivalent dose (MED) during follow-up categorized as ≤50mg versus >50mg per day. Pain and other sources of confounding were controlled by propensity scores and inverse probability of treatment weighting. Cox proportional hazard models were computed to estimate the association between duration and dose of opioid and onset of TRD. After controlling for confounding by weighting data, opioid use for 31-90days and for >90days, compared to 1-30days, was significantly associated with new onset TRD (HR=1.25; 95% CI: 1.09-1.45 and HR=1.52; 95% CI: 1.32-1.74, respectively). MED was not associated with new onset TRD. The risk of developing TRD increased as time spent on opioid analgesics increased. Long-term opioid treatment of chronic pain may interfere with treatment of depression.

New depression diagnosis following prescription of codeine, hydrocodone or oxycodone

PURPOSE

Longer duration of prescription opioid use is associated with risk of major depression after controlling for daily morphine equivalent dose and pain. It is not known if risk of depression varies as a function of the type of opioid prescribed.

METHODS

A retrospective cohort design was used to model onset of new depression diagnosis among 11 462 Veterans Health Administration (VA) patients who were prescribed only codeine, only hydrocodone or only oxycodone for >30 days. Patients were free of prevalent opioid use and depression at baseline (2000-2001). Follow-up was 2002-2012. Propensity scores and weighting were used to balance covariates across opioid type. Cox-proportional hazard models were computed, using weighted data and additional adjustment for morphine equivalent dose (MED), duration of use, and pain after opioid initiation, to estimate the risk of new depression diagnosis among patients prescribed only codeine, only oxycodone vs. those prescribed only hydrocodone.

RESULTS

After controlling for confounding, we observed that patients prescribed codeine, compared to hydrocodone, were significantly more likely to have a new depression diagnosis (HR = 1.27; 95%CI: 1.12-1.43). Oxycodone was significantly associated with onset of new depression diagnosis when exposure was modeled as total days exposed in post-hoc analysis, but not when exposure was duration of incident period of use.

CONCLUSIONS

Although codeine is a less potent opioid, after controlling for MED, chronic use of this agent is associated with nearly a 30% greater risk of depression compared to hydrocodone. Additional research is needed to determine the mechanisms for this association. Copyright © 2016 John Wiley & Sons, Ltd.

Increased Risk of Depression Recurrence After Initiation of Prescription Opioids in Noncancer Pain Patients

Several studies have shown that chronic opioid analgesic use is associated with increased risk of new-onset depression. It is not known if patients with remitted depression are at increased risk of relapse after exposure to opioid analgesics. A retrospective cohort design using patient data from the Veterans Health Administration (VHA; n = 5,400), and Baylor Scott & White Health (BSWH; n = 842) was performed with an observation period in the VHA from 2002 to 2012 and in the BSWH from 2003 to 2012. Eligible patients had a diagnosis of depression at baseline and experienced a period of remission. Risk of depression recurrence was modeled in patients that either started taking an opioid or continued without opioid prescriptions before or during remission. Cox proportional hazard models were used to measure the association between opioid use and depression recurrence controlling for pain, and other confounders. Patients exposed to an opioid compared with those unexposed had a significantly greater risk of depression recurrence in both patient populations (VHA: hazard ratio [HR] = 2.17, 95% confidence interval [CI], 2.01-2.34; BSWH: HR = 1.77; 95% CI, 1.42-2.21). These results suggest opioid use doubles the risk of depression recurrence even after controlling for pain, psychiatric disorders, and opioid misuse. Further work is needed to determine if risk increases with duration of use. Repeated screening for depression after opioid initiation may be warranted.

PERSPECTIVE

In 2 large patient cohorts with large differences in demographic characteristics and comorbidity, patients with remitted depression who were exposed to opioid analgesics were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid -free. Routine, not just at initiation of treatment, screening for depression is warranted.

Antidepressant medication use and glycaemic control in co-morbid type 2 diabetes and depression

OBJECTIVE

Depression is prevalent in diabetes and is associated with increased risks of hyperglycaemia, morbidity and mortality. The effect of antidepressant medication (ADM) on glycaemic control is uncertain owing to a paucity of relevant data. We sought to determine whether the use of ADM is associated with glycaemic control in depressed patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective cohort study (n = 1399) was conducted using electronic medical record registry data of ambulatory primary care visits from 2008 to 2013. Depression and type 2 diabetes were identified from ICD-9-CM codes; ADM use was determined from prescription orders; and glycaemic control was determined from measures of glycated haemoglobin (A1c). Good glycaemic control was defined as A1c < 7.0% (53 mmol/mol). Generalized estimating equations were used to determine the effect of depression and ADM use on glycaemic control.

RESULTS

Good glycaemic control was achieved by 50.9% of depressed subjects receiving ADM versus 34.6% of depressed subjects without ADM. After adjusting for covariates, depressed patients receiving ADM were twice as likely as those not receiving ADM to achieve good glycaemic control (odds ratio = 1.95; 95% confidence interval: 1.02-3.71).

CONCLUSIONS

In this retrospective cohort study of a large sample of primary care patients with type 2 diabetes, ADM use was associated with improved glycaemic control.

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

PURPOSE

Recent results suggests the risk of a new onset of depression increases with longer duration of opioid analgesic use. It is unclear whether new-onset depression related to opioid analgesic use is a function of the dose prescribed or the duration of use or both.

METHODS

Using a retrospective cohort design, we collected patient data from 2000 to 2012 from the Veterans Health Administration (VHA), and from 2003 to 2012 from both Baylor Scott & White Health (BSWH) and the Henry Ford Health System (HFHS). Patients (70,997 VHA patients, 13,777 BSWH patients, and 22,981 HFHS patients) were new opioid users, aged 18 to 80 years, without a diagnosis of depression at baseline. Opioid analgesic use duration was defined as 1 to 30, 31 to 90, and more than 90 days, and morphine equivalent dose (MED) was defined as 1 to 50 mg/d, 51 to 100 mg/d, and greater than 100 mg/d of analgesic. Pain and other potential confounders were controlled for by inverse probability of treatment-weighted propensity scores.

RESULTS

New-onset depression after opioid analgesic use occurred in 12% of the VHA sample, 9% of the BSWH sample, and 11% of the HFHS sample. Compared with 1- to 30-day users, new-onset depression increased in those with longer opioid analgesic use. Risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from hazard ratio [HR] = 1.18 (95% CI, 1.10-1.25) in VHA to HR = 1.33 (95% CI, 1.16-1.52) in HFHS; in opioid analgesic use of more than 90 days, it ranged from HR = 1.35 (95% CI, 1.26-1.44) in VHA to HR = 2.05 (95% CI, 1.75-2.40) in HFHS. Dose was not significantly associated with a new onset of depression.

CONCLUSIONS

Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression. Opioid analgesic use, not just pain, should be considered a potential source when patients report depressed mood.

A Plan for Useful and Timely Family Medicine and Primary Care Research

Our nation's health care system is changing. Nowhere is this more evident than in primary care, where fundamental improvements are necessary if we are to achieve the Triple Aim. Such improvements are possible if we can put useful and timely information into the hands of stakeholders to enable practical decision-making. To do this, family medicine and primary care researchers need to (1) build on our substantial current research foundation, (2) increase the relevance and pace of our research, (3) reconceive the research workforce to engage new partners, (4) disseminate findings more rapidly into the hands of those who can take action, and (5) build a "question-ready" research infrastructure to make this possible. Family medicine researchers face exciting opportunities: technical capacity to generate and manage large amounts of data; clinic- and system-level networks for testing innovations; digital health technologies for real-time and asynchronous monitoring and management of risk factors and chronic diseases; the know-how to make fast, local improvements in our systems of care; partnerships beyond those traditionally engaged in research that can multiply our capacity to generate new knowledge; and new methods for creating generalizable knowledge from the study of local efforts. This is a historic time for family medicine research. Now is the time to build on our past work, accelerate the pace, and capitalize on emerging opportunities that open an incredibly bright future.

Depression leads to incident vascular disease: evidence for the relevance to primary care

BACKGROUND

Depression is a known risk factor for vascular disease in community cohorts and in large, system-wide, health care databases. It is not known if the association between depression and incident vascular disease exists when patient data is restricted to depression presenting in primary care.

METHODS

Data were from a medical record registry capturing all primary care encounters at a large academic medical practice from 2008 to 2013. From 27,225 registry patients, we identified 7383 patients free of vascular disease for 18 months prior to baseline. ICD-9-CM codes were used to define depression and vascular disease. Volume of health care use, demographics and comorbid diagnoses were obtained from the patient data registry. Cox proportional hazard models with time dependent covariates were computed to measure the association between depression and incident vascular disease before and after adjusting for covariates.

RESULTS

Of the 7383 patients initially free of vascular disease, 14% were diagnosed with depression and 8.6% developed vascular disease. Incident vascular disease was significantly (P < 0.01) higher among patients with depression (12.7%) compared to those without depression (7.9%). In the unadjusted model, depression was associated with a 49% increased risk of developing vascular disease (odds ratio [OR] = 1.49; 95% confidence interval [CI]: 1.19-1.86) and this association remained significant after adjusting for all potential confounders (OR = 1.28; 95% CI: 1.02-1.62).

CONCLUSIONS

The association between depression and incident vascular disease is observed in patients diagnosed and managed by primary care physicians. Primary care physicians have an opportunity to impact this association. Guidelines for primary care providers are needed to prompt aggressive depression treatment and vascular disease screening.

Interpersonal violence in Texas: a physician's role

The overall national incidence rates of domestic violence are falling, yet the Texas rates are rising and are now twice the national average. Domestic violence, now termed intimate-partner violence, affects both men and women of all ages, races, and socioeconomic strata. While some risk factors are known, the Texas disparities are not yet fully understood. Studies indicate three contributors to the national decline: the provision of legal services, improvements in economic status, and population aging. Legal action has been shown to decrease repeat incidents by 80%. A little known Texas law requires doctors to provide safety and shelter information to patients with injuries believed to be caused by family violence and to document in the patient's medical record that the information was made available to the patient. Our best hope to aid in breaking the cycle of violence is to actively screen and distribute safety information to our patients. Every physician can ask every patient, "Do you feel safe in your home?"

Vaginal bleeding associated with pregnancy

Vaginal bleeding during pregnancy provokes physical and emotional stress to patients and physicians. Physicians must be prepared to assess the medical implications of acute blood loss to these patients and their unborn children quickly. When mother and fetus are stable, the recognition and treatment of the underlying cause is essential to decreasing additional maternal and fetal morbidity and mortality associated with the bleeding episode.

Evaluation and management of dyspepsia

Dyspepsia, often defined as chronic or recurrent discomfort centered in the upper abdomen, can be caused by a variety of conditions. Common etiologies include peptic ulcers and gastroesophageal reflux. Serious causes, such as gastric and pancreatic cancers, are rare but must also be considered. Symptoms of possible causes often overlap, which can make initial diagnosis difficult. In many patients, a definite cause is never established. The initial evaluation of patients with dyspepsia includes a thorough history and physical examination, with special attention given to elements that suggest the presence of serious disease. Endoscopy should be performed promptly in patients who have "alarm symptoms" such as melena or anorexia. Optimal management remains controversial in young patients who do not have alarm symptoms. Although management should be individualized, a cost-effective initial approach is to test for Helicobacter pylori and treat the infection if the test is positive. If the H. pylori test is negative, empiric therapy with a gastric acid suppressant or prokinetic agent is recommended. If symptoms persist or recur after six to eight weeks of empiric therapy, endoscopy should be performed.

Alcohol-related problems: recognition and intervention

Early identification of alcohol-related problems is important because these problems are prevalent, pose serious health risks to patients and their families, and are amenable to intervention. Physicians may be able to help patients change their drinking behaviors. The most effective tool for screening is a thorough history of the patient's drinking behavior, designed to identify patterns of alcohol-related difficulties with physical and mental health, family life, legal authorities and employment. Alcohol drinkers can be categorized as at-risk, problem or alcohol dependent, according to a protocol developed by the National Institute on Alcohol Abuse and Alcoholism. The severity of the alcohol problem and the patient's readiness to change should determine the intervention selected by the family physician.