Cluster-Randomized Comparative Effectiveness Trial of Physician-Directed Clinical Decision Support Versus Patient-Directed Education to Promote Appropriate Use of Opioids for Chronic Pain

We compared the effectiveness of physician-directed clinical decision support (CDS) administered via electronic health record versus patient-directed education to promote the appropriate use of opioids by conducting a cluster-randomized trial involving 82 primary care physicians and 951 of their patients with chronic pain. Primary outcomes were satisfaction with patient-physician communication consumer assessment of health care providers and system clinician and group survey (CG-CAHPS) and pain interference patient-reported outcomes measurement information system. Secondary outcomes included physical function (patient-reported outcomes measurement information system), depression (PHQ-9), high-risk opioid prescribing (>90 morphine milligram equivalents per day [≥90 mg morphine equivalent/day]), and co-prescription of opioids and benzodiazepines. We used multi-level regression to compare longitudinal difference-in-difference scores between arms. The odds of achieving the maximum CG-CAHPS score were 2.65 times higher in the patient education versus the CDS arm (P = .044; 95% confidence interval [CI] 1.03-6.80). However, baseline CG-CAHPS scores were dissimilar between arms, making these results challenging to interpret definitively. No difference in pain interference was found between groups (Coef = -0.64, 95% CI -2.66 to 1.38). The patient education arm experienced higher odds of Rx ≥ 90 milligrams morphine equivalent/day (odds ratio = 1.63; P = .010; 95% CI 1.13, 2.36). There were no differences between groups in physical function, depression, or co-prescription of opioids and benzodiazepines. These results suggest that patient-directed education may have the potential to improve satisfaction with patient-physician communication, whereas physician-directed CDS via electronic health records may have greater potential to reduce high-risk opioid dosing. More evidence is needed to ascertain the relative cost-effectiveness between strategies. PERSPECTIVE: This article presents the results of a comparative-effectiveness study of 2 broadly used communication strategies to catalyze dialog between patients and primary care physicians around chronic pain. The results add to the decision-making literature and offer insights about the relative benefits of physician-directed versus patient-directed interventions to promote the appropriate use of opioids.

Home-based virtual reality for chronic pain: protocol for an NIH-supported randomised-controlled trial

INTRODUCTION

Chronic pain is highly prevalent and associated with a large burden of illness; there is a pressing need for safe, home-based, non-pharmacological, interventions. Virtual reality (VR) is a digital therapeutic known to be effective for acute pain, but its role in chronic pain is not yet fully elucidated. Here we present a protocol for the National Institute of Health (NIH) Back Pain Consortium (BACPAC) VR trial that evaluates the effectiveness of three forms of VR for patients with chronic lower back pain (cLBP), a highly prevalent form of chronic pain.

METHODS AND ANALYSIS

The NIH BACPAC VR trial will randomise 360 patients with cLBP into one of three arms, each administered through a head-mounted display: 1) skills-based VR, a program incorporating principles of cognitive behavioural therapy, mindful meditation and physiological biofeedback therapy using embedded biometric sensors; 2) distraction-based VR, a program using 360-degree immersive videos designed to distract users from pain; and 3) sham VR, a non-immersive program using two-dimensional videos within a VR headset. Research participants will be monitored for 12 weeks using a combination of patient-reported outcomes administered via REDCap (Research Electronic Data Capture), wearable sensor data collected via Fitbit Charge 4 and electronic health record data. The primary outcome will be the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scale. Secondary outcomes will include PROMIS Anxiety, PROMIS Sleep Disturbance, opioid prescription data and Pain Catastrophizing Scale Short Form. A subgroup analysis will explore patient level predictors for VR efficacy.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Institutional Review Board of Cedars-Sinai Health System in April 2020. The results will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04409353.

Anterior cruciate ligament repair versus reconstruction: A kinematic analysis

BACKGROUND

The purpose of this study was to compare the biomechanical properties of an anterior cruciate ligament (ACL) anatomic repair of a true femoral avulsion to an anatomic ACL reconstruction. It was hypothesized that the ACL repair and ACL reconstruction would have comparable biomechanical behavior when compared to the native knee.

METHODS

Ten paired fresh-frozen cadaveric knees (n = 20) were used to investigate knee kinematics when an anterior drawer force, varus, valgus, internal, and external rotational moment were applied at 0, 15, 30, 45, 60, and 90 degrees of flexion. Displacement and rotation were recorded in the following conditions: ACL-intact, ACL-deficient, and ACL-repaired vs reconstructed.

RESULTS

Sectioning of the ACL significantly increased anterior tibial translation (0°, 15°, 30° and 45°) compared to the intact state. The mean anterior displacement difference from intact was lower in the ACL-repaired knees compared to reconstructed knees at 30° and 90°. There were no significant differences between conditions in varus, valgus, internal, or external rotations.

CONCLUSION

ACL repair and ACL reconstruction procedures restored knee anterior tibial translation in matched paired specimens. There were no differences in valgus, varus, internal, or external rotation. Although, ACL-repaired knees (avulsion model) demonstrated less anterior tibial translation when compared to ACL-reconstructed knees, this difference was less than one millimeter. Based on the findings of this study, repair and reconstruction procedures both restored anterior tibial translation in matched-pair specimens. This suggests that the initial functionality of both techniques is similar and that further clinical studies are needed to compare the long-term stability.

Diaphragmatic hernia masquerading as pneumothorax in two toddlers

In two separate incidents, two toddlers with no previous history of respiratory ailments presented to the emergency department of a children's hospital with progressive respiratory distress. Both children had unilateral lung findings on auscultation and initial chest radiographs that were consistent with a pneumothorax. Thoracostomy and chest tube insertion were performed during initial resuscitation efforts. In both cases, subsequent radiographs revealed that the stomach was located in the left hemithorax, suggestive of a diaphragmatic hernia. Nasogastric tube insertion relieved the respiratory distress of these two children. Recognition of the "acquired" congenital diaphragmatic hernia in the setting of extreme aerophagia or mild abdominal trauma may prevent unnecessary procedures during the resuscitation of children with acute respiratory distress and unilateral lung findings.

Protein synthesis patterns following stage-specific heat shock in early Drosophila embryos

Very short heat shocks are administered to carefully staged early embryos of Drosophila melanogaster, and the effects on protein synthesis pattern investigated. A shock as short as 2 min will induce the heat shock response (reduction of normal protein synthesis, increased synthesis of the heat shock proteins) in syncytial blastoderm or later stages. Thus the initial events of the heat shock response must occur within 2 min, and not reverse upon rapid return to 22 degrees C. A low level of synthesis of the 70 kDA heat shock protein is sometimes visible in unshocked animals, but may be induced by the labeling procedure. Survival following a short shock is not strictly correlated with a high level of heat shock response. Pre-blastoderm embryos do not produce significant heat shock protein, but survive a 2 min 43 degrees C heat shock better than do heat shock response competent blastoderm embryos. The protein synthesis pattern prior to the blastoderm stage is very stable, possibly enhancing survival following a short shock. Shocks of 3 min or longer are more detrimental to pre-blastoderm embryos than to later stages, confirming the role of the heat shock response in survival following a longer shock. Stage-specific developmental defects (phenocopies) may be induced by heat shock at the blastoderm or later stages. Induction of these defects may require disruption of the normal protein synthesis pattern. Use of very short heat shocks to induce the heat shock response will be valuable in identifying the precise time at which a specific defect can be induced.

Effects of deficiencies in the engrailed region of Drosophila melanogaster

The engrailed gene of Drosophila melanogaster is believed to be involved in control of determination and differentiation of posterior compartments. en1/en1 causes a partial transformation of the posterior compartment of wing and first leg to mirror-image anterior, which prompted the hypothesis that engrailed + is a "selector gene" required for the posterior pathway decision. The incomplete transformation was thought due to residual en+ activity in en1; a deletion of engrailed (en28) was constructed to determine if a complete transformation can occur. en28 is homozygous lethal and cell lethal. en28/en1 survives to adult stage, but causes a weaker transformation than en1/en1, indicating that en1 is not a simple hypomorph. A more distal deletion, en30, survives over en-lethal alleles. Both en30/en1 and en28/en30 survive to adult stage, but do not cause a stronger posterior to anterior transformation than en1/en1; thus this effect may be allele specific. New abnormalities included (1) transformation of the posterior wing blade to haltere, an effect dependent on the bx+ (but not pbx+) pseudoallele of the bithorax complex; (2) abnormal bristle pattern, tarsal fusion, and degenerate posterior claws of all legs. Although these abnormalities are posterior compartment specific, they are not expected of a "selector gene." Thus the function of engrailed may be more complex than originally believed.