SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Prevalence of apical periodontitis and its association with previous root canal treatment, root canal filling length and type of coronal restoration - a cross-sectional study

AIM

To analyse the prevalence of periapical lesions and their association with previous root canal treatment, root canal filling length and type of coronal restoration using in vivo cone-beam computed tomographic (CBCT) assessment.

METHODOLOGY

A global sample of 20 836 teeth, with a combined total of 27 046 roots, from 1160 patients, was analysed via CBCT assessment in eight health centres. Each tooth was evaluated by one out of five examiners after having performed a defined calibration procedure on the basis of 319 teeth. Intra- and inter-rater reliability tests were performed. Each tooth was classified according the tooth number, presence/absence of periapical lesions, presence/absence of previous root canal treatment, length of root canal filling (short, good or overfilling) and type of coronal restoration. The z-test for proportions was used to analyse differences between tooth subgroups, and an odds ratio was determined in order to analyse the association between treatment status and periapical lesions. A P < 0.05 was considered significant.

RESULTS

At a tooth level, the overall prevalence of periapical lesions in the sample was 10.4%. Maxillary teeth were associated with a significantly larger percentage of lesions (13.1%), whilst maxillary first molars had the greater proportion of lesions (21.2%). The prevalence of periapical lesions was significantly larger in root filled teeth (55.5%), short root canal fillings (72.7%) and in teeth restored with crowns (46.1%). At a root level, the mesiobuccal roots of both maxillary first molars had a tendency for a larger percentage of periapical lesions.

CONCLUSION

History of root canal treatment, root canal filling length and type of coronal restoration influenced the presence of periapical lesions. Molars were more commonly associated with periapical lesions on root filled teeth, particularly those with short root fillings and those with crowns.

Cover Art: <i>Two Ships</i>

Artist's Statement for the cover art of IJPS volume 4, issue 2: Two Ships, 2017. Watercolor and chalk on paper.

Comparison of the properties of Bacillus subtilis spores made in liquid or on agar plates

AIMS

To compare the properties of the spores of Bacillus subtilis prepared in liquid and on plates.

METHODS AND RESULTS

The spores of B. subtilis were prepared at 37 degrees C using a nutrient exhaustion medium either in liquid or on agar plates. The levels of core water, dipicolinic acid (DPA) and small, acid-soluble spore proteins (SASP) were essentially identical in spores made in liquid or on plates. Spores prepared in liquid were killed approximately threefold more rapidly at 90 degrees C in water than the spores prepared on plates, and the spores prepared in liquid were more sensitive to nitrous acid and a diluted stable superoxidized water. Spores prepared in liquid also germinated more rapidly with several agents than those prepared on plates. Pellets of spores prepared on plates were darker than spores prepared in liquid, and spores prepared in liquid had more readily extracted coat protein. However, there were no major differences in the relative levels of individual coat proteins or the cross-linking of the coat protein GerQ in the two types of spores, although the inner membrane of spores prepared on plates had a higher ratio of anteiso- to iso-fatty acids.

CONCLUSIONS

The preparation in liquid yielded spores with some different properties than those made on agar plates. Spores made in liquid had lower resistance to heat and several chemicals, and germinated more readily with several agents. There were also differences in the composition of the inner membrane of spores prepared under these two conditions. However, there were no major differences in the levels of DPA, core water, SASP and individual coat proteins or the cross-linking of a coat protein in spores made in liquid and on plates.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work demonstrates that the preparation method can affect the resistance and germination properties of bacterial spores, even if an identical medium and temperature are used. Evidence was also obtained consistent with the role of the inner membrane in spore resistance and germination, and that some factor in addition to core water, DPA and SASP content plays a role in spore resistance to wet heat.

Consumer involvement--a vital piece of the quality quilt: the California HealthCare Foundation's strategy for engaging California consumers

How can the delivery of health services be made accountable to the needs and desires of those who receive and, ultimately, pay for them? The approach of the California HealthCare Foundation (CHCF) has been to build a supply of consumer friendly information, to encourage societal vigilance through public reporting, and to disseminate it using both traditional and non-traditional strategies in order to reach underserved and disenfranchised populations.

Social determinants of (un)healthy behaviors

Medical education has historically relied on the rational choice model as a vehicle for promoting health behavior change, and has largely overlooked the powerful relationships between social class and health behaviors. The rational choice model, which assumes that people can choose to pursue behaviors that are needed for their health, has some clinical utility, especially in some circumstances, but it runs the risk of missing key sources of influence and of blaming the victim. The biopsychosocial model provides an alternative basis for teaching about health behavior change. Health behavior needs to be understood in a broad social context, in which social class is recognized as playing a large part in shaping many people's health behaviors through multiple pathways, including limited opportunities for self-fulfillment, financial constraints, health beliefs, self-efficacy, stress, and social support. In addition to highlighting the limitations of the rational choice model, we illustrate how to integrate the socio-cultural context into teaching about behavior change. Specific curricular suggestions include exercises for: (1) increasing students' awareness of their own biases regarding unhealthy behaviors and individual responsibility for change; (2) enhancing knowledge of social factors that impact health; (3) building advocacy skills; (4) learning from patients; and (5) practicing counseling skills through role-plays.

Cholesterol testing and management: a national comparison of family physicians, general internists, and cardiologists

BACKGROUND

We wanted to compare the frequency of cholesterol testing and treatment of hypercholesterolemia in patients cared for by family physicians, general internists, and cardiologists.

METHODS

This study was a continuous cross-sectional survey of 1991 ambulatory office visits using a national probability sample of US physicians' office practices (National Ambulatory Care Survey). The physicians surveyed self-reported their specialty as family practice, internal medicine, or cardiology. Records of 33,795 patient visits to 1354 physicians were reviewed to find out whether the physicians reported cholesterol testing, cholesterol counseling, and charting of patient use of lipid-lowering medications. The results were compared among the three specialist groups.

RESULTS

During an annual health examination (9.77 million office visits), a cholesterol test was reported by 23.5 percent of family physicians, 43.5 percent of internists, and 13.1 percent of cardiologists (P < 0.01). For all hypercholesterolemic patients (23.52 million office visits), the age- and sex-adjusted percentages of reported cholesterol-reduction counseling during office visits were 38.3 percent for family physicians, 42.4 percent for internists, and 36.5 percent by cardiologists (NS), and percentages of reported lipid-lowering medication prescriptions were 13.4 percent for family physicians, 25.1 percent for internists, and 28.4 percent for cardiologists (P < 0.01). In hypercholesterolemic patients with coronary heart disease (3.47 million office visits), the age- and sex-adjusted percentages of cholesterol reduction counseling reported during office visits were 64.4 percent for family physicians, 47.1 percent for internists, and 35.9 percent for cardiologists (NS) and the age- and sex-adjusted percentages of lipid-lowering medication prescriptions reported were 13.9 percent for family physicians, 62.5 percent for internists, and 34.7 percent for cardiologists (P < 0.01).

CONCLUSIONS

Recommended goals regarding cholesterol testing and management were not reached by any physician group. Internists tested for hypercholesterolemia during an annual health examination more frequently and had more patients using lipid-lowering medications than did family physicians or cardiologists. Understanding the reasons for these specialty differences might lead to improvement in the diagnosis and management of hypercholesterolemia and therefore reduction in cardiovascular disease.

Hypocholesterolemic activity of raloxifene (LY139481): pharmacological characterization as a selective estrogen receptor modulator

After once-daily oral dosing in ovariectomized rats, raloxifene (LY139481) hydrochloride produced dose- and time-dependent reductions in serum cholesterol and high-density lipoprotein-cholesterol. Paired-feeding studies demonstrated that effects of raloxifene on serum lipids were not secondary to effects on food consumption. Maximal reductions in serum cholesterol occurred within 4 days of raloxifene administration or sooner, depending on the administered dose. The ED50 for 50% reduction in serum cholesterol by raloxifene was 0.13 +/- 0.04 mg/kg/day (mean +/- S.E.M., n = 17); maximal cholesterol reduction by raloxifene (68%) was significantly less than that produced by estrogen (17 alpha-ethinylestradiol; 89%) after 4 to 7 days of daily dosing. Dose-response curves for cholesterol lowering by raloxifene were generated in the presence of varying doses of 17 alpha-ethinylestradiol; two-way analysis of variance revealed significant interactions between estrogen and raloxifene with respect to cholesterol lowering (P < .001). Furthermore, a high dose of raloxifene (10 mg/kg/day) prevented further reduction of serum cholesterol by estrogen (1-100 micrograms/kg/ day) beyond that produced by raloxifene alone. For a series of closely related structural analogs of raloxifene, log(ED50) values for cholesterol lowering were highly correlated with log(relative binding affinity) for the estrogen receptor (r = 0.93; P < .0001). Thus, cholesterol lowering by raloxifene in ovariectomized rats is mediated primarily via partial agonist effects at estrogen receptors. Taken together with previous observations in uterine tissue of estrogen antagonism by raloxifene in the absence of significant agonism, the present findings support the classification of raloxifene as a selective estrogen receptor modulator.

The effect of physician and patient gender on preventive medicine practices in patients older than fifty

This study examined whether the sex of physicians and patients affected the preventive care of middle-aged and older patients of family physicians. The charts of 61 male and 75 female patients older than 50 years, whose primary physicians were third-year family practice residents, were reviewed to determine whether tests to screen for colorectal, breast, and cervical cancer had been offered to them in the previous 18 months by their primary physicians. Male residents had offered rectal examinations significantly more frequently than female residents to male patients older than 70. Female residents had offered mammograms, pelvic exams, and Pap smears significantly more frequently to women older than 50 than had male residents. Female residents had significantly higher rates of offering pelvic exams and Pap smears to women between the ages of 50 and 70, but this difference was not significant for women over 70. There were no significant differences in the number of refusals by male or female patients to male or female residents. Results suggest that the sex and age of the patient and the sex of the physician may play a role in differential rates of cancer screening.

Studies of the developmental toxicity of polycarboxylate dispersing agents

Three linear polycarboxylate compounds, two linear polyacrylates (90,000 MW and 4,500 MW) and one linear polyacrylate-maleate copolymer (12,000 MW), were tested for their teratogenic potential in female Sprague Dawley rats. These polymers, which were tested as sodium salts, are used as dispersing agents in detergent formulations at levels of 1-5%. All compounds were administered by gavage during organogenesis (days 6-15 of pregnancy). No adverse effects on development were seen with any of the three compounds at any of the doses tested. The highest dose, and therefore the minimum no-effect dose, for the three linear polymers was 1125 mg/kg/day for the 90,000 MW polyacrylate, 3000 mg/kg/day for the 4,500 MW polyacrylate, and 6670 mg/kg/day for the polyacrylate-maleate copolymer. Based on these data, these compounds are not developmentally toxic, even at very high dose levels.

Phosphatidylinositol turnover in isolated soybean membranes stimulated by the synthetic growth hormone 2,4-dichlorophenoxyacetic acid

Phospholipids of plant membranes isolated from homogenates of dark-grown hypocotyls of soybean (Glycine max L.) undergo rapid and specific degradative changes. The degradation of phosphatidylinositol (PI) in such membranes is enhanced in the presence of the synthetic auxin, 2,4-dichlorophenoxyacetic acid (2,4-D), measured as the hydrolysis of PI or by an enhancement of [3H]inositol incorporation into membrane-associated PI stimulated by Mn2+, but not dependent upon added CTP, Mg2+, or diglyceride. The response is rapid and enhanced by auxin throughout the physiological range of growth-promoting concentrations (optimum at about 7 X 10(-7) M). The growth-inactive 2,4-D analogue, 2,3-dichlorophenoxyacetic acid (2,3-D), is without effect. These findings suggest a cell-free response of isolated membranes to the hormone mediated by a definable enzymatic reaction.