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Gold LS, Heagerty PJ, Hansen RN, Friedly JL, Johnston SK, Deyo RA, Curatolo M, Turner JA, Rundell SD, Wysham K, Jarvik JG, Suri P. Mortality with concurrent treatment with gabapentin and opioids among people with spine diagnoses in the U.S. Medicare population: a propensity-matched cohort study. medRxiv 2024:2024.04.26.24306460. [PMID: 38746254 PMCID: PMC11092734 DOI: 10.1101/2024.04.26.24306460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
IMPORTANCE Given the negative impact of opioid use on population health, prescriptions for alternative pain-relieving medications, including gabapentin, have increased. Concurrent gabapentin and opioid prescriptions are commonly reported in retrospective studies of opioid-related overdose deaths. OBJECTIVE To determine whether people who filled gabapentin and opioid prescriptions concurrently ('gabapentin + opioids') had greater mortality than those who filled an active control medication (tricyclic antidepressants [TCAs] or duloxetine) and opioids concurrently ('TCAs/duloxetine + opioids'). We hypothesized that people treated with gabapentin + opioids would have higher mortality rates compared to people treated with TCAs/duloxetine + opioids. DESIGN Propensity score-matched cohort study with an incident user, active control design. The median (maximum) follow-up was 45 (1093) days. SETTING Population-based. PARTICIPANTS Medicare beneficiaries with spine-related diagnoses 2017-2019. The primary analysis included those who concurrently (within 30 days) filled at least 1 incident gabapentin + at least 1 opioid or at least 1 incident TCA/duloxetine + at least 1 opioid. EXPOSURES People treated with gabapentin + opioids (n=67,133) were matched on demographic and clinical factors in a 1:1 ratio to people treated with TCAs/duloxetine + opioids (n=67,133). MAIN OUTCOMES AND MEASURES The primary outcome was mortality at any time. A secondary outcome was occurrence of a major medical complication at any time. RESULTS Among 134,266 participants (median age 73.4 years; 66.7% female), 2360 died before the end of follow-up. No difference in mortality was observed between groups (adjusted hazard ratio (HR) and 95% confidence interval (CI) for gabapentin + opioids was 0.98 (0.90, 1.06); p=0.63). However, people treated with gabapentin + opioids were at slightly increased risk of a major medical complication (1.02 (1.00, 1.04); p=0.03) compared to those treated with TCAs/duloxetine + opioids. Results were similar in analyses (a) restricted to less than or = 30-day follow-up and (b) that required at least 2 fills of each prescription. CONCLUSIONS AND RELEVANCE When treating pain in older adults taking opioids, the addition of gabapentin did not increase mortality risk relative to addition of TCAs or duloxetine. However, providers should be cognizant of a small increased risk of major medical complications among opioid users initiating gabapentin compared to those initiating TCAs or duloxetine.
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Wartko PD, Krakauer C, Turner JA, Cook AJ, Boudreau DM, Sullivan MD. STRategies to Improve Pain and Enjoy life (STRIPE): results of a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy. Pain 2023; 164:2852-2864. [PMID: 37624901 PMCID: PMC10843637 DOI: 10.1097/j.pain.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/19/2023] [Indexed: 08/27/2023]
Abstract
ABSTRACT Because long-term opioid therapy (LtOT) for chronic pain has uncertain benefits and dose-dependent harms, safe and effective strategies for opioid tapering are needed. Adapting a promising pilot study intervention, we conducted the STRategies to Improve Pain and Enjoy life (STRIPE) pragmatic clinical trial. Patients in integrated health system on moderate-to-high dose of LtOT for chronic noncancer pain were randomized individually to usual care plus intervention (n = 79) or usual care only (n = 74). The intervention included pain coping skills training and optional support for opioid taper, delivered in 18 telephone sessions over a year, with pharmacologic guidance provided to participants' primary care providers by a pain physician. Coprimary outcomes were daily opioid dose (morphine milligram equivalent [MME]), calculated using pharmacy dispensing data, and the self-reported Pain, Enjoyment of Life and General Activity scale at 12 months (primary time point) and 6 months. Secondary outcomes included opioid misuse, opioid difficulties, opioid craving, pain self-efficacy, and global impression of change, depression, and anxiety. Only 41% randomized to the intervention completed all sessions. We did not observe significant differences between intervention and usual care for MME (adjusted mean difference: -2.3 MME; 95% confidence interval: -10.6, 5.9; P = 0.578), the Pain, Enjoyment of Life, General Activity scale (0.0 [95% confidence interval: -0.5, 0.5], P = 0.985), or most secondary outcomes. The intervention did not lower opioid dose or improve pain or functioning. Other strategies are needed to reduce opioid doses while improving pain and function for patients who have been on LtOT for years with high levels of medical, mental health, and substance use comorbidity.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Judith A. Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States of America
| | - Andrea J. Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Denise M. Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Genentech, Inc., South San Francisco, CA, United States of America (current primary affiliation)
| | - Mark D. Sullivan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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Liu P, Wu Y, Xiao Z, Gold LS, Heagerty PJ, Annaswamy T, Friedly J, Turner JA, Jarvik JG, Suri P. Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis. Pain 2023; 164:811-819. [PMID: 36036907 PMCID: PMC9968359 DOI: 10.1097/j.pain.0000000000002768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 08/16/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.
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Affiliation(s)
- Pinyan Liu
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Yitao Wu
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Ziyu Xiao
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Laura S. Gold
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
| | - Thiru Annaswamy
- Dallas VA Medical Center, 4500 S. Lancaster Rd. Dallas, TX 75216, USA
| | - Janna Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359612, Seattle, WA 98104, USA
| | - Judith A. Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Jeffrey G. Jarvik
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle, USA, 325 Ninth Avenue, Box 359612 Seattle, WA 98104, USA
| | - Pradeep Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359612, Seattle, WA 98104, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
- Division of Rehabilitation Care Services, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
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4
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Chen JA, Anderson ML, Cherkin DC, Balderson BH, Cook AJ, Sherman KJ, Turner JA. Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain. J Pain 2023; 24:282-303. [PMID: 36180008 PMCID: PMC9898119 DOI: 10.1016/j.jpain.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 02/06/2023]
Abstract
Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.
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Affiliation(s)
- Jessica A Chen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
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Webster F, Connoy L, Longo R, Ahuja D, Amtmann D, Anderson A, Ashton-James CE, Boyd H, Chambers CT, Cook KF, Cowan P, Crombez G, Feinstein AB, Fuqua A, Gilam G, Jordan I, Mackey SC, Martins E, Martire LM, O'Sullivan P, Richards DP, Turner JA, Veasley C, Würtzen H, Yang SY, You DS, Ziadni M, Darnall BD. Patient Responses to the Term Pain Catastrophizing: Thematic Analysis of Cross-sectional International Data. J Pain 2023; 24:356-367. [PMID: 36241160 PMCID: PMC9898136 DOI: 10.1016/j.jpain.2022.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/03/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2022]
Abstract
Pain catastrophizing is understood as a negative cognitive and emotional response to pain. Researchers, advocates and patients have reported stigmatizing effects of the term in clinical settings and the media. We conducted an international study to investigate patient perspectives on the term pain catastrophizing. Open-ended electronic patient and caregiver proxy surveys were promoted internationally by collaborator stakeholders and through social media. 3,521 surveys were received from 47 countries (77.3% from the U.S.). The sample was mainly female (82.1%), with a mean age of 41.62 (SD 12.03) years; 95% reported ongoing pain and pain duration > 10 years (68.4%). Forty-five percent (n = 1,295) had heard of the term pain catastrophizing; 12% (n = 349) reported being described as a 'pain catastrophizer' by a clinician with associated high levels of feeling blamed, judged, and dismissed. We present qualitative thematic data analytics for responses to open-ended questions, with 32% of responses highlighting the problematic nature of the term. We present the patients' perspective on the term pain catastrophizing, its material effect on clinical experiences, and associations with negative gender stereotypes. Use of patient-centered terminology may be important for favorably shaping the social context of patients' experience of pain and pain care. PERSPECTIVE: Our international patient survey found that 45% had heard of the term pain catastrophizing, about one-third spontaneously rated the term as problematic, and 12% reported the term was applied to them with most stating this was a negative experience. Clinician education on patient-centered terminology may improve care and reduce stigma.
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Affiliation(s)
- Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Laura Connoy
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Riana Longo
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | | | - Dagmar Amtmann
- University of Washington (UW), Department of Rehabilitation Medicine, UW Center on Outcomes Research in Rehabilitation (UWCORR), Seattle, Washington, USA
| | | | - Claire E Ashton-James
- Sydney Medical School, Kolling Institute, The University of Sydney, St Leonards, New South Wales, Australia
| | | | - Christine T Chambers
- Departments of Psychology and Neuroscience & Pediatrics, Dalhousie University; Centre for Pediatric Pain Research, IWK Health, Halifax, Nova Scotia
| | | | - Penney Cowan
- American Chronic Pain Association, World Patients Alliance
| | - Geert Crombez
- Psychology and Educational Sciences, Department of Experimental Clinical and Health Psychology, Ghent University, Gent, Belgium
| | - Amanda B Feinstein
- Stanford University School of Medicine/Stanford Children's Health, Menlo Park, California, USA
| | - Anne Fuqua
- University of Alabama Birmingham, Albama, USA
| | - Gadi Gilam
- The Institute of Biomedical and Oral Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Eduarda Martins
- Centro Hospitalar Póvoa de Varzim/Vila do Conde, EPE, Portugal
| | - Lynn M Martire
- Penn State University, University Park, Pennsylvania, USA
| | - Peter O'Sullivan
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Dawn P Richards
- Five02 Labs Inc and the Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Judith A Turner
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Su-Yin Yang
- Tan Tock Seng Hospital, Department of Psychology, Tan Tock Seng Hospital, Singapore
| | - Dokyoung S You
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Maisa Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA.
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Curatolo M, Rundell SD, Gold LS, Suri P, Friedly JL, Nedeljkovic SS, Deyo RA, Turner JA, Bresnahan BW, Avins AL, Kessler L, Heagerty PJ, Jarvik JG. Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults. Eur J Pain 2022; 26:1469-1480. [PMID: 35604636 PMCID: PMC9296573 DOI: 10.1002/ejp.1975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/21/2022] [Accepted: 05/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is limited research on the long-term effectiveness of epidural steroid injections (ESI) in older adults despite the high prevalence of back and leg pain in this age group. We tested the hypotheses that older adults undergoing ESI, compared to patients not receiving ESI: 1) have worse pain, disability and quality of life ("outcomes") pre-ESI, 2) have improved outcomes after ESI, and 3) have improved outcomes due to a specific ESI effect. METHODS We prospectively studied patients ≥65 years old presenting to primary care with new episodes of back pain in three US healthcare systems (BOLD registry). Outcomes were leg and back pain intensity, disability and quality of life, assessed at baseline and 3-, 6-, 12- and 24-month follow-ups. We categorized participants as: 1) ESI within 6 months from the index visit (n=295); 2) no ESI within 6 months (n=4,809); 3) no ESI within 6 months, propensity-score matched to group 1 (n=483). We analyzed the data using linear regression and Generalized Estimating Equations. RESULTS Pain intensity, disability and quality of life at baseline were significantly worse at baseline in ESI patients (group 1) than in group 2. The improvement from baseline to 24 months in all outcomes was statistically significant for group 1. However, no statistically significant differences were observed between outcome trajectories for the propensity-score matched groups 1 and 3. CONCLUSIONS Older adults treated with ESI have long-term improvement. However, the improvement is unlikely the result of a specific ESI effect.
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Affiliation(s)
- M Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - S D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,Department of Neurological Surgery, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - L S Gold
- Department of Radiology, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - P Suri
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - S S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, and Spine Unit, Harvard Vanguard Medical Associates, Boston, MA
| | - R A Deyo
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J A Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - B W Bresnahan
- Department of Radiology, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - A L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - L Kessler
- Department of Health Systems and Population Health, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - P J Heagerty
- Department of Family Medicine, Oregon Health and Science University, Portland, OR.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J G Jarvik
- Department of Radiology, University of Washington, Seattle, WA.,Department of Neurological Surgery, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
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7
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Iraji A, Faghiri A, Fu Z, Kochunov P, Adhikari BM, Belger A, Ford JM, McEwen S, Mathalon DH, Pearlson GD, Potkin SG, Preda A, Turner JA, Van Erp TGM, Chang C, Calhoun VD. Moving beyond the 'CAP' of the Iceberg: Intrinsic connectivity networks in fMRI are continuously engaging and overlapping. Neuroimage 2022; 251:119013. [PMID: 35189361 PMCID: PMC9107614 DOI: 10.1016/j.neuroimage.2022.119013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/05/2022] Open
Abstract
Resting-state functional magnetic resonance imaging is currently the mainstay of functional neuroimaging and has allowed researchers to identify intrinsic connectivity networks (aka functional networks) at different spatial scales. However, little is known about the temporal profiles of these networks and whether it is best to model them as continuous phenomena in both space and time or, rather, as a set of temporally discrete events. Both categories have been supported by series of studies with promising findings. However, a critical question is whether focusing only on time points presumed to contain isolated neural events and disregarding the rest of the data is missing important information, potentially leading to misleading conclusions. In this work, we argue that brain networks identified within the spontaneous blood oxygenation level-dependent (BOLD) signal are not limited to temporally sparse burst moments and that these event present time points (EPTs) contain valuable but incomplete information about the underlying functional patterns. We focus on the default mode and show evidence that is consistent with its continuous presence in the BOLD signal, including during the event absent time points (EATs), i.e., time points that exhibit minimum activity and are the least likely to contain an event. Moreover, our findings suggest that EPTs may not contain all the available information about their corresponding networks. We observe distinct default mode connectivity patterns obtained from all time points (AllTPs), EPTs, and EATs. We show evidence of robust relationships with schizophrenia symptoms that are both common and unique to each of the sets of time points (AllTPs, EPTs, EATs), likely related to transient patterns of connectivity. Together, these findings indicate the importance of leveraging the full temporal data in functional studies, including those using event-detection approaches.
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Affiliation(s)
- A Iraji
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, and Emory University, Atlanta, GA, United States of America.
| | - A Faghiri
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, and Emory University, Atlanta, GA, United States of America
| | - Z Fu
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, and Emory University, Atlanta, GA, United States of America
| | - P Kochunov
- Maryland Psychiatric Research Center, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, United States of America
| | - B M Adhikari
- Maryland Psychiatric Research Center, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, United States of America
| | - A Belger
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States of America
| | - J M Ford
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States of America; San Francisco VA Medical Center, San Francisco, CA, United States of America
| | - S McEwen
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
| | - D H Mathalon
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States of America; San Francisco VA Medical Center, San Francisco, CA, United States of America
| | - G D Pearlson
- Departments of Psychiatry and Neuroscience, Yale University, School of Medicine, New Haven, CT, United States of America
| | - S G Potkin
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine, CA, United States of America
| | - A Preda
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine, CA, United States of America
| | - J A Turner
- Department of Psychology, Georgia State University, Atlanta, GA, United States of America
| | - T G M Van Erp
- Clinical Translational Neuroscience Laboratory, Department of Psychiatry and Human Behavior, University of California Irvine, Irvine, CA, United States of America
| | - C Chang
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States of America
| | - V D Calhoun
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, and Emory University, Atlanta, GA, United States of America.
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8
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Kimmel DB, Vennin S, Desyatova A, Turner JA, Akhter MP, Lappe JM, Recker RR. Bone architecture, bone material properties, and bone turnover in non-osteoporotic post-menopausal women with fragility fracture. Osteoporos Int 2022; 33:1125-1136. [PMID: 35034156 DOI: 10.1007/s00198-022-06308-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/11/2022] [Indexed: 12/19/2022]
Abstract
UNLABELLED Macro- and microarchitectural, bone material property, dynamic histomorphometric, and bone turnover marker data were studied in normal bone mineral density (BMD) post-menopausal women with fragility fracture. Women with fracture had thinner iliac cortices and more homogeneous bone material properties in cortical bone than age/BMD-matched non-fracture women. Low cortical thickness and bone tissue heterogeneity in normal BMD women are associated with prevalent fragility fracture. INTRODUCTION Bone mass (bone mineral density, (BMD)) of the spine and hip is today's best single measurement for evaluating future fragility fracture risk. However, the majority of fragility fractures occur in women with BMD T-score above the WHO osteoporotic BMD threshold of - 2.5, indicating that non-BMD endpoints may play a role in their fragility fractures. We hypothesize that in non-osteoporotic women, bone micoarchitecture, bone material properties, dynamic histomorphometric endpoints, and bone turnover markers are related to fragility fracture. METHODS Two groups (N = 60 each) of post-menopausal women with total hip BMD T-score ranging from + 0.3 to -2.49 were recruited: fragility fracture and age/BMD-matched, non-fragility fracture women. Normal (T-score > - 0.99) and osteopenic (T-score ≤ - 1.0) BMD cohorts were designated within both the fracture and non-fracture groups. Transiliac biopsy specimens were obtained to evaluate dynamic histomorphometric and microarchitectural endpoints and bone material properties by static and dynamic nanoindentation testing. All variables for fracture and non-fracture women within each BMD cohort were compared by the Wilcoxon signed-rank test (P < 0.01). RESULTS Compared to non-fracture/normal BMD women, fracture/normal BMD women display lower iliac cortical thickness (- 12%, P = 0.0041) and lower heterogeneity of hardness (- 27%, P = 0.0068), elastic modulus (- 35%, P = 0.0009), and storage modulus (- 23%, P = 0.0054) in the cortical bone tissue, and lower heterogeneity of hardness (- 13%, P = 0.0088) in the trabecular bone tissue. Osteopenic women had no abnormalities related to fracture status. CONCLUSION Post-menopausal women with normal BMD and fragility fracture have low cortical thickness and heterogeneity of several bone material properties in cortical and trabecular mineralized bone tissue. These differences may explain a portion of the excess bone fragility in women with normal BMD and fragility fracture.
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Affiliation(s)
- D B Kimmel
- Osteoporosis Research Center, Creighton University, Omaha, NE, 68131, USA
- , The Villages, USA
| | - S Vennin
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - A Desyatova
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - J A Turner
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - M P Akhter
- Osteoporosis Research Center, Creighton University, Omaha, NE, 68131, USA
| | - J M Lappe
- Osteoporosis Research Center, Creighton University, Omaha, NE, 68131, USA
| | - R R Recker
- Osteoporosis Research Center, Creighton University, Omaha, NE, 68131, USA
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9
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Eastwood CR, Edwards JP, Turner JA. Review: Anticipating alternative trajectories for responsible Agriculture 4.0 innovation in livestock systems. Animal 2021; 15 Suppl 1:100296. [PMID: 34246598 DOI: 10.1016/j.animal.2021.100296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022] Open
Abstract
Technological change has been a constant feature of livestock systems leading to the third agricultural 'green' revolution of the mid-20th century. Digital technologies are now leading us into the fourth agricultural revolution, where sustainable food production is supported by technologies that collect data useful for farm and supply chain performance improvement, along with task automation and compliance. However, the potential benefits of digital agricultural futures are uncertain and plagued by unrealized expectations of previous innovations. The aims of this paper are to articulate current trends in technology and livestock systems and anticipate future trajectories for Agriculture 4.0 in relation to meeting sustainability and animal welfare outcomes for livestock systems. We use a 'Futures Triangle' approach to review the role of technology in livestock systems. The main findings are that previous work envisioning technological livestock futures have favoured pull of the future factors (techno-optimists) or weight of the past (techno-pessimists), rather than a balance of pull, push and weighting factors. Responsible Agriculture 4.0 innovation requires public-private collaboration of innovation system stakeholders, including policy makers, farmers, consumers, as well as technology developers, to enable development of transition pathways from a systems perspective. The use of responsible innovation processes, including anticipation on alternative futures, should also be built into innovation processes to support critical reflection on technological trajectories and related innovation system consequences, both desirable and undesirable.
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Affiliation(s)
- C R Eastwood
- Feed and Farm Systems Group, DairyNZ Ltd, PO Box 85066, Lincoln University, 7647 Lincoln, New Zealand.
| | - J P Edwards
- Feed and Farm Systems Group, DairyNZ Ltd, PO Box 85066, Lincoln University, 7647 Lincoln, New Zealand
| | - J A Turner
- AgResearch, Ruakura Research Centre, 10 Bisley Road, Hamilton 3214, New Zealand
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10
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Wartko PD, Boudreau DM, Turner JA, Cook AJ, Wellman RD, Fujii MM, Garcia RC, Moser KA, Sullivan MD. STRategies to Improve Pain and Enjoy life (STRIPE): Protocol for a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy. Contemp Clin Trials 2021; 110:106499. [PMID: 34217889 DOI: 10.1016/j.cct.2021.106499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/05/2021] [Accepted: 06/28/2021] [Indexed: 10/21/2022]
Abstract
High-dose, long-term opioid therapy (LtOT) is associated with risk for serious harms. Rapid opioid discontinuation may lead to increased pain, psychological distress, and illicit opioid use, but gradual, supported opioid taper may reduce these risks. We previously demonstrated that an opioid taper support and pain coping skills training intervention reduced opioid dose more than usual care (43% vs 19% dose reduction from baseline), with no increase in pain intensity and a significant reduction in activity interference. We aim to adapt and test this intervention in the Kaiser Permanente Washington healthcare system with STRategies to Improve Pain and Enjoy life (STRIPE), a pragmatic, randomized trial. Our goal was to randomize 215 participants on moderate-high dose (≥40 morphine milligram equivalent/day) LtOT to either cognitive-behavioral therapy-based pain coping skills training involving 18 telephone sessions over 52 weeks with optional opioid taper support or usual care. Data are collected from electronic health records, claims, and self-report. The primary outcomes are mean daily opioid dose and the pain intensity, interference with enjoyment of life, and interference with general activity (PEG) score at 12 months (primary time point) and 6 months (secondary time point). Secondary outcomes include having ≥30% opioid dose reduction from baseline, and patient-reported problem opioid use, opioid-related difficulties, pain self-efficacy, opioid craving, global impression of change, and anxiety and depressive symptoms at 6 and 12 months. If effective, this treatment could reduce opioid exposure and associated risks to patients, families, and communities while offering patients an alternative for managing pain. Trial registration: The study was first registered at Clinicaltrials.gov on November 16, 2018 (identifier: NCT03743402).
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America; Department of Pharmacy, University of Washington, Seattle, WA, United States of America; Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Judith A Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
| | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America; Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Robert D Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Monica M Fujii
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Robin C Garcia
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Kathryn A Moser
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Mark D Sullivan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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11
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Bresnahan BW, Jarvik JG, Meier EN, James KT, Gold LS, Rundell SD, Turner JA, Suri P, Luetmer PH, Friedly JL, Sherman KJ, Heagerty PJ, Kallmes DF, Avins AL, Griffith BD, Kessler LG. Expected Organizational Costs for Inserting Prevalence Information Into Lumbar Spine Imaging Reports. J Am Coll Radiol 2021; 18:1415-1422. [PMID: 34216559 DOI: 10.1016/j.jacr.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written. OBJECTIVES To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial. RESEARCH DESIGN Time and cost estimation associated with implementing the LIRE intervention in a health organization. SUBJECTS Providers and patients assessed in the LIRE trial. MEASURES Expected personnel costs required to implement the LIRE intervention. RESULTS Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost. CONCLUSIONS The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging.
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Affiliation(s)
- Brian W Bresnahan
- Department of Radiology, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington.
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Eric N Meier
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kathryn T James
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Laura S Gold
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Sean D Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Judith A Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | | | - Janna L Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | | | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brent D Griffith
- Diagnostic Radiology, Henry Ford Hospital, Henry Ford Health System, Detroit, Michigan
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington
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12
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Suri P, Meier EN, Gold LS, Marcum ZA, Johnston SK, James KT, Bresnahan BW, O'Reilly M, Turner JA, Kallmes DF, Sherman KJ, Deyo RA, Luetmer PH, Avins AL, Griffith B, Heagerty PJ, Rundell SD, Jarvik JG, Friedly JL. Providing Epidemiological Data in Lumbar Spine Imaging Reports Did Not Affect Subsequent Utilization of Spine Procedures: Secondary Outcomes from a Stepped-Wedge Randomized Controlled Trial. Pain Med 2021; 22:1272-1280. [PMID: 33595635 DOI: 10.1093/pm/pnab065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. DESIGN Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. SETTING Primary care clinics within four integrated health care systems in the United States. SUBJECTS 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. METHODS Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). RESULTS The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93-1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91-1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. CONCLUSIONS Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.
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Affiliation(s)
- Pradeep Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Eric N Meier
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Laura S Gold
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sandra K Johnston
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn T James
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brian W Bresnahan
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael O'Reilly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Judith A Turner
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Richard A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Andrew L Avins
- Division of Research (ALA), Kaiser Permanente Northern California, Oakland, California, USA
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Patrick J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sean D Rundell
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Jarvik
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Janna L Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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13
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Jarvik JG, Meier EN, James KT, Gold LS, Tan KW, Kessler LG, Suri P, Kallmes DF, Cherkin DC, Deyo RA, Sherman KJ, Halabi SS, Comstock BA, Luetmer PH, Avins AL, Rundell SD, Griffith B, Friedly JL, Lavallee DC, Stephens KA, Turner JA, Bresnahan BW, Heagerty PJ. The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2015713. [PMID: 32886121 PMCID: PMC7489827 DOI: 10.1001/jamanetworkopen.2020.15713] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. OBJECTIVE To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. INTERVENTIONS Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). MAIN OUTCOMES AND MEASURES Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. RESULTS We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). CONCLUSIONS AND RELEVANCE In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02015455.
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Affiliation(s)
- Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Eric N. Meier
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | - Kathryn T. James
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Katherine W. Tan
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
- Flatiron Health, New York, New York
| | - Larry G. Kessler
- Department of Health Services, University of Washington, Seattle
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Richard A. Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, Portland
| | | | - Safwan S. Halabi
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | | | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sean D. Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
| | - Janna L. Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | - Kari A. Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Judith A. Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Brian W. Bresnahan
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
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Rundell SD, Patel KV, Krook MA, Heagerty PJ, Suri P, Friedly JL, Turner JA, Deyo RA, Bauer Z, Nerenz DR, Avins AL, Nedeljkovic SS, Jarvik JG. Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain. Pain Med 2020; 20:1898-1906. [PMID: 30615144 DOI: 10.1093/pm/pny270] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To estimate the prevalence of co-occurring pain sites among older adults with persistent back pain and associations of multisite pain with longitudinal outcomes. DESIGN Secondary analysis of a cohort study. SETTING Three integrated health systems in the United States. SUBJECTS Eight hundred ninety-nine older adults with persistent back pain. METHODS Participants reported pain in the following sites: stomach, arms/legs/joints, headaches, neck, pelvis/groin, and widespread pain. Over 18 months, we measured back-related disability (Roland Morris, scored 0-24), pain intensity (11-point numerical rating scale), health-related quality of life (EuroQol-5D [EQ-5D], utility from 0-1), and falls in the past three weeks. We used mixed-effects models to test the association of number and type of pain sites with each outcome. RESULTS Nearly all (N = 839, 93%) respondents reported at least one additional pain site. There were 216 (24%) with one additional site and 623 (69%) with multiple additional sites. The most prevalent comorbid pain site was the arms/legs/joints (N = 801, 89.1%). Adjusted mixed-effects models showed that for every additional pain site, RMDQ worsened by 0.65 points (95% confidence interval [CI] = 0.43 to 0.86), back pain intensity increased by 0.14 points (95% CI = 0.07 to 0.22), EQ-5D worsened by 0.012 points (95% CI = -0.018 to -0.006), and the odds of falling increased by 27% (odds ratio = 1.27, 95% CI = 1.12 to 1.43). Some specific pain sites (extremity pain, widespread pain, and pelvis/groin pain) were associated with greater long-term disability. CONCLUSIONS Multisite pain is common among older adults with persistent back pain. Number of pain sites was associated with all outcomes; individual pain sites were less consistently associated with outcomes.
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Affiliation(s)
- Sean D Rundell
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center.,Department of Health Services
| | | | | | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Pradeep Suri
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center.,VA Puget Sound Health Care System, Seattle, Washington
| | - Janna L Friedly
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Richard A Deyo
- Department of Family Medicine.,Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Zoya Bauer
- Seattle Children's Research Institute, Seattle, Washington
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, and Spine Unit, Harvard Vanguard Medical Associates, Boston, Massachusetts
| | - Jeffrey G Jarvik
- Comparative Effectiveness, Cost, and Outcomes Research Center.,Department of Health Services.,Department of Radiology.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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15
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Lee TL, Sherman KJ, Hawkes RJ, Phelan EA, Turner JA. The Benefits of T'ai Chi for Older Adults with Chronic Back Pain: A Qualitative Study. J Altern Complement Med 2020; 26:456-462. [PMID: 32379976 DOI: 10.1089/acm.2019.0455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To determine the perceived benefits of t'ai chi in older adults with chronic low-back pain (cLBP). Design: A qualitative analysis from a randomized controlled feasibility trial. Subjects: Eighteen participants (65+ years old) with cLBP of at least moderate intensity. Intervention: A 36-week intervention beginning with twice weekly classes for 12 weeks, weekly classes for 6 weeks, biweekly classes for 6 weeks, and monthly classes for 12 weeks. Participants were asked to practice at home on nonclass days and videos were provided to assist in that process. Outcome Measures: Participants in the focus groups were asked to provide feedback on their experiences with the study as well as the benefits of their t'ai chi practice. We used demographic and class attendance data to describe the sample. Results: Regarding the benefits of t'ai chi practice, five major themes were identified: functional benefits, pain reduction/pain relief, psychospiritual benefits, the importance of social support in learning t'ai chi, and the integration of t'ai chi into daily activities. The most common functional benefits were improvements in balance, flexibility, leg strength, and posture. Some reported pain reduction or pain relief, but others did not. Increased relaxation, mindfulness, and a sense of connectedness were subthemes that emerged from psychospiritual benefits. Social support benefits included motivation to attend class and group support while learning a new skill. Finally, improved body awareness allowed participants to integrate t'ai chi skills into their daily activities. Conclusions: This qualitative analysis demonstrates the multifaceted benefits of t'ai chi for older adults living with cLBP.
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Affiliation(s)
- Tamsin L Lee
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Karen J Sherman
- Kaiser Permanente WA Health Research Institute, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rene J Hawkes
- Kaiser Permanente WA Health Research Institute, Seattle, WA, USA
| | - Elizabeth A Phelan
- Department of Medicine and Health Services, University of Washington, Seattle, WA, USA
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.,Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Sherman KJ, Wellman RD, Hawkes RJ, Phelan EA, Lee T, Turner JA. T'ai Chi for Chronic Low Back Pain in Older Adults: A Feasibility Trial. J Altern Complement Med 2020; 26:176-189. [PMID: 32013530 DOI: 10.1089/acm.2019.0438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Design: Feasibility randomized controlled trial. Settings/Location: Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Patients: Adults 65 years of age and older with cLBP. Interventions: Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Outcome Measures: Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Results: Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. Conclusion: The TC intervention is feasible in this population, while the HE group requires modifications in delivery.
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Affiliation(s)
- Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA
| | - Robert D Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Rene J Hawkes
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Elizabeth A Phelan
- Department of Medicine and Health Services, University of Washington, Seattle, WA
| | - Tamsin Lee
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington, Seattle, WA
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17
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Rebmann T, Charney RL, Loux TM, Turner JA, Abbyad YS, Silvestros M. Emergency Medical Services Personnel's Pandemic Influenza Training Received and Willingness to Work during a Future Pandemic. PREHOSP EMERG CARE 2020; 24:601-609. [PMID: 31800338 DOI: 10.1080/10903127.2019.1701158] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Identify determinants of emergency medical service (EMS) personnel's willingness to work during an influenza pandemic. Background: Little is known about the willingness of EMS personnel to work during a future influenza pandemic or the extent to which they are receiving pandemic training. Methods: EMS personnel were surveyed in July 2018 - Feb 2019 using a cross-sectional approach; the survey was available both electronically and on paper. Participants were provided a pandemic scenario and asked about their willingness to respond if requested or required; additional questions assessed their attitudes and beliefs and training received. Chi-square tests assessed differences in attitude/belief questions by willingness to work. Logistic regressions were used to identify significant predictors of response willingness when requested or required, controlling for gender and race. Results: 433 individuals completed the survey (response rate = 82.9%). A quarter (26.8%, n = 116) received no pandemic training; 14.3% (n = 62) participated in a pandemic exercise. Significantly more EMS personnel were willing to work when required versus when only requested (88.2% vs 76.9%, X2 = 164.1, p < .001). Predictors of willingness to work when requested included believing it is their responsibility to work, believing their coworkers were likely to work, receiving prophylaxis for themselves and their family members, and feeling safe working during a pandemic. Discussion: Many emergency medical services personnel report lacking training or disaster exercises related to influenza pandemics, and a fair percentage are unwilling to work during a future event. This may limit healthcare surge capacity and could contribute to increased morbidity and mortality. Findings from this study indicate that prehospital staff's attitudes and beliefs about pandemics influence their willingness to work. Pre-event training and planning should address these concerns.
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18
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Rokidi S, Paschalis EP, Klaushofer K, Vennin S, Desyatova A, Turner JA, Watson P, Lappe J, Akhter MP, Recker RR. Organic matrix quality discriminates between age- and BMD-matched fracturing versus non-fracturing post-menopausal women: A pilot study. Bone 2019; 127:207-214. [PMID: 31229674 DOI: 10.1016/j.bone.2019.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/16/2019] [Accepted: 06/20/2019] [Indexed: 12/29/2022]
Abstract
Women with similar areal Bone Mineral Densities (BMD) may show divergent fracture incidence due to differences in bone quality. The hypothesis tested in the present pilot study is that postmenopausal (PM) women who have sustained osteoporotic fractures have altered organic matrix quality compared to those who have not. We used Raman microspectroscopy to analyze transiliac biopsies collected from fracturing (n = 6, mean age 62.5 ± 7.4 yrs; Cases) and non-fracturing PM women (n = 6, age- and BMD-matched; mean age 62.2 ± 7.3 yrs; Controls). Previous results show differences in intrinsic material properties by nanoindentation that are more homogenously distributed and could facilitate microcrack propagation in Cases, along with lower mineral carbonate/phosphate ratio by Fourier transform infrared spectroscopic imaging, and no differences in bone tissue mineralization by digitized microradiography. No differences between groups were seen by conventional histomorphometry. Spectra were acquired 2 μm away from previously performed nanoindents, in cortical and cancellous compartments. The determined parameters were: mineral to matrix ratio (MM), and nanoporosity (a surrogate for tissue water (TW)), glycosaminoglycan (GAG), pyridinoline (Pyd; trivalent enzymatic collagen cross-link), N(6)-carboxymethyllysine (CML; advanced glycation endproduct), and pentosidine (PEN; advanced glycation endproduct) content. ANCOVA indicated no differences in any of the spectroscopic outcomes between cancellous and cortical compartments. On the other hand, Cases had lower nanoporosity (TW) and GAG, and elevated Pyd, and CML content compared to Controls. In conclusion, the results of the present study indicate significant differences in organic matrix quality in PM women that sustain fragility fractures versus age- and BMD-matched controls, highlighting its importance as a potential independent determinant of fracture incidence.
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Affiliation(s)
- S Rokidi
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Heinrich Collin Str. 30, A-1140 Vienna Austria
| | - E P Paschalis
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Heinrich Collin Str. 30, A-1140 Vienna Austria.
| | - K Klaushofer
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Heinrich Collin Str. 30, A-1140 Vienna Austria
| | - S Vennin
- Iniversity of Nebraska-Lincoln, NE, USA
| | | | | | - P Watson
- Osteoporosis Research Center, Creighton University, Omaha, NE, USA
| | - J Lappe
- Osteoporosis Research Center, Creighton University, Omaha, NE, USA
| | - M P Akhter
- Osteoporosis Research Center, Creighton University, Omaha, NE, USA
| | - R R Recker
- Osteoporosis Research Center, Creighton University, Omaha, NE, USA
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19
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Kleider-Offutt HM, Grant A, Turner JA. Common cortical areas involved in both auditory and visual imageries for novel stimuli. Exp Brain Res 2019; 237:1279-1287. [PMID: 30859240 DOI: 10.1007/s00221-019-05492-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 11/25/2022]
Abstract
We examine cross-modality commonalities in visual and auditory imageries during fMRI scanning in a sample of healthy young adults. In a visual task combining viewed and imagined stimuli, 28 participants were asked to imagine novel scenes related to the other images, and in a similar auditory task combining heard and imagined stimuli, to imagine novel sentences spoken by individuals they had heard speaking previously. We identified a common set of regions in medial and lateral Brodmann area 6, as well as inferior frontal gyrus (BA 44/45), partially supporting previous meta-analytic results. Comparing individuals with high or low reported imagery ability, we replicated a previous result showing individuals with lower visual imagery ability showed greater activation in the cerebellum, frontal and dorsolateral prefrontal cortex, while there was no relationship with auditory imagery ability in this sample. The emphasis on imagining novel stimuli, rather than familiar or previously experienced stimuli, confirms the role of the supramodal imagery network underlying creative imagery.
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Affiliation(s)
- H M Kleider-Offutt
- Department of Psychology and The Neuroscience Institute, Georgia State University, P.O. Box 5010, Atlanta, GA, 30302, USA
| | - A Grant
- Department of Psychology and The Neuroscience Institute, Georgia State University, P.O. Box 5010, Atlanta, GA, 30302, USA
| | - J A Turner
- Department of Psychology and The Neuroscience Institute, Georgia State University, P.O. Box 5010, Atlanta, GA, 30302, USA.
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20
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Ferri J, Ford JM, Roach BJ, Turner JA, van Erp TG, Voyvodic J, Preda A, Belger A, Bustillo J, O'Leary D, Mueller BA, Lim KO, McEwen SC, Calhoun VD, Diaz M, Glover G, Greve D, Wible CG, Vaidya JG, Potkin SG, Mathalon DH. Resting-state thalamic dysconnectivity in schizophrenia and relationships with symptoms. Psychol Med 2018; 48:2492-2499. [PMID: 29444726 DOI: 10.1017/s003329171800003x] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Schizophrenia (SZ) is a severe neuropsychiatric disorder associated with disrupted connectivity within the thalamic-cortico-cerebellar network. Resting-state functional connectivity studies have reported thalamic hypoconnectivity with the cerebellum and prefrontal cortex as well as thalamic hyperconnectivity with sensory cortical regions in SZ patients compared with healthy comparison participants (HCs). However, fundamental questions remain regarding the clinical significance of these connectivity abnormalities. METHOD Resting state seed-based functional connectivity was used to investigate thalamus to whole brain connectivity using multi-site data including 183 SZ patients and 178 matched HCs. Statistical significance was based on a voxel-level FWE-corrected height threshold of p < 0.001. The relationships between positive and negative symptoms of SZ and regions of the brain demonstrating group differences in thalamic connectivity were examined. RESULTS HC and SZ participants both demonstrated widespread positive connectivity between the thalamus and cortical regions. Compared with HCs, SZ patients had reduced thalamic connectivity with bilateral cerebellum and anterior cingulate cortex. In contrast, SZ patients had greater thalamic connectivity with multiple sensory-motor regions, including bilateral pre- and post-central gyrus, middle/inferior occipital gyrus, and middle/superior temporal gyrus. Thalamus to middle temporal gyrus connectivity was positively correlated with hallucinations and delusions, while thalamus to cerebellar connectivity was negatively correlated with delusions and bizarre behavior. CONCLUSIONS Thalamic hyperconnectivity with sensory regions and hypoconnectivity with cerebellar regions in combination with their relationship to clinical features of SZ suggest that thalamic dysconnectivity may be a core neurobiological feature of SZ that underpins positive symptoms.
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Affiliation(s)
- J Ferri
- Department of Psychiatry,University of California,San Francisco, San Francisco, CA,USA
| | - J M Ford
- Department of Psychiatry,University of California,San Francisco, San Francisco, CA,USA
| | - B J Roach
- San Francisco VA Health Care System,San Francisco, CA,USA
| | - J A Turner
- The Mind Research Network,Albuquerque, NM,USA
| | - T G van Erp
- Department of Psychiatry and Human Behavior,University of California,Irvine, Irvine, CA,USA
| | - J Voyvodic
- Department of Psychiatry,Duke University,Raleigh-Durham, NC,USA
| | - A Preda
- Department of Psychiatry and Human Behavior,University of California,Irvine, Irvine, CA,USA
| | - A Belger
- Department of Psychiatry,University of North Carolina,Chapel Hill, NC,USA
| | - J Bustillo
- Department of Psychiatry,University of New Mexico,Albuquerque, NM,USA
| | - D O'Leary
- Department of Psychiatry,University of Iowa,Iowa City, IA,USA
| | - B A Mueller
- Department of Psychiatry,University of Minnesota,Minneapolis, MN,USA
| | - K O Lim
- Department of Psychiatry,University of Minnesota,Minneapolis, MN,USA
| | - S C McEwen
- Department of Psychiatry,University of California,Los Angeles, Los Angeles, CA,USA
| | - V D Calhoun
- The Mind Research Network,Albuquerque, NM,USA
| | - M Diaz
- Department of Psychiatry,Duke University,Raleigh-Durham, NC,USA
| | - G Glover
- Department of Radiology,Stanford University,Stanford, CA,USA
| | - D Greve
- Department of Radiology,Massachusetts General Hospital,Boston, MA,USA
| | - C G Wible
- Department of Psychiatry,Harvard University,Boston, MA,USA
| | - J G Vaidya
- Department of Psychiatry,University of Iowa,Iowa City, IA,USA
| | - S G Potkin
- Department of Psychiatry and Human Behavior,University of California,Irvine, Irvine, CA,USA
| | - D H Mathalon
- Department of Psychiatry,University of California,San Francisco, San Francisco, CA,USA
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21
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Jarvik JG, Gold LS, Tan K, Friedly JL, Nedeljkovic SS, Comstock BA, Deyo RA, Turner JA, Bresnahan BW, Rundell SD, James KT, Nerenz DR, Avins AL, Bauer Z, Kessler L, Heagerty PJ. Long-term outcomes of a large, prospective observational cohort of older adults with back pain. Spine J 2018; 18:1540-1551. [PMID: 29391206 DOI: 10.1016/j.spinee.2018.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/25/2017] [Accepted: 01/19/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although back pain is common among older adults, there is relatively little research on the course of back pain in this age group. PURPOSE Our primary goals were to report 2-year outcomes of older adults initiating primary care for back pain and to examine the relative importance of patient factors versus medical interventions in predicting 2-year disability and pain. STUDY DESIGN/SETTING This study used a predictive model using data from a prospective, observational cohort from a primary care setting. PATIENT SAMPLE The study included patients aged ≥65 years at the time of new primary care visits for back pain. OUTCOME MEASURES Self-reported 2-year disability (Roland-Morris Disability Questionnaire [RDQ]) and back pain (0-10 numerical rating scale [NRS]). METHODS We developed our models using a machine learning least absolute shrinkage and selection operator approach. We evaluated the predictive value of baseline characteristics and the incremental value of interventions that occurred between 0 and 90 days, and the change in patient disability and pain from 0 to 90 days. Limitations included confounding by indication and unmeasured confounding. RESULTS Of 4,665 patients (89%) with follow-up, both RDQ (from mean 9.6 [95% confidence interval {CI} 9.4-9.7] to mean 8.3 [95% CI 8.0-8.5]) and back pain NRS (from mean 5.0 [95% CI 4.9-5.1] to mean 3.5 [95% CI 3.4-3.6]) scores improved slightly. Only 16% (15%-18%) reported no back pain-related disability or back pain at 2 years after initial visits. Regression model parameters explained 40% of the variation (R2) in 2-year RDQ scores, and the addition of 0- to 3-month change in RDQ score and pain improved prediction (R2=51%). The most consistent predictors of 2-year RDQ scores and back pain NRS scores were 0- to 90-day change in each respective outcome and patient confidence in improvement. Patients experienced 50% and 43% improvement in back pain and disability, respectively, 2 years after their initial visit. However, fewer than 20% of patients had complete resolution of their back pain and disability at that time. CONCLUSIONS Baseline patient factors were more important than early interventions in explaining disability and pain after 2 years.
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Affiliation(s)
- Jeffrey G Jarvik
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Department of Neurological Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA.
| | - Laura S Gold
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Katherine Tan
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Janna L Friedly
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Spine Unit, Harvard Vanguard Medical Associates, 75 Francis St, Boston, MA, 02115, USA
| | - Bryan A Comstock
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Richard A Deyo
- Department of Family Medicine, Department of Internal Medicine, Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, 3303 SW Bond Ave, Portland, OR, 97239, USA
| | - Judith A Turner
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Pharmacy, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Sean D Rundell
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Kathryn T James
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Andrew L Avins
- Division of Research, Northern California Kaiser-Permanente, 2000 Broadway, Oakland, CA, 94612, USA
| | - Zoya Bauer
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Larry Kessler
- Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Patrick J Heagerty
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
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22
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Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 391:2368-2383. [PMID: 29573872 DOI: 10.1016/s0140-6736(18)30489-6] [Citation(s) in RCA: 1151] [Impact Index Per Article: 191.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 07/18/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022]
Abstract
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Johannes R Anema
- Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
| | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Paulo H Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Bart W Koes
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wilco Peul
- Department of Neurosurgery, Leiden University, Leiden, Netherlands
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, NSW, Australia
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23
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Fu Z, Tu Y, Di X, Du Y, Pearlson GD, Turner JA, Biswal BB, Zhang Z, Calhoun VD. Characterizing dynamic amplitude of low-frequency fluctuation and its relationship with dynamic functional connectivity: An application to schizophrenia. Neuroimage 2017; 180:619-631. [PMID: 28939432 DOI: 10.1016/j.neuroimage.2017.09.035] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/05/2017] [Accepted: 09/18/2017] [Indexed: 12/23/2022] Open
Abstract
The human brain is a highly dynamic system with non-stationary neural activity and rapidly-changing neural interaction. Resting-state dynamic functional connectivity (dFC) has been widely studied during recent years, and the emerging aberrant dFC patterns have been identified as important features of many mental disorders such as schizophrenia (SZ). However, only focusing on the time-varying patterns in FC is not enough, since the local neural activity itself (in contrast to the inter-connectivity) is also found to be highly fluctuating from research using high-temporal-resolution imaging techniques. Exploring the time-varying patterns in brain activity and their relationships with time-varying brain connectivity is important for advancing our understanding of the co-evolutionary property of brain network and the underlying mechanism of brain dynamics. In this study, we introduced a framework for characterizing time-varying brain activity and exploring its associations with time-varying brain connectivity, and applied this framework to a resting-state fMRI dataset including 151 SZ patients and 163 age- and gender matched healthy controls (HCs). In this framework, 48 brain regions were first identified as intrinsic connectivity networks (ICNs) using group independent component analysis (GICA). A sliding window approach was then adopted for the estimation of dynamic amplitude of low-frequency fluctuation (dALFF) and dFC, which were used to measure time-varying brain activity and time-varying brain connectivity respectively. The dALFF was further clustered into six reoccurring states by the k-means clustering method and the group difference in occurrences of dALFF states was explored. Lastly, correlation coefficients between dALFF and dFC were calculated and the group difference in these dALFF-dFC correlations was explored. Our results suggested that 1) ALFF of brain regions was highly fluctuating during the resting-state and such dynamic patterns are altered in SZ, 2) dALFF and dFC were correlated in time and their correlations are altered in SZ. The overall results support and expand prior work on abnormalities of brain activity, static FC (sFC) and dFC in SZ, and provide new evidence on aberrant time-varying brain activity and its associations with brain connectivity in SZ, which might underscore the disrupted brain cognitive functions in this mental disorder.
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Affiliation(s)
- Zening Fu
- The Mind Research Network, Albuquerque, NM, USA; School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China.
| | - Yiheng Tu
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
| | - Xin Di
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, USA
| | - Yuhui Du
- The Mind Research Network, Albuquerque, NM, USA
| | - G D Pearlson
- Olin Neuropsychiatry Research Center, The Institute of Living, Hartford, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - J A Turner
- Department of Psychology, Georgia State University, GA, USA
| | - Bharat B Biswal
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, USA
| | - Zhiguo Zhang
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
| | - V D Calhoun
- The Mind Research Network, Albuquerque, NM, USA; Department of Electrical and Computer Engineering, University of New Mexico, Albuquerque, NM, USA
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Hainline B, Turner JA, Caneiro JP, Stewart M, Lorimer Moseley G. Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Med 2017; 51:1259-1264. [PMID: 28827315 DOI: 10.1136/bjsports-2017-097890] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/10/2017] [Accepted: 06/26/2017] [Indexed: 11/04/2022]
Abstract
Pain is a common problem among elite athletes and is frequently associated with sport injury. Both injury and pain interfere with peak performance. Pain management should be based on the physiological, anatomical and psychosocial influences on the individual's pain and is not equivalent to injury management, which focuses on musculoskeletal recovery and return-to-play. This narrative review provides a foundation for understanding the differing causes and types of pain in elite athletes, thereby serving as a springboard for comprehensive pain management.
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Affiliation(s)
- Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
| | - Judith A Turner
- University of Washington School of Medicine, Seattle, Washington, DC, USA
| | - J P Caneiro
- School of Physiotherapy and Exercise Science, Curtin University, Curtin, Western Australia
| | - Mike Stewart
- East Kent Hospitals University NHS Foundation Trust, Canterbury, Great Britain
| | - G Lorimer Moseley
- Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia
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25
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Hainline B, Derman W, Vernec A, Budgett R, Deie M, Dvořák J, Harle C, Herring SA, McNamee M, Meeuwisse W, Lorimer Moseley G, Omololu B, Orchard J, Pipe A, Pluim BM, Ræder J, Siebert C, Stewart M, Stuart M, Turner JA, Ware M, Zideman D, Engebretsen L. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med 2017; 51:1245-1258. [DOI: 10.1136/bjsports-2017-097884] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/10/2017] [Accepted: 06/26/2017] [Indexed: 12/18/2022]
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26
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Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Bauer Z, Avins AL, Nedeljkovic SS, Nerenz DR, Shi X(R, Annaswamy T, Standaert CJ, Smuck M, Kennedy DJ, Akuthota V, Sibell D, Wasan AD, Diehn F, Suri P, Rundell SD, Kessler L, Chen AS, Jarvik JG. Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Arch Phys Med Rehabil 2017; 98:1499-1507.e2. [DOI: 10.1016/j.apmr.2017.02.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 11/15/2022]
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27
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Vennin S, Desyatova A, Turner JA, Watson PA, Lappe JM, Recker RR, Akhter MP. Intrinsic material property differences in bone tissue from patients suffering low-trauma osteoporotic fractures, compared to matched non-fracturing women. Bone 2017; 97:233-242. [PMID: 28132909 PMCID: PMC5367951 DOI: 10.1016/j.bone.2017.01.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 01/10/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
Osteoporotic (low-trauma) fractures are a significant public health problem. Over 50% of women over 50yrs. of age will suffer an osteoporotic fracture in their remaining lifetimes. While current therapies reduce skeletal fracture risk by maintaining or increasing bone density, additional information is needed that includes the intrinsic material strength properties of bone tissue to help develop better treatments, since measurements of bone density account for no more than ~50% of fracture risk. The hypothesis tested here is that postmenopausal women who have sustained osteoporotic fractures have reduced bone quality, as indicated with measures of intrinsic material properties compared to those who have not fractured. Transiliac biopsies (N=120) were collected from fracturing (N=60, Cases) and non-fracturing postmenopausal women (N=60, age- and BMD-matched Controls) to measure intrinsic material properties using the nano-indentation technique. Each biopsy specimen was embedded in epoxy resin and then ground, polished and used for the nano-indentation testing. After calibration, multiple indentations were made using quasi-static (hardness, modulus) and dynamic (storage and loss moduli) testing protocols. Multiple indentations allowed the median and variance to be computed for each type of measurement for each specimen. Cases were found to have significantly lower median values for cortical hardness and indentation modulus. In addition, cases showed significantly less within-specimen variability in cortical modulus, cortical hardness, cortical storage modulus and trabecular hardness, and more within-specimen variability in trabecular loss modulus. Multivariate modeling indicated the presence of significant independent mechanical effects of cortical loss modulus, along with variability of cortical storage modulus, cortical loss modulus, and trabecular hardness. These results suggest mechanical heterogeneity of bone tissue may contribute to fracture resistance. Although the magnitudes of differences in the intrinsic properties were not overwhelming, this is the first comprehensive study to investigate, and compare the intrinsic properties of bone tissue in fracturing and non-fracturing postmenopausal women.
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Affiliation(s)
- S Vennin
- University of Nebraska-Lincoln, NE, United States
| | - A Desyatova
- University of Nebraska-Lincoln, NE, United States
| | - J A Turner
- University of Nebraska-Lincoln, NE, United States
| | - P A Watson
- Osteoporosis Research Center, Creighton University, Omaha, NE, United States
| | - J M Lappe
- Osteoporosis Research Center, Creighton University, Omaha, NE, United States
| | - R R Recker
- Osteoporosis Research Center, Creighton University, Omaha, NE, United States
| | - M P Akhter
- Osteoporosis Research Center, Creighton University, Omaha, NE, United States.
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28
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McGorum BC, Symonds HW, Knottenbelt C, Cave TA, MacDonald SJ, Stratton J, Leon I, Turner JA, Pirie RS. Alterations in amino acid status in cats with feline dysautonomia. PLoS One 2017; 12:e0174346. [PMID: 28333983 PMCID: PMC5363954 DOI: 10.1371/journal.pone.0174346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/07/2017] [Indexed: 12/11/2022] Open
Abstract
Feline dysautonomia (FD) is a multiple system neuropathy of unknown aetiology. An apparently identical disease occurs in horses (equine grass sickness, EGS), dogs, rabbits, hares, sheep, alpacas and llamas. Horses with acute EGS have a marked reduction in plasma concentrations of the sulphur amino acids (SAA) cyst(e)ine and methionine, which may reflect exposure to a neurotoxic xenobiotic. The aim of this study was to determine whether FD cats have alterations in amino acid profiles similar to those of EGS horses. Amino acids were quantified in plasma/serum from 14 FD cats, 5 healthy in-contact cats which shared housing and diet with the FD cats, and 6 healthy control cats which were housed separately from FD cats and which received a different diet. The adequacy of amino acids in the cats’ diet was assessed by determining the amino acid content of tinned and dry pelleted foods collected immediately after occurrences of FD. Compared with controls, FD cats had increased concentrations of many essential amino acids, with the exception of methionine which was significantly reduced, and reductions in most non-essential amino acids. In-contact cats also had inadequate methionine status. Artefactual loss of cysteine during analysis precluded assessment of the cyst(e)ine status. Food analysis indicated that the low methionine status was unlikely to be attributable to dietary inadequacy of methionine or cystine. Multi-mycotoxin screening identified low concentrations of several mycotoxins in dry food from all 3 premises. While this indicates fungal contamination of the food, none of these mycotoxins appears to induce the specific clinico-pathologic features which characterise FD and equivalent multiple system neuropathies in other species. Instead, we hypothesise that ingestion of another, as yet unidentified, dietary neurotoxic mycotoxin or xenobiotic, may cause both the characteristic disease pathology and the plasma SAA depletion.
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Affiliation(s)
- Bruce C. McGorum
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Roslin, Midlothian, United Kingdom
- * E-mail:
| | | | - Clare Knottenbelt
- School of Veterinary Medicine, University of Glasgow, Glasgow, Strathclyde, United Kingdom
| | - Tom A. Cave
- Cave Vet Specialists, Wellington, Somerset, United Kingdom
| | | | | | - Irene Leon
- Fera Science Limited, Sand Hutton, York, United Kingdom
| | | | - R. Scott Pirie
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Roslin, Midlothian, United Kingdom
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29
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Von Korff M, Shortreed SM, LeResche L, Saunders K, Thielke S, Thakral M, Rosenberg D, Turner JA. A longitudinal study of depression among middle-aged and senior patients initiating chronic opioid therapy. J Affect Disord 2017; 211:136-143. [PMID: 28113120 DOI: 10.1016/j.jad.2016.12.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/23/2016] [Accepted: 12/31/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved understanding how depressive symptoms change with sustained opioid use is needed. METHODS We prospectively assessed patients 45 years or older initiating chronic opioid therapy (COT) at baseline and at 4 and 12 months, differentiating recent COT initiators (n=748) and continuing users (n=468). Level of opioid use before 12-month follow-up was classified as regular/higher-dose, intermittent/lower-dose, or minimal/no use. Depressive symptoms were assessed using the Patient Health Questionnaire-8 (PHQ-8). RESULTS Depressive symptoms decreased, on average, from baseline to 12 months regardless of level of opioid use. COT patients with regular/higher-dose compared to those with intermittent/lower-dose opioid use (who had similar pain outcomes) did not differ in PHQ-8 scores at 12 months (adjusted mean difference -0.14, 95% CI, -1.07, 0.78 for COT initiators). At 12 months, COT patients with intermittent/lower-dose use had higher adjusted PHQ-8 scores than did those with minimal/no opioid use (adjusted mean difference 0.77, 95% CI, 0.03-1.52 for COT initiators). However, 77% of patients who discontinued opioids cited improved pain as a reason for discontinuation, while 21% cited negative emotional effects of opioids as a reason for discontinuation. Discontinuation was more common among persons who, at baseline, attributed 3 or more depressive symptoms to opioid use. LIMITATIONS Results are relevant to older COT patients receiving low to moderate opioid doses. CONCLUSIONS Depressive symptoms did not increase with sustained opioid use. Depressive symptoms were not higher with regular/higher-dose compared to intermittent/lower-dose use. Persons who perceived negative effects of opioids on emotions more often discontinued their use.
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Affiliation(s)
| | - Susan M Shortreed
- Group Health Research Institute, Seattle, WA, USA; Department of Biostatistics, University of Washington, USA
| | - Linda LeResche
- Department of Oral Medicine, University of Washington, Seattle, WA, USA
| | | | - Stephen Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA; Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, WA, USA
| | - Manu Thakral
- Group Health Research Institute, Seattle, WA, USA
| | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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30
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Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA 2017; 317:642-644. [PMID: 28196244 DOI: 10.1001/jama.2016.17814] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | | | | | - Andrea J Cook
- Group Health Research Institute, Seattle, Washington
| | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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31
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Sullivan MD, Turner JA, DiLodovico C, D'Appollonio A, Stephens K, Chan YF. Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial. J Pain 2016; 18:308-318. [PMID: 27908840 DOI: 10.1016/j.jpain.2016.11.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/18/2016] [Accepted: 11/02/2016] [Indexed: 11/19/2022]
Abstract
Patients receiving long-term opioid therapy for chronic pain and interested in tapering their opioid dose were randomly assigned to a 22-week taper support intervention (psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills) or usual care (N = 35). Assessments were conducted at baseline and 22 and 34 weeks after randomization. Using an intention to treat approach, we constructed linear regression models to compare groups at each follow-up. At 22 weeks, adjusted mean daily morphine-equivalent opioid dose in the past week (primary outcome) was lower in the taper support group, but this difference was not statistically significant (adjusted mean difference = -42.9 mg; 95% confidence interval, -92.42 to 6.62; P = .09). Pain severity ratings (0-10 numeric rating scale) decreased in both groups at 22 weeks, with no significant difference between groups (adjusted mean difference = -.68; 95% confidence interval, -2.01 to .64; P = .30). The taper support group improved significantly more than the usual care group in self-reported pain interference, pain self-efficacy, and prescription opioid problems at 22 weeks (all P-values < .05). This taper support intervention is feasible and shows promise in reducing opioid dose while not increasing pain severity or interference. PERSPECTIVE In a pilot randomized trial comparing a prescription opioid taper support intervention to usual care, lower opioid doses and pain severity ratings were observed at 22 weeks in both groups. The groups did not differ significantly at 22 weeks in opioid dose or pain severity, but the taper support group improved significantly more in pain interference, pain self-efficacy, and perceived opioid problems. These results support the feasibility and promise of this opioid taper support intervention.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Cory DiLodovico
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Angela D'Appollonio
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Kari Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Ya-Fen Chan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
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32
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Okada N, Fukunaga M, Yamashita F, Koshiyama D, Yamamori H, Ohi K, Yasuda Y, Fujimoto M, Watanabe Y, Yahata N, Nemoto K, Hibar DP, van Erp TGM, Fujino H, Isobe M, Isomura S, Natsubori T, Narita H, Hashimoto N, Miyata J, Koike S, Takahashi T, Yamasue H, Matsuo K, Onitsuka T, Iidaka T, Kawasaki Y, Yoshimura R, Watanabe Y, Suzuki M, Turner JA, Takeda M, Thompson PM, Ozaki N, Kasai K, Hashimoto R. Abnormal asymmetries in subcortical brain volume in schizophrenia. Mol Psychiatry 2016; 21:1460-6. [PMID: 26782053 PMCID: PMC5030462 DOI: 10.1038/mp.2015.209] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/06/2015] [Accepted: 11/13/2015] [Indexed: 12/31/2022]
Abstract
Subcortical structures, which include the basal ganglia and parts of the limbic system, have key roles in learning, motor control and emotion, but also contribute to higher-order executive functions. Prior studies have reported volumetric alterations in subcortical regions in schizophrenia. Reported results have sometimes been heterogeneous, and few large-scale investigations have been conducted. Moreover, few large-scale studies have assessed asymmetries of subcortical volumes in schizophrenia. Here, as a work completely independent of a study performed by the ENIGMA consortium, we conducted a large-scale multisite study of subcortical volumetric differences between patients with schizophrenia and controls. We also explored the laterality of subcortical regions to identify characteristic similarities and differences between them. T1-weighted images from 1680 healthy individuals and 884 patients with schizophrenia, obtained with 15 imaging protocols at 11 sites, were processed with FreeSurfer. Group differences were calculated for each protocol and meta-analyzed. Compared with controls, patients with schizophrenia demonstrated smaller bilateral hippocampus, amygdala, thalamus and accumbens volumes as well as intracranial volume, but larger bilateral caudate, putamen, pallidum and lateral ventricle volumes. We replicated the rank order of effect sizes for subcortical volumetric changes in schizophrenia reported by the ENIGMA consortium. Further, we revealed leftward asymmetry for thalamus, lateral ventricle, caudate and putamen volumes, and rightward asymmetry for amygdala and hippocampal volumes in both controls and patients with schizophrenia. Also, we demonstrated a schizophrenia-specific leftward asymmetry for pallidum volume. These findings suggest the possibility of aberrant laterality in neural pathways and connectivity patterns related to the pallidum in schizophrenia.
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Affiliation(s)
- N Okada
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - M Fukunaga
- Division of Cerebral Integration, National Institute for Physiological Sciences, Aichi, Japan
| | - F Yamashita
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - D Koshiyama
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Yamamori
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - K Ohi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Y Yasuda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - M Fujimoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Y Watanabe
- Department of Radiology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - N Yahata
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Molecular Imaging Center, National Institute of Radiological Sciences, Chiba, Japan
| | - K Nemoto
- Department of Neuropsychiatry, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - D P Hibar
- Imaging Genetics Center, University of Southern California, Marina del Rey, CA, USA
| | - T G M van Erp
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - H Fujino
- Graduate School of Human Sciences, Osaka University, Osaka, Japan
| | - M Isobe
- Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - S Isomura
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Natsubori
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Narita
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - N Hashimoto
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - J Miyata
- Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - S Koike
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Office for Mental Health Support, Division for Counseling and Support, The University of Tokyo, Tokyo, Japan
| | - T Takahashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - H Yamasue
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - K Matsuo
- Division of Neuropsychiatry, Department of Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - T Onitsuka
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Iidaka
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Y Kawasaki
- Department of Neuropsychiatry, Kanazawa Medical University, Ishikawa, Japan
| | - R Yoshimura
- Department of Psychiatry, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Y Watanabe
- Division of Neuropsychiatry, Department of Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - M Suzuki
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - J A Turner
- Department of Psychology, Georgia State University, Atlanta, GA, USA
- Department of Neuroscience, Georgia State University, Atlanta, GA, USA
| | - M Takeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - P M Thompson
- Imaging Genetics Center, University of Southern California, Marina del Rey, CA, USA
| | - N Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - K Kasai
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - R Hashimoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
- Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, Osaka, Japan
| | - COCORO
- Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Cerebral Integration, National Institute for Physiological Sciences, Aichi, Japan
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Radiology, Osaka University Graduate School of Medicine, Osaka, Japan
- Molecular Imaging Center, National Institute of Radiological Sciences, Chiba, Japan
- Department of Neuropsychiatry, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Imaging Genetics Center, University of Southern California, Marina del Rey, CA, USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
- Graduate School of Human Sciences, Osaka University, Osaka, Japan
- Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
- Office for Mental Health Support, Division for Counseling and Support, The University of Tokyo, Tokyo, Japan
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
- Division of Neuropsychiatry, Department of Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Aichi, Japan
- Department of Neuropsychiatry, Kanazawa Medical University, Ishikawa, Japan
- Department of Psychiatry, University of Occupational and Environmental Health, Fukuoka, Japan
- Department of Psychology, Georgia State University, Atlanta, GA, USA
- Department of Neuroscience, Georgia State University, Atlanta, GA, USA
- Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, Osaka, Japan
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Affiliation(s)
| | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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34
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Nimmo DR, Herrmann SJ, Carsella JS, McGarvy CM, Foutz HP, Herrmann-Hoesing LM, Gregorich JM, Turner JA, Vanden Heuvel BD. Mercury and selenium in fish of Fountain Creek, Colorado (USA): possible sources and implications. Springerplus 2016; 5:437. [PMID: 27104125 PMCID: PMC4828357 DOI: 10.1186/s40064-016-2088-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 03/31/2016] [Indexed: 11/10/2022]
Abstract
Fountain Creek in Colorado USA is a major tributary that confluences with the Arkansas River at Pueblo, Colorado, the result being the tributary’s influence on Arkansas River water quality affecting down-stream users. In a previous study, we found that bryophytes (aquatic plants) accumulated selenium in Fountain Creek watershed and this finding prompted us to investigate the extent of the metalloid in the whole-body tissues of fish. One hundred 11 fish (six species) were collected and analyzed for Se by inductively-coupled plasma emission mass spectrometry. Analysis of all analytical data also showed mercury in all of the fish whole bodies and selected tissues. There was a general increase in selenium but a decrease in mercury in fish with downstream travel-distance. The highest whole-body selenium was in Pueblo, Colorado (3393 µg/kg, dry weight; 906 µg/kg, wet weight); the highest mercury in fish was in the Monument Creek tributary north of Colorado Springs, Colorado (71 µg/kg, dry weight; 19 µg/kg, wet weight). In four tissues of 11 female fish captured, selenium was highest in the livers at eight sites but highest in the ovaries at three sites. Mercury was highest in the epaxial muscle at all sites. Selenium availability could be due to the watershed lithology and land uses; however, mercury could be carried by atmospheric deposition from coal-fired power plants and historic mining activities. Selenium in fish tissues and water samples were compared to U.S. national water quality criteria.
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Affiliation(s)
- D R Nimmo
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - S J Herrmann
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - J S Carsella
- Department of Chemistry, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - C M McGarvy
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - H P Foutz
- Division of Colorado Parks and Wildlife, 6060 Broadway, Denver, CO USA
| | - L M Herrmann-Hoesing
- Department of Veterinary Microbiology and Pathology, Washington State University, Pullman, WA 99164 USA
| | - J M Gregorich
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - J A Turner
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
| | - B D Vanden Heuvel
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO 81001 USA
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Turner JA, Shortreed SM, Saunders KW, LeResche L, Von Korff M. Association of levels of opioid use with pain and activity interference among patients initiating chronic opioid therapy: a longitudinal study. Pain 2016; 157:849-857. [PMID: 26785321 PMCID: PMC4939796 DOI: 10.1097/j.pain.0000000000000452] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about long-term pain and function outcomes among patients with chronic noncancer pain initiating chronic opioid therapy (COT). In the Middle-Aged/Seniors Chronic Opioid Therapy study of patients identified through electronic pharmacy records as initiating COT for chronic noncancer pain, we examined the relationships between level of opioid use (over the 120 days before outcome assessment) and pain and activity interference outcomes at 4- and 12-month follow-ups. Patients aged 45+ years (N = 1477) completed a baseline interview; 1311 and 1157 of these comprised the 4- and 12-month analysis samples, respectively. Opioid use was classified based on self-report and electronic pharmacy records for the 120 days before the 4- and 12-month outcome assessments. Controlling for patient characteristics that predict sustained COT and pain outcomes, patients who had used opioids minimally or not at all, compared with those with intermittent/lower-dose and regular/higher-dose opioid use, had better pain intensity and activity interference outcomes. Adjusted mean (95% confidence interval) pain intensity (0-10 scale) at 12 months was 4.91 (4.68-5.13) for the minimal/no use group and 5.71 (5.50-5.92) and 5.72 (5.51-5.93) for the intermittent/lower-dose and regular/higher-dose groups, respectively. A similar pattern was observed for pain intensity at 4 months and for activity interference at both time points. Better outcomes in the minimal/no use group could reflect pain improvement leading to opioid discontinuation. The similarity in outcomes of regular/higher-dose and intermittent/lower-dose opioid users suggests that intermittent and/or lower-dose use vs higher-dose use may confer risk reduction without reducing benefits.
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Affiliation(s)
- Judith A. Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Susan M. Shortreed
- Group Health Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Linda LeResche
- Department of Oral Medicine, University of Washington, Seattle, Washington, USA
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van Erp TGM, Hibar DP, Rasmussen JM, Glahn DC, Pearlson GD, Andreassen OA, Agartz I, Westlye LT, Haukvik UK, Dale AM, Melle I, Hartberg CB, Gruber O, Kraemer B, Zilles D, Donohoe G, Kelly S, McDonald C, Morris DW, Cannon DM, Corvin A, Machielsen MWJ, Koenders L, de Haan L, Veltman DJ, Satterthwaite TD, Wolf DH, Gur RC, Gur RE, Potkin SG, Mathalon DH, Mueller BA, Preda A, Macciardi F, Ehrlich S, Walton E, Hass J, Calhoun VD, Bockholt HJ, Sponheim SR, Shoemaker JM, van Haren NEM, Pol HEH, Ophoff RA, Kahn RS, Roiz-Santiañez R, Crespo-Facorro B, Wang L, Alpert KI, Jönsson EG, Dimitrova R, Bois C, Whalley HC, McIntosh AM, Lawrie SM, Hashimoto R, Thompson PM, Turner JA. Subcortical brain volume abnormalities in 2028 individuals with schizophrenia and 2540 healthy controls via the ENIGMA consortium. Mol Psychiatry 2016; 21:547-53. [PMID: 26033243 PMCID: PMC4668237 DOI: 10.1038/mp.2015.63] [Citation(s) in RCA: 596] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 03/05/2015] [Accepted: 03/18/2015] [Indexed: 12/17/2022]
Abstract
The profile of brain structural abnormalities in schizophrenia is still not fully understood, despite decades of research using brain scans. To validate a prospective meta-analysis approach to analyzing multicenter neuroimaging data, we analyzed brain MRI scans from 2028 schizophrenia patients and 2540 healthy controls, assessed with standardized methods at 15 centers worldwide. We identified subcortical brain volumes that differentiated patients from controls, and ranked them according to their effect sizes. Compared with healthy controls, patients with schizophrenia had smaller hippocampus (Cohen's d=-0.46), amygdala (d=-0.31), thalamus (d=-0.31), accumbens (d=-0.25) and intracranial volumes (d=-0.12), as well as larger pallidum (d=0.21) and lateral ventricle volumes (d=0.37). Putamen and pallidum volume augmentations were positively associated with duration of illness and hippocampal deficits scaled with the proportion of unmedicated patients. Worldwide cooperative analyses of brain imaging data support a profile of subcortical abnormalities in schizophrenia, which is consistent with that based on traditional meta-analytic approaches. This first ENIGMA Schizophrenia Working Group study validates that collaborative data analyses can readily be used across brain phenotypes and disorders and encourages analysis and data sharing efforts to further our understanding of severe mental illness.
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Affiliation(s)
- T G M van Erp
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - D P Hibar
- Imaging Genetics Center, University of Southern California, Los Angeles, CA, USA
| | - J M Rasmussen
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - D C Glahn
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Olin Neuropsychiatric Research Center, Institute of Living, Hartford, CT, USA
| | - G D Pearlson
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Olin Neuropsychiatric Research Center, Institute of Living, Hartford, CT, USA
| | - O A Andreassen
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - I Agartz
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Psychiatric Research, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - L T Westlye
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - U K Haukvik
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - A M Dale
- MMIL, Department of Radiology, University of California, San Diego, CA, USA
- Department of Cognitive Science, Neurosciences and Psychiatry, University of California, San Diego, CA, USA
| | - I Melle
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - C B Hartberg
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Psychiatric Research, Diakonhjemmet Hospital, Oslo, Norway
| | - O Gruber
- Department of Psychiatry, University Medical Center Göttingen, Göttingen, Germany
| | - B Kraemer
- Department of Psychiatry, University Medical Center Göttingen, Göttingen, Germany
| | - D Zilles
- Department of Psychiatry, University Medical Center Göttingen, Göttingen, Germany
- Center for Translational Research in Systems Neuroscience and Psychiatry, Department of Psychiatry and Psychotherapy, Georg August University, Göttingen, Germany
| | - G Donohoe
- Cognitive Genetics and Therapy Group, School of Psychology, National University of Ireland, Galway, Ireland
- Neuropsychiatric Genetics research group, Department of Psychiatry and Trinity College Institute of Psychiatry, Trinity College, Dublin, Ireland
| | - S Kelly
- Imaging Genetics Center, University of Southern California, Los Angeles, CA, USA
- Neuropsychiatric Genetics research group, Department of Psychiatry and Trinity College Institute of Psychiatry, Trinity College, Dublin, Ireland
| | - C McDonald
- Clinical Neuroimaging Laboratory, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - D W Morris
- Cognitive Genetics and Therapy Group, School of Psychology, National University of Ireland, Galway, Ireland
- Neuropsychiatric Genetics research group, Department of Psychiatry and Trinity College Institute of Psychiatry, Trinity College, Dublin, Ireland
| | - D M Cannon
- Clinical Neuroimaging Laboratory, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - A Corvin
- Neuropsychiatric Genetics research group, Department of Psychiatry and Trinity College Institute of Psychiatry, Trinity College, Dublin, Ireland
| | - M W J Machielsen
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L Koenders
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L de Haan
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - D J Veltman
- University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T D Satterthwaite
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - D H Wolf
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R C Gur
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R E Gur
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - S G Potkin
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - D H Mathalon
- Department of Psychiatry, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - B A Mueller
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - A Preda
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - F Macciardi
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
| | - S Ehrlich
- Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Technische Universität, Dresden, Germany
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- MGH/MIT/HMS Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - E Walton
- Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Technische Universität, Dresden, Germany
| | - J Hass
- Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Technische Universität, Dresden, Germany
| | - V D Calhoun
- Mind Research Network, Albuquerque, NM, USA
- Department of Electrical and Computer Engineering, University of New Mexico, Albuquerque, NM, USA
| | - H J Bockholt
- Mind Research Network, Albuquerque, NM, USA
- Advanced Biomedical Informatics Group, LLC, Iowa City, IA, USA
- The University of Iowa, Iowa City, IA, USA
| | - S R Sponheim
- Minneapolis VA Healthcare System & Department of Psychiatry, University of Minnesota, Twin Cities, MN, USA
| | | | - N E M van Haren
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H E H Pol
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R A Ophoff
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Center for Neurobehavioral Genetics, University of California, Los Angeles, CA, USA
| | - R S Kahn
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Roiz-Santiañez
- Department of Psychiatry, University Hospital Marqués de Valdecilla, School of Medicine, University of Cantabria-IDIVAL, Santander, Spain
- CIBERSAM, Centro Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - B Crespo-Facorro
- Department of Psychiatry, University Hospital Marqués de Valdecilla, School of Medicine, University of Cantabria-IDIVAL, Santander, Spain
- CIBERSAM, Centro Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - L Wang
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - K I Alpert
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - E G Jönsson
- Norwegian Centre for Mental Disorders Research (NORMENT), KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - R Dimitrova
- Division of Psychiatry, University of Edinburgh Medical School, Edinburgh, UK
| | - C Bois
- Division of Psychiatry, University of Edinburgh Medical School, Edinburgh, UK
| | - H C Whalley
- Division of Psychiatry, University of Edinburgh Medical School, Edinburgh, UK
| | - A M McIntosh
- Division of Psychiatry, University of Edinburgh Medical School, Edinburgh, UK
| | - S M Lawrie
- Division of Psychiatry, University of Edinburgh Medical School, Edinburgh, UK
| | - R Hashimoto
- Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, Osaka, Japan
| | - P M Thompson
- Imaging Genetics Center, University of Southern California, Los Angeles, CA, USA
| | - J A Turner
- Mind Research Network, Albuquerque, NM, USA
- Departments of Psychology and Neuroscience, Georgia State University, Atlanta, GA, USA
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Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2016; 315:1240-9. [PMID: 27002445 PMCID: PMC4914381 DOI: 10.1001/jama.2016.2323] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain. OBJECTIVE To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care. DESIGN, SETTING, AND PARTICIPANTS Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). INTERVENTIONS CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received. MAIN OUTCOMES AND MEASURES Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks. RESULTS There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes. CONCLUSIONS AND RELEVANCE Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01467843.
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Affiliation(s)
- Daniel C. Cherkin
- Corresponding author. Group Health Research Institute; 1730 Minor Avenue, Suite 1600, Seattle, WA 98101; ; (206) 287-2875
| | - Karen J. Sherman
- Group Health Research Institute; Department of Epidemiology, University of Washington
| | | | - Andrea J. Cook
- Group Health Research Institute; Department of Biostatistics, University of Washington
| | | | - Rene J. Hawkes
- Group Health Research Institute, University of Washington
| | | | - Judith A. Turner
- Departments of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington
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Von Korff M, Turner JA, Shortreed SM, Saunders K, Rosenberg D, Thielke S, LeResche L. Timeliness of Care Planning upon Initiation of Chronic Opioid Therapy for Chronic Pain. Pain Med 2016; 17:511-520. [PMID: 26814284 PMCID: PMC6281132 DOI: 10.1093/pm/pnv054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/23/2015] [Accepted: 10/17/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic opioid therapy (COT) guidelines recommend developing a COT care plan at the initiation of COT. OBJECTIVE Assess the timeliness of care planning upon initiation of COT. DESIGN Observational cohort study in a setting incentivizing and tracking documentation of COT care plans in electronic health records (EHRs). PARTICIPANTS Study participants (N = 896) were aged 45 years or older, had initiated an episode of opioid use within the prior 6 months, and reported regular use of prescription analgesics when screened for a baseline interview about 3 months after an index opioid prescription MEASURES: A timely care plan was defined by an EHR documented care plan prior to or within 4 months after the index opioid prescription. RESULTS Among COT initiators, 30% had a timely COT care plan documented in the EHR within 4 months following index prescription, while 51% had a documented COT care plan within 12 months following index prescription. Among those interviewed at 1 year follow-up (N = 735), 252 (34.2%) reported opioid use on 7 or more days in the prior 2 weeks. Less than half (45.6%) of the 252 individuals who sustained regular opioid use at 1 year had predicted at baseline that it was somewhat, very, or extremely likely they would be using opioids regularly in 1 year. CONCLUSIONS Patients initiating COT were unlikely to have timely COT care plans. Many who sustained regular opioid use at 1 year had not anticipated using opioids long term.
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Affiliation(s)
| | - Judith A Turner
- Departments of Psychiatry and Behavioral Sciences
- Rehabilitation Medicine
- Anesthesiology and Pain Medicine
| | - Susan M Shortreed
- *Group Health Research Institute, Seattle, Washington, USA
- Biostatistics, and
| | | | - Dori Rosenberg
- *Group Health Research Institute, Seattle, Washington, USA
| | - Stephen Thielke
- Departments of Psychiatry and Behavioral Sciences
- Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, Washington, USA
| | - Linda LeResche
- Oral Medicine, University of Washington, Seattle, Washington, USA
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Wright C, Gupta CN, Chen J, Patel V, Calhoun VD, Ehrlich S, Wang L, Bustillo JR, Perrone-Bizzozero NI, Turner JA. Polymorphisms in MIR137HG and microRNA-137-regulated genes influence gray matter structure in schizophrenia. Transl Psychiatry 2016; 6:e724. [PMID: 26836412 PMCID: PMC4872419 DOI: 10.1038/tp.2015.211] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 10/06/2015] [Accepted: 10/09/2015] [Indexed: 02/06/2023] Open
Abstract
Evidence suggests that microRNA-137 (miR-137) is involved in the genetic basis of schizophrenia. Risk variants within the miR-137 host gene (MIR137HG) influence structural and functional brain-imaging measures, and miR-137 itself is predicted to regulate hundreds of genes. We evaluated the influence of a MIR137HG risk variant (rs1625579) in combination with variants in miR-137-regulated genes TCF4, PTGS2, MAPK1 and MAPK3 on gray matter concentration (GMC). These genes were selected based on our previous work assessing schizophrenia risk within possible miR-137-regulated gene sets using the same cohort of subjects. A genetic risk score (GRS) was determined based on genotypes of these four schizophrenia risk-associated genes in 221 Caucasian subjects (89 schizophrenia patients and 132 controls). The effects of the rs1625579 genotype with the GRS of miR-137-regulated genes in a three-way interaction with diagnosis on GMC patterns were assessed using a multivariate analysis. We found that schizophrenia subjects homozygous for the MIR137HG risk allele show significant decreases in occipital, parietal and temporal lobe GMC with increasing miR-137-regulated GRS, whereas those carrying the protective minor allele show significant increases in GMC with GRS. No correlations of GMC and GRS were found in control subjects. Variants within or upstream of genes regulated by miR-137 in combination with the MIR137HG risk variant may influence GMC in schizophrenia-related regions in patients. Given that the genes evaluated here are involved in protein kinase A signaling, dysregulation of this pathway through alterations in miR-137 biogenesis may underlie the gray matter loss seen in the disease.
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Affiliation(s)
- C Wright
- The Mind Research Network, Albuquerque, NM, USA
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, USA
| | - C N Gupta
- The Mind Research Network, Albuquerque, NM, USA
| | - J Chen
- The Mind Research Network, Albuquerque, NM, USA
| | - V Patel
- The Mind Research Network, Albuquerque, NM, USA
| | - V D Calhoun
- The Mind Research Network, Albuquerque, NM, USA
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, USA
- Department of Electrical and Computer Engineering, University of New Mexico, Albuquerque, NM, USA
| | - S Ehrlich
- Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität, Dresden, Germany
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - L Wang
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J R Bustillo
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - N I Perrone-Bizzozero
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - J A Turner
- The Mind Research Network, Albuquerque, NM, USA
- Department of Psychology and Neuroscience Institute, Georgia State University, Atlanta, GA, USA
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Shortreed SM, Von Korff M, Thielke S, LeResche L, Saunders K, Rosenberg D, Turner JA. Electronic Health Records to Evaluate and Account for Non-response Bias: A Survey of Patients Using Chronic Opioid Therapy. Obs Stud 2016; 2:24-38. [PMID: 28042621 PMCID: PMC5193131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND In observational studies concerning drug use and misuse, persons misusing drugs may be less likely to respond to surveys. However, little is known about differences in drug use and drug misuse risk factors between survey respondents and nonrespondents. METHODS Using electronic health record (EHR) data, we compared respondents and non-respondents in a telephone survey of middle-aged and older chronic opioid therapy patients to assess predictors of interview nonresponse. We compared general patient characteristics, specific opioid misuse risk factors, and patterns of opioid use associated with increased risk of opioid misuse. Inverse probability weights were calculated to account for nonresponse bias by EHR-measured covariates. EHR-measured covariate distributions for the full sample (nonrespondents and respondents), the unweighted respondent sample, and the inverse probability weighted respondent sample are reported. We present weighted and unweighted prevalence of self-reported opioid misuse risk factors. RESULTS Among 2489 potentially eligible patients, 1477 (59.3%) completed interviews. Response rates differed with age (45-54 years, 51.8%; 55-64 years, 58.7%; 65-74 years, 67.9%; and 75 years or older, 59.9%). Tobacco users had lower response rates than did nonusers (53.5% versus 60.9%). Charlson comorbidity score was also related to response rates. Individuals with a Charlson score of 2 had the highest response rate at 65.6%; response rates were lower amoung patients with the lowest (the patients with the fewest health conditions had response rates of 56.7-60.0%) and the highest Charlson scores (patients with the most health conditions had response rates of 52.2-56.0%). These bivariate relationships persisted in adjusted multivariable logistic regression models predicting survey response. Response rates of persons with and without specific opioid misuse risk factors were similar (e.g., 58.7% for persons with substance abuse diagnoses, 59.4% for those without). Opioid use patterns associated with opioid misuse did not predict response rates (e.g., 60.6% versus 59.2% for those receiving versus not receiving opioids from 3 or more physicians outside their primary care clinic). Very few patient characteristics predicted non-response; thus, inverse probability weights accounting for nonresponse had little impact on the distributions of EHR-measured covariates or self-reported measures related to opioid use and misuse. CONCLUSIONS Response rates differed by characteristics that predict nonresponse in general health surveys (age, tobacco use), but did not appear to differ by specific patient or drug use risk factors for prescription opioid misuse among middle- and older-aged chronic opioid therapy patients. When observational studies are conducted in health plan populations, electronic health records may be used to evaluate nonresponse bias and to adjust for variables predicting interview nonresponse, complementing other research uses of EHR data in observational studies.
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Affiliation(s)
- Susan M Shortreed
- Group Health Research Institute, Seattle, WA, USA., Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Stephen Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA., Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, WA, USA
| | - Linda LeResche
- Department of Oral Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences; Department of Rehabilitation Medicine; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Herrmann SJ, Nimmo DR, Carsella JS, Herrmann-Hoesing LM, Turner JA, Gregorich JM, Heuvel BDV, Nehring RB, Foutz HP. Differential Accumulation of Mercury and Selenium in Brown Trout Tissues of a High-Gradient Urbanized Stream in Colorado, USA. Arch Environ Contam Toxicol 2016; 70:204-218. [PMID: 26608694 DOI: 10.1007/s00244-015-0241-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/08/2015] [Indexed: 06/05/2023]
Abstract
Total mercury (THg) and selenium (Se) were analyzed by Inductively Coupled Plasma Mass Spectrometry in 11 internal and external tissues and stomach contents from 23 brown trout, Salmo trutta, of a 22.9-km reach of a high-gradient stream (upper Fountain Creek) in Colorado, USA, impacted by coal-fired power plants, shale deposits, and urbanization. Trout and water were sampled from four sites ranging from 2335 to 1818 m elevation. Lengths, weights, and ages of fish between pairs of the four sites were not significantly different. The dry weight (dw) to wet weight (ww) conversion factor for each tissue was calculated with egg-ovary highest at 0.379 and epaxial muscle fourth highest at 0.223. THg and Se in stomach contents indicated diet and not ambient water was the major source of Hg and Se bioaccumulated. Mean THg ww in kidney was 40.33 µg/kg, and epaxial muscle second highest at 36.76 µg/kg. None of the tissues exceeded the human critical threshold for Hg. However, all 23 trout had at least one tissue type that exceeded 0.02 mg/kg THg ww for birds, and four trout tissues exceeded 0.1 mg/kg THg ww for mammals, indicating that piscivorous mammals and birds should be monitored. Se concentrations in tissues varied depending on ww or dw listing. Mean Se dw in liver was higher than ovary at the uppermost site and the two lower sites. Liver tissue, in addition to egg-ovary, should be utilized as an indicator tissue for Se toxicity.
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Affiliation(s)
- S J Herrmann
- Department of Biology, Colorado State University - Pueblo, Pueblo, CO, 81001, USA.
| | - D R Nimmo
- Department of Biology, Colorado State University - Pueblo, Pueblo, CO, 81001, USA
| | - J S Carsella
- Department of Chemistry, Colorado State University - Pueblo, Pueblo, CO, 81001, USA
| | - L M Herrmann-Hoesing
- Department of Veterinary Microbiology and Pathology, Washington State University, Pullman, WA, 99164, USA
| | - J A Turner
- Department of Biology, Colorado State University - Pueblo, Pueblo, CO, 81001, USA
| | - J M Gregorich
- Department of Biology, Colorado State University - Pueblo, Pueblo, CO, 81001, USA
| | - B D Vanden Heuvel
- Department of Biology, Colorado State University - Pueblo, Pueblo, CO, 81001, USA
| | - R B Nehring
- Division of Colorado Parks and Wildlife, 6060 Broadway, Denver, CO, 80216, USA
| | - H P Foutz
- Division of Colorado Parks and Wildlife, 6060 Broadway, Denver, CO, 80216, USA
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Sullivan MD, Bauer AM, Fulton-Kehoe D, Garg RK, Turner JA, Wickizer T, Franklin GM. Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation. J Pain 2016; 17:561-8. [PMID: 26828802 DOI: 10.1016/j.jpain.2015.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 11/19/2015] [Accepted: 12/22/2015] [Indexed: 11/16/2022]
Abstract
UNLABELLED By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used. PERSPECTIVE Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington
| | - Renu K Garg
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Thomas Wickizer
- Department of Health Services, University of Washington, Seattle, Washington
| | - Gary M Franklin
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Department of Neurology, University of Washington, Seattle, Washington; Washington State Department of Labor and Industries, Olympia, Washington
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Shortreed SM, Von Korff M, Thielke S, LeResche L, Saunders K, Rosenberg D, Turner JA. Electronic Health Records to Evaluate and Account for Non-response Bias: A Survey of Patients Using Chronic Opioid Therapy. ACTA ACUST UNITED AC 2016. [DOI: 10.1353/obs.2016.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Turner JA, Comstock BA, Standaert CJ, Heagerty PJ, Jarvik JG, Deyo RA, Wasan AD, Nedeljkovic SS, Friedly JL. Can patient characteristics predict benefit from epidural corticosteroid injections for lumbar spinal stenosis symptoms? Spine J 2015; 15:2319-31. [PMID: 26096484 DOI: 10.1016/j.spinee.2015.06.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 04/08/2015] [Accepted: 06/13/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Epidural corticosteroid injections are commonly used to treat back and leg pain associated with lumbar spinal stenosis. However, little is known about which patient characteristics may predict favorable responses. PURPOSE The aim was to identify patient characteristics associated with benefits from epidural injections of corticosteroid with lidocaine versus epidural injections of lidocaine only for lumbar spinal stenosis symptoms. STUDY DESIGN/SETTING This was a secondary analysis of Lumbar Epidural steroid injections for Spinal Stenosis randomized controlled trial data from 16 US clinical sites. PATIENT SAMPLE Patients aged older than or equal to 50 years with moderate-to-severe leg pain and lumbar central spinal stenosis randomized to epidural injections of corticosteroids with lidocaine (n=200) or lidocaine only (n=200) were included. OUTCOME MEASURES Primary outcomes were the Roland-Morris Disability Questionnaire (RMDQ) and 0 to 10 leg pain intensity ratings. Secondary outcomes included the Brief Pain Inventory Interference Scale and the Swiss Spinal Stenosis Questionnaire. METHODS At baseline, clinicians rated severity of patient spinal stenosis, and patients completed predictor and outcome measures. Patients completed outcome measures again 3 and 6 (primary end point) weeks after randomization/initial injection. Analysis of covariance was used with treatment by covariate interactions to identify baseline predictors of greater benefit from corticosteroid+lidocaine versus lidocaine alone. We also identified nonspecific (independent of treatment) predictors of outcomes. RESULTS Among 21 candidate predictors and six outcomes, only one baseline variable predicted greater benefit from corticosteroid+lidocaine versus lidocaine only at 3 or 6 weeks. Compared with patients who rated their health-related quality of life as high on the EQ-5D Index, patients who rated it as poor had greater improvement with corticosteroid than with lidocaine only in leg pain at 6 (but not 3) weeks (interaction coefficient=2.94; 95% confidence interval [CI]=0.11-5.76; p=.04) and in RMDQ disability scores at 3 (but not 6) weeks (interaction coefficient=4.77, 95% CI= -0.04 to 9.59; p = .05). Several baseline patient characteristics predicted outcomes regardless of treatment assignment. CONCLUSIONS Among 21 baseline patient characteristics examined, none, including clinician-rated spinal stenosis severity, were consistent predictors of benefit from epidural injections of lidocaine+corticosteroid versus lidocaine only.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA; Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Christopher J Standaert
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington, Box 359728, 325 Ninth Ave, Seattle, WA 98104-2499, USA; Department of Health Services, University of Washington, Box 359728, 325 Ninth Ave, Seattle, WA 98104-2499, USA; Department of Neurological Surgery, University of Washington, Box 359728, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| | - Ajay D Wasan
- Department of Anesthesiology, University of Pittsburgh, 200 Lothrop St, Pittsburgh, PA 15213, USA; Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Spine Unit, Harvard Vanguard Medical Associates, BWH Pain Management Center, 850 Boylston St, Chestnut Hill, MA 02467, USA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
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Jarvik JG, Comstock BA, James KT, Avins AL, Bresnahan BW, Deyo RA, Luetmer PH, Friedly JL, Meier EN, Cherkin DC, Gold LS, Rundell SD, Halabi SS, Kallmes DF, Tan KW, Turner JA, Kessler LG, Lavallee DC, Stephens KA, Heagerty PJ. Lumbar Imaging With Reporting Of Epidemiology (LIRE)--Protocol for a pragmatic cluster randomized trial. Contemp Clin Trials 2015; 45:157-163. [PMID: 26493088 PMCID: PMC4674321 DOI: 10.1016/j.cct.2015.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/09/2015] [Accepted: 10/11/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diagnostic imaging is often the first step in evaluating patients with back pain and likely functions as a "gateway" to a subsequent cascade of interventions. However, lumbar spine imaging frequently reveals incidental findings among normal, pain-free individuals suggesting that treatment of these "abnormalities" may not be warranted. Our prior work suggested that inserting the prevalence of imaging findings in patients without back pain into spine imaging reports may reduce subsequent interventions. We are now conducting a pragmatic cluster randomized clinical trial to test the hypothesis that inserting this prevalence data into lumbar spine imaging reports for studies ordered by primary care providers will reduce subsequent spine-related interventions. METHODS/DESIGN We are using a stepped wedge design that sequentially randomizes 100 primary care clinics at four health systems to receive either standard lumbar spine imaging reports, or reports containing prevalence data for common imaging findings in patients without back pain. We capture all outcomes passively through the electronic medical record. Our primary outcome is spine-related intervention intensity based on Relative Value Units (RVUs) during the following year. Secondary outcomes include subsequent prescriptions for opioid analgesics and cross-sectional lumbar spine re-imaging. DISCUSSION If our study shows that adding prevalence data to spine imaging reports decreases subsequent back-related RVUs, this intervention could be easily generalized and applied to other kinds of testing, as well as other conditions where incidental findings may be common. Our study also serves as a model for cluster randomized trials that are minimal risk and highly pragmatic.
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Affiliation(s)
- Jeffrey G Jarvik
- Department of Radiology, University of Washington, USA; Department of Neurological Surgery, University of Washington, USA; Department of Health Services, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA.
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, USA; Center for Biomedical Statistics, University of Washington, USA
| | - Kathryn T James
- Department of Radiology, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health Sciences University, Portland, OR, USA; Department of Internal Medicine, Oregon Health Sciences University, Portland, OR, USA; Department of Public Health and Preventive Medicine, Oregon Health Sciences University, Portland, OR, USA; Oregon Institute for Occupational Health Sciences, Oregon Health Sciences University, Portland, OR, USA
| | | | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Eric N Meier
- Department of Biostatistics, University of Washington, USA; Center for Biomedical Statistics, University of Washington, USA
| | | | - Laura S Gold
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Safwan S Halabi
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | | | - Katherine W Tan
- Department of Biostatistics, University of Washington, USA; Center for Biomedical Statistics, University of Washington, USA
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, USA; Department of Rehabilitation Medicine, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA
| | - Larry G Kessler
- Department of Health Services, University of Washington, USA
| | | | - Kari A Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, USA; Center for Biomedical Statistics, University of Washington, USA
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Saunders KW, Shortreed S, Thielke S, Turner JA, LeResche L, Beck R, Von Korff M. Evaluation of Health Plan Interventions to Influence Chronic Opioid Therapy Prescribing. Clin J Pain 2015; 31:820-829. [PMID: 25621426 PMCID: PMC4620063 DOI: 10.1097/ajp.0000000000000159] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Evaluate health plan interventions targeting physician chronic opioid therapy (COT) prescribing. MATERIALS AND METHODS In 2006, Group Health's (GH) Integrated Group Practice (IGP) initiated diverse interventions targeting COT prescriber norms and practices. In 2010, the IGP implemented a COT guideline, including a mandated online course for physicians managing COT. These interventions were not implemented in GH's network practices. We compared trends in GH-IGP and network practices for 2006 to 2012 in the percent of patients receiving COT and their opioid dose. We compared physician beliefs before versus after the mandated course and precourse to postcourse changes in COT dosing for IGP physicians who took the course. RESULTS From 2006 to 2012, mean (SE) daily opioid dose among IGP COT patients (intervention setting) declined from 74.1 mg (1.9 mg) morphine equivalent dose (MED) to 48.3 mg (1.0 mg) MED. Dose changes among GH network COT patients (control setting) were modest-88.2 mg (5.0 mg) MED in 2006 to 75.7 mg (2.3 mg) MED in 2012. Among physicians taking the mandated course in 2011, we observed precourse to postcourse changes toward more conservative opioid prescribing beliefs. However, COT dosing trends did not change precourse to postcourse. DISCUSSION Following initiatives implemented to alter physician prescribing practices and norms, mean opioid dose prescribed to COT patients declined more in intervention than control practices. Physicians reported more conservative beliefs regarding opioid prescribing immediately after completing an online course in 2011, but the course was not associated with additional reductions in mean daily opioid dose prescribed by physicians completing the course.
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Affiliation(s)
| | | | - Stephen Thielke
- Departments of Psychiatry and Behavioral Sciences
- Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center
| | - Judith A Turner
- Departments of Psychiatry and Behavioral Sciences
- Rehabilitation Medicine
- Anesthesiology and Pain Medicine
| | | | - Randi Beck
- Department of Physical Medicine and Rehabilitation, Group Health, Seattle, WA
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Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW, Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015; 313:1143-53. [PMID: 25781443 DOI: 10.1001/jama.2015.1871] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In contrast to the recommendations for younger adults, many guidelines allow for older adults with back pain to undergo imaging without waiting 4 to 6 weeks. However, early imaging may precipitate interventions that do not improve outcomes. OBJECTIVE To compare function and pain at the 12-month follow-up visit among older adults who received early imaging with those who did not receive early imaging after a new primary care visit for back pain without radiculopathy. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort of 5239 patients 65 years or older with a new primary care visit for back pain (2011-2013) in 3 US health care systems. We matched controls 1:1 using propensity score matching of demographic and clinical characteristics, including diagnosis, pain severity, pain duration, functional status, and prior resource use. EXPOSURES Diagnostic imaging (plain films, computed tomography [CT], magnetic resonance imaging [MRI]) of the lumbar or thoracic spine within 6 weeks of the index visit. PRIMARY OUTCOME back or leg pain-related disability measured by the modified Roland-Morris Disability Questionnaire (score range, 0-24; higher scores indicate greater disability) 12 months after enrollment. RESULTS Among the 5239 patients, 1174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on the disability questionnaire. The mean score for patients who underwent early radiography was 8.54 vs 8.74 among the control group (difference, -0.10 [95% CI, -0.71 to 0.50]; mixed model, P = .36). The mean score for the early MRI/CT group was 9.81 vs 10.50 for the control group (difference,-0.51 [-1.62 to 0.60]; mixed model, P = .18). CONCLUSIONS AND RELEVANCE Among older adults with a new primary care visit for back pain, early imaging was not associated with better 1-year outcomes. The value of early diagnostic imaging in older adults for back pain without radiculopathy is uncertain.
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Affiliation(s)
- Jeffrey G Jarvik
- Department of Radiology, University of Washington, Seattle2Department of Neurological Surgery, University of Washington, Seattle3Department of Health Services, University of Washington, Seattle4Comparative Effectiveness, Cost and Outcomes Research Center
| | - Laura S Gold
- Department of Radiology, University of Washington, Seattle4Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle11Department of Pharmacy, University of Washington, Seattle
| | - Bryan A Comstock
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle5Department of Biostatistics, University of Washington, Seattle
| | - Patrick J Heagerty
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle5Department of Biostatistics, University of Washington, Seattle
| | - Sean D Rundell
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle7Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Judith A Turner
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle6Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle
| | - Andrew L Avins
- Division of Research, Northern California Kaiser to Permanente, Oakland
| | - Zoya Bauer
- Department of Radiology, University of Washington, Seattle4Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, Seattle4Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle
| | - Janna L Friedly
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle7Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Kathryn James
- Department of Radiology, University of Washington, Seattle
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Spine Unit, Harvard Vanguard Medical Associates, Boston, Massacusetts
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Xu Shi
- Department of Biostatistics, University of Washington, Seattle
| | | | - Leighton Chan
- Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, National Institutes of Health, Bethesda, Maryland
| | - Jason M Schwalb
- Department of Neurosurgery and the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Richard A Deyo
- Department of Family Medicine, Internal Medicine, and Public Health and Preventive Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland
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Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015; 162:276-86. [PMID: 25581257 DOI: 10.7326/m14-2559] [Citation(s) in RCA: 1057] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness. PURPOSE To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults. DATA SOURCES MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO, and CINAHL (January 2008 through August 2014); relevant studies from a prior review; reference lists; and ClinicalTrials.gov. STUDY SELECTION Randomized trials and observational studies that involved adults with chronic pain who were prescribed long-term opioid therapy and that evaluated opioid therapy versus placebo, no opioid, or nonopioid therapy; different opioid dosing strategies; or risk mitigation strategies. DATA EXTRACTION Dual extraction and quality assessment. DATA SYNTHESIS No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited. LIMITATIONS Non-English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding. CONCLUSION Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Roger Chou
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Judith A. Turner
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Emily B. Devine
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Ryan N. Hansen
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Sean D. Sullivan
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Ian Blazina
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Tracy Dana
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Richard A. Deyo
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
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Eaves ER, Sherman KJ, Ritenbaugh C, Hsu C, Nichter M, Turner JA, Cherkin DC. A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies. BMC Complement Altern Med 2015; 15:12. [PMID: 25652396 PMCID: PMC4322442 DOI: 10.1186/s12906-015-0531-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 01/16/2015] [Indexed: 12/04/2022]
Abstract
BACKGROUND The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.
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Affiliation(s)
- Emery R Eaves
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | | | - Cheryl Ritenbaugh
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | | | - Mark Nichter
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | - Judith A Turner
- Department of Psychiatry & Behavioral Sciences and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE, Von Korff M. Chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results. J Gen Intern Med 2014; 29:1663-71. [PMID: 25217208 PMCID: PMC4242878 DOI: 10.1007/s11606-014-3010-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/25/2014] [Accepted: 08/11/2014] [Indexed: 03/17/2023]
Abstract
BACKGROUND Urine drug tests (UDTs) are recommended for patients on chronic opioid therapy (COT). Knowledge of the risk factors for aberrant UDT results could help optimize their use. OBJECTIVE To identify primary care COT patient and opioid regimen characteristics associated with aberrant UDT results. DESIGN Population-based observational. SAMPLE 5,420 UDTs for Group Health integrated group practice COT patients. MEASURES Group Health database measures of patient demographics, medical history, COT characteristics, and UDT results. RESULTS Thirty percent of UDTs had aberrant results, including prescribed opioid non-detection (12.3%), tetrahydrocannabinol (THC; 11.2%), non-prescribed opioid (5.3%), illicit drug (excluding THC; 0.6%), non-prescribed benzodiazepine (1.7%), and dilute (4.8%). Adjusted odds ratios (95% CI) of any aberrant result were higher for males than females (1.24 [1.07, 1.43]), patients with versus without prior substance use disorder diagnoses (1.42 [1.17, 1.72]), and current smokers versus non-smokers (1.50 [1.30, 1.73]). Odds ratios were lower for patients aged 45-64 (0.77 [0.65, 0.92]) and 65+ (0.40 [0.32, 0.50]) versus patients aged 20-44 and for patients on long-acting opioids only (0.72 [0.55, 0.95]) or long-acting plus short-acting (0.67 [0.54, 0.83]) versus short-acting only. Adjusted odds of prescribed opioid non-detection were lower for patients aged 45-64 (0.79 [0.63, 0.998]) and 65+ (0.44 [0.32, 0.59]) versus patients aged 20-44, for those on 40-<120 mg daily morphine-equivalent dose (0.52 [0.39, 0.70]) or 120+ mg (0.22 [0.11, 0.43]) versus <40 mg, and for patients on long-acting (0.35 [0.21, 0.57]) or long-acting plus short-acting (0.35 [0.24, 0.50]) opioids (versus short-acting only); and odds ratios were higher for patients with versus without prior diagnoses of substance use disorder (1.70 [1.31, 2.20]). CONCLUSIONS In this primary care setting, results were aberrant for 30% of UDTs of COT patients, largely because of prescribed opioid non-detection and THC. Aberrant results of almost all types were more likely among patients under the age of 45. Other risk factors varied across aberrancies, but commonly included current smoking and prior substance use disorder diagnosis.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA,
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