Nurse-Supported Web-Based Cognitive Behavioral Therapy for Chronic Musculoskeletal Pain: A Randomized Controlled Trial.

BACKGROUND: Web-based cognitive behavioral therapy (CBT) has increased access to effective pain management. Though efficacy of web-based and face-to-face CBT may be comparable, fewer studies have examined whether remote clinical support in addition to web-based CBT can improve pain-related outcomes. OBJECTIVES: The objectives of this study were to determine if the addition of phone-based support to web-based CBT could enhance pain-related outcomes in patients with chronic musculoskeletal pain (CMP). STUDY DESIGN: Randomized controlled clinical trial. SETTING: The internal medicine and rheumatology clinics at Atrium Health Wake Forest Baptist. METHODS: Patients were recruited from a major academic medical center. Sixty patients were randomized to web-based CBT with 6 phone calls (nurse support group, n = 30) vs web-based CBT alone (control group, n = 30). The purpose of the calls was to enhance patients' engagement in the online program. All patients had access to the program from baseline to week 16. Outcome measures were collected at baseline, week 8, and week 16. Adjusting for baseline measurements, analysis of covariance  was used to determine within- and between-group differences. RESULTS: Both nurse support and control groups demonstrated significant within-group improvements in Brief Pain Inventory (BPI) pain interference (-1.3 [-2.0, -0.7, P < 0.05] and -1.7 [-2.3, -1.0, P < 0.05]), BPI pain intensity (-1.2 [-1.7, -0.6, P < 0.05] and -1.3 [-1.8, -0.8, P < 0.05]), Patient-Reported Outcomes Measurement System (PROMIS) pain interference (-5.0 [-6.9, -3.2, P < 0.05] and -5.4 [-7.2, -3.5, P < 0.05]), and PROMIS pain intensity (-1.4 [-2.0, -0.9, P < 0.05] and -1.4 [-1.9, -0.8, P < 0.05]), respectively. However, there were no significant between-group differences amongst the 2 treatment groups in all measures, except PROMIS sleep disturbance that favored the nurse support group (50.5 ± 1.3 vs 54.3 ± 1.3, P < 0.05). LIMITATIONS: Small sample size and lack of treatment fidelity assessment. CONCLUSIONS: Web-based CBT was effective with and without motivational support from nurses. Phone-based support did not enhance pain-related outcomes of web-based CBT. If confirmed in a larger study, web-based CBT without motivational support may be considered as a low-cost treatment intervention for patients with CMP.

Pro-inflammatory HDL in women with obesity and nonalcoholic steatohepatitis.

BACKGROUND: Individuals with non-alcoholic fatty liver disease (NAFLD), which includes non-alcoholic steatohepatitis (NASH), are at increased risk for cardiovascular events, independent of traditional risk factors. Limited data on pro-inflammatory high density lipoprotein (HDL) in NASH exists in the literature. We hypothesized that HDL from individuals with NASH would be more pro-inflammatory than HDL from individuals without NASH. METHODS: Study participants were individuals with obesity who had undergone bariatric surgery with wedge liver biopsy. Using HDL isolated from serum obtained from study participants at the time of surgery, HDL-elicited macrophage cytokine expression (TNF-α, IL-1ß, and IL-6) from THP-1 macrophages, HDL-associated receptor expression (ABCA1 and ABCG1) from apolipoprotein E deficient (apo E-/-) mouse peritoneal macrophages, and isolevuglandin (isoLG) modified HDL were measured. RESULTS: 11 women with NASH and 15 women without NASH were included in the study. Both TNF-α (P = 0.032) and IL-1ß (P = 0.029) were significantly more expressed by THP-1 macrophages exposed to HDL from women with NASH compared to women without NASH. ABCA1 and ABCG1 expression by apo E-/- mouse peritoneal macrophages was not significantly different when exposed to HDL from either women with NASH or women without NASH. IsoLG-modified HDL isolated from the serum of women with NASH trended higher than women without NASH. CONCLUSION: Our study suggests a more pro-inflammatory HDL in women with obesity and NASH compared to women with obesity and without NASH.

All-cause and cause-specific mortality in persons with fibromyalgia and widespread pain: An observational study in 35,248 persons with rheumatoid arthritis, non-inflammatory rheumatic disorders and clinical fibromyalgia.

PURPOSE: Studies of the relation of fibromyalgia (FM) and widespread pain (WSP) to mortality have differed as to the presence or absence of an association and the extent of cause-specific mortality. However, no studies have investigated which definitions of FM and WSP associate with mortality, nor of FM mortality in other diseases. We investigated these issues and the meaning of mortality in patients with FM. METHODS: We used Cox regression to study 35,248 rheumatic disease patients with up to 16 years of mortality follow-up in all patients and separately in those with diagnoses of rheumatoid arthritis (RA) (N = 26,458), non-inflammatory rheumatic disorders (NIRMD) (N = 5,167) and clinically diagnosed FM (N = 3,659). We applied 2016 FM criteria and other FM and WSP criteria to models adjusted for age and sex as well as to models that included a full range of covariates, including comorbid disease and functional status. We estimated the degree of explained of variance (R2) as a measure of predictive ability. RESULTS: We found positive associations between al`l definitions of FM and WSP and all-cause mortality, with relative risks (RR)s ranging from 1.19 (95%CI 1.15-1.24) for American College of Rheumatology (ACR) 1990 WSP to 1.38 (1.31-1.46) in age and sex adjusted revised 2016 criteria (FM 2016). However, in full covariate models the FM 2016 RR reduced further to 1.15 (1.09-1.22). The association with mortality was noted with RA (1.52 (1.43-1.61)), NIRMD (1.43 (1.24-1.66)) and clinical FM (1.41 (1.14-1.75) - where 37% of FM diagnosed patients did not satisfy FM 2016 criteria. In the all-patient analyses, the age and sex explained variation (R2) was 0.255, increasing to 0.264 (4.4%) when FM 2016 criteria were added, and to 0.378 in a full covariate model. Death causes related to FM 2016 status included accidents, 1.45 (1.11-1.91); diabetes 1.78 (1.16-2,71); suicide, 3.01 (1.55-5.84) and hypertensive related disorders, 3.01 (1.55-5.84). Cancer deaths were less common 0.77 (0.68-0.88). CONCLUSIONS: FM is weakly associated with mortality within all criteria definitions of FM and WSP examined (3.4% of explained variance), and across all diseases (RA, NIRMD, clinical FM) equally. Clinical and criteria-defined FM had different mortality outcomes. We found no evidence for a positive association of cancer and FM or WSP.

Investigating the use of nonattenuation corrected PET images for the attenuation correction of PET data.

PURPOSE: The aim of this study is to investigate the feasibility of using the nonattenuated PET images (PET-NAC) as a means for the AC of PET data. METHODS: A three-step iterative segmentation process is proposed. In step 1, a patient's body contour is segmented from the PET-NAC using an active contour algorithm. Voxels inside the contour are then assigned a value of 0.096 cm(-1) to represent the attenuation coefficient of soft tissue at 511 keV. This segmented attenuation map is then used to correct for attenuation the raw PET data and the resulting PET images are used as the input to Step 2 of the process. In step 2, the lung region is segmented using an optimal thresholding approach and the corresponding voxels are assigned a value of 0.024 cm(-1) representing the attenuation coefficients of lung tissue at 511 keV. The updated attenuation map is then used for a second time to correct for attenuation the raw PET data, and the resulting PET images are used as the input to step 3. The purpose of Step 3 is to delineate parts of the heart and liver in the lung contour using a region growing approach since these parts were unavoidably excluded in the lung contour in step 2. These parts are then corrected by using a value of 0.096 cm(-1) in the attenuation map. Finally the attenuation coefficients of the bed are included based on CT images to eliminate the impact of the couch on the accuracy of AC. The final attenuation map is then used to AC the raw PET data and generates the final PET image, which we name iterative AC PET (PET-IAC). To assess the proposed segmentation approach, a phantom and 14 patients (with a total of 55 lesions including bone) were scanned on a GE Discovery-RX PET∕CT scanner. PET-IAC images were generated using the proposed process and compared to those of CT-AC PET (PET-CTAC). Visual inspection, lesion SUV, and voxel by voxel histograms between PET-IAC and PET-CTAC for phantom and patient studies were performed to assess the accuracy of image quantification. RESULTS: Visual inspection showed a small difference in lung parenchyma between the PET-IAC and PET-CTAC. Tumor SUV based on PET-IAC were on average different by 3%±9% (6%±7%) compared to the SUVs from the PET-CTAC in the phantom (patient) studies. For bone lesions only, the average difference was 3%±6%. The histogram comparing PET-CTAC and PET-IAC resulted in an average regression line of y=(1.08±0.07)x+(0.00007±0.0013), with R2=0.978±0.0057. CONCLUSIONS: Preliminary results suggest that PET-NAC for the AC of PET images is feasible. Such an approach can potentially be used for dedicated PET or PET∕MR hybrid systems while minimizing scan time or potential image artifacts, respectively.

Reliability of predicting image signal-to-noise ratio using noise equivalent count rate in PET imaging.

PURPOSE: Several investigators have shown that noise equivalent count rate (NECR) is linearly proportional to the square of image signal-to-noise ratio (SNR) when PET images are reconstructed using filtered back-projection. However, to our knowledge, none have shown a similar relationship in fully 3D ordered-subset expectation maximization (OSEM) reconstruction. This paper has two aims. The first is to investigate the NECR-SNR relationship for 3D-OSEM reconstruction using phantom studies while the second aim is to evaluate the NECR-SNR relationship using patient data. METHODS: An anthropomorphic phantom was scanned on a GE Discovery-STE (DSTE) PET∕CT scanner in 3D mode with an initial activity concentration of 66.34 kBq∕cc. PET data were acquired over the lower chest∕upper abdomen region in dynamic mode. The experiment was repeated with the same activity concentration on a GE Discovery-RX (DRX) scanner. Care was taken to place the phantom at identical positions in both scanners. PET data were then reconstructed using 3D Reprojection (3D-RP) and 3D-OSEM with different reconstruction parameters and the NECR and SNR for each frame∕image were calculated. SNR(2) was then plotted versus the NECR for each scanner, reconstruction method and parameters. In addition, 40 clinical PET∕CT studies from the two scanners (20 patients∕scanner) were evaluated retrospectively. The patient studies from each scanner were further divided into two subgroups of body mass indices (BMI). Each PET study was acquired in 3D mode and reconstructed using both 3D-OSEM and 3D-RP. The NECR and SNR of the bed position covering the patient liver were calculated for each patient and averaged for each subgroup. Comparisons of the NECR and SNR between scanner types and BMIs were performed using a t-test and a p value less than 0.05 was considered significant. RESULTS: Phantom results showed that SNR(2) versus NECR was linear for 3D-RP reconstruction across all activity concentration on both scanners, as expected. However, when 3D-OSEM was used, this relationship was nonlinear at activity concentrations beyond the peak NECR on both scanners. On the other hand, the plot of SNR(2) versus trues count rate was linear for 3D-OSEM across all activity concentrations on both scanners independent of reconstruction parameters used. In addition, for activity concentrations <30kBq∕cc, phantom results showed a higher SNR (by 12 ± 10%; p < 0.05) and NECR for the DRX scanner compared to DSTE for 3D-RP reconstruction. However, for 3D-OSEM reconstruction, these two scanners had similar SNRs (different by 2% ± 9%; p > 0.05), despite having different NECRs. Patient studies showed a statistically significant difference in NECR as well as the SNR for 3D-RP reconstruction between the two scanners. However, no statistically significant difference was found for 3D-OSEM. A statistically significant difference in both NECR and SNR were found between the different BMI subgroups for both 3D-RP and 3D-OSEM reconstructions. CONCLUSIONS: For the scanners and reconstruction algorithm used in this study, our results suggest that the image SNR cannot be predicted by the NEC when using 3D-OSEM reconstruction particularly for those clinical applications requiring high activity concentration. Instead, our results suggest that image SNR varies with activity concentration and is dominated by the 3D-OSEM reconstruction algorithm and its associated parameters, while not being affected by the scanner type for the range of activity concentrations usually found in the clinic.

Ilizarov technique of lengthening and then nailing for height increase.

PURPOSE: To investigate the risks and types of complications associated with the Ilizarov technique of lengthening and then nailing in persons of normal height. METHODS: Records of 26 men and 6 women aged 21 to 47 (mean, 27) years with body height of 160 to 176 (mean, 170) cm who underwent tibial and fibular lengthening and then intramedullary nailing were reviewed. They were skeletally mature healthy persons, with no systemic/local bone disease, deformity or limb length discrepancy. Pain was assessed using the visual analogue scale (VAS). Patient satisfaction in terms of the treatment outcomes and expectations was also assessed. Complications encountered during or after treatment were recorded. RESULTS: The mean lengthening achieved was 7.6 (range, 3.5-12) cm or 26% (range, 10-40%) of the original length. The mean duration of external fixation was 96 (range, 45-135) days. The mean follow-up duration after intramedullary nailing was 38.7 (range, 24-93) months. The mean VAS pain score was 9.3 at week 1, 6.6 at week 4, and 5.7 at week 8. After intramedullary nailing, the mean VAS pain score was 2.6 at week 4, 0.9 at month 6, and 0.3 at year 1. 91% of the patients were satisfied with the outcome at week 6; 81% after intramedullary nailing, and 94% at the one-year follow-up. Four patients had revision operations: one for pin exchange owing to pin bending after a fall, one for adjusting external rotation of the tibia after nailing, one for bone grafting for delayed union, and one for drainage of a haematoma just after nailing. CONCLUSION: Most complications related to patient discomfort and psychological stress, which were important issues in this type of patients.