Assessing Loneliness among Adults Receiving Outpatient Treatment with Medication for Opioid Use Disorder (MOUD).

Loneliness is a significant risk factor for substance use, however, impacts of treatments on loneliness are relatively unexplored. Living in a rural location is a greater risk factor for loneliness. This study examined data from a quasi-experimental study in rural Appalachia, comparing the effectiveness of Mindfulness-Based Relapse Prevention (MBRP) versus Treatment as Usual (TAU) among adults receiving MOUD in outpatient therapy. Our objective was to determine whether observed reductions in self-reported craving, anxiety, depression, and increased perceived mindfulness would also improve loneliness reports. Eighty participants (n = 35 MBRP; n = 45 TAU) were included in the analysis from a group-based Comprehensive Opioid Addiction Treatment program. Outcomes tracked included craving, anxiety, depression, mindfulness, and loneliness as measured by the Revised UCLA Loneliness Scale (R-UCLA). A linear mixed model ANOVA determined the significance of the treatments on changes in loneliness scores at baseline, 12 weeks, 24 weeks, and 36 weeks post-recruitment. Both groups reported significantly reduced loneliness over the course of the study (F = 16.07, p < 0.01), however there were no significant differences between groups. Loneliness was also significantly positively (p < 0.01) correlated with anxiety (0.66), depression (0.59), and craving (0.38), and significantly (p < 0.01) inversely correlated (-0.52) with mindfulness. Results suggest that participation in MOUD group-based outpatient therapy has the potential to diminish loneliness and associated poor psychological outcomes. Thus, it is possible that a more targeted intervention for loneliness would further diminish loneliness, which is important as loneliness is linked to risk for relapse.

Sex Disparities in the Presentation of Gallbladder Disease.

INTRODUCTION: Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients. METHODS: All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted. RESULTS: Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient. CONCLUSION: These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

Testing Mindfulness-Based Relapse Prevention with Medications for Opioid Use Disorder Among Adults in Outpatient Therapy: a Quasi-experimental Study.

OBJECTIVES: This study aimed to explore the effectiveness of mindfulness-based relapse prevention (MBRP) with individuals receiving medication for opioid use disorder (MOUD) in a naturalistic, open-ended outpatient group treatment setting. METHODS: Eighty participants (mean age 36.3) who had at least 90 consecutive days substance free self-selected into treatment (MBRP, n = 35) or comparison groups (treatment as usual, TAU, n = 45). Outcomes tracked included treatment retention and relapse, and self-reported craving, anxiety, depression, and mindfulness at baseline, 12 weeks, 24 weeks, and 36 weeks post-recruitment. MBRP group participants attended biweekly 60-min sessions for 24 weeks. A linear mixed model analysis of variance determined the significance of the MBRP intervention on changes in craving, anxiety, depression, and mindfulness. RESULTS: No significant differences in sex, education level, insurance status, relationship status, or employment status were detected at baseline between groups. The 36-week retention (74%, MBRP/MOUD; 71%, TAU/MOUD) and relapse rates (43%, MBRP/MOUD; 47%, TAU/MOUD) were similar for the groups. There were only four relapses on opioids. Significant reductions (p < .05) were observed in the MBRP/MOUD group for craving, anxiety, and depression in addition to significant increases in mindfulness compared to those in TAU/MOUD. CONCLUSIONS: Although state and federal resources are available to expand MOUD, no standard of behavioral therapy has been established as most complimentary to MOUD. The current study results suggest MBRP can be implemented as an outpatient therapy for individuals in MOUD.

Gender Disparities in the Presentation of Gallbladder Disease.

Although gallbladder disease (GBD) is more common in females, we have noticed a trend toward more complicated cases in male patients. We reviewed all cholecystectomies performed at our institution over the last five years. After eliminating cases with confounding variables, we identified 1529 records. Charts were reviewed for age, gender, BMI, procedure performed, operative time, length of stay, and preoperative diagnosis. Descriptive and inferential statistical analyses were conducted along with linear regression. There were 1444 laparoscopic, 64 laparoscopic converted to open, and 21 primary open cases. Patients were 1008 (66%) females and 521 (34%) males. Average operative time was 89.8 minutes. Cholecystectomy averaged 17.7 minutes longer in males (P = 0.0046). Two per cent of female patients and 7.9 per cent male patient converted to open. Males were more likely to have complicated GBD, whereas women had uncomplicated disease. Average age was 51.9 years for males versus 42.7 years for females. Age, gender, BMI, length of stay, and preoperative diagnosis were all independently significant in predicting operative time. In our study, women presented with uncomplicated GBD, whereas men presented with complicated GBD. This suggests that male patients present at a later stage of disease.

Borrelia burgdorferi CheD Promotes Various Functions in Chemotaxis and the Pathogenic Life Cycle of the Spirochete.

Borrelia burgdorferi possesses a sophisticated chemotaxis signaling system; however, the roles of the majority of the chemotaxis proteins in the infectious life cycle have not yet been demonstrated. Specifically, the role of CheD during host colonization has not been demonstrated in any bacterium. Here, we systematically characterized the B. burgdorferi CheD homolog using genetics and biochemical and mouse-tick-mouse infection cycle studies. Bacillus subtilis CheD plays an important role in chemotaxis by deamidation of methyl-accepting chemotaxis protein receptors (MCPs) and by increasing the receptor kinase activity or enhancing CheC phosphatase activity, thereby regulating the levels of the CheY response regulator. Our biochemical analysis indicates that B. burgdorferi CheD significantly enhances CheX phosphatase activity by specifically interacting with the phosphatase. Moreover, CheD specifically binds two of the six MCPs, indicating that CheD may also modulate the receptor proteins. Although the motility of the cheD mutant cells was indistinguishable from that of the wild-type cells, the mutant did exhibit reduced chemotaxis. Importantly, the mutant showed significantly reduced infectivity in C3H/HeN mice via needle inoculation. Mouse-tick-mouse infection assays indicated that CheD is dispensable for acquisition or transmission of spirochetes; however, the viability of cheD mutants in ticks is marginally reduced compared to that of the wild-type or complemented cheD spirochetes. These data suggest that CheD plays an important role in the chemotaxis and pathogenesis of B. burgdorferi We propose potential connections between CheD, CheX, and MCPs and discuss how these interactions play critical roles during the infectious life cycle of the spirochete.

A retrospective comparison of ring pessary and multicomponent behavioral therapy in managing overactive bladder.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) is a physically, psychologically, and socially disabling condition that affects millions of women worldwide and is especially prevalent postmenopause. The objective of our study was to compare the cure rates of ring pessary with those of multicomponent behavioral therapy in managing overactive bladder. METHODS: We performed a comparative retrospective parallel cohort study of all women whose overactive bladder was treated with multicomponent behavioral therapy or ring pessary over a 42-month period. At the end of the 6-month treatment period, cure was defined as the subjective (self-reported) absence of urinary urgency, frequency, nocturia, and urge incontinence in the preceding 30 days; the objective absence of these symptoms in a 7-day voiding diary; and a Patient Global Impression of Improvement response of "much better" or "very much better." RESULTS: Ring pessary and multicomponent behavioral therapy had similar cure rates (29 out of 150 [19 %] vs 46 out of 231 [20 %] respectively, P = 0.889; OR of 1.04, 95 % confidence interval 0.618-1.742, P = 0.887). They also produced comparable cure rates in premenopausal (4 out of 31 [13 %] vs 14 out of 68 [21 %], P = 0.358) and postmenopausal subjects (25/ out of 19 [21 %] vs 32 out of 163 [20 %], P = 0.776), and in women who had undergone previous treatment (21 out of 108 [19 %] vs 31 out of 176 [18 %], P = 0.699) and those who had not (8 out of 42 [19 %] vs 15 out of 55 [27 %], P = 0.345). Logistic regression showed that neither treatment outcome is significantly associated with demographic characteristics; Pelvic Organ Prolapse Quantification at the anterior and posterior vaginal walls and at the vaginal cuff; previous treatment; overactive bladder symptoms; pad usage; or any combination thereof. CONCLUSIONS: Ring pessary has a cure rate similar to that of multicomponent behavioral therapy in managing overactive bladder.

Critical structure sparing in stereotactic ablative radiotherapy for central lung lesions: helical tomotherapy vs. volumetric modulated arc therapy.

BACKGROUND: Helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT) are both advanced techniques of delivering intensity-modulated radiotherapy (IMRT). Here, we conduct a study to compare HT and partial-arc VMAT in their ability to spare organs at risk (OARs) when stereotactic ablative radiotherapy (SABR) is delivered to treat centrally located early stage non-small-cell lung cancer or lung metastases. METHODS: 12 patients with centrally located lung lesions were randomly chosen. HT, 2 & 8 arc (Smart Arc, Pinnacle v9.0) plans were generated to deliver 70 Gy in 10 fractions to the planning target volume (PTV). Target and OAR dose parameters were compared. Each technique's ability to meet dose constraints was further investigated. RESULTS: HT and VMAT plans generated essentially equivalent PTV coverage and dose conformality indices, while a trend for improved dose homogeneity by increasing from 2 to 8 arcs was observed with VMAT. Increasing the number of arcs with VMAT also led to some improvement in OAR sparing. After normalizing to OAR dose constraints, HT was found to be superior to 2 or 8-arc VMAT for optimal OAR sparing (meeting all the dose constraints) (p = 0.0004). All dose constraints were met in HT plans. Increasing from 2 to 8 arcs could not help achieve optimal OAR sparing for 4 patients. 2/4 of them had 3 immediately adjacent structures. CONCLUSION: HT appears to be superior to VMAT in OAR sparing mainly in cases which require conformal dose avoidance of multiple immediately adjacent OARs. For such cases, increasing the number of arcs in VMAT cannot significantly improve OAR sparing.

Perception of cancer recurrence risk: more information is better.

OBJECTIVE: Breast cancer is the most common cancer among women worldwide. Given the advances in extending survival, the number of recently diagnosed breast cancer patients and longer-term breast cancer survivors is growing. The goals of this study were to better understand (1) perceptions of provider cancer recurrence risk communication, (2) perceived risk of breast cancer recurrence in cancer patients and survivors, and (3) accuracy of perceived risk. METHODS: A survey was conducted on women with a prior breast cancer (n=141). RESULTS: Approximately 40% of women perceived that providers had not talked about their breast cancer recurrence risk; although only 1 person reported not wanting a physician to talk to her about her risk. Women were largely inaccurate in their assessments of risk. Greater worry, living in a rural area, and longer time since diagnosis were associated with greater inaccuracy. Women tended to think about distal recurrence of cancer as often of local recurrence. CONCLUSIONS: Perceived risk of breast cancer recurrence was inaccurate, and patients desired more communication about recurrence risk. PRACTICE IMPLICATIONS: Consistent with findings from other studies, greater efforts are needed to improve the communication of cancer recurrence risk to patients. Attention should be paid to those from rural areas and to distal cancer recurrence in women with a previous history of breast cancer.

A cross-sectional survey of the relationship between fecal incontinence and constipation.

INTRODUCTION AND HYPOTHESIS: We compared the prevalence of fecal incontinence between constipated and nonconstipated women and correlated its prevalence with the number of Rome III constipation symptoms. METHODS: We performed a cross-sectional survey to evaluate the prevalence of fecal incontinence and constipation among women who presented to two gynecologic clinics for routine care over a 24-month period. Fecal incontinence was defined as loss of well-formed and/or loose stool beyond the patient's control that occurred at least once in the last 4 weeks, was bothersome, had been present for the past 3 or more months, and had affected the person's activities, relationships, or feelings. Constipation was diagnosed using the Rome III criteria. Our study was exempt from institutional review board approval because it was a survey and did not ask for information that could be used to identify the participant. RESULTS: Mean age of the 2,319 participants was 50.1 ± 15 years and mean body mass index (BMI) was 28.7 ± 7. Seven hundred and twenty-five (31 %) women had constipation, and 233 (10 %) had fecal incontinence. One hundred and one (43 %) incontinent women had coexisting constipation. Logistic regression analysis identified white race (p = .013), menopause (p = .010), and constipation (p = .004) as risk factors for fecal incontinence. After controlling for these risk factors, constipated women were more likely to have fecal incontinence than nonconstipated women [relative risk (RR) 1.60, 95 % confidence interval (CI) 1.26-2.05]. In addition, the prevalence of fecal incontinence was strongly associated with the number of Rome III constipation symptoms (p < .001). CONCLUSION: Constipation is an important risk factor for fecal incontinence.

Identification of a novel marker associated with risk for delayed chemotherapy-induced vomiting.

PURPOSE: Besides chemotherapy drugs, a number of patient-related factors (i.e., gender, age, history of alcohol consumption, and/or motion sickness) may be used to calculate the risk for chemotherapy-induced vomiting. We evaluated data with the intent of identifying a unique variable associated with delayed vomiting in patients receiving moderately emetogenic chemotherapy (MEC). METHODS: From an ongoing research study, the serotonin metabolite, 5-hydroxyindole acetic acid (5-HIAA), creatinine, and substance P were measured over a 72-h period in 25 patients receiving MEC. All patients were treated with a 5-hydroxytryptamine-3 receptor antagonist plus dexamethasone according to published guidelines; none received aprepitant prophylactically. Urine 5-HIAA/creatinine and serum substance P values were grouped according to the development (+) or absence (-) of delayed emesis. Baseline mean values associated with the two neurotransmitters were analyzed by analysis of variance. RESULTS: Eleven patients developed moderate to severe delayed vomiting; the other 14 were symptom-free. The pretreatment log (mean 5-HIAA/creatinine) was 1.22 and 1.81 in the (+) and (-) emesis groups, respectively, p = 0.0049; the pretreatment log (mean substance P) for the same respective groups was 5.33 and 4.09 pg/mL, p > 0.05. The log (mean ratio of substance P to 5-HIAA/creatinine) between-group difference in those with and without emesis was 4.53 and 2.52, respectively, p = 0.0002. The 5-HIAA/creatinine and ratio of substance P to 5-HIAA/creatinine data were also used to determine cutoff points which resulted in the optimal predictive accuracy. CONCLUSIONS: These preliminary findings suggest that an elevated pretreatment ratio of substance P to 5-HIAA/creatinine >70 is associated with the development of delayed vomiting induced by MEC.

A retrospective cohort study of perioperative management on the morbidity of urogynecologic surgery.

INTRODUCTION AND HYPOTHESIS: To determine whether premenopausal and early (<70) and late postmenopausal women whose comorbidities were screened and managed using a standardized protocol experienced comparable perioperative complications after urogynecologic surgery. METHODS: We retrospectively reviewed the charts of all women who presented for surgical management of their pelvic floor disorders over 4.5 years for any complications, which occurred intraoperatively to 6 weeks postoperatively. RESULTS: Late postmenopausal women underwent more vaginal (100/124, 159/246, and 226/288, p < 0.001) and obliterative (15/124, 0/246, and 4/288, p < 0.001), and fewer abdominal (9/124, 87/246, and 58/288, p < 0.001) procedures and had lower body mass index (27.1, 31.4, and 29.4, P < 0.001) and fewer smokers (4/124, 86/246, and 52/288, p < 0.001) than premenopausal and early postmenopausal subjects. After adjusting for these differences, the proportions that experienced perioperative complications were similar among the three groups (P = 0.789). CONCLUSIONS: With standardized screening and management, our premenopausal and early and late postmenopausal women experienced similar perioperative complications.

A prospective cohort study of pelvic support changes among nulliparous, multiparous, and pre- and post-menopausal women.

OBJECTIVE(S): To evaluate whether vaginal delivery affects maternal pelvic support beyond the puerperium by comparing pelvic support changes between nulliparas and multiparas, and whether menopause predisposes women to develop prolapse that protrudes beyond the hymen by comparing its occurrence between pre- and post-menopausal subjects. STUDY DESIGN: Women who presented to our gynecology clinic for routine care and returned for follow-up after 36 ± 3 months were evaluated for pelvic support changes using the Pelvic Organ Prolapse Quantification, which measured changes in 1-cm increments. Exclusion criteria were women who were seen in the urogynecology clinic or had hysterectomy, vaginal repair, continence procedure, childbirth during the study period, or radiation therapy. RESULTS: The proportion that experienced a 1-cm (21/101 vs. 27/164, p=0.374) and at least a 2-cm (5/101 vs. 9/164, p=0.849) descent of the leading edge of prolapse was similar between our 101 nulliparous and 164 multiparous subjects. At the initial examination, nine multiparas and one nullipara had prolapse outside the hymen (9/164 vs. 1/101, p=0.056). The proportion that developed pelvic support defect, which protruded beyond the hymen, was similar between the two groups (1/100 vs. 5/155, p=0.243). Eighty-five of our 265 subjects were post-menopausal while 180 were pre-menopausal. The proportions that developed a 1-cm (18/85 vs. 30/180, p=0.374) and at least a 2-cm (7/85 vs. 7/180, p=0.140) descent of the leading edge of prolapse were similar between the two groups. Eight post-menopausal and two pre-menopausal women had prolapse outside the hymen at the initial examination (8/85 vs. 2/180, p=0.002). More post-menopausal subjects developed support defect, which protruded beyond the hymen, than their pre-menopausal counterparts (5/77 vs. 1/178, p=0.010). Logistic regression showed that menopause (p=0.019) is an independent risk factor for developing prolapse which protruded outside the hymen, while parity (p=0.168) and interaction between menopause and parity (p=0.606) are not significantly associated with its occurrence. CONCLUSION(S): Vaginal birth has little effect on the pelvic support changes beyond the puerperium while menopause predisposes women to prolapse their pelvic organ outside the hymen.

Higher infused CD34+ cell dose and overall survival in patients undergoing in vivo T-cell depleted, but not t-cell repleted, allogeneic peripheral blood hematopoietic cell transplantation.

BACKGROUND AND OBJECTIVES: Understanding the effect of cellular graft composition on allogeneic hematopoietic cell transplantation (AHCT) outcomes is an area of great interest. The objective of the study was to analyze the correlation between transplant-related outcomes and administered CD34+, CD3+, CD4+ and CD8+ cell doses in patients who had undergone peripheral blood, AHCT and received either in vivo T-cell depleted or T-cell replete allografts. DESIGN AND SETTING: Comparison of consecutive patients who underwent peripheral blood AHCT in our institution between January 2003 and December 2009. PATIENTS AND METHODS: The cohort of 149 patients was divided into two groups; non T-cell depleted (NTCD) (n=54) and T-cell depleted (TCD) (n=95). Study endpoints were overall survival (OS), progression free survival (PFS), engraftment kinetics (neutrophil and platelet recovery), incidence of acute graft versus host disease (acute GVHD), chronic GVHD, nonrelapse mortality (NRM) and disease relapse. RESULTS: Multivariate analysis showed that higher infused CD34+ cell dose improved OS (relative risk 0.58, 95% CI 0.34-0.98, P=.04), PFS (relative risk 0.59, 95% CI 0.35-1.00, P=.05) and NRM (relative risk 0.49, 95% CI 0.24-0.99, P=.048) in the TCD group. By multivariate analysis, there was no difference in engraftment, grades II-IV acute GVHD, extensive chronic GVHD and relapse in the two groups relative to the infused cell doses. There was a trend towards improved OS (relative risk 0.54, 95% CI 0.29-1.01, P=.05) with higher CD3+ cell dose in the TCD group. CONCLUSION: Our findings suggest that higher CD34+ cell dose imparts survival benefit only to in vivo TCD peripheral blood AHCT recipients.

Testicular torsion: a case study and evaluation of young men's knowledge about testicular pain.

PURPOSE: This study examines an illustrative case, and investigates the knowledge of 267 freshman males regarding testicular torsion (TT). In addition, we discuss the predisposing factors and common presentations of TT, and highlight the importance of seeking immediate care for testicular pain. METHODS: A case is presented and a study was done in which participants were asked to complete the anonymous "Men's Health Questionnaire" as they entered one of three university dining halls. RESULTS: Many, 48%, chose the correct response to sudden, severe testicular pain, however 39% chose to delay care. Most were never taught the significance of testicular pain or about TT. Our case report illustrates testicular loss as an end result of delayed presentation. CONCLUSIONS: Education of young men regarding TT is needed. This could lead to a decrease in delayed care seeking, and thus reduced testicular loss due to torsion.

Analysis of the HD-GYP domain cyclic dimeric GMP phosphodiesterase reveals a role in motility and the enzootic life cycle of Borrelia burgdorferi.

HD-GYP domain cyclic dimeric GMP (c-di-GMP) phosphodiesterases are implicated in motility and virulence in bacteria. Borrelia burgdorferi possesses a single set of c-di-GMP-metabolizing enzymes, including a putative HD-GYP domain protein, BB0374. Recently, we characterized the EAL domain phosphodiesterase PdeA. A mutation in pdeA resulted in cells that were defective in motility and virulence. Here we demonstrate that BB0374/PdeB specifically hydrolyzed c-di-GMP with a K(m) of 2.9 nM, confirming that it is a functional phosphodiesterase. Furthermore, by measuring phosphodiesterase enzyme activity in extracts from cells containing the pdeA pdeB double mutant, we demonstrate that no additional phosphodiesterases are present in B. burgdorferi. pdeB single mutant cells exhibit significantly increased flexing, indicating a role for c-di-GMP in motility. Constructing and analyzing a pilZ pdeB double mutant suggests that PilZ likely interacts with chemotaxis signaling. While virulence in needle-inoculated C3H/HeN mice did not appear to be altered significantly in pdeB mutant cells, these cells exhibited a reduced ability to survive in Ixodes scapularis ticks. Consequently, those ticks were unable to transmit the infection to naïve mice. All of these phenotypes were restored when the mutant was complemented. Identification of this role of pdeB increases our understanding of the c-di-GMP signaling network in motility regulation and the life cycle of B. burgdorferi.

Analysis of the Borrelia burgdorferi cyclic-di-GMP-binding protein PlzA reveals a role in motility and virulence.

The cyclic-dimeric-GMP (c-di-GMP)-binding protein PilZ has been implicated in bacterial motility and pathogenesis. Although BB0733 (PlzA), the only PilZ domain-containing protein in Borrelia burgdorferi, was reported to bind c-di-GMP, neither its role in motility or virulence nor it's affinity for c-di-GMP has been reported. We determined that PlzA specifically binds c-di-GMP with high affinity (dissociation constant [K(d)], 1.25 µM), consistent with K(d) values reported for c-di-GMP-binding proteins from other bacteria. Inactivation of the monocistronically transcribed plzA resulted in an opaque/solid colony morphology, whereas the wild-type colonies were translucent. While the swimming pattern of mutant cells appeared normal, on swarm plates, mutant cells exhibited a significantly reduced swarm diameter, demonstrating a role of plzA in motility. Furthermore, the plzA mutant cells were significantly less infectious in experimental mice (as determined by 50% infectious dose [ID(50)]) relative to wild-type spirochetes. The mutant also had survival rates in fed ticks lower than those of the wild type. Consequently, plzA mutant cells failed to complete the mouse-tick-mouse infection cycle, indicating plzA is essential for the enzootic life cycle of B. burgdorferi. All of these defects were corrected when the mutant was complemented in cis. We propose that failure of plzA mutant cells to infect mice was due to altered motility; however, the possibility that an unidentified factor(s) contributed to interruption of the B. burgdorferi enzootic life cycle cannot yet be excluded.

Suicide and unintentional poisoning mortality trends in the United States, 1987-2006: two unrelated phenomena?

BACKGROUND: Two counter trends in injury mortality have been separately reported in the US in recent times - a declining suicide rate and a rapidly rising unintentional poisoning mortality rate. Poisoning suicides are especially difficult to detect, and injury of undetermined intent is the underlying cause-of-death category most likely to reflect this difficulty. We compare suicide and poisoning mortality trends over two decades in a preliminary assessment of their independence and implications for suicide misclassification. METHODS: Description of overall and gender- and age-specific trends using national mortality data from WISQARS, the Web-based Injury Statistics Query and Reporting System, maintained by the Centers for Disease Control and Prevention (CDC). Subjects were the 936,633 residents dying in the 50 states and the District of Columbia between 1987 and 2006 whose underlying cause of death was classified as suicide, unintentional poisoning, or injury mortality of undetermined intent. RESULTS: The official US suicide rate declined 18% between 1987 and 2000, from 12.71 to 10.43 deaths per 100,000 population. It then increased to 11.15 deaths per 100,000 by 2006, a 7% rise. By contrast to these much smaller rate changes for suicide, the unintentional poisoning mortality rate rose more than fourfold between 1987 and 2006, from 2.19 to 9.22 deaths per 100,000. Only the population aged 65 years and older showed a sustained decline in the suicide rate over the entire observation period. Consistently highest in gender-age comparisons, the elderly male rate declined by 35%. The elderly female rate declined by 43%. Unlike rate trends for the non-elderly, both declines appeared independent of corresponding mortality trends for unintentional poisoning and poisoning of undetermined intent. The elderly also deviated from younger counterparts by having a smaller proportion of their injury deaths of undetermined intent classified as poisoning. Poisoning manifested as a less common method of suicide for this group than other decedents, except for those aged 15-24 years. Although remaining low, the undetermined poisoning mortality rate increased over the observation period. CONCLUSIONS: The official decline in the suicide rate between 1987 and 2000 may have been a partial artifact of misclassification of non-elderly suicides within unintentional poisoning mortality. We recommend in-depth national, regional, and local population-based research investigations of the poisoning-suicide nexus, and endorse calls for widening the scope of the definition of suicide and evaluation of its risk factors.

Estimation of a valuation function for a diabetes mellitus-specific preference-based measure of health: the Diabetes Utility Index.

Preference-based measures of health (PBMH) provide 'preference' or 'utility' weights that enable the calculation of QALYs for the economic evaluations of interventions. The Diabetes Utility Index (DUI) was developed as a brief, self-administered, diabetes mellitus-specific PBMH that can efficiently estimate patient-derived health state utilities. To describe the development of the valuation function for the DUI, and to report the validation results of the valuation function. Multi-Attribute Utility Theory (MAUT) was used as the framework to develop a valuation function for the DUI. Twenty of 768 possible health states of the DUI classified as anchor states, single-attribute level states including corner states, and marker states were selected and described for preference elicitation interviews. Visual analogue scale and standard gamble (SG) exercises were used to measure preferences from individuals with diabetes recruited from primary care and community settings in and around Morgantown, WV, USA for the 20 health states defined by combinations of DUI attributes and severity levels. Data collected in the interviews were used to develop a valuation function that calculates utilities for the DUI health states and calculates attribute-level utilities. A validation survey of the valuation function was conducted in collaboration with the West Virginia University (WVU) Diabetes Institute. A total of 100 individuals with diabetes were interviewed and their preferences for various DUI health states measured. From data generated in the interviews, a DUI valuation function was developed on a scale where 1.00 = perfect health (PH) and 0.00 = the all worse 'pits' state, and adjusted to yield utilities on the conventional scale 1.00 = PH and 0.00 = dead. A total of 396 patients with diabetes who received care at WVU clinics completed a DUI mail validation survey (response rate = 33%). Clinical data consisting of International Classification of Diseases, 9th edition, diagnosis codes and glycosylated haemoglobin (HbA(1c)) values for the respondents were merged with their responses to the DUI. The utilities calculated by the scoring function of the DUI compared favourably to cardinal SG utilities for three DUI health states for which both assessments were available. The DUI utility function slightly underestimated actual SG utilities for mild and moderate health states (mean absolute difference = 0.05). There was a small but significant correlation between DUI utility scores and average past year HbA(1c) values (r = -0.30; p < 0.001). Respondents with two or more complications had significantly lower DUI utilities than those with no complications (p < 0.001) or one complication (p = 0.015). Insulin users had significantly lower DUI utilities than non-users (p < 0.001), and those with HbA(1c) values <7% had significantly higher DUI utilities than those with HbA(1c) values of >or=7% (p < 0.001). No significant association was found between DUI scores and age or sex. These results show evidence of the feasibility and validity of the DUI. Further research is suggested to demonstrate the generalizability of these findings, to study the responsiveness of the DUI, and to examine the clinical meaningfulness of DUI change scores.

Concordance between substance P levels and antiemetic guidelines.

Practice guidelines now include an antagonist of the substance P/NK1 (neurokinin 1) receptor pathway as part of the standard antiemetic regimen for patients receiving highly, as well as certain moderately, emetogenic chemotherapy regimens. Accumulated laboratory data were used to determine the degree of concordance between substance P levels and the current antiemetic guidelines. Five blood samples were collected over 72 hours from 22 adult patients treated with cisplatin-containing chemotherapy regimens. Overall, the mean baseline substance P level was 318 pg/mL. Although increases in substance P were observed during both phases of the emetic response, analysis by least squares means grouped by cisplatin dosage and vomiting phase was significantly different (P< 0.0001). Preliminary analysis of substance P levels appears to provide additional justification for including the NK1 receptor antagonist in the current antiemetic practice guidelines. In addition, these data provide biochemical justification for the cisplatin dosage criterion used in clinical trials.

Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain.

STUDY DESIGN: The effectiveness and efficacy of Iyengar yoga for chronic low back pain (CLBP) were assessed with intention-to-treat and per-protocol analysis. Ninety subjects were randomized to a yoga (n = 43) or control group (n = 47) receiving standard medical care. Participants were followed 6 months after completion of the intervention. OBJECTIVE: This study aimed to evaluate Iyengar yoga therapy on chronic low back pain. Yoga subjects were hypothesized to report greater reductions in functional disability, pain intensity, depression, and pain medication usage than controls. SUMMARY OF BACKGROUND DATA: CLBP is a musculoskeletal disorder with public health and economic impact. Pilot studies of yoga and back pain have reported significant changes in clinically important outcomes. METHODS: Subjects were recruited through self-referral and health professional referrals according to explicit inclusion/exclusion criteria. Yoga subjects participated in 24 weeks of biweekly yoga classes designed for CLBP. Outcomes were assessed at 12 (midway), 24 (immediately after), and 48 weeks (6-month follow-up) after the start of the intervention using the Oswestry Disability Questionnaire, a Visual Analog Scale, the Beck Depression Inventory, and a pain medication-usage questionnaire. RESULTS: Using intention-to-treat analysis with repeated measures ANOVA (group x time), significantly greater reductions in functional disability and pain intensity were observed in the yoga group when compared to the control group at 24 weeks. A significantly greater proportion of yoga subjects also reported clinical improvements at both 12 and 24 weeks. In addition, depression was significantly lower in yoga subjects. Furthermore, while a reduction in pain medication occurred, this was comparable in both groups. When results were analyzed using per-protocol analysis, improvements were observed for all outcomes in the yoga group, including agreater trend for reduced pain medication usage. Although slightly less than at 24 weeks, the yoga group had statistically significant reductions in functional disability, pain intensity, and depression compared to standard medical care 6-months postintervention. CONCLUSION: Yoga improves functional disability, pain intensity, and depression in adults with CLBP. There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group.