The Impact of Spirituality and Religiosity on Mental Health and Quality of Life of Patients with Active Crohn's Disease.

We aim to investigate the association among religious/spiritual coping (RSC), quality of life (QOL), and mental health in patients with active Crohn's disease (CD). This cross-sectional study included 102 patients with active CD. Religious and spiritual beliefs were common among patients, being positive RSC higher than negative RSC. Negative coping was associated with mood disorders (depressive or anxiety symptoms) through the Hospital Anxiety and Depression Scale (ß = 0.260, p < 0.01) but not with QOL (Inflammatory Bowel Disease Questionnaire) (ß = - 0.105, p = NS) after adjustments. Positive coping and other religious/spiritual beliefs and behaviors were not associated with either QOL or mental health. This study suggests that a negative RSC is associated with worse mental health outcomes. This may detrimentally impact adaptations to deal with CD in the active phase, although patients generally tend to use more common positive strategies. These findings may increase the awareness of health professionals while dealing with spiritual beliefs in patients with CD.

Early Evidence for Zika Virus Circulation among Aedes aegypti Mosquitoes, Rio de Janeiro, Brazil.

During 2014-2016, we conducted mosquito-based Zika virus surveillance in Rio de Janeiro, Brazil. Results suggest that Zika virus was probably introduced into the area during May-November 2013 via multiple in-country sources. Furthermore, our results strengthen the hypothesis that Zika virus in the Americas originated in Brazil during October 2012-May 2013.

Thieno[2,3-b]pyridine derivatives: a new class of antiviral drugs against Mayaro virus.

Mayaro virus (MAYV) is an arthropod-borne virus and a member of the family Togaviridae, genus Alphavirus. Its infection leads to an acute illness accompanied by long-lasting arthralgia. To date, there are no antiviral drugs or vaccines against infection with MAYV and resources for the prevention or treatment of other alphaviruses are very limited. MAYV has served as a model to study the antiviral potential of several substances on alphavirus replication. In this work we evaluated the antiviral effect of seven new derivatives of thieno[2,3-b]pyridine against MAYV replication in a mammalian cell line. All derivatives were able to reduce viral production effectively at concentrations that were non-toxic for Vero cells. Molecular modeling assays predicted low toxicity risk and good oral bioavailability of the substances in humans. One of the molecules, selected for further study, demonstrated a strong anti-MAYV effect at early stages of replication, as it protected pre-treated cells and also during the late stages, affecting virus morphogenesis. This study is the first to demonstrate the antiviral effect of thienopyridine derivatives on MAYV replication in vitro, suggesting the potential application of these substances as antiviral molecules against alphaviruses. Additional in vivo research will be needed to expand the putative therapeutic applications.

Transcutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms and its impact on health-related quality of life in patients with Parkinson disease: a randomized controlled trial.

PURPOSE: A randomized controlled trial study was performed to evaluate the efficacy of transcutaneous tibial nerve stimulation (TTNS) and sham TTNS, in patients with Parkinson disease (PD) with lower urinary tract symptoms (LUTS). DESIGN: Randomized controlled trial. SUBJECTS AND SETTINGS: Thirteen patients with a diagnosis of PD and bothersome LUTS were randomly allocated to one of the following groups: Group I: TTNS group (n = 8) and group II: Sham group (n = 5). Both groups attended twice a week during 5 weeks; each session lasted 30 minutes. METHODS: Eight patients received TTNS treatment and 5 subjects allocated to group II were managed with sham surface electrodes that delivered no electrical stimulation. Assessments were performed before and after the treatment; they included a 3-day bladder diary, Overactive Bladder Questionnaire (OAB-V8), and the International Consultation on Incontinence Quality of Life Questionnaire Short Form (ICIQ-SF), and urodynamic evaluation. RESULTS: Following 5 weeks of treatment, patients allocated to TTNS demonstrated statistically significant reductions in the number of urgency episodes (P = .004) and reductions in nocturia episodes (P < .01). Participants allocated to active treatment also showed better results after treatment in the OAB-V8 and ICIQ-SF scores (P < .01, respectively). Urodynamic testing revealed that patients in the active treatment group showed improvements in intravesical volume at strong desire to void (P < .05) and volume at urgency (P < .01) when compared to subjects in the sham treatment group. CONCLUSION: These findings suggest that TTNS is effective in the treatment of LUTS in patients with PD, reducing urgency and nocturia episodes and improving urodynamic parameters as well as symptom scores measured by the OAB-V8 and health-related quality-of-life scores measured by the ICIQ-SF.

Dengue virus transmission by blood stem cell donor after travel to Sri Lanka; Germany, 2013.

Three days after donation of peripheral blood stem cells to a recipient with acute myeloblastic leukemia, dengue virus was detected in the donor, who had recently traveled to Sri Lanka. Transmission to the recipient, who died 9 days after transplant, was confirmed.

Phytotoxicity and cytogenotoxicity of pesticide mixtures: analysis of the effects of environmentally relevant concentrations on the aquatic environment.

In this study, we investigate the toxicity of commercial formulations based on glyphosate, 2,4-D, imidacloprid, and iprodione, in isolation and mixed, on Allium cepa. The mixtures consisted of combinations in the lowest (M1), intermediate (M2), and highest concentrations (M3) of each pesticide. We measured physiological (germination rate, germination speed, and radicular length) and cyto-genotoxic (mitotic index and frequency of aberrant cells) parameters. In addition, we analyzed the cell cycle progression and cell death induction by flow cytometry. When applied in isolation, the pesticides changed the parameters evaluated. M1 and M2 inhibited root length and increased the frequency of aberrant cells. Their genotoxic effect was equivalent to that of pesticides applied in isolation. Furthermore, M1 and M2 caused cell death and M2 changed the cell cycle progression. M3 had the greatest deleterious effect on A. cepa. This mixture inhibited root length and promoted an additive or synergistic effect on the mitotic index. In addition, M3 changed all parameters analyzed by flow cytometry. This research clearly demonstrates that the pesticides tested, and their mixtures, may pose a risk to non-target organisms.

From species descriptions to diversity patterns: the validation of taxonomic data as a keystone for ant diversity studies reproducibility and accuracy.

Research findings in natural sciences need to be comparable and reproducible to effectively improve our understanding of ecological and behavioural patterns. In this sense, knowledge frontiers in biodiversity studies are directly tied to taxonomic research, especially in species-rich tropical regions. Here we analysed the taxonomic information available in 470 studies on Brazilian ant diversity published in the last 50 years. We aimed to quantify the proportion of studies that provide enough data to validate taxonomic identification, explore the frequency of studies that properly acknowledge their taxonomic background, and investigate the primary resources for ant identification in Brazil. We found that most studies on Brazilian ant diversity (73.6%) explicitly stated the methods used to identify their specimens. However, the proportion of papers that provide complete data for the repository institutions and vouchered specimens is vanishingly small (5.8%). Additionally, only 40.0% of the studies consistently presented taxon authorities and years of description, rarely referencing taxonomic publications correctly. In turn, the number of specialists and institutions consulted for ant identification in Brazil has increased in the last years, along with the number of studies that explicitly provide their taxonomic procedures for ant identification. Our findings highlight a shift between generations regarding the recognition of taxonomy as fundamental science, deepening our understanding of biodiversity.

N-acetylcysteine prevents pulmonary edema and acute kidney injury in rats with sepsis submitted to mechanical ventilation.

Sepsis is a common cause of acute kidney injury (AKI) and acute lung injury. Oxidative stress plays as important role in such injury. The aim of this study was to evaluate the effects that the potent antioxidant N-acetylcysteine (NAC) has on renal and pulmonary function in rats with sepsis. Rats, treated or not with NAC (4.8 g/l in drinking water), underwent cecal ligation and puncture (CLP) 2 days after the initiation of NAC treatment, which was maintained throughout the study. At 24 h post-CLP, renal and pulmonary function were studied in four groups: control, control + NAC, CLP, and CLP + NAC. All animals were submitted to low-tidal-volume mechanical ventilation. We evaluated respiratory mechanics, the sodium cotransporters Na-K-2Cl (NKCC1) and the α-subunit of the epithelial sodium channel (α-ENaC), polymorphonuclear neutrophils, the edema index, oxidative stress (plasma thiobarbituric acid reactive substances and lung tissue 8-isoprostane), and glomerular filtration rate. The CLP rats developed AKI, which was ameliorated in the CLP + NAC rats. Sepsis-induced alterations in respiratory mechanics were also ameliorated by NAC. Edema indexes were lower in the CLP + NAC group, as was the wet-to-dry lung weight ratio. In CLP + NAC rats, α-ENaC expression was upregulated, whereas that of NKCC1 was downregulated, although the difference was not significant. In the CLP + NAC group, oxidative stress was significantly lower and survival rates were significantly higher than in the CLP group. The protective effects of NAC (against kidney and lung injury) are likely attributable to the decrease in oxidative stress, suggesting that NAC can be useful in the treatment of sepsis.

Childhood enuresis is a risk factor for bladder dysfunction in adult life?

AIMS: To verify the relationship between enuresis in childhood and the type of urinary incontinence in adults, considering the gender and age. METHODS: In this retrospective cohort study the database used contained the records of patients who had with urinary complaints and underwent urodynamic studies in the period from 1999 to 2008. A multinomial logistic regression model was adjusted for the type of UI. RESULTS: A total of 661 patient records were analyzed, 585 (88.5%) women and 76 (11.5%) men, with mean age 54 (SD = 13.3). Patients with urge urinary incontinence (UUI) were compared to those with stress urinary incontinence (SUI) and the variables associated were the presence of enuresis in childhood (OR = 2.37, IC: 1.43-3.92) and age >50 years (OR = 2.64, CI: 1.68-4.15). Comparing patients with mixed urinary incontinence (MUI) and SUI, the presence of enuresis was also associated ((OR = 1.77, CI: 1.15-2.73) and the age of more than 50 years (OR = 1.71, CI: 1.19-2.44). For both categories of urinary incontinence, the variable sex was not associated. CONCLUSIONS: Individuals with MUI and UUI in adult life were more likely to have a history of enuresis in childhood than those with SUI.

A RT-PCR method for selective amplification and phenotypic characterization of all three serotypes of Sabin-related polioviruses from viral mixtures.

Outbreaks caused by vaccine-derived polioviruses are challenging the final eradication of paralytic poliomyelitis. Therefore, the surveillance of the acute flaccid paralysis cases based on poliovirus isolation and characterization remains an essential activity. Due to the use of trivalent oral poliovirus vaccine (OPV), mixtures containing more than one serotype of Sabin-related polioviruses are frequently isolated from clinical samples. Because each poliovirus isolate needs to be individually analyzed, we designed polymerase chain reaction primers that can selectively distinguish and amplify a genomic segment of the three Sabin-related poliovirus serotypes present in mixtures, thus, optimizing the diagnosis and providing prompt information to support epidemiologic actions.

Comparison of intraocular pressure measurements between the Tono-Pen XL® and Perkins® applanation tonometers in dogs and cats.

OBJECTIVE: To compare the accuracy between two applanation tonometers, Tono-Pen XL(®) and Perkins(®), in ophthalmoscopically normal dogs and cats. ANIMALS: Both eyes of 25 conscious and healthy dogs and cats were evaluated. Both eyes of five dogs and cats immediately after sacrifice were used as controls for the postmortem study. PROCEDURE: In conscious animals, the tonometry was performed with topical anesthesia using 0.5% proxymetacaine eye drops for both tonometers and 1% fluorescein eye drops for the Perkins tonometer. Readings of intraocular pressure (IOP) in the postmortem study were taken using manometry and tonometry by Tono-Pen XL(®) and Perkins(®). RESULTS: The correlation coefficient (r(2) ) in dogs between manometry and applanation tonometers Tono-Pen XL(®) and Perkins(®) were, respectively, 0.896 and 0.981 and in cats were 0.905 and 0.988. The mean IOP values in conscious dogs with Tono-Pen XL(®) and Perkins(®) were, respectively, 17.5 ± 3.7 mmHg (10.0-25.0 mmHg) and 15.3 ± 2.1 mmHg (12.0-19.8 mmHg) and in conscious cats were 16.8 ± 3.6 mmHg (10.5-24.5 mmHg) and 15.5 ± 1.3 mmHg (13.0-18.5 mmHg). CONCLUSION: There was a strong correlation between the IOP values obtained by direct ocular manometry and the Tono-Pen XL(®) and Perkins(®) tonometers in dogs and cats. There was no statistically significant difference between the mean IOP obtained with both tonometers in conscious animals, there was, however, a difference between the minimum and mainly in the maximum values that were on average 5-6 mmHg higher with Tono-Pen XL(®) than those measured with Perkins(®), which justifies a table of normal values differentiated for each tonometer.

Assessing Cassava Flour Consumption Impact on Iodine Nutritional Status in Schoolchildren from Public Schools in Brazil.

Cassava (Manihot esculenta Crantz) is an important food source in many developing countries. This root contains cyanoglucosides, which can aggravate iodine deficiency disorders (IDDs). To analyze the impact of cassava flour consumption (CFC) on urinary iodine concentration (UIC) among schoolchildren from public schools in Bahia, Brazil. Cross-sectional study was conducted on 1231 schoolchildren (ages 6-14 years old). Anthropometric parameters, household food insecurity, UIC, and CFC were evaluated. CFC prevalence was 90.8%. The mean UIC indicated adequate iodine nutrition in group A (CFC positive) and group B (CFC negative) (203.29 ± 81.08 µg/L versus 225.98 ± 76.59 µg/L, respectively). We found that daily cassava flour intake did not significantly raise the risk of iodine deficiency (ID) (odds ratio [OR] = 1.43 [confidence interval (CI) 0.72-2.82]; p = 0.29), nor did it significantly protect against excessive iodine intake (EII) (OR = 0.70[CI 0.39-1.26]; p = 0.24). The prevalence of iodine deficiency (ID) (12.6% versus 8.9%) and EII (9.6% versus 15%) did not significantly differ between both groups. The results of this study suggest that the cyanides present in cassava flour have very little influence on iodine metabolism, which is probably justified by cassava processing methods.

Influence of Religiousness and Spirituality on Remission Rate, Mental Health, and Quality of Life of Patients With Active Crohn's Disease: A Longitudinal 2-Year Follow-up Study.

BACKGROUND AND AIMS: Studies on inflammatory bowel disease [IBD] have shown that religiousness and spirituality [R/S] were associated with better mental health and quality of life [QOL]. However, longitudinal studies assessing the impact of R/S on long-term clinical outcomes of Crohn's disease [CD] are scarce. The aim of this study was to assess the influence of R/S on the course of CD after a 2-year follow-up and to determine whether these R/S beliefs were associated with mental health and QOL. METHODS: A longitudinal 2-year follow-up study was conducted at a referral centre for IBD, including patients with moderately to severely active CD. Clinical data, disease activity [Harvey-Bradshaw Index], QOL [Inflammatory Bowel Disease Questionnaire-IBDQ], depression and anxiety [Hospital Anxiety and Depression Scale-HADS], and R/S [Duke Religion Index-DUREL, Spirituality Self-Rating Scale-SSRS, and Spiritual/Religious Coping-SRCOPE scale] were assessed at baseline and at the end of the 2-year follow-up. Linear and logistic regression models were employed. RESULTS: A total of 90 patients [88.2%] were followed up for 2 years. On logistic regression, baseline levels of spirituality (odds ratio [OR] = 1.309; 95% confidence interval [CI]= 1.104-1.552, p = 0.002) and intrinsic religiousness [OR = 1.682; 95% CI = 1.221-2.317, p = 0.001] were predictors of remission at 2 years. On linear regression, the different dimensions of R/S did not significantly predict IBDQ or anxiety and depression scores after 2 years. CONCLUSIONS: R/S predicted remission of CD patients after a 2-year follow-up. However, these beliefs failed to predict mental health or QOL. Health professionals who treat CD should be aware of the religious and spiritual beliefs of their patients, given these beliefs may impact on the disease course.

Low urinary selenium levels are associated with iodine deficiency in Brazilian schoolchildren and adolescents.

BACKGROUND: Selenium (Se) and iodine (Io) are important micronutrients for the proper functioning of the thyroid gland, as they are crucial for the synthesis and activation of the thyroid hormones (TH) triiodothyronine (T3) and thyroxine (T4). OBJECTIVE: To evaluate the Se and Io nutritional status among schoolchildren. METHODOLOGY: Cross-sectional, descriptive and analytical study conducted in 982 schoolchildren aged 6-14 years from public schools in the state of Bahia, Brazil. Sociodemographic and anthropometric variables, as well as urinary Se (USC) and Io concentrations (UIC) using the inductively coupled plasma mass spectrometry (ICP-MS) method and thyroid-stimulating hormone (TSH) from filter paper blood collection, were evaluated. RESULTS: The median USC and UIC were 38.7 and 210.0 (IQR: 26.8-52.9 and 129.3-334.1 µg/L, respectively). The prevalence of iodine deficiency and excessive UIC were observed in 17.1% and 30.9% of schoolchildren, respectively. Concomitant low USC and IoD was found in 3.9% of schoolchildren. There was a positive correlation between USC and UIC (r = 0.60; p = 0.00). The median TSH was 0.95 (IQR: 0.69-1.30 µUI/L). CONCLUSIONS: This study demonstrates that USC is a good biomarker for assessing Se status, meantime more studies are needed to establish cutoff USC in child population. Despite adequate median intake, a subgroup of schoolchildren had IoD and low USC. The correlation between UIC and USC point at the importance of two micronutrients, raising the question whether measuring Se should be included in monitoring programs that address the prevention of nutritional disturbances.

Association of Salt Iodization and Urine Iodine Concentration in Schoolchildren from Public Schools in Northeast of Brazil.

Iodine deficiency (ID) is recognized as a leading risk factor for child development. Universal salt iodization (USI) is an effective and well-established intervention strategy for the prevention of iodine deficiency disorders (IDD). To evaluate the levels of iodine in household salt samples and the urinary iodine concentration (UIC) in schoolchildren aged 6 to 14 years in public schools in Bahia, Brazil. A cross-sectional study was conducted with 1231 students (6 to 14 years old) from 17 public schools in Bahia. The iodine concentration was evaluated in salt and UIC samples. The adapted Sandell-Kolthoff reaction was used to determine urinary iodine levels. A spectrophotometer (UV-Vis) was used to examine the reduction of ceric ammonium sulfate. A standard iodine solution using a potassium iodate was used to extrapolate the iodine concentrations. The total of 665 salt samples had a median iodine concentration of 24 mg/kg (25th-75th percentile 17.0 to 28.5 mg/kg). The largest proportion (79.6%) of salt samples had iodine concentration in the recommended range, 17.6% of the samples presented iodine at a salt concentration below the established level (<15 mg/kg) and a small proportion was above it (2.8%). The general mean urinary iodine concentration (MUIC) was 217.53 ± 28.30 µg/L and median was 205.50 µg/L. The students evaluated and the salt samples analyzed showed satisfactory results, as recommended by Brazilian legislation and nutritional recommendations of the World Health Organization (WHO).

Pelvic floor muscle training in the treatment of lower urinary tract dysfunction in women with multiple sclerosis.

AIMS: Evaluate the role of pelvic floor muscle training (PFMT) on the treatment of lower urinary tract dysfunction (LUTD) in multiple sclerosis (MS) patients. METHODS: In this randomized controlled trial, twenty seven female patients with a diagnosis of MS and LUTD complaints were randomized, in two groups: Treatment group (GI) (N = 13) and Sham group (GII) (N = 14). Evaluation included urodynamic study, 24-hr Pad testing, three day voiding diary and pelvic floor evaluation according to PERFECT scheme. Intervention was performed twice a week for 12 weeks in both groups. GI intervention consisted of PFMT with assistance of a vaginal perineometer. GII received a sham treatment consisted on the introduction of a perineometer inside the vagina with no contraction required. RESULTS: At the end of the treatment GI was complaining less about storage and voiding symptoms than GII. Furthermore, differences found between groups were: reduction of pad weight (P = 0.00) (Mean: 87,51 grams initial and 6,03 grams final in GI. 69,46 grams initial and 75,88 grams final in GII), number of pads (P = 0.01) (Mean: 3,61 initial and 2,15 final in GI. 3,42 initial and 3,28 final in GII) and nocturia events (P < 0.00) (Mean: 2,38 initial and 0,46 final in GI. 2,55 initial and 2,47 final in GII) and improvements of muscle power (P = 0.00), endurance (P < 0.00), resistance (P < 0.00) and fast contractions (P < 0.00), domains of PERFECT scheme. CONCLUSIONS: PFMT is an effective approach to treat LUTD in female with MS.

Disentangling the effects of sampling scale and size on the shape of species abundance distributions.

Many authors have tried to explain the shape of the species abundance distribution (SAD). Some of them have suggested that sampling spatial scale is an important factor shaping SADs. These suggestions, however, did not consider the indirect and well-known effect of sample size, which increases as samples are combined to generate SADs at larger spatial scales. Here, we separate the effects of sample size and sampling scale on the shape of the SAD for three groups of organisms (trees, beetles and birds) sampled in the Brazilian Atlantic Forest. We compared the observed SADs at different sampling scales with simulated SADs having the same richness, relative abundances but comparable sample sizes, to show that the main effect shaping SADs is sample size and not sampling spatial scale. The effect of scale was minor and deviations between observed and simulated SADs were present only for beetles. For trees, the match between observed and simulated SADs was improved at all spatial scales when we accounted for conspecific aggregation, which was even more important than the sampling scale effect. We build on these results to propose a conceptual framework where observed SADs are shaped by three main factors, in decreasing order of importance: sample size, conspecific aggregation and beta diversity. Therefore, studies comparing SADs across sites or scales should use sampling and/or statistical approaches capable of disentangling these three effects on the shape of SADs.

Hypertension and Salt-Restrictive Diet Promotes Low Urinary Iodine Concentration in High-Risk Pregnant Women: Results from a Cross-Sectional Study Conducted After Salt Iodination Reduction in Brazil.

During pregnancy, the demand for daily iodine increases by 50-70% which occurs to reach around 250 µg/day. Limited information is available on the association of high-risk pregnancy (HRP) with urinary iodine concentration (UIC) and variables such as socioeconomic factors. To analyze iodine nutritional status and socioeconomic, demographic and anthropometric characteristics among women with HRP screened at the main referral public health center at Bahia, Brazil, a cross-sectional study was conducted in 241 women with HRP (15-46 years old) in Salvador, Bahia, Brazil. The median UIC (MUIC) was 119 µg/L (25-75th, 58.7-200.4 µg/L), indicating mild iodine deficiency. Low UIC (< 150 µg/L) was detected in 61.8% (n = 149) - 18.3% between 100 and 150 µg/L, 24.5% between 50 and 100 µg/L, and 19.1% with UIC < 50 µg/L. Overall, 53% (n = 128) of our population adhered to a low-salt diet, and 32.5% (n = 77) had hypertension. Among the 73% of hypertensive women adhering to a salt-restricted diet, there was a 112% increased risk of iodine deficiency observed (OR = 2.127; 95% confidence interval [1.178-3.829]; p = 0.011). Adhering to a salt-restricted diet was associated with iodine deficiency (OR = 1.82; 95% confidence interval [1.073-3.088], p = 0,026). Hypertension and salt restriction diet significantly increased susceptibility for iodine deficiency in HRP. Therefore, low-salt diet when prescribed to pregnant women (PW) might be carefully followed by iodine nutritional status assessment or universal preconception iodine supplementation.

Effectiveness of additional deep-water running for disability, lumbar pain intensity, and functional capacity in patients with chronic low back pain: A randomised controlled trial with 3-month follow-up.

BACKGROUND: Aquatic exercise (AQE) programme is commonly used as an alternative to the chronic low back pain (CLBP) treatment. The addition of aquatic aerobic exercises to AQE may be beneficial to patients with CLBP. DESIGN: Randomised controlled trial. OBJECTIVES: To assess the effectiveness of AQE with the addition of aerobic exercise - deep-water running (DWR) - compared to exclusive AQE in improving disability, lumbar pain intensity, and functional capacity in patients with CLBP. METHODS: Fifty-four adult patients with CLBP were randomised either to the experimental group (AQE + DWR) or the control group (AQE). An assessor who was blinded to the group allocation performed both pre- and post-interventions assessments. Both treatments lasted 9 weeks, with a 3-month follow-up. The primary outcome was disability, as evaluated using the Roland Morris Disability Questionnaire. The secondary outcomes were pain and functional capacity; pain was assessed using a visual analogue scale (VAS), and functional capacity (travelled distance) was measured using the 6-min walk test (6WT). RESULTS: A significant difference in pain was observed between groups after intervention in favour of DWR (mean difference -1.3 cm [95% confidence interval (CI) -2.17 to -0.45], d‾ = 0.80 [95% CI 0.22 to 1.33]). CONCLUSION: Treatment with DWR was effective in the short term for achieving the desired outcome of pain reduction when compared with AQE only but not for disability and functional capacity.