Patient-reported outcomes in a large community-based pain medicine practice: evaluation for use in phenotype modeling.

BACKGROUND: An academic, community medicine partnership was established to build a phenotype-to-outcome model targeting chronic pain. This model will be used to drive clinical decision support for pain medicine in the community setting. The first step in this effort is an examination of the electronic health records (EHR) from clinics that treat chronic pain. The biopsychosocial components provided by both patients and care providers must be of sufficient scope to populate the spectrum of patient types, treatment modalities, and possible outcomes. METHODS: The patient health records from a large Midwest pain medicine practice (Michigan Pain Consultants, PC) contains physician notes, administrative codes, and patient-reported outcomes (PRO) on over 30,000 patients during the study period spanning 2010 to mid-2014. The PRO consists of a regularly administered Pain Health Assessment (PHA), a biopsychosocial, demographic, and symptomology questionnaire containing 163 items, which is completed approximately every six months with a compliance rate of over 95%. The biopsychosocial items (74 items with Likert scales of 0-10) were examined by exploratory factor analysis and descriptive statistics to determine the number of independent constructs available for phenotypes and outcomes. Pain outcomes were examined both in the aggregate and the mean of longitudinal changes in each patient. RESULTS: Exploratory factor analysis of the intake PHA revealed 15 orthogonal factors representing pain levels; physical, social, and emotional functions; the effects of pain on these functions; vitality and health; and measures of outcomes and satisfaction. Seven items were independent of the factors, offering unique information. As an exemplar of outcomes from the follow-up PHAs, patients reported approximately 60% relief in their pain. When examined in the aggregate, patients showed both a decrease in pain levels and an increase in coping skills with an increased number of visits. When examined individually, 80-85% of patients presenting with the highest pain levels reported improvement by approximately two points on an 11-point pain scale. CONCLUSIONS: We conclude that the data available in a community practice can be a rich source of biopsychosocial information relevant to the phenotypes of chronic pain. It is anticipated that phenotype linkages to best treatments and outcomes can be constructed from this set of records.

Phase I study and preliminary pharmacology of the novel innate immune modulator rBBX-01 in gynecologic cancers.

PURPOSE: A recombinant protein product, rBBX-01, is the first innate immunostimulator derived from a protozoan (Eimeria protozoan) and has shown potent preclinical in vivo and in vitro activities. This phase I trial was done to determine the safety and basic pharmacology of rBBX-01. EXPERIMENTAL DESIGN: Eligible patients had recurrent incurable gynecologic malignancies. The study was divided into three components: a starting low-dose phase (0.85, 2.0, and 4.0 microg/m2), an intrapatient dose acceleration phase (4.0-1,024.0 microg/m2), and a high-dose phase (1,000 and 2,000 microg/m2). All treatment doses were administered daily for 5 days. Patients were allowed a second cycle of treatment if there was evidence of response. RESULTS: Sixteen patients received a total of 20 cycles of rBBX-01. All patients tolerated the drug well, exhibiting no local or systemic, acute or delayed, adverse reactions. Plasma levels of rBBX-01 were detectable in all patients over the entire dose range, although changes in the pharmacodynamic marker (interleukin-12) exhibited patient-to-patient variability. Of 14 patients with ovarian, primary peritoneal, or endometrial cancer with elevated CA125 biomarkers at the start of treatment, 4 responded with decreased levels of CA125. One patient showed decreasing CA125 levels for 10 months and received no additional chemotherapy for 11 months. Those patients exhibiting reductions in CA125 also exhibited increased levels of plasma interleukin-12 during the week of therapy. CONCLUSION: The immunostimulator rBBX-01 was safe in multidose regimens in heavily pretreated women. Of the 14 patients with elevated CA125 levels, an approximately 30% response rate was detected. rBBX-01 should receive additional testing in the clinical setting.

A 17-year oscillation in cancer mortality birth cohorts on three continents - synchrony to cosmic ray modulations one generation earlier.

Cross-generational effects (grandmother effects) associated with epigenetic imprinting, environmental exposures, and lifestyle choices are beginning to be explored by various investigators. The possibility that low-level background radiation can be a driver of such effects has been suggested previously and is explored further in this study. Age-period-cohort analysis was performed on United States (US), United Kingdom (UK), and Australian (AU) female breast cancer mortality of the twentieth century, as well as on UK female total cancer mortality, to extract the high-frequency oscillations in the birth cohort time series. US fetal and infant congenital mortality were examined to extend the birth cohorts to modern times. A approximately 17-year cycle was detected in all birth cohort series, which spanned approximately 180 years from 1820 to 2000. This suggests a global, environmental cause. To mimic previous work in examining a possible link to cosmic radiation, the 17- to 18-year cycles of the cosmogenic nuclide (14)C, the sunspot double-cycle, neutron monitors, and a compilation of ground-based magnetic field observations were examined in the birth cohort and germ cell cohort time frames. Evidence is presented that optimal alignments with extraterrestrial oscillations occur in the time frame of the germ-cell cohort, one generation before the birth cohorts. Furthermore, the alignment is optimized by accounting for the changes in the maternal age distribution over time. These findings have potential importance to the mechanisms of disease as well as species adaptation and evolution.

Intestinal protozoa are hypothesized to stimulate immunosurveillance against colon cancer.

Colon cancer in humans results in considerable morbidity and mortality throughout most of the world. During the twentieth century, there was a rapid rise in colon cancer within modernizing countries that has not been adequately explained, although the role of diet has been widely explored. Previously, we showed that the presence of the endemic Eimeria spp. protozoan in intestinal tissues is associated with regions of low tumorigenesis in the large and small bovine intestine and that an Eimeria surface protein is a potent activator of dendritic cells and a useful immunomodulator, with anti-cancer and anti-viral properties. Therefore, we hypothesize that the persistent presence of such an intestinal protozoan enhances immunosurveillance by elevating the intestinal alert status and that the loss of these organisms could lead to a higher incidence of colon cancer. Preliminary support of this hypothesis derives from the observations that domestic animals, known to maintain this protozoan, have very low colon cancer incidence. We propose that this also may occur in human populations that use human excrement (night soil) as a fertilizer, a practice that serves to complete the life cycle of this type of microbe. We examine some evidence for this hypothesis in Japan's mortality patterns, where we show that colon cancer increased after the cessation of night soil use, but before the change to a western diet. We conclude that this hypothesis, a variation of the hygiene hypothesis, is worth further consideration and continued elaboration.

Discordant patient pain level reporting between questionnaires and physician encounters of the same day.

We examined the consistency of pain reporting by patients in a community pain management practice in Michigan. We compared pain levels (range 0-10) entered by patients in questionnaires versus those provided during their face-to-face physician encounter on the same day. Both of these values were available for approximately 10,000 encounters during the study period (2010-2014). Two subpopulations of patients were identifiable. One was consistent in reporting worst or least pain levels on the questionnaire and during the provider encounter. The other was discordant. Factor analysis had previously identified severity scales for patient biopsychosocial characteristics derived from the full questionnaire. The two subpopulations differed in their factor profiles even though they had similar demographics. In general, pain reported directly to physicians was more correlated to biopsychosocial indicators. Pain self-reporting using questionnaires has often been assumed to be ground truth, but those obtained during the physician encounter may be more reliable.

What determines age-related disease: do we know all the right questions?

The average human lifespan has increased throughout the last century due to the mitigation of many infectious diseases. More people now die of age-related diseases than ever before, but these diseases have been resistant to elimination. Progress has been made in treatments and preventative measures to delay the onsets of these diseases, but most cancers and vascular diseases are still with us and they kill about the same fraction of the population year after year. For example, US Caucasian female deaths from breast plus genital cancers have remained a fairly constant approximately 7% of the age-related disease deaths from 1938 to 1998 and have been consistently approximately 2-fold greater than female colon plus rectal cancer deaths over that span. This type of stability pattern pervades the age-related diseases and suggests that intrinsic properties within populations determine these fractions. Recognizing this pattern and deciphering its origin will be necessary for the complete understanding of these major causes of death. It would appear that more than the random processes of aging drive this effect. The question is how to meaningfully approach this problem. This commentary discusses the epidemiological and aging perspectives and their current limitations in providing an explanation. The age of bioinformatics offers hope, but only if creative systems approaches are forthcoming.

Protein from intestinal Eimeria protozoan stimulates IL-12 release from dendritic cells, exhibits antitumor properties in vivo and is correlated with low intestinal tumorigenicity.

The small intestine (SI) of vertebrates exhibits low tumorigenesis and rarely supports metastatic growth from distant tumors. Many theories have been proposed to address this phenomenon, but none has been consistently supported. One candidate mechanism is that the vast immunologic compartment of the SI provides a heightened level of tumor immunosurveillance. Consistent with this, we have identified a molecule of low abundance from bovine SI that has the hallmarks of a potent immunostimulant and may be associated with the natural suppression of cancer in the intestinal tract. The protein originates from an endemic gut protozoan, Eimeria spp., and is homologous to the antigen 3-1E previously isolated from the avian apicomplexan E. acervulina. We show here that it is a very potent stimulator of IL-12 release from dendritic cells, upregulates inflammatory modulators in vivo (IL-12, MCP-1, IL-6, TNF-alpha and INF-gamma) and has antitumor properties in mice. In addition, it is synergistic in vitro with anti-CD40 antibody, IFN-gamma, IL-4 and GM-CSF; is active across species barriers in vivo; and has no observable toxicity. Based on these activities, we speculate that it is an inducer of protozoan-targeted innate immunity, which may explain its potential benefit to the intestinal tract and potency as an agent in cancer immunotherapy.