Factors associated with participation in a walking intervention for veterans who smoke and have chronic pain.

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720-3550] (sedentary) (n = 65), 7307 [IQR: 5952-8533] (not sedentary) (n = 24), and 3196 [IQR: 2237-5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation.Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016.

Post-9/11 deployment history and the incidence of breast cancer among women veterans.

PURPOSE: To determine if women Veterans who deployed in support of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) would show a greater likelihood of breast cancer (BC) than other women Veterans. METHODS: This was a retrospective cohort study of women aged <60 years who received Veterans Affairs medical center primary care, 2001-2021. The exposure was OEF/OIF deployment and the outcome was a BC diagnosis after entering Veterans Affairs care. Poisson models evaluated the association between deployment and BC incidence, covarying demographics, lifestyle factors, and hormonal contraceptive and hormone replacement therapy use. Analyses were also stratified by age and race, and a sensitivity analysis adjusted for healthcare utilization over the initial 2 years. RESULTS: Of 576,601 women, 24.6% (n = 141,935) deployed during post-9/11 conflicts. Across follow-up [median: 8.2 years], 1.2% women were diagnosed with BC. Those who deployed in support of OEF/OIF were 23% less likely to be diagnosed with BC than women who did not deploy (95% CI: 0.73, 0.86). The association remained in stratified models and when including healthcare utilization. CONCLUSIONS: Despite the exposures of OEF/OIF deployment, there was a significantly lower incidence of BC among women who deployed versus not, possibly due to a healthy soldier effect or to differences in screening.

Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain.

INTRODUCTION: Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective. METHODS: The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation. RESULTS: The 371 participants are 88% male, a median age of 60 years old (range 24-82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as "Fair" (40%) to "Poor" (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)). CONCLUSIONS: PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.

I smoke to cope with pain: patients' perspectives on the link between cigarette smoking and pain.

BACKGROUND: For people with chronic pain, cigarette smoking is associated with greater pain intensity and impairment. Researchers have hypothesized a reciprocal relationship in which pain and smoking exacerbate each other, resulting in greater pain and increased smoking. This study aimed to qualitatively examine patient perspectives on this association. METHODS: A retrospective thematic analysis of smoking cessation counseling notes for 136 veterans in the Pain and Smoking Study, a tailored smoking cessation trial, was conducted. A validated codebook was applied to each counseling note by four independent coders using Atlas.ti (Atlas.ti, Berlin, Germany). Coders participated in a consensus-forming exercise with salient themes validated among the wider research team. KEY RESULTS: Participants averaged 60 years of age (range 28-77 years) and were 9% female. The median number of cigarettes smoked per day was 15, with a mean pain intensity score in the last week (from 0-10) of 5.1. While not all patients acknowledged a connection between pain and smoking, we found that (1) pain motivates smoking and helps manage pain-related distress, as a coping strategy and through cognitive distraction, and (2) pain motivates smoking but smoking does not offer pain relief. Concerns about managing pain without smoking was identified as a notable barrier to cessation. CONCLUSION: Many patients with chronic pain who smoke readily identified pain as a motivator of their smoking behavior and are reluctant to quit for this reason. Integrated interventions for smokers with pain should address these perceptions and expectancies and promote uptake of more adaptive self-management strategies for pain.

Leukoencephalopathy with calcifications and cysts: Genetic and phenotypic spectrum.

Biallelic mutations in SNORD118, encoding the small nucleolar RNA U8, cause leukoencephalopathy with calcifications and cysts (LCC). Given the difficulty in interpreting the functional consequences of variants in nonprotein encoding genes, and the high allelic polymorphism across SNORD118 in controls, we set out to provide a description of the molecular pathology and clinical spectrum observed in a cohort of patients with LCC. We identified 64 affected individuals from 56 families. Age at presentation varied from 3 weeks to 67 years, with disease onset after age 40 years in eight patients. Ten patients had died. We recorded 44 distinct, likely pathogenic, variants in SNORD118. Fifty two of 56 probands were compound heterozygotes, with parental consanguinity reported in only three families. Forty nine of 56 probands were either heterozygous (46) or homozygous (three) for a mutation involving one of seven nucleotides that facilitate a novel intramolecular interaction between the 5' end and 3' extension of precursor-U8. There was no obvious genotype-phenotype correlation to explain the marked variability in age at onset. Complementing recently published functional analyses in a zebrafish model, these data suggest that LCC most often occurs due to combinatorial severe and milder mutations, with the latter mostly affecting 3' end processing of precursor-U8.

Self-Efficacy for Adoption and Maintenance of Exercise Among Fibromyalgia Patients: A Pilot Study.

Objective. While multimodal treatment approaches for fibromyalgia (FM), incorporating exercise, have been found most effective, information about factors associated with exercise adoption and maintenance is lacking. Design, Setting, and Methods. Women veterans with FM (N = 19) completed an anonymous Internet survey measuring FM impact (FI), adoption of exercise behavior, and self-efficacy for exercise. Using classifications of behavior specified by the transtheoretical model, the self-efficacy of participants classified in the action or maintenance (AM) stages was compared with those in earlier stages (precontemplation through preparation) of exercise readiness. Multivariate analysis of variance analyses examined differences in FI domains by stage of change. Analysis of covariance examined whether exercise self-efficacy differed by stage of change while controlling for FI. Results. Higher levels of self-efficacy were detected among participants in the AM stages. Participants in the AM stages also reported higher levels of FI symptoms. After controlling for FI, self-efficacy did not differ significantly between the 2 groups; however the effect size was large (η2 = .11). Conclusions. Findings of this pilot study suggest a role for self-efficacy in exercise adoption and maintenance, even in the setting of higher FM symptoms. Replication of this study with a larger sample size is warranted.

Pain and emotional eating: further investigation of the Yale Emotional Overeating Questionnaire in weight loss seeking patients.

Providers frequently report pain as a barrier to weight loss yet the relationship between the pain experience and eating behavior is poorly understood. The current study examines overeating in response to physical pain (Pain Overeating). Weight-loss seeking Veterans (N = 126) completed the Yale Emotional Overeating Questionnaire, a measure used to assess the frequency of overeating in response to a range of emotions that was adapted to include a Pain Overeating item, and validated measures of pain, eating pathology, and mental health. Fifty-one participants (42.5%) engaged in at least one Pain Overeating episode in the past month, and 14.2% engaged in this behavior daily. Pain Overeating was significantly related to pain intensity and interference, and accounted for statistically significant variance in predicting BMI, eating pathology and depression. Findings suggest eating in response to physical pain is common among weight-loss seeking Veterans and may have important implications for weight management treatment.

A Brief, Integrated, Telephone-Based Intervention for Veterans Who Smoke and Have Chronic Pain: A Feasibility Study.

Objective: High rates of co-occurring smoking and chronic pain are observed in the veteran population. Individuals who smoke and have chronic pain report lower self-efficacy to quit and are less successful in their attempts. Design: In this pilot study, we assess the feasibility of a telephone-delivered intervention designed to integrate evidence-based smoking cessation and pain management components in a way that allows patients to understand the interplay between the two while attempting to have them build off each other and develop coping skills to address both concerns. Patients: Study participants (N = 7) were veterans who received primary care in the VA Healthcare System and reported current smoking and a worst pain intensity score of 4 or greater. Intervention: A five-session telephone intervention was delivered over eight weeks. Participants completed a survey at baseline and 10-week follow-up. Outcome Measures: Feasibility was assessed by examining engagement with the intervention. Results: Four out of seven participants completed all five sessions. Two out of seven veterans reported quitting smoking, and five out of seven reported clinically meaningful improvements in pain intensity and functional interference. Conclusions: Insights gained from this study were used to modify an intervention being examined in a randomized controlled trial to test its effectiveness on both smoking and pain outcomes.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones.

Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

Impact of Cigarette Smoking Status on Pain Intensity Among Veterans With and Without Hepatitis C.

Objective: Chronic pain is a significant problem in patients living with hepatitis C virus (HCV). Tobacco smoking is an independent risk factor for high pain intensity among veterans. This study aims to examine the independent associations with smoking and HCV on pain intensity, as well as the interaction of smoking and HCV on the association with pain intensity. Design/Particpants: Cross-sectional analysis of a cohort study of veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who had at least one visit to a Veterans Health Administration (VHA) primary care clinic between 2001 and 2014. Methods: HCV was identified using ICD-9 codes from electronic medical records (EMRs). Pain intensity, reported on a 0-10 numeric rating scale, was categorized as none/mild (0-3) and moderate/severe (4-10). Results: Among 654,841 OEF/OIF/OND veterans (median age [interquartile range] = 26 [23-36] years), 2,942 (0.4%) were diagnosed with HCV. Overall, moderate/severe pain intensity was reported in 36% of veterans, and 37% were current smokers. The adjusted odds of reporting moderate/severe pain intensity were 1.23 times higher (95% confidence interval [CI] = 1.14-1.33) for those with HCV and 1.26 times higher (95% CI = 1.25-1.28) for current smokers. In the interaction model, there was a significant Smoking Status × HCV interaction (P = 0.03). Among veterans with HCV, smoking had a significantly larger association with moderate/severe pain (adjusted odds ratio [OR] = 1.50, P < 0.001) than among veterans without HCV (adjusted OR = 1.26, P < 0.001). Conclusions: We found that current smoking is more strongly linked to pain intensity among veterans with HCV. Further investigations are needed to explore the impact of smoking status on pain and to promote smoking cessation and pain management in veterans with HCV.

Gender Differences in Demographic and Clinical Correlates among Veterans with Musculoskeletal Disorders.

BACKGROUND: Studies suggest that women may be at greater risk for developing chronic pain and pain-related disability. METHODS: Because musculoskeletal disorders (MSD) are the most frequently endorsed painful conditions among veterans, we sought to characterize gender differences in sociodemographic and clinical correlates among veterans upon entry into Veterans Health Administration's Musculoskeletal Disorders Cohort (n = 4,128,008). RESULTS: Women were more likely to be younger, Black, unmarried, and veterans of recent conflicts. In analyses adjusted for gender differences in sociodemographics, women were more likely to have diagnoses of fibromyalgia, temporomandibular disorders, and neck pain. Almost one in five women (19.4%) had more than one MSD diagnosis, compared with 15.7% of men; this higher risk of MSD multimorbidity remained in adjusted analyses. Adjusting for sociodemographics, women with MSD were more likely to have migraine headache and depressive, anxiety, and bipolar disorders. Women had lower odds of cardiovascular diseases, substance use disorders, and several MSDs, including back pain conditions. Men were more likely to report "no pain" on the pain intensity Numeric Rating Scale, whereas more women (41%) than men (34%) reported moderate to severe pain (Numeric Rating Scale 4+). CONCLUSIONS: Because women veterans are more likely to have conditions such as fibromyalgia and mental health conditions, along with greater pain intensity in the setting of MSD, women-specific pain services may be needed.

Cigarette Smoking Status and Receipt of an Opioid Prescription Among Veterans of Recent Wars.

Objective: Cigarette smokers seeking treatment for chronic pain have higher rates of opioid use than nonsmokers. This study aims to examine whether veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who smoke are more likely to receive an opioid prescription than nonsmokers, adjusting for current pain intensity. Design: Cross-sectional analysis of a cohort study of OEF/OIF/OND veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2012. Methods: Smoking status was defined as current, former, and never. Current pain intensity (+/- 30 days of smoking status), based on the 0-10 numeric rating scale, was categorized as no pain/mild (0-3) and moderate/severe (4-10). Opioid receipt was defined as at least one prescription filled +/- 30 days of smoking status. Results: We identified 406,954 OEF/OIF/OND veterans: The mean age was 30 years, 12.5% were women (n = 50,988), 66.3% reported no pain or mild pain intensity, 33.7% reported moderate or severe pain intensity, 37.2% were current smokers, and 16% were former smokers. Overall, 33,960 (8.3%) veterans received one or more opioid prescription. Current smoking (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.52-1.61) and former smoking (OR = 1.27, 95% CI = 1.22-1.32) were associated with a higher likelihood of receipt of an opioid prescription compared with never smoking, after controlling for other covariates. Conclusions: We found an association between smoking status and receipt of an opioid prescription. The effect was stronger for current smokers than former smokers, highlighting the need to determine whether smoking cessation is associated with a reduction in opioid use among veterans.

Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans.

OBJECTIVE: Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). DESIGN: The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders. RESULTS: Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder. CONCLUSIONS: We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.

STI diagnosis and HIV testing among OEF/OIF/OND veterans.

IMPORTANCE: Patients with sexually transmitted infection (STI) diagnosis should be tested for human immunodeficiency virus (HIV), regardless of previous HIV test results. OBJECTIVE: Estimate HIV testing rates among recent service Veterans with an STI diagnosis and variation in testing rates by patient characteristics. DESIGN, SETTING, AND PARTICIPANTS: The sample comprised 243,843 Veterans who initiated Veterans Health Administration (VHA) services within 1 year after military separation. Participants were followed for 2 years to determine STI diagnoses and HIV testing rates. We used relative risks regression to examine variation in testing rates. MAIN OUTCOMES AND MEASURES: We used VHA administrative data to identify STI diagnoses and HIV testing and results. RESULTS: Veterans with an STI diagnosis (n = 1815) had higher HIV testing rates than those without (34.9% vs. 7.3%, P<0.0001), but were not more likely to have a positive test result (1.1% vs. 1.4%, P = 0.53). Among Veterans with an STI diagnosis, testing increased from 25% to 45% over the observation period; older age was associated with a lower rate of testing, whereas race and ethnicity, multiple deployments, posttraumatic stress disorder, and substance abuse disorders were associated with a higher rate. CONCLUSIONS AND RELEVANCE: Since VHA implemented routine HIV testing, overall rates of testing have increased. However, among Veterans at significant risk for HIV because of an STI diagnosis, only 45% had an HIV test in the most recent year of observation. Other patient characteristics such as alcohol and drug abuse were associated with being tested for HIV. Providers should be reminded that an STI is a sufficient reason to test for HIV.

Recessive mutations in the gene encoding the tight junction protein occludin cause band-like calcification with simplified gyration and polymicrogyria.

Band-like calcification with simplified gyration and polymicrogyria (BLC-PMG) is a rare autosomal-recessive neurological disorder showing highly characteristic clinical and neuroradiological features. Affected individuals demonstrate early-onset seizures, severe microcephaly, and developmental arrest with bilateral, symmetrical polymicrogyria (PMG) and a band of gray matter calcification on brain imaging; as such, the disorder can be considered as a "pseudo-TORCH" syndrome. By using autozygosity mapping and copy number analysis we identified intragenic deletions and mutations in OCLN in nine patients from six families with BLC-PMG. The OCLN gene encodes occludin, an integral component of tight junctions. Neuropathological analysis of an affected individual showed similarity to the mouse model of occludin deficiency with calcification predominantly associated with blood vessels. Both intracranial calcification and PMG are heterogeneous in etiology. Neuropathological and clinical studies of PMG have suggested that in utero ischemic or vascular insults may contribute to this common cortical abnormality. Tight junctions are functional in cerebral blood vessels early in fetal development and continue to play a vital role in maintenance of the blood-brain barrier during postnatal life. We provide evidence that the tight junction protein occludin (encoded by the OCLN gene) is involved in the pathogenesis of malformations of cortical development.

Impact of gender and parent of origin on the phenotypic expression of hereditary nonpolyposis colorectal cancer in a large Newfoundland kindred with a common MSH2 mutation.

PURPOSE: This study was designed to provide precise estimates of death and cancer risks, by gender and parent of origin, in hereditary nonpolyposis colorectal cancer independent of mutation, geographic variation, and ascertainment bias. METHODS: A group of 12 families with a founder MSH2 mutation (nucleotide 943+3, A --> T) causing hereditary nonpolyposis colorectal cancer was identified in Newfoundland. Genetic testing was offered to those at 50 percent risk of inheriting the mutation. Medical records were reviewed to identify cancer types, age at onset of cancer, and age at death. Ascertainment bias was limited by analyzing only sibships with good ascertainment of genetic status (> or =50 percent of sibships had known genetic status). RESULTS: Of 302 family members with hereditary nonpolyposis colorectal cancer or at 50 percent risk, 151 (50 percent) were considered to be mutation carriers, 96 (32 percent) were mutation negative, and 55 (18 percent) were of unknown mutation status. By age 50 years, 72 percent of males and 72 percent of females who were hereditary nonpolyposis colorectal cancer mutation carriers had developed cancer. The age-related risks of colorectal cancer or of death of cancer were significantly higher in males than in females (relative risk = 2.8, P = 0.0001 and relative risk = 2.1, P = 0.01, respectively). The mutation was transmitted by the mother more frequently than the father. Females who inherited the mutation from their father had an increased risk of developing colorectal cancer (relative risk = 2.5, P = 0.05) and of dying of cancer (relative risk = 2.7, P = 0.04) compared with females who inherited the mutation from their mother. CONCLUSIONS: Investigation of large kindreds from the same geographic area who share the same MSH2 mutation and in whom family members have been identified with little ascertainment bias suggests that the risks for colorectal cancer and death of cancer are higher for male mutation carriers than for females and that females who inherit the mutation from their father are at higher risk of colorectal cancer than females who inherit the mutation from their mother.