Implementation of Quitline Financial Incentives to Increase Counseling Sessions Among Adults Who Use Menthol Tobacco Products.

Since 2017, the Vermont Tobacco Control Program (VTCP) has worked to reduce the impact of flavored tobacco products on Vermonters. With the proposed U.S. Food and Drug Administration (FDA) rules banning menthol cigarettes and flavored cigars and proposed legislation banning sales of all menthol and flavored tobacco products in Vermont, VTCP prioritized resources to support cessation among Vermonters who use menthol tobacco products. In March 2021, VTCP began offering a tailored quitline protocol for adults who use menthol tobacco, including financial incentives, for completed coaching sessions. From March 2021 to May 2022, 66 quitline callers enrolled in the menthol incentive protocol, representing 8% of all quitline callers and 25% of participants in the state's quitline incentive programs. A greater proportion of callers in the menthol incentive program completed three or more quitline calls (58% vs. 38%) and enrolled in phone and text support (61% vs. 32%). Quitline callers enrolled in any incentive protocols (menthol, Medicaid/uninsured, or pregnant) were more likely to request one or two forms of nicotine replacement therapy (NRT). Quitlines remain an effective, evidence-based method of tobacco cessation, especially in reaching vulnerable populations. Given the targeted marketing of menthol brands to Black and African American populations, LGBTQ+ populations, youth, and neighborhoods with lower incomes, addressing menthol cigarette use is key to improving health equity and health of Vermonters. Early data indicates that the use of financial incentives can increase engagement with a state quitline among menthol tobacco users through greater completion of cessation coaching calls, enrollment in text message support, and NRT usage.

Heterogeneous trajectories of depression and resilience following limb amputation.

OBJECTIVE: To identify longitudinal trajectories of depression in the first 6 months following limb loss and to explore baseline predictors of trajectories, including pain and demographic factors. A secondary aim was to evaluate whether trajectories of depression were associated with elevated symptoms of posttraumatic stress (PTS) at 6 months. DESIGN: Secondary longitudinal data analysis of an inception cohort study of persons with new-onset limb loss. Participants completed assessments at three intervals (initial, 3 months, and 6 months). SETTING: Hospitalized care, acute rehabilitation, ambulatory care, and community. PARTICIPANTS: Participants were recruited from consecutive cases of amputation surgery in a metropolitan hospital system over a period of 4 years (2002-2007). The final sample (n = 203) was predominantly White (79.3%) and male (78.8%) with an average age of 49.4 years (standard deviation [SD] = 14.6). MAIN OUTCOME MEASURE(S): Depression was assessed via the Patient Health Questionnaire-9 (PHQ-9); posttraumatic stress symptoms were measured via the PTSD checklist- Civilian Version (PCL-C). RESULTS: Four trajectories of depression were identified via Latent Growth Mixture Modeling: Resilience (73.2%), Chronic Depression (11.2%), Emerging Depression (8.9%), and Recovery (6.7%). Average pain intensity significantly predicted trajectory membership. Membership in the Chronic Depression class predicted elevated 6-month PTS compared to all other classes; membership in the Resilience class predicted lower PTS than in the Chronic and Emerging Depression classes but did not differentiate from the Recovery trajectory. CONCLUSIONS: Findings reveal that the course of depression post-amputation is heterogenous, with varying profiles of symptom development, maintenance, and remission. A majority of individuals were classified as Resilient, whereas a substantial minority of individuals developed clinically significant depression between 3 and 6 months (Emerging Depression), suggesting that early screening during acute care may be insufficient. We detected a significant prospective relation between depression trajectories and distal PTS, advancing the potential clinical utility of trajectory modeling as a risk surveillance tool.

Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial.

PURPOSE/OBJECTIVE: To examine the impact of three behavioral interventions for chronic pain on substance use. RESEARCH METHOD/DESIGN: Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment. RESULTS: Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up. CONCLUSIONS/IMPLICATIONS: HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Incentivizing Pregnant Women to Quit Smoking in the Real World-A Community-Based Pilot Intervention.

Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes. Financial incentives interventions yield quit rates of approximately 30% during pregnancy, versus ~4% in traditional smoking cessation programs. This pilot study assessed the feasibility of translating an efficacious University of Vermont research-based intervention into a rural community setting delivered by the Vermont Department of Health. Pregnant women using tobacco products were recruited from the Women, Infants and Children program and Rutland Women's Healthcare. Women were provided in-person tobacco cessation counseling during regularly scheduled meetings and received gift cards throughout pregnancy and 3 months postpartum contingent upon biochemically verified smoking abstinence. Cessation counseling and abstinence monitoring began with high frequency (three visits per week), tapering through postpartum to biweekly visits. Gift card values began at $15, increasing by $5 for consecutive negative samples, to $40 maximum. Participants completed three surveys (enrollment, 4-6 weeks postpartum, 6-12 months postpartum) assessing smoking habits, and barriers and facilitators of treatment engagement and success. From 2018 to 2020, we enrolled 20 pregnant women, of whom six self-reported quitting tobacco at some point during the intervention. At study completion, three reported sustained abstinence. Results suggest that it is feasible to translate a research-based smoking cessation program into a community setting. This article discusses the challenges faced and the lessons learned when implementing research in a rural community setting, recruiting and retaining participants, and adapting protocols during the Covid-19 pandemic.

Economic analysis of financial incentives for smoking cessation during pregnancy and postpartum.

Higgins and colleagues' recently-completed randomized controlled trial and pooled data with 4 related trials of smoking cessation in pregnant women in Vermont (USA) showed that abstinence-contingent financial incentives (FI) increased abstinence over control conditions from early pregnancy through 24-weeks postpartum. Control conditions were best practices (BP) alone in the recent trial and payments provided independent of smoking status (noncontingently) in the others. This paper reports economic analyses of abstinence-contingent FI. Merging trial results with maternal and infant healthcare costs from all Vermont Medicaid deliveries in 2019, we computed incremental cost-effectiveness ratios (ICERs) for quality-adjusted life years (QALYs) and compared them to established thresholds. The healthcare sector cost (±standard error) of adding FI to BP averaged $634.76 ± $531.61 per participant. Based on this trial, the increased probability per BP + FI participant of smoking abstinence at 24-weeks postpartum was 3.17%, the cost per additional abstinent woman was $20,043, the incremental health gain was 0.0270 ± 0.0412 QALYs, the ICER was $23,511/QALY gained, and the probabilities that BP + FI was very cost-effective (ICER≤$65,910) and cost-effective (ICER≤$100,000) were 67.9% and 71.0%, respectively. Based on the pooled trials, the corresponding values were even more favorable-8.89%, $7138, 0.0758 ± 0.0178 QALYs, $8371/QALY, 98.6% and 99.3%, respectively. Each dollar invested in abstinence-contingent FI over control smoking-cessation programs yielded $4.20 in economic benefits in the recent trial and $11.90 in the pooled trials (very favorable benefit-cost ratios). Medicaid and commercial insurers may wish to consider covering financial incentives for smoking abstinence as a cost-effective service for pregnant beneficiaries who smoke. Trial Registration: ClinicalTrials.gov identifier: NCT02210832.

Randomized Controlled Trial Examining the Efficacy of Adding Financial Incentives to Best practices for Smoking Cessation Among pregnant and Newly postpartum Women.

We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ2 [2] = 9.01, P = .01), with percent SGA deliveries (+SEM) greatest in BP, intermediate in BP + FI, and lowest in NS (17.65 + 4.13, 10.81 + 3.61, and 2.53 + 1.77, respectively). Reliability analyses supported the efficacy of financial incentives for increasing abstinence antepartum and postpartum and decreasing SGA deliveries; external-validity analyses supported relationships between antepartum cessation and SGA risk. Adding financial incentives to Best Practice increases smoking cessation among antepartum and postpartum women and improves other maternal-infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210832.

Vermont's comprehensive public health framework for tobacco control and prevention.

When the Centers for Disease Control and Prevention published the Best Practices Guide for Comprehensive Tobacco Control - 2014 it provided an opportunity for Vermont's Tobacco Control Program to create a new state plan. Bringing together partner agencies, advocates and health organizations, the workgroup faced a challenge: there wasn't consensus around focusing on e-cigarettes. There was concern that if too much emphasis was placed on addressing this emerging product, it would be at the cost of reducing combustible use. Youth smoking rates were declining while adult smoking prevalence in Vermont remained stagnant and difficult to move downward. Through applying the lens of best practice and examining the data, the workgroup determined that an ambitious state plan was necessary. Adopting a set of principles grounded in public health and performance measurement, the plan's five goals are to reduce use of all tobacco products among youth and adults. The state plan established a vision of a Vermont free of tobacco use for the program and partners to use, emphasizing data-driven interventions and advancing policymaking, including addressing flavored tobacco products. The tobacco control and regulatory framework in Vermont has worked consistently at the state and local level on strategies involving youth engagement, coalition prevention activities, counter marketing and enforcement. Vermont's framework has evolved to recognize that no matter where a Vermonter is living or working, the protections and services provided by a tobacco program should be equitable. Future application of the public health framework includes exploring innovative policy approaches to curtail the vaping epidemic.

A Framework for Effective Promotion of a Medicaid Tobacco Cessation Benefit.

Tobacco burden is significantly greater among those insured by Medicaid, with a smoking prevalence about twice as high as the national average (28% vs. 15%). Over the past decade, smoking prevalence among those insured by Medicaid has remained relatively unchanged while overall smoking prevalence in the United States and among other insurance groups decreased. This indicates need for targeting tobacco control strategies to those insured by Medicaid. In response, the Vermont Tobacco Control Program (VTCP) set out to implement best practice by making its Medicaid cessation benefit more comprehensive and raising awareness and use of the benefit to support members in quitting. The VTCP collaborated with its Medicaid and health department leadership to implement this initiative, learning and adapting processes along the way. The VTCP identified a framework and considerations for programs implementing best practice to expand access and utilization of cessation supports. Elements of success include collaboration, data sharing, and promotion. As a result, the VTCP created an infrastructure that increases access, awareness, and use of cessation supports among Medicaid members and providers. Between 2013 and 2017, the quit ratio among Vermont Medicaid members increased from 8% to 13% and the smoking rate decreased from 36% to 31%.

Post-traumatic Stress Disorder Symptoms are Associated With Incident Chronic Back Pain: A Longitudinal Twin Study of Older Male Veterans.

STUDY DESIGN: A longitudinal cotwin control study of the Vietnam Era Twin Registry. OBJECTIVE: The aim of this study was to examine the association of post-traumatic stress disorder (PTSD) symptoms with incident chronic back pain (CBP), while controlling for genetic factors and early family environment. SUMMARY OF BACKGROUND DATA: It is unknown whether PTSD symptoms are associated with an increased incidence of CBP. METHODS: In 2010 to 2012, a baseline survey was undertaken as part of a large-scale study of PTSD. Study participants completed the PTSD Symptom Checklist (PCL) and a self-report measure of CBP. In 2015 to 2017, a follow-up survey was sent to all 171 monozygotic (MZ) twin pairs (342 individuals) where both cotwins had no history of CBP at baseline, but only one cotwin in the pair met criteria for having current PTSD symptoms (one twin with PCL <30 and the cotwin with PCL ≥30). No other inclusion/exclusion criteria were applied. CBP at 5-year follow-up was defined as back pain of duration ≥3 months in the low back or mid/upper back. Covariates included age, race, education, income, Veterans Affairs health care use, disability compensation, smoking, body mass index, and depression. Statistical analysis estimated the cumulative incidence of CBP according to baseline PTSD symptoms. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were estimated in matched-pair cotwin control analyses adjusting for familial factors. RESULTS: Among 227 males completing 5-year follow-up, including 91 MZ twin pairs, the mean age was 62 years. Five-year incidence of CBP in those without and with baseline PTSD symptoms was 40% and 60%, respectively. Baseline PTSD symptoms were significantly associated with incident CBP in crude and multivariable-adjusted within-pair analyses (RR 1.6, 95% CI 1.2-2.1; P = 0.002). CONCLUSION: PTSD symptoms were associated with an increased incidence of CBP, without confounding by genetic factors or early family environment. PTSD symptoms may be a modifiable risk factor for prevention of CBP. LEVEL OF EVIDENCE: 3.

Perceived social support moderates the relationship between activities of daily living and depression after lower limb loss.

OBJECTIVE: This study examined the moderating influence of perceived social support on the prospective relationship between baseline levels of activities of daily living (ADL) and depressive symptoms during the 1st year following amputation. METHOD: Participants included 73 veterans with new/first unilateral lower extremity amputation due to vascular disease or diabetes. Baseline levels of perceived social support, ADL function, and mobility were assessed by retrospective recall 6 weeks after amputation. Depressive symptoms were measured at 6 weeks and 12 months following surgery. RESULTS: Perceived social support moderated the relationship between baseline ADL functioning and depressive symptoms at 12 months (ß = -0.27, p < .001) after controlling for 6-week depressive symptoms and sociodemographic and physical/functional variables. Lower levels of baseline ADL function were associated with depressive symptoms at 12 months among those who reported lower levels of perceived social support. CONCLUSION: These data allowed us to identify those participants with both low ADL function at baseline and low social support as being at higher risk for depression symptoms postamputation. The findings support the stress buffering hypothesis and suggest that perceived social support may be an important modifiable target of intervention among individuals with lower levels of functioning. (PsycINFO Database Record

The development and validation of the AMPREDICT model for predicting mobility outcome after dysvascular lower extremity amputation.

OBJECTIVE: The objective of this study was the development of AMPREDICT-Mobility, a tool to predict the probability of independence in either basic or advanced (iBASIC or iADVANCED) mobility 1 year after dysvascular major lower extremity amputation. METHODS: Two prospective cohort studies during consecutive 4-year periods (2005-2009 and 2010-2014) were conducted at seven medical centers. Multiple demographic and biopsychosocial predictors were collected in the periamputation period among individuals undergoing their first major amputation because of complications of peripheral arterial disease or diabetes. The primary outcomes were iBASIC and iADVANCED mobility, as measured by the Locomotor Capabilities Index. Combined data from both studies were used for model development and internal validation. Backwards stepwise logistic regression was used to develop the final prediction models. The discrimination and calibration of each model were assessed. Internal validity of each model was assessed with bootstrap sampling. RESULTS: Twelve-month follow-up was reached by 157 of 200 (79%) participants. Among these, 54 (34%) did not achieve iBASIC mobility, 103 (66%) achieved at least iBASIC mobility, and 51 (32%) also achieved iADVANCED mobility. Predictive factors associated with reduced odds of achieving iBASIC mobility were increasing age, chronic obstructive pulmonary disease, dialysis, diabetes, prior history of treatment for depression or anxiety, and very poor to fair self-rated health. Those who were white, were married, and had at least a high-school degree had a higher probability of achieving iBASIC mobility. The odds of achieving iBASIC mobility increased with increasing body mass index up to 30 kg/m2 and decreased with increasing body mass index thereafter. The prediction model of iADVANCED mobility included the same predictors with the exception of diabetes, chronic obstructive pulmonary disease, and education level. Both models showed strong discrimination with C statistics of 0.85 and 0.82, respectively. The mean difference in predicted probabilities for those who did and did not achieve iBASIC and iADVANCED mobility was 33% and 29%, respectively. Tests for calibration and observed vs predicted plots suggested good fit for both models; however, the precision of the estimates of the predicted probabilities was modest. Internal validation through bootstrapping demonstrated some overoptimism of the original model development, with the optimism-adjusted C statistic for iBASIC and iADVANCED mobility being 0.74 and 0.71, respectively, and the discrimination slope 19% and 16%, respectively. CONCLUSIONS: AMPREDICT-Mobility is a user-friendly prediction tool that can inform the patient undergoing a dysvascular amputation and the patient's provider about the probability of independence in either basic or advanced mobility at each major lower extremity amputation level.

The role of expectations in pain after dysvascular lower extremity amputation.

OBJECTIVE: The objective was to determine the relationship between pain expectations assessed prior to surgery and satisfaction with pain 4 and 12 months after major dysvascular lower extremity amputation. RESEARCH METHOD: The study included a prospective cohort of male (n = 19) veterans experiencing their first lower extremity amputation due to complications of diabetes mellitus or peripheral arterial disease. Measures included presurgical expectations of pain at 4 and 12 months postamputation, actual average pain and satisfaction with pain at 4 and 12 months postamputation, and agreement between expected and actual pain. RESULTS: Sixty-eight percent of participants expected to experience no or minimal pain at 4 months; 95% expected to experience no or minimal pain at 12 months. Thirty-two percent and 58% of participants had more pain than they expected at 4 and 12 months, respectively. Participants whose pain expectations were met reported higher satisfaction with their actual level of pain at 12 months postamputation, even after adjusting for current pain levels. CONCLUSION: The results underscore the potential value of fostering realistic expectations about the degree to which amputation may impact average pain.

Prevalence and 1-year course of alcohol misuse and smoking in persons with lower extremity amputation as a result of peripheral arterial disease.

OBJECTIVE: The aim of this study was to describe prevalence of alcohol misuse and smoking among individuals with amputations as a result of peripheral arterial disease before surgery and 12 mos after surgery, changes in these behaviors over time, and factors associated with change. DESIGN: This is a prospective cohort study of 75 veterans experiencing their first major unilateral amputation. Measures included demographic and general health information, Alcohol Use Disorders Identification Test, smoking behaviors, and social support. RESULTS: Sixteen percent of the participants reported engaging in alcohol misuse at presurgical baseline; and 13% at 12 mos after amputation. Thirty-seven percent of the participants were categorized as smokers at baseline; this number dropped to 29% at 12 mos after amputation. Among those who decreased drinking and quit smoking, there was a trend indicating greater social support. CONCLUSIONS: The participants endorsed drinking and smoking behaviors at levels consistent with other types of disability and with veterans using the Veterans Health Administration for their health care. Even with a variety of health concerns, after amputation, most of the smokers and those engaging in alcohol misuse continued to smoke and drink at their preamputation rate. The presence of social support may encourage health behavior change and is an important area for future research and intervention.

Body mass index patterns following dysvascular lower extremity amputation.

PURPOSE: Using preliminary data, we examined: (i) patterns of body mass index (BMI) over the year following amputation by amputation level and (ii) the association between BMI and mobility and prosthetic device use. METHOD: Patients from three medical centers undergoing dysvascular amputation (N = 87; M age = 62) participated in interviews pre-surgically and at 6 weeks, 4 months, and 12 months following amputation. The main outcome was self-reported BMI, adjusting for limb weight lost due to amputation. Additional outcomes were mobility and time spent using and walking in a prosthetic device. RESULTS: Adjusted BMI slightly decreased at 6 weeks (pre-surgery M = 31.2; 6 weeks M = 30.3) and 4 months (M = 30.7) but exceeded baseline levels by 12 months (M = 31.7). There were no significant BMI differences by amputation level. In multivariable analyses, higher pre-surgical BMI was associated with fewer hours of prosthetic device walking at month 4 (ß = -0.49) and poorer overall mobility at month 12 (ß = -0.22). CONCLUSIONS: BMI increased at one year following amputation surgery. Higher pre-surgical BMI was associated with poorer mobility and prosthetic device use. Interventions are needed to prevent excess weight gain in the year following amputation. IMPLICATIONS FOR REHABILITATION: • People undergoing lower-extremity amputation have high rates of overweight and obesity and continue to gain weight in the year following amputation. • Objective assessment of body mass index (both with and without a prosthetic device) and waist circumference would help future research efforts. • Targeting weight loss post-amputation could improve the health of people with lower-extremity amputations.

Mobility changes in individuals with dysvascular amputation from the presurgical period to 12 months postamputation.

OBJECTIVES: To describe changes in ambulation among individuals with lower-extremity amputation secondary to peripheral artery disease and/or diabetes prior to surgery through 12 months after surgery. To compare differences in ambulation by amputation level and to examine risk factors for change in ambulation over time. DESIGN: Prospective cohort study. SETTING: Two Veterans Affairs medical centers, 1 university hospital, and a level I trauma center. PARTICIPANTS: Patients with peripheral artery disease or diabetes (N=239) undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 57% (n=136) met study criteria, and of these, 64% (n=87) participated. INTERVENTIONS: Standard of care at each facility. MAIN OUTCOME MEASURES: Ambulatory function measured using the Locomotor Capability Index-5. RESULTS: Seventy-five of the 87 (86%) subjects enrolled finished their 12-month follow-up interview. Ambulatory mobility declined during the period immediately prior to surgery (premorbid) and remained low at 6 weeks postsurgery. On average, ambulation improved after surgery but did not return to premorbid levels. In the final multivariate model, age and history of lower-extremity arterial reconstruction were significantly associated with a poorer ambulatory trajectory over time, while other factors, such as amputation level, prior alcohol use, and length of disability prior to amputation, were not. CONCLUSIONS: The findings highlight the importance of considering premorbid ambulatory function. Informing providers and patients about the trajectory and time course of changes in ambulation can enhance patient education, patient expectations, and treatment planning.

Prosthetic fitting, use, and satisfaction following lower-limb amputation: a prospective study.

Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes.

BACKGROUND: Information about longer-term functional outcomes following lower extremity amputation for peripheral vascular disease and diabetes remains limited. This study examined factors associated with mobility success during the first year following amputation. METHODS: Prospective cohort study of 87 amputees experiencing a first major unilateral amputation surgery. Seventy-five (86%) participants completed 12-month follow-up interview. RESULTS: Twenty-eight subjects (37%) achieved mobility success, defined as returning to or exceeding a baseline level of mobility on the locomotor capability index (LCI-5). Forty-three subjects (57%) were satisfied with their mobility. Individuals who were 65 years of age and older (risk difference [RD] = -0.52; 95% confidence interval [CI]: -0.75, -0.29), reported a current alcohol use disorder (RD = -0.37; 95% CI: -0.48, -0.26), had a history of hypertension (RD = -0.23; 95% CI: -0.43, -0.03) or treatment for anxiety or depression (RD = -0.39; 95% CI: -0.50, -0.28) were less likely to achieve mobility success. Mobility success was associated with mobility satisfaction (RD = 0.36; 95% CI: 0.20, 0.53) and satisfaction with life (RD = 0.28; 95% CI: 0.06, 0.50). Although higher absolute mobility at 12 months was also associated with mobility satisfaction and overall life satisfaction, 50% of individuals who achieved success with low to moderate 12-month mobility function reported they were satisfied with their mobility. CONCLUSION: Defining success after amputation in relation to an individual's specific mobility prior to the development of limb impairment which led to amputation provides a useful, patient-centered measure that takes other aspects of health, function, and impairment into account.

Injection anxiety remains a long-term barrier to medication adherence in multiple sclerosis.

OBJECTIVE: To evaluate the contribution injection anxiety to disease modifying therapy (DMT) adherence among individuals with multiple sclerosis (MS). Injection anxiety has been associated with medication discontinuation early in the course of treatment, but little is known about the relationship between injection anxiety and sustained DMT adherence over time. METHOD: Eighty-nine outpatients receiving care at a Veterans Administration MS clinic completed a telephone survey at baseline and monthly telephone follow-up for 6 months. RESULTS: Participants were established DMT users (M = 3.43 years, SD = 3.29), with relatively high adherence overall (over 80% achieved 80% adherence or greater). Using logistic regression and controlling for demographics, MS disability, type of DMT, and time on DMT, the authors found that baseline injection anxiety predicted lower levels of adherence at 4 months and 6 months, with a similar trend at 2 months. CONCLUSION: Sustained adherence to DMT remains a challenge for a subset of individuals with MS well beyond the initial period of acclimation. Injection anxiety is an important and promising target of psychological intervention during all periods of medication use.

Development and implementation of three mitogen-activated protein kinase (MAPK) signaling pathway imaging assays to provide MAPK module selectivity profiling for kinase inhibitors: MK2-EGFP translocation, c-Jun, and ERK activation.

This chapter describes the development and implementation of three independent imaging assays for the major mitogen-activated protein kinase (MAPK) signaling modules: p38, JNK, and ERK. There are more than 500 protein kinases encoded in the human genome that share an ATP-binding site and catalytic domain conserved in both sequence and structure. The majority of kinase inhibitors have been found to be competitive with ATP, raising concerns regarding kinase selectivity and potency in an environment of millimolar intracellular concentrations of ATP, as well as the potential for off-target effects via the many other cellular proteins that bind and/or utilize ATP. The apparent redundancy of the kinase isoforms and functions in the MAPK signaling modules present additional challenges for kinase inhibitor selectivity and potency. Imaging assays provide a method to address many of these concerns. Cellular imaging approaches facilitate analysis of the targets expressed in the context of their endogenous substrates and scaffolding proteins and in a complex environment for which subcellular localization, cross talk between pathways, phosphatase regulatory control, and intracellular ATP concentrations are relevant to the functions of the kinase. The assays described herein provide a strategy to profile kinase inhibitors for MAPK pathway selectivity while simultaneously providing information on cell morphology or toxicity. Results suggest that the MAPK pathways are indeed susceptible to nonselective kinase inhibitors such as staurosporin and inhibitors that inhibit upstream MAPK Kinase Kinases (MKKKs) and MAPK Kinases (MKKs) in the MAPK signaling pathway, especially those involved in cross talk between the pathways. However, selective MAPK inhibitors were identified that exhibited pathway selectivity as evidenced by significantly lower IC(50) values for their respective p38, JNK, or ERK signaling pathway assays.

A two-year longitudinal study of social support following amputation.

PURPOSE: (1) To describe one aspect of social support, social integration, longitudinally for 2 years following lower limb amputation and (2) to explore the impact of social support on depression, pain interference, life satisfaction, mobility, and occupational functioning. METHOD: Eighty-nine adults recruited from consecutive admissions to an orthopaedic surgery service completed telephone interviews 1, 6, 12 and 24 months following amputation surgery. Dependent variables included the Social Integration (SI) sub-scale of the Craig Handicap Assessment and Reporting Technique (CHART) and the Multidimensional Scale of Perceived Social Support (MSPSS). RESULTS: There was a high level of SI among most persons following lower limb amputations that was relatively unchanged in the 2 years following surgery. However, mean levels of SI were lower in this group compared to a sample without disabilities. MSPSS scores were highly variable, ranging from almost no support to the maximum amount of support. MSPSS was an important concurrent predictor of pain interference, life satisfaction, and mobility, controlling for demographic and amputation-related factors. Baseline MSPSS predicted mobility and occupational functioning 6 months post-amputation, controlling for demographic and amputation-related factors. CONCLUSIONS: Findings suggest that interventions aimed at improving the quality of social relationships after amputation may facilitate participation in activities.