Harnessing the conditioned pain modulation response in migraine diagnosis, outcome prediction, and treatment-A narrative review.

OBJECTIVE: To present the potential use and relevance of the conditioned pain modulation (CPM) response to migraine diagnosis, outcome prediction, and treatment. BACKGROUND: The CPM response is a widely used laboratory test to examine inhibitory pain modulation capabilities. METHODS: This narrative review summarizes and synthesizes the findings on the CPM response in patients with migraine. RESULTS: For diagnosis, we summarized the studies comparing CPM responses between patients with migraine and individuals without migraine or with other headache syndromes, as well as between patients with subtypes of migraine. For prediction, we summarized the studies utilizing the CPM response to predict migraine outcome, such as response to interventions. For treatment, we described a device that utilizes the CPM response for acute and preventative migraine treatment. In addition, we suggest the requirements needed for the CPM response to be used for migraine diagnosis, outcome prediction, and treatment. CONCLUSIONS: Although more research is needed, the CPM response could be a useful tool for improving migraine management.

Ethical issues surrounding the use of images from donated cadavers in the anatomical sciences.

Body donor programs rely on the generosity and trust of the public to facilitate the provision of cadaver resources for anatomical education and research. The uptake and adoption of emerging technologies, including those allowing the acquisition and distribution of images, are becoming more widespread, including within anatomical science education. Images of cadavers are useful for research and education, and their supply and distribution have commercial potential for textbooks and online education. It is unclear whether the utilization of images of donated cadavers are congruent with donor expectations, societal norms and boundaries of established public understanding. Presently, no global "best practices" or standards exist, nor is there a common model requiring specific image-related consent from body donors. As ongoing success of body donation programs relies upon the ethical and institutional governance of body utilization to maintain trust and a positive relationship with potential donors and the community, discussions considering the potential impact of image misuse are important. This paper discusses the subject of images of donated cadavers, commenting on images in non-specific use, education, research, and commercial applications. It explores the role and significance of such images in the context of anatomical science and society, and discusses how misuse - including unconsented use - of images has the potential to affect donor program success, suggesting that informed consent is currently necessary for all images arising from donated cadavers. Its purpose is to encourage discussion to guide responsible utilization of cadaver images, while protecting the interests of body donors and the public.

Formaldehyde Levels in Traditional and Portable Classrooms: A Pilot Investigation.

The pilot study discussed in this article assessed formaldehyde levels in portable classrooms (PCs) and traditional classrooms the authors evaluated formaldehyde levels in day and overnight indoor air (TCs) and explored factors influencing indoor air quality (e.g., carbon dioxide, temperature, and relative humidity). In a cross-sectional design, samples from nine PCs renovated within three years previously and three TCs in a school district in metropolitan Atlanta, Georgia. Formaldehyde levels ranged from 0.0068 to 0.038 parts per million (ppm). In both types of classroom, overnight formaldehyde median levels (PCs = 0.018 ppm; TCs = 0.019 ppm) were higher than day formaldehyde median levels (PCs = 0.011 ppm; TCs = 0.016 ppm). Carbon dioxide levels measured 470-790 ppm at 7:00 a.m. and 470-1800 ppm at 4:00 p.m. Afternoon medians were higher in TCs (1,400 ppm) than in PCs (780 ppm). Consistent with previous studies, formaldehyde levels were similar among PCs and TCs. Reducing carbon dioxide levels by improving ventilation is recommended for classrooms.

Trends in adult current asthma prevalence and contributing risk factors in the United States by state: 2000-2009.

BACKGROUND: Current asthma prevalence among adults in the United States has reached historically high levels. Although national-level estimates indicate that asthma prevalence among adults increased by 33% from 2000 to 2009, state-specific temporal trends of current asthma prevalence and their contributing risk factors have not been explored. METHODS: We used 2000-2009 Behavioral Risk Factor Surveillance System data from all 50 states and the District of Columbia (D.C.) to estimate state-specific current asthma prevalence by 2-year periods (2000-2001, 2002-2003, 2004-2005, 2006-2007, 2008-2009). We fitted a series of four logistic-regression models for each state to evaluate whether there was a statistically significant linear change in the current asthma prevalence over time, accounting for sociodemographic factors, smoking status, and weight status (using body mass index as the indicator). RESULTS: During 2000-2009, current asthma prevalence increased in all 50 states and D.C., with significant increases in 46/50 (92%) states and D.C. After accounting for weight status in the model series with sociodemographic factors, and smoking status, 10 states (AR, AZ, IA, IL, KS, ME, MT, UT, WV, and WY) that had previously shown a significant increase did not show a significant increase in current asthma prevalence. CONCLUSIONS: There was a significant increasing trend in state-specific current asthma prevalence among adults from 2000 to 2009 in most states in the United States. Obesity prevalence appears to contribute to increased current asthma prevalence in some states.

Asthma prevalence among US elderly by age groups: age still matters.

OBJECTIVE: For over three decades, the greatest burden of asthma deaths has occurred among persons aged 65 years and older. This study analyzed the association between increasing age and asthma prevalence among age groups within the US elderly population. METHODS: We analyzed aggregated data on 54,485 civilian, noninstitutionalized US adults aged 65 years and older from the 2001-2010 National Health Interview Survey (NHIS). We estimated the prevalence of current asthma, lifetime asthma, and chronic obstructive pulmonary disease (COPD) among US elderly by 5-year age groups and age stages ("young elderly" aged 65-84 years and "oldest old" aged ≥85 years). We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) to identify asthma prevalence patterns among elderly populations. RESULTS: From 2001 to 2010, the estimated average annual prevalence of current asthma among US elderly was 7.0%. Estimates of lifetime asthma, COPD, and co-occurring current asthma and COPD were 9.9%, 9.7%, and 3.0%, respectively. Prevalence of asthma decreased with advancing age while prevalence of COPD increased with advancing age. When controlling for study variables and significant interactions (p = .05) with COPD, the odds of reporting current asthma decreased with advancing age: 0.87 (95% CI, 0.76-1.01) for 70- to 74-year-olds; 0.76 (95% CI, 0.66-0.87) for 75- to 79-year-olds; 0.62 (95% CI, 0.51-0.75) for 80- to 84-year-olds; and 0.45 (95% CI, 0.36-0.55) for ≥85-year-olds, as compared to 65- to 69-year-olds. CONCLUSIONS: Asthma continues to affect a substantial proportion of the US elderly population. Increased diagnosis of COPD may overshadow correct diagnosis and treatment in populations with advancing age. Treatment guidelines should focus on preventable risk behaviors to increase the quality of life within this population.

An official american thoracic society statement: work-exacerbated asthma.

RATIONALE: Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work. OBJECTIVES: The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research. METHODS: Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus. MEASUREMENTS AND MAIN RESULTS: WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful. CONCLUSIONS: WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.

A national survey of adult asthma prevalence by urban-rural residence U.S. 2005.

OBJECTIVES: We analyzed national data to estimate asthma prevalence among U.S. adults by urban-rural residence and to determine the relative contributions of sociodemographic and health behavior characteristics on the probability of reporting asthma. METHODS: We linked the 2005 Behavioral Risk Factor Surveillance System (BRFSS) to Urban Influence Codes (UICs), categorizing respondents into four urban-rural groups: metropolitan, adjacent metropolitan, micropolitan, and remote. BRFSS collects health data from all 50 states. UICs classify respondent's county as urban or rural based on population size and proximity to metropolitan areas. We calculated asthma prevalence estimates and generated odds ratios (ORs) for the probability of reporting asthma. RESULTS: Overall asthma prevalence (7.9%; 95%CI = 7.73-8.08) was not statistically different (p = 0.28) by urban-rural residence. After adjusting for selected characteristics, adjacent metropolitan (OR = 0.96; 95%CI = 0.90-1.02) and remote (OR = 0.95; 95%CI = 0.85-1.05) residents were less likely--and micropolitan (OR = 1.04; 95%CI = 0.93-1.16) residents were more likely--to report asthma compared with metropolitan residents; but confidence intervals included null. CONCLUSIONS: Asthma prevalence is as high in rural as in urban areas. Certain demographic, behavioral, and health care characteristics unique to place of residence might affect asthma prevalence. Because these results substantially change our understanding of asthma prevalence in rural areas, further investigation is needed to determine geographic-related risk factors.

Medical care and alcohol use after testing hepatitis C antibody positive at STD clinic and HIV test site screening programs.

OBJECTIVES: The Centers for Disease Control and Prevention recommend screening individuals at risk for hepatitis C virus (HCV) infection. However, few published data describe outcomes of individuals with antibody to HCV (anti-HCV) identified through screening programs. The purpose of this study was to assess rates of medical evaluation and HCV treatment, change in alcohol consumption, and barriers to medical care after testing anti-HCV positive through a public screening program. METHODS: Anti-HCV positive individuals identified through San Diego sexually transmitted disease (STD) clinics and an HIV test site screening program were informed of positive test results, provided education and referral, and contacted by telephone three, six, and > or =12 months later. RESULTS: From September 1, 1999, to December 31, 2001, 411 anti-HCV positive individuals were newly identified, of whom 286 (70%) could be contacted > or = three months after receipt of test results (median length [range] of follow-up 14 [3-35] months). Of these 286, 156 (55%) reported having received a medical evaluation, of whom 19 (12%) began HCV treatment. Of 132 who reported drinking alcohol before diagnosis, 100 (76%) reported drinking less after diagnosis. Individuals with medical insurance at diagnosis were more likely than those without insurance to obtain a medical evaluation during follow-up (75 [68%] of 111 vs. 70 [45%] of 155; p < 0.001). Among those who did not obtain an evaluation, the most commonly reported reason was lack of insurance. CONCLUSIONS: Only about half of newly identified anti-HCV positive individuals received a medical evaluation, although 76% reported drinking less alcohol. Identifying ways to improve medical access for those who are anti-HCV positive could improve the effectiveness of screening programs.

Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial.

BACKGROUND: Closed-suction drainage to reduce seromas is standard after mastectomy. This study evaluates the safety of early drain removal. METHODS: Women undergoing mastectomy were randomized to early removal on postoperative day 2 or standard removal (< 30 mL drainage in 24 hours or postoperative day 14). Primary endpoints were time to drain removal and physician visits. Secondary endpoints were number of seroma aspirations, drain reinsertions, and infections. RESULTS: Twenty-seven patients were recruited before an interim analysis was performed to address safety concerns. Three patients withdrew before trial completion, leaving 14 patients in the standard group and 10 in the early group. Patients in the standard group had significantly fewer seroma aspirations, fewer drain reinsertions, and fewer physician visits. The trial was halted because of the higher rate of events in the early group. CONCLUSION: Surgical drains cannot be safely removed on postoperative day 2 after mastectomy. Early removal significantly increases the occurrence of seromas requiring treatment.

Integrating hepatitis, STD, and HIV services into a drug rehabilitation program.

BACKGROUND: Considering the difficulties in providing screening and vaccination services for inmates in short-stay incarceration facilities, an evaluation was conducted of the integration of prevention services in an alternative sentencing drug rehabilitation program (alternative to incarceration) in San Diego CA. METHODS: During the period April 1999 to December 2002, clients were asked to complete a brief risk-assessment questionnaire, and were offered hepatitis B virus (HBV) vaccination, HBV and hepatitis C virus (HCV) serologic testing, STD screening, and HIV counseling and testing. RESULTS: Of the estimated 1125 rehabilitation program enrollees, 930 (83%) participated in the integration program services. Most clients were male (64%), were aged >30 years (64%), and few (7%) reported previous HBV vaccination. Of the 854 clients eligible for hepatitis B vaccination, 98% received the first dose, 69% the second dose, and 42% completed the series. Eleven percent of clients had prior HBV infection, and 14.7% had HCV infection, with positivity rates being highest among those with a history of injection drug use-HBV, 19%, and HCV, 36%. HIV infection was rare (prevalence, 0.3%), and STDs were uncommon (chlamydia prevalence, 2%, and gonorrhea prevalence, 0.6%). Total annual cost of integration services (excluding HIV testing) was dollar 31,994 equating to dollar 122 per client served. CONCLUSIONS: Alternative sentencing drug rehabilitation programs provide a venue to efficiently deliver integrated hepatitis and other prevention services. Considering the vast number of high-risk persons in drug rehabilitation, probation, parole, and inmate release programs, an opportunity exists to greatly expand hepatitis services.

Title VII funding and physician practice in rural or low-income areas.

CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. PURPOSE: To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. METHODS: A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000. FINDINGS: Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities. CONCLUSIONS: Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.

Clinical Decision Support Systems and Prevention: A Community Guide Cardiovascular Disease Systematic Review.

CONTEXT: Clinical decision support systems (CDSSs) can help clinicians assess cardiovascular disease (CVD) risk and manage CVD risk factors by providing tailored assessments and treatment recommendations based on individual patient data. The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors, practices for CVD-related preventive care services such as clinical tests and prescribed treatments, and management of CVD risk factors. EVIDENCE ACQUISITION: An existing systematic review (search period, January 1975-January 2011) of CDSSs for any condition was initially identified. Studies of CDSSs that focused on CVD prevention in that review were combined with studies identified through an updated search (January 2011-October 2012). Data analysis was conducted in 2013. EVIDENCE SYNTHESIS: A total of 45 studies qualified for inclusion in the review. Improvements were seen for recommended screening and other preventive care services completed by clinicians, recommended clinical tests completed by clinicians, and recommended treatments prescribed by clinicians (median increases of 3.8, 4.0, and 2.0 percentage points, respectively). Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol, and hemoglobin A1C levels. CONCLUSIONS: CDSSs are effective in improving clinician practices related to screening and other preventive care services, clinical tests, and treatments. However, more evidence is needed from implementation of CDSSs within the broad context of comprehensive service delivery aimed at reducing CVD risk and CVD-related morbidity and mortality.

Hospitalizations for severe lower respiratory tract infections.

BACKGROUND: Hospitalization for lower respiratory tract infections (LRTIs) among children have been well characterized. We characterized hospitalizations for severe LRTI among children. METHODS: We analyzed claims data from commercial and Medicaid insurance enrollees (MarketScan) ages 0 to 18 years from 2007 to 2011. LRTI hospitalizations were identified by the first 2 listed International Classification of Diseases, Ninth Revision discharge codes; those with ICU admission and/or receiving mechanical ventilation were defined as severe LRTI. Underlying conditions were determined from out- and inpatient discharge codes in the preceding year. We report insurance specific and combined rates that used both commercial and Medicaid rates and adjusted for age and insurance status. RESULTS: During 2007-2011, we identified 16797 and 12053 severe LRTI hospitalizations among commercial and Medicaid enrollees, respectively. The rates of severe LRTI hospitalizations per 100000 person-years were highest in children aged <1 year (commercial: 244; Medicaid: 372, respectively), and decreased with age. Among commercial enrollees, ≥ 1 condition increased the risk for severe LRTI (1 condition: adjusted relative risk, 2.68; 95% confidence interval, 2.58-2.78; 3 conditions: adjusted relative risk, 4.85; 95% confidence interval, 4.65-5.07) compared with children with no medical conditions. Using commercial/Medicaid combined rates, an estimated 31289 hospitalizations for severe LRTI occurred each year in children in the United States. CONCLUSIONS: Among children, the burden of hospitalization for severe LRTI is greatest among children aged <1 year. Children with underlying medical conditions are at greatest risk for severe LRTI hospitalization.

Influenza A (H1N1) 2009 monovalent vaccination among adults with asthma, U.S., 2010.

BACKGROUND: The 2009 pandemic influenza A (H1N1) virus (2009 H1N1) was first identified in April 2009 and quickly spread around the world. The first doses of influenza A (H1N1) 2009 monovalent vaccine (2009 H1N1 vaccine) became available in the U.S. in early October 2009. Because people with asthma are at increased risk of complications from influenza, people with asthma were included among the initial prioritized groups. PURPOSE: To evaluate 2009 H1N1 vaccination coverage and identify factors independently associated with vaccination among adults with asthma in the U.S. METHODS: Data from the 2009-2010 BRFSS (Behavioral Risk Factor Surveillance System) influenza supplemental survey were used; responses from March through June 2010 were analyzed to estimate vaccination levels of 2009 H1N1 vaccine among respondents aged 25-64 years with asthma. Multivariable logistic regression and predictive marginal models were performed to identify factors independently associated with vaccination. RESULTS: Among adults aged 25-64 years with asthma, 25.5% (95% CI=23.9%, 27.2%) received the 2009 H1N1 vaccination. Vaccination coverage ranged from 9.9% (95% CI=6.4%, 15.1%) in Mississippi to 46.1% (95% CI=33.3%, 61.2%) in Maine. Characteristics independently associated with an increased likelihood of vaccination among adults with asthma were as follows: had a primary doctor, had other high-risk conditions, and received seasonal influenza vaccination in the 2009-2010 season. CONCLUSIONS: Vaccination coverage among adults aged 25-64 years with asthma was only 25.5% and varied widely by state and demographic characteristics. National and state-specific 2009 H1N1 vaccination coverage data for adults with asthma are useful for evaluating the vaccination campaign and for planning and implementing strategies for increasing vaccination coverage in possible future pandemics.

Asthma and serious psychological distress: prevalence and risk factors among US adults, 2001-2007.

BACKGROUND: For millions of adults, effective control of asthma requires a regimen of care that may be compromised by psychological factors, such as anxiety and depression. This study estimated the prevalence and risk factors for serious psychological distress (SPD) and explored their relationship to health-related quality of life (HRQOL) among adults with asthma in the United States. METHODS: We analyzed data from 186,738 adult respondents from the 2001-2007 US National Health Interview Survey. We calculated weighted average prevalence estimates of current asthma and SPD by demographic characteristics and health-related factors. We used logistic regression analysis to calculate odds ratios for factors that may have predicted asthma, SPD, and HRQOL. RESULTS: From 2001 to 2007, the average annual prevalence of current asthma was 7.0% and the average prevalence of SPD was 3.0%. Among adults with asthma, the prevalence of SPD was 7.5% (95% CI, 7.0%-8.1%). A negative association between HRQOL and SPD was found for all adults, independent of asthma status. A similar pattern of risk factors predicted SPD and the co-occurrence of SPD and asthma, although adults with asthma who reported lower socioeconomic status, a history of smoking or alcohol use, and more comorbid chronic conditions had significantly higher odds of SPD. CONCLUSION: This research suggests the importance of mental health screening for persons with asthma and the need for clinical and community-based interventions to target modifiable lifestyle factors that contribute to psychological distress and make asthma worse.

Influenza vaccination among adults with asthma findings from the 2007 BRFSS survey.

BACKGROUND: Asthma prevalence among U.S. adults is estimated to be 6.7%. People with asthma are at increased risk of complications from influenza. Influenza vaccination of adults and children with asthma is recommended by the Advisory Committee on Immunization Practices. The Healthy People 2010 Objectives call for annual influenza vaccination of at least 60% of adults aged 18-64 years with asthma and other conditions associated with an increased risk of complications from influenza. PURPOSE: To assess influenza vaccination coverage among adults with asthma in the United States. METHODS: Data from the 2007 Behavioral Risk Factor Surveillance System restricted to individuals interviewed during February through August were analyzed in 2008 to estimate national and state prevalence of self-reported receipt of influenza vaccination among respondents aged 18-64 years with asthma. Logistic regression provided predictive marginal vaccination coverage for each covariate, adjusted for demographic and access to care characteristics. RESULTS: Among adults aged 18-64 years with asthma, influenza vaccination coverage was 39.9% (95% CI=38.3%, 41.5%) during the 2006-2007 season (coverage ranged from 26.9% [95% CI=19.8%, 35.3%] in California to 53.3% [95% CI=42.8%, 63.6%] in Tennessee). Influenza vaccination coverage was 33.9% (95% CI=31.9%, 35.9%) for adults aged 18-49 years with asthma compared to 54.7% (95% CI=52.4%, 57.0%) for adults aged 50-64 years with asthma. Among people aged 18-64 years, vaccination coverage was 28.8% among those without asthma. People with asthma who had an increased likelihood of vaccination were aged 50-64 years, female, non-Hispanic white, and had diabetes, activity limitations, health insurance, a regular healthcare provider, routine checkup in the previous year, and formerly smoked or never smoked. CONCLUSIONS: Influenza vaccination coverage continues to be below the national objective of 60% for people aged 18-64 years with asthma as a high-risk condition. Increased state and national efforts are needed to improve influenza vaccination levels among this population and particularly among those aged 18-49 years.

Asthma prevalence among US children in underrepresented minority populations: American Indian/Alaska Native, Chinese, Filipino, and Asian Indian.

OBJECTIVES: The purpose of this work was to estimate asthma prevalence among US children in racial minority subgroups who have been historically underrepresented in the pediatric asthma literature. These subgroups include American Indian/Alaska Native, Chinese, Filipino, and Asian Indian children. We also explored the association between these race categories and asthma after adjusting for demographic and sociodemographic characteristics and explored the effect of place of birth as it relates to current asthma. PATIENTS AND METHODS: Data on all 51944 children aged 2 to 17 years from the 2001-2005 National Health Interview Survey were aggregated and analyzed to estimate the prevalence of current asthma, lifetime asthma, and asthma attacks according to race and place of birth. Logistic regression was used to determine adjusted odds ratios for current asthma according to race and place of birth while controlling for other demographic and sociodemographic variables. RESULTS: National estimates of current asthma prevalence among the children in the selected minority subgroups ranged from 4.4% in Asian Indian children to 13.0% in American Indian/Alaska Native children. Overall, children born in the United States had greater adjusted odds of reporting current asthma than did children born outside of the United States. CONCLUSIONS: Smaller racial and ethnic minority groups are often excluded from asthma studies. This study reveals that, among children from different Asian American subgroups, wide variation may occur in asthma prevalence. We also found that children born in the United States were more likely than children born outside of the United States to have current asthma.