Treatment Patterns, Healthcare Resource Utilization, and Direct Costs Among Patients Initiating Concomitant Use of a Calcitonin Gene-Related Peptide Monoclonal Antibody (CGRP mAb) and Novel Acute Medication in the United States.

Purpose: To describe treatment patterns, all-cause and migraine-related healthcare resource utilization (HCRU), and direct costs among people with migraine treated with concomitant calcitonin gene-related peptide monoclonal antibody (CGRP mAb) and novel acute migraine medications (ubrogepant, rimegepant, lasmiditan) in the United States (US). Patients and Methods: This retrospective, observational cohort study utilized data from the IBM MarketScan® Research Databases and included adults initiating CGRP mAb or novel acute migraine medication as index medications between May 01, 2018, and Feb 28, 2021. All-cause and migraine-related HCRU (number of visits) and costs at baseline (12 months pre-index) and at follow-up (12 months post-index) were descriptively analyzed; differences between values at follow-up and baseline were reported. Results: Of 4,167 included in the analysis (mean [SD] age: 43.7 [11.2] years), 89.2% were women, and 59.7% had chronic migraine. Adherence to the indexed CGRP mAb was 47% (using proportion of days covered [PDC]) and 80.1% (using medication possession ratio [MPR]); mean (SD) persistence was 273.4 (115.3) days). At follow-up, 43.9% of the patients discontinued their index preventive medication of which 80.2% switched to a different preventive migraine medication; 17.0% restarted their index preventive medication. Reductions in all-cause inpatient HCRU, all-cause inpatient and outpatient costs, and migraine-related outpatient HCRU were observed at follow-up vs. baseline, whereas increases in all-cause outpatient HCRU, all-cause medication costs, migraine-related inpatient HCRU, and migraine-related inpatient, outpatient, and medication costs were observed. Conclusion: In this study, observed treatment patterns with the indexed CGRP mAb were consistent with prior reports. Concomitant treatment with CGRP mAb and novel acute migraine medications led to reductions in some outcomes of HCRU and direct costs, however, increases were also observed. Treatment utilization, reductions in HCRU and cost savings identified in this study in favor of concomitant CGRP mAb and novel acute medications may help clinicians and other healthcare decision makers assessing appropriate therapeutic options for migraine management.

SARS-CoV-2 in relation to global vaccination and booster doses: what is the future of vaccination in the battle against COVID-19?

Many of the deletions and large mutations found in the Omicron version of COVID-19 are identical to those seen in the α, π, ß, and δ based VOCs. Such deletions and alterations have long been known to increase the viral risk of transmission and binding ability. Additionally, these changes are anticipated to increase the chances of immunological evasion and antibody secretion. T478K, G339D, Y505H, S373P, S371L, S375F, N440K, K417N, S477N, G446S, Q493R, E484A, G496S, N501Y, Q498R, and D614G are all mutations that potentially affect the virus's behavior. The N terminal region of the spike is typically targeted by NABs or neutralizing antibodies, immunologic polypeptides that prevent viruses from infecting cells. If the target region of the NABs significantly alters, the viruses may be able to avoid the autoimmune response generated by initial infection and vaccination. A possible "receptor shift" wherein ACE2 is not exclusively an Omicron receptor is worrying, given the huge number of mutations within the RBD region. D614G is the most prevalent mutation discovered among the three major pandemic variants. The Omicron variant is the most divergent variation seen in large numbers thus far in the pandemic, raising concerns that it could be linked to a faster transmission rate, lower vaccine effectiveness, and a greater risk of re-infection. Since identifying the Omicron variant, various countries have made significant modifications to their vaccination programs, including the recommendation of a third injection of boosting vaccination dosages in large populations to reduce the risk of adverse effects. However, all three vaccine producers (Johnson et Johnson, BioNTech, Pfizer, and Moderna) have published statements claiming vaccines would protect against severe sickness and that variant-specific vaccinations and boosters are in the works. This review sheds insight on several genetic mutations and their evolution in distinct variations. However, further study is needed to improve our understanding of illness transmissibility, immune escape capacity, patient features and severity, and the use of further diagnostic and therapeutic techniques (Fig. 1, Ref. 20). Keywords: SARS-CoV-2, global vaccination, booster doses, COVID-19.

Outcomes and prognostic variables of radiofrequency zygapophyseal joint neurotomy in Utah workers' compensation patients.

PURPOSE: The prevalence of radiofrequency zygapophyseal joint neurotomy (RFN) has increased substantially across the past decade. Limited research exists that has examined pre-procedure predictors of RFN outcomes, particularly within workers' compensation populations. The purpose of this study was to determine if pre-procedure biopsychosocial variables are predictive of outcomes in a cohort of compensated Utah patients who have undergone RFN. PATIENTS AND METHODS: This was a retrospective cohort study consisting of a review of pre-procedure medical records and a telephone outcome survey. The sample consisted of 101 compensated workers from Utah who had undergone RFN. Fifty-six patients (55%) responded to the outcome survey. Patients were an average of 46 months post-neurotomy at the time of follow-up. Outcome measures included patient satisfaction, disability status, Roland-Morris Disability Questionnaire, Stauffer-Coventry Index, and Short-Form Health Survey-36 (v.2). Statistical techniques utilized included frequencies, mean comparisons, and logistic and multiple regressions. RESULTS: Forty percent of patients were totally disabled at the time of follow-up. Lawyer involvement, older age, and a positive history of depression were predictors of poor outcomes in logistic and multiple regression equations. CONCLUSION: Presurgical biopsychosocial variables were predictive of multidimensional patient outcomes, and a high rate of total disability was observed. Additional research on the effectiveness of RFN for workers' compensation patients is recommended.

Lumbar Fusion in Utah Workers' Compensation Patients: Changing Outcomes Across a Decade.

STUDY DESIGN: This study was a retrospective-cohort design involving a review of patient medical and cost records and a 2-year postsurgery follow-up outcome survey. OBJECTIVE: To evaluate the functional and cost outcomes associated with recent lumbar fusion surgeries in Utah workers and compare these outcomes with a comparable prior study cohort. SUMMARY OF BACKGROUND DATA: Lumbar fusion performed on injured workers has dramatically increased over the past 2 decades and this likely coincided with the increased use of more advanced surgical instrumentation. Considering the recent changes in lumbar fusion surgery, there is a need to identify how patient outcomes have changed among injured workers. MATERIALS AND METHODS: Retrospective chart review and 2-year postsurgery follow-up survey of patient outcomes were performed. Postsurgical outcomes for this sample were compared with established norms for back pain patients and a previous cohort of compensated lumbar fusion patients obtained from Workers' Compensation Fund of Utah. RESULTS: The current cohort evidenced a solid fusion rate of 89% and significant increase in the use of surgical instrumentation, particularly titanium fusion cages. Despite increased solid fusion rates, injured workers who have undergone lumbar fusion in Utah demonstrated equivalent and in some cases worse outcomes than those documented a decade ago. Specifically, there were significant increases in back pain dysfunction and narcotic medication usage in the current versus the past cohort. Medical and compensation costs for compensated lumbar fusion patients in Utah also significantly increased since the mid-1990s. CONCLUSION: Over the past decade, injured workers who have undergone lumbar fusion in Utah showed an increase in solid fusion rates and costs without a corresponding improvement in patient outcomes. LEVEL OF EVIDENCE: 3.

Occupational and biopsychosocial risk factors for carpal tunnel syndrome.

OBJECTIVE: To investigate a biopsychosocial model of risk for carpal tunnel syndrome (CTS). In addition, a host of exploratory psychosocial variables was investigated as potential risk factors for CTS. METHODS: A case-control design was used comparing 87 CTS and 74 sex-matched general orthopedic patients from an outpatient orthopedic clinic. All participants underwent the same diagnostic protocol (ie, physical evaluation and electrodiagnostic testing) and completed a self-report questionnaire assessing a wide range of potential occupational, personological, and psychosocial risk factors. RESULTS: Multiple logistic regression analyses revealed that occupational repetition, not engaging in vigorous exercise, physical activities with wrist strain, poorer physical health, and lower job satisfaction were significantly related to the presence of CTS. Obesity was borderline significantly related to the presence of CTS. CONCLUSIONS: The biopsychosocial model provides a useful heuristic for conceptualizing CTS risk among injured workers.

The impact of furloughs on emotional exhaustion, self-rated performance, and recovery experiences.

The notion that strain can result as employees' resources are threatened or lost is well established. However, the transition from resource threats to resource losses is an important but understudied aspect of employee strain. We argue that the threat-to-loss transition triggers accelerated resource loss and a shift in how employees utilize their remaining resources unless employees engage in recovery experiences during the transition. Using a discontinuous change framework, we examine employee furloughs-the placement of employees on leave with no salary of any kind-in terms of the transition from resource threat to loss: Resources may be threatened when the furlough is announced and lost when the furlough occurs. Using 4 data collections with 180 state government employees, we found mean levels of emotional exhaustion increased and mean levels of self-reported performance decreased following the furlough. The discontinuous changes in exhaustion and performance were significantly impacted by employees' recovery experiences during the furlough. We discuss the implications of these findings for other threat-to-loss and recovery research as well as for organizations implementing furloughs.

Specificity of psychological treatments for bulimia nervosa and binge eating disorder? A meta-analysis of direct comparisons.

Treatment guidelines state that cognitive-behavioral therapy (CBT) and interpersonal therapy are the best-supported psychotherapies for bulimia nervosa (BN) and that CBT is the preferred psychological treatment for binge eating disorder (BED). However, no meta-analysis which both examined direct comparisons between psychological treatments for BN and BED and considered the role of moderating variables, such as the degree to which psychotherapy was bona fide, has previously been conducted Thus, such an analysis was undertaken. We included 77 comparisons reported in 53 studies. The results indicated that: (a) bona fide therapies outperformed non-bona fide treatments, (b) bona fide CBT outperformed bona fide non-CBT interventions by a statistically significant margin (only approaching statistical significance for BN and BED when examined individually), but many of these trials had confounds which limited their internal validity, (c) full CBT treatments offered no benefit over their components, and (d) the distribution of effect size differences between bona fide CBT treatments was homogeneously distributed around zero. These findings provide little support for treatment specificity in psychotherapy for BN and BED.

The moderating role of attention-deficit/hyperactivity disorder in the work engagement-performance process.

Attention-deficit/hyperactivity disorder (ADHD) is a cognitive disability that affects millions. Although individuals with ADHD are employed throughout many organizations and there is evidence that their performance is lower, scant research exists describing how ADHD impacts an individual's performance. In this article, we extend attentional control theory to examine how ADHD impacts both the effectiveness and efficiency of employee performance. Across 3 samples, 2 of general working adults (n = 257 and 170) and 1 of nurses (n = 243), we found that ADHD was associated with lower performance (rated via self-, coworker, and supervisor ratings) and that the relationship was strongest for in-role performance, suggesting that employees with ADHD may be diverting attention away from task-relevant behaviors. Furthermore, although work engagement was associated with higher performance, that relationship was diminished among those who experienced higher levels of ADHD, suggesting lower performance efficiency. We discuss the implications of these findings for research on attentional control and the management of those with ADHD at work.

Botulinum toxins: mechanisms of action, antinociception and clinical applications.

Botulinum toxin (BoNT) is a potent neurotoxin that is produced by the gram-positive, spore-forming, anaerobic bacterium, Clostridum botulinum. There are 7 known immunologically distinct serotypes of BoNT: types A, B, C1, D, E, F, and G. Clostridum neurotoxins are produced as a single inactive polypeptide chain of 150kDa, which is cleaved by tissue proteinases into an active di-chain molecule: a heavy chain (H) of ∼100 kDa and a light chain (L) of ∼50 kDa held together by a single disulfide bond. Each serotype demonstrates its own varied mechanisms of action and duration of effect. The heavy chain of each BoNT serotype binds to its specific neuronal ecto-acceptor, whereby, membrane translocation and endocytosis by intracellular synaptic vesicles occurs. The light chain acts to cleave SNAP-25, which inhibits synaptic exocytosis, and therefore, disables neural transmission. The action of BoNT to block the release of acetylcholine botulinum toxin at the neuromuscular junction is best understood, however, most experts acknowledge that this effect alone appears inadequate to explain the entirety of the neurotoxin's apparent analgesic activity. Consequently, scientific and clinical evidence has emerged that suggests multiple antinociceptive mechanisms for botulinum toxins in a variety of painful disorders, including: chronic musculoskeletal, neurological, pelvic, perineal, osteoarticular, and some headache conditions.

Predicting back pain treatment outcomes among workers' compensation patients: important information for clinical neuropsychologists.

Low back pain is an increasingly prevalent and costly issue in the United States. It is a particularly relevant problem for Workers' Compensation patients, who typically experience worse surgical and functional outcomes than their non-compensated counterparts. Neuropsychologists often provide intervention and assessment services to compensated patients with back pain, and thus it is critical they possess a basic understanding of the factors that might predispose an injured worker to poor spine surgery outcomes. This paper will review the current literature regarding presurgical biopsychosocial factors which have been implicated in poor back surgery outcomes among injured workers. We provide some tentative guidelines for neuropsychologists to utilize in providing services to injured workers with back pain.

Predicting compensation and medical costs of lumbar fusion patients receiving workers' compensation in utah using presurgical biopsychosocial variables.

STUDY DESIGN: A retrospective-cohort investigation (N = 245) utilizing a review of patient medical records and costs accrued through the Workers' Compensation Fund of Utah. OBJECTIVE: To replicate a previous study of compensation and medical costs in compensated lumbar fusion patients, to identify changes in costs across time, and to identify biopsychosocial variables predictive of current costs. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated that medical costs associated with lumbar fusion have been rising drastically. It is unclear whether rising fusion costs are occurring in compensation populations. Prior studies have also demonstrated that costs can be predicted on the basis of presurgical biopsychosocial variables, and there is a need to determine whether such variables are still relevant. METHODS: A retrospective review of patient medical records and compensation and medical costs paid by the Workers' Compensation Fund of Utah was performed. RESULTS: Since the mid-1990s, medical costs for compensated lumbar fusion patients in Utah have risen approximately 174%, whereas compensation costs have increased roughly with the pace of inflation. Wage and assignment to nurse case management predicted compensation costs, whereas assignment to nurse case management also predicted medical costs. CONCLUSION: Medical costs among compensated Utah patients receiving lumbar fusion have risen dramatically since the 1990s, whereas compensation costs have not. Biopsychosocial variables continue to be predictive of these costs, although to a more modest degree than in prior studies. Further investigations should look at other factors leading to increased medical costs.

Reliability, validity, and responsiveness of the Japanese version of the Neck Pain and Disability Scale.

BACKGROUND: Until recently, no Japanese versions have existed of the more popular, patient-reported disability questionnaires for neck pain. This study aimed to test the reliability, validity, and responsiveness of the Japanese version of the Neck Pain and Disability Scale (NPDS), one of the most widely used questionnaires in patients with neck pain. METHODS: In this validation study, 167 outpatients with neck pain participated. Patients received the NPDS and the Medical Outcome Study Short Form 36-item Health Survey (SF-36), and used Visual Analog Scales (VASs) to assess pain and global health. To examine test-retest reliability, patients who were considered stable by clinicians were given the NPDS 2 weeks after baseline. To examine responsiveness, patients who had not undergone treatment at the time of the first data collection or had no change in treatment over 3 months were studied again 2 weeks after starting a new medication or physical therapy. RESULTS: Of the 167 participants, 143 completed the questionnaires (85.6%). Factor analysis showed two factors, defined as neck-pain-related disability (factor 1) and neck-related pain (factor 2). Cronbach's α coefficient for factor 1, factor 2, and total score was 0.94, 0.93, and 0.96. The intra-class correlation coefficients for the 19 more stable patients were 0.79, 0.88, and 0.87. For concurrent validity, the correlation between NPDS subscales and total score and SF-36 subscale scores ranged from r = -0.54 to -0.22 (p < 0.01). Correlations between the NPDS subscales and total score and VAS of pain ranged from 0.56 to 0.77 (p < 0.01) and those for VAS of global health ranged from 0.48 to 0.63 (p < 0.01). The NPDS subscales and total scores of the 41 patients retested after treatment were significantly improved. CONCLUSIONS: The Japanese version of the NPDS is a useful scale with reliability, validity, and responsiveness in assessing patients suffering from neck pain.

Presurgical biopsychosocial variables predict medical, compensation, and aggregate costs of lumbar discectomy in Utah workers' compensation patients.

BACKGROUND CONTEXT: Elective lumbar discectomy among injured workers is a prevalent spine surgery that often requires a lengthy rehabilitation. It is important to determine presurgical biopsychosocial predictors of compensation and medical costs in such patients. PURPOSE: To determine if presurgical biopsychosocial variables are predictive of compensation and medical costs in a cohort of Utah patients who have undergone open or microlumbar discectomy that are receiving workers' compensation. STUDY DESIGN/SETTING: A retrospective cohort study consisting of a review of presurgical medical records and accrued medical and compensation costs. PATIENT SAMPLE: A consecutive sample of 266 compensated workers from Utah who had undergone either open discectomy or microlumbar discectomy from 1994 to 2000. All patients were at least 2 years postsurgery at the time of follow-up. OUTCOME MEASURES: Total accrued medical, compensation, and aggregate costs. METHODS: A retrospective review of presurgical biopsychosocial variables and total accrued medical, compensation, and aggregate costs. RESULTS: Presurgical variables were statistically significantly correlated with medical and compensation costs. Multiple linear regression models accounted for 31% of variation in compensation costs, 32% in medical costs, and 43% in total aggregate costs. CONCLUSIONS: Presurgical biopsychosocial variables are important predictors of compensated lumbar discectomy costs. Medical cost control programs might benefit from identifying biopsychosocial variables related to increased costs.

Career success implications of political skill.

The authors investigated the individual characteristic of political skill and its relation to 5 different career-related outcomes (total compensation, promotions, career satisfaction, life satisfaction, and perceived external job mobility). They examined data obtained from a sample of 191 employees working a wide range of occupations. The results reveal that political skill is associated with 4 of the 5 outcomes. In addition, they examined the 4 dimensions of political skill and found that the networking ability dimension dominates the relations with the examined outcomes. The authors discuss practical implications, limitations, and directions for future research.

Attenuating the effects of social stress: the impact of political skill.

This study investigates the impact of perceived social stressors on job and career satisfaction. Additionally, the authors investigate whether individuals' reported levels of political skill could attenuate the negative effects of social stressors on these outcome variables. The authors test these hypotheses with a sample of 246 alumni from a private, Midwestern university. The authors' results provide support for the hypothesized negative influence of social stressors on job and career satisfaction and indicate that political skill can moderate these relationships. Practical implications and directions for future research are offered.

Myofascial pain disorders: theory to therapy.

Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and actuates movement against inertia. Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading. Muscular pain is often attributed to a myofascial pain disorder, a condition originally described by Drs Janet Travell and David Simons. Among patients seeking treatment from a variety of medical specialists, myofascial pain has been reported to vary from 30% to 93% depending on the subspecialty practice and setting. Forty-four million Americans are estimated to have myofascial pain; however, controversy exists between medical specialists regarding the diagnostic criteria for myofascial pain disorders and their existence as a pathological entity. Muscles with activity or injury-related pain are usually abnormally shortened with increased tone and tension. In addition, myofascial pain disorders are characterised by the presence of tender, firm nodules called trigger points. Within each trigger point is a hyperirritable spot, the 'taut-band', which is composed of hypercontracted extrafusal muscle fibres. Palpation of this spot within the trigger point provokes radiating, aching-type pain into localised reference zones. Research suggests that myofascial pain and dysfunction with characteristic trigger points and taut-bands are a spinal reflex disorder caused by a reverberating circuit of sustained neural activity in a specific spinal cord segment. The treatment of myofascial pain disorders requires that symptomatic trigger points and muscles are identified as primary or ancillary pain generators. Mechanical, thermal and chemical treatments, which neurophysiologically or physically denervate the neural loop of the trigger point, can result in reduced pain and temporary resolution of muscular overcontraction. Most experts believe that appropriate treatment should be directed at the trigger point to restore normal muscle length and proper biomechanical orientation of myofascial elements, followed by treatment that includes strengthening and stretching of the affected muscle. Chronic myofascial pain is usually a product of both physical and psychosocial influences that complicate convalescence.

Recurrent transverse myelitis after lumbar spine surgery: a case report.

STUDY DESIGN: A case of recurrent idiopathic transverse myelitis occurring after surgery is reported. OBJECTIVES: To present a case of idiopathic transverse myelitis recurring after surgery and to heighten awareness for the diagnosis and management of this disorder. SUMMARY AND BACKGROUND DATA: Transverse myelitis presenting with acute spinal pain and neurologic deficit must be considered along with structural causes of myelopathy by the spine specialist. This intramedullary spinal cord disorder may be caused by parainfectious and postvaccinal sequelae, multiple sclerosis, spinal cord ischemia, autoimmune disorders, and paraneoplastic syndromes. These various etiologies are often difficult to differentiate. However, a patient's history, clinical course, MRI studies, and laboratory findings often allow such classification. Determination of etiology provides pertinent information regarding potential recurrence, treatment, and prognosis. METHODS: The patient history, physical examination, radiologic and laboratory studies, and pertinent literature were reviewed. RESULTS: Thoracolumbar myelitis developed in the reported patient 6 weeks after lumbar spine surgery during an otherwise uncomplicated postoperative recovery. The workup did not identify a specific cause, and the patient recovered to ambulatory status. However, 4 months after surgery, acute transverse myelitis developed again, this time affecting the cervical spinal cord. Despite aggressive intervention with corticosteroids, the patient has remained nonambulatory with severe neurologic residua. In spite of an extensive workup, a definitive cause was not determined, although an autoimmune etiology was suspected. The patient has stabilized without recurrence using immunosuppressant therapies. CONCLUSIONS: Acute transverse myelitis is an intramedullary spinal cord disorder that may present to the spine specialist during the postoperative period. This diagnosis requires swift and aggressive diagnostic and treatment intervention. Although sometimes difficult, establishment of causation may help to determine therapy and prognosis.

The neck pain and disability scale: test-retest reliability and construct validity.

OBJECTIVE: This research established test-retest reliability and construct validity for the Neck Pain and Disability Scale (NPAD). METHODS: Two groups of patients with neck pain completed the NPAD. The first group filled out the scale twice before treatment, whereas the second completed it with a number of other outcome measures once a month for 4 months, for evaluation of treatment with injections. RESULTS: The reliability coefficient (r2 = 0.93) calculated from the data for the first group of patients indicated high test-retest reliability. Construct validity was demonstrated with the second group when the NPAD was compared with a number of other pain measures and found to have a larger treatment effect. The Neck Pain and Disability Scale factor scores also indicated that treatment effects varied across the four factors. CONCLUSIONS: The NPAD is a stable and responsive measure for patients with neck pain. The Neck Pain and Disability Scale factor scores are useful in identifying treatment effects on the specific dimensions involved in the pain experience.

Chronic lumbar spine and radicular pain: pathophysiology and treatment.

The lumbar spine forms the foundation and infrastructure of an organic skyscraper equipped with the physiologic capacity to act as a crane for lifting and a crankshaft for walking. Subjected to aging like other "human machinery," the lumbar spine adapts to the wear and tear of gravity and biomechanical loading through structural and neurochemical changes. Many of the changes are maladaptive, resulting in pain, physical and functional disability, and altered neurophysiologic circuitry. Some compensatory reactions are constructive, but others cause more interference with the organism's capacity to cope. A conceptional understanding of the multifaceted structural, biomechanical, biochemical, medical, and psychosocial influences that compose this mix elucidates the complexity of applying effective treatments.