Antiretroviral treatment outcomes among late HIV presenters initiating treatment with integrase inhibitors or protease inhibitors.

OBJECTIVES: The aim of the study was to investigate the efficacy and safety of first-line antiretroviral therapy (ART) with integrase inhibitor (INI) or protease inhibitor (PI)-based regimens in patients with low CD4 cell counts and/or an AIDS-defining disease. METHODS: We conducted a retrospective, multicentre analysis to investigate discontinuation proportions and virological response in patients with CD4 cell counts < 200 cells/µL and/or AIDS-defining disease when starting first-line ART. Proportions of those discontinuing ART were compared using univariate analysis. Virological response was analysed using the Food & Drug Administration (FDA) snapshot analysis (HIV-1 RNA < 50 HIV-1 RNA copies/mL at week 48). RESULTS: Two hundred and eighteen late presenters were included in the study: 13.8% were women and 23.8% were of non-European ethnicity, and the mean baseline CD4 count was 91 cells/µL (standard deviation 112 cells/µL). A total of 131 late presenters started on INI- and 87 on PI-based treatment. It was found that 86.1% of patients treated with INIs and 81.1% of patients treated with PIs had a viral load < 50 copies/mL at week 48; proportions of discontinuation because of adverse events were 6.1% in the INI group and 11.5% in the PI group. No significant differences in discontinuation proportions were observed at week 12 or 48 between INI- and PI-based regimens (P = 0.76 and 0.52, respectively). Virological response was equally good in those receiving INIs and those receiving PIs (86.1% vs. 81.1%, respectively; P = 0.36). CONCLUSIONS: In a European cohort of late presenters starting first-line INI or PI-based ART regimens, there were no significant differences in discontinuation proportions or virological response at week 48.

Measuring Sarcopenia Severity in Older Adults and the Value of Effective Interventions.

OBJECTIVES: Little is known about the severity and long-term health and economic consequences of sarcopenia. We developed a sarcopenia index to measure severity in older Americans and estimated the long-term societal benefits generated by effective interventions to mitigate severity. DESIGN: Using a micro-simulation model, we quantified the potential societal value generated in the US in 2010-2040 by reductions in sarcopenia severity in older adults. All analyses were performed in Stata and SAS. SETTING AND PARTICIPANTS: Secondary data from the National Health and Nutrition Examination Survey (NHANES) (N = 1634) and Health and Retirement Study (HRS) (N = 952) were used to develop a sarcopenia severity index in older adults. MEASUREMENTS: Multi-trait multi-method and factor analyses were used to validate and calibrate the sarcopenia severity index, which was modeled as a function of gait speed, walking without an assistive device, and moderate physical activity. RESULTS: In representative elderly populations, reducing sarcopenia severity by improving gait speed by 0.1 m/s in those with gait speed under 0.8 m/s generated a cumulative benefit of $65B by 2040 (2015 dollars). Improving walking ability in those with walking difficulty generated cumulative social benefit of $787B by 2040. CONCLUSIONS: Reducing sarcopenia severity would generate significant health and economic benefits to society-almost $800B in the most optimistic scenarios.

Novel use of epidural catheter: Air injection for neuroprotection during radiofrequency ablation of spinal osteoid osteoma.

Osteoid osteoma (OO) is a benign bone tumor, with a male-female ratio of approximately 2:1 and mainly affecting long bones. Ten percent of the lesions occur in the spine, mostly within the posterior elements. Treatment options for OO include surgical excision and percutaneous imaging-guided radiofrequency ablation (RFA). Lesions within the spine have an inherent risk of thermal damage to the vital structure because of proximity to the neural elements. We report a novel use of the epidural catheter for air injection for the neuroprotection of nerves close to the OO of the spine. A 12-year-old and 30 kg male child with an OO of the L3 vertebra was taken up for RFA. His preoperative examinations were within normal limits. The OO was very close to the L3 nerve root. Under general anesthesia, lumbar epidural catheter was placed in the L3-L4 space under imaging guidance. Ten ml of aliquots of air was injected under imaging guidance to avoid injury to the neural structures due to RFA. The air created a gap between neural elements and the tumor and served as an insulating material thereby protecting the neural elements from damage due to the RFA. Postoperatively, the patient did not develop any neurological deficit.

Use of Phosphite Salts in Laboratory and Semicommercial Tests to Control Citrus Postharvest Decay.

Potassium phosphite (KP) concentrations that inhibited the germination of 50% of Penicillium digitatum conidia were 229, 334, 360, 469, 498, or 580 mg/liter at pH 3, 4, 5, 6, 7, or 8, respectively. Increasing phosphate content in media reduced phosphite toxicity. To control green or blue mold, fruit were inoculated with P. digitatum or P. italicum, then immersed 24 h later in KP, calcium phosphite (CaP), sodium carbonate, sodium bicarbonate, or potassium sorbate for 1 min at 20 g/liter for each at 25 or 50°C. Mold incidence was lowest after potassium sorbate, CaP, or KP treatments at 50°C. CaP was often more effective than KP but left a white residue on fruit. KP was significantly more effective when fruit were stored at 10 or 15°C after treatment compared with 20°C. Acceptable levels of control were achieved only when KP was used in heated solutions or with fungicides. KP was compatible with imazalil (IMZ) and other fungicides and improved their effectiveness. KP increased thiabendazole or IMZ residues slightly. Phosphite residues did not change during storage for 3 weeks, except they declined when KP was applied with IMZ. KP caused no visible injuries or alteration in the rate of color change of citrus fruit in air or ethylene at 5 µl/liter.

Quality of life in haemophilia A: Hemophilia Utilization Group Study Va (HUGS-Va).

This study describes health-related quality of life (HRQoL) of persons with haemophilia A in the United States (US) and determines associations between self-reported joint pain, motion limitation and clinically evaluated joint range of motion (ROM), and between HRQoL and ROM. As part of a 2-year cohort study, we collected baseline HRQoL using the SF-12 (adults) and PedsQL (children), along with self-ratings of joint pain and motion limitation, in persons with factor VIII deficiency recruited from six Haemophilia Treatment Centres (HTCs) in geographically diverse regions of the US. Clinically measured joint ROM measurements were collected from medical charts of a subset of participants. Adults (N = 156, mean age: 33.5 ± 12.6 years) had mean physical and mental component scores of 43.4 ± 10.7 and 50.9 ± 10.1, respectively. Children (N = 164, mean age: 9.7 ± 4.5 years) had mean total PedsQL, physical functioning, and psychosocial health scores of 85.9 ± 13.8, 89.5 ± 15.2, and 84.1 ± 15.3, respectively. Persons with more severe haemophilia and higher self-reported joint pain and motion limitation had poorer scores, particularly in the physical aspects of HRQoL. In adults, significant correlations (P < 0.01) were found between ROM measures and both self-reported measures. Except among those with severe disease, children and adults with haemophilia have HRQoL scores comparable with those of the healthy US population. The physical aspects of HRQoL in both adults and children with haemophilia A in the US decrease with increasing severity of illness. However, scores for mental aspects of HRQoL do not differ between severity groups. These findings are comparable with those from studies in European and Canadian haemophilia populations.

The influence of types of decision support on physicians' decision making.

OBJECTIVE: To determine whether physicians' post-test probability estimates are influenced by receiving test characteristics and impact their subsequent clinical decisions. DESIGN: Questionnaire based randomised controlled trial. SETTING: Mailed survey with a vignette describing an infant whose pretest likelihood of pertussis was 30% and direct fluorescent-antibody (DFA) test was negative for pertussis. SUBJECTS: Nationally representative sample of US paediatricians (n = 1502). INTERVENTIONS: Random receipt of no additional information (controls), the DFA's sensitivity and specificity (TC group) or the test's sensitivity and specificity with their definitions (TCD group). MAIN OUTCOME MEASURES: Estimated post-test probability (PTP) of pertussis, PTP of 0.50, "nearly correct" PTP (+/-5%), intended erythromycin management and intended hospital disposition. ANALYSES: Chi2 and t tests. RESULTS: Despite the negative DFA result, 67% of the 635 (49.7%) participants who responded estimated a PTP higher than the pretest probability of 30%; the overall mean estimated PTP was 0.41 (SD 0.26) (correct answer: 0.18). The TCD group's mean PTP was significantly higher than controls' mean PTP (0.45 vs 0.38, p<0.001), while the TC and control groups' mean PTP did not differ significantly (0.41 vs 0.38, p = 0.16). With decision support significantly more TC and TCD participants compared to controls estimated the PTP as 0.50 (38% vs 17%, p<0.001; 41% vs 17%, p<0.001, respectively) and also estimated a nearly correct PTP more often (20% vs 13%, p = 0.06; 19% vs 13%, p = 0.08, respectively). The mean PTP of participants intending to discontinue erythromycin therapy or discharge the patient home was significantly lower than that of participants who intended continuing erythromycin or hospitalisation (0.20 vs 0.43, p<0.001; 0.40 vs 0.49, p = 0.005, respectively). CONCLUSIONS: Paediatricians differed in their response to information about test characteristics. For many, it increased errors in estimating post-test probability; for others, it reduced errors. Estimated post-test probability was logically associated with intended clinical management.

Workers' risk of unemployment after traumatic brain injury: a normed comparison.

We examined, among those persons working preinjury, the risk of unemployment 1 year after traumatic brain injury (TBI) relative to expected risk of unemployment for the sample under a validated risk-adjusted econometric model of employment in the U.S. population. Results indicate that 42% of TBI cases were unemployed versus 9% expected, relative risk (RR) = 4.5, 95% confidence interval (CI) (4.12, 4.95). The relative risk for unemployment was higher among males, those with higher education, persons with more severe injuries, and more impaired early neuropsychological or functional status. Difference in unemployment rates gave similar results for gender, severity of injury, and early neuropsychological and functional status. However, for education, the excess was smaller among those more highly educated, but the unemployment rate in the more highly educated in the general population was sufficiently small to yield a larger relative risk. In conclusion, after accounting for underlying risk of unemployment in the general population, unemployment is substantially higher after TBI for people who were employed when they were injured. The differential employment status varies depending on demographics, severity of brain injury, early functional outcome, and neurobehavioral indicators. For characteristics such as education, associated with rates of unemployment in the general population, different methods used to compare the rates may yield different results.

Quantification of the Toxicity of Aqueous Chlorine to Spores of Penicillium digitatum and Geotrichum citri-aurantii.

Chlorine toxicity to Penicillium digitatum and Geotrichum citri-aurantii, causes of green mold and sour rot of citrus, respectively, was quantified. In 3% wt/vol NaHCO3 containing 200 µg free chlorine per ml at pH 8.3, 95% of P. digitatum spores died (LT95) by 180 s at 5°C, while only 32 s were required at 24°C. The LT95 of G. citri-aurantii arthrospores was 108 and 31 s at 5 and 24°C, respectively. Mortality slowed 2- to 4-fold for each unit of increase from pH 7 to 10. The LT95 of P. digitatum spores in 200 µg free chlorine per ml at 24°C at pH 7, 8, 9, and 10 was 13.2, 19.1, 29.4, and 88.4 s, respectively. The LT95 of G. citri-aurantii at pH 7, 8, 9, and 10 was 3.0, 12.6, 56.6, and 114 s, respectively. Models were prepared describing mortality. Brief immersion in 200 µg free chlorine per ml reduced viable spores of P. digitatum and G. citri-aurantii from 106 to 103 spores per lemon, and naturally occurring yeast and molds from 106 to 104 CFU. In fruit wound-inoculated and immersed 24 h later in water, 4,000 µg free chlorine per ml, or 3% wt/vol NaHCO3, green mold occurrence after storage was 98.5, 68.3 and 7.5%, respectively.

Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.

OBJECTIVE: To determine if persons with traumatic brain injury (TBI) who are insured by Medicaid or health maintenance organizations (HMOs) are more likely to receive postacute care in skilled nursing facilities (SNFs) than in rehabilitation facilities, compared with persons insured by commercial fee-for-service (FFS) plans. DESIGN: Retrospective cohort study. SETTING: County hospital admitting 30% of all Washington State TBI patients. PATIENTS: Patients with moderate to severe TBI discharged to rehabilitation facilities or SNFs between 1992 and 1997 (n = 1271); 56.3% were insured by Medicaid, 26.1% by FFS plans, and 17.6% by HMOs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disposition on discharge from acute care (rehabilitation facilities vs SNF); adjusted relative risk (RR) and confidence interval (CI) for different insurance types. RESULTS: After accounting for confounding factors, Medicaid patients were 68% more likely (RR = 1.68, 95% CI = 1.34-2.11) and HMO patients were 23% more likely (RR = 1.23, 95% CI =.90-1.68) to go to a SNF than FFS patients. However, the latter difference was not statistically significant. CONCLUSIONS: An association exists between insurance type and postacute care site. Efforts should be made to determine the effect this relationship has on the cost and outcomes for TBI patients.

Functional status examination: a new instrument for assessing outcome in traumatic brain injury.

The Functional Status Examination (FSE) is a new measure designed to evaluate change in activities of everyday life as a function of an event or illness, including traumatic brain injury. The measure covers physical, social, and psychological domains. The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to preinjury functioning. Based on 133 prospectively studied patients with moderate to severe traumatic brain injury, the FSE has favorable psychometric properties including good test-retest reliability (r = 0.80) and close correspondence of assessments provided by the patient and their significant other (SO; r = 0.80). The FSE correlated significantly with each of three severity indices with closest relationships occurring between the FSE assessed by the SO and posttraumatic amnesia (r = 0.76). The FSE assessed by the SO was significantly (p < 0.05) more closely related to each severity index than the Glasgow Outcome Scale (GOS) or Sickness Impact Profile and, for two of the three indices, than the SF-36. All measures showed significant change from 1 to 6 months after injury with the FSE showing the largest effect sizes. The FSE is significantly related to important constructs such as family burden, SO depression, and sacrifices the family makes, as well as overall indices of recovery and satisfaction with level of functioning. The latter relationships are significantly stronger than for the GOS. The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.

Clinician judgments of functional outcomes: how bias and perceived accuracy affect rating.

OBJECTIVE: To evaluate the accuracy of clinician judgments of patient function, the susceptibility of judges to bias, and the relation between a judge's degree of belief in his/her accuracy of classification to observed accuracy when using the FIM instrument. PARTICIPANTS: Fifty rehabilitation professionals. SETTING: 3 urban medical centers. DESIGN: Four randomized experiments among subjects to examine the effect of potentially biasing information on FIM ratings of patient vignettes. Participants answered 60 true/false questions regarding patient function and FIM score and indicated confidence in the accuracy of their answers. INTERVENTIONS: Manipulation of patient information. MAIN OUTCOME MEASURES: The standard FIM 7-point scale, observed proportion of correct responses to the 60 true/false questions, and a 6-category confidence scale for each of the 60 questions were used as dependent measures. RESULTS: FIM ratings assigned to others biased participants' FIM ratings of patient vignettes. Functional ability was overestimated when ratings in other domains were high and underestimated when they were low. Participants were overconfident in their ability to answer FIM questions accurately across all professional disciplines. CONCLUSION: Bias and poor judgment of level accuracy play a significant role in clinician ratings of patient functioning. Blind ratings and training in debiasing are potential solutions to the problem.

Genomic imprinting in plants: observations and evolutionary implications.

The epigenetic phenomenon of genomic imprinting occurs among both plants and animals. In species where imprinting is observed, there are parent-of-origin effects on the expression of imprinted genes in offspring. This review focuses on imprinting in plants with examples from maize, where gene imprinting was first described, and Arabidopsis. Our current understanding of imprinting in plants is presented in the context of cytosine methylation and imprinting in mammals, where developmentally essential genes are imprinted. Important considerations include the structure and organization of imprinted genes and the role of regional, differential methylation. Imprinting in plants may be related to other epigenetic phenomena including paramutation and transgene silencing. Finally, we discuss the role of gene structure and evolutionary implications of imprinting in plants.

Describing and predicting the nature of procedural pain after thermal injuries: implications for research.

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients.

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

Characterization of cuticular proteins in the red flour beetle, Tribolium castaneum.

We are characterizing the cuticular proteins of Tribolium castaneum (Herbst) (Coleoptera:Tenebrionidae) to determine their role in the function of the exoskeleton. Based on qualitative analyses of cuticles, we focused on the sodium dodecyl sulfate (SDS)-extractable proteins. A small-scale cuticle "mini-prep" procedure was devised that yields preparations virtually free of contaminating cellular material compared to hand-dissected preparations, as assessed by fluorescent microscopy using DAPI to stain nuclei. Proteins extracted in 1% SDS from various developmental stages (last larval instar, pupal, adult) were analyzed by one-dimensional denaturing polyacrylamide gel electrophoresis and by two-dimensional gel electrophoresis. The cuticular protein profiles show both similarities and differences among the stages examined. The amino acid composition, glycosylation, and partial amino acid sequence of several abundant cuticular proteins indicate similarity to cuticular proteins of other insects.

Weighted health status in the Medicare population: development of the Weighted Health Index for the Medicare Current Beneficiary Survey (WHIMCBS).

We present an approach to constructing an aggregate index of health at the population level with data from Medicare beneficiaries using the 1991 (N = 12,667), 1995 (N = 15,590), and 1997 (N=17,058) Medicare Current Beneficiary Survey (MCBS). Similar to other work with survey data, we develop a weighted health status index from which one can calculate a point in time health status score for any beneficiary. Scores range from 1.0, representing "excellent health and no activity limitation", to 0.0, representing deceased. Sequences of numerically weighted health states experienced over time can be summed to calculate years of healthy life for beneficiaries. We test both the stability of the scoring system when developed on independent samples, as well as the sensitivity of years of healthy life calculations to changes in scoring assumptions. Findings suggest that, in addition to mortality, morbidity appears to play a significant role in the years of healthy life accrued by Medicare beneficiaries since entry into the Medicare program. Further, the index scoring system is highly stable when derived on independent samples. Finally, calculations of years of healthy life are robust to changes in scoring assumptions. The weighted health index for Medicare current beneficiaries (WHIMCBS) is a stable overall index of health and may be a useful ongoing indicator of health within the Medicare population.

Do Medicare patients with disabilities receive preventive services? A population-based study.

OBJECTIVE: To compare health maintenance procedure rates of Medicare patients with different levels of disability. STUDY DESIGN: Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL). RESULTS: Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community. CONCLUSIONS: Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

Recovery after treatment and sensitivity to base rate.

Accurate classification of patients as having recovered after psychotherapy depends largely on the base rate of such recovery. This article presents methods for classifying participants as recovered after therapy. The approach described here considers base rate in the statistical model. These methods can be applied to psychotherapy outcome data for 2 purposes: (a) to determine the robustness of a data set to differing base-rate assumptions and (b) to formulate an appropriate cutoff that is beyond the range of cases that are not robust to plausible base-rate assumptions. Discussion addresses a fundamental premise underlying the study of recovery after psychotherapy.

Managed oncology care: the disease management model.

BACKGROUND: As oncology becomes an increasing financial burden on the U.S. health care system, effort is being focused on finding methods to more effectively deliver, manage, and monitor the highly complex panoply of cancer care services required by patients. This issue has growing significance and importance in light of an aging U.S. population and the rapid penetration of managed care. METHODS: SalickNet, Salick Health Care's disease management and managed care company, has been a pioneer in the development and implementation of cancer disease management programs. The cornerstone is a proprietary computer-based disease management system called OMARS (Oncology Management Assessment Reporting System). The flexible yet sophisticated architecture allows for the management of integrated care, data processing, and the generation of compelling custom reporting, fulfilling the goal of maximizing coordinated and effective patient care. CONCLUSIONS: Based on data collected and analyzed across critical clinical, quality of life, and patient satisfaction outcome measures, strong evidence exists that the SalickNet Disease Management Model is a highly effective vehicle for bringing about cost, quality, and outcomes advantages in cancer care.

The contribution of job satisfaction to the transition from acute to chronic low back pain.

OBJECTIVE: To determine the extent to which job satisfaction predicts pain, psychological distress, and disability 6 months after an initial episode of low back pain (LBP). DESIGN: A longitudinal design was used to follow an inception cohort experiencing first-episode low back pain with assessment at 2 and 6 months after pain onset. SETTING: Urban medical center outpatient orthopedic clinic. PATIENTS: The consecutive sample was comprised of 82 men with initial-onset acute LBP (T6 or below, daily pain for 6 to 10 weeks). INTERVENTION: Usual orthopedic care. MAIN OUTCOME MEASURES: The primary study outcomes were pain (Descriptor Differential Scale, Visual Analog Scales); disability (Sickness Impact Profile, Quality of Well-Being); and psychological distress (Beck Depression Inventory, Hamilton Rating Scale for Depression, Automatic Thoughts Questionnaire); predictor variables were orthopedic impairment (Waddell Physical Impairment Index) and job satisfaction (Job Descriptive Index, Work APGAR). RESULTS: Measures of job satisfaction, pain, disability, and psychological distress at baseline and 6 months after pain onset were separately reduced into factors using principle components factor analysis. In hierarchical multiple regression analyses, baseline job satisfaction significantly predicted variance in outcome scores at 6 months after pain onset, beyond the variance explained by control factors (demographics; baseline pain, mood, and disability; orthopedic impairment). Zero-order correlations between job satisfaction and orthopedic impairment were small and nonsignificant, suggesting that these two variables act independently in predicting outcome. Although type of work performed (desk work or work requiring light, moderate, or heavy lifting) and social position were correlated with job satisfaction at baseline, neither contributed to the prediction of outcome at 6 months. CONCLUSIONS: Satisfaction with one's job may protect against development of chronic pain and disability after acute onset back pain and, alternatively, dissatisfaction may heighten risk of chronicity. Vocational factors should be considered in the rehabilitation of acute back injury.