Care ally-assisted massage for Veterans with chronic neck pain: TOMCATT results.

PURPOSE: Chronic neck pain (CNP) is prevalent and challenging to treat. Despite evidence of massage's effectiveness for CNP, multiple accessibility barriers exist. The Trial Outcomes for Massage: Care Ally-Assisted vs. Therapist Treated (TOMCATT) study examined a care ally-assisted massage (CA-M) approach compared to a waitlist control prior to a study design modification (WL-C0). METHODS: CA-M consisted of in-person training for veteran/care-ally dyads to learn a standardized 30-minue massage routine, instructional DVD, and printed treatment manual. Participants were to complete three care ally-assisted massage sessions weekly for 12-weeks. Outcomes collected at baseline, 1-, 3-, and 6-months included validated measures of neck pain severity and associated disability. Linear mixed-model approaches were used for analysis with 3-months as the primary outcome timepoint. RESULTS: Participants (N = 203) were 56.7 ± 14 years old, 75% White, 15% female, and 75% married/partnered. Among 102 CA-M participants, 45% did not attend the in-person training and subsequently withdrew from the study and were more likely to be younger (p = .016) and employed (p = .004). Compared to WL-C0, CA-M participants had statistically significant reductions in pain-related disability at 3-months (-3.4, 95%CI = [-5.8, -1.0]; p = .006) and 6-months (-4.6, 95%CI = [-7.0, -2.1]; p < .001) and pain severity at 3-months (-1.3, 95%CI = [-1.9, -0.8]; p < .001) and 6-months (-1.0, 95%CI = [-1.6, -0.4]; p = .007), respectively. CONCLUSION: In this analysis, CA-M led to greater reductions in CNP with disability and pain severity compared to WL-C0, despite treatment engagement and retention challenges. Future work is needed to determine how to better engage Veterans and their care-allies to attend CA-M training.

Eosinophilic Gastroenteritis : Brief Review.

Eosinophilic gastroenteritis (EGE) is a rare disease which belongs to primary eosinophilic gastrointestinal disorders (primary EGIDs), characterized by an accumulation of eosinophils in the gastrointestinal (GI) tract and is strongly associated with atopy and allergy. The clinical presentations vary depending on the site and depth of eosinophilic intestinal infiltration. Radiology pictures may show irregular thickening of the folds, but these findings can also be present in other conditions like inflammatory bowel disease and lymphoma. The endoscopic appearance is also nonspecific. The definite diagnosis requires biopsy for histological evidence of GI eosinophilic infiltration and clinicians make the diagnosis in correlation with and by exclusion of other possible causes of eosinophilic infiltration. Because EGE is a rare disease, the treatment is based on limited case reports and clinicians' experience. Corticosteroids are the mainstay of therapy. The prognosis of EGE is relatively good when patients receive timely and proper treatment.

Systematic review with meta-analysis: the efficacy of levofloxacin triple therapy as the first- or second-line treatments of Helicobacter pylori infection.

BACKGROUND: Levofloxacin triple therapy has been used for the first-line and second-line treatment of Helicobacter pylori infection for more than 10 years. AIMS: To systematically review the efficacy of levofloxacin triple therapy in the first- and second-line treatment, and to assess the time trend and factors that might affect its efficacy. METHODS: Prospective trials reporting the efficacy of levofloxacin triple therapy in either the first-line or second-line treatment of H. pylori infection in adults were searched from the PubMed and Cochrane database from January 2000 to September 2015. Meta-analysis was performed to calculate the cumulative eradication rate and the efficacies in subgroups. RESULTS: Of the 322 articles identified, a total of 4574 patients from 41 trials, including 16 trials in the first-line treatment and 25 trials in the second-line treatment were eligible for analysis. The cumulative eradication rate was 77.3% (95% confidence intervals, CI: 74.7-79.6) and was 80.7% (95% CI 77.1-83.7) in the first-line treatment and 74.5% (95% CI: 70.9-77.8) in the second-line treatment. The efficacies of levofloxacin triple therapy before 2008, between 2009 and 2011, and after 2012 were 77.4%, 79.6% and 74.8% respectively. The eradication rate was higher when levofloxacin was given once daily (80.6%, 95% CI: 77.1-83.7) than twice daily (73.6%, 95% CI: 69.7-77.2). The efficacy was significantly higher in levofloxacin-susceptible strains than resistant strains (81.1% vs. 36.3%, risk ratio 2.18, 95% CI: 1.6-3, P < 0.001). CONCLUSION: The efficacy of levofloxacin triple therapy has been lower than 80% in many countries and it is not recommended when the levofloxacin resistance is higher than 5-10%.

Pain self-management training increases self-efficacy, self-management behaviours and pain and depression outcomes.

BACKGROUND: Self-management practices among patients with medical and psychiatric comorbidity is not well understood. We assessed the effects of a combined pharmacological and behavioural intervention on self-efficacy to manage symptoms and self-management behaviours in patients with pain and comorbid depression. METHODS: Longitudinal analysis of self-management behaviours and their relationship with outcomes in a 12-month trial of 250 primary care patients with chronic musculoskeletal pain and comorbid depression. Participants were randomized to either usual care or an intervention that consisted of optimized antidepressant therapy followed by six sessions of a pain self-management (PSM) programme. RESULTS: Participants in the intervention group significantly increased the time spent performing self-management behaviours including strengthening and stretching exercises, progressive muscle relaxation and visualization at 12 months. Moreover, intervention participants reported greater self-efficacy to manage their pain and depression. The number of pain self-management sessions received showed a dose-response relationship with improvement in both pain and depression severity. CONCLUSION: A combined intervention increased patient self-management behaviours and self-efficacy to manage symptoms among primary care patients with chronic musculoskeletal pain and depression. Receipt of the full dose of the entire PSM programme was related to improvements in pain interference and depression severity. WHAT DOES THIS STUDY ADD?: A nurse-led six-session PSM programme increased self-efficacy as well as specific behaviours such as strengthening and stretching exercises, progressive muscle relaxation and visualization. There was a dose-response in that attending a greater proportion of the PSM sessions led to greater improvement in both pain and depression outcomes.

Systematic review with meta-analysis: 10- or 14-day sequential therapy vs. 14-day triple therapy in the first line treatment of Helicobacter pylori infection.

BACKGROUND: Whether 10-day or 14-day sequential therapy is superior to 14-day triple therapy in the first-line treatment of Helicobacter pylori remains controversial. AIM: To compare the efficacy of 10-day or 14-day sequential therapy vs. 14-day triple therapy. METHODS: Randomised controlled trials (RCTs) comparing 10-day or 14-day sequential therapy and 14-day triple therapy as first-line treatment in adults were searched from the PubMed and Cochrane databases from 2000 to October 2015. Abstracts from international annual conferences were also searched. The primary and secondary outcomes were the eradication rate according to the intention-to-treat analysis and adverse effects, respectively. RESULTS: Of the 109 articles identified, 13 RCTs including 2749 patients in the sequential therapy group and 2424 patients in the 14-day triple therapy group were eligible. Overall, sequential therapy for 10 or 14 days was not significantly superior to 14-day triple therapy [Risk ratio (RR) 1.04, 95% confidence interval (CI) 0.99-1.08, P = 0.145]. However, there was significant heterogeneity (I(2) = 57.6%, P = 0.005). In the subgroup analysis of four trials, we found that 14-day sequential therapy was significantly more effective than 14-day triple therapy (RR: 1.09, 95% CI: 1.04-1.16, P = 0.002), and there was no significant heterogeneity (I(2) = 0%, P = 0.624) in this comparison. Sequential therapy given for 10 days was not superior to 14-day triple therapy (RR: 1.03, 95% CI: 0.98-1.09, P = 0.207). There was no significant difference in the risk of adverse effects. CONCLUSION: Sequential therapy given for 14 days, but not 10 days, was more effective than 14-day triple therapy as first-line treatment.

Communicating about opioids for chronic pain: a qualitative study of patient attributions and the influence of the patient-physician relationship.

BACKGROUND: Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient-provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This study's objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in-depth interviews with patients to gain insight into the patient­provider relationship and its influence on clinical communication. METHOD: Forty patients with chronic pain were audio recorded during their primary care clinic appointments and then interviewed about their pain care and relationships with their providers. Ten patients were excluded from analysis because pain was not discussed during the clinic visit. RESULTS: Qualitative analysis revealed that patients responded in markedly different ways to similar physician treatment decisions about opioids. Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring. Others attributed these limitations to acting out of genuine concern for patients' health. These attributions appeared to be shaped by features of the patient­physician relationship as described by patients. Results are discussed within the framework of attribution theory. CONCLUSIONS: Understanding how patients and providers discuss opioid treatment is critical for optimal pain treatment. Physicians might be able to improve communication by re-framing treatment discussions about opioids around external factors, such as benefits and harms, and engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient.

The influence of patient's sex, race and depression on clinician pain treatment decisions.

BACKGROUND: Pain treatments often vary across patients' demographic and mental health characteristics. Most research on this topic has been observational, has focused on opioid therapy exclusively and has not examined individual differences in clinician decision making. The current study examined the influence of patient's sex, race and depression on clinicians' chronic pain treatment decisions. METHODS: We used virtual human technology and lens model methodology to enhance study realism and facilitate a richer understanding of treatment decisions. Clinicians and trainees (n = 100) made treatment decisions (opioid, antidepressant, pain specialty referral, mental health referral) for 16 computer-simulated patients with chronic low back pain. Patients' sex, race and depression status were manipulated across vignettes (image and text). RESULTS: Individual- and group-level analyses indicated that patient's depression status had the strongest and most consistent influence on treatment decisions. Although less influential overall, patient's sex and race were significantly influential for a subset of participants. Furthermore, the results indicated that participants who were influenced by patient's race had less experience in treating chronic pain than those who were not influenced by patient's race [t(11.59) = 4.75; p = 0.001; d = 1.20]. CONCLUSIONS: The results of this study indicated considerable variability in participants' chronic pain treatment decisions. These data suggest that interventions to reduce variability in treatment decision making and improve pain care should be individually tailored according to clinicians' decision profiles.

Prevalence of pain and association with quality of life, depression and glycaemic control in patients with diabetes.

AIMS: To determine the prevalence of pain and its association with glycaemic control, mental health and physical functioning in patients with diabetes. METHODS: Cross-sectional data from a multi-site, prospective cohort study of 11 689 participants with diabetes. We analysed the associations of pain severity and interference with glycated haemoglobin (HbA(1c)) measurements and Medical Outcomes Study SF-Mental and Physical Component Summary-12 (MCS-12 and PCS-12) scores. RESULTS: Of participants, 57.8% reported moderate to extreme pain and, compared with those without pain, were somewhat older (60.8 vs. 59.9 years, P < 0.001), more obese (body mass index of 32.1 vs. 29.8 kg/m(2), P < 0.001), more likely to report being depressed or anxious (41.3 vs. 16.2%, P < 0.001) and more likely to report fair or poor health (48.5 vs. 23.1%, P < 0.001). Bivariate comparisons demonstrated that patients with extreme pain had higher HbA(1c) than those without pain (8.3 vs. 8.0%, P = 0.001). In multivariable analyses, pain was not associated with HbA(1c) (P = 0.304) but was strongly associated with worse MCS-12 (P < 0.001), PCS-12 (P < 0.001) and depression (P < 0.001). Depression was 1.3 (95% CI: 1.12, 1.96) times more likely in patients with moderate pain and 2.0 (95% CI: 1.56, 2.46) times more likely in patients with extreme pain. CONCLUSIONS: Moderate to extreme pain was present in 57.8% of diabetic patients. Pain was strongly associated with poorer mental health and physical functioning, but not worse glycaemic control. Recognizing the high prevalence of pain and its strong association with poorer health-related quality of life may be important to improve the comprehensive management of diabetes.

Stromelysin expression regulates collagenase activation in human fibroblasts. Dissociable control of two metalloproteinases by interferon-gamma.

The expression of collagenolytic activity by cells represents the rate-limiting step in the turnover of collagen during remodeling. The collagenase gene is transcriptionally activated in normal dermal or rheumatoid synovial fibroblasts by interleukin-1 beta (IL-1 beta), resulting in secretion of trypsin-activatable procollagenase measuring in the range of 2.0-5.0 units/10(6) cells/48 h in the 14C-fibril assay. The addition of interferon-gamma (IFN-gamma; 50-100 units/ml) inhibits the expression of collagenase activity by 45-80% in these cells. The IL-1 beta induction of procollagenase protein was not altered by IFN-gamma, as judged by Western blot analysis using a monoclonal antibody to collagenase and by gelatin zymography, and procollagenase mRNA was also unaltered, as assessed by Northern blot analysis. Because collagenolytic activity is also controlled by the quantity of tissue inhibitor of metalloproteinases present, its expression was examined by Western blot analysis using a polyclonal antibody to tissue inhibitor of metalloproteinases and by reverse gelatin zymography. Tissue inhibitor of metalloproteinase protein was found to be unaltered or slightly less abundant in conditioned media from cultures treated with IL-1 beta and IFN-gamma when compared with that from cultures treated with IL-1 beta alone. However, the expression of the metalloproteinase activator of procollagenase, stromelysin, was found to be significantly inhibited by the addition of IFN-gamma. Addition of purified activated stromelysin to these conditioned media completely reconstituted collagenolytic activity. These observations demonstrate in an intact system that stromelysin is a specific activator necessary for the development of collagenolytic activity. Despite stromelysin's lack of catalytic activity against collagen, its expression can serve as a control point in the regulation of collagenolysis.