Influence of vitamin D deficiency on T cell subsets and related indices during spinal tuberculosis.

The present study investigated the effects of vitamin D deficiency on T cell subsets in patients with spinal tuberculosis. In addition, the influence of vitamin D deficiency was investigated on the expression of cytokines IL-1ß, IL-6 and TNF-α in intervertebral disc lesions of patients. One hundred and seventeen patients with spinal tuberculosis who received operative treatment in the Department of Orthopedics in Wuhan City Third Hospital from March 2012 to March 2015 were collected. The patients were divided depending upon vitamin D content into the control group (64 cases, vitamin D content <25 nmol/l) and experimental group (53 cases, vitamin D content >50 nmol/l). Immunofluorescence method was applied to determine the content of T cell subsets in both groups of patients. Intervertebral disc lesion tissues of two groups of patients were obtained during surgery then treated with HE staining and immunohistochemical staining. The values of average optical density obtained under light microscope were observed as the expression quantities of IL-1ß, IL-6 and TNF-α, to explore the relationship between vitamin D and the expression of cytokines. When vitamin D is lacking, the expression of T lymphocyte subsets in patients with spinal tuberculosis significantly decreased. Compared with experimental group, the difference was statistically significant (P<0.05). Further, the expression of cytokines IL-1ß, IL-6 and TNF-α in intervertebral disc lesion tissues of patients with spinal tuberculosis were significantly higher than those of patients with spinal tuberculosis whose vitamin D content was normal (P<0.05). In the control group, vitamin D content was negatively correlated with the expression of IL-1ß, IL-6 and TNF-α. The expression of T lymphocyte subsets in patients with vitamin D deficiency was significantly reduced, and the immune function decreased. The expression of IL-1ß, IL-6 and TNF-α in lesions were significantly higher than those of patients with normal vitamin D content. In addition, the lower the content of vitamin D was, the more active the expression of inflammatory factors were, which was not conducive to the recovery of tuberculosis lesions.

The expression of MYH9 in osteosarcoma and its effect on the migration and invasion abilities of tumor cell.

OBJECTIVE: To determine the expression of non-muscle myosin heavy chain 9 (MYH9) in osteosarcoma and its effect on the migration and invasion abilities of tumor cell. METHODS: A total of 65 cases of osteosarcoma and 20 cases with benign osteochondroma who underwent resection operation in the Orthopaedics Department of our hospital from January 1st 2009 to January 1st 2015 were selected. Their mRNA levels of MYH9 were tested by qrt-PCR. Immunohistochemical method was used to examine the expression of MYH9 in osteosarcoma and the correlation between the positive expression of MYH9 and the clinicopathological features of patients was illustrated by statistical analysis. MYH9 was compounded artificially. The expression of MYH9 in SAOS2 osteosarcoma cells was decreased by siRNA. Scratch test was used to determine the change of SAOS2 cell migration ability after MYH9 silence. Transwell assay was employed to detect the change of cell invasion ability after MYH9 silence. RESULTS: The expression levels of mRNA of MYH9 and protein in osteosarcoma tissues were significantly higher than those in benign osteochondroma tissues. The high expression of MYH9 in osteosarcoma tissues was apparently related to the high Enneking classification (III classification) and lung metastasis. SiRNA of MYH9 could evidently decrease the expression level of MYH9 in SAOS2. The down-regulated expression of MYH9 could inhibit the migration and invasion abilities of SAOS2 cells. CONCLUSIONS: MYH9 shows a trend of high expression in osteosarcoma tissues, and its high expression is associated with features such as tumor invasion and metastasis. The down-regulated MYH9 can realize an anti-tumor effect by inhibiting the migration and invasion of osteosarcoma cells.

The study of KBP of road construction workers of highway AIDS prevention project before and after intervention.

OBJECTIVE: To get scientific basis for further health education through the research of the road construction workers' KBP before and after the interventions of highway AIDS prevention project. METHODS: Multi-stage random sampling method was employeed to select workers of 8 sites from 14 sites along highway to investigate their AIDS knowledge, belief and performance (KBP) before and after highway AIDS prevention project. RESULTS: Over 90% of the investigated workers had ever heard about AIDS, and the non-skilled workers of lower educational level improved more after intervention. The correct answer rate of the three transmitting ways of AIDS of drivers which is the focused group of highway before and after intervention had the obvious statistical significance (P<0.05), and the other group's correct answer rates also had improved after intervention. Most people's understanding of preventing AIDS through correct use of condoms when having sex had a statistically significant difference(P<0.05) after prevention. The rates of using condoms of foremen and skilled workers when having sex with commercial sex worker/casual partner increased after intervention. CONCLUSIONS: The health education of HIV among the road construction workers is effective and further health education of HIV prevention should be carried out among the road construction workers to improve their knowledge and awareness of avoiding the high-risk behaviors.

Efficiency influence of exogenous betaine on anaerobic sequencing batch biofilm reactor treating high salinity mustard tuber wastewater.

When treating a composite mustard tuber wastewater with high concentrations of salt (about 20 g Cl(-) L(-1)) and organics (about 8000 mg L(-1) COD) by an anaerobic sequencing batch biofilm reactor (ASBBR) in winter, both high salinity and low temperature will inhibit the activity of anaerobic microorganisms and lead to low treatment efficiency. To solve this problem, betaine was added to the influent to improve the activity of the anaerobic sludge, and an experimental study was carried to investigate the influence of betaine on treating high salinity mustard tuber wastewater by the ASBBR. The results show that, when using anaerobic acclimated sludge in the ASBBR, and controlling biofilm density at 50% and water temperature at 8-12 degrees C, the treatment efficiency of the reactor could be improved by adding the betaine at different concentrations. The efficiency reached the highest when the optimal dosage ofbetaine was 0.5 mmol L(-1). The average effluent COD, after stable acclimation, was 4461 mg L(-1). Relative to ASBBR without adding betaine, the activity of the sludge increased significantly. Meanwhile, the dehydrogenase activity of anaerobic microorganisms and the COD removal efficiency were increased by 18.6% and 18.1%, respectively.

Activity scheduling as a core component of effective care management for late-life depression.

BACKGROUND: Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes. METHODS: This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol. RESULTS: Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active-non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months. CONCLUSION: Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement.

Health care costs associated with traumatic brain injury and psychiatric illness in adults.

A cohort design was used to determine the contribution of traumatic brain injury (TBI) and psychiatric illness to health care costs for adolescents and adults in the 3 years following mild or moderate-to-severe TBI compared to a matched cohort without TBI, controlling for confounders. In all, 3756 subjects 15 years or older from a large health maintenance organization database were examined. We identified subjects who sustained a TBI in 1993 (n=939) and selected three control subjects per TBI-exposed subject (n=2817), matched for age, sex, and enrollment at the time of injury. Unadjusted mean costs in 2009-adjusted dollars were compared using Kruskal-Wallis tests and Mann-Whitney U tests, and adjusted mean costs were compared using gamma regression analyses. Average costs were 76% higher in the 3 years after injury for the mild TBI group, and 5.75 times greater for the moderate-to-severe TBI group compared to controls. The presence of psychiatric illness was associated with more than doubling of total costs for both inpatient and outpatient non-mental health care. Gamma regression analyses confirmed significantly higher costs in patients with TBI or psychiatric illness. A significant interaction between moderate-to-severe TBI and psychiatric illness indicated a 3.39 times greater cost among patients with both exposures compared with those exposed to moderate-to-severe TBI without psychiatric illness. TBI and psychiatric illness were each associated with significant increases in health care costs; those with the combination of moderate-to-severe TBI and psychiatric illness had much higher costs than any other group.

Generalized propensity score for estimating the average treatment effect of multiple treatments.

The propensity score method is widely used in clinical studies to estimate the effect of a treatment with two levels on patient's outcomes. However, due to the complexity of many diseases, an effective treatment often involves multiple components. For example, in the practice of Traditional Chinese Medicine (TCM), an effective treatment may include multiple components, e.g. Chinese herbs, acupuncture, and massage therapy. In clinical trials involving TCM, patients could be randomly assigned to either the treatment or control group, but they or their doctors may make different choices about which treatment component to use. As a result, treatment components are not randomly assigned. Rosenbaum and Rubin proposed the propensity score method for binary treatments, and Imbens extended their work to multiple treatments. These authors defined the generalized propensity score as the conditional probability of receiving a particular level of the treatment given the pre-treatment variables. In the present work, we adopted this approach and developed a statistical methodology based on the generalized propensity score in order to estimate treatment effects in the case of multiple treatments. Two methods were discussed and compared: propensity score regression adjustment and propensity score weighting. We used these methods to assess the relative effectiveness of individual treatments in the multiple-treatment IMPACT clinical trial. The results reveal that both methods perform well when the sample size is moderate or large.

Long-term chronic opioid therapy discontinuation rates from the TROUP study.

OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. METHODS: Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. RESULTS: There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR = 0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR = 0.83 (95%CI: 0.78-0.89), AR Medicaid HR = 0.78 (95%CI: 0.67-0.90). CONCLUSIONS: Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.

Trends in the prescription of opioids for adolescents with non-cancer pain.

OBJECTIVES: Opioids are among the most commonly abused drugs among adolescents, and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations. METHODS: We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions and types of medications given, as well as clinical and demographic features of adolescents receiving opioids. RESULTS: In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short-acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition. DISCUSSION: Prescription of opioids among adolescents with NCP is common, and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms.

OBJECTIVE: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. METHODS: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. RESULTS: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. CONCLUSION: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

Multisite investigation of traumatic brain injuries, posttraumatic stress disorder, and self-reported health and cognitive impairments.

CONTEXT: Few large-scale, multisite investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms and health outcomes across the spectrum of patients with mild, moderate, and severe traumatic brain injury (TBI). OBJECTIVES: To understand the risk of developing PTSD symptoms and to assess the impact of PTSD on the development of health and cognitive impairments across the full spectrum of TBI severity. DESIGN: Multisite US prospective cohort study. SETTING: Eighteen level I trauma centers and 51 non-trauma center hospitals. PATIENTS: A total of 3047 (weighted n = 10 372) survivors of multiple traumatic injuries between the ages of 18 and 84 years. MAIN OUTCOME MEASURES: Severity of TBI was categorized from chart-abstracted International Classification of Diseases, Ninth Revision, Clinical Modification codes. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist 12 months after injury. Self-reported outcome assessment included the 8 Medical Outcomes Study 36-Item Short Form Health Survey health status domains and a 4-item assessment of cognitive function at telephone interviews 3 and 12 months after injury. RESULTS: At the time of injury hospitalization, 20.5% of patients had severe TBI, 11.7% moderate TBI, 12.9% mild TBI, and 54.9% no TBI. Patients with severe (relative risk, 0.72; 95% confidence interval, 0.58-0.90) and moderate (0.63; 0.44-0.89) TBI, but not mild TBI (0.83; 0.61-1.13), demonstrated a significantly diminished risk of PTSD symptoms relative to patients without TBI. Across TBI categories, in adjusted analyses patients with PTSD demonstrated an increased risk of health status and cognitive impairments when compared with patients without PTSD. CONCLUSIONS: More severe TBI was associated with a diminished risk of PTSD. Regardless of TBI severity, injured patients with PTSD demonstrated the greatest impairments in self-reported health and cognitive function. Treatment programs for patients with the full spectrum of TBI severity should integrate intervention approaches targeting PTSD.

Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample.

OBJECTIVE: To estimate the prevalence of major and minor depression, panic disorder, and suicidal ideation during pregnancy while also identifying factors independently associated with antenatal depressive disorders. METHODS: In this prospective study, participants were 1,888 women receiving ongoing prenatal care at a university obstetric clinic from January 2004 through January 2009. Prevalence of psychiatric disorders was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria based on the Patient Health Questionnaire. Multiple logistic regression identified factors associated with probable major depressive disorder and any depressive disorder. RESULTS: Antenatal depressive disorders were present in 9.9% with 5.1% (97) meeting criteria for probable major depression and 4.8% (90) meeting criteria for probable minor depression. Panic disorder was present in 3.2% (61), and current suicidal ideation was reported by 2.6% (49). Among patients with probable major depression, 29.5% (28) reported current suicidal ideation. Psychosocial stress (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.21-1.36), domestic violence (OR 3.45; 95% CI 1.46-8.12), chronic medical conditions (OR 3.05; 95% CI 1.63-5.69), and race (Asian: OR 5.81; 95% CI 2.55-13.23; or African American: OR 2.98; 95% CI 1.24-7.18) each significantly increased the odds of probable antepartum major depressive disorder, whereas older age (OR 0.92; 95% CI 0.88-0.97) decreased the odds. Factors associated with odds of any depression were similar overall except that Hispanic ethnicity (OR 2.50; 95% CI 1.09-5.72) also independently increased the odds of any depression. CONCLUSION: Antenatal major and minor depressive disorders are common and significantly associated with clinically relevant and identifiable risk factors. By understanding the high point prevalence and associated factors, clinicians can potentially improve the diagnosis and treatment rates of serious depressive disorders in pregnant women. LEVEL OF EVIDENCE: II.

Emergency department visits among recipients of chronic opioid therapy.

BACKGROUND: There has been an increase in overdose deaths and emergency department visits (EDVs) involving use of prescription opioids, but the association between opioid prescribing and adverse outcomes is unclear. METHODS: Data were obtained from administrative claim records from Arkansas Medicaid and HealthCore commercially insured enrollees, 18 years and older, who used prescription opioids for at least 90 continuous days within a 6-month period between 2000 and 2005 and had no cancer diagnoses. Regression analysis was used to examine risk factors for EDVs and alcohol- or drug-related encounters (ADEs) in the 12 months following 90 days or more of prescribed opioids. RESULTS: Headache, back pain, and preexisting substance use disorders were significantly associated with EDVs and ADEs. Mental health disorders were associated with EDVs in HealthCore enrollees and with ADEs in both samples. Opioid dose per day was not consistently associated with EDVs but doubled the risk of ADEs at morphine-equivalent doses over 120 mg/d. Use of short-acting Drug Enforcement Agency Schedule II opioids was associated with EDVs compared with use of non-Schedule II opioids alone (relative risk range, 1.09-1.74). Use of Schedule II long-acting opioids was strongly associated with ADEs (relative risk range, 1.64-4.00). CONCLUSIONS: Use of Schedule II opioids, headache, back pain, and substance use disorders are associated with EDVs and ADEs among adults prescribed opioids for 90 days or more. It may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher-risk recipients.

Healthcare costs associated with mild traumatic brain injury and psychological distress in children and adolescents.

PRIMARY OBJECTIVE: Comparison of healthcare costs for youth with mild traumatic brain injuries (TBIs) to costs in a matched cohort of children without TBI in the 3 years following injury. RESEARCH DESIGN: This study used a prospective cohort design with 3-year follow-up. Costs were examined using the well-established two-step model and controlling for potential confounding variables. METHODS AND PROCEDURES: Four-hundred and ninety subjects from a large health maintenance organization, 14 years old or younger, who sustained a mild TBI in 1993, were identified using computerized records. For each youth with mild TBI, three control subjects were selected (n = 1470), matched on age, sex and enrolment at the time of injury. EXPERIMENTAL INTERVENTIONS: Not applicable. MAIN OUTCOMES AND RESULTS: TBI exposure was associated with an increase in the proportion of subjects who had non-zero medical costs in all categories examined and a 75% increase in mean total costs. Presence of psychological distress was also associated with increased proportion of subjects with costs in all categories examined and was associated with an approximate doubling of mean total costs. CONCLUSIONS: Mild TBI and psychological distress were each associated with significant increases in healthcare costs in an HMO setting.

Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study.

OBJECTIVE: To estimate the prevalence of and risk factors for opioid abuse/dependence in long-term users of opioids for chronic pain, including risk factors for opioid abuse/dependence that can potentially be modified to decrease the likelihood of opioid abuse/dependence, and non-modifiable risk factors for opioid abuse/dependence that may be useful for risk stratification when considering prescribing opioids. METHODS: We used claims data from two disparate populations, one national, commercially insured population (HealthCore) and one state-based, publicly insured (Arkansas Medicaid). Among users of chronic opioid therapy, we regressed claims-based diagnoses of opioid abuse/dependence on patient characteristics, including physical health, mental health and substance abuse diagnoses, sociodemographic factors, and pharmacological risk factors. RESULTS: Among users of chronic opioid therapy, 3% of both the HealthCore and Arkansas Medicaid samples had a claims-based opioid abuse/dependence diagnosis. There was a strong inverse relationship between age and a diagnosis of opioid abuse/dependence. Mental health and substance use disorders were associated with an increased risk of opioid abuse/dependence. Effects of substance use disorders were especially strong, although mental health disorders were more common. Concerning opioid exposure; lower days supply, lower average doses, and use of Schedule III-IV opioids only, were all associated with lower likelihood of a diagnosis of opioid abuse/dependence. CONCLUSION: Opioid abuse and dependence are diagnosed in a small minority of patients receiving chronic opioid therapy, but this may under-estimate actual misuse. Characteristics of the patients and of the opioid therapy itself are associated with the risk of abuse and dependence.

An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP study.

CONTEXT: Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time. OBJECTIVES: To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005. METHODS: For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids. RESULTS: Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders. CONCLUSION: Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.

Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study.

The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000-2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.

Survey of the use of massage for children with cerebral palsy.

BACKGROUND: Conventional medicine and complementary and alternative medicine (CAM) are merging into the broader field of "integrative medicine." Massage is no longer considered complementary or alternative in some conventional medical circles today. PURPOSE: We aimed to determine the prevalence of massage use among children with cerebral palsy (CP) in the Pacific Northwest in the United States, the reasons that massage is being used, and the limits of recruitment for a future randomized controlled trial. METHODS: This study, the first step in a three-stage research plan, was conducted at the Neurodevelopmental and Neurology clinics at Seattle Children's Hospital, a tertiary pediatric hospital that provides service to patients primarily from Washington, Alaska, Montana, and Idaho. As a feasibility study (stage one), it precedes a planned pilot study (stage two), and subsequently, a full-scale randomized controlled trial (stage three) of whether massage can improve the health of children with CP. The study subjects-104 families with a child with CP ranging in age from 17 months to 21 years-were surveyed by the principal investigator and a research assistant in exam rooms at the hospital. RESULTS: In the families surveyed, 80% of the children had received massage at some point. Massage was currently being used in 51%, and trained professionals were providing the massage in 23%. Most families use massage for musculoskeletal relaxation, to improve quality of life, and to help their children sleep. Lower maternal income was associated with relatives as compared with professional massage therapists providing the massage. Massage therapy use by the mother and more severe CP were significantly associated with current use of massage for the child. CONCLUSIONS: Most children with CP in the Pacific Northwest have used massage. Most parents surveyed believe that massage is helpful to their child. Additional research is needed to determine whether massage should be routinely recommended for children with CP.

Psychosocial stress during pregnancy.

OBJECTIVE: We sought to identify factors associated with high antenatal psychosocial stress and describe the course of psychosocial stress during pregnancy. STUDY DESIGN: We performed a cross-sectional analysis of data from an ongoing registry. Study participants were 1522 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2008. Multiple logistic regression identified factors associated with high stress as measured by the Prenatal Psychosocial Profile stress scale. RESULTS: The majority of participants reported antenatal psychosocial stress (78% low-moderate, 6% high). Depression (odds ratios [OR], 9.6; 95% confidence interval [CI], 5.5-17.0), panic disorder (OR, 6.8; 95% CI, 2.9-16.2), drug use (OR, 3.8; 95% CI, 1.2-12.5), domestic violence (OR, 3.3; 95% CI, 1.4-8.3), and having > or =2 medical comorbidities (OR, 3.1; 95% CI, 1.8-5.5) were significantly associated with high psychosocial stress. For women who screened twice during pregnancy, mean stress scores declined during pregnancy (14.8 +/- 3.9 vs 14.2 +/- 3.8; P < .001). CONCLUSION: Antenatal psychosocial stress is common, and high levels are associated with maternal factors known to contribute to poor pregnancy outcomes.

Age and sex trends in long-term opioid use in two large American health systems between 2000 and 2005.

OBJECTIVE: To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems. DESIGN: Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2). PATIENTS: Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000). RESULTS: Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase. CONCLUSIONS: No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.