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Introduction: Lumbosacral radiculopathy (LR), also known as sciatica, is a common type of radiating neurologic pain involving burning, tingling, and numbness in the lower extremities. It has an estimated lifetime prevalence as high as 43%. Objectives: The objective of this randomized controlled trial was to evaluate the impact of virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) on patients with LR during the COVID-19 pandemic. Methods: Potentially eligible patients were identified using electronic health record queries and phone screenings. Participants were then randomized to MORE or treatment-as-usual (TAU) for 8 weeks, with pain intensity assessed daily. At baseline and follow-up visits, participants completed questionnaires assessing the primary outcome, disability, as well as quality of life, depression, mindful reinterpretation of pain, and trait mindfulness. Results: In our study, patients undergoing virtual delivery of MORE had greater improvements in daily pain intensity (P = 0.002) but not in disability (P = 0.09), depression (P = 0.26), or quality of life (P = 0.99 and P = 0.89, SF-12 physical and mental component scores, respectively), relative to TAU patients. In addition, patients in MORE experienced significantly greater increases in mindful reinterpretation of pain (P = 0.029) and trait mindfulness (P = 0.035). Conclusion: Among patients with lumbar radiculopathy, MORE significantly reduced daily pain intensity but did not decrease disability or depression symptoms. Given the long duration of symptoms in our sample, we hypothesize the discrepancy between changes in daily pain intensity and disability is due to fear avoidance behaviors common in patients with chronic pain. As the first trial of a mindfulness intervention in patients with LR, these findings should inform future integrative approaches to LR treatment, particularly when considering the increasing use of virtual interventions throughout the COVID-19 pandemic.
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RATIONALE AND OBJECTIVES: Spinal osteoporotic compression fractures (OCFs) can be an early biomarker for osteoporosis but are often subtle, incidental, and underreported. To ensure early diagnosis and treatment of osteoporosis, we aimed to build a deep learning vertebral body classifier for OCFs as a critical component of our future automated opportunistic screening tool. MATERIALS AND METHODS: We retrospectively assembled a local dataset, including 1790 subjects and 15,050 vertebral bodies (thoracic and lumbar). Each vertebral body was annotated using an adaption of the modified-2 algorithm-based qualitative criteria. The Osteoporotic Fractures in Men (MrOS) Study dataset provided thoracic and lumbar spine radiographs of 5994 men from six clinical centers. Using both datasets, five deep learning algorithms were trained to classify each individual vertebral body of the spine radiographs. Classification performance was compared for these models using multiple metrics, including the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive predictive value (PPV). RESULTS: Our best model, built with ensemble averaging, achieved an AUC-ROC of 0.948 and 0.936 on the local dataset's test set and the MrOS dataset's test set, respectively. After setting the cutoff threshold to prioritize PPV, this model achieved a sensitivity of 54.5% and 47.8%, a specificity of 99.7% and 99.6%, and a PPV of 89.8% and 94.8%. CONCLUSION: Our model achieved an AUC-ROC>0.90 on both datasets. This testing shows some generalizability to real-world clinical datasets and a suitable performance for a future opportunistic osteoporosis screening tool.
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Aprendizado Profundo , Fraturas por Compressão , Osteoporose , Fraturas da Coluna Vertebral , Masculino , Humanos , Fraturas por Compressão/diagnóstico por imagem , Estudos Retrospectivos , Densidade Óssea , Fraturas da Coluna Vertebral/diagnóstico por imagem , Osteoporose/complicações , Osteoporose/diagnóstico por imagem , Vértebras Lombares/diagnóstico por imagem , AlgoritmosRESUMO
BACKGROUND: Clinical guidelines recommend standing radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis, although reliable evidence about the standing position is absent. To our knowledge, no studies have compared different radiographic views and pairings to detect the presence and magnitude of stable and dynamic spondylolisthesis. QUESTIONS/PURPOSES: (1) What is the percentage of new patients presenting with back or leg pain with stable (3 mm or greater listhesis on standing radiographs) and dynamic (3 mm or greater listhesis difference on standing-supine radiographs) spondylolisthesis? (2) What is the difference in the magnitude of spondylolisthesis between standing and supine radiographs? (3) What is the difference in the magnitude of dynamic translation among flexion-extension, standing-supine, and flexion-supine radiographic pairs? METHODS: This cross-sectional, diagnostic study was performed at an urban, academic institution between September 2010 and July 2016; 579 patients 40 years or older received a standard radiographic three-view series (standing AP, standing lateral, and supine lateral radiographs) at a new patient visit. Of those individuals, 89% (518 of 579) did not have any of the following: history of spinal surgery, evidence of vertebral fracture, scoliosis greater than 30°, or poor image quality. In the absence of a reliable diagnosis of dynamic spondylolisthesis using this three-view series, patients may have had flexion and extension radiographs, and approximately 6% (31 of 518) had flexion and extension radiographs. A total of 53% (272 of 518) of patients were female, and the patients had a mean age of 60 ± 11 years. Listhesis distance (in mm) was measured by two raters as displacement of the posterior surface of the superior vertebral body in relation to the posterior surface of the inferior vertebral body from L1 to S1; interrater and intrarater reliability, assessed with intraclass correlation coefficients, was 0.91 and 0.86 to 0.95, respectively. The percentage of patients with and the magnitude of stable spondylolisthesis was estimated on and compared between standing neutral and supine lateral radiographs. The ability of common pairs of radiographs (flexion-extension, standing-supine, and flexion-supine) to detect dynamic spondylolisthesis was assessed. No single radiographic view or pair was considered the gold standard because stable or dynamic listhesis on any radiographic view is often considered positive in clinical practice. RESULTS: Among 518 patients, the percentage of patients with spondylolisthesis was 40% (95% CI 36% to 44%) on standing radiographs alone, and the percentage of patients with dynamic spondylolisthesis was 11% (95% CI 8% to 13%) on the standing-supine pair. Standing radiographs detected greater listhesis than supine radiographs did (6.5 ± 3.9 mm versus 4.9 ± 3.8 mm, difference 1.7 mm [95% CI 1.2 to 2.1 mm]; p < 0.001). Among 31 patients, no single radiographic pairing identified all patients with dynamic spondylolisthesis. The listhesis difference detected between flexion-extension was no different from the listhesis difference detected between standing-supine (1.8 ± 1.7 mm versus 2.0 ± 2.2 mm, difference 0.2 mm [95% CI -0.5 to 1.0 mm]; p = 0.53) and flexion-supine (1.8 ± 1.7 mm versus 2.5 ± 2.2 mm, difference 0.7 mm [95% CI 0.0 to 1.5]; p = 0.06). CONCLUSION: This study supports current clinical guidelines that lateral radiographs should be obtained with patients in the standing position, because all cases of stable spondylolisthesis of 3 mm or greater were detected on standing radiographs alone. Each radiographic pair did not detect different magnitudes of listhesis, and no single pair detected all cases of dynamic spondylolisthesis. Clinical concern for dynamic spondylolisthesis may justify standing neutral, supine lateral, standing flexion, and standing extension views. Future studies could identify and evaluate a set of radiographic views that provides the greatest capacity to diagnose stable and dynamic spondylolisthesis. LEVEL OF EVIDENCE: Level III, diagnostic study.
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Espondilolistese , Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Masculino , Espondilolistese/diagnóstico por imagem , Posição Ortostática , Estudos Transversais , Reprodutibilidade dos Testes , Vértebras LombaresRESUMO
PURPOSE: To study familial factors associated with child maltreatment in a birth population, Alaska piloted a mixed-design method that linked child welfare data with the Pregnancy Risk Assessment Monitoring System (PRAMS). We replicated this approach in Oregon and validated it in both states. METHODS: We linked vital records, child welfare, and PRAMS data to create two 2009 birth cohorts for each state: one based on vital records (full birth cohort) and one on PRAMS (stratified random sample). For each cohort, we estimated the incidence proportions (IP) of child maltreatment before age 9 years and compared those estimated using PRAMS with those observed using the full birth cohort. RESULTS: The Oregon PRAMS cohort estimated that 28.7% (95% CI: 24.0, 33.4), 20.9% (17.1, 24.7), and 8.3% (6.0, 10.5) of children experienced an alleged, investigated, and substantiated maltreatment, respectively, versus 32.0%, 25.0%, and 9.9% from the birth cohort. The corresponding Alaska estimates were 29.1% (26.1, 32.0), 22.6% (19.9, 25.2), and 8.3% (6.7, 9.9) of children from the PRAMS cohort versus 29.1%, 23.5%, and 9.1% in the birth cohort. CONCLUSIONS: The IP of child maltreatment in two states was accurately estimated with PRAMS cohorts. Researchers can study a comprehensive set of factors that may influence child maltreatment by incorporating PRAMS into birth cohort linkages.
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Maus-Tratos Infantis , Criança , Feminino , Humanos , Gravidez , Incidência , Projetos de Pesquisa , Medição de Risco , Alaska/epidemiologiaRESUMO
Background: Osteoporosis is common among older adults. Women are more likely to have osteoporosis than men. The prevalence varies with race/ethnicity, with the highest prevalence observed among non-Hispanic, Asian women. Prior studies identified a negative association between smoking and bone mineral density (BMD). The association between smoking and osteoporosis has not been investigated according to race/ethnicity. Materials and Methods: We included 4,226 U.S. adults aged 50 years or older with complete information on smoking history, BMD, and other independent variables from the 2005-2010 National Health and Nutrition Examination Surveys. Design-based multinomial logistic regression was utilized to estimate prevalence odds ratios (POR) of osteoporosis (T-score ≤ -2.5) and of low bone density (T-score between -1.0 and -2.5) in relation to lifetime smoking pack-years, stratified by sex and race/ethnicity. Results: Participants were 61.5 (standard error 0.21) years old on average and 48% women (n = 2,027). Among women, a smoking history ≥30 pack-years was positively associated with osteoporosis (POR: 2.40; 95% confidence interval [CI]: 1.42-4.06). Similar POR were observed among non-Hispanic White, non-Hispanic Black, and Mexican American women. However, POR for ≥30 pack-years and low bone density were positive but not statistically significant. Among men, null associations of smoking history, osteoporosis, and low bone density were observed, except for a positive association of ≥30 pack-years and low bone density among non-Hispanic Black men. Conclusion: Osteoporosis was twice as prevalent among women who smoked ≥30 pack-years than among women who never smoked, regardless of race/ethnicity. Smoking history and osteoporosis were not associated among men.
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Doenças Ósseas Metabólicas , Osteoporose , Masculino , Humanos , Feminino , Idoso , Lactente , Prevalência , Inquéritos Nutricionais , Osteoporose/epidemiologia , Densidade Óssea , Fumar/epidemiologiaRESUMO
BACKGROUND: Life-space mobility represents the distance, frequency, and independence of mobility, ranging from one's bedroom to beyond their town. Older men with lower urinary tract symptoms (LUTS) may limit their life-space to stay close to a bathroom. However, it's unknown whether LUTS severity or urinary bother are associated with risk of life-space mobility restriction. METHODS: We analyzed data from 3025 community-dwelling men age ≥71 years without life-space mobility restriction at analytic baseline (Year 7) of the Osteoporotic Fractures in Men (MrOS) study. The American Urologic Association Symptom Index (AUASI) was assessed at baseline and includes one question assessing urinary bother ("If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?"; score 0-1,2,3,4-6) and seven items to classify LUTS severity as none/mild (score 0-7), moderate (8-19), or severe (20-35). The University of Alabama Life-space Assessment was used to define life-space mobility restriction (≤60) at baseline and follow-up (Year 9). We used log-binomial regression with robust variance estimators to model adjusted risk ratios (ARR) for LUTS severity and urinary bother with incident life-space mobility restriction, controlling for age, site, health-related factors, and comorbidities. We then mutually adjusted for urinary bother and LUTS severity. RESULTS: Overall, the 2-year risk of life-space mobility restrictions was 9.9%. Compared to men without urinary bother (scores 0-1), the risk of life-space mobility restriction was significantly higher among men with bother scores of 4-6 (ARR = 2.20, 95% CI: 1.52, 3.19), independent of LUTS severity and confounders. Conversely, LUTS severity was not independently associated with the risk of life-space mobility restriction. CONCLUSIONS: Urinary bother, but not LUTS severity, is independently associated with incident life-space mobility restriction among older men. To maintain life-space mobility in older men with LUTS, future studies should identify shared mechanisms and interventions that minimize urinary bother.
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Avaliação Geriátrica , Locomoção , Sintomas do Trato Urinário Inferior , Humanos , Masculino , Idoso , Idoso de 80 Anos ou mais , Sintomas do Trato Urinário Inferior/epidemiologia , Sintomas do Trato Urinário Inferior/fisiopatologia , Sintomas do Trato Urinário Inferior/psicologia , Incontinência Urinária/epidemiologia , Incontinência Urinária/fisiopatologia , Incontinência Urinária/psicologia , Estudos de Coortes , Autorrelato , Fraturas Ósseas , Vida IndependenteRESUMO
BACKGROUND: Musculoskeletal pain, a possible marker of central sensitization, is associated with higher prevalence of lower urinary tract symptoms (LUTS) among older men. We investigated whether musculoskeletal pain is associated with LUTS progression. METHODS: Participants were 5 569 men age ≥65 years enrolled in the prospective, multicenter Osteoporotic Fractures in Men (MrOS) Study. Self-reported musculoskeletal pain within 12 months before baseline was categorized as any pain and multilocation pain. Pain interference within 4 weeks of baseline was assessed with the SF-12 questionnaire. LUTS were assessed repeatedly with the American Urological Association Symptom Index (AUA-SI). Men with severe LUTS at baseline were excluded. LUTS progression was defined as the first occurrence of a ≥4-point AUA-SI increase during a 2-year follow-up interval. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using multivariable pooled logistic regression. RESULTS: LUTS progression was 37% higher among men with any musculoskeletal pain compared with men without pain (IRR 1.37, 95% CI: 1.21, 1.54). Positive associations were also observed between LUTS progression and pain at 1 (IRR 1.31, 95% CI: 1.13, 1.48) and ≥2 locations (IRR 1.42, 95% CI: 1.24, 1.60). Compared with men without pain interference, men with quite a bit/extreme pain interference were most likely to experience LUTS progression (minimal interference IRR 1.15, 95% CI: 1.03, 1.26; moderate interference IRR 1.28, 95% CI: 1.11, 1.45; quite a bit/extreme interference IRR 1.47, 95% CI: 1.22, 1.71). CONCLUSIONS: Among men initially without severe LUTS, musculoskeletal pain is associated with an increased risk of LUTS progression. Studies using validated measures of central sensitization and LUTS progression among men are warranted.
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Sintomas do Trato Urinário Inferior , Dor Musculoesquelética , Masculino , Humanos , Idoso , Vida Independente , Estudos Prospectivos , Dor Musculoesquelética/epidemiologia , Sensibilização do Sistema Nervoso Central , Sintomas do Trato Urinário Inferior/complicações , Sintomas do Trato Urinário Inferior/epidemiologiaRESUMO
Introduction: Given the known relationships between breastfeeding and hypertension, and between hypertension and stroke, we examined the association between breastfeeding a child and stroke later in life. We hypothesized a history of breastfeeding is associated with lower prevalence of stroke. Methods: Our study population included parous females 20 years and older. Potential confounders included family income-to-poverty ratio, education, smoking status, parity, and age at first live birth. Potential effect measure modifiers included race/ethnicity and age at survey. Multivariable logistic regression models were used to estimate crude and adjusted prevalence odds ratios (ORs) and 95% confidence intervals (CIs) for the association between breastfeeding and stroke. Results: The odds of stroke among those who ever breastfed were lower than those who never breastfed (OR = 0.68, 95% CI: 0.55-0.86; p < 0.01). Adjusting for education decreased the strength of the association (OR = 0.80, 95% CI: 0.63-1.01; p = 0.06). In analyses stratified by age, the inverse association between breastfeeding status was significant among those ages 20-64 years (OR = 0.69, 95% CI: 0.47-1.00) but not among those 65 years and older (OR = 0.99, 95% CI: 0.73-1.34). Conclusions: Ever breastfeeding a child was associated with lower prevalence of stroke in a nationally representative U.S. sample of parous females 20 years and older. Results were strongest among those <65 years old.
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Aleitamento Materno , Acidente Vascular Cerebral , Adulto , Idoso , Feminino , Humanos , Hipertensão/epidemiologia , Pessoa de Meia-Idade , Inquéritos Nutricionais , Gravidez , Prevalência , Acidente Vascular Cerebral/epidemiologia , Adulto JovemRESUMO
RATIONALE AND OBJECTIVES: Osteoporosis affects 9% of individuals over 50 in the United States and 200 million women globally. Spinal osteoporotic compression fractures (OCFs), an osteoporosis biomarker, are often incidental and under-reported. Accurate automated opportunistic OCF screening can increase the diagnosis rate and ensure adequate treatment. We aimed to develop a deep learning classifier for OCFs, a critical component of our future automated opportunistic screening tool. MATERIALS AND METHODS: The dataset from the Osteoporotic Fractures in Men Study comprised 4461 subjects and 15,524 spine radiographs. This dataset was split by subject: 76.5% training, 8.5% validation, and 15% testing. From the radiographs, 100,409 vertebral bodies were extracted, each assigned one of two labels adapted from the Genant semiquantitative system: moderate to severe fracture vs. normal/trace/mild fracture. GoogLeNet, a deep learning model, was trained to classify the vertebral bodies. The classification threshold on the predicted probability of OCF outputted by GoogLeNet was set to prioritize the positive predictive value (PPV) while balancing it with the sensitivity. Vertebral bodies with the top 0.75% predicted probabilities were classified as moderate to severe fracture. RESULTS: Our model yielded a sensitivity of 59.8%, a PPV of 91.2%, and an F1 score of 0.72. The areas under the receiver operating characteristic curve (AUC-ROC) and the precision-recall curve were 0.99 and 0.82, respectively. CONCLUSION: Our model classified vertebral bodies with an AUC-ROC of 0.99, providing a critical component for our future automated opportunistic screening tool. This could lead to earlier detection and treatment of OCFs.
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Aprendizado Profundo , Fraturas por Compressão , Osteoporose , Fraturas da Coluna Vertebral , Masculino , Feminino , Humanos , Fraturas por Compressão/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem , Osteoporose/diagnóstico por imagem , RadiografiaRESUMO
BACKGROUND: Lower urinary tract symptoms (LUTS) are associated with frailty phenotype, a risk factor for functional decline. Our objective was to determine the association between baseline LUTS and 2-year risk of new functional limitation among older men. METHODS: We analyzed data from the Osteoporotic Fractures in Men (MrOS) study with baseline at Year 7 and follow-up through Year 9. Participants included 2716 community-dwelling men age ≥ 71 years without any baseline self-reported functional limitation. LUTS severity (American Urologic Association Symptom Index) was classified as none/mild (score 0-7), moderate (8-19), and severe (20-35). At baseline and follow-up, men reported their ability to complete several mobility, activities of daily living (ADLs), and cognition-dependent tasks. Risk was estimated for 3 incident functional limitation outcomes: (1) mobility (any difficulty walking 2-3 blocks or climbing 10 steps), (2) ADL (any difficulty bathing, showering, or transferring), and (3) cognition-dependent (any difficulty managing money or medications). We used Poisson regression with a robust variance estimator to model adjusted risk ratios (ARR) and 95% CIs controlling for age, site, and comorbidities; other demographic/lifestyle factors did not meet criteria for inclusion. RESULTS: Overall, the 2-year risk was 15% for mobility, 10% for ADLs, and 4% for cognition-dependent task limitations. Compared to none/mild LUTS, risk of incident mobility limitations was increased for moderate (ARR = 1.35, 95% CI: 1.12, 1.63) and severe LUTS (ARR = 1.98, 95% CI: 1.48, 2.64). Men were also at higher risk for incident ADL limitations if they reported moderate (ARR = 1.32, 95% CI: 1.05, 1.67) and severe LUTS (ARR = 1.62, 95% CI: 1.07,2.43). Results were somewhat attenuated after adjusting for the frailty phenotype but remained statistically significant. LUTS were not associated with incident cognition-dependent task limitations. CONCLUSIONS: LUTS severity is associated with incident mobility and ADL limitations among older men. Increased clinical attention to risk of functional limitations among older men with LUTS is likely warranted.
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Atividades Cotidianas , Sintomas do Trato Urinário Inferior , Idoso , Humanos , Vida Independente , Sintomas do Trato Urinário Inferior/epidemiologia , Limitação da Mobilidade , CaminhadaRESUMO
BACKGROUND: Adiposity increases risk for male lower urinary tract symptoms (LUTS), although longitudinal studies have produced conflicting results. No prior studies have evaluated longitudinal associations of changes in adiposity with concurrent LUTS severity among older men. METHODS: We used repeated adiposity measurements from dual-energy x-ray absorptiometry (DXA), body mass index (BMI), and American Urological Association Symptom Index (AUASI) measured at 4 study visits over a 9-year period among 5 949 men enrolled in the Osteoporotic Fractures in Men (MrOS) study. Linear mixed effect models adjusted for age, health-related behaviors, and comorbidities were created to evaluate the association between baseline and change in visceral adipose tissue (VAT) area, total fat mass, and BMI with change in LUTS severity measured by the AUASI. RESULTS: A nonlinear association was observed between baseline VAT area and change in AUASI: men in baseline VAT tertile (T) 2 had a lower annual increase in AUASI score compared to men in T1 and T3 (T2 vs T1: ß = -0.07; 95% CI -0.12, -0.03; p = .008; T3 vs T1: NS) but differences were small. No significant associations were observed between change in VAT area and change in AUASI score. Neither baseline tertiles nor change in total fat mass or BMI were associated with change in AUASI score. CONCLUSIONS: Changes in VAT area, total fat mass, and BMI were not associated with change in LUTS severity in this cohort. Thus, despite other health benefits, interventions targeting adiposity alone are unlikely to be effective for preventing or treating LUTS among older men.
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Adiposidade , Sintomas do Trato Urinário Inferior , Idoso , Estudos de Coortes , Humanos , Gordura Intra-Abdominal , Sintomas do Trato Urinário Inferior/epidemiologia , Sintomas do Trato Urinário Inferior/terapia , Masculino , ObesidadeRESUMO
The World Health Organization lists air pollution as one of the top five risks for developing chronic non-communicable disease, joining tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity. This review focuses on how host defense mechanisms against adverse airborne exposures relate to the probable interacting and overlapping pathophysiological features of neurodegeneration and multiple chemical sensitivity. Significant long-term airborne exposures can contribute to oxidative stress, systemic inflammation, transient receptor subfamily vanilloid 1 (TRPV1) and subfamily ankyrin 1 (TRPA1) upregulation and sensitization, with impacts on olfactory and trigeminal nerve function, and eventual loss of brain mass. The potential for neurologic dysfunction, including decreased cognition, chronic pain and central sensitization related to airborne contaminants, can be magnified by genetic polymorphisms that result in less effective detoxification. Onset of neurodegenerative disorders is subtle, with early loss of brain mass and loss of sense of smell. Onset of MCS may be gradual following long-term low dose airborne exposures, or acute following a recognizable exposure. Upregulation of chemosensitive TRPV1 and TRPA1 polymodal receptors has been observed in patients with neurodegeneration, and chemically sensitive individuals with asthma, migraine and MCS. In people with chemical sensitivity, these receptors are also sensitized, which is defined as a reduction in the threshold and an increase in the magnitude of a response to noxious stimulation. There is likely damage to the olfactory system in neurodegeneration and trigeminal nerve hypersensitivity in MCS, with different effects on olfactory processing. The associations of low vitamin D levels and protein kinase activity seen in neurodegeneration have not been studied in MCS. Table 2 presents a summary of neurodegeneration and MCS, comparing 16 distinctive genetic, pathophysiological and clinical features associated with air pollution exposures. There is significant overlap, suggesting potential comorbidity. Canadian Health Measures Survey data indicates an overlap between neurodegeneration and MCS (p < 0.05) that suggests comorbidity, but the extent of increased susceptibility to the other condition is not established. Nevertheless, the pathways to the development of these conditions likely involve TRPV1 and TRPA1 receptors, and so it is hypothesized that manifestation of neurodegeneration and/or MCS and possibly why there is divergence may be influenced by polymorphisms of these receptors, among other factors.
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Sensibilidade Química Múltipla , Humanos , Canadá , Olfato/fisiologiaRESUMO
AIMS: Features of central sensitization (CS) are present in almost all chronic pain conditions, including painful urinary conditions and back pain. Recently CS was proposed as a mechanism of nonpainful lower urinary tract symptoms (LUTS). Using musculoskeletal pain as an indicator of CS, we investigated whether the prevalence of musculoskeletal pain is greater among community-dwelling men with moderate or severe LUTS compared to those with mild LUTS. METHODS: We conducted a cross-sectional study of 5966 men ≥65 years who attended the Osteoporotic Fractures in Men Study baseline visit. LUTS were assessed with the American Urological Association Symptom Index (AUA-SI) and categorized as none/mild (0-7), moderate (8-19), or severe (≥20). Self-reported back, neck, hip, or knee pain within the 12 months before baseline was categorized as any pain and multilocation pain. We tested our hypothesis using odds ratios (OR) and 95% confidence intervals (CI) estimated from multivariable logistic regression models. RESULTS: The adjusted odds of any pain were higher among men with moderate (OR 1.49, 95% CI: 1.29-1.72) and severe LUTS (OR 1.76, 95% CI: 1.28-2.40) compared to those with no/mild LUTS. The adjusted odds of pain at ≥ 2 locations were 69% higher among men with moderate (OR 1.69, 95% CI: 1.45-196) and more than double among men with severe LUTS (OR 2.24, 95% CI: 1.62-3.10) compared to men with no/mild LUTS. CONCLUSIONS: Musculoskeletal pain, especially at multiple locations, is associated with greater LUTS severity among older men. CS may represent a novel shared mechanism of pain and LUTS.
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Sintomas do Trato Urinário Inferior , Dor Musculoesquelética , Idoso , Sensibilização do Sistema Nervoso Central , Estudos Transversais , Humanos , Sintomas do Trato Urinário Inferior/epidemiologia , Masculino , Dor Musculoesquelética/epidemiologia , Fatores de RiscoRESUMO
OBJECTIVE: The Patient-Reported Outcomes Measurement Information System (PROMIS)-Plus-Osteoarthritis of the Knee (OAK) profile integrates universal PROMIS items with knee-specific items across 13 domains. We evaluated the psychometric properties of a subset of six domains associated with quality of life in people with OAK. STUDY DESIGN AND SETTING: In a cross-sectional study of OAK patients (n=600), we estimated reliability using Pearson and Spearman correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and known-groups validity with PROMIS Global Health. Measure responsiveness was tested via paired t-tests in a longitudinal study (n=238), pre/post total knee replacement. RESULTS: Across the six domains, internal consistency reliability (Cronbach's alpha) was 0.77-0.95 and test-retest reliability (intraclass correlation coefficients) was ≥0.90. Correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and PROMIS Global supported convergent and divergent validity. Known-groups validity testing revealed better scores in all domains for high vs. low global status groups, and knee-specific items added value in physical function and pain. All domains reflected (p<0.001) better health status scores at follow up. CONCLUSION: The six PROMIS-Plus-OAK profile domains demonstrated good psychometric characteristics. The measure integrates universal and knee-specific content to provide enhanced relevance, measurement precision and efficient administration for patient care and clinical research.
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Nível de Saúde , Osteoartrite do Joelho/epidemiologia , Dor/epidemiologia , Medidas de Resultados Relatados pelo Paciente , Adolescente , Adulto , Idoso , Causalidade , Estudos Transversais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/psicologia , Dor/fisiopatologia , Psicometria , Qualidade de Vida/psicologia , Reprodutibilidade dos Testes , Estados Unidos/epidemiologia , Adulto JovemRESUMO
PURPOSE: Most international practice guidelines recommend screening for chronic kidney disease among older men with lower urinary tract symptoms. However, prior studies supporting these guidelines are insufficient due to incomplete assessments of kidney function and inadequate adjustment for confounding factors. MATERIALS AND METHODS: We conducted a cross-sectional study among 5,530 American men older than 65 years in the multicenter Osteoporotic Fractures in Men Study. Chronic kidney disease was defined per international guidelines as estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 based on serum creatinine or cystatin C, or urinary albumin-to-creatinine ratio 30 mg/gm or greater. Lower urinary tract symptoms were assessed with the American Urological Association Symptom Index. Associations were estimated using multivariable linear and modified Poisson regression models. RESULTS: Chronic kidney disease prevalence was 16% among 5,530 men with serum creatinine, 24% among 1,504 men with serum cystatin C and 14% among 1,487 men with urinary albumin-to-creatinine measurements. Lower urinary tract symptoms were not associated with lower estimated glomerular filtration rate based on serum creatinine or cystatin C. Although symptom severity was modestly associated with a higher prevalence of chronic kidney disease in age/site adjusted analyses, confidence intervals were wide and associations using all 3 definitions were not statistically significant after adjustment for important confounders, including cardiovascular disease and analgesic use. CONCLUSIONS: Lower urinary tract symptoms are not independently associated with multiple measures of kidney dysfunction or prevalence of chronic kidney disease among older community dwelling men. Our results do not support recommendations for kidney function testing among older men with lower urinary tract symptoms.
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Vida Independente/estatística & dados numéricos , Sintomas do Trato Urinário Inferior/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Albuminúria/diagnóstico , Fatores de Confusão Epidemiológicos , Creatinina/sangue , Creatinina/urina , Estudos Transversais , Cistatina C/sangue , Taxa de Filtração Glomerular/fisiologia , Humanos , Sintomas do Trato Urinário Inferior/complicações , Sintomas do Trato Urinário Inferior/diagnóstico , Sintomas do Trato Urinário Inferior/fisiopatologia , Masculino , Prevalência , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/etiologia , Índice de Gravidade de Doença , Micção/fisiologiaRESUMO
BACKGROUND/OBJECTIVES: To estimate associations between lower urinary tract symptoms (LUTS) and phenotypic frailty in older men. DESIGN: Cross-sectional study. SETTING: Community-dwelling men recruited from 2000 to 2002 from six U.S. academic centers for the Osteoporotic Fractures in Men Study. PARTICIPANTS: A total of 5,979 men aged 65 and older. MEASUREMENTS: The independent variable was LUTS severity (none/mild, moderate, or severe) assessed with the American Urologic Association Symptom Index. Participants were categorized as frail, intermediate stage, or robust using an adapted Cardiovascular Health Study index (components: low lean mass, weakness, exhaustion, slowness, and low physical activity). Associations were estimated with odds ratios and 95% confidence intervals (CIs) from multivariable multinomial logistic regression models adjusted for potential confounders of age, other demographics, health-related behaviors, and comorbidities. RESULTS: The prevalence of frailty was 7%, 11%, and 18% among men with none/mild, moderate, and severe LUTS, respectively. Moderate and severe LUTS, overall and by storage and voiding subscores, were associated with higher odds of both intermediate stage and frailty in all models. After adjustment for confounders, the odds of frailty was 1.41 times higher among men with moderate LUTS (95% CI = 1.14-1.74) and 2.51 times higher among men with severe LUTS (95% CI = 1.76-3.55), compared with none/mild LUTS. Severe LUTS was associated with a greater odds of individual frailty components exhaustion and low physical activity. CONCLUSION: The prevalence of phenotypic frailty is higher among older community-dwelling men with moderate or severe LUTS compared with those with mild or no LUTS. The positive association between LUTS severity and frailty among older men appears independent of age and known frailty risk factors. Although the temporal direction of this association and the utility of LUTS or frailty interventions in this population remain unclear, the high co-occurrence of these conditions could lead to earlier identification of frailty when clinically appropriate.
Assuntos
Comorbidade , Fragilidade/epidemiologia , Vida Independente , Sintomas do Trato Urinário Inferior/epidemiologia , Incontinência Urinária , Fatores Etários , Idoso , Estudos Transversais , Humanos , Masculino , Prevalência , Fatores de Risco , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Hip osteoarthritis (OA) limits lower extremity physical function. Exercise therapy may improve physical function and reduce pain in patients with hip OA. OBJECTIVE: To evaluate the feasibility of a randomized controlled trial (RCT) to measure the effect of a structured hip-specific resistance and aerobic exercise program on physical function and self-reported pain in adults with hip OA. DESIGN: Pilot RCT. SETTING: Academic medical center. PARTICIPANTS: Thirty one adults with radiographic hip OA. INTERVENTIONS: Participants were randomly allocated in a 2:1 ratio to a 3-month structured exercise intervention (n = 21) or a 3-month waitlist control (n = 10). MAIN OUTCOME MEASURES: The 6-minute walk test was the primary outcome measure. Self-reported physical function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale and pain visual analog scale (VAS). Measures of feasibility were assessed as secondary outcomes. RESULTS: From baseline to 3 months, the median change from baseline in distance covered during the 6-minute walk test in the intervention group (49 m) was double that of the control group (22 m), but the difference was not statistically significant (P = .13). Likewise, the WOMAC physical function subscale score median changes in the intervention group (5 points) were double that of the controls (2 points), although the difference was not statistically significant (P = .06). Median change in pain scores was slightly reduced in each group but not significantly different between groups (P = .53). CONCLUSION: Although no statistically significant between-group differences were found in this pilot RCT, improvements were seen in measures of physical function compared to controls. A larger RCT of this structured exercise program may be warranted.
Assuntos
Terapia por Exercício , Osteoartrite do Quadril , Manejo da Dor , Adulto , Humanos , Osteoartrite do Quadril/complicações , Osteoartrite do Quadril/terapia , Dor/etiologia , Projetos PilotoRESUMO
STUDY DESIGN: A cross-sectional study. OBJECTIVE: This study investigates the prevalence of incidental vertebral marrow signal abnormality (VMSA) in thoracolumbar spine magnetic resonance imaging (MRI) ordered for the evaluation of back and/or leg pain and assess the clinical work-up for VMSAs. SUMMARY OF BACKGROUND DATA: Patients presenting with back pain are often referred for spine MRI for diagnostic evaluation. VMSA is most frequently found in the lumbar spine and is of clinical concern because it can represent malignancy. Standardized procedures for reporting and managing VMSAs do not exist. METHODS: The radiology database at the Oregon Health & Science University health system was queried to identify patients with thoracolumbar spine MRI scans performed between January 2014 and June 2016. Patients 16 years or older with MRIs ordered by providers at a multidisciplinary spine specialty clinic for the diagnostic evaluation of back and/or leg pain were included. Radiology reports were searched for keywords pertaining to VMSAs, such as "malignancy." Medical records of these patients were further reviewed for the clinical work-up and final diagnoses pertaining to the VMSA. RESULTS: The study sample included 1503 individual patients, of whom 65 (4%) had MRI radiology reports that described a VMSA. Thirty-one (48%) of the 65 patients with VMSAs had further evaluation recommended by radiology. Ten (32%) of these 31 patients were followed clinically without further diagnostic testing for the VMSA. Of the 65 patients with VMSAs, only one was diagnosed with malignancy (multiple myeloma). CONCLUSION: While VMSAs are not frequently found on thoracolumbar MRIs ordered to evaluate back and/or leg pain, there is a large amount of heterogeneity in how these abnormalities are documented and managed. This may indicate the need for clinical guidelines for the reporting and management of VMSAs detected on spine MRI and for improvement in communication between radiologists and ordering providers. LEVEL OF EVIDENCE: 3.
Assuntos
Medula Óssea/diagnóstico por imagem , Doenças do Tecido Conjuntivo/diagnóstico por imagem , Achados Incidentais , Vértebras Lombares/diagnóstico por imagem , Anormalidades Musculoesqueléticas/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Adulto , Idoso , Dor nas Costas/diagnóstico por imagem , Dor nas Costas/etiologia , Doenças do Tecido Conjuntivo/complicações , Doenças do Tecido Conjuntivo/epidemiologia , Estudos Transversais , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Anormalidades Musculoesqueléticas/complicações , Anormalidades Musculoesqueléticas/epidemiologia , PrevalênciaRESUMO
OBJECTIVE: To assess family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health (EH). DESIGN: Two-part study with questionnaire construction using a modified Delphi method, and a Web-based questionnaire administered to family medicine residents between November 2015 and January 2016. SETTING: All Canadian family medicine programs (for questionnaire construction) and 4 Ontario family medicine training programs (for questionnaire administration). PARTICIPANTS: First- to third-year family medicine residents (for questionnaire administration). MAIN OUTCOME MEASURES: Responses to 93 survey items that measured family medicine residents' knowledge of, attitudes toward, and clinical practices related to EH. RESULTS: For the final administered questionnaire, 203 of 887 (22.9%) family medicine residents responded. Although 92.0% of respondents somewhat or strongly believed that taking an environmental exposure history was important, only 18.1% of them had specific training in taking environmental exposure history, and 48.4% believed that taking an exposure history takes up too much time in office practice. While 82.9% of residents correctly identified recreational water use as a cause of gastroenteritis, only 60.2% correctly identified radon as a cause of lung cancer and 37.6% knew that elevated ground-level ozone is associated with asthma. Only 10.8% believed their supervisors had a good understanding of environmental exposures. Residents who believed their supervisors understood environmental exposures were more likely to take exposure histories for patients with uncontrolled asthma (P < .05), and those who discussed EH exposure with supervisors frequently, or thought environmental exposure histories were very important, were more likely to provide patients with EH education materials (P < .01). CONCLUSION: Although family medicine residents are aware of the importance of assessing patients' environmental exposures, they lack training and mentorship in EH. As a health determinant of critical importance, EH should be a high priority for inclusion in postgraduate family medicine education.
Assuntos
Saúde Ambiental/educação , Medicina de Família e Comunidade/educação , Conhecimentos, Atitudes e Prática em Saúde , Internato e Residência/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Ontário , Análise de Regressão , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Lower urinary tract symptoms (LUTS) and urinary bother have been reported in adults undergoing surgery and have been associated with urinary tract infections, longer hospital stays, increased surgical costs, and decreased patient satisfaction. Previous reports indicate that up to one in two patients with lumbar spine pathology have moderate-to-severe LUTS, but little is known about LUTS in patients with cervical spine conditions. QUESTIONS/PURPOSES: (1) What is the prevalence of moderate-to-severe LUTS and clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (2) Does the presence of myelopathy affect frequency of moderate-to-severe LUTS or clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (3) Do MRI findings of spinal cord injury or compression correlate with presence and severity of LUTS? METHODS: We performed a cross-sectional study using clinical data collected from adult patients undergoing elective cervical spine surgery. Over an approximately 30-month period, we approached all patients who were evaluated in the preoperative clinic before undergoing elective cervical spine surgery. Of the 257 approached, 242 participated (94%). Study participants ranged in age from 34 to 83 years with a mean age of 58 years (SD 12). There were 108 males (45%) and 134 females (55%). A validated questionnaire, the International Prostate Symptom Score (IPSS), was used to identify LUTS. The IPSS score ranges from 0 to 35 points with LUTS presence defined as a score of ≥ 8 and LUTS severity categorized as mild (IPSS 0-7), moderate (IPSS 8-19), or severe (IPSS 20-35). Quality of life resulting from urinary bother is scored 0 to 6 with scores ≥ 4 considered clinically relevant urinary bother. Patients were grouped into a myelopathy group and a nonmyelopathy group based on diagnosis as assigned by the operating surgeon. MRIs were analyzed by one spine surgeon to identify the presence of cord signal, number of levels with cord compression (mm), and a calculated compression ratio score with cord compression and with compression ratio among patients with myelopathy. RESULTS: The prevalence of moderate LUTS in our patient sample was 40% (97 of 242; 95% confidence interval [CI], 34%-47%). The prevalence of severe LUTS in our patient sample was 8% (19 of 242; 95% CI, 5%-12%). Clinically relevant urinary bother was reported in 18% of patients (41 of 228; 95% CI, 13%-24%). After adjustment for age and sex, the odds of moderate-to-severe LUTS among patients with myelopathy was greater than that observed in patients without myelopathy (adjusted odds ratio, 2.0; p = 0.015). The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]; p < 0.001). With the numbers available, among patients with myelopathy, there was no difference in distribution of LUTS symptom severity or IPSS score according to cord signal presence (50% [23 of 46]) and absence (65% [31 of 48]; p = 0.153), number of levels with compression (70% [seven of 10 with four levels]; 59% [13 of 22 with three levels]; 51% [19 of 37] with two levels; and 60% [15 of 25] with one level; p = 0.730), millimeters of cord compression (r = 0.02; p = 0.854), or compression ratio (r = 0.09; p = 0.413). CONCLUSIONS: Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina, prompting potentially unnecessary imaging and studies. Given that urinary bother is reported less frequently than LUTS, patients may be less likely to seek care for urinary symptoms before undergoing surgery. Therefore, it is important to increase provider awareness of the high prevalence of LUTS. LEVEL OF EVIDENCE: Level III, prognostic study.