Hypogonadism in men with chronic pain linked to the use of long-acting rather than short-acting opioids.

AIM: There is a need to elucidate the variables associated with testosterone suppression among men on daily opioid therapy for chronic pain. OBJECTIVE: The objective of this study was to examine several variables related to opioid use including daily dose, duration of action (long acting vs. short acting), and specific opioid to ascertain specific influences on total serum testosterone levels in men with chronic pain who use opioids daily. SETTING: This is a retrospective cohort study of men within the Kaiser Permanente, Northern California (KPNC) health care system on some form of daily opioid use for chronic pain. PARTICIPANTS: Eighty-one men between the age of 26 and 79 years were seen in a chronic pain clinic between January 2009 and June 2010. All men were on stable dose of an opioid for at least 3 months, none with a previous diagnosis of hypogonadism. MAIN OUTCOME MEASURES: Total serum AM testosterone levels were measured at KPNC Regional Laboratory. RESULTS: Average total serum AM testosterone levels for this population showed 53% of all men receiving daily opioids were hypogonadal (AM total serum testosterone <250 ng/dL). In men receiving long-acting opioids, 74% (34/46) were hypogonadal compared with 34% (12/35) in men using short-acting opioids (hydrocodone or oxycodone) exclusively [AM total testosterone: median, 126 ng/dL; mean, 169 ng/dL (SD, 128 ng/dL) vs. median, 283 ng/dL; mean, 315 ng/dL (SD, 142 ng/dL); P<0.001]. After controlling for daily dosage and body mass index, men on long-acting opioids had 4.78 times greater odds of becoming hypogonadal than did men on short-acting opioids [95% confidence interval (CI), 1.51-15.07; P=0.008]. Body mass index was also significantly associated with hypogonadism (odds ratio, 1.13; 95% CI, 1.03-1.24; P=0.006), whereas daily dose was not (odds ratio, 1.02; 95% CI, 0.99-1.05; P=0.29). CONCLUSIONS: Among a contemporary sample of men receiving chronic daily opioids, we found a high prevalence of hypogonadism associated with duration of action, but not with total daily dose of the opioid.

Risk score for prediction of 10 year dementia risk in individuals with type 2 diabetes: a cohort study.

BACKGROUND: Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes. METHODS: Using data from two longitudinal cohorts of patients with type 2 diabetes (aged ≥60 years) with 10 years of follow-up, we created (n=29,961) and validated (n=2413) the risk score. We built our prediction model by evaluating 45 candidate predictors using Cox proportional hazard models and developed a point system for the risk score based on the size of the predictor's ß coefficient. Model prediction was tested by discrimination and calibration methods. Dementia risk per sum score was calculated with Kaplan-Meier estimates. FINDINGS: Microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education were most strongly predictive of dementia and constituted the risk score (C statistic 0·736 for creation cohort and 0·746 for validation cohort). The dementia risk was 5·3% (95% CI 4·2-6·3) for the lowest score (-1) and 73·3% (64·8-81·8) for the highest (12-19) sum scores. INTERPRETATION: To the best of our knowledge, this is the first risk score for the prediction of 10 year dementia risk in patients with type 2 diabetes mellitus. The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials. FUNDING: Kaiser Permanente Community Benefit, National Institute of Health, Utrecht University, ZonMw, and Fulbright.

Treatment of vitamin D deficiency within a large integrated health care delivery system.

BACKGROUND: In the past decade, increasing attention has focused on identification and treatment of vitamin D deficiency although repletion outcomes of pharmacologic vitamin D therapy have not been examined at a population level. OBJECTIVE: To investigate population trends and outcomes of pharmacologic treatment of vitamin D deficiency. METHODS: We conducted a retrospective cohort study using data from an integrated health system with approximately 3.2 million members. Automated laboratory and pharmacy databases were used to identify patients aged 18 years or older with hypovitaminosis D (defined as a 25-hydroxy-vitamin D [25(OH)D] serum level < 20 nanograms [ng] per mL) who newly initiated pharmacologic ergocalciferol (50,000 international units [IU] per week) during 2007-2010 and did not have a prescription for ergocalciferol in the prior 12 months. Patients were required to be continuously enrolled for 12 months before and 6 months after ergocalciferol initiation. Age, gender, race/ethnicity, body mass index, and 25(OH)D levels were obtained from health plan electronic medical records and administrative, laboratory, and pharmacy databases. Outcome and predictors of repletion among the subset who received 12 weekly doses of 50,000 IU ergocalciferol (total dose 600,000 IU) were examined using multivariable logistic regression. RESULTS: There were 72,093 vitamin D-deficient patients who newly initiated pharmacologic ergocalciferol. During the study period, the use of ergocalciferol increased nearly 8-fold from 161 per 100,000 adult members in 2007 to 1,241 per 100,000 adult members in 2010. One-fifth (n = 14,727) had severe vitamin D deficiency (25[OH]D level < 10 ng per mL). Among 23,322 patients receiving 50,000 IU ergocalciferol for 12 weeks in whom subsequent 25(OH)D levels were measured between 90 and 365 days after the index ergocalciferol prescription date, 74.0% achieved 25(OH)D of at least 20 ng per mL, and 35.8% achieved 25(OH)D of at least 30 ng per mL. Increasing age (adjusted odds ratio [OR] 1.02, 95% CI 1.02-1.02) and higher baseline 25(OH)D level (OR 1.11, 95% CI 1.10-1.12) were associated with greater odds of successful repletion. Asian race (OR 0.80, 95% CI 0.73-0.88), Hispanic ethnicity (OR 0.71, 95% CI 0.65-0.77), and increasing overweight/obesity (OR 0.78, 95% CI 0.72-0.85 for body mass index [BMI], 25.0-29.9 kg/m²; OR 0.66, 95% CI 0.60-0.71 for BMI 30.0-39.9 kg/m²; OR 0.53, 95% CI 0.48-0.60 for BMI ≥ 40 kg/m²) were associated with lower odds of repletion compared with BMI 18.5-24.9 kg/m². CONCLUSIONS: There is increasing recognition and treatment of vitamin D deficiency within the health care setting. Patients of younger age, Asian and Hispanic race/ethnicity, and those who are obese or with more severe vitamin D deficiency may be at greater risk for incomplete repletion using standard regimens and may require additional treatment to achieve optimal levels.

Domestic violence and abuse, health status, and social functioning.

BACKGROUND: Current and past history of domestic violence (DV), including physical, sexual, and emotional abuse is common among women patients seen in health care settings and is associated with a higher frequency of many health problems. However, the association of DV with self-assessed social functioning is less well known. METHODS: We administered a telephone survey to a random sample of 391 women HMO members seen for a routine annual check-up. The survey included questions about current and past physical, sexual, and emotional violence and self-assessed social functioning and health status from the SF-36. We included questions about attitudes toward routine DV screening, likelihood of disclosure, and the health care setting as a resource. RESULTS: Seven percent of the women reported recent DV and 34% reported lifetime abuse. Abuse was related to limitations in social functioning (adjusted OR = 2.26). Among women with no recent history of abuse, those with a history of past physical (adjusted OR = 1.90), sexual (adjusted OR = 2.04), or emotional (adjusted OR = 2.20) abuse reported significantly poorer social functioning. Emotional abuse, even in the absence of a history of physical or sexual abuse, was strongly associated with limitations in social functioning (adjusted OR = 4.95). Most women believed it appropriate for clinicians to inquire routinely about DV (87%) and 83% believed that the health care setting was a source of help. CONCLUSIONS: Current and past DV, including emotional abuse, adversely affect social functioning. Therefore, clinicians in the health care setting have a unique and important opportunity to assist women victims of DV and abuse.

Trauma history and relapse probability among patients seeking substance abuse treatment.

We estimated the prevalence of trauma history and relapse in a sample of 959 patients at two outpatient chemical dependence clinics of a managed healthcare organization. A large majority (89%) reported a history of at least one traumatic event. The most common traumatic events were serious accidents, being robbed, seeing someone killed or seriously injured, and partner violence. One third of the patients had a history of substance abuse disorder relapse. There were gender and ethnic differences in the types of traumatic events reported. There were ethnic differences in relapse rates, which were highest among African American and multicultural patients. The types of traumatic events reported differed in patients of various sexual orientations. Bisexual patients had the highest rates of relapse, even when trauma exposure was controlled. Clinical implications of the findings are discussed.

Is a history of trauma associated with a reduced likelihood of cervical cancer screening?

OBJECTIVE: We tested the hypothesis that a history of trauma (especially sexual trauma) was associated with a reduced likelihood of having had medically appropriate cervical cancer screening. STUDY DESIGN: A case-control study using mailed self-report questionnaires. POPULATION: The questionnaires were completed by an age-stratified random sample of adult women members of a large health maintenance organization. The sample included 364 women who had received medically appropriate cervical cancer screening and 372 who had not. OUTCOMES MEASURED: We defined cases as women who, according to their medical record, had not had cervical cancer screening within 2 years before the study. Controls were defined as women who had been screened. We evaluated exposures to trauma that we hypothesized to be associated with the case/control state. RESULTS: Women who had been sexually abused in childhood were less likely to have had a Pap smear within the past 2 years (36.0% vs. 50.4%, P =.050). Other traumatic events were associated with Pap testing in bivariate analyses but not when demographic characteristics and clinic location were controlled. Childhood sexual abuse remained associated with reduced odds of Pap screening in logistic regression analyses that controlled for clinic location, demographics, attitudes about Pap screening, and posttraumatic stress disorder symptoms (adjusted OR = 0.56, 95% CI 0.34 to 0.91). CONCLUSIONS: These findings suggest that childhood sexual abuse may lead to decreased probability of screening for cervical cancer, potentially contributing to the poorer health seen in other studies of women who have been sexually abused.